2017 Section 7 Green Book

Reprinted by permission of Head Neck. 2016; 38 Suppl 1:E1794-1802.

ORIGINAL ARTICLE

Surgical management of oropharyngeal squamous cell carcinoma: Survival and functional outcomes

Bhavna Kumar, MS, Michael J. Cipolla, MD, Matthew O. Old, MD, Nicole V. Brown, MS, Stephen Y. Kang, MD, Peter T. Dziegielewski, MD, Kasim Durmus, MD, Enver Ozer, MD, Amit Agrawal, MD, Ricardo L. Carrau, MD, David E. Schuller, MD, Marino E. Leon, MD, Quintin Pan, PhD, Pawan Kumar, PhD, Valerie Wood, MD, Jessica Burgers, MD, Paul E. Wakely Jr, MD, Theodoros N. Teknos, MD *

Department of Otolaryngology – Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio.

Accepted 19 September 2015 Published online 23 December 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/hed.24319

ABSTRACT: Background. The purpose of this study was to further define the impact of primary surgery in the management of oropharyn- geal squamous cell carcinoma (SCC). Methods. Two hundred ninety-six patients with oropharyngeal SCC treated with primary surgery were included. Multivariable analysis and recursive partitioning analysis (RPA) identified predictors of survival and gastrostomy tube presence. Results. Multivariable analysis identified that HPV negativity ( p 5 .0002), presence of extranodal extension ( p 5 .0025), and advanced T classifi- cation ( p 5 .0081) were independent predictors of survival. For HPV- positive patients, surgical approach ( p 5 .0111) and margin status ( p 5 .0287) were significant predictors of survival. For HPV-negative patients, INTRODUCTION The worldwide incidence of oropharyngeal squamous cell carcinoma (SCC) is rising at an alarming rate. 1,2 Once a rare disease, oropharyngeal SCC is now the most com- mon malignancy encountered by the head and neck oncol- ogist. 1,3 This dramatic shift in tumor incidence has been linked to increasing rates of infection with the carcinogenic strains of human papillomavirus (HPV). 4 Traditionally, head and neck malignancies, including oro- pharyngeal SCC, have been treated with open surgical resection, reconstruction, and postoperative radiother- apy. 5,6 However, after the publication of the Veterans Affairs Laryngeal Cancer Study Group trial in 1991, there * Corresponding author: T. N. Teknos, Department of Otolaryngology – Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, 915 Olentangy River Road, Suite 4000, Columbus OH 43212. E-mail: ted.teknos@osumc.edu Contract grant sponsor: This work was supported by The Ohio State University Comprehensive Cancer Center funds. This work was presented as an Abstract at the American Head and Neck Society Annual Meeting, Orlando, Florida, April 10–11, 2013; and it was also presented in part at the 2014 Multidisciplinary Head and Neck Cancer Sympo- sium, American Society of Clinical Oncology (ASCO)/American Society for Radi- ation Oncology (ASTRO)/American Head and Neck Society (AHNS), Scottsdale, Arizona, February 20–22, 2014.

extranodal extension ( p 5 .0021) and advanced T classification ( p 5 .0342) were significant predictors of survival. Smoking status and advanced neck disease did not impact survival, and the addition of adju- vant chemotherapy did not confer survival benefit in HPV-positive or HPV-negative subgroups. Conclusion. Independent predictors of survival are unique in patients with oropharyngeal SCC treated with primary surgery. V C 2015 Wiley Periodicals, Inc. Head Neck 38 : E1794–E1802, 2016 KEY WORDS: surgery oropharynx, oropharyngeal cancer, human papillomavirus, squamous cell carcinoma, transoral surgery has been an increased emphasis on nonsurgical approaches to therapy. 7,8 Specifically with regard to oropharyngeal SCC, a meta-analysis by Parsons et al 5 noted similar sur- vival outcomes in patients treated with surgery followed by radiotherapy as those treated with primary radiotherapy and surgical salvage. Furthermore, because of functional and cosmetic morbidity associated with conventional open en bloc resections in oropharyngeal SCC, “organ preservation” approaches began to be explored. 9–14 In time, radiotherapy alone was supplanted by concurrent chemoradiotherapy because of improved primary tumor control. 10,15 Novel and ever-intensifying chemotherapeutic approaches were also investigated in oropharyngeal SCC. 16–20 However, with the proliferation of “organ preservation” approaches to oropha- ryngeal SCC, dramatic increases in the rates of treatment- related toxicities have been documented. 20–23 There have been notable increases in the rates of xerostomia (33%), gastrostomy tube dependence (12%), cervical stricture (6%), and osteoradionecrosis, even with the use of the latest radiation techniques. 24 Published gastrostomy tube rates have ranged from 7% to as high as 31% at 1 year after chemoradiotherapy. 25,26 In a landmark publication, Ang et al 15 retrospectively reviewed patients with oropharyngeal SCC enrolled in Radiation Therapy Oncology Group (RTOG) 0129, com- paring high-dose cisplatin given concurrently with either

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