Aug. 19, 2025
Transoral laser microsurgery (TLM) has been a mainstay of treating head and neck cancer for decades because it allows surgeons to precisely resect tumors with minimal damage to surrounding tissue. The emergence of transoral robotic surgery (TORS) addressed certain limitations of TLM. But for head and neck surgeons at Mayo Clinic, it isn't a matter of one surgical treatment or the other.
"We offer TLM and TORS because they both have advantages," says Oluwafunmilola T. Okuyemi, M.D., a head and neck surgeon at Mayo Clinic in Jacksonville, Florida. "The ability to perform either surgical technique, or use them in combination, is another way for us to personalize the treatment of head and neck cancers."
The need for personalized treatment is critical now more than ever as the incidence of human papillomavirus (HPV)-related head and neck malignancies continues to rise in the United States. Oropharyngeal cancer rates are rising by an average of 0.6% yearly, with a higher prevalence in males, according to a 2023 Delaware Journal of Public Health study.
"Oropharyngeal squamous cell carcinoma (OPSCC) in the tonsils, at the base of the tongue, nasopharynx, in the soft palate and in the lateral pharyngeal walls can all be caused by HPV," says Dr. Okuyemi. "But the biology of HPV-positive cancer is different from non-HPV-related cancers. It makes transoral surgeries, such as TLM and TORS, effective treatment options."
Adapting the treatment approach for HPV-positive oropharyngeal cancer
According to the Centers for Disease Control and Prevention, HPV causes up to 70% of oropharyngeal cancers in the United States, with HPV-associated oropharyngeal cancers now surpassing HPV-related cervical cancers. It's changing how physicians approach and treat this cancer type.
"We are not seeing as many oropharyngeal cancers related to heavy smoking or drinking as we used to," says Dr. Okuyemi. "Now we see oropharyngeal cancers more in 40- and 50-year-olds, caused by HPV." The unique biology of most HPV-positive (HPV+) tumors of the head and neck offers an improved response to therapies and a better overall prognosis compared with OPSCC associated with smoking.
If HPV is suspected, the head and neck tumor board relies on a NavDx test, known as liquid biopsy, to confirm or rule out HPV+ cancer. "People who have a history of smoking can also have HPV," says Dr. Okuyemi. "It's rare, but we see it since we treat a high volume of patients." If HPV causes the cancer, the treatment pathway is different.
"We can treat HPV+ cancer with either surgery or chemoradiation, and it will normally respond well," says Dr. Okuyemi. "The advantage of a transoral surgical approach is that it's minimally invasive and allows us to get local control of the cancer. It also provides a good pathologic evaluation of the tumor, which can help us determine who needs adjuvant therapy."
Mayo Clinic surgeons use TLM and TORS for more than 75% of HPV-related oropharyngeal cancer.
Transoral laser microsurgery (TLM) vs transoral robotic surgery (TORS)
Both TLM and TORS offer the precision necessary to treat cancer in delicate areas of the head and neck. The procedures are comparable in terms of bleeding risk, recovery time, operative adverse effects and survival. Dr. Okuyemi says it's critical to consider access and other nuances of the tumor to determine which type of transoral surgery will provide the best outcome.
"TLM — performed with a laryngoscope, microscope and CO2 laser — does well with smaller tumors in more-delicate areas where I want more-precise control of my cuts and margins, with limited collateral thermal damage of surrounding tissue," says Dr. Okuyemi. Unlike TORS, which typically involves cutting around the tumor, TLM uses a laser to cut through the tumor to establish depth and margins, prior to cutting around the tumor. "The laser allows me to differentiate between cutting through cancer and cutting normal tissue, so I can conserve as much tissue — and as a result, function — as possible."
TLM also causes less collateral damage to surrounding tissue. "The water in tissues absorbs the heat and energy of the laser and helps minimize damage to the surrounding normal tissue," says Dr. Okuyemi. "That translates into less pain for the patient."
TORS is performed at Mayo Clinic using the latest da Vinci SP robot — a Food and Drug Administration-approved platform for robotic otolaryngology surgery. Mayo Clinic head and neck surgeons are trained in robotic surgery, and Dr. Okuyemi says they manage most HPV+ tumors with TORS or TLM.
"While the robot can sometimes be more difficult to use in narrow areas because it involves more tools, it performs precise maneuvers, works better than a laser for larger tumors, and has a clear advantage with visualization," says Dr. Okuyemi. "When resecting a tumor that is deep down or hard to see, the robot's flexibility provides an exceptional 3D view."
In complex cases, Dr. Okuyemi takes advantage of both techniques. "When I'm operating in narrow areas, such as the larynx or hypopharynx, I like the precision of a laser," she says. "But for other regions, the choice of the laser or robot is tailored to the patient's anatomy and other salient clinical factors to ensure the best visualization while making precise cuts."
Continued focus on de-escalating oropharyngeal cancer treatment
Adjuvant radiation therapy, with or without chemotherapy, is a standard of care for HPV+ oropharyngeal cancer. However, it can have significant acute and long-term side effects that can impact quality of life and overall survival. Minimally invasive transoral surgery, such as TLM and TORS, can pave the way for de-escalated adjuvant therapy and help reduce treatment-related side effects.
Mayo Clinic continues to research additional methods for treatment de-escalation. Their de-escalated adjuvant radiation therapy (DART) 2.0 clinical trial is evaluating a blood-based biomarker to determine its potential role in directing treatment decisions for people with HPV+ OPSCC.
Building on the previous DART clinical trial, DART 2.0 aims to combine biomarker response with clinical and pathologic factors to guide treatment intensity for patients regardless of whether they have surgery.
For more information
Gribb JP, et al. Human papilloma Virus (HPV) and the current state of oropharyngeal cancer prevention and treatment (PDF). Delaware Journal of Public Health. 2023;9:26.
Mayo Clinic. De-Escalated Adjuvant and Definitive Radiation Therapy Informed by DART 2.0 ctHPV-DNA. ClinicalTrials.gov.
HPV and oropharyngeal cancer. Centers for Disease Control and Prevention.
Cancers linked with HPV each year. Centers for Disease Control and Prevention.
Refer a patient to Mayo Clinic.