It is well recognised that the current emergence of HPV-positive oropharyngeal squamous cell carcinoma (OPSCC) as a distinct disease entity requires a fresh look at standard treatment modalities that are based on chemoradiotherapy for stage III/IVa OPSCC. The Newcastle experience is reported in this article, with the largest reported single-centre transoral laser microsurgery (TLM) series involving 153 patients from 2006 to 2013. Sixty-six percent of their patients were HPV-positive and 81% involved stage III or IV disease. The ‘Steiner/Ambrosch transtumoral’ TLM surgical approach outlined in this paper is underpinned by what they call a ‘zero-tolerance policy’ for involved margins, which undergo repeated resection if necessary to obtain clearance.

This approach led to 94.8% being treated without postoperative chemoradiotherapy. The emphasis of the results reported here focuses on survival and dysphagia outcomes, key measures for this often younger patient population. Based on three-year follow-up data they report overall survival of 84.5% and disease-free survival of 78.2%.

They compare this to the previous large Steiner et al. series with five-year outcome data of 59% overall survival and 69% disease-free survival. Dysphagia rates, using the proxy of gastrostomy tube dependence at one year, were only 1.3%, which contrasts markedly with rates of 8.6% reported in large concurrent chemotherapy-IMRT series. The authors openly reflect on the limitations of this retrospective series, and the current international OPSCC trials being undertaken to definitively guide our treatment of this rapidly evolving disease. While we await the results of those trials, this large UK series demonstrates the seemingly favourable oncologic and particularly functional outcomes that TLM offers to this cohort of patients. 

Transoral laser microsurgery for oropharyngeal squamous cell carcinoma: a paradigm shift in therapeutic approach.
Wilkie MD, Upile NS, Lau AS, et al.
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Aileen Lambert

Great Ormond Street Hospital, London, UK.

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