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Johns Hopkins Pediatric

Treatment with TORS, Less Radiation

April 8, 2016

Inner hair cell (blue)

With transoral robotic surgery, the robot allows the surgeon to operate around corners. “It’s perfectly designed to for the base of the tongue and lingual tonsils, says head and neck surgeon Christine Gourin.

In 2013, commercial realtor Henry Hanna, 69, noticed a small lump under the right side of his jaw. The pea-sized mass was barely noticeable, completely invisible underneath his full beard. But despite its unobtrusive nature, the lump would be life-changing—a needle biopsy performed by his local otolaryngologist-head and neck surgeon showed that it was HPV-related squamous cell carcinoma. He suggested that Hanna go to Johns Hopkins otolaryngologist–head and neck surgeon Christine Gourin for definitive care.

Although Hanna presented with a neck mass, the location of his primary tumor was unclear. Most HPV-related oropharyngeal cancers arise from small primary tumors buried within the tonsils. But Hanna had his tonsils removed as a child. The best site to search, Gourin reasoned, were the lingual tonsils, located behind the tongue base. However, reaching the lingual tonsils would be a challenge with traditional surgery—nearly impossible through a transoral route and leading to significant morbidity when performed through the neck.

That’s why Gourin recommended transoral robotic surgery (TORS). “With TORS, the robot allows you to see and operate around corners,” she says. “It’s perfectly designed for the base of the tongue and lingual tonsils.”

Soon before Christmas that year, Gourin and her colleagues used TORS to resect Hanna’s lingual tonsils as well as traditional surgery to remove lymph nodes in his neck. The lingual tonsil tissue appeared normal, so the primary site remained a mystery. However, because that tissue had been successfully removed with TORS, Hanna was now a candidate to receive a lower dose of radiation than he would have needed had his lingual tonsil tissue remained in place.

Being able to deliver less radiation is a game changer for relatively young, active patients such as Hanna, Gourin explains. “We know that a lower dose of radiation reduces the risk of long-term swallowing trouble, dental issues, and thyroid problems,” she says. “The effects of treatment have become increasingly important because patients with a good prognosis, like Mr. Hanna, are likely to live long enough to experience sequelae from treatment.”

To further combat sequelae, Hanna, like other Johns Hopkins patients who receive oropharyngeal radiation, received speech and swallowing therapy. In his regular follow-up appointments, Gourin continues to recommend daily exercises to prevent future issues.

“I believe that you can never fully discharge from care patients who have had oropharyngeal cancers,” she says. “The risk of developing late swallowing problems never goes away.”

More than two years out from his cancer diagnosis, Hanna continues to thrive and now counsels other men with the same diagnosis. “I have more enthusiasm for my life and work than before my diagnosis,” he says. “I’m not looking to slow down.” 

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