Salvage surgery for recurrent cancers of the oropharynx: comparing TORS with standard open surgical approaches

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.

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.

Evaluation of a newly developed oral and maxillofacial surgical robotic platform (KD-SR-01) in head and neck surgery: a preclinical trial in porcine models

Traditional open head and neck surgery often leaves permanent scars, significantly affecting appearance. The emergence of surgical robots has introduced a new era for minimally invasive surgery. However, the complex anatomy of the head and neck region, particularly the oral and maxillofacial areas, combined with the high costs associated with established systems such as the da Vinci, has limited the widespread adoption of surgical robots in this field. Recently, surgical robotic platform in China has developed rapidly, exemplified by the promise shown by the KangDuo Surgical Robot (KD-SR). Although the KD-SR has achieved some results comparable to the da Vinci surgical robot in urology and colorectal surgery, its performance in complex head and neck regions remains untested. This study evaluated the feasibility, effectiveness, and safety of the newly developed KD-SR-01, comparing it with standard endoscopic systems in head and neck procedures on porcine models. We performed parotidectomy, submandibular gland resection, and neck dissection, collected baseline characteristics, perioperative data, and specifically assessed cognitive workload using the NASA-TLX. None of the robotic procedures were converted to endoscopic or open surgery. The results showed no significant difference in operation time between the two groups (P = 0.126), better intraoperative bleeding control (P = 0.001), and a significant reduction in cognitive workload (P < 0.001) in the robotic group. In conclusion, the KD-SR-01 is feasible, effective, and safe for head and neck surgery. Further investigation through well-designed clinical trials with long-term follow-up is necessary to establish the full potential of this emerging robotic platform.

Increasing radiation therapy and lower survival for human papillomavirus-related oropharynx cancer associated with a shift to community cancer center care

BACKGROUND

Studies have shown lower overall survival for patients with head and neck cancer treated at low-volume or community cancer centers. As the incidence of human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma steadily rises in the United States, we hypothesized that a greater proportion of patients with HPV-related oropharyngeal squamous cell carcinoma is being treated at community cancer centers, with a shift toward primary nonsurgical treatment.

METHODS

This cohort study included patients from the US National Cancer Database who received a diagnosis of HPV-related oropharyngeal squamous cell carcinoma from 2010 to 2019 and underwent treatment at a community cancer center or academic cancer center. The proportion of patients with HPV-related oropharyngeal squamous cell carcinoma treated at community cancer centers and receiving primary nonsurgical treatment was analyzed over time. Four-year overall survival was compared between community cancer centers and academic cancer centers.

RESULTS

The majority (67.4%) of 20 298 patients were treated at an academic cancer center, yet the proportion of patients treated at community cancer centers increased by 10% from 2010 to 2019 (P < .01 for trend). The proportion of patients undergoing primary nonsurgical treatment increased from 62.1% to 73.7% from 2010 to 2019 (P < .01 for trend), and patients were statistically significantly more likely to undergo nonsurgical treatment at community cancer centers than at academic cancer centers (adjusted odds ratio = 1.20, 95% confidence interval = 1.18 to 1.22). Treatment at community cancer centers was associated with worse survival overall (adjusted hazard ratio = 1.19, 95% confidence interval = 1.09 to 1.31), specifically for patients receiving primary nonsurgical treatment (adjusted hazard ratio = 1.22, 95% confidence interval = 1.11 to 1.34).

CONCLUSIONS

Treatment of HPV-related oropharyngeal squamous cell carcinoma has recently shifted to community cancer centers, with an increase in the proportion of nonsurgical treatment and worse overall survival at these centers compared with academic cancer centers. Concentration of care for HPV-related oropharyngeal squamous cell carcinoma at academic cancer centers and dedicated head and neck cancer centers may increase access to all available treatment modalities and improve survival.

The emerging role of robotics in plastic and reconstructive surgery: a systematic review and meta-analysis

The role of robotics has grown exponentially. There is an active interest amongst practitioners in the transferability of the potential benefits into plastic and reconstructive surgery; however, many plastic surgeons report lack of widespread implementation, training, or clinical exposure. We report the current evidence base, and surgical opportunities, alongside key barriers, and limitations to overcome, to develop the use of robotics within the field. This systematic review of PubMed, Medline, and Embase has been conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PROSPERO (ID: CRD42024524237). Preclinical, educational, and clinical articles were included, within the scope of plastic and reconstructive surgery. 2, 181, articles were screened; 176 articles met the inclusion criteria across lymph node dissection, flap and microsurgery, vaginoplasty, craniofacial reconstruction, abdominal wall reconstruction and transoral robotic surgery (TOR). A number of benefits have been reported including technical advantages such as better visualisation, improved precision and accuracy, and tremor reduction. Patient benefits include lower rate of complications and quicker recovery; however, there is a longer operative duration in some categories. Cost presents a significant barrier to implementation. Robotic surgery presents an exciting opportunity to improve patient outcomes and surgical ease of use, with feasibility for many subspecialities demonstrated in this review. However, further higher quality comparative research with careful case selection, which is adequately powered, as well as the inclusion of cost-analysis, is necessary to fully understand the true benefit for patient care, and justification for resource utilisation.

Salvage transoral robotic surgery in recurrent oropharyngeal carcinoma: a single-center retrospective study

PURPOSE

Salvage surgery is still the best therapeutic option for resectable recurrent oropharyngeal squamous cell carcinoma (rOPSCC). Transoral robotic surgery may potentially reduce the morbidity of standard open approaches. The aim of the study is to present oncological and functional outcomes of a monocentric experience in salvage transoral robotic surgery.

METHODS

We performed a single-center retrospective analysis of patients submitted to transoral robotic salvage surgery with or without neck dissection for cT1-3 rOPSCC. We investigated complication rate, survival outcomes (Overall Survival, Disease Specific Survival, Loco-Regional Recurrence Free Survival) and functional outcomes (tracheal tube and/or gastrostomy dependence).

RESULTS

Sixty-one patients were included in the analysis. No major complications or perioperative deaths were recorded. The estimated 2-year OS was 76.7%, DSS 81.8% and LRRFS 50.5%. In multivariable analysis rpT, PNI (perineural infiltration) and HPV-positivity were significantly associated with LRRFS (Hazard Ratios: T3 vs T1 6.43, PNI yes vs no 4.19, HPV+ yes vs no 2.63). At last follow up, 97% of patients were tracheal tube-free, while 93% were gastrostomy-free.

CONCLUSION

Transoral robotic salvage surgery is a successful treatment in selected patients affected by rOPSCC because it grants good oncologic and functional outcomes.

Transoral robotic surgery for oropharyngeal cancer: a systematic review on the role of margin status

INTRODUCTION

Nowadays, robotic surgery finds application in the field of head and neck in the treatment of oropharyngeal tumors. The aim of this work is to examine the efficacy of transoral robotic surgery (TORS) in performing safe oncological resections of oropharyngeal squamous cell carcinoma (OPSCC), with particular attention to the status of margins.

EVIDENCE ACQUISITION

Literature search of English-language studies focused on TORS through PubMed, the Cochrane Library and EMBASE databases. A total of 431 papers returned to search, but only 24 met the inclusion criteria. The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Guidelines.

EVIDENCE SYNTHESIS

Within the selected studies, the overall rate of OPSCC positive margins following TORS is minimal, especially when patient selection is adequate and when TORS is used by high volume centers.

CONCLUSIONS

TORS is a very precise and viable therapeutic tool that provides good results in terms of surgical radicality with low positive margin rates and good results in terms of overall survival and disease-free survival; however, there is still a great heterogeneity in margins definition within the available literature. Consequently, even if this surgical approach is very promising, it is still challenging to draw firm conclusions nowadays.

Surgical margins in head and neck squamous cell carcinoma: A narrative review

Head and neck squamous cell carcinoma (HNSCC), a prevalent and frequently recurring malignancy, often necessitates surgical intervention. The surgical margin (SM) plays a pivotal role in determining the postoperative treatment strategy and prognostic evaluation of HNSCC. Nonetheless, the process of clinical appraisal and assessment of the SMs remains a complex and indeterminate endeavor, thereby leading to potential difficulties for surgeons in defining the extent of resection. In this regard, we undertake a comprehensive review of the suggested surgical distance in varying circumstances, diverse methods of margin evaluation, and the delicate balance that must be maintained between tissue resection and preservation in head and neck surgical procedures. This review is intended to provide surgeons with pragmatic guidance in selecting the most suitable resection techniques, and in improving patients' quality of life by achieving optimal functional and aesthetic restoration.

Role of TORS as De-Escalation Strategy in HPV-Related Oropharyngeal Cancer, What We Need to Know

Human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) presents unique challenges and opportunities for treatment, particularly regarding de-escalation strategies to reduce treatment morbidity without compromising oncological outcomes. This paper examines the role of Transoral Robotic Surgery (TORS) as a de-escalation strategy in managing HPV-related OPSCC. We conducted a comprehensive literature review from January 2010 to June 2023, focusing on studies exploring TORS outcomes in patients with HPV-positive OPSCC. These findings highlight TORS's potential to reduce the need for adjuvant therapy, thereby minimizing treatment-related side effects while maintaining high rates of oncological control. TORS offers advantages such as precise tumor resection and the ability to obtain accurate pathological staging, which can guide the tailoring of adjuvant treatments. Some clinical trials provide evidence supporting the use of TORS in specific patient populations. The MC1273 trial demonstrated promising outcomes with lower doses of adjuvant radiotherapy (RT) following TORS, showing high locoregional tumor control rates and favorable survival outcomes with minimal side effects. ECOG 3311 evaluated upfront TORS followed by histopathologically directed adjuvant therapy, revealing good oncological and functional outcomes, particularly in intermediate-risk patients. The SIRS trial emphasized the benefits of upfront surgery with neck dissection followed by de-escalated RT in patients with favorable survival and excellent functional outcomes. At the same time, the PATHOS trial examined the impact of risk-adapted adjuvant treatment on functional outcomes and survival. The ongoing ADEPT trial investigates reduced-dose adjuvant RT, and the DART-HPV study aims to compare standard adjuvant chemoradiotherapy (CRT) with a reduced dose of adjuvant RT in HPV-positive OPSCC patients. These trials collectively underscore the potential of TORS in facilitating treatment de-escalation while maintaining favorable oncological and functional outcomes in selected patients with HPV-related OPSCC. The aim of this scoping review is to discuss the challenges of risk stratification, the importance of HPV status determination, and the implications of smoking on treatment outcomes. It also explores the evolving criteria for adjuvant therapy following TORS, focusing on reducing radiation dosage and volume without compromising treatment efficacy. In conclusion, TORS emerges as a viable upfront treatment option for carefully selected patients with HPV-positive OPSCC, offering a pathway toward treatment de-escalation. However, selecting the optimal candidate for TORS-based de-escalation strategies is crucial to fully leverage the benefits of treatment de-intensification.

Oncological and functional outcomes for transoral robotic surgery following previous radiation treatment for upper aerodigestive tract head and neck cancers. A French multicenter GETTEC group study

BACKGROUND

Transoral robotic surgery (TORS) opens new perspectives. We evaluated the outcomes for patients having undergone TORS after previous radiotherapy.

METHODS

A retrospective multicenter study (n = 138) in a previously irradiated area between 2009 and 2020. Survival was assessed with the Kaplan-Meier method. Prognostic factors were evaluated using a chi-squared test, Fisher's test, or Wilcoxon's test.

RESULTS

The median length of hospital stay was 12.5 days. Bleeding was the most frequent postoperative complication (15.2%, n = 22). Prophylactic vessel ligation did not significantly decrease bleeding. Complications were significantly lower for Tis, T1, and N0 tumors. 91.6% (n = 120) of the patients with a perioperative tracheotomy could be decannulated. Larynx was functional for 65.94% of the patients. The median length of follow-up was 26 months. The 5-year overall and relapse-free survival rates were respectively 59.9% and 43.4%.

CONCLUSION

Oncological and functional results confirmed the value of TORS as a treatment in previously irradiated area.

Transoral Robotic Surgery for Oropharyngeal and Hypopharyngeal Squamous Cell Carcinoma

With oropharyngeal cancer incidence rising globally, largely due to human papillomavirus (HPV), and hypopharyngeal cancer known for poor outcomes, innovative treatments are needed. Transoral robotic surgery (TORS) offers a minimally invasive approach that may improve upon traditional open surgery and radiotherapy/chemoradiotherapy (RT/CRT) methods. We conducted a literature review and included 40 PubMed studies comparing TORS, open surgery, and RT/CRT for oropharyngeal and hypopharyngeal squamous cell carcinoma (SCC), focusing on survival rates and swallowing function outcomes. TORS provides favorable survival outcomes and typically results in superior swallowing function post-treatment compared to other therapeutic modalities in both oropharyngeal and hypopharyngeal SCCs. The clinical benefits of TORS, including improved operative precision and minimized tissue disruption, along with the elimination of surgical incision recovery and reduced RT toxicity, suggest it is a valuable surgical approach for head and neck cancers.

Transoral robotic surgery in oropharyngeal squamous cell carcinoma: A comparative study between da Vinci Single-Port and da Vinci Xi systems

BACKGROUND

The recently developed da Vinci single-port (SP) system offers potential advantages in maneuverability within narrower surgical spaces. This study aims to compare intra- and post-operative outcomes, technical advantages, and limitations of transoral resections using the da Vinci SP and da Vinci Xi systems for oropharyngeal squamous cell carcinoma (OPSCC).

METHODS

A single-center retrospective cohort study included patients with OPSCC who underwent transoral robotic surgery (TORS) after neoadjuvant chemotherapy (NCT). Data on pre-operative variables, intraoperative data, postoperative complications, and functional outcomes were collected.

RESULTS

A total of 209 patients (males: 175; mean age: 59.0 ± 9.3) were included (SP: n = 136; Xi: n = 73). A significantly lower docking time was measured for the SP group (5.7 ± 2.5 min vs. 10.0 ± 4.4 min; p <.001). Similarly, the console time was reduced for the SP group though not reaching statistical significance (76.3 ± 30.7 min vs. 88.1 ± 36.9 min; p =.06). A greater proportion of patients showed wide negative resection margins in the SP group (71 % vs. 56 %; p =.10), although not statistically significant. No significant differences were observed in complication rates or postoperative functional outcomes.

DISCUSSION

This study demonstrates the safety and efficacy of the da Vinci SP system in oropharyngeal surgery, with potential advantages in terms of reduced docking and console times. The findings suggest that the SP system offers improved maneuverability and instrument placement compared to the da Vinci Xi system.

Oncological results of salvage treatment in patients with oropharynx carcinoma treated with radiotherapy

OBJECTIVE

To evaluate the possibilities of salvage after local recurrence in patients with oropharyngeal carcinomas treated with radiotherapy, and to analyse the prognostic factors related to the final control of the disease.

METHODS

Retrospective study of 596 patients with oropharyngeal carcinoma treated with radiotherapy during the period 1991-2018.

RESULTS

One hundred and eighty-one patients (30.4%) had a local recurrence. Of the patients with a local recurrence, 51 (28.2%) were treated with salvage surgery. Variables that were associated with the patient not receiving salvage surgery were age greater than 75 years, tumour location in the posterior hypopharyngeal wall, an initial tumour extent cT4, and a recurrence-free interval of less than 6 months. Five-year specific survival of patients treated with salvage surgery was 19.1% (95% CI: 7.3%-30.9%). Variables that were related to specific survival were extent of recurrence and status of resection margins. Final tumour control was not achieved in any of the patients with extensive recurrence (rpT3-4, n = 25) or positive resection margins (n = 22).

CONCLUSION

Patients with oropharyngeal carcinomas treated with radiotherapy with local tumour recurrence have a limited prognosis. Most patients (71.8%) were not considered candidates for salvage surgery. The 5-year specific survival of patients treated with salvage surgery was 19.1%.

Oropharyngeal free flap reconstruction: Transoral robotic surgery versus open approach

Objective

Transoral robotic surgery (TORS) has evolved since its 2009 US Food and Drug Administration approval for use in local stage T1-T2 oropharyngeal carcinoma. The ability to resect increasingly larger and more complex lesions has led to the need to introduce reconstructive techniques through this route, avoiding the classic transmandibular or pull-through approach. Few studies have compared the safety, efficacy, and advantages of TORS versus classic open approaches in oropharyngeal salvage surgery with reconstruction using microanastomosed flaps. Here we retrospectively compare our center's experience with the open approach and TORS and describe the technical variations used.

Methods

Between 2013 and 2021, 30 stage III-IV oropharyngeal cancer patients underwent salvage surgery with reconstruction in our center. From 2013 to 2017, 15 patients underwent surgery with the classic open approach, and from 2018 to 2021, an additional 15 patients underwent TORS. We have compared surgical outcomes, post-surgical results, and survival in the two groups.

Results

Patient characteristics were similar in the two groups. TORS was associated with shorter surgical time (p < .001), fewer complications (p = .01), shorter hospital stay (p < .001), and lower feeding tube requirements (p = .003). No significant differences were observed between the two groups in the free margin rate or survival.

Conclusion

Oropharyngeal salvage surgery with TORS with free flap reconstruction reduced associated morbidity compared to the open approach in a patient cohort with poor prognosis.

Level of Evidence

4.

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.

Review of RM-1929 Near-Infrared Photoimmunotherapy Clinical Efficacy for Unresectable and/or Recurrent Head and Neck Squamous Cell Carcinoma

Head and neck squamous cell carcinoma (HNSCC) contribute to a significant global cancer burden. Developments in current therapeutic approaches have improved patient outcomes but have limited efficacy in patients with unresectable and/or recurrent HNSCC. RM-1929 near-infrared photoimmunotherapy (NIR-PIT) is an emerging treatment that is currently being investigated in a Phase III clinical trial and has been conditionally approved for the treatment of unresectable and/or recurrent HNSCC in Japan. Here, we collect a series of case reports and clinical trial data to assess the efficacy of RM-1929 NIR-PIT. Disease control rates ranged from 66.7 to 100% across these studies, and overall response rates ranged from 43.3 to 100%, suggesting positive clinical outcomes. Low-grade postoperative localized pain and edema were the most frequently reported side effects, and preliminary reports on quality of life and pain levels suggest that RM-1929 NIR-PIT does not significantly decrease quality of life and is manageable with existing pain management strategies, including opioids. These preliminary data in real-world use of RM-1929 NIR-PIT show that it is a well-tolerated therapy that has clinically meaningful outcomes for patients with unresectable and/or recurrent HNSCC.

Transoral robotic surgery vs. non-robotic surgeries for oropharyngeal squamous cell carcinoma: systematic review and meta-analysis

To compare the effectiveness of transoral robotic surgery (TORS) and non-robotic surgeries (NRES) in patients with oropharyngeal squamous cell carcinoma (OPSCC), medical databases were searched including PubMed, Web of Science, Medline, Embase, and Cochrane Library up to January 2023. The methodology follows PRISMA guidelines, including the PRISMA flow diagram. Data from the included studies were extracted independently by two researchers. Seven studies involving five hundred seventy-seven patients were included. Of these, 275 underwent TORS and 302 underwent NRES. The disease-free survival rate was significantly higher in the TORS group than in the NRES group (OR = 3.43, 95% CI 1.92-6.15, P < 0.0001). However, there were no significant differences in positive surgical margins, hospital stays, operation time, blood loss, postoperative bleeding rate, perioperative tracheostomy, perioperative feeding tube, and overall survival rate. These findings can initially guide the preoperative counseling of TORS in patients with OPSCC, and preliminarily confirm that the adoption of TORS deserves careful consideration.

Functional and quality-of-life outcomes following salvage surgery for recurrent squamous cell carcinoma of the head and neck: a systematic review and meta-analysis

BACKGROUND

Recurrent head and neck squamous cell carcinomas (HNSCC) are frequently managed with salvage surgery, but the impact these operations have on function and quality-of-life (QoL) is understudied. This review aimed to provide a quantitative and qualitative assessment of the functional and QoL effects of salvage surgical procedures.

METHODS

Systematic review and meta-analysis were conducted of studies reporting QoL and function following salvage HNSCC resections.

RESULTS

The search identified 415 articles and 34 were selected for inclusion. Pooled random effects analysis revealed long-term feeding and tracheostomy tube rates of 18% and 7%. Pooled long-term feeding tube rates in open oral and oropharyngeal, transoral robotic, total and partial laryngectomy surgeries were 41%, 25%, 11% and 4%. Eight studies used validated QoL questionnaires.

CONCLUSIONS

Functional and QoL outcomes from salvage surgery are acceptable, but appear to be worse following open procedures. Prospective studies measuring changes over time are needed to assess these procedures impact on patient well-being.

Complications following salvage transoral robotic surgery with and without reconstruction: A systematic review of the literature

BACKGROUND

Transoral robotic surgery (TORS) has been used in the salvage setting for head and neck cancers both with and without reconstruction. The complications of salvage TORS and the effect of reconstruction on complications has not been studied.

OBJECTIVE

To study the complications of salvage TORS and examine the effect of reconstruction on complication rates.

METHOD

An electronic search of the English- language literature using PubMed, Medline, and the Cochrane database was conducted and a systematic review performed in accordance with PRISMA guidelines (CRD42020181057).

RESULTS

A total of 23 studies including 533 patients have been published on salvage TORS.The average patient age was 61.2 years.Prior treatment was described for 420 patients.205 (48.8%) underwent prior definitive radiotherapy (RT).160 (38.1%) underwent definitive chemoradiotherapy (CRT).Only 55 (13.1%) had prior surgery.Overall, there were 158 complications with a pooled rate of 33.6% (95%CI: 25.4-42.3%).77 were major complications requiring surgical intervention with a pooled rate of 18.9% (95% CI: 14.8-23.3%).The number of patients undergoing reconstruction among salvage cases in the literature is 59 (9.19%), with 24 local flaps and 25 microvascular free flaps.Reconstruction was associated with lower overall hemorrhage rates but had no impact on major hemorrhage rates.

CONCLUSIONS

The pooled incidence rates of major complications, major POH and emergency tracheostomy following salvage TORS are 18.9%, 10.5%, and 4.4%.The rate of death following salvage TORS is 3.6%. Reconstruction was associated with lower overall hemorrhage rate after salvage TORS but had no impact on major postoperative hemorrhage rates.

Review of Outcomes after Salvage Surgery for Recurrent Squamous Cell Carcinoma of the Head and Neck

Surgery with adjuvant chemoradiotherapy or chemoradiotherapy is the mainstay in treatment for advanced stage head and neck squamous cell carcinoma; however, locoregional recurrences are frequent. Salvage surgery could be proposed in selected patients to improve local control, disease-free, and overall survival. Factors for improved disease-free and overall survival in patients treated with salvage surgery include age, tumor location, the initial T stage, HPV status, resection margins, and the time elapsing from the initial treatment. Clinical trials with adjuvant therapies have shown promise after salvage surgery in terms of tolerance and response, but clinical guidelines for using these adjuvant treatments are currently lacking. The aim of this review is to present current knowledge concerning the incidence and management of recurrent head and neck squamous cell carcinoma and current data concerning survival and morbidity after salvage surgery.

Current management and future challenges in salivary glands cancer

Salivary gland cancers (SGCs) are rare, accounting for less than 5% of all malignancies of the head and neck region, and are morphologically heterogeneous. The diagnosis is mainly based on histology, with the complementary aid of molecular profiling, which is helpful in recognizing some poorly differentiated, borderline, or atypical lesions. Instrumental imaging defines the diagnosis, representing a remarkable tool in the treatment plan. Ultrasound and magnetic resonance are the most common procedures used to describe the primary tumour. The treatment of SGCs is multimodal and consists of surgery, radiotherapy, and systemic therapy; each treatment plan is, however, featured on the patient and disease's characteristics. On 24 June 2022, in the meeting "Current management and future challenges in salivary gland cancers" many experts in this field discussed the state of the art of SGCs research, the future challenges and developments. After the meeting, the same pool of experts maintained close contact to keep these data further updated in the conference proceedings presented here. This review collects the insights and suggestions that emerged from the discussion during and after the meeting per se.

Factors Leading to Gastrostomy Tube and Tracheostomy Requirements in Patients Treated Initially With Radiotherapy and Salvaged With Surgery and Free Flap Reconstruction

OBJECTIVE

Patients with recurrent oropharyngeal cancer can achieve survival benefits from surgical salvage, and often require simultaneous free-flap reconstruction. Resection and reconstruction can impact function, leading to tube dependence.

PRIMARY OBJECTIVE

describe rates of tracheostomy and gastrostomy tube dependence after oropharyngeal resection and free flap after prior radiation.

SECONDARY OBJECTIVE

evaluate patient, tumor, and treatment factors associated with tube dependence.

STUDY DESIGN

Retrospective, multi-institutional cohort study. Patients treated from 2003 to 2020. Average follow-up 21.4 months.

SETTING

Five tertiary care centers.

METHODS

Consecutive cohort of patients undergoing resection and simultaneous free-flap reconstruction for oropharyngeal squamous cell carcinoma after head and neck radiation.

PRIMARY OUTCOMES

gastrostomy tube dependence and tracheostomy or tracheostoma 1 year after surgery. Univariable and multivariable logistic regression were performed to identify factors associated with dependence.

RESULTS

89 patients underwent oropharyngectomy and free-flap reconstruction; 18 (20%) underwent total laryngectomy as part of tumor extirpation. After surgery, 51 patients (57%) lived 12 months. Among patients alive at 12 months, 22 (43%) were at least partially-dependent on gastrostomy tube, and 15 (29%) had either tracheostomy or tracheostoma. On multivariable analysis, extensive glossectomy (OR 16.6, 95% CI 1.83-389, p = 0.026) and total laryngectomy (OR 11.2, 95% CI 1.71-105, p = 0.018) were associated with long-term gastrostomy tube. No factors were associated with long-term tracheostomy on multivariable analysis.

CONCLUSION

Even among long-term survivors after salvage resection and free-flap reconstruction, rates of tube dependence are significant. This multi-institutional review is the largest such study to the date and may help inform shared decision-making.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2141-2147, 2023.

Risk factors for adverse events associated with endoscopic submucosal dissection for superficial pharyngeal cancer

BACKGROUND

Superficial pharyngeal cancer can be treated with curative intent while preserving function using minimally invasive peroral endoscopic resection techniques such as endoscopic submucosal dissection (ESD). However, severe adverse events occasionally occur, such as laryngeal edema requiring temporary tracheotomy and fistula formation. Therefore, we investigated the risk factors for adverse events associated with ESD for superficial pharyngeal cancer.

METHODS

This retrospective observational study was conducted at a single institution, and 63 patients who underwent ESD were enrolled. The primary outcome was the risk factors for adverse events associated with ESD. The secondary outcomes were adverse events associated with ESD and their frequency.

RESULTS

The overall adverse event rate was 15.9% (10/63). The incidence of laryngeal edema requiring prophylactic temporary tracheotomy was 11.1%, while laryngeal edema requiring emergency temporary tracheotomy, postoperative bleeding, aspiration pneumonia, fistula, abscess, and stricture formation occurred in 1.6% of patients, respectively. Logistic regression analyses showed that a history of radiotherapy for head and neck cancer was a risk factor for adverse events (odds ratio [OR], 16.67; 95% confidence interval [CI], 3.04-91.34; p = 0.001). After adjusting the model for differences in the baseline risk factors using the inverse probability of treatment weighting method, the adverse events were found to increase in association with a history of radiotherapy for head and neck cancer (OR, 39.66; 95% CI,5.85-268.72; p < 0.001).

CONCLUSION

History of radiotherapy for head and neck cancer is an independent risk factor for adverse events associated with ESD for superficial pharyngeal cancer. Among adverse events, laryngeal edema requiring prophylactic temporary tracheotomy was particularly high.

Updates in Robotic Head and Neck Reconstructive Surgery

The use of robotics in head and neck surgery has drastically increased over the past two decades. Transoral robotic surgery has revolutionized the surgical approach to the upper aerodigestive tract including the oropharynx and supraglottic larynx. The expanded use and improving technology of robotics have allowed for new approaches in both the ablative and reconstructive aspects of head and neck surgery. Here, we discuss the recent updates in robotics in head and neck surgery and future directions the field may turn.

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.

Current Approaches to Salvage Surgery for Head and Neck Cancer: A Comprehensive Review

Salvage surgeries of head and neck cancer are often complicated and do not always show decent results. This type of procedure is tough on the patient, as many crucial organs can be affected. A long period of reeducation usually follows the surgery because of the need to rehabilitate functions such as speech or swallowing. In order to lighten the journey of the patients, it is important to develop new technologies and techniques to ease the surgery and limit its damages. This seems even more crucial since progress has been made in the past years, allowing more salvage therapy to take place. This article aims at showing the available tools and procedures for salvage surgeries, such as transoral robotic surgery, free-flap surgery, sentinel node mapping, and many others, that help the work of the medical team to operate or obtain a better understanding of the status of the cancer when taken in charge. Yet, the surgical procedure is not the only thing determining the outcome of the operation. The patient themself and their cancer history also play an important part in the care and must be acknowledged.

Positive Deep Initial Incision Margin Affects Outcomes in TORS for HPV+ Oropharynx Cancer

OBJECTIVE

Evaluate the effect of initial incision margins (IIM) on clinical outcomes after transoral robotic surgery (TORS) for human papillomavirus positive (HPV+) squamous cell cancers of the oropharynx (OPSCC).

METHODS

Retrospective chart review of patients undergoing TORS for HPV+ OPSCC from 2007 to 2015 was performed. Overall survival (OS), disease-specific survival (DSS), recurrence, and metastases were evaluated in the context of pathology, IIM, final margins, adjuvant therapy, and patient characteristics.

RESULTS

Ninety-five patients with HPV+ OPSCC undergoing primary surgery were identified. 88% of these patients had no evidence of disease at the conclusion of the study (average follow-up 45 months). Twenty were identified that had true positive IIM and 16 had very close IIM, with the remainder demonstrating widely negative margins. Tumor very close to or involving the deep margin but not a mucosal margin was associated with a higher risk of recurrence. Perineural invasion and lymphovascular invasion were associated with positive IIM. Positive or very close IIM on the deep margin was found to impact DSS and recurrence.

CONCLUSION

Obtaining negative IIM while performing TORS for HPV+ OPSCC is a modifiable factor that affects recurrence and DSS. Larger surgical margins should be considered in patients with perineural invasion or whose tumor abuts the initial deep margin.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:1132-1137, 2023.

Management of Recurrent HPV-Positive Oropharyngeal Squamous Cell Carcinoma: a Contemporary Review

PURPOSE OF REVIEW

To review the impact of contemporary treatment strategies on salvage outcomes in patients with recurrent human papilloma virus-positive oropharyngeal squamous cell carcinoma (HPV + OPSCC).

RECENT FINDINGS

Secondary to HPV, changes in disease biology have impacted primary treatments and subsequent approaches to patients with recurrence. With treatment strategies more inclusive of upfront surgery, the characteristics of patients with recurrence HPV + OPSCC have been further redefined. Less invasive endoscopic surgical approaches such as transoral robotic surgery (TORS), and the continued refinement of conformal radiotherapy techniques, have improved treatment options for patients with recurrent HPV + OPSCC. Systemic treatment options have continued to expand including potentially effective immune-based therapies. Effective surveillance with systemic and oral biomarkers offers hope of earlier detection of recurrence. Management of patients with recurrent OPSCC remains difficult. Modest improvements in salvage treatment have been observed within the HPV + OPSCC cohort largely reflecting disease biology and improved treatment techniques.

Intraoperative Imaging Techniques to Improve Surgical Resection Margins of Oropharyngeal Squamous Cell Cancer: A Comprehensive Review of Current Literature

Inadequate resection margins in head and neck squamous cell carcinoma surgery necessitate adjuvant therapies such as re-resection and radiotherapy with or without chemotherapy and imply increasing morbidity and worse prognosis. On the other hand, taking larger margins by extending the resection also leads to avoidable increased morbidity. Oropharyngeal squamous cell carcinomas (OPSCCs) are often difficult to access; resections are limited by anatomy and functionality and thus carry an increased risk for close or positive margins. Therefore, there is a need to improve intraoperative assessment of resection margins. Several intraoperative techniques are available, but these often lead to prolonged operative time and are only suitable for a subgroup of patients. In recent years, new diagnostic tools have been the subject of investigation. This study reviews the available literature on intraoperative techniques to improve resection margins for OPSCCs. A literature search was performed in Embase, PubMed, and Cochrane. Narrow band imaging (NBI), high-resolution microendoscopic imaging, confocal laser endomicroscopy, frozen section analysis (FSA), ultrasound (US), computed tomography scan (CT), (auto) fluorescence imaging (FI), and augmented reality (AR) have all been used for OPSCC. NBI, FSA, and US are most commonly used and increase the rate of negative margins. Other techniques will become available in the future, of which fluorescence imaging has high potential for use with OPSCC.

Presentation and outcomes of patients with clinically T1-2, N0 oropharynx squamous cell carcinoma: The interplay of primary treatment modality and human papillomavirus status

BACKGROUND

To examine the pattern of utilization and outcomes of definitive radiotherapy (RT) versus primary robotic-assisted surgery in patients with early-stage oropharyngeal squamous cell carcinoma (OPSCC).

METHODS

A retrospective cohort analysis of patients with clinically T1-2, N0 OPSCC was performed using the National Cancer Database, 2010-2016.

RESULTS

A total of 1451 patients were included. Prevalence of human papillomavirus (HPV)-positive tumors was 58.30%. Primary surgery was performed in 30.25% of the sample. Tongue base and clinically T1 tumors were each associated with a higher likelihood of undergoing surgery (p < 0.05). Histopathology of patients who underwent surgery demonstrated a prevalence of 15.95% with lymphovascular invasion, 16.67% with extranodal extension, 19.36% were T updated, and 30.00% were N upstaged. Improved survival was observed in the surgery + adjuvant RT group compared to RT alone for HPV-positive tumors (HR: 0.27; 95%CI: 0.12, 0.62; p = 0.002).

CONCLUSION

This study provides epidemiological perspective regarding management pattern and outcomes of patients with early-stage OPSCC.

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.

Transoral Robotic Surgery for Recurrent Tumors of the Upper Aerodigestive Tract (RECUT): An International Cohort Study

BACKGROUND

Transoral robotic surgery (TORS) is an emerging minimally invasive surgical treatment for residual, recurrent, and new primary head and neck cancers in previously irradiated fields, with limited evidence for its oncological effectiveness.

METHODS

A retrospective observational cohort study of consecutive cases performed in 16 high-volume international centers before August 2018 was conducted (registered at clinicaltrials.gov [NCT04673929] as the RECUT study). Overall survival (OS), disease-free survival, disease-specific survivals (DSS), and local control (LC) were calculated using Kaplan-Meier estimates, with subgroups compared using log-rank tests and Cox proportional hazards modeling for multivariable analysis. Maximally selected rank statistics determined the cut point for closest surgical resection margin based on LC.

RESULTS

Data for 278 eligible patients were analyzed, with median follow-up of 38.5 months. Two-year and 5-year outcomes were 69.0% and 62.2% for LC, 71.8% and 49.8% for OS, 47.2% and 35.7% for disease-free survival, and 78.7% and 59.1% for disease-specific survivals. The most discriminating margin cut point was 1.0 mm; the 2-year LC was 80.9% above and 54.2% below or equal to 1.0 mm. Increasing age, current smoking, primary tumor classification, and narrow surgical margins (≤1.0 mm) were statistically significantly associated with lower OS. Hemorrhage with return to theater was seen in 8.1% (n = 22 of 272), and 30-day mortality was 1.8% (n = 5 of 272). At 1 year, 10.8% (n = 21 of 195) used tracheostomies, 33.8% (n = 66 of 195) used gastrostomies, and 66.3% (n = 53 of 80) had maintained or improved normalcy of diet scores.

CONCLUSIONS

Data from international centers show TORS to treat head and neck cancers in previously irradiated fields yields favorable outcomes for LC and survival. Where feasible, TORS should be considered the preferred surgical treatment in the salvage setting.

Current perspectives on recurrent HPV-mediated oropharyngeal cancer

In the recent years, the prevalence of HPV-positive oropharyngeal squamous cell carcinoma (OPSCC) has increased significantly. Currently, nearly 80-90% of all oropharynx tumors are HPV-positive. In addition, it is now recognized that HPV-positive tumor status is associated with good prognosis and improved response to chemoradiation. However, within this setting, there are still patients with HPV-positive OPSCC who will experience recurrence. With the increasing incidence of HPV-mediated OPSCC, recurrent HPV disease is also becoming more prevalent and there is an increasing need to understand the unique presentation and treatment of recurrent HPV-mediated disease. In this review, we will discuss epidemiology of recurrent HPV-positive OPSCC, role of surgical salvage, re-irradiation, and the role of upcoming novel treatments and immunotherapy. Historically, recurrent oropharyngeal disease has been associated with poor prognosis and high morbidity. However, recent advances have transformed the landscape for salvage treatment of HPV-mediated OPSCC. Liquid biomarkers offer potential for early detection of recurrence, robotic techniques may reduce morbidity of surgical salvage, improvements in re-irradiation approaches reduce toxicities, and novel immune based therapies on the horizon are offering promising results. These advances combined with the improved prognosis of HPV-positive disease offer to transform our approach to recurrent disease of the oropharynx.

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.

Treatment Options in Early Stage (Stage I and II) of Oropharyngeal Cancer: A Narrative Review

OBJECTIVE

to show an overview on the treatments' options for stage I and II oropharyngeal carcinomasquamous cell carcinoma (OPSCC).

BACKGROUND

The traditional primary treatment modality of OPSCC at early stages is intensity modulated radiation therapy (IMRT). Trans-oral robotic surgery (TORS) has offered as an alternative, less invasive surgical option. Patients with human papilloma virus (HPV)-positive OPSCC have distinct staging with better overall survival in comparison with HPV-negative OPSCC patients.

METHODS

a comprehensive review of the English language literature was performed using PubMed, EMBASE, the Cochrane Library, and CENTRAL electronic databases.

CONCLUSIONS

Many trials started examining the role of TORS in de-escalating treatment to optimize functional consequences while maintaining oncologic outcome. The head-neck surgeon has to know the current role of TORS in HPV-positive and negative OPSCC and the ongoing trials that will influence its future implementation. The feasibility of this treatment, the outcomes ensured, and the side effects are key factors to consider for each patient. The variables reported in this narrative review are pieces of a bigger puzzle called tailored, evidence-based driven medicine. Future evidence will help in the construction of robust and adaptive algorithms in order to ensure the adequate treatment for the OPSCC at early stages.

Indocyanine green fluorescence-guided surgery in head and neck cancer: A systematic review

OBJECTIVE

To assess the feasibility and effectiveness of indocyanine green (ICG) for image-guided resection of head and neck cancer (HNC).

DATA SOURCES

PubMed, Embase, and Scopus databases.

REVIEW METHODS

Searches were conducted from database inception to February 2022. Patient and study characteristics, imaging parameters, and imaging efficacy data were extracted from each study.

RESULTS

Nine studies met inclusion criteria, representing 103 head and neck tumors. Weighted mean ICG dose and imaging time were 1.27 mg/kg and 11.77 h, respectively. Among the five studies that provided quantitative metrics of imaging efficacy, average ICG tumor-to-background ratio (TBR) was 1.56 and weighted mean ONM-100 TBR was 3.64. Pooled sensitivity and specificity across the five studies were 91.7 % and 71.9 %, respectively.

CONCLUSION

FGS with ICG may facilitate real-time tumor-margin delineation to improve margin clearance rates and progression-free survival. Future studies with validated, quantitative metrics of imaging success are necessary to further evaluate the prognostic benefit of these techniques.

Swallowing and communication outcomes following primary transoral robotic surgery for advanced or recurrent oropharyngeal cancer: Case series

Purpose: Transoral robotic surgery (TORS) is most commonly undertaken as a minimally invasive approach for early staged oropharyngeal cancers (OPC), with good expectations for a functional recovery. A small number of patients, however, require TORS for recurrent or advanced OPC tumours. Their prospects for longer term recovery of communication and swallowing are both unreported and hypothesised to be poorer than the majority of TORS cases. This case-series describes the recovery of swallowing and communication function post-TORS for this unique group of patients.Method: Consecutive recruitment was carried out prospectively at a quaternity oncology referral centre. Participants were aged 18 years and older, with reconstruction involving a free-flap and tracheostomy. Patients were assessed using Fibreoptic Endoscopic Evaluation of Swallowing, and clinician and patient-reported outcomes 12-months post-TORS. Their pre-operative baseline and three-month post-TORS FOIS scores were collated retrospectively.Result: Six participants were recruited over an 18-month period of which three patients underwent TORS for recurrent, and three for advanced OPC. Those with recurrent-OPC did not return to their baseline diet and demonstrated post-swallow silent aspiration of pharyngeal residue. Three of the six were rehabilitated back to their baseline intelligibility (100%).Conclusion: TORS in the recurrent OPC setting appears congruent with high rates of silent aspiration and prolonged reliance on a feeding tube due to oropharyngeal dysphagia, as well as compromised intelligibility. This is the first study that evaluates this instrumentally and provides clinically relevant evidence to inform practice.

Transoral robotic surgery with neck dissection versus nonsurgical treatment in stage I and II human papillomavirus-negative oropharyngeal cancer

BACKGROUND

Surgery + adjuvant therapy was shown to have improved overall survival (OS) versus nonsurgical treatment in T1-T2N1-N2b human papillomavirus (HPV)-negative oropharyngeal cancer (OPC). Our objective was to compare OS in transoral robotic surgery (TORS) with neck dissection versus nonsurgical treatment for T1-T2N0 HPV-negative OPC.

METHODS

Patients with T1-T2N0 HPV-negative OPC were identified in the National Cancer Database. OS was compared between groups: (1) TORS with neck dissection +/- adjuvant therapy, (2) primary radiotherapy (>60 Gy) +/- chemotherapy using Kaplan-Meier and multivariable Cox proportional hazards models.

RESULTS

There were 665 (78.4%) patients treated nonsurgically and 183 (21.6%) patients in the TORS group. Adjusting for age, comorbidity score, facility type, tumor subsite, and tumor stage, primary nonsurgical treatment was associated with worse OS (hazard ratio: 1.90, 95% CI: 1.34-2.69).

CONCLUSION

For T1-T2N0 HPV-negative OPC, TORS with neck dissection may be associated with a survival benefit over nonsurgical treatment.

Patient Benefit and Quality of Life after Robot-Assisted Head and Neck Surgery

Robotic systems for head and neck surgery are at different stages of technical development and clinical application. Currently, robotic systems are predominantly used for transoral surgery of the pharynx and larynx. Robotic surgery of the neck, the thyroid, and the middle and inner ear is much less common; however, some oncological and functional outcomes have been reported. This article provides an overview of the current state of robot-assisted head and neck surgery with a special emphasis on patient benefit and postoperative quality of life (QoL). The focus is placed on the role of transoral robotic surgery (TORS) for the resection of oropharyngeal carcinomas. For this application, reported long-term outcomes show functional post-operative advantages for selected oropharyngeal cancer patients after TORS compared to open surgery and primary radiotherapy. Since TORS also plays a significant role in the context of potential therapy de-escalation for HPV-positive oropharyngeal cancer patients, ongoing trials are presented. Regarding the evaluation of the therapeutic benefit and the QoL of cancer patients, special attention has to be paid to the large degree of variability of individual patients' preferences. Influencing factors and tools for a detailed assessment of QoL parameters are therefore detailed at the beginning of this article. Notably, while some robotic systems for ear and skull base surgery are being developed in Europe, TORS systems are mainly used in North America and Asia. In Europe and Germany in particular, transoral laser microsurgery (TLM) is a well-established technology for transoral tumor resection. Future trials comparing TORS and TLM with detailed investigation of QoL parameters are therefore warranted and might contribute to identifying suitable fields for the application of the different techniques.

Nutritional outcomes in patients undergoing transoral robotic surgery for head and neck cancers compared to conventional open surgery. A systematic review

This systematic review examined nutritional outcomes in patients undergoing transoral robotic surgery (TORS), compared to open surgery (OS) for head and neck cancer. PUBMED, CINAHL, and Web of Science were systematically reviewed. Target nutritional outcomes included: weight, nutritional status, use of enteral feeding, swallowing function/ability, and time to oral diet. Risk of bias was assessed using the risk of bias in non-randomized studies tool, and certainty of evidence was assessed using grading of recommendations, assessment, development, and evaluation (GRADE). Eight studies were included (total n = 608). Compared to OS, TORS probably reduces short- and long-term enteral feeding use or duration (GRADE "moderate" certainty), may reduce time to full swallow ability (GRADE "low" certainty), but it remains uncertain whether TORS reduces long-term patient reported swallowing function or time to oral feeding (GRADE "very-low" certainty). No studies examined nutritional status or weight. There is limited body of evidence examining nutrition outcomes following TORS. Further studies are warranted, which may improve the certainty of evidence and assist in determining the optimal nutrition care for these patients.

Therapeutic strategies: Surgery for human papillomavirus-associated oropharyngeal carcinoma

Treatment of oropharyngeal cancer (OPC) has undergone considerable evolution since the discovery of human papillomavirus (HPV)-associated OPC. It is widely understood that HPV OPC affects a younger population and standard treatment offers improved oncologic outcomes compared with non-HPV OPC but can cause significant toxicities and long-term side effects. Surgery for treatment de-escalation is an active area of research. The purpose of this review is to explore surgery as it relates to the treatment of HPV OPC with a focus on the evolution of treatment, rationale for surgery, surgical techniques, outcomes, and the role of surgery in de-escalation of treatment.

National Analysis of Oropharyngeal Salivary Gland Malignancies Treated With Transoral Robotic Surgery

OBJECTIVES

(1) To compare perioperative outcomes and overall survival of patients with oropharyngeal salivary gland malignancies (OPSGMs) treated with transoral robotic surgery (TORS) versus other approaches. (2) To identify clinical factors associated with a robotic surgical approach.

STUDY DESIGN

Retrospective analysis of the National Cancer Database (NCDB).

SETTING

NCDB.

METHODS

Data obtained from the NCDB were analyzed between 2010 and 2017 for patients with T1-T4a OPSGMs without distant metastases treated surgically. Patients were stratified by surgical approach (TORS vs nonrobotic), and clinicopathologic factors were compared with the t test or chi-square test for continuous or categorical variables, respectively. Overall survival was analyzed by patient demographics and clinical factors according to Kaplan-Meier and Cox proportional hazards models. Factors associated with TORS were assessed with logistic regression.

RESULTS

A total of 785 patients were analyzed. A non-soft palate primary site (odds ratio, 12.9; 95% CI, 6.6-25.2) and treatment at an academic facility (odds ratio, 2.0; 95% CI, 1.2-3.5) were independently associated with TORS. There were no significant differences in the positive margin rate, 30-day mortality, or overall survival between the groups. The 30-day unplanned readmission rate was higher in patients treated with TORS versus nonrobotic resections (5.8% vs 1.7%, P = .0004). When stratified by tumor subsite, there was a significant decrease in hospital length of stay in patients with tongue base tumors undergoing TORS versus nonrobotic resections (P = .029).

CONCLUSION

This study suggests that TORS may be a viable treatment modality for appropriately selected patients with OPSGM.

Transoral Robotic Surgery for Residual and Recurrent Oropharyngeal Cancers

Transoral robotic surgery (TORS) is a well-established treatment option for treatment-naïve oropharyngeal cancer. For residual, recurrent, and new primary oropharyngeal tumors emerging in previously irradiated fields, the global experience of management with TORS is limited. This article discusses current concepts on this topic, offers a deeper insight into the transoral anatomy for these cases, and covers the specific complexities of resections in the various subsites of the oropharynx. It provides practical tips on reconstruction, recovery, and rehabilitation as well as offering a synthesis of the current evidence and exploring future trends.

Image-guided surgery in otolaryngology: A review of current applications and future directions in head and neck surgery

Image-guided surgery (IGS) has become a widely adopted technology in otolaryngology. Since its introduction nearly three decades ago, IGS technology has developed rapidly and improved real-time intraoperative visualization for a diverse array of clinical indications. As usability, accessibility, and clinical experiences with IGS increase, its potential applications as an adjunct in many surgical procedures continue to expand. Here, we describe the basic components of IGS and review both the current state and future directions of IGS in otolaryngology, with attention to current challenges to its application in surgery of the nonrigid upper aerodigestive tract.

Opportunities and Limits in Salvage Surgery in Persistent or Recurrent Head and Neck Squamous Cell Carcinoma

Except for HPV-induced cancers of the oropharynx, survival rates in patients with squamous cell carcinoma of the head and neck (HNSCC) have not changed substantially over the last decades. Salvage surgery plays an important role where primary treatment was unsuccessful since 50% of advanced-stage patients relapse after nonsurgical primary treatment. Depending on a variety of factors, a considerable number of patients in whom primary treatment was not successful can still be cured by salvage surgery. It is the goal of this review to elucidate these factors with the aim to counsel patients and their relatives realistically about the chances of being cured.