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...