Transoral Laser Microsurgery

Removing throat and neck tumors through the mouth minimizes risks and speeds recovery.

Listen to Bruce Haughey, MD, describe this procedure in a Cancer Connection podcast.
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By Gwen Ericson
Article originally appeared in the spring 2008 issue of Outlook magazine

A diagnosis of cancer of the mouth or throat can be especially devastating. Chemotherapy, radiotherapy and surgery to treat the condition can dramatically alter facial appearance and threaten the ability to swallow, talk, eat, smell, taste, hear and even to breathe normally.

Bruce Haughey, MD, and his colleagues who treat head and neck cancer at the Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine have been able to significantly lessen the impact of an oral or throat cancer diagnosis.

Transoral Surgery
Working through an operating microscope as he performs the surgery, Haughey gets a close-up view of the tumor site, allowing pinpoint accuracy while removing the diseased tissue.
Whenever possible, they are using new surgical techniques that don't require cutting through the skin and muscle of the neck. In many instances, these minimally invasive, transoral (through-the-mouth) surgeries are getting patients out of the hospital faster, controlling the cancer better, and preserving mouth and throat function more effectively.

Haughey, the Dr. Joseph B. Kimbrough Chair in Maxillofacial Surgery and Prosthodontics and chief of the Division of Head and Neck Surgical Oncology, tells of a patient who recently contacted him because her doctor had offered her lengthy and expensive chemotherapy and radiation treatment for vocal-cord cancer.

"She had heard about the minimally invasive surgery we were performing for laryngeal cancer," Haughey says. "It wasn't something that was available at any of her local Washington, D.C.-area hospitals. She wanted to get rid of her cancer but was hoping to avoid the long treatment and recovery and high expense of chemotherapy and radiation."

Using transoral laser microsurgery – in which a microscope and laser are used to view and cut out the cancer without opening the neck – Haughey was able to get the patient out of the hospital in one day. And that was the extent of the treatment she needed because the surgery removed all detectable traces of the cancer. The patient was "tickled pink," Haughey says.

The neck is packed with delicate and crucial structures – the voice box or larynx, the windpipe or trachea, the esophagus, the tongue, muscles that move the jaws and allow the head to turn, large nerves, lymph nodes and lymph vessels, blood vessels, the spine and many more. Not only does reaching a throat tumor by opening the neck threaten these structures – potentially affecting speaking, eating, drinking, smelling, tasting and breathing – but it also creates a wound that even when healed can interfere with mobility and function. If it doesn't heal well, the incision can be a conduit for leakage of saliva and other fluids.

So when a patient's circumstances permit, Haughey and colleagues Brian Nussenbaum, MD, and Ravindra Uppaluri, MD, PhD, remove throat and mouth tumors transorally, using instruments specifically designed for insertion through the open mouth. For cancer of the larynx, for example, the surgeon first inserts a tube into the throat and expands it so that he can slide in an endoscope with a lighted camera and microscope lens to illuminate and view the area, a laser for cutting and other instruments to grasp tissue or hold it out of the way.

Using an endoscope or operating microscope "leads to a high level of precision in removing the whole tumor," says Haughey, "and contributes to the very good cancer outcomes we see with the procedure."

In a typical open surgical procedure to remove a throat tumor, a larger block of tissue would be cut away around a tumor. But in transoral laser microsurgery, a lot of the guesswork is eliminated as the tumor is cut out piece by piece with the laser until all traces are gone. Nearby tissue is disrupted to a lesser degree. The microscope increases the certainty that the doctors have eliminated all cancerous tissue.

Haughey and colleagues have just completed a study of patients with larynx, oral cavity and pharynx tumors treated with these endoscopic resection techniques and radiotherapy when necessary. After two years, none of the patients in the study have had a primary tumor recurrence. "We're delighted with that result," Haughey says. "Two years is the interval in which treatment failure usually occurs, if it is going to."

In addition to faster and easier recovery and better control of cancer, these techniques offer better preservation of speech and swallowing because of their conservation approach. Another reason transoral surgery leads to better functionality is that it often doesn't require a tracheostomy in which an opening is cut in the windpipe and a tube inserted for breathing. In open surgical neck procedures, about 80 percent of patients need a tracheostomy; with minimally invasive techniques that percentage is in the teens. Tracheostomy markedly affects breathing, speech and swallowing, temporary but sometimes permanent changes.

To enable effective transoral surgeries, physicians had to design instruments of the right diameter, length and configuration. Haughey is working with a German company that created many of the original instruments to develop one that will allow viewing and performing laser surgery around a corner, enabling removal of more types of cancer.

For some types of head and neck cancers, nonsurgical combination treatments consisting of chemotherapy and radiation therapy are the treatment of choice and may be used more frequently at other cancer centers for a variety of head and neck cancers. Unfortunately, in some patients, this approach can lead to greater tissue damage than even open surgery and can obliterate swallowing and speech function permanently or require major reconstructive surgery.

"With the ongoing improvements in the surgical technology for transoral laser microsurgery and the compelling data suggesting this is an effective cancer-curing procedure, we are probably justified in offering it to virtually any patient who is suitable for the technique," Haughey says.

Because of the advantages of transoral surgery, the team held a course at the School of Medicine in May to teach these exacting techniques to experienced professionals from around the world. This was the first formal course in the United States on this type of surgical approach to head and neck cancer.

Haughey has led the development of methods for reconstructing tissues damaged by cancer – including pioneering techniques for reconstructing the tongue using a flap of skin and muscle from the forearm. But with minimally invasive techniques, the need for reconstruction is minimized. "We're left with a relatively small wound that heals fairly quickly without additional tissue being required for reconstruction."

Transoral surgical techniques for head and neck cancer have answered an important need.

"We are dealing with some of the most visible parts of the body as well as some of the most used functions," Haughey says. "We have worked to develop these procedures because we take both the treatment of the tumor and the functional outcome very seriously."