Expert consensus on surgical treatment of oropharyngeal cancer
China Anti-Cancer Association Head and Neck Oncology Committee, China Anti-Cancer Association Holistic Integrative Oral Cancer on Preventing and Screening Committee, RUAN Min, HAN Nannan, AN Changming, CHEN Chao, CHEN Chuanjun, DONG Minjun, HAN Wei, HOU Jinsong, HOU Jun, HUANG Zhiquan, LI Chao, LI Siyi, LIU Bing, LIU Fayu, LV Xiaozhi, LV Zhenghua, REN Guoxin, SHAN Xiaofeng, SHANG Zhengjun, SUN Shuyang, JI Tong, SUN Chuanzheng, SUN Guowen, TIAN Hao, WANG Yuanyin, WANG Yueping, WEN Shuxin, WU Wei, YE Jinhai, YU Di, ZHANG Chunye, ZHANG Kai, ZHANG Ming, ZHANG Sheng, ZHENG Jiawei, ZHOU Xuan, ZHOU Yu, ZHU Guopei, ZHU Ling, MIAO Susheng, HE Yue, FANG Jugao, ZHANG Chenping, ZHANG Zhiyuan
Affiliations
China Anti-Cancer Association Head and Neck Oncology Committee, China Anti-Cancer Association Holistic Integrative Oral Cancer on Preventing and Screening Committee, RUAN Min, HAN Nannan, AN Changming, CHEN Chao, CHEN Chuanjun, DONG Minjun, HAN Wei, HOU Jinsong, HOU Jun, HUANG Zhiquan, LI Chao, LI Siyi, LIU Bing, LIU Fayu, LV Xiaozhi, LV Zhenghua, REN Guoxin, SHAN Xiaofeng, SHANG Zhengjun, SUN Shuyang, JI Tong, SUN Chuanzheng, SUN Guowen, TIAN Hao, WANG Yuanyin, WANG Yueping, WEN Shuxin, WU Wei, YE Jinhai, YU Di, ZHANG Chunye, ZHANG Kai, ZHANG Ming, ZHANG Sheng, ZHENG Jiawei, ZHOU Xuan, ZHOU Yu, ZHU Guopei, ZHU Ling, MIAO Susheng, HE Yue, FANG Jugao, ZHANG Chenping, ZHANG Zhiyuan
1 Department of Oral & Maxillofacial-Head & Neck Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, College of Stomatology, Shanghai Jiao Tong University, National Center for Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, Shanghai 200011, China;2 Department of Head and Neck Surgery, Cancer Hospital, Chinese Academy of Medical Sciences, Beijing 100021, China;3 Department of Head and Neck Surgery, Cancer Hospital of the University of Chinese Academy of Sciences, Hangzhou 310005, China;4 Department of Stomatology, First Affiliated Hospital of University of Science and Technology of China, Hefei 230001, China;5 Department of Radiology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China;6 Department of Oral and Maxillofacial Surgery, Nanjing Stomatological Hospital, Medicine School of Nanjing University, Nanjing 210001, China;7 Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Sun Yat-sen University, Guangzhou 510055, China;8 Department of Oral and Maxillofacial Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei 230000, China;9 Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China;10 Department of Head & Neck Oncology Surgery, Sichuan Cancer Hospital, Chengdu 610042, China;11 Department of Oral and Maxillofacial Surgery, Hospital of Stomatology Wuhan University, Wuhan 430022, China;12 Department of Oral Maxillofacial-Head and Neck Surgery, Hospital of Stomatology, China Medical University, Shenyang 110002, China;13 Department of Stomatology, Zhujiang Hospital, Southern Medical University, Guangzhou 510515, China;14 Department of Otolaryngology Head and Neck Surgery, Shandong Ear, Nose and Throat Hospital, Jinan 250021, China;15 Department of Oral and Maxillofacial Surgery, Hospital of Stomatology Peking University, Beijing 100081, China;16 Department of Oral and Maxillofacial Surgery, Zhongshan Hospital, Fudan University School of Medicine, Shanghai 200032, China;17 Department of Head and Neck Oncology Surgery, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming 650118, China;18 Department of Head and Neck Surgery, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha 410031, China;19 Department of Oral and Maxillofacial Surgery, Affiliated Stomatological Hospital of Anhui Medical University, Hefei 230031, China;20 Department of Otolaryngology Head and Neck Surgery, Shanxi Bethune Hospital, Taiyuan 030032, China;21 Department of Oral and Maxillofacial Surgery, Stomatological Hospital, Air Force Medical University, Xi'an 710032, China;22 Department of Oral and Maxillofacial Surgery, Rui'an People's Hospital, Wenzhou 325299, China;23 Department of Oral Pathology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, College of Stomatology, Shanghai Jiao Tong University, National Center for Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, Shanghai 200011, China;24 Department of Stomatology, The First Affiliated Hospital of Bengbu Medical University, Bengbu 233099, China;25 Department of Head and Neck Surgery, Eye & ENT Hospital of Fudan University, Shanghai 200031, China;26 Department of Oral and Maxillofacial Surgery, The Second Xiangya Hospital of Central South University, Changsha 410011, China;27 Department of Maxillofacial, Otorhinolaryngological Head and Neck Surgery, Tianjin Medical University of Cancer Hospital, Tianjin 300000, China;28 Department of Head and Neck Surgery, Harbin Medical University Cancer Hospital, Harbin 163711, China;29 Department of Otorhinolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
With the increasing proportion of human papilloma virus (HPV) infection in the pathogenic factors of oropharyngeal cancer, a series of changes have occurred in the surgical treatment. While the treatment mode has been improved, there are still many problems, including the inconsistency between diagnosis and treatment modes, the lack of popularization of reconstruction technology, the imperfect post-treatment rehabilitation system, and the lack of effective preventive measures. Especially in terms of treatment mode for early oropharyngeal cancer, there is no unified conclusion whether it is surgery alone or radiotherapy alone, and whether robotic minimally invasive surgery has better functional protection than radiotherapy. For advanced oropharyngeal cancer, there is greater controversy over the treatment mode. It is still unclear whether to adopt a non-surgical treatment mode of synchronous chemoradiotherapy or induction chemotherapy combined with synchronous chemoradiotherapy, or a treatment mode of surgery combined with postoperative chemoradiotherapy. In order to standardize the surgical treatment of oropharyngeal cancer in China and clarify the indications for surgical treatment of oropharyngeal cancer, this expert consensus, based on the characteristics and treatment status of oropharyngeal cancer in China and combined with the international latest theories and practices, forms consensus opinions in multiple aspects of preoperative evaluation, surgical indication determination, primary tumor resection, neck lymph node dissection, postoperative defect repair, postoperative complication management prognosis and follow-up of oropharyngeal cancer patients. The key points include: ① Before the treatment of oropharyngeal cancer, the expression of P16 protein should be detected to clarify HPV status; ② Perform enhanced magnetic resonance imaging of the maxillofacial region before surgery to evaluate the invasion of oropharyngeal cancer and guide precise surgical resection of oropharyngeal cancer. Evaluating mouth opening and airway status is crucial for surgical approach decisions and postoperative risk prediction; ③ For oropharyngeal cancer patients who have to undergo major surgery and cannot eat for one to two months, it is recommended to undergo percutaneous endoscopic gastrostomy before surgery to effectively improve their nutritional intake during treatment; ④ Early-stage oropharyngeal cancer patients may opt for either surgery alone or radiation therapy alone. For intermediate and advanced stages, HPV-related oropharyngeal cancer generally prioritizes radiation therapy, with concurrent chemotherapy considered based on tumor staging. Surgical treatment is recommended as the first choice for HPV unrelated oropharyngeal squamous cell carcinoma (including primary and recurrent) and recurrent HPV related oropharyngeal squamous cell carcinoma after radiotherapy and chemotherapy; ⑤ For primary exogenous T1-2 oropharyngeal cancer, direct surgery through the oral approach or da Vinci robotic surgery is preferred. For T3-4 patients with advanced oropharyngeal cancer, it is recommended to use temporary mandibulectomy approach and lateral pharyngotomy approach for surgery as appropriate; ⑥ For cT1-2N0 oropharyngeal cancer patients with tumor invasion depth >3 mm and cT3-4N0 HPV unrelated oropharyngeal cancer patients, selective neck dissection of levels IB to IV is recommended. For cN+ HPV unrelated oropharyngeal cancer patients, therapeutic neck dissection in regions I-V is advised; ⑦ If PET-CT scan at 12 or more weeks after completion of radiation shows intense FDG uptake in any node, or imaging suggests continuous enlargement of lymph nodes, the patient should undergo neck dissection; ⑧ For patients with suspected extracapsular invasion preoperatively, lymph node dissection should include removal of surrounding muscle and adipose connective tissue; ⑨ The reconstruction of oropharyngeal cancer defects should follow the principle of reconstruction steps, with priority given to adjacent flaps, followed by distal pedicled flaps, and finally free flaps. The anterolateral thigh flap with abundant tissue can be used as the preferred flap for large-scale postoperative defects.
