ORIGINAL ARTICLE TRANSORAL LASER MICROSURGERY AS PRIMARY TREATMENT FOR ADVANCED-STAGE OROPHARYNGEAL CANCER: A UNITED STATES MULTICENTER STUDY Bruce H. Haughey, MBChB, 1 Michael L. Hinni, MD, 2 John R. Salassa, MD, 3 Richard E. Hayden, MD, 2 David G. Grant, MBChB, 3 Jason T. Rich, MD, 1 Simon Milov, MD, 1 James S. Lewis, Jr, MD, 4 Murli Krishna, MD 5 1 Department of Otolaryngology–Head and Neck Surgery Washington University School of Medicine, St. Louis, Missouri. E-mail: haugheyb@ent.wustl.edu 2 Department of Otolaryngology–Head and Neck Surgery, Mayo Clinic, Scottsdale, Arizona 3 Department of Otolaryngology, Mayo Clinic, Jacksonville, Florida 4 Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri 5 Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, Florida Accepted 4 October 2010 Published online 31 January 2011 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/hed.21669 Abstract: Background. Nonsurgical modalities are some- times advocated as the standard of care for advanced oropha- ryngeal tumors. Oncologic and functional results have been modest. The aim of our study was to evaluate outcomes of a minimally invasive approach, using transoral laser microsur- gery (TLM) as the primary treatment for advanced oropharyn- geal carcinoma. Methods. A prospectively assembled database of 204 patients with American Joint Committee on Cancer (AJCC) stages III and IV tonsil or tongue base cancer, treated primar- ily with TLM during 1996–2006 at 3 centers with minimum 2- year follow-up was analyzed. Survival, locoregional control, and swallowing status were recorded. Results. Mean follow-up was 49 months and 79.4% of patients were alive. Three-year overall survival, disease-spe- cific survival, and disease-free survival were 86%, 88%, and 82%, respectively. Local control was 97%, and 87% of patients had normal swallowing or episodic dysphagia. Conclusions. TLM as a primary treatment for advanced oropharyngeal malignancy confers excellent survival and swal- lowing proficiency. V V C 2011 Wiley Periodicals, Inc. Head Neck 33: 1683–1694, 2011 Keywords: tonsil cancer; base of tongue cancer; minimally invasive; human papillomavirus; laser Over the past decade, the recorded incidence of oro- pharyngeal cancer has increased, attributed mainly to the human papillomavirus (HPV). 1,2 Nonsurgical therapies that use varied combinations and timing of radiotherapy (RT) and chemotherapy are currently popular for advanced-stage oropharyngeal cancers. 3,4 Although the available literature on RT versus RT with chemotherapy reports improvement in survival and locoregional control with chemoradiotherapy (CRT) compared with RT alone, absolute survival and disease control rates using this treatment approach have remained modest. 5,6 For example, a multicenter phase III trial reported 3-year overall survival (OS), disease-free survival (DFS), and locoregional control rates of 51%, 42%, and 66%, respectively. 6 Another recent study comprising 1681 patients documented an overall recurrence rate of 25.8% for early and late stages and a local recurrence rate of 11.8% using a nonsurgical, primary treatment policy. 7 Salvage sur- gery was performed in 24% of locally recurrent cases (41/168) and two thirds of this salvage cohort (67%) developed subsequent rerecurrence. 7 Furthermore, RT to the head and neck with con- current chemotherapy is associated with a high rate of severe acute toxicities 8 in the majority of patients, treatment-related mortality, swallowing dysfunction, and late toxic effects such as pharyngeal fibrosis and severe xerostomia, necessitating nonoral feeding. 6,8–11 In the past, conventional surgical intervention for advanced oropharyngeal cancer has been open en bloc surgery to the pharynx and neck with free flap recon- struction, a major procedure that requires the surgeon to dismantle and repair normal musculoskeletal struc- tures of the neck and maxillofacial skeleton for access. 12 This en bloc approach often precludes a detailed, magnified view of the invasive front of the tu- mor and the required flaps incur donor wounds. With this approach, survivorship has been modest, although recent surgical reports document that p16þ patients have a favorable prognosis maintained under surgical treatment. 13,14 Transoral approaches to the oropharynx are, by contrast, less invasive. Transoral laser microsurgery Correspondence to: Bruce H. Haughey This work was presented orally at the Meeting of the American Head and Neck Society on May 31, 2009, in Phoenix, Arizona. V V C 2011 Wiley Periodicals, Inc. TLM for Advanced-Stage Oropharyngeal Cancer HEAD & NECK—DOI 10.1002/hed December 2011 1683