Cutting Edge Concept in the Treatment of tongue, tonsil, and throat cancer

May 21, 2011

During my first 3 years of medical school in Cleveland, I frankly did not know anything about cancers of the mouth and throat (otherwise called "Head & Neck Cancer").  Really, I did not know you could get cancer in the tongue or tonsil!  It wasn't until the final year of medical school that I was exposed to the field of Head & Neck Surgery, that I realize the impact of these cancers on the quality of life of patients.

Those cancers are generally not featured in the media, and I would argue that most of us will live a lifetime without meeting more than a handful of patients who have this type of cancer.  There is no marathon, 10K walk, or charity gala on behalf of Head & Neck Cancer... right?  Well, we did have some high-profile patients in the past few years.  We all remember Michael Douglas (actor), George Karl (former coah of the now defunct Supersonics...moment of silence), and Roger Ebert (movie critic)...

Well, this type of cancer is now being diagnosed at an increasing rate.  And not just in the smoking population!  We are now seeing many young patients, who have never smoked, who get diagnosed with Head & Neck cancer.  I mean, we are talking about patients in their 20's and 30's!  This is possibly due to generational lifestyle changes, as there is now strong scientific evidence that certain types of HPV (Human Papilloma Virus) are causing this cancer.  Yes... It's the same virus that causes cervical cancer in women.  This topic probably warrants its own separate blog, and I'll get on it next time!

The symptoms, diagnosis, and pathophysiology of this cancer is beyond the scope of this blog.  If you want to know more about symptoms, diagnosis, etc..., just leave a comment, and I'll try to answer your questions and comments as promptly as possible. 

The goal of this blog is to highlight some of the new treatment paradigm for this type of cancer.  More specifically, new minimally invasive surgical procedures called Transoral Laser Microsurgery (TLM) and Trans Oral Robotic Surgery (TORS).

Traditionally, Head & Neck cancers require either major surgery or intense chemo-radiation, or sometimes even a combination of surgery and chemo-radiation.  Surgery will often result in difficulty swallowing and speaking.  Chemo-radiation has improved results in swallow and speech, but even the non-surgical treatment protocol will often leave the patient with significant deficit.   

So what are the new options?  What if we could remove the cancers through the mouth?  What if we didn't have to break open the lip and jaw to get to the throat?  What if we could excise the cancer and still allow the patient to swallow and talk normally?  What if we could decrease the amount of radiation and chemo?  Well, many innovators have asked themselves these questions, and we have now some answers to these questions.  Evolving answers, obviously, as new technology will continuously allow us to push the cutting edge even further.

First, TLM.  Using endoscopic instruments (tiny little surgical tools), a surgical microscope (magnified 10 times), and specialized lasers (yes, we doctors are geeks...), we can carve out cancers inside the mouth and throat very precisely.  It's done through a natural opening.  Yes, the mouth!  Surprisingly, when you hear "you have a big mouth", that is a real statement.  We have surgical instrumenst that will stretch open your mouth wide open for us to get in there with our endoscopic instruments.  That way, there is no need to open your jaw bone to gain access to the cancer.  When using the TLM technique, most patients can resume a normal swallow within a week or so.  Speech is virtually unchanged.  Most patients stay in the hospital for a couple of days then typically go home.


This is very well tolerated by the vast majority of patients.  Even for large bulky cancers, this surgery has many benefits.  By removing bulky cancers first, we can often de-intensify the course of chemo-radiation, which results in better ultimate swallow and speech function. 

Then the natural progression has been to use the DaVinci robotic system to further improve this surgical technique.  So let's talk about TORS.

TORS implies that we perform the same minimally invasive surgery through the mouth, but just using the robot.  Why use the robot?  Well, this is almost bordering on science fiction, but it's real and it keeps getting better all the time.

There are two major advantages.  First, the robotic system has specialized arms, that literally snake around tight corners.  It enable us to reach deep spaces, like the base of tongue, that were previously difficult to reach through the mouth.  The articulated arms of the robot really revolutionized surgery for base of tongue cancers.  Second, we all have tremors... with or without coffee.  Even fine tremors can be magnified when working in tight spaces, like inside the mouth.  And the robot will essentially eliminate all those tremors.  That means, I can drink my espresso before a robotic surgery!  It is truly a magnificent tool.  And then, to top it off, the robot has this specialized 3-D high definition camera.  This allow us to visualize the inside of the mouth and throat in an amazing fashion.  I still remember when my father finally caved in and bought a color TV in 1982, later than most of my friends... I was in awe, and I was in awe when I first looked through the console of the robotic system.  I couldn't believe my eyes.

All this sounds fantastic, but really, the point of this blog, is to highlight some of the new surgical techniques we now provide at Swedish Cancer Institute.  TLM and TORS are only offered at very select institutions.  They are tremendous options for patients with Head & Neck cancers...Better outcome with same cure rate.  Question?  Just send me a comment.  I type slow but I will answer.  If only a robot could type for me, I would be golden...     



Topics: Cancer, Services


Dr. Kim:I can�t tell you how happy I am to find you�re blog. I�m in the process of helping my dear friends (seniors) who are looking for treatment for their brother. Dana has Squamous cell carcinoma. The Cancer started on his tonsils and then matsized to his neck. The tumor has been treated with Chemo and Radiation for the past 6 weeks. I wish I had the actual details of his treatment. I am working on getting copies of his most recent CT Scan from this past week. From what I understand the Tumor its self has not grown, they are stating he still has LIVE Cells and the fingers on the Tumor have now grown into the tissue of his Virtrabray�s, and around his Corerouted Artery. There has been a conversation about having surgery to remove as much of the Tumor, as they can. This surgery would include removing ½ of his tongue and his voice box. I understand there is a high concern of a blood clot taking place during this surgery. I have read all the information you have provided on the website about...
Hi Ellen, you can reach Dr. Kim's office to make an appointment by calling (206) 292-6464.
Hi Dr. Kim, my name is Jessica and my father has neck cancer. He has gone though 6 weeks of radiation and chemo. They have now found out that it didn't work. The doctors he has have told him it's on his spinal cord and volcal cords. They have also told him one minute nobody in the world will do surgery to take it out and the next they want to do surgery. He has a PET scan today. My question to you is what can we do? Jessica Wyzykowski
Hi Jessica, Dr. Kim would be glad to see your father and discuss potential options - please contact his office at (206) 292-6464 to set up an appointment.
My husband was diagnosed last week with Squamos carcinoma of the throat. He has a PET scan this Wednesday. It appears the normal course of treatment is radiation and chemo. Do most medical plans cover laser or robotic assisted treatments?
Hi Marcia, yes, many plans do cover surgical options. I encourage you to talk with your insurance provider to find out more about coverage options. If you'd like to make an appointment with Dr. Kim, you can reach his office at (206) 292-6464.
My husband was diagnosed a couple of weeks ago, he had CT scan, etc. he has tumor on base of tongue, 2cm, and side of neck 3cm. Surgeon set up biopsy, for base of tongue with TLM, after biopsy they were going to schedule the actual surgery with TLM. They went in and it was explained to me that my husband's anatomy was not ideal for this surgery. Namely, my husband has 18 inch neck, small jawline, short neck. According to surgeon,, they attempted a few times and the visibility was limited, and at one point tumor started to bleed, so they woke my husband. My question is this, would he have been a candidate for the Robot TORS surgery? Or would have results been the same? Are there patients who are not ideal for Laser surgery or TORS surgeryMore information regarding my husband, he never smoked, does not drink, except socially. When we had consult with surgeon, I asked about robot and his reply was that it's "too big" we prefer to use laser here. We do use Robot., but not as much as laser.My husband is so disapp...
Claire, TLM and TORS are 2 variations on the same theme. We also try to be selective when choosing the modality. As you have mentioned, access to the cancer dictates which technique to use. The patient�s anatomy, and the actual location of the cancer may favor one technique more than the other. If your surgeon is facile in TLM and TORS, I suspect that he/she is a very competent surgeon, and I would have to trust his/her clinical decision. I myself have aborted cases, when the access became too difficult for both TLM and TORS. On occasion, I will also start with TORS, but then convert to TLM if the robotic instrumentations are not adequate to obtain precise final pathologic margins. Furthermore, if at the time of surgery, I feel that I cannot obtain clear margins around the cancer, I will also abort, since I do not add any benefit with surgery: those patients will require full dose chemoradiation anyway.The base of tongue can be tricky. Without actually seeing his anatomy and CT scan, I am limited in ...
My husband was diagnosed yesterday with throat tonsil carcinoma and in a lymph. today we are having the biopsie and MRI I am looking for the best painless less invasive treatment for him he is 63 stopped smoking 10 years ago drinks wine every night has not lost weight is in very good health not over weight and plays gold 5 days a week for the past 10 years so healthy. Could you give me information on a possible treatment .Thank you Jacqueline We are on the God Coast. This is the only article I have read of yours . I just discovered it.
Jacqueline, it is a bit difficult to say exactly what is needed. I assume he has a squamous cell carcinoma. If that is the case, he will need staging imaging studies. Either a CT scan (neck, chest, abdomen) or a PET-CT (full body). I do not typically get an MRI, and most head & neck surgeons would probably not jump into an MRI. I would get an MRI if there is suspicion about invasion into the skull base or other specific reasons.Based on the scans, he will need consultation with radiation oncology as well. We usually discuss those cancers during our Head & Neck tumor board and try to come up with the most meaningful option.Usually, options are:1.Primary chemo-radiation.2.Surgery (possibly via robotic technique), followed by adjuvant therapy.He will need dental evaluation and speech & swallow consultation as well.Beyond that, it is challenging to answer more details online. I would be glad to see him in the office - you can schedule an appointment by calling (206) 292-6464.