Transoral Robotic Surgery

Detecting Extranodal Extension in HPV-Related Oropharyngeal Cancer via Machine Learning

OBJECTIVE

To assess the performance of machine learning (ML) models trained on large publicly available databases in predicting extranodal extension (ENE) within a smaller single-institution cohort.

METHODS

Patient data were derived from two datasets. The first, the NCDB containing 5551 patients, was used to train and validate the ML algorithms. NCDB data was split into training (80%) and testing (20%) sets. To ensure fair comparison of prediction performance, data were randomly divided. The second, the WVU cohort containing 62 patients, was used as an independent test set for validation and simulation of a real-world scenario. Six key ENE-related variables (predictors) were selected based on importance and data availability.

RESULTS

The generalizability of the ML models was validated using real data from our institute with an average AUC ROC of 0.74. Of all the models, AdaBoost had reasonable performance: precision of 72%, NPV of 0.74%, specificity of 0.81, AUC ROC of 0.74. Similarly, the XGBOOST and ensemble models demonstrated the strongest combination of sensitivity and precision, critical for correctly predicting ENE, with AUC ROC ranging from 0.71 to 0.75. Most models demonstrated modest sensitivity in predicting ENE.

CONCLUSION

This study proved the feasibility of using ML algorithms to predict ENE by using oncologic variables from the NCDB as a training dataset. These trained models generalize well, such that they accurately predicted ENE on a real-world single institution dataset.

LEVEL OF EVIDENCE: 3

Transoral Robotic Surgery in the Multidisciplinary Care of Patients With Oropharyngeal Squamous Cell Carcinoma: ASCO Guideline

PURPOSE

To provide evidence-based recommendations for the use of transoral robotic surgery (TORS) in the multidisciplinary management of oropharyngeal squamous cell cancer (OPC).

METHODS

ASCO convened a multidisciplinary Expert Panel to evaluate the evidence and formulate recommendations. The literature search included studies published between January 1, 2002, and August 31, 2024, and comprised systematic reviews, meta-analyses, randomized controlled trials, and observational studies. Outcomes of interest include overall and disease-free survival, functional outcomes, and quality of life. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations.

RESULTS

A total of 58 publications were identified to inform the evidence base for this guideline.

RECOMMENDATIONS

Evidence-based recommendations address the evaluation and workup of patients with human papillomavirus (HPV)-positive OPC, the role of TORS, patient selection, adjuvant therapy, HPV-negative OPC, and use of TORS in salvage or recurrent setting.Additional information is available at www.asco.org/head-neck-cancer-guidelines.

Adjuvant Proton Radiation Following Transoral Robotic Surgery for HPV-Positive Oropharyngeal Squamous Cell Carcinoma

OBJECTIVE

Advances in the treatment of human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) include transoral robotic surgery (TORS) and proton beam therapy (PBT). This study aims to improve understanding of the treatment toxicities associated with adjuvant PBT following TORS for OPSCC.

STUDY DESIGN

A retrospective review.

SETTING

An academic tertiary care center in Baltimore, Maryland.

METHODS

Patients undergoing TORS followed by adjuvant PBT from 2017 to 2023 were reviewed.

RESULTS

Forty-seven patients with HPV-associated OPSCC underwent TORS followed by adjuvant PBT. Forty-one (87.2%) patients were male. The median age at first radiation fraction was 61.7 years. Forty-one (87.2%) identified as white and 6 (12.8%) as African American. Most patients had T1 (23 [48.9%]) or T2 (22 [46.8%]), N1 (41 [87.2%]) disease. The majority (98.3%) of acute toxicities were grade 1 or 2, with only 1 (2.1%) patient developing grade 3 toxicities. Three (6.4%) patients required a feeding tube for nutrition during adjuvant proton radiation treatment. The 3 patients who required feeding tubes during radiation also required postoperative nasogastric tubes for a median of 16 days, compared with 3 days for all other patients (Mann-Whitney U, P = .02). The most common chronic toxicities included xerostomia, dysphagia, dysgeusia, and lymphedema, which decreased over time.

CONCLUSION

HPV-associated OPSCC treated with TORS followed by adjuvant PBT demonstrated a favorable toxicity profile with mostly grade 1 or 2 acute toxicities. Feeding tube requirement during adjuvant PBT was low at 6.4%. Many chronic toxicities appeared to decrease in frequency with time from radiation, although further study is required.

A Bibliometric Analysis of HPV-Positive Oropharyngeal Squamous Cell Carcinoma from 2000 to 2023

Human-papillomavirus-positive oropharyngeal squamous cell carcinoma (HPV-positive OPSCC) is a distinct disease characterized by unique clinical and molecular features compared to HPV-negative OPSCC. A comprehensive bibliometric analysis of HPV-positive OPSCC research was conducted in this study to identify key trends, research hotspots, and emerging frontiers in the field. Data were retrieved from the Web of Science Core Collection database. The distributions of contributors, including countries, institutions, authors, journals, and cooperative networks related to HPV-positive OPSCC, were analyzed and visualized using VOSviewer 1.6.20, CiteSpace 6.3.R1, and the R package Bibliometrix 4.0.0. In addition, the most influential publications and high-frequency keywords were identified and analyzed to discern key topics in this field. A total of 3895 articles and reviews on HPV-positive OPSCC were identified, involving 106 countries, 620 journals, and 18949 authors. The main contributors include the USA (1908 publications), Johns Hopkins University (310 publications), the journal Head and Neck (320 publications), and Erich M. Sturgis (94 publications). The top three keywords are "survival", "radiotherapy", and "p16". There has been a steadily increasing research interest in HPV-positive OPSCC over the last 23 years. Current studies focus on diagnosis, treatment strategies, prognosis, recurrence, and disease surveillance. This bibliometric analysis highlights key contributors and emerging themes, offering insights for future research directions.

P16/HPV-negative oropharyngeal squamous cell carcinoma survival: Comparing primary surgery to primary chemoradiotherapy. A systematic review and meta-analysis

OBJECTIVES

This study investigated differences in survival for p16/HPV-negative OPSCC patients treated with primary surgery versus primary (chemo-)radiation therapy (CRT).

MATERIALS AND METHODS

PubMed, CINAHL and Web of Science databases and the online Cochrane Library were searched for relevant English language studies describing the survival outcomes of p16/HPV-negative OPSCC patients treated with primary surgery or primary CRT. The primary endpoint was the 5-year OS; the secondary endpoints included 5-year DSS and DFS, and 3- and 2-year OS, DSS and DFS. The pooled survival curves were estimated using a distribution-free approach assuming random effects. Cumulative KM curves for OS, DSS and DFS were built for each treatment group.

RESULTS

Twenty-two publications were included in the final analysis. Patients included (n = 1903) were divided according to treatment ("surgery" group, n = 942; "RT/CRT" group, n = 961). For all the endpoints, surgery demonstrated improved short- and long-term survival compared to RT/CRT, although selection bias may have impacted the outcomes. The estimated pooled 5-year OS for the surgery and the RT/CRT group was 54.1 % (95 % CI: 44.4%-65.9 %) and 45.7 % (95 % CI: 41.8%-49.9 %), respectively.

CONCLUSION

Primary surgery and primary CRT for p16/HPV-negative OPSCC both provide acceptable survival outcomes, although in many cases surgery has shown improved survival rates. Further research should focus on when each treatment modality should be used to achieve the goals of treatment completion, survival and functional outcomes.

Precision and Pitfalls: A Prospective Study Analysing the Immediate Postoperative Sequelae and Oncological Outcome of TORS When Used in Diagnostic Algorithm of Carcinoma Unknown Primary

With the realm of carcinoma unknown primary, incorporating Trans Oral Robotic Surgery represents the diagnostic frontier. This study emphasises the immediate postoperative sequelae and also oncological outcome of patients who underwent TORS to diagnose the primary site in unknown primary carcinoma and assesses the feasibility in the Indian scenario. A prospective study was carried out at a tertiary care centre over two years (January 2020 to January 2022). Patients underwent TORS-assisted ipsilateral radical tonsillectomy, tongue base mucosal wedge biopsy and neck dissection as a part of the diagnostic algorithm of carcinoma unknown primary. The postoperative complications, need for nasogastric feeding, need for tracheostomy, return to oral diet and duration of hospital stay were assessed in these patients. Oncological outcomes were assessed in the same population with the median follow up duration of 49 months. The study encompassed a group of 18 patients of Carcinoma Unknown Primary (CUP) who underwent a comprehensive set of procedures, including ipsilateral radical tonsillectomy, mucosal tongue base wedge biopsy, and neck dissection for the identification of the primary site. The average duration of inpatient stay post-surgical procedure was 3.33 ± 0.57 days. A late postoperative complication of Transoral Robotic Surgery (TORS) manifested as minor intraoral bleeding in 11.1% of patients (n = 2/18). An immediate postoperative complication related to neck dissection, specifically neck hematoma, occurred in 11.76% of patients (n = 2/17). Tracheostomy and nasogastric feeds were implemented for a short period in only 5.9% of patients (n = 1/17). Survival analysis conducted on the same population, with a median follow-up of 33 months, revealed no differences in Overall Survival (OS) and Disease-Free Survival (DFS) concerning primary site identification and HPV positivity. Transoral Robotic Surgery (TORS) with concurrent neck dissection proves to be an effective diagnostic and concurrent treatment option for patients with Carcinoma of unknown primary (CUP) with secondary squamous cell neck metastasis. This minimally invasive approach shows a 3-year overall survival rate of 88.69% and a disease-free survival rate of 89.12% with median follow up duration of 33 months.

Trans Oral Robotic Surgery for HPV-Negative Oropharyngeal Squamous Cell Carcinoma: Follow-Up on Oncological and Functional Outcomes

BACKGROUND

The efficacy of transoral robotic surgery (TORS) for HPV-negative oropharyngeal cancers (OPSCC) is less explored, especially regarding long-term outcomes and prognostic factors.

METHODS

We conducted a retrospective monocentric study on 37 patients with HPV-negative OPSCC treated with TORS with a median follow-up of 3 years, assessing survival outcomes using Kaplan-Meyer statistics and swallowing function via the functional outcome swallowing scale (FOSS). Histopathological parameters were collected either from medical records or histology slides were re-evaluated.

RESULTS

Patients demonstrated high disease-specific survival (DSS) but lower overall survival (OS), with a cohort characterized by high comorbidity rates. Vascular invasion was a significant adverse factor for relapse-free survival (RFS) and OS, while lymphatic invasion was not. Most patients demonstrated significant preservation of swallowing function.

CONCLUSIONS

TORS for HPV-negative OPSCC demonstrates high DSS and preserved swallowing function. Vascular invasion is a key prognostic factor for survival outcomes.

Case presentation of a robot-assisted bilateral benign tonsillectomy using the da Vinci SP system

Since the first use of a da Vinci system to perform a radical tonsillectomy in 2007, transoral robotic surgery (TORS) has been further developed and finally accepted as a safe surgical method. The recent introduction of the da Vinci Single-Port (SP) system has brought new innovations in the field of ears, nose and throat (ENT) medicine, e.g. to perform minimally invasive head and neck tumor surgery. In Europe, the da Vinci SP system has recently received CE Mark approval for TORS application. We present the first case of a robot-assisted bilateral benign tonsillectomy with the da Vinci SP system in Germany and demonstrate the technical feasibility of this platform.

Transoral non-robotic surgery for oropharyngeal squamous cell carcinoma

PURPOSE

This retrospective cohort study aims to evaluate the clinical, oncological, and functional outcomes of transoral non-robotic surgery for oropharyngeal squamous cell carcinoma (OPSCC).

MATERIALS AND METHODS

Data from 131 patients with surgically treated OPSCC (2010-2022) were analyzed. Patients who underwent exclusively transoral surgery were included in the study. The surgeries were performed under microscopic or endoscopic guidance and either a CO2 laser or an ultrasound/radiofrequency scalpel was used as a cutting instrument, depending on the characteristics and location of the tumor. Functional outcomes were assessed in terms of length of hospital stay, tracheostomy rate, duration of feeding tube dependency and complications. Survival outcomes were assessed in terms of overall survival (OS), disease-free survival (DFS) and disease-specific survival (DSS).

RESULTS

Of 74 included patients, transoral surgery demonstrated safety with no major complications. Tracheotomy was performed in 51.4 % of cases, and was maintained for a median of 10 days. Complete swallowing recovery was restored in 97.3 % of cases, after a median of 5 days. The median length of hospital stay was 12 days. At 5 years, OS was 68.2 %, PFS was 58.2 % and DSS was 83.6 %.

CONCLUSION

The study confirms the safety and efficacy of a transoral approach for OPSCC. Having the capability to utilize and access a variety of tools provides the opportunity to tailor the technique to the individual patient and specific circumstances.

Perforator Flaps and Robotic Surgery for Head and Neck Reconstruction

Head and neck cancer (HNC) is the sixth most common cancer across the world. Despite a general reduction in tobacco consumption and therefore reduction in risk exposure there has been an increasing incidence of oropharyngeal squamous cell carcinoma. Progress made in the past decades in free tissue transfer reconstruction and robotic surgery have merged into transoral robotic reconstruction with free perforator flaps for head and neck. We reviewed and discussed indications and contraindications for this type of procedure, as well as potential limits refinements.

Ten-Year Efficacy of Transoral Surgery for Squamous Carcinoma of the Lateral Oropharynx

OBJECTIVES

To document the 10-year results of transoral mandibular preservation surgery for patients with T1-2 squamous cell carcinoma (SCC) arising from the lateral oropharynx.

METHODS

This was a retrospective 30-year review using STROBE guidelines at an academic, tertiary referral center. A total of 294 patients with T1-2 SCC of the lateral oropharynx were reviewed. Only 19% of patients were never-smokers, suggesting a predominantly HPV-negative population. All patients had transoral mandibular preservation surgery. Follow-up therapy included neck dissection (76.5%), induction chemotherapy (57.8%), and postoperative radiation therapy (31.6%) Local control, survival, and functional endpoints, as well as the consequences of local recurrence, were analyzed.

RESULTS

The 10-year local disease control was 88.3%. Local recurrence was salvaged in 50% of cases, resulting in an overall 94.5% local control rate. The overall 10-year survival was 50%. Mortality was related to metachronous second primary cancer (MSPC) (29.2%), medical comorbidities (25.7%), uncontrolled local recurrence (10%), and complications following transoral resection (4.2%). In multivariate analysis, the development of an MSPC significantly increased (p < 0.005) the risk of death. Overall, 95.2% of patients achieved mandibular preservation. However, gastrostomy and tracheostomy dependence occurred in 1% and 0.3% of cases, respectively.

CONCLUSIONS

For a patient population with a significant percentage of tobacco-associated oropharyngeal cancer (OPC), transoral surgery was associated with long-term minimal postoperative complications and a high rate of local control. MSPC was the main cause of death during the first 10 postoperative years. Such long-term figures support transoral surgery as an effective first-line treatment for early-stage predominantly tobacco-related OPC.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:4564-4572, 2024.

Transoral Laser or Robotic Surgery Outcomes for Oropharyngeal Carcinoma: Secondary Analysis of the PATHOS Randomized Clinical Trial

Background

Transoral robotic surgery (TORS) or transoral laser microsurgery (TLM) offer excellent oncological outcomes for oropharyngeal squamous cell carcinoma caused by human papillomavirus (HPV) infection. TORS may offer greater margin clearance around tumors than TLM.

Objective

To determine whether the differing energy sources used and surgical technique of TORS or TLM is associated with postoperative early swallowing function, feeding tube use, and specific factors related to quality of life.

Design, Setting, and Participants

This prespecified cohort study was performed within the Postoperative Adjuvant Treatment for HPV-Positive Tumours (PATHOS) randomized clinical trial at 40 centers in the UK, Germany, France, the US, and Australia between November 1, 2015, and August 31, 2023. PATHOS trial participants with HPV-positive oropharyngeal carcinoma of stages T1 to T3 and N0 to N2b M0 (TNM7) who underwent TLM or TORS were eligible. Of 989 consecutively recruited patients on the PATHOS trial, 508 were eligible for this substudy.

Exposures

The exposure of interest was TORS or TLM.

Main Outcomes and Measures

Preplanned outcome measures included nasogastric tube insertion rates within 4 weeks after surgery, length of in-hospital stay following surgery, specific scales from the MD Anderson Dysphagia Inventory (MDADI), 35-item European Organization for Research and Treatment of Cancer Head and Neck Questionnaire (H&N35), and 30-item Quality of Life Questionnaire (QLQ C30), water swallow test results, and videofluoroscopy scores.

Results

Of the 508 patients included in the analysis (390 [76.8%] male; median age, 58.3 [IQR, 52.8-63.6] years), 195 had TLM and 313 had TORS. Nasogastric tube insertion rates were higher after TORS than TLM (85 of 189 [45.0%] vs 10 of 126 [7.9%]; adjusted odds ratio [OR], 4.41 [95% CI, 1.01-19.32]). Mean scores favored TLM with small effect sizes in all MDADI domains and the H&N35 swallowing item at 4 weeks after surgery; between-group difference for the MDADI composite score was -4.89 (95% CI, -8.27 to -1.50); for the MDADI physical functioning score, -6.37 (95% CI, -10.15 to -2.59); for the MDADI global score, -10.02 (95% CI, -16.50 to -3.54); and for H&N35 swallowing score, 7.24 (95% CI, 2.17-12.30). No other measures showed evidence of clinically meaningful differences.

Conclusions and Relevance

In this cohort study, functional outcomes were moderately less impaired 4 weeks following TLM compared with TORS. Once the longer-term outcomes for these patients are known, these findings could aid the design and use of future head and neck-specific surgical robots.

Trial Registration

ClinicalTrials.gov Identifier: NCT02215265.

A Comprehensive Systematic Review on Functional Results, Speech and Swallowing Outcomes after Trans-Oral Robotic Surgery for Oropharyngeal Squamous Cell Cancer

Background: Transoral robotic surgery (TORS) is nowadays considered a valuable minimally invasive approach to treat oropharyngeal squamous cell carcinoma (OPSCC). The aim of this technique is to improve functional preservation and reduce morbidity with excellent oncologic outcomes compared to the traditional transoral approach and chemoradiotherapy (CRT). The purpose of this systematic review is to assess an exhaustive overview of functional outcomes of TORS for OPSCC by evaluating several parameters reported in the available literature, such as the prevalence and dependence of tracheotomy, feeding tubes (FTs) and percutaneous endoscopic gastrostomy (PEG), the length of hospitalization, swallowing scores, speech tests and quality of life (QoL) questionnaires. Methods: A systematic literature review has been performed following the PRISMA 2020 checklist statement. A computer-aided search was carried out using an extensive set of queries on the Embase/PubMed, Scopus and Web of Sciences databases relating to papers published from 2007 to 2024. Results: A total of 28 papers were systematically reviewed, reporting 1541 patients' data. The mean time of hospitalization was 6 days. A planned tracheotomy was performed in 8% of patients with a mean time of removal of 8 days. The prevalence and dependence of FT was 60% and 10%, respectively. Moreover, the presence of a high-stage T tumor with the contextual requirement of adjuvant therapies, the involvement of base tongues and the patient's age being >55 years increased the risk of requiring an FT and PEG. Swallowing and long-term QoL outcomes highlight the superiority of the TORS approach alone compared to TORS with adjuvant therapies. Conclusions: TORS presented various favorable functional outcomes compared to other surgical approaches and primary CRT. However, adjuvant therapies after TORS strongly reduced the advantage of the robotic procedure, thus suggesting that T1 and T2 tumors may benefit mainly from TORS alone.

Robotic surgery: bibliometric analysis, continental distribution, and co-words analysis from 2001 to 2023

The project aimed to conduct an up-to-date and comprehensive bibliometric analysis of robotic surgery to provide a detailed and holistic understanding of the field. Three strategies were employed in the data analysis i.e. search terms were explored in (A) the title, abstract, and keywords and (B) only in the title of the documents. In 3rd part we analyzed the top 100 most cited papers. Vosviewer and R Studio were utilized for detailed bibliometric and network analyses. Strategy one identified 38,469 publications, and strategy two identified 6451 publications from 2001 to 2023. The top authors, universities, countries, sponsors, and sources based on the number of publications were identified for both strategies. The top 100 most cited papers were analyzed, providing the annual number of publications and various citation metrics. Top authors (by number of publications, total citations, h-index, g-index, and m-index), universities, and countries within these highly cited papers, along with their co-authorship networks and dynamics, were examined. Co-words analysis of the top 100 most cited papers revealed the primary focus of these documents across 25 categories. This comprehensive bibliometric analysis of robotic surgery highlighted significant contributions and collaborations in the field, emphasizing the importance of global and collaborative efforts in advancing robotic surgery research.

Robot-assisted versus conventional neck dissection: a propensity score matched case-control study on perioperative and oncologic outcomes

The widespread acceptance of robotic surgery is extending to oral procedures. The demand for minimally invasive techniques is driving research into the cosmetic and oncologic benefits of robotic neck surgery. This study used propensity score matching to analyze the clinical course and postoperative outcomes of robot-assisted neck dissections for oncologic efficacy and surgical safety. Between May 2020 and April 2024, 200 OSCC patients underwent surgery and 42 were excluded. The cohort included 158 patients, 128 of whom underwent unilateral neck dissection and 30 of whom underwent bilateral neck dissection. Robotic-assisted neck dissection (RAND) was performed in 36 patients while conventional transcervical neck dissection (CTND) was performed in 122 patients. Data analysis included several factors, including lymph node retrieval and perioperative outcomes, with 1:1 propensity score matching to ensure fairness. Each of the 39 neck specimens with 36 patients was selected. The CTND group was 8 years older overall than the RAND group, but otherwise similar in terms of primary site and clinical stage. The RAND group had a 55-min longer operative time and 140 cc more hemovac drainage than the CTND group, but the hospital stay and intensive care unit duration were the same, and the number of lymph nodes retrieved was the same. Survival rates also showed no difference across all stages. This shows that RAND is in no way inferior to CTND in terms of perioperative or oncologic outcomes, and demonstrates the safety of robot-assisted surgery, even in patients who require flaps or in patients with advanced stages.

Safety and outcome of three-dimensional transoral videolaryngoscopic surgery

BACKGROUND

Transoral videolaryngoscopic surgery (TOVS) is widely used in Japan, and conventional two-dimensional (2D) endoscopic methods have been established. Three-dimensional (3D) endoscopic surgery offers superior distance perception because it provides stereoscopic views. Recently, we have developed 3D endoscopy for TOVS (3D TOVS).

METHODS

This study included 46 patients with pharyngeal cancer who underwent 3D TOVS. The perioperative complications and survival curves were retrospectively analyzed.

RESULTS

One patient with oropharyngeal cancer who underwent neck dissection and transoral resection simultaneously experienced postoperative hemorrhage of the neck. Another patient with oropharyngeal cancer underwent hemostasis for postoperative pharyngeal hemorrhage. There was one case of aspiration pneumonia. One patient developed cervical lymph node recurrence; however, there was no local recurrence or primary mortality. The 2-year overall survival, disease-specific survival, local control rates, locoregional control rate, and invasive disease-free survival were 90.9%, 100%, 100%, 97.4%, and 79.9%, respectively.

CONCLUSIONS

Three-dimensional endoscopy can be safely applied to TOVS.

[Surgical Treatment of Oropharyngeal Cancer - Recommendations of the Current German S3 Guideline, Part I]

In general, a trend towards transoral resection (as opposed to classic open approaches) + neck dissection + adjuvant radio- (chemo-) therapy has been observed for oropharyngeal carcinoma over the last 20 years. Techniques of transoral surgery (TOS), including transoral laser microsurgery (TLM) and transoral robotic surgery (TORS) have been propagated in retrospective comparisons with conventional surgery or primary radiochemotherapy as gentle, minimally invasive procedures with good late functional results. Meta-analyses of mostly uncontrolled retrospective analyses suggest that TORS may have better disease-free survival (DFS) and a reduced risk of free flap reconstruction compared with open surgery. TORS (TOS) was associated with fewer tumor-positive resection margins (R1), a lower number of recurrences, fewer intraoperative tracheostomies, a shorter inpatient stay and a shorter duration of postoperative nasal tube feeding compared to open surgery. In principle, based on the best evidence currently available from registry studies, stage I-II oropharyngeal carcinomas can be treated either with primary surgery or radiochemotherapy with a comparable chance of survival. With comparable evidence for stage III and IVa, p16neg. oropharyngeal carcinomas, the majority of authors advocate primary surgery followed by adjuvant radiotherapy or radiochemotherapy as the treatment of first choice. For p16pos. patients the results of registry studies are inconsistent, although the largest registry study on 450 HPV-positive stage III patients shows a significant superiority of primary surgery + adjuvant radiochemotherapy. Since all registry studies did not adjust for smoking status, among other factors, the current data situation should be evaluated with the necessary caution.

The influence of perioperative enoxaparin on bleeding after TORS oropharyngectomy

Perioperative enoxaparin is often avoided in patients undergoing transoral robotic (TORS) oropharyngectomy. Our goal was to quantify the risk of postoperative hemorrhage (POH) in patients receiving enoxaparin after TORS oropharyngectomy. This was a retrospective database cohort study set up in 89 separate healthcare organizations. The TriNetX electronic database was queried for patients with OPSCC who underwent TORS oropharyngectomy. Propensity-score matching was used to create two cohorts, one receiving and one not receiving perioperative enoxaparin. Outcome measures were the POH rate within 1 day of surgery ("primary") and POH rate within 2-30 days of surgery ("secondary"). 1109 patients undergoing TORS for OPSCC were identified, 400 of which received perioperative enoxaparin. One-to-one propensity score matching resulted in 310 patients per cohort. After matching, the primary POH rates between patients receiving and not receiving enoxaparin were 3.23% for both cohorts (OR 1.000, 95% CI 0.410 to 2.438). The secondary POH rates between those receiving and not receiving enoxaparin were 5.47% vs. 3.54% (OR 1.577, 95% CI 0.726 to 3.424). The number needed to harm (NNH) with perioperative enoxaparin use for secondary POH after TORS was 53; no difference was found in primary POH rates. While not statistically significant, the use of perioperative enoxaparin after TORS is associated with increased odds of secondary POH with a NNH of 53; no difference was found in rates of primary POH. For patients undergoing TORS, enoxaparin use requires careful weighing of the risks and benefits.

Effect of palatine tonsil tumor resection on postoperative velopharyngeal insufficiency in transoral surgery

BACKGROUND

Velopharyngeal insufficiency (VPI) is a known complication of transoral surgery (TOS) for oropharyngeal HPV-mediated squamous cell carcinoma. Controversy exists regarding adequate resection margins for balancing functional and oncologic outcomes.

METHODS

This retrospective study was exempted by the IRB. Patients who underwent TOS from January 2017 to October 2022 were included. Patient characteristics, treatment details, and oncologic and functional outcomes were evaluated.

RESULTS

Fifty-five patients were included. Mean and median follow-up was 34 months. 98% of patients were AJCC stage I/II. Recurrence-free survival was 96% with no local recurrences. Univariate analysis demonstrated an association between VPI and pT stage (p = 0.035), medial pterygoid resection (p = 0.049), and palatal attachment sacrifice (p < 0.001). Multivariate analysis showed sacrifice of the palatal attachments remained a significant risk for VPI (p = 0.009).

CONCLUSION

Loss of soft palate pharyngeal attachments is an independent risk factor for VPI. When oncologically appropriate, the palatal attachments to the pharynx may be preserved.

Transoral robotic surgery (TORS) in Japan: procedures, advantages and current status

Transoral robotic surgery (TORS), introduced by Weinstein et al. in 2005, has been widely adopted as a minimally invasive procedure, particularly for the treatment of patients with early stage oropharyngeal cancer. TORS is typically performed using the da Vinci Surgical System, similar to robot-assisted surgeries for other malignancies. The main difference between TORS and these other robot-assisted surgeries is that it is performed through the natural orifice of the mouth, which limits the surgical working space, and that it progresses from the lumen of the pharynx to the deeper tissues. The advantages of TORS are mainly due to the benefits of using the da Vinci Surgical System, such as three-dimensional high-definition images, magnification, multiple forceps articulation, tremor-stabilization function and motion scale function. To date, many big data and meta-analyses have shown that TORS is superior to conventional surgeries, such as open surgery, in terms of oncological outcomes, post-operative functionality and quality of life. In Japan, TORS is expected to spread across the country, as it has been covered by health insurance since April 2022. This review highlights the procedures of TORS, its unique aspects, its unparalleled advantages as a minimally invasive surgery for treating laryngeal and pharyngeal cancers, and its current status in Japan.

Swallowing Function and Quality of Life in Patients Treated With Transoral Videolaryngoscopic Surgery for Pharyngolaryngeal Cancer

BACKGROUND

It is controversial whether transoral resection for early pharyngolaryngeal cancer preserves swallowing function and quality of life. We investigated swallowing function and quality of life before and after transoral videolaryngoscopic surgery (TOVS).

METHODS

Seventy-three patients with pharyngolaryngeal cancer who underwent TOVS between July 2012 and July 2022 were enrolled in this prospective analysis. The Hyodo score and European Organization for Research and Treatment of Cancer Quality of Life Questionnaires were recorded preoperatively and at three, six, and 12 months postoperatively, in addition to the postoperative functional outcome swallowing scale (FOSS) at six months postoperatively.

RESULTS

Although most patients could consume food orally without restrictions with a preferable FOSS score, 23 patients showed impaired Hyodo scores. Age ≥65 years significantly predicted impaired swallowing. Sub-scores of the impaired patient group showed worsening for the glottal closure reflex when the endoscope touched the epiglottis or arytenoid, as well as a reduction in the extent of pharyngeal clearance following the ingestion of blue-dyed water.

CONCLUSION

After TOVS, swallowing function is generally well preserved. Elderly patients, especially those with laryngeal hypoesthesia and poor clearance, are at risk of swallowing dysfunction.

Topical Hemostatic Agents and Risk of Postoperative Hemorrhage After Transoral Robotic Surgery

Objective: Postoperative hemorrhage is the most common complication of transoral robotic surgery (TORS). The available research literature on topical hemostatic agents is deficient, despite their wide use. This study aims to evaluate the frequency and severity of hemorrhagic events after TORS procedures, performed with various topical hemostatic agents. Methods: This study was planned as a retrospective review to identify postoperative hemorrhage events in a database of all consecutive adult patients who required TORS from January 1, 2015, to April 1, 2020. All procedures were performed in one single institution by the same surgeon. In 2017, bovine gelatin matrix with thrombin (BgMT) was replaced by the porcine gelatin matrix with thrombin (PgMT) for all procedures. Postoperative hemorrhage was identified, along with hemostatic agents employed and other variables. Results: A cohort of 80 TORS procedures was obtained from a population of 78 individuals (60 males:18 females). BgMT was used in 28 procedures (35%), and five cases of postoperative hemorrhage were identified (17.8%), two of them were severe. PgMT was used in 52 procedures (65%) just observing one minor hemorrhagic event (1.92%). Although a significant difference was observed for total events between groups (P = .0183), there was no difference between major or severe hemorrhagic events (P = .1196). The overall rate of major and severe postoperative hemorrhage in the study population was 2.5% (n = 80). Conclusions: This is the first study to evaluate topical hemostatic agents during TORS procedures. The PgMT group had a reduced incidence of total postoperative hemorrhages, although there was no difference in the number of severe hemorrhagic events. The overall simplicity and cost-effectiveness of these agents would support their use, particularly considering the potential risk associated with airway hemorrhage.

Advancements in robotic surgery: innovations, challenges and future prospects

The use of robots has revolutionized healthcare, wherein further innovations have led to improved precision and accuracy. Conceived in the late 1960s, robot-assisted surgeries have evolved to become an integral part of various surgical specialties. Modern robotic surgical systems are equipped with highly dexterous arms and miniaturized instruments that reduce tremors and enable delicate maneuvers. Implementation of advanced materials and designs along with the integration of imaging and visualization technologies have enhanced surgical accuracy and made robots safer and more adaptable to various procedures. Further, the haptic feedback system allows surgeons to determine the consistency of the tissues they are operating upon, without physical contact, thereby preventing injuries due to the application of excess force. With the implementation of teleoperation, surgeons can now overcome geographical limitations and provide specialized healthcare remotely. The use of artificial intelligence (AI) and machine learning (ML) aids in surgical decision-making by improving the recognition of minute and complex anatomical structures. All these advancements have led to faster recovery and fewer complications in patients. However, the substantial cost of robotic systems, their maintenance, the size of the systems and proper surgeon training pose major challenges. Nevertheless, with future advancements such as AI-driven automation, nanorobots, microscopic incision surgeries, semi-automated telerobotic systems, and the impact of 5G connectivity on remote surgery, the growth curve of robotic surgery points to innovation and stands as a testament to the persistent pursuit of progress in healthcare.

A Descriptive Study of Quality of Life Following Neoadjuvant Chemotherapy and Transoral Robotic Surgery for Human Papillomavirus-Associated Oropharyngeal Squamous Cell Carcinoma

BACKGROUND

Patients with oropharyngeal squamous cell carcinoma (OPSCC) treated with radiation-based therapy suffer from short- and long-term toxicities that affect quality of life (QOL). Transoral robotic surgery (TORS) has an established role in the management of early OPSCC but adjuvant treatment is often indicated postoperatively due to the high incidence of nodal metastasis associated with advanced human papillomavirus (HPV)-related OPSCC. To overcome the need for adjuvant radiation therapy (RT), neoadjuvant chemotherapy followed by TORS and neck dissection (ND) is proposed. This study aimed to assess if QOL in HPV-associated OPSCC receiving neoadjuvant chemotherapy followed by TORS and ND returns to baseline within 12 months of completing treatment.

METHODS

A 12 month longitudinal study was carried out at McGill University Health Centre in Montreal, Canada, among a convenience sample of patients with American Joint Committee on Cancer Seventh Edition stage III and IVa HPV-related OPSCC who were treated with neoadjuvant chemotherapy followed by TORS and ND. QOL data were obtained pretreatment and at 1, 3, 6, and 12 months following treatment completion using the European Organisation for Research and Treatment of Cancer Core and Head and Neck extension modules. Paired t tests and mixed models for repeated measures analysis were used to assess changes in QOL from baseline to 12 months postoperatively and over time, respectively.

RESULTS

Nineteen of 23 patients (median age 58 years) who received the study treatment fulfilled the eligibility criteria. OPSCC subsites were palatine tonsil (n = 12) and base of tongue (n = 7). All 19 patients were treated per protocol and none required adjuvant RT as per pathology review and protocol requirements at a postoperative multidisciplinary team tumor board discussion. No significant differences were found when comparing 12 month QOL follow-up scores to pretreatment scores in measures that would likely be affected by RT [eg, swallowing (P = .7), social eating (P = .8), xerostomia (P = .9)].

CONCLUSION

In HPV-related OPSCC, neoadjuvant chemotherapy followed by TORS and ND as definitive treatment is associated with excellent QOL outcomes. Postoperative QOL scores returned to baseline by 3 months and were maintained for all measures, indicating a return to normal function.

Transoral robotic surgery without adjuvant therapy: A systematic review and meta-analysis of the association between surgical margins and local recurrence

BACKGROUND

Transoral robotic surgery (TORS) is increasingly employed in the management of oropharyngeal cancer without adjuvant treatment. Attaining safe surgical margins is paramount to preventing local recurrence (LR), but the necessary surgical margin dimension remains contentious.

METHODS

Systematic review and meta-analysis of studies reporting margin status and LR following TORS without adjuvant therapy for primary OPSCC.

RESULTS

The search identified 269 articles and 11 were selected for inclusion, with 406 patients included in the meta-analysis. Heterogeneity was noted in the definition of "close" margins. Random-effects pooled rate of positive margins was 7 % (95 % CI 0.04-0.12, I2 = 54 %, p = 0.02) and close margins was 7 % (95 % CI 0.02-0.27, I2 = 86 %, p=<0.01). The random-effects overall rate of LR was 6 % (95 % CI 0.04-0.10, I2 = 11 %, p = 0.35), 13 % (95 % CI 0.02-0.620, I2 = 0 %, p = 1.0) after a positive margin, and 3 % (95 % CI 0.03-0.24, I2 = 23 %, p = 0.26) after a close margin. Odds ratio (OR) for LR indicated higher risk of LR for positive compared to close margins (7.5; 95 % CI 1.31-42.91, I2 = 0 %, p = 0.51), and a slightly lower risk of LR between close and negative margins (2.22; 95 % CI 0.67-7.38, I2 = 0 %, p = 0.8). A lack of frozen-section analysis (OR 2.91, p = 0.36) and HPV-negative disease (OR 1.68, p = 0.03) were associated with an elevated risk of LR.

CONCLUSIONS

TORS as a standalone treatment is associated with low rates of LR; however, the literature is hampered by considerable heterogeneity in margin definitions. Larger multicentre studies are required to determine the precise margin cut-off required for oropharyngeal tumours managed with TORS alone.

Compartmental Transoral Robotic Lateral Oropharyngectomy with the da Vinci Single-Port System: Surgical Technique

BACKGROUND

Transoral robotic surgery (TORS) has renovated the surgical management of oropharyngeal squamous cell carcinoma (OPSCC), allowing a minimally invasive surgical approach with optimal oncological outcomes. The recent introduction of the da Vinci Single Port (SP) system resulted in a considerable improvement of TORS technique.

METHODS

In this video, we illustrate the transoral robotic lateral oropharyngectomy performed with the da Vinci SP system in a 50-year-old male patient suffering from a p16+ oropharyngeal squamous cell carcinoma cT4N1M0.

RESULTS

The transoral robotic lateral oropharyngectomy is illustrated step by step. The structures encountered during the resection are described, and the surgical margins are defined based on anatomical landmarks. The most critical regions encountered during resection are pointed out, and the tip and tricks of this surgery are reported.

CONCLUSIONS

A step-by-step transoral lateral oropharyngectomy is described to increase its reproducibility. The da Vinci SP system owns various benefits for performing transoral lateral oropharyngectomy due to the increased maneuverability in the narrower oral cavity working spaces.

Velopharyngeal incompetence following transoral robotic surgery for oropharyngeal carcinoma: A scoping review

PURPOSE

Following transoral robotic surgery (TORS) for oropharyngeal carcinoma (OPC), velopharyngeal incompetence (VPI) is a known consequence that may contribute to swallowing and speech disorders. As the incidence of OPC increases affecting a younger demographic, a better understanding of VPI is required to support speech and swallowing rehabilitation.

METHOD

A scoping review was conducted using Arskey & O'Malley's framework. Studies were identified from five databases between 2007 and 2020. The methodological quality was measured with the RevMan Risk of Bias Tool by two independent evaluators.

RESULT

A total of seven studies met the inclusion criterion. There was a combined total of 306 participants, their average age was 59.2 years. A high risk of bias and degree of heterogeneity across all seven cohort studies was observed. Validated and instrumental evaluations of VPI were present in two papers, with the majority only reporting the presence or absence of VPI. The incidence of VPI reported in each study ranged from 0 to 53%, (median 3.5%).

CONCLUSION

There are few high-quality studies and considerable heterogeneity in the terminology, inclusion criteria and measurement of VPI. Instrumentation, to date, has been rarely used but is necessary for a normed and validated approach to VPI. Based on this review, there is considerable need for larger studies which instrumentally and longitudinally assess VPI as a consequence of TORS, in order to guide patient education and management prior to, and following their surgery.

Eugene Nicholas Myers' Lecture on Head and Neck Cancer, 2020: The Surgeon as a Prognostic Factor in Head and Neck Cancer Patients Undergoing Surgery

This paper is a transcript of the 29 th Eugene N. Myers, MD International Lecture on Head and Neck Cancer presented at the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) in 2020. By the end of the 19 th century, the survival rate in treated patients was 10%. With the improvements in surgical techniques, currently, about two thirds of patients survive for > 5 years. Teamwork and progress in surgical reconstruction have led to advancements in ablative surgery; the associated adjuvant treatments have further improved the prognosis in the last 30 years. However, prospective trials are lacking; most of the accumulated knowledge is based on retrospective series and some real-world data analyses. Current knowledge on prognostic factors plays a central role in an efficient treatment decision-making process. Although the influence of most tumor- and patient-related prognostic factors in head and neck cancer cannot be changed by medical interventions, some environmental factors-including treatment, decision-making, and quality-can be modified. Ideally, treatment strategy decisions should be taken in dedicated multidisciplinary team meetings. However, evidence suggests that surgeons and hospital volume and specialization play major roles in patient survival after initial or salvage head and neck cancer treatment. The metrics of surgical quality assurance (surgical margins and nodal yield) in neck dissection have a significant impact on survival in head and neck cancer patients and can be influenced by the surgeon's expertise. Strategies proposed to improve surgical quality include continuous performance measurement, feedback, and dissemination of best practice measures.

Transoral Robotic surgery - excision of Tongue base Tumour with the Entire Hyoid bone in a Salvage Setting

Objectives - Transoral robotic surgery (TORS) is an already well established modality of treatment for early stage oropharyngeal cancer. This case report will throw light on the role of TORS as a treatment option for oropharyngeal cancer in a salvage setting. Methods - This is a case of a 69 year old patient who was a follow up case of carcinoma base of tongue, status - post concurrent chemoradiation who presented with residual disease at the primary site. Results - TORS was used as a successful treatment modality for base of tongue carcinoma in a salvage setting. The surgical procedure included removal of the entire hyoid bone in toto along with the tumour which is not reported in literature. The procedure also helped us in achieving an R0 resection. Conclusion - TORS should be considered as an important management modality for tongue base tumours in upfront as well as salvage setting.

Single centre analysis of perioperative complications in trans-oral robotic surgery for oropharyngeal carcinomas

Trans Oral Robotic Surgery (TORS) is a modality in the management of oropharyngeal squamous cell carcinoma(OPSCC). This study was conducted to show the rates of peri-operative complications after TORS for OPSCC in our experience. Single centre retrospective analysis of consecutive OPSCC treated with TORS. The surgical complication severity was recorded according to Clavien-Dindo criteria (CDC). Eighty-seven OPSCC were operated with TORS. According to CDC, grade I, grade II and IIIb were registered in 8%, 4.6% and 11.5% of cases, respectively. The postoperative pain, registered with visual-analogue scale (VAS) score, was 8 ± 1.2 for the secondary healing wounds and 6.2 ± 1.5 for the flap reconstructions (p < 0.01). The impact on swallowing function was not significant between secondary healing and flap reconstructions(p = 0.96). Any major or life-threatening intraoperative complications have not been recorded. Only one patient had postoperative bleeding into the neck whilst 13.3% of patients had postoperative bleeding from the primary tumor. No total local or free flap failure were registered. The mean duration of tracheostomy use was 7.4 ± 2.6 days, and nasogastric tube 14.3 ± 6.9 days. Only one patient, who had also reconstruction with flap, experienced a postoperative severe dysphagia with severe aspiration, needing a permanent tracheostomy tube and percutaneous endoscopic gastrostomy feeding. TORS for OPSCC showed less morbidity, lower risk of severe complication and mortality. Thus, this treatment modality could be offered as first line treatment in selected cases.

Etiology, diagnosis, treatment, and prevention of human papilloma virus-associated oropharyngeal squamous cell carcinoma

Classical oropharyngeal squamous cell carcinoma (OPSCC) caused by alcohol consumption and smoking and HPV-associated OPSCC caused by human papillomavirus (HPV) infection have different etiologies, incidences, and prognoses. Therefore, the 8th American Joint committee on Cancer (AJCC) and Union for International Cancer Control (UICC) TNM classifications propose distinguishing HPV-associated OPSCC from classical OPSCC and classifying it as an independent disease. Therefore, this review provides an overview of HPV-associated OPSCC from the perspectives of epidemiology, carcinogenesis, development, diagnosis, treatment, and prevention. The incidence of HPV-associated OPSCC is increasing. Although HPV vaccination has been shown to be effective at reducing the incidence of cervical cancer, it is still unclear how it affects the incidence of HPV-associated OPSCC. Additionally, the prognosis of patients with HPV-associated OPSCC is extremely favorable compared to that of patients with classical OPSCC. Therefore, patients with HPV-associated OPSCC may undergo reduced-dose therapy, although attempts to reduce treatment intensity should be carefully planned to ensure they do not compromise oncological outcomes, and large-scale trials aimed at reducing treatment intensity are ongoing.

Transoral Robotic Surgery for Head and Neck Cancer: Advances and Residual Knowledge Gaps

Minimally invasive surgery is a growing field in surgical oncology. After acquiring its first Food and Drug Administration approval in 2009 for T1–T2 malignancies of the oral cavity, oropharynx, and larynx, transoral robotic surgery (TORS) has gained popularity thanks to its wristed instruments and magnified three-dimensional view, enhancing surgical comfort in remote-access areas. Its indications are expanding in the treatment of head and neck cancer, i.e., resection of tumors of the larynx, hypopharynx, or parapharyngeal space. However, this expansion must remain cautious and based on high-level evidence, in order to guarantee safety and oncological outcomes which are comparable to conventional approaches. This narrative review assesses the current role of TORS in head and neck cancer from an evidence-based perspective, and then identifies what knowledge gaps remain to be addressed.

A Survey of Transoral Robotic Mechanisms: Distal Dexterity, Variable Stiffness, and Triangulation

Robot-assisted technologies are being investigated to overcome the limitations of the current solutions for transoral surgeries, which suffer from constrained insertion ports, lengthy and indirect passageways, and narrow anatomical structures. This paper reviews distal dexterity mechanisms, variable stiffness mechanisms, and triangulation mechanisms, which are closely related to the specific technical challenges of transoral robotic surgery (TORS). According to the structure features in moving and orienting end effectors, the distal dexterity designs can be classified into 4 categories: serial mechanism, continuum mechanism, parallel mechanism, and hybrid mechanism. To ensure adequate adaptability, conformability, and safety, surgical robots must have high flexibility, which can be achieved by varying the stiffness. Variable stiffness (VS) mechanisms based on their working principles in TORS include phase-transition-based VS mechanism, jamming-based VS mechanism, and structure-based VS mechanism. Triangulations aim to obtain enough workspace and create adequate traction and counter traction for various operations, including visualization, retraction, dissection, and suturing, with independently controllable manipulators. The merits and demerits of these designs are discussed to provide a reference for developing new surgical robotic systems (SRSs) capable of overcoming the limitations of existing systems and addressing challenges imposed by TORS procedures.

Treatment Considerations for Patients with Locoregionally Advanced Head and Neck Cancer with a Contraindication to Cisplatin

OPINION STATEMENT

Significant advancements have been made in the treatment of locally advanced head and neck cancer, predominantly driven by the integration of concurrent chemotherapy with radiation therapy as a standard of care for many patients. The most heavily investigated chemotherapeutic is cisplatin, yet many patients are ineligible for cisplatin due to the presence of pre-existing medical comorbidities. Moreover, given the toxicity profile of cisplatin, identifying which patients stand to benefit from cisplatin is challenging, which is particularly evident in older patients. Efforts to better risk-stratify patients based on age, performance status, and the degree of pre-existing comorbidities are ongoing and have been increasingly utilized in national clinical trials. In parallel, exploration into alternative systemic agents, including novel targeted therapies and immunotherapies, in cisplatin-ineligible patients are rapidly expanding. Cumulatively, identifying appropriate treatment paradigms in patients who harbor contraindications to cisplatin can not only improve clinical outcomes but also critically mitigate detrimental adverse effects.

Transoral robotic resection of advanced recurrent nasopharyngeal carcinoma involving the internal carotid artery

BACKGROUND

Transoral robotic surgery (TORS) is a reliable, minimally invasive approach for treating recurrent nasopharyngeal carcinoma (rNPC). However, tumours involving the internal carotid artery (ICA) are considered to be unsuitable for TORS. This paper presents the first case of transoral robotic resection of advanced rNPC involving the ICA.

MATERIALS AND METHODS

This case is a 55 year-old male patient who received radiotherapy 27 years ago. This patient underwent a standard TORS resection 2 weeks after ipsilateral ICA embolization.

RESULTS

Postoperative Magnetic resonance imaging and biopsy results indicated total resection. During the 2 month follow-up, no severe complications were found, and the primary site was tumour-free.

CONCLUSION

This study preliminarily presents the feasibility and efficiency of advanced rNPC resection with TORS. TORS can potentially provide better quality of life for patients as a less invasive approach than current endoscopic surgery. Even so, the surgical approach should be selected strictly according to the tumour's location.

Analysis of Outcomes following TORS in a Mixed Cohort of Recurrent and New T1-T2 Oropharyngeal Cancer- A Single Institution Study

Purpose

. The transoral robotic surgery is a newer modality being used in surgical treatment of early oropharyngeal cancer. The aim of this study is to assess the outcome of these cases in terms of two year disease free survival and overall survival.

Methods

Between July 2016 and September 2018, 58 patients suffering from early oropharyngeal cancer underwent transoral robotic surgery with neck dissection at a tertiary referral centre. 43 of them have completed two years follow up and were analyzed for disease free survival and overall survival. 41 patients had HPV analysis done .

Results

The surgical margins were positive in 9/43 patients ( 6 in upfront surgery and 3 in the salvage cohort). Adjuvant therapy was administered to 16/34 patients on account of either positive margins or multiple nodal metastasis. 88% patients were found to be HPV negative. The two year disease free survival for the upfront cohort was 88.2% and salvage cohort was 55.5%. The overall survival was 86.05%.

Conclusions

The study highlights good locoregional control and two year disease free survival in HPV negative oropharyngeal cancer undergoing robotic surgery. Additionally, a positive surgical margin and recurrence were the statistically significant variables influencing 2 year disease free survival. Trans oral robotic surgery is an excellent tool for early tumors of the oropharynx. The presence of a positive surgical margin is a grim sign for survival and has a significant impact on positive outcome.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-022-03139-5.

Surgical clinical trials for HPV-positive oropharyngeal carcinoma

The treatment of HPV-positive oropharyngeal squamous cell carcinoma (OPSCC) continues to evolve as multiple ongoing and recently completed clinical trials investigate the role of surgery, radiation therapy, chemotherapy, and immunotherapy. Current trials are investigating transoral robotic surgery (TORS) in treatment de-escalation protocols in an effort to optimize quality of life, while maintaining historical survival rates. The advantage of TORS is its minimally invasive approach to primary resection of the tumor as well as valuable pathologic staging. The ORATOR trial reported poorer quality of life in patients treated with TORS compared to primary radiotherapy though this was not a clinically meaningful difference. The recently published ECOG 3311 trial showed that surgery can be used to safely de-escalate the adjuvant radiation dose to 50 Gy in intermediate-risk patients. In this review, we summarize and discuss the past and current clinical trials involving surgery in the treatment of HPV-positive OPSCC.

Swallowing After Primary TORS and Unilateral or Bilateral Radiation for Low- to Intermediate-Risk Tonsil Cancer

OBJECTIVE

The primary course of treatment for patients with low- to intermediate-risk tonsil cancer has evolved with a shift toward primary transoral robotic surgery (TORS) or radiation therapy (RT). While favorable outcomes have been reported after deintensification via unilateral TORS or RT (uniRT), comparisons of functional outcomes between these treatments are lacking. We compared clinical outcomes (Dynamic Imaging Grade of Swallowing Toxicity [DIGEST] and feeding tube [FT]) and patient-reported swallowing outcomes (MD Anderson Dysphagia Inventory [MDADI]) based on primary treatment strategy: TORS, uniRT, or bilateral RT (biRT).

STUDY DESIGN

Secondary analysis of prospective cohort.

SETTING

Single institution.

METHODS

The study sample comprised 135 patients with HPV/p16+ T1-T3, N0-2b (American Joint Committee on Cancer, seventh edition), N0-1 (eighth edition) squamous cell carcinoma of the tonsil were sampled from a prospective registry. Modified barium swallow studies graded per DIGEST, FT placement and duration, and MDADI were collected.

RESULTS

Baseline DIGEST grade significantly differed among treatment groups, with higher dysphagia prevalence in the TORS group (34%) vs the biRT group (12%, P = .04). No significant group differences were found in DIGEST grade or dysphagia prevalence at subacute and longitudinal time points (P = .41). Mean MDADI scores were similar among groups at baseline (TORS, 92; uniRT, 93; biRT, 93; P = .90), subacute (TORS, 83; uniRT, 88; biRT, 82; P = .38) and late time points (TORS, 86; uniRT, 86; biRT, 87; P = .99). FT placement and duration significantly differed among primary treatment groups (FT [median days]: TORS, 89% [3]; uniRT, 8% [82]; biRT, 37% [104]; P < .001).

CONCLUSION

While TORS and uniRT offer optimal functional outcomes related to dysphagia, results suggest that no measurable clinician-graded or patient-reported differences in swallow outcomes exist among these primary treatment strategies and biRT. Aside from baseline differences that drive treatment selection, differences in FT rate and duration by primary treatment strategy likely reflect diverse toxicities beyond dysphagia.

The Sinai Robotic Surgery Trial in HPV-related oropharyngeal squamous cell carcinoma (SIRS 2.0 trial) – study protocol for a phase II non-randomized non-inferiority trial

Background

Human papillomavirus associated oropharyngeal squamous cell carcinoma (HPVOPSCC) usually affects a younger patient population. As such, the risk for long term toxicity associated with therapy is an important consideration. Multiple trials focused on de-escalation of therapy to preserve survival outcomes while minimizing treatment toxicity are currently in progress, however the question of which patients are ideal candidates for de-escalation remains unanswered. Circulating tumor DNA (cfHPVDNA) has emerged as a means of monitoring disease in patients with HPVOPSCC. Undetectable postoperative cfHPVDNA levels portend a better prognosis and by extension, may identify ideal candidates for de-escalation therapy. We propose an overview and rationale for a new institutional clinical trial protocol focusing on the use of cfHPVDNA to risk stratify patients for adjuvant therapy. We hypothesize that many surgical patients currently receiving radiation therapy may be clinically observed without adjuvant therapy.

Methods

Patients with measurable cfHPVDNA and clinically resectable HPVOPSCC will undergo TORS resection of tumors and neck dissection. Patients with undetectable cfHPVDNA at 3 weeks post-op will be allocated to low or high-risk treatment protocol groups. The low risk group consists of patients with <4 positive lymph nodes, ≤2 mm extranodal extension (ENE), and perineural invasion (PNI) or lymphovascular invasion (LVI) alone. The high-risk group is made up of patients with ≥4 positive lymph nodes, gross ENE, positive margins, N2c disease and/or the combination of both PNI and LVI. The low-risk group will be allocated to an observation arm, while the high-risk group will receive 46 Gy of adjuvant radiotherapy and weekly cisplatin therapy. The primary outcome of interest is 2-year disease recurrence with secondary outcomes of 2-year disease free survival, locoregional control, overall survival, and quality of life measures. A sample of 126 patients in the low-risk group and 73 patients in the high-risk group will be required to evaluate non-inferiority to the standard of care.

Discussion

This study will provide much needed recurrence and survival data for patients that undergo primary TORS followed by observation or de-escalated adjuvant therapy. Additionally, it will help delineate the role of cfHPVDNA in the risk stratification of patients that undergo treatment de-intensification.

Transoral Robotic Surgery for Oropharyngeal Squamous Cell Carcinoma of the Tonsil versus Base of Tongue: A Systematic Review and Meta-Analysis

Simple Summary

Transoral Robotic Surgery (TORS) has become widely adopted for the surgical removal of oropharyngeal squamous cell carcinoma (OPSCC). However, it is currently unknown if TORS has equal efficacy and outcomes in patients with tonsillar or base of tongue (BOT) OPSCC. Therefore, we performed a systematic review, including articles describing the surgical management of OPSCC with TORS that compared margin status, complications, and recurrence between tonsil and BOT. BOT OPSCC had a higher rate of positive margins compared to tonsillar OPSCC. However, no differences were seen in the recurrence or postoperative hemorrhage rates of BOT and tonsillar OPSCC. While a higher rate of positive margins was seen in BOT OPSCC when compared to tonsillar OPSCC, this did not translate to a higher recurrence rate in the BOT group. Future research on which subset of patients with BOT is more likely to have positive margins is warranted to improve the utility of TORS further.

Abstract

Transoral Robotic Surgery (TORS) has become widely adopted for the surgical removal of oropharyngeal squamous cell carcinoma (OPSCC), with the most common locations being in the tonsil and base of tongue (BOT). However, it is currently unknown if TORS has equal efficacy and outcomes in patients with tonsillar or BOT OPSCC. Therefore, the aim of this study was to compare the margin status and recurrence rates of tonsillar and BOT OPSCC after TORS. Per PRISMA guidelines, PubMed, Scopus, and CINAHL were systematically searched from inception to 2/28/2022. Articles including the surgical management of OPSCC with TORS that compared margin status, complications, and recurrence between tonsil and BOT were included. Meta-analyses of proportions and odds ratios were performed. A total of 28 studies were included, comprising 1769 patients with tonsillar OPSCC and 1139 patients with BOT OPSCC. HPV positivity was seen in 92.3% of tumors. BOT OPSCC had a higher rate of positive margins compared to tonsillar OPSCC (28.1% [95%CI 15.1–43.3] vs. 7.5% [95%CI 3.3–13.3]). No differences were seen in recurrence between BOT and tonsillar OPSCC (OR 1.1 [95%CI 0.8–1.5], p = 0.480). In addition, no differences in postoperative hemorrhage were seen between tonsillar and BOT OPSCC (10.7% [95%CI 6.1–16.5] vs. 8.8% [95% CI 1.5–21.3]). While a higher rate of positive margins was seen in BOT OPSCC when compared to tonsil OPSCC, this did not translate to a higher recurrence rate in the BOT group. Future research on which subset of patients with BOT is more likely to have positive margins is warranted to improve the utility of TORS further.

Practice patterns in transoral robotic surgery: results of an American head and neck society survey

To understand perioperative practices for transoral robotic surgery (TORS) among academic medical centers. An electronic cross-sectional survey was distributed to fellows and program directors participating in 49 American Head and Neck Society fellowships. Operative decisions, medical and swallowing management, and disposition planning were assessed. Thirty-eight responses were collected (77.6%). Twenty-three centers (60.5%) performed > 25 cases annually with the remainder performing fewer. The da Vinci Si was the most commonly used platform (n = 28, 73.7%). A majority of institutions advocated tailored resection to adequate margins (n = 27, 71.1%) over fixed subunit-based resection (n = 11, 28.9%). Most surgeons (n = 29, 76.3%) performed neck dissection concurrent with TORS, and 89.5% (n = 34) routinely ligated external carotid artery branches. A minority of institutions (n = 17, 45.9%) endorsed a standardized TORS care pathway. Antibiotic choices and duration varied, the most common choice being ampicillin/sulbactam (n = 21, 55.3%), and the most common duration being 24 h or less (n = 22, 57.9%). Multimodal analgesia was used at 36 centers (94.7%), steroids at 31 centers (81.6%), and pharmacologic venous thromboembolic prophylaxis at 29 centers (76.3%). Nasogastric feeding tubes were placed during surgery at 20 institutions (54.1%). Speech-language pathologists routinely performed postoperative swallow evaluations at 29 (78.4%) sites. Practice patterns are variable among institutions performing TORS. While certain surgical and postoperative practices were quite common, many institutions reported no standard TORS care pathway. Further understanding of the impact of individual practices on outcomes is necessary to develop evidence-based perioperative protocols for TORS.

Upfront transoral robotic surgery (TORS) versus intensity-modulated radiation therapy (IMRT) in HPV-positive oropharyngeal cancer: real-world data from a tertiary comprehensive cancer center

Objective

Methods

Results

Conclusions

Transoral robotic surgery and neck dissection alone for head and neck squamous cell carcinoma: Influence of resection margins on oncological outcomes

OBJECTIVES

This study reports oncological outcomes of transoral robotic surgery (TORS) and neck dissection (ND) alone for head and neck squamous cell carcinoma (HNSCC) and aims to analyse the influence of resection margins on local recurrence rates.

MATERIALS AND METHODS

Fifty-one patients treated with curative intent for HNSCC, with TORS and ND alone between 2013 and 2019 at two tertiary centres were included in this observational multi-centre prospective cohort study. Oncological outcomes are reported on 47 patients for whom the aim was to treat with TORS and ND alone; this excluded four patients who were recommended adjuvant radiotherapy based on resective pathology but did not receive treatment. Local control is the primary endpoint; disease specific, progression free and overall survival are secondary outcomes.

RESULTS

With a median follow up of 43 months, estimated outcomes at 3 years (n = 47) were as follows: local control 92%, progression free survival 80%, disease specific survival 94%, and overall survival 84%. Presence of a positive margin on the main specimen was the only statistically significant predictor of local recurrence on univariate Cox regression analysis. Time dependent receiver operating characteristic curve identified margins of 1.1 mm as a threshold for local control, with area under the curve 0.788 (95% CI 0.616-0.960), indicating a good classifier.

CONCLUSION

This is the first UK surgery alone series reporting mature oncological outcomes following TORS and ND. Positive margins on the resected specimen are the strongest predictor of local recurrence, with conventional definitions of "close margins" having no impact.

Human papillomavirus-related oropharyngeal carcinoma

It was not until around 2000 that human papillomavirus-related oropharyngeal carcinoma was recognized as carcinoma with clinical presentations different from nonrelated head and neck carcinoma. Twenty years after and with the revision of the tumor-node-metastasis classification in 2017, various clinical trials focused on human papillomavirus-related oropharyngeal carcinoma to improve the prognosis and quality of life of patients with this disease. However, the incidence of human papillomavirus-related cancers is increasing, which is expected to be particularly prominent in Japan, where human papillomavirus vaccination is not widely available. In this review, we describe the current status of clinical trials (mainly focused on initial surgery and radiation dose reduction) for, primary and secondary prevention of, and the present status of human papillomavirus-related oropharyngeal carcinoma in Japan.

A benchmark for oncologic outcomes and model for lethal recurrence risk after transoral robotic resection of HPV-related oropharyngeal cancers

OBJECTIVES

Increasing use of transoral robotic surgery (TORS) is likely to impact outcomes for HPV+ oropharyngeal squamous cell carcinomas (OPSCCs). We aimed to describe oncologic outcomes for a large HPV+ OPSCC cohort after TORS and develop a risk prediction model for recurrence under this treatment paradigm.

MATERIALS AND METHODS

634 HPV+ OPSCC patients receiving TORS-based therapy at a single institution were reviewed retrospectively to describe survival across the entire cohort and for patients suffering recurrence. Risks for distant metastatic recurrence (DMR) and locoregional recurrence (LRR) were modeled using multivariate logistic regression analyses of case-control sub-cohorts.

RESULTS

5-year overall and recurrence-free survival were 91.2% and 86.1%, respectively. 5-year overall survival was 52.5% following DMR and 83.3% after isolated LRR (P = .01). In case-control analyses, positive surgical margins were associated with DMR (adjusted OR 5.8, CI 2.1-16.0, P = .001), but not isolated LRR, and increased DMR risk 4.2 fold in patients with early clinical stage disease. By contrast, LRR was associated with not receiving recommended adjuvant therapy (OR 13.4, CI 6.3-28.5, P < .001).

CONCLUSIONS

This study sets a benchmark for oncologic outcomes from HPV+ OPSCC after TORS-based therapy. Under this treatment paradigm, margins are relevant for assessing lethal recurrence risk during clinical trial design and post-treatment surveillance.

The omission of intentional primary site radiation following transoral robotic surgery in 59 patients: No local-regional failures

BACKGROUND

We assessed locoregional control with omission of intentional primary site radiation after transoral robotic surgery (TORS) and quantified nontargeted primary site dose.

METHODS

Following Institutional Review Board (IRB) approval, patients treated with primary TORS resection for squamous cell carcinomas of the oropharynx were reviewed. Patients with cT1-2 tumors, >2 mm margins, in whom the surgeon resected the primary without revising specimen-driven margins, qualified for omission of primary site radiation.

RESULTS

From 2014 to 2019, 112 patients met criteria. Fifty-nine (52%) patients did not receive radiation targeting the primary site; of whom, 22 received no radiation. In this group, there were no local failures; mean age was 58 years and median follow-up was 25 months. Thirty-seven patients received adjuvant radiation targeting the neck, mean bystander dose to the primary site was 28.8 Gy (range, 13.3-50.6 Gy).

CONCLUSION

In a 59 patient population, omission of radiation to the primary site after TORS resulted in no locoregional failures.