Golusiński Wojciech, Golusińska-Kardach Ewelina
Department of Head and Neck Surgery, Poznan University of Medical Sciences, Poznan, Poland.
Front Oncol. 2019 May 24;9:388. doi: 10.3389/fonc.2019.00388. eCollection 2019.
In the last few decades, the surgical treatment of oropharyngeal squamous cell carcinoma (OPSCC) has undergone enormous changes. Until the 1990s, open surgery was the primary treatment for OPSCC. However, due to the potentially severe functional morbidity of this approach, open surgery was largely displaced by concurrent chemoradiotherapy (CRT) in the 1990s. At the same time, new, less-invasive surgical approaches such as transoral surgery with monopolar cautery began to emerge, with the potential to reduce functional morbidity and avoid the late-onset toxicity of CRT. More recently, the growing incidence of HPV-positive disease has altered the patient profile of OPSCC, as these patients tend to be younger and have a better long-term prognosis. Consequently, this has further bolstered interest in minimally-invasive techniques to de-intensify treatment to reduce long-term toxicity and treatment-related morbidity. In this context, there has been a renewed interest in the primary surgery, which allows for accurate pathologic staging and thus-potentially-de-intensification of postoperative CRT. The continuous advances in minimally-invasive surgical approaches, including transoral laser microsurgery (TLM) and transoral robotic surgery (TORS), have also altered the surgical landscape. These minimally-invasive approaches offer excellent functional outcomes, without the severe toxicity associated with intensive CRT, thus substantially reducing treatment-related morbidity. In short, given the increasing prevalence of HPV-positive OPSCC, together with the severe long-term sequela of aggressive CRT, surgery appears to be recapturing its previous role as the primary treatment modality for this disease. While a growing body of evidence suggests that TLM and TORS offer oncologic outcomes that are comparable to CRT and open surgery, many questions remain due to the lack of prospective data. In the present review, we explore the emerging range of surgical options and discuss future directions in the treatment of OPSCC, including the most relevant clinical trials currently underway.
在过去几十年中，口咽鳞状细胞癌（OPSCC）的外科治疗发生了巨大变化。直到20世纪90年代，开放手术一直是OPSCC的主要治疗方法。然而，由于这种方法可能导致严重的功能障碍，开放手术在20世纪90年代基本上被同步放化疗（CRT）所取代。与此同时，新的、侵入性较小的手术方法，如单极电烙术经口手术开始出现，有可能降低功能障碍并避免CRT的迟发性毒性。最近，HPV阳性疾病发病率的上升改变了OPSCC的患者特征，因为这些患者往往更年轻，长期预后更好。因此，这进一步激发了人们对微创技术的兴趣，以减弱治疗强度，降低长期毒性和治疗相关的发病率。在这种背景下，人们对原发手术重新产生了兴趣，原发手术能够进行准确的病理分期，从而有可能减弱术后CRT的强度。包括经口激光显微手术（TLM）和经口机器人手术（TORS）在内的微创外科手术方法的不断进步，也改变了手术格局。这些微创方法提供了出色的功能结果，没有与强化CRT相关的严重毒性，从而大大降低了治疗相关的发病率。简而言之，鉴于HPV阳性OPSCC的患病率不断上升，以及积极的CRT带来的严重长期后遗症，手术似乎正在重新获得其作为该疾病主要治疗方式的先前地位。虽然越来越多的证据表明TLM和TORS提供的肿瘤学结果与CRT和开放手术相当，但由于缺乏前瞻性数据，许多问题仍然存在。在本综述中，我们探讨了新兴的手术选择范围，并讨论了OPSCC治疗的未来方向，包括目前正在进行的最相关的临床试验。
