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Health Matters: Providence Mission Hospital | 9 Innovations in Head and Neck Surgery Dr. Quang Luu gets help from a new robot to perform delicate procedures with great precision. Q uang Luu, MD, a board-certified specialist in otolaryngology/head and neck surgery at Providence Mission Hospital, has performed hundreds of throat surgeries for cancers of the tonsils and tongue since he completed his surgical residency in 2007. He says that over those 14 years he has seen a significant increase in patients with throat cancers. It used to be that the two most common causes of oropharyngeal cancers were alcohol and tobacco use, but in recent years those triggers have been overtaken by what is now recognized as an epidemic of cancers caused by human papillomavirus (HPV) infection. HPV includes more than 200 related viruses, most of which produce no symptoms in people who have been infected. However, two virulent strains—HPV 16 and 18—cause cancer, including certain reproductive and throat cancers. With 73% of Americans positive for HPV, throat cancer is now the sixth most common cancer in the U.S. ADVANCES IN TREATMENT In March, Dr. Luu started performing transoral robotic surgery (TORS) using a new generation of robot, the da Vinci SP from Intuitive. The minimally invasive system uses a single, flexible cannula that contains both a camera and tools that give the surgeon the ability to work with precision in the back of the throat. Dr. Luu had previously used the da Vinci Si system, which has four separate robotic arms. "Prior to that," Dr. Luu explains, "the procedure was to split the mouth open to access the back of the tongue. That surgery was fraught with complications." Known as a mandibulotomy, this traditional approach almost always requires that the patient have a tracheostomy, in which the surgeon cuts into the windpipe so a breathing tube can be inserted. Between the mandibulotomy and the tracheostomy, patients need to spend about two weeks in the hospital recovering, the first part of it in the ICU. By contrast, the TORS procedure doesn't necessitate a tracheostomy, dramatically reduces the risk of excessive bleeding and swelling and usually allows the patient to go home from the hospital in only two days. "The TORS option is such a vast improvement," says Dr. Luu. "At this point, I'd be loath to use the conventional approach." A SECOND BREAKTHROUGH But the safety of TORS isn't its only advantage: It can also eliminate the need for post-surgical chemotherapy and radiation because of its reach and precision. Using the 3D, high-definition imaging provided by the da Vinci system's tiny camera, viewed via its console, Dr. Luu can see the extent of the cancer much better and be more confident that it's been fully excised. And that's where a second breakthrough technology comes into play: a blood test that could ultimately have much broader implications. Right now, Naveris's NavDx blood test is used only for surveillance of patients who have been treated for an HPV-related oropharyngeal cancer, but it has the potential to be used widely as a screening tool. Post-surgery, NavDx is employed on an ongoing basis to look for DNA being shed by an HPV-driven tumor that's circulating in the bloodstream. If the "liquid biopsy" identifies that biomarker, it's evidence of a remaining or recurring tumor. "This test is very exciting to us head and neck surgeons," says Dr. Luu. "It's proven to be very sensitive and effective. It's the first blood test of its kind." He recalls one patient for whom all the conventional diagnostic tests—PET scan, needle biopsy, endoscopy—came up empty, but whose NavDx test suggested that an HPV-related cancer was indeed present. Dr. Luu persisted and ultimately found that the patient had a rare cancer in a tear duct, which he was then able to treat. "Now we have the options of better technique and better surveillance," says Dr. Luu of the dual evolutions of TORS and NavDx. "And that means providing better patient care." Head and Neck Associates of Orange County are the most skilled and experienced head and neck cancer surgeons in Southern California, with expertise in the most advanced surgical techniques for microvascular reconstruction. To learn more, visit hnaoc.com.

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