HJAR Jul/Aug 2020

HEALTHCARE JOURNAL OF ARKANSAS I  JUL / AUG 2020 53 John R. Sims, MD Head and Neck Oncologic and Microvascular Reconstructive Surgeon CARTI, Inc. The Rise of Oropharyngeal Cancer and Transoral Robotic Surgery (TORS) Oropharyngeal cancer has been increas- ing in incidence over the past decade, and recent data suggests that it is now the most common type of head and neck cancer. This rise in incidence is mostly due to HPV (hu- man papillomavirus), which now causes ap- proximately 70–80 percent of oropharyn- geal cancers. Fortunately, these viral related tumors are, in general, more responsive to treatment, and carry a more favorable prog- nosis than previous oropharyngeal cancers. The oropharynx, which includes the ton- sils and the base of the tongue, is a chal- lenging area of the head and neck to access surgically. Historically, oncologic oropha- ryngeal surgery often required dividing the jaw at the midline and swinging it laterally, in order to access the most posterior portion of the tongue and pharynx. Due to the morbid- ity of surgical treatment, in the late 90s and early 2000s, cancers of the oropharynx were almost universally treated non-surgically with high-dose chemotherapy and radia- tion. But with the recent rise of HPV-related cancers and advances inminimally invasive surgical techniques such as transoral laser microsurgery (TLM) and transoral robotic surgery (TORS), the pendulum has started to shift back toward surgical treatment of tonsil and base of tongue cancers. In 2009, the surgical robot was approved for head and neck surgery by the FDA, and it is now offered at many major cancer centers across the United States. Use of the surgical robot has many ad- vantages, most notably the ability to remove hard to reach tumors through the mouth, and avoiding the morbidity of previous surgical approaches. TORS has resulted in faster operative times, shorter hospital stays, and improved functional outcomes for patients—all without sacrificing onco- logic success. Up front surgical management of oropharyngeal cancers has also allowed for more accurate staging, as well as avoid- ance or decreased doses of radiation and/or chemotherapy. Clinical trials are currently underway to identify additional treatment de-escalation following TORS. Early results have shown promise for further reduction of treatment side effects and improvement of functional outcomes. Preoperative 3D Planning for Optimized Reconstruction While the surgical removal of advanced oral cavity cancers has not changed signif- icantly over the last several decades, our ability to reconstruct the defect left by the ablative surgery has advanced greatly. The development of free tissue transfer for head and neck reconstruction in the late 70s and early 80s was a giant leap forward, and is now the standard of care for advanced head and neck cancer reconstruction. The use of advanced microvascular techniques allows for the transfer of virtually any type of tis- sue—skin, fascia, muscle, bone, nerves—with designated arteries and veins that can then be sewn into a new blood supply in the head and neck. This allows the transferred tis- sue to take on a whole new life in the head and neck, and take the place of the removed tongue, jaw, etc. While this type of surgery is complex, te- dious, and requires longer operative times, advances in the field over the last 30 years have led to a greater than 95 percent success rate. However, this success rate is purely a measure of the transferred tissue surviving, and the patient healing from the surgery. It does not consider the final function and quality of life of the patient. While a large part of reconstructive sur- gery relies on the expertise and experience of the surgeon, recent technological advanc- es have allowed for further refinement of re- constructive strategies. Three-dimensional computer models can now be created based on CT or MRI scans of the patient. Using these models, surgeons can pre-plan sur- gical cuts around a tumor, as well as plan and design the reconstruction weeks be- fore a patient’s actual surgery. These com- puter models are then able to be 3D-printed, sterilized, and used at the time of surgery as a three-dimensional road map for the surgeon, allowing for pinpoint accuracy to the millimeter. Studies have shown that this advanced technology can shorten the time a patient is under general anesthesia, and ultimately improve patient outcomes. These 3D-printed models can also be used as a pa- tient education tool that allows for improved preoperative understanding, empowering patients to have a more active role in their cancer care at a time in their life when they often feel the most powerless. n Dr. Sims completed a residency in otolaryngology- head and neck surgery atTheMayo Clinic in Roches- ter, Minnesota, followed by a fellowship in head and neck oncologic and microvascular reconstructive surgery at Mount Sinai Beth Israel in New York City, NewYork. He earned amedical degree from the Uni- versity ofArkansas for Medical Sciences.He received a Bachelor of Science in biological sciences from Ouachita Baptist University inArkadelphia,Arkansas..