2017 Section 7 Green Book

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 (

.0002),

presence of extranodal extension (

.0025), and advanced T classifi-

cation (

.0081) were independent predictors of survival. For HPV-

positive patients, surgical approach (

.0111) and margin status (

.0287) were significant predictors of survival. For HPV-negative patients,

extranodal extension (

.0021) and advanced T classification (

.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.

2015 Wiley

Periodicals, Inc.

Head Neck

: E1794–E1802, 2016

KEY WORDS:

surgery oropharynx, oropharyngeal cancer, human

papillomavirus, squamous cell carcinoma, transoral surgery

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).

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

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

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.

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

retrospectively

reviewed patients with oropharyngeal SCC enrolled in

Radiation Therapy Oncology Group (RTOG) 0129, com-

paring high-dose cisplatin given concurrently with either

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.

HEAD & NECK—DOI 10.1002/HED APRIL 2016

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

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