在头部和颈部癌症发现未知的主
在2010年仲夏，46岁的休斯顿人保罗·威特（Paul Wyett）发现了一个发现他的脖子上的一个小肿块，他认为这是向内生长的头发。他说：“它膨胀了，然后消失了，但从未完全消失。”
他的初级保健医生怀疑神经纤维肿瘤，并将他转介给耳鼻喉科医生，他进行了针对性的活检，产生了不确定的结果。他的妻子阿德里安·利说：“但是我们了解到，肿瘤正在接触保罗的颈动脉并入侵颈静脉，这对我们来说都不好。”
Wyett接受了颈部肿块的切除，最终病理报告表明肿瘤是鳞状细胞癌。根据该报告，他的医生将Wyett送往罗恩·卡尼（Ron Karni），医学博士, an assistant professor in theDepartment of Otorhinolaryngology-Head and Neck Surgery在Uthealth和Memorial Hermann-Texas医疗中心获得董事会认证的耳鼻喉科医生。
在与Wyett的初步咨询期间，Karni博士得知，尽管他的患者有颈部鳞状细胞癌的证据，但尚未确定主要部位。他说：“尽管当今的成像研究准确性，但估计没有确定的主要部位的医生出现的头颈部癌症中有10％。”“保罗的办公室检查包括内窥镜检查，并没有透露明显的病变，但是在仔细审查了他的CT和PET扫描后，我注意到他左扁桃体和舌头基地的微妙异常。”
The plan of care for oropharyngeal cancer is dependent on staging, and because most head and neck cancers present as late stage with metastasis, treatment includes chemotherapy and radiation therapy. “Patients with an unidentified primary site of malignancy in the mouth or throat face radiation therapy that includes all the mucosal membranes from the back of the nose to the chest,” Dr. Karni says. “Radiation therapy of this magnitude is often toxic and can produce severe mucositis, difficulty swallowing, throat pain and weight loss. But surgery and a lesser dose of radiation may be possible if we can locate the primary site.”
在与Wyett和他的妻子一起审查治疗方案时，Karni博士为他们提供了一种创新的解决方案，以解决未知主要站点的问题：Da Vinci手术系统的使用。Da Vinci机器人于2009年12月获得FDA批准用于切除舌头和喉咙肿瘤的横向机器人手术（TOR），其优势超出了传统的手术方法，尤其是在隆隆坡和舌底部的地区。
“Instead of having to divide the lower lip or divide the mandible in the midline, we can approach these tumors directly through the mouth,” Dr. Karni says. “The challenge in treating tumors of the neck transorally is to achieve adequate visualization of the tumor for resection despite the sharp angles between the oral cavity and pharynx. The robot’s camera allows us to see around structures such as the tongue, and provides a highly magnified three-dimensional view. In this case, I felt strongly that the da Vinci’s capabilities would allow me to locate Paul’s lesion and remove it.”
Wyetts也对机器人辅助选择感到满意。“我们对Karni博士有很高的信心，” Adrienne Leigh说。“在为我们做出治疗决定和对我们的所有选择教育之间，他非常擅长漫步，以便我们可以做出自己的知情决定。这是一种协作方法。最后，我们认为“为什么不利用这项创新？”我们喜欢医生，我们喜欢该程序的概述。它似乎很合适。”
Karni博士于2010年9月10日将Wyett带到了OR。使用Da Vinci机器人，他能够在半小时内识别出患者扁桃体底座的下极附近的4毫米溃疡。他使用专门适合机器人臂的激光去除病变，这是一种肿瘤，肿瘤的尺寸为1.7厘米，在扁桃体和舌底座之间埋葬，以及周围的组织负缘。他还使用机器人进行颈部解剖，去除了左颈的淋巴结以包含癌症的扩散。
Wyett能够在手术后立即进食。卡尼博士说：“因为我们能够识别和删除主要地点，所以保罗正在接受较低剂量的辐射量。“这种新颖的口咽癌的新型侵入性方法是使有资格进行手术的患者在手术后立即说话，吞咽和呼吸，副作用很少。”
“Dr. Karni is definitely leading the pack when it comes to transoral robotic surgery,” says Etan Weinstock, MD, an assistant professor in the Department, who has pursued subspecialty training in head and neck surgical oncology with a fellowship at The University of Texas M. D. Anderson Cancer Center. “But as a technology applied to otorhinolaryngology, robotic-assisted surgery is still in its infancy. Our main goal as physicians is always to offer the patient the greatest chance of survival and the lowest possible treatment morbidity. For early-stage disease, survival is equivalent between surgery and chemotherapy/radiation. For late-stage disease, you have to do chemotherapy and radiation regardless. For patients with advanced disease, adding surgery may increase the risk of morbidity.”
More than 85 percent of cancers of the oropharynx are basal tongue cancers, usually squamous cell, Dr. Weinstock says. “But about 70 percent of patients who present with oropharyngeal cancers have stage 3 or stage 4 disease that has spread locally in the head and neck, and about 20 percent of them will develop distant metastases. The patients I’m seeing have very advanced oropharyngeal cancer. For these patients I recommend the gold-standard treatment protocol, which has a 30-year track record of success. With this protocol, the prognosis remains relatively good even with advanced disease. Stage 1 and some select stage 2 tumors may be amenable to robotic surgery, but in the event of advanced disease the patient will require the chemo-radiation protocol anyway.
他补充说：“罗恩是创新的，机器人技术是一个很好的工具。”“我们仍然需要有关跨性机器人手术后发病率和存活率的更多确定数据。”
Dr. Karni points to emerging data in the literature on the efficacy of TORS for oropharyngeal cancer. “We’re just now beginning to report results showing that robotic surgery is producing good outcomes. It’s my belief that TORS is going to change the playing field between physicians and oropharyngeal cancer. It gives us another tool as surgeons and gives our patients a precise minimally invasive approach with few side effects.”
“最重要的是，我们可以通过化学疗法和放射线为患者提供器官保护方案，以及微创的内窥镜手术和机器人辅助手术。”Martin J. Citardi, MD，Uthealth Otorhinolaryngology兼教授兼主席，纪念Hermann-TMC的Otorhinolaryngology负责人。“每个患者的癌症都不一样。我们总是问自己，‘我治愈这种癌症的机会是什么？如何为患者产生最佳结果？哪种治疗将对该特定患者产生最少的副作用？’我们选择的治疗方案是分期，解剖学，病理学，医师基于经验以及患者的愿望和舒适性的直觉。”
Wyett finished his radiation therapy the week after Thanksgiving 2010. “From what we understand, Paul has a good prognosis,” his wife says. “The first problem is finding the primary site. The next question is can you resect to negative margins? Then it’s a matter of whether you can remove the lymph nodes. This particular cancer responds well to chemotherapy and radiation but it’s one of the toughest treatments to undergo. It’s been a lot for us to deal with.
她补充说：“我要说的是，您接受治疗的态度确实有所作为。”“从一开始，保罗说，‘今天要癌症的几率很高，显然是我的轮到了。我们将通过它。’”
Dr. Karni’s clinical interests include general otorhinolaryngology, robotic-assisted and minimally invasive approaches to surgery, management of thyroid and parathyroid disorders including diagnostic ultrasonography, head and neck cancer, treatment of salivary gland disorders, surgery of the nose and paranasal sinuses, evaluation of voice and swallowing problems including transnasal esophagoscopy, and sleep medicine.
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