Transoral laser microsurgery improves outcomes for head and neck cancer patients
Posted on 16 October 2018
Dr Karen Lehmann, an ear, nose and throat surgeon at Mediclinic Panorama, explains the benefits of this minimally invasive endoscopic procedure.
Head and neck cancers usually originate in the squamous cells lining the mouth, lips, nose, larynx and throat. Most of these malignancies are known as squamous cell carcinomas. Dr Karen Lehmann, an ENT surgeon based at Mediclinic Panorama, says two types of head and neck cancers are emerging as most common: those that are triggered by smoking, and those caused by a human papillomavirus (HPV) infection.
“We’ve seen for a long time that smoking and alcohol are major etymological factors in the development of some head and neck cancers,” she says. “But a new group is emerging, in which younger, mostly male patients are developing cancer in the oral cavity region due to the sexually-transmitted spread of HPV.”
Smoking and regular alcohol use can take years to develop tumours in the head and neck, changing the DNA makeup of the tissue in the area. “We talk in terms of pack years. If you smoke one pack a day for a year, that’s a pack year. Two packs a day, that’s two pack years. After 20 or 25 pack years, we start seeing molecular changes. Generally, to smoke that much, a patient will present with head and neck cancer in their late 50s or 60s. The HPV group, however, is much younger.”
Dr Lehmann and oncology surgeon Dr Etienne Myburgh have established a multidisciplinary team at Mediclinic Panorama in order to ensure these patients get the innovative care they need. “Our referrals often come from dentists and maxillofacial surgeons,” she says. “They might see a lesion that doesn’t heal, or do a biopsy, and at that point, that patient needs a team of specialists.”
Head and neck cancer patients face a range of treatment options, each of varying effectiveness depending on the type and spread of their disease. “A multidisciplinary team approach helps guide our decision-making,” she says. “We have an oncologist, a radiologist, an oral pathologist, an ENT and a general head and neck surgeon on the team. We will look at patients together, discuss the staging and location of the tumour, and make recommendations based on what we together feel is the best way forward for the patient.”
Dr Lehmann and her team follow international guidelines in determining the best course of treatment. “It is important to us that our patients know what they are in for, and that there is a plan in place before they begin their treatment,” she says. “The final decision is of course up to the individual, but we offer them a management plan that has been devised by multiple specialists.”
Usually, treatment for most head and neck cancers will involve surgery, with supplementary radiation. Due to the size of the throat area, and the proximity of organs to one another, there is a risk of damage to vital surrounding nerves and tissues. Open surgery techniques can cause discomfort and an extended hospital stay.
Dr Lehmann is pioneering a relatively new, transoral microsurgery technique for early-stage throat cancers that requires no cutting of the external tissue, as it uses an endoscope to operate from the inside out. “Transoral endoscopic laser surgery offers solutions for patients with early-stage cancer, where chemotherapy or radiotherapy may be too invasive or wide-ranging in its effects, and of course for patients who are wary of losing their voice boxes, for example, and want to avoid surgery from the outside.”
Transoral laser microsurgery makes use of a carbon dioxide laser to cut through the tumour itself, as opposed to a scalpel cutting through muscle to reach and manually remove a malignancy. “We are guided by a microscope, which is attached to the endoscope,” says Dr Lehmann. “It actually allows me to see, as I cut through a tumour, how it burns away. So we are able to operate on a piece-by-piece basis, destroying the tumour without removing or damaging the organ.”
This procedure is particularly effective as a way of treating cancers on the tongue, tonsils, soft palate and upper oesophagus. It may even be able to reach areas of the head and neck not usually accessible by means of robotic surgery, although Dr Lehmann says its reach will be guided by the surgeon’s skill set.
The minimally invasive approach of transoral surgery also allows the patient to go back for more if necessary, she says, whereas radiation for head and neck cancers can only be done once. “We use this technique as a part of our management plan, where we can.” It’s not applicable for all stages of every head and neck cancer, of course, and it’s not for every patient, but it is a relatively quick procedure, which allows us to see the outcomes sooner. This helps our planning, as we can adapt our approach if needed.”
Endoscopic laser microsurgery gives surgeons increased control, which allows for greater accuracy and an improved patient experience, says Dr Lehmann. “Swallowing, speaking – these are crucial functions. If we can help our patients get back to their normal lives a few days earlier, then yes, we feel we have succeeded.”