Squamous cell carcinoma of the oropharynx: surgery, radiation therapy, or both

Free Flap Reconstruction of the Oropharynx

Reconstruction of the oropharynx plays a critical role in preserving quality of life after surgical resection of oropharyngeal carcinoma. Free tissue is one of several reconstructive options, which can closely approximate native oropharyngeal anatomy and lead to favorable functional outcomes in carefully selected patients. Here, the authors provide an overview of the indications, treatment options, functional outcomes, potential complications, and future considerations for free flap reconstruction of the oropharynx.

Surgical and functional outcomes after salvage oropharyngectomy

OBJECTIVES

Salvage oropharyngeal surgery with free-flap reconstruction after failed radiation therapy (RT) presents unique challenges and complications. The aim of this retrospective review is to examine surgical complications and functional outcomes in patients who received salvage surgery for recurrent or persistent oropharyngeal cancer following RT.

PATIENTS AND METHODS

Patients diagnosed with oropharyngeal cancer and underwent salvage oropharyngectomy at the University of Florida between 2016-2021 were identified from inpatient and outpatient records of the Head and Neck Oncology Team. Outcomes measured were tracheostomy dependence, tube-feed dependence, and intact oral intake status. Survival outcomes using Kaplan-Meier product limit method were calculated.

RESULTS AND CONCLUSION

Twenty-six patients were included in the analysis. Average age was 63.7 years. Fourteen (53.8 %) oropharyngectomies used a transmandibular approach, ten (38.5 %) through a combined transoral and transcervical approach, and two (7.7 %) through a transcervical approach. Average time to tracheostomy decannulation was 25.1 days. At 6 months, twenty (83.3 %) patients were gastric tube independent with twelve (54.2 %) patients tolerating any oral intake. At 12 months, gastric tube independent feeds decreased to nine (60 %) patients with thirteen (92.9 %) patients tolerating oral intake. The median overall survival was 27 months with local cancer recurrence being the most common cause of death. Patients undergoing salvage oropharyngectomy for recurrent disease continue to face prolonged tracheostomy and tube dependent feedings. Despite intact swallowing function, patients preferred to use gastric tube feedings, likely for speed, ease, and convenience. Further studies are needed to analyze factors influencing these conflicting functional outcomes and predictive factors impacting survival.

Feasibility of endoscopic resection for superficial laryngopharyngeal cancer after radiotherapy

BACKGROUND AND AIM

We aimed to elucidate the feasibility of endoscopic resection (ER) for salvage and metachronous lesions following chemoradiotherapy (CRT) and radiotherapy (RT) for laryngopharyngeal cancer.

METHODS

Consecutive patients who underwent ER for superficial laryngopharyngeal cancer between March 2005 and September 2022 were retrospectively reviewed and stratified into salvage (16 patients, 16 lesions), metachronous (18 patients, 27 lesions), and naïve RT (217 patients, 306 lesions) groups. Salvage lesions were residual or local recurrent after CRT, and metachronous lesions were second primary lesions in the irradiated field following complete response. Short-term outcomes were evaluated, including R0 resection, en bloc resection, procedure time, adverse events, local recurrence rate, and clinical course.

RESULTS

The en bloc resection rates were 88%, 93%, and 88%; R0 resection rates were 50%, 52%, and 56%; procedure times were 25, 27, and 25 min, in the salvage, metachronous, and naïve RT groups, none of which were significantly different among the three groups. Although adverse event rates tended to be higher in the salvage and metachronous groups than in the naïve RT group, the differences were not significant (18%, 15%, and 8%). The cumulative local recurrence rates at 2 years were 21%, 13%, and 6%, significantly higher in the salvage group than in the naïve RT group. The local control rates with ER alone were 94%, 93%, and 97%; none were significantly different among the three groups.

CONCLUSION

ER for salvage and metachronous superficial lesions can be safely performed, suggesting its acceptability as a minimally invasive treatment.

Topographic anatomy of the submental artery and its clinical implications for reconstructive surgery

Knowledge about the anatomy of the submental artery (SA) is of immense importance when performing plastic and reconstructive procedures. A retrospective study was performed to analyze the topographic anatomy of the SA. The measurements were performed on 80 consecutive patients who underwent head and neck computed tomography angiography (CTA). The SA was present in 131 out of 137 hemifaces (95.6%). The vessel originated from the facial artery in all cases (100.0%). Moreover, the SA was found to have 0-4 branches. However, most commonly, the said artery had no branches of considerable size (51.1%). Due to the high variability of the course of the said artery, the authors of the present study created a novel classification system presenting the most prevalent courses of the SA in the submental region. The current study utilized 131 hemifaces of 80 (CTA) to create a heat map of the SA, illustrating its precise origin and course in the submental region. The findings of this study could assist surgeons in developing a mental map of the arterial anatomy of the submental region, potentially improving the efficiency of localizing the SA and reducing the risk of complications during plastic and reconstructive procedures.

Proton Radiation Therapy for Head and Neck Cancers

Head and neck (HnN) cancers are among the most common cancers in the world. Proton therapy (PT) is one of the latest advancements in the treatment modalities of cancers. Proton therapy is specifically used to treat HnN cancer patients due to its less toxic effects on the surrounding critical structures. Keeping in view the opportunities for further advancements, there is a lot of literature covering PT in HnN cancer patients. However, few compiled studies are not enough to compare the toxicities, overall survival (OS), local control (LC), and quality of life (QoL) of PT with that of intensity-modulated radiation therapy (IMRT). The objective of this review is to compile and summarize the literature available on the toxicities, OS, LC, and QoL in HnN cancer patients post PT. We have gathered and summarized the literature found under the keyword "proton therapy for head and neck cancers". Proton therapy is a preferable option over IMRT because it isolates tumors of the HnN, reduces exposure of healthy cells to radiation, and allows accurate tumor scanning using the pencil beam technique. In view of this article, we can say that PT is a preferable mode of radiotherapy for HnN cancer patients in view of its accuracy and lower incidents of acute and late toxicities.

Elective Irradiation of Retropharyngeal Lymph Nodes as an Indication for Adjuvant Radiation Therapy After Transoral Surgery for Tonsil Cancer

Treatment of squamous cell carcinoma of the tonsil involves primary radiation therapy (RT) or surgical resection. Historically, if RT was the primary or adjuvant treatment modality, most of the bilateral retropharyngeal lymph nodes (RPLNs) were treated electively with a therapeutic dose for subclinical disease, regardless of whether radiographically pathologic lymph nodes were seen on initial diagnostic imaging. De-escalation strategies include the incorporation of transoral surgery with the goal to either eliminate or reduce the dose of adjuvant RT or chemotherapy. Transoral surgery does not include elective removal of the RPLNs, and no guideline or outcome paper recommends adjuvant RT specifically to electively treat RPLNs. In this Topic Discussion, we discuss pertinent literature and suggest management decisions. The management decisions discussed in this Topic Discussion pertain to only tonsillar primaries and not those of the soft palate or base of the tongue.

Airway protection and outcomes after staged versus concurrent bilateral neck dissections with transoral base of tongue cancer resection

OBJECTIVES

To assess airway, safety, and resource utilization outcomes between transoral base of tongue (BOT) surgery with staged versus concurrent bilateral neck dissections (BND).

METHODS

A retrospective cohort study of patients with human papilloma virus (HPV)-related BOT cancer who underwent transoral surgery and BND from January 2015 through June 2022 was conducted. Free flap patients were excluded.

RESULTS

Of 126 patients (46 [37%] staged and 80 [63%] concurrent BND), there were no significant differences in rates of postoperative intubation, tracheostomy, intensive care admission, operative takebacks, gastrostomy, and 30-day readmission. Total operative time (median difference 1.4 [95% CI 0.9-1.8] hours), length of stay (1.0 [1.0-1.0] day), and time between primary surgery and adjuvant therapy initiation (4.0 [0.0-8.0] days) were lower in the concurrent BND cohort.

CONCLUSION

Concurrent BND alongside transoral BOT resection is safe with similar airway outcomes and lower total operative time, length of stay, and time to adjuvant therapy initiation compared to staged BND.

Epidemiological and clinical description of patients with oropharyngeal cancer treated in a public oncology referral hospital in Chile

Introduction

The incidence of squamous carcinoma of the oropharynx (OPSCC) has presented an increase worldwide, a fact that occurs along with a phenomenon of epidemiological transition, whose pathogenesis is linked to human papilloma virus (HPV) in a significant part of the cases. Published evidence at the Latin American level is scarce. The present study aims to evaluate the epidemiological and clinical characteristics of patients with oropharyngeal cancer treated in a public oncology reference centre in Chile.

Methodology

A cross-sectional study was carried out. Patients with histological confirmation of OPSCC aged 18 years or older, referred to the National Cancer Institute of Chile between 2012 and 2023 were included. The association with HPV was determined by immunohistochemistry for p16.

Results

178 patients were analysed, most of them in locoregionally advanced stages involving the palatine tonsil. Seventy-seven percent were male, with a median age of 60 years. Sixty-seven percent of patients were positive for p16, with a progressive increase to 85% in the last 2 years of the study. The p16(+) patients were younger and had fewer classical risk factors. Primary treatment was radiotherapy in 94% of patients.

Conclusion

The epidemiological profile of patients with OPSCC treated in a Chilean public oncology referral centre reflects the epidemiological transition observed in developed countries. This change justifies the need to adapt health policies and conduct research that considers the characteristics of this new epidemiological profile.

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.

Comparison of sequential versus simultaneous integrated boost of volumetric modulated arc therapy in treatment of oropharyngeal carcinoma

OBJECTIVE

Volumetric modulated arc therapy (VMAT) is a useful treatment technique that can reduce treatment time while producing improved dose distribution to target structures. The main aim of the study is to evaluate the outcome of oropharyngeal cancer patients treated with VMAT, sequential (SEQ) versus simultaneous integrated boost (SIB) technique in terms of survival and failures and to assess late radiation toxicities with their dosimetric parameters.

MATERIAL AND METHODS

Total 54 patients of histologically proved oropharyngeal cancer patients treated by definitive radiotherapy using VMAT technique in January 2019 to December 2020 were followed up and evaluated in terms of survival, patterns of failure and late radiation toxicities by RTOG toxicity criteria.

RESULTS

After a median follow up of 12 months, overall survival (OS) and disease free survival (DFS) were 64.8% and 48.1% respectively. In terms of patterns of failure, 44.4% showed local recurrence, 7.4% as regional relapse and 3.7% showed distant metastasis. While comparing sequential versus SIB, no significant difference was found in OS (64.9% vs. 59.8%, p = 0.689), DFS (52.8% vs. 35.3%, p = 0.266), local control (LC) (58.3% vs. 47.1%, p = 0.437) and regional control (RC) (94.3% vs. 88.2%, p = 0.151) respectively. Among late radiation toxicities, the most common were xerostomia (42.2% for SEQ and 24.2% for SIB group), dysphagia (33.3% for SEQ and 15.1% for SIB group) and hoarseness of voice (15.1% for SEQ and 12.1% for SIB group).

CONCLUSION

SIB technique proved better than SEQ technique in terms of pattern of failure or late toxicity, but no significant difference can be reported.

Dose Escalation of Oropharyngeal Cancer: Long-Time Follow-Up and Side Effects

Previous studies on dose-escalated radiotherapy in head and neck cancer have shown mixed results, and it is not established which patients would benefit from dose escalation. Further, while dose escalation does not appear to increase late toxicity, this needs to be confirmed with longer follow-up. In this study, we analysed treatment outcome and toxicity in 215 patients with oropharyngeal cancer treated with dose-escalated radiotherapy (>72 Gy, EQD2, α/β = 10 Gy, boost by brachytherapy or simultaneous integrated boost) and a matched cohort of 215 patients treated with standard dose external-beam radiotherapy (68 Gy) between 2011 and 2018 at our institution. The 5-year overall survival (OS) was 77.8% (72.4-83.6) and 73.7% (67.8-80.1) in the dose-escalated and standard dose group, respectively (p = 0.24). Median follow-up was 78.1 (49.2-98.4) and 60.2 (38.9-89.4) months in the dose-escalated and standard dose groups, respectively. Grade ≥3 osteoradionecrosis (ORN) and late dysphagia were more common in the dose-escalated group compared to the standard dose group, with 19 (8.8%) vs. 4 (1.9%) patients developing grade ≥3 ORN (p = 0.001), and 39 (18.1%) vs. 21 (9.8%) patients developing grade ≥3 dysphagia (p = 0.01). No predictive factors to help select patients for dose-escalated radiotherapy were found. However, the remarkably good OS in the dose-escalated cohort, despite a predominance of advanced tumour stages, encourages further attempts to identify such factors.

Dose escalation in oropharyngeal cancer: a comparison of simultaneous integrated boost and brachytherapy boost

BACKGROUND

Local recurrence is the most common pattern of failure in head and neck cancer. It can therefore be hypothesised that some of these patients would benefit from an intensified local treatment, such as radiation dose escalation of the primary tumour. This study compares treatment and toxicity outcomes from two different boost modalities in oropharyngeal cancer: simultaneous integrated boost (SIB) and brachytherapy boost.

METHODS

Two hundred and forty-four consecutive patients treated with > 72 Gy for oropharyngeal squamous cell carcinoma between 2011 and 2018 at our institution were retrospectively analysed. Data on side effects were collected from a local quality registry and supplemented with a review of medical records. Patients receiving a brachytherapy boost first had external beam radiotherapy consisting of 68 Gy in 2 Gy fractions to the gross tumour volume (GTV), and elective radiotherapy to the neck bilaterally. The brachytherapy boost was typically given using pulsed dose rate, 15 fractions and 0.56-0.66 Gy per fraction [total dose in EQD2 = 75.4-76.8 Gy (α/β = 10)]. The typical dose escalated radiotherapy with external beam radiotherapy only, was delivered using SIB with 74,8 Gy in 2.2 Gy fractions [EQD2 = 76.0 Gy (α/β = 10)] to the primary tumour, 68 Gy in 2 Gy fractions to GTV + 10 mm margin and elective radiotherapy to the neck bilaterally.

RESULTS

Dose escalation by SIB was given to 111 patients and brachytherapy boost to 134 patients. The most common type of cancer was base of tongue (55%), followed by tonsillar cancer (42%). The majority of patients had T3- or T4-tumours and 84% were HPV-positive. The 5-year OS was 72,4% (95% CI 66.9-78.3) and the median follow-up was 6.1 years. Comparing the two different dose escalation modalities we found no significant differences in OS or PFS and these results remained after a propensity-score matched analysis was performed. The analysis of grade ≥ 3 side effects showed no significant differences between the two different dose escalation techniques.

CONCLUSIONS

We found no significant differences in survival or grade ≥ 3 side effects comparing simultaneous integrated boost and brachytherapy boost as alternative dose escalation modalities in the treatment of oropharyngeal cancer.

A 3D map of the lingual artery-The perfect tool for transoral robotic surgeries on the base of tongue

BACKGROUND

Knowledge about the anatomy of the lingual artery (LA) is of immense importance when performing procedures on the base of tongue (BOT).

METHODS

A retrospective analysis was performed to establish morphometric data of the LA. The measurements were performed on 55 consecutive patients who underwent head and neck computed tomography angiographies (CTA).

RESULTS

A total of 96 LAs were analyzed. Additionally, a three-dimensional heat map (showing the oropharyngeal region from the lateral, anterior, and superior point of view) of the occurrence of the LA and its branches was created.

CONCLUSION

The length of the main trunk of the LA was measured to be 31.94 ± 11.44 mm. This reported distance is thought to be a surgical safe zone when performing transoral robotic surgery (TORS) on the BOT because it represents the area where the LA does not give off any major branches.

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.

Consensuses, controversies, and future directions in treatment deintensification for human papillomavirus-associated oropharyngeal cancer

The most common cancer caused by human papillomavirus (HPV) infection in the United States is oropharyngeal cancer (OPC), and its incidence has been rising since the turn of the century. Because of substantial long-term morbidities with chemoradiation and the favorable prognosis of HPV-positive OPC, identifying the optimal deintensification strategy for this group has been a keystone of academic head-and-neck surgery, radiation oncology, and medical oncology for over the past decade. However, the first generation of randomized chemotherapy deintensification trials failed to change the standard of care, triggering concern over the feasibility of de-escalation. National database studies estimate that up to one third of patients receive nonstandard de-escalated treatments, which have subspecialty-specific nuances. A synthesis of the multidisciplinary deintensification data and current treatment standards is important for the oncology community to reinforce best practices and ensure optimal patient outcomes. In this review, the authors present a summary and comparison of prospective HPV-positive OPC de-escalation trials. Chemotherapy attenuation compromises outcomes without reducing toxicity. Limited data comparing transoral robotic surgery (TORS) with radiation raise concern over toxicity and outcomes with TORS. There are promising data to support de-escalating adjuvant therapy after TORS, but consensus on treatment indications is needed. Encouraging radiation deintensification strategies have been reported (upfront dose reduction and induction chemotherapy-based patient selection), but level I evidence is years away. Ultimately, stage and HPV status may be insufficient to guide de-escalation. The future of deintensification may lie in incorporating intratreatment response assessments to harness the powers of personalized medicine and integrate real-time surveillance.

Pre-CCRT 18-fluorodeoxyglucose PET-CT improves survival in patients with advanced stages p16-negative oropharyngeal squamous cell carcinoma via accurate radiation treatment planning

PURPOSE

No large-scale prospective randomized study with a long-term follow-up period has evaluated the survival outcomes of preconcurrent chemoradiotherapy (CCRT) 18-fluorodeoxyglucose positron emission tomography-computed tomography (¹⁸FDG PET-CT) in patients with non-human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC).

PATIENTS AND METHODS

We included patients with stage I-IVA p16-negative OPSCC receiving definitive CCRT and categorized them into two groups according to pre-CCRT ¹⁸FDG PET-CT and compared their outcomes: the case group consisted of patients who underwent pre-CCRT ¹⁸FDG PET-CT, whereas the comparison group consisted of patients who did not receive pre-CCRT ¹⁸FDG PET-CT.

RESULTS

The final cohort consisted of 3942 patients (1663 and 2279 in the case and comparison groups, respectively). According to multivariable Cox regression analysis, pre-CCRT ¹⁸FDG PET-CT was not a significant prognostic factor for overall survival in patients with stages I-II of p16-negative OPSCC receiving standard CCRT. The adjusted hazard ratio (95% confidence interval) of all-cause death for the patients with advanced stages (III-IVA) of p16-negative OPSCC receiving pre-CCRT ¹⁸FDG PET-CT was 0.75 (0.87-0.94, P = 0.0236).

CONCLUSIONS

Routine use of pre-CCRT ¹⁸FDG PET-CT is not necessary for each patient with p16-negative OPSCC. Pre-CCRT ¹⁸FDG PET-CT is associated with improved survival in patients with stage III-IVA p16-negative OSCC, but might be not in those with stage I-II p16-negative OPSCC. No large-scale prospective randomized study with a long-term follow-up period has evaluated the survival outcomes of preconcurrent chemoradiotherapy (CCRT) 18-fluorodeoxyglucose positron emission tomography-computed tomography (¹⁸FDG PET-CT) in patients with p16-negative oropharyngeal squamous cell carcinoma (OPSCC). Our study is the first, largest, homogenous modality study on PET-CT including a long-term follow-up cohort to examine the survival outcomes of pre-CCRT ¹⁸FDG PET-CT or non-pre-CCRT PET-CT for patients with p16-negative OPSCC receiving standard CCRT stratified by different clinical stages. Routine use of pre-CCRT ¹⁸FDG PET-CT is not necessary for each patient with p16-negative OPSCC. Pre-CCRT ¹⁸FDG PET-CT is associated with improved survival in patients with stage III-IVA p16-negative OPSCC, but might be not in those with stage I-II p16-negative OPSCC.

Analysis of T1-T2 stage oropharyngeal squamous cell carcinoma treated with transoral robotic surgery

Objective

Transoral robotic surgery (TORS) has become an effective treatment for early-stage oropharyngeal squamous cell carcinomas (OPSCCs). We aimed to analyze the clinical safety and efficacy of TORS for human papilloma virus (HPV)-positive and HPV-negative OPSCC in China.

Methods

Patients with OPSCC of pT1-T2 stage who underwent TORS from March 2017 to December 2021 were analyzed.

Results

A total of 83 patients (HPV-positive, n = 25; HPV-negative, n = 58) were included. The median age of the patients was 57.0 years and 71 were men. The majority of primary tumor sites were palatine tonsils (52, 62.7%) and base of tongues (20, 24.1%). Three patients have a positive margin. A total of 12 (14.5%) patients received tracheotomies, the average duration of tracheostomy tube use was 9.4 days, and nasogastric tube was 14.5 days. No patient had a long-term tracheotomy. The 3-year overall survival (OS), disease-free survival (DFS), and recurrence-free survival (RFS) for all 83 patients were 89.5%, 80.1%, and 83.3%, respectively. The OS at 3 years between the HPV-positive group and HPV-negative group were 100% versus 84.3% (P = .07), while the DFS and RFS between two groups also showed no significant difference. Among multivariate cox regression analysis of all potential risk factors, smoking was the significant risk factors for disease recurrence (P < .05).

Conclusion

Transoral robotic surgery achieved encouraging oncologic outcomes and safety in T1-T2 stage OPSCC treatment, regardless of HPV status.

Level of Evidence

4.

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.

Prognostic factors in oropharyngeal squamous cell carcinoma in the state of São Paulo, Brazil: 10-year follow-up

OBJECTIVE

To descriptively analyze the epidemiological data, clinical stage, and outcomes of oropharyngeal squamous cell carcinoma in the state of São Paulo, Brazil, and to estimate the influence of clinical stage and treatment type on overall and disease-free survival.

METHODS

We retrospectively analyzed epidemiological data from the São Paulo Cancer Center Foundation database relative to patients with oropharyngeal squamous cell carcinoma diagnosed between 2004 and 2014 in the state of São Paulo. Univariate and multivariate Cox regression analyses were performed to assess factors associated with the outcomes. A forward stepwise selection procedure was used. Survival curves were estimated by the Kaplan-Meier method and compared by the Gehan-Breslow-Wilcoxon test.

RESULTS

A total of 8075 individuals with oropharyngeal squamous cell carcinoma were identified. Of these, 86.3% were diagnosed at an advanced stage and 13.7% at an early stage. Only 27.2% of patients were treated surgically, whereas 57.5% were treated medically. Patients undergoing surgery had longer overall survival than those receiving medical treatment in both early- and advanced-stage oropharyngeal squamous cell carcinoma. However, there was no significant difference in disease-free survival between surgical and medical treatment.

CONCLUSION

No significant difference in disease-free survival between medical and surgical treatment suggests similar complete remission rates with both approaches. Patients receiving medical treatment had shorter overall survival, which may be due to complications from chemotherapy and radiotherapy. However, we cannot confirm this relationship based on the data provided by the São Paulo Cancer Center Foundation. Prospective studies are warranted to assess whether the lower overall survival rate in patients receiving medical treatment is secondary to complications from chemotherapy and radiotherapy.

LEVEL OF EVIDENCE

2C.

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.

Prediction of survival in oropharyngeal squamous cell carcinoma using machine learning algorithms: A study based on the surveillance, epidemiology, and end results database

Background

We determined appropriate survival prediction machine learning models for patients with oropharyngeal squamous cell carcinoma (OPSCC) using the “Surveillance, Epidemiology, and End Results” (SEER) database.

Methods

In total, 4039 patients diagnosed with OPSCC between 2004 and 2016 were enrolled in this study. In particular, 13 variables were selected and analyzed: age, sex, tumor grade, tumor size, neck dissection, radiation therapy, cancer directed surgery, chemotherapy, T stage, N stage, M stage, clinical stage, and human papillomavirus (HPV) status. The T-, N-, and clinical staging were reconstructed based on the American Joint Committee on Cancer (AJCC) Staging Manual, 8th Edition. The patients were randomly assigned to a development or test dataset at a 7:3 ratio. The extremely randomized survival tree (EST), conditional survival forest (CSF), and DeepSurv models were used to predict the overall and disease-specific survival in patients with OPSCC. A 10-fold cross-validation on a development dataset was used to build the training and internal validation data for all models. We evaluated the predictive performance of each model using test datasets.

Results

A higher c-index value and lower integrated Brier score (IBS), root mean square error (RMSE), and mean absolute error (MAE) indicate a better performance from a machine learning model. The C-index was the highest for the DeepSurv model (0.77). The IBS was also the lowest in the DeepSurv model (0.08). However, the RMSE and RAE were the lowest for the CSF model.

Conclusions

We demonstrated various machine-learning-based survival prediction models. The CSF model showed a better performance in predicting the survival of patients with OPSCC in terms of the RMSE and RAE. In this context, machine learning models based on personalized survival predictions can be used to stratify various complex risk factors. This could help in designing personalized treatments and predicting prognoses for patients.

Survival Outcomes Related to Treatment Modalities in Patients With Oropharyngeal Squamous Cell Carcinoma

BACKGROUND

More patients with oropharyngeal squamous cell carcinoma (OPSCC) in Eastern countries receive surgically inclusive treatment (SIT), while most patients in Western countries receive nonsurgical treatment (NST). The optimal treatment modality for OPSCC patients remains controversial.

METHODS

A total of 153 consecutive OPSCC cases diagnosed between 2009 and 2019 in West China Hospital (WCH) and 15,400 OPSCC cases from the Surveillance, Epidemiology, and End Results (SEER) database (2000-2017) were obtained. Clinical characteristics, treatments, and survival outcomes were retrospectively collected. We constructed Kaplan-Meier curves and performed univariate (UVA) and multivariate (MVA) analyses to compare the prognosis of OPSCC patients among the WCH, SEER Asian, and SEER all ethnic populations by different treatment modality, human papilloma virus (HPV) infection status, age, and tumor stage.

RESULTS

Overall, the proportions of patients with younger age, advanced tumors and HPV-negative status, and receiving SIT in WCH population were higher than those in the SEER all ethnic population, while the proportions in the SEER Asian population were between those of the other two populations. We observed consistent beneficial effects of SIT on the overall survival (OS) in OPSCC patients in all three populations (SEER Asian: MVA, hazard ratio (HR): 0.2, p < .001; SEER all ethnic: MVA, HR: 0.46, p < .001; WCH: UVA, HR: 0.62, p = .071), and HPV-negative Asian patients showed greater benefits from the SIT than HPV-positive Asian patients (HPV Negative: HR: 0.16, p = .005; HPV positive: HR = 0.28, p = .059). Male was a risk factor for reduced OS in OPSCC patients in the WCH population (HR: 3.17, p = .043), but was a protective factor in the SEER population (HR: 0.8, p = .002), which might be related to the differences of HPV infection status.

CONCLUSIONS

Even though differences in patient characteristics existed between the Chinese, American, and Asian American populations, our ten-year real-world data and SEER data suggested that patients with OPSCC who received SIT had a better prognosis than those who received NST.

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.

Role of Human Papilloma Virus and Lifestyle Factors in Overall Survival of Patients with Oropharyngeal Squamous Cell Carcinoma

Background: Patients with human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) have a significantly better treatment response and overall survival (OS) rates than non-HPV-associated OPSCC. Objectives: We conducted the present study to further characterize the interplay between lifestyle risk factors, which are not only HPV status, but also smoking history and alcohol consumption, and the OS to optimize the treatment of patients with OPSCC. Materials and Methods: Between January 2006 and December 2013, 94 patients newly diagnosed with OPSCC were treated with curative intent at Aichi Cancer Center Hospital (Nagoya, Japan). To determine negative prognostic factors associated with the OS, univariate and multivariable Cox regression analyses were performed. Results: Of the 94 OPSCC patients, 53 (56.4%) were positive for HPV. The univariate analysis revealed that T classification, smoking history, alcohol consumption, and HPV status were significant determinants of the OS. In the multivariate analysis, adjusted for the clinical stage, smoking history, alcohol consumption, HPV status, and a smoking history of >10 pack-years was an independent negative prognostic factor for the OS among patients with OPSCC (HR: 10.4, 95 %CI: 1.34−80.6, p < 0.05). Conclusions: Smoking is a very important negative prognostic factor even in cases of HPV-associated OPSCC. The impact of smoking needs to be reaffirmed when deciding on treatment plans and de-escalation trials in OPSCC, even in cases of HPV-associated OPSCC.

Robotic vs. transoral laser surgery of malignant oropharyngeal tumors-what is best for the patient? : A contemporary review

Human papillomavirus (HPV)-associated squamous cell carcinoma of the oropharynx is a malignancy of increasing prevalence. The oncologic community is currently evaluating the safety and efficacy of de-intensifying treatment without compromising oncologic outcomes. Paramount to these treatment algorithms is primary surgery through transoral approaches. This article reviews the literature and concepts pertaining to transoral surgery and describes the two most common techniques, transoral laser microsurgery (TLM) and transoral robotic surgery (TORS).

Evolution of a Paradigm Switch in Diagnosis and Treatment of HPV-Driven Head and Neck Cancer—Striking the Balance Between Toxicity and Cure

More than a decade after the discovery of p16 immunohistochemistry (IHC) as a surrogate for human papilloma virus (HPV)-driven head and neck squamous cell carcinoma (HNSCC), p16-IHC has become a routinely evaluated biomarker to stratify oropharyngeal squamous cell carcinoma (OPSCC) into a molecularly distinct subtype with favorable clinical prognosis. Clinical trials of treatment de-escalation frequently use combinations of biomarkers (p16-IHC, HPV-RNA in situ hybridization, and amplification of HPV-DNA by PCR) to further improve molecular stratification. Implementation of these methods into clinical routine may be limited in the case of RNA by the low RNA quality of formalin-fixed paraffin-embedded tissue blocks (FFPE) or in the case of DNA by cross contamination with HPV-DNA and false PCR amplification errors. Advanced technological developments such as investigation of tumor mutational landscape (NGS), liquid-biopsies (LBx and cell-free cfDNA), and other blood-based HPV immunity surrogates (antibodies in serum) may provide novel venues to further improve diagnostic uncertainties. Moreover, the value of HPV/p16-IHC outside the oropharynx in HNSCC patients needs to be clarified. With regards to therapy, postoperative (adjuvant) or definitive (primary) radiochemotherapy constitutes cornerstones for curative treatment of HNSCC. Side effects of chemotherapy such as bone-marrow suppression could lead to radiotherapy interruption and may compromise the therapy outcome. Therefore, reduction of chemotherapy or its replacement with targeted anticancer agents holds the promise to further optimize the toxicity profile of systemic treatment. Modern radiotherapy gradually adapts the dose. Higher doses are administered to the visible tumor bulk and positive lymph nodes, while a lower dose is prescribed to locoregional volumes empirically suspected to be invaded by tumor cells. Further attempts for radiotherapy de-escalation may improve acute toxicities, for example, the rates for dysphagia and feeding tube requirement, or ameliorate late toxicities like tissue scars (fibrosis) or dry mouth. The main objective of current de-intensification trials is therefore to reduce acute and/or late treatment-associated toxicity while preserving the favorable clinical outcomes. Deep molecular characterization of HPV-driven HNSCC and radiotherapy interactions with the tumor immune microenvironment may be instructive for the development of next-generation de-escalation strategies.

Early postoperative functional outcomes following transoral surgery for oropharyngeal cancer: A systematic review

There has been increased interest in the use of transoral surgery (TOS) for the treatment of oropharyngeal cancer (OPC). This systematic review summarizes the available evidence for validated functional outcomes following TOS for OPC, within the early postoperative period. Key databases were searched. Primary TOS resections of human subjects were included. Validated functional outcomes extracted included instrumental assessment, clinician rated, and patient reported measures. Database searches yielded 7186 titles between 1990 and December 2020. Full-text articles were obtained for 296 eligible studies, which were screened and a resulting 14 studies, comprising 665 participants were included in the review. Oropharyngeal dysfunction following TOS was observed across all three categories of outcome measures (OMs) reported and was dependent on pretreatment function, T-classification, and tumor volume. Future investigations should include optimal OMs to be used in the postoperative setting to allow for conclusive comparisons.

De-escalation studies in HPV-positive oropharyngeal cancer: How should we proceed?

Human papilloma virus (HPV) is a well-established causative factor in a subset of squamous cell carcinomas of the head and neck (HNSCC). Although HPV can be detected in various anatomical subsites, HPV-positive oropharyngeal squamous cell carcinoma (OPSCC) is the most common HPV-related malignancy of the head and neck, and its worldwide incidence is constantly rising. Patients with OPSCC are generally younger, have less co-morbidities and generally have better prognosis due to different biological mechanisms of carcinogenesis. These facts have generated hypotheses on potential treatment modifications, aiming to minimize treatment-related toxicities without compromising therapy efficacy. Numerous randomized clinical trials have been designed to verify this strategy and increasingly real-world evidence data from retrospective, observational studies is becoming available. Until now, the data do not support any modification in contemporary treatment protocols. In this narrative review, we outline recent data provided by both randomized controlled trials and real-world evidence of HPV-positive OPSCC in terms of clinical value. We critically analyze the potential value and drawbacks of the available data and highlight future research directions. This article was written by members and invitees of the International Head and Neck Scientific Group.(www.IHNSG.com).

Upfront Surgery vs. Primary Chemoradiation in an Unselected, Bicentric Patient Cohort with Oropharyngeal Squamous Cell Carcinoma-A Matched-Pair Analysis

Simple Summary

Oropharyngeal squamous cell carcinoma (OPSCC) is a common malignancy of the upper aerodigestive tract with rising incidence. While surgical and non-surgical approaches are applied in curative treatment, none of these has proven superior to date. In this study, we investigated overall survival in an unselected, bicentric cohort of patients with OPSCC and compared upfront surgery vs. primary chemoradiation treatments. A matched-pair analysis was performed to exclude confounding factors and reduce bias. Our results suggest that regardless of the treatment modality chosen, overall survival rates are comparable in both cohorts. As a consequence, future studies on functional outcome of patients with OPSCC are mandatory to identify the treatment modality most likely resulting in improved quality of life in patients with OPSCC.

Abstract

The two pillars of therapy for oropharyngeal squamous cell carcinoma (OPSCC) are upfront surgery and primary chemoradiotherapy. Substantial regional preferences exist with regard to the selection of treatment. Despite new therapeutic approaches, patient survival remains poor, with an approximate overall survival (OS) rate of 50% at five years. This study was conducted to investigate a potential survival benefit depending on the treatment modality in OPSCC patients. We retrospectively collected data of 853 patients with histologically confirmed OPSCC from the Giessen and Maastricht cancer databases. To identify risk factors affecting survival, a Cox-proportional hazard model was applied to 442 patients with complete data sets. Based on this cohort a matched-pair analysis with 158 patients was performed to compare OS rates of patients treated either with upfront surgery or primary chemoradiation. For the collective cohort, patients treated with upfront surgery had significantly improved OS rates compared to patients treated with primary chemoradiation. In the matched-pair analysis adjusted for patients’ T-, N- and HPV-status as well as risk profile, we observed that both treatment approaches offered equivalent OS rates. Our study emphasizes that treatment recommendations should be made whenever possible on the basis of side-effect profiles caused by the therapeutic approach used. To draw further conclusions, results of the ongoing “best of” (NCT2984410) study are eagerly awaited, investigating the functional outcome after treatment of OPSCC 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.

Autologous fat grafting in the face and neck: Multinational trends and knowledge of the safety, applications, and indications considering oncologic risk potential

BACKGROUND

Autologous fat grafting (AFG) is evolving in both aesthetic and reconstructive applications, since the body of evidence for its use has expanded. The earliest controversies were evident in lipofilling for oncological breast reconstruction, and to this day, some countries do not allow it for fear of inducing tumourigenesis in an oncologically ablated field.

METHODS

We sought to review contemporary harvesting and processing techniques for AFG in the craniofacial region, therefore distributed a survey to evaluate the clinical impact of oncological risk across four European countries.

RESULTS

We found no significant geographical differences between the German-speaking and the English groups concerning their harvesting and processing technique. Half of our respondents discuss the possibility of pro-oncologic behavior of AFG.

CONCLUSION

AFG harvesting and processing techniques do not considerably vary by geography. Further studies should evaluate oncologic risk potential of AFG in head and neck tumor sites, especially because there is no excellent article regarding this phenomenon.Level of Evidence: V.

Cancer of the Oropharynx and the Association with Human Papillomavirus

Squamous cell carcinoma of the oropharynx (OPC) consists of human papillomavirus (HPV)-negative disease caused by tobacco and alcohol use, and HPV-positive disease caused by the sexually transmitted infection HPV. These entities have unique but overlapping risk factors, epidemiologic trends, staging systems, and survival outcomes. HPV-positive tumor status confers a significant survival benefit compared with HPV-negative disease. OPC treatment entails a combination of surgery, radiation, and chemotherapy. Ongoing trials will determine whether treatment of HPV-related disease may be safely deintensified to decrease morbidity. Emerging HPV-related biomarkers are under study as tools to inform screening, diagnosis, treatment, and surveillance for HPV-positive OPC.

Robotic and Endoscopic Approaches to Head and Neck Surgery

Technological developments have disrupted the practice of medicine throughout history. Endoscopic and robotic techniques in head and neck surgery have emerged over the past half-century and have been incrementally adapted to expanding indications within otolaryngology. Robotic and endoscopic surgery have an established role in treatment of oropharyngeal and laryngeal cancers, reducing surgical morbidity and improving survival relative to traditional open approaches. Surgical treatment of human papillomavirus-mediated oropharyngeal cancer via transoral robotic surgery offers equivalent oncologic and functional outcomes relative to radiotherapy. Newer iterations of single-port robotic systems continue to expand the scope of robotics in head and neck surgery.

Survival and toxicity in patients with human papilloma virus-associated oropharyngeal squamous cell cancer receiving trimodality therapy including transoral robotic surgery

BACKGROUND

Patients with oropharyngeal cancer who undergo transoral robotic surgery (TORS) and have high-risk features generally receive adjuvant chemoradiotherapy or trimodality therapy (TMT). The notion that TMT leads to high toxicity is largely based on studies that included human papilloma virus (HPV)-negative cancers and/or nonrobotic surgery; we sought to describe outcomes in HPV-associated oropharyngeal squamous cell cancer (HPV + OPSCC) undergoing TORS-TMT.

METHODS

In consecutive patients with HPV + OPSCC receiving TMT at an academic center from 2010 to 2017, survival was estimated using Kaplan-Meier methodology, and toxicities were ascertained via chart review.

RESULTS

In our cohort of 178 patients, 5-year survival was 93.6%. Feeding tube rates were 25.8% at therapy completion and 0.7% at 1 year. Rates of grade ≥ 3 kidney injury, anemia, and neutropenia in cisplatin-treated patients were 2.7%, 3.4%, and 11.0%, respectively.

CONCLUSIONS

Patients with HPV + OPSCC who underwent TORS-TMT had excellent survival and low rates of toxicity and feeding tube dependence. These outcomes compare favorably to historical cohorts treated with definitive chemoradiotherapy.

Preoperative predictors of difficult oropharyngeal exposure for transoral robotic surgery: The Pharyngoscore

BACKGROUND

Insufficient exposure may require termination of procedure in transoral robotic surgery (TORS). The aim of study was to develop a "Pharyngoscore" to quantify the risk of difficult oropharyngeal exposure (DOE) before TORS.

METHODS

Three-hundred six patients undergoing any surgical procedure at one Academic Hospital were prospectively enrolled. Oropharynx was exposed with Feyh-Kastenbauer retractor. Exposure was evaluated by direct and endoscopic visualization of the four oropharyngeal subsites. Preoperative clinical/anthropometric parameters were studied in good oropharyngeal exposure and DOE groups. Logistic regression was performed to explore association between clinical/anthropometric parameters and DOE. Statistically significant parameters at multivariate analysis were incorporated into a nomogram.

RESULTS

Sixty-five (21.2%) subjects were characterized by DOE. Variables associated with DOE at univariate analysis were male (p = 0.031), modified Mallampati Class (MMC) ≥ III (p < 0.001), smaller interincisor gap (p < 0.001), and larger neck circumference (p = 0.006). MMC, interincisor gap, and neck circumference were significant at multivariate analysis and were presented with a nomogram for creating the Pharyngoscore.

CONCLUSIONS

The Pharyngoscore is a promising tool for calculating DOE probability before TORS.

Oncologic outcomes of transoral robotic surgery for HPV-negative oropharyngeal carcinomas

BACKGROUND

Patients with human papillomavirus (HPV)-negative oropharyngeal squamous cell carcinoma (OPSCC) continue to experience disappointing outcomes following chemoradiotherapy (CRT) and appreciable morbidity following historical surgical approaches. We aimed to investigate the oncologic outcomes and perioperative morbidity of a transoral robotic surgery (TORS) approach to surgically resectable HPV-negative OPSCC.

METHODS

Retrospective analysis HPV-negative OPSCC patients who underwent TORS, neck dissection and pathology-guided adjuvant therapy (2005-2017).

RESULTS

Fifty-six patients (91.1% stage III/IV) were included. Three-year overall survival, locoregional control, and disease-free survival were 85.5%, 84.4%, and 73.6%, respectively (median follow-up 30.6 months, interquartile range 18.4-66.6). Eighteen (32.1%) patients underwent adjuvant radiotherapy and 20 (39.3%) underwent adjuvant CRT. Perioperative mortality occurred in one (1.8%) patient and hemorrhage occurred in two (3.6%) patients. Long-term gastrostomy and tracheostomy rates were 5.4% and 0.0%, respectively.

CONCLUSION

The TORS approach for resectable HPV-negative OPSCC can achieve encouraging oncologic outcomes with infrequent morbidity.

Association of Primary Treatment Modality for Advanced-Stage Oropharyngeal Squamous Cell Carcinoma With Survival Outcomes

IMPORTANCE

Definitive chemoradiotherapy and upfront surgical treatment are both accepted as the standard of care for advanced-stage oropharyngeal squamous cell carcinoma. However, the optimal primary treatment modality remains unclear.

OBJECTIVE

To evaluate the comparative effectiveness of definitive chemoradiotherapy and upfront surgical treatment for advanced-stage oropharyngeal cancer.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective comparative effectiveness analysis used data from the population-based Taiwan Cancer Registry. Included patients were diagnosed with clinical stage III or IV oropharyngeal squamous cell carcinoma from 2007 to 2015 and were identified from the registry. Patients with T4b or N3 disease were excluded. Data were analyzed from June 2019 through December 2020.

INTERVENTIONS

Definitive chemoradiotherapy or upfront surgical treatment.

MAIN OUTCOMES AND MEASURES

The primary outcome was overall survival, for which data were available through December 31, 2018. Secondary outcomes were progression-free survival, locoregional recurrence-free survival, and distant metastasis-free survival.

RESULTS

Among 1180 patients, 694 patients (58.8%) were in the definitive chemoradiotherapy group and 486 patients (41.2%) were in the upfront surgical treatment group. The median (interquartile range) follow-up was 3.62 (1.63-5.47) years, and most patients were men (1052 [89.1%] men) with a primary tumor in the tonsils (712 patients [60.3%]), moderately differentiated histology (604 patients [51.2%]), clinical N2 disease (858 patients [72.7%]), and clinical stage IVA disease (938 patients [79.5%]). The mean (SD) age was 54.59 (10.35) years. Primary treatment with an upfront surgical procedure was associated with a decreased risk of death during the study period (hazard ratio [HR], 0.81; 95% CI, 0.69-0.97; P = .02). However, when adjusted for age, subsite, histological grade, and T and N classification, upfront surgical treatment was no longer associated with an increased risk of death during the study period (HR, 0.96; 95% CI, 0.80-1.16; P = .70). Progression-free survival was worse in the group receiving upfront surgical treatment than in the group receiving chemoradiotherapy (HR, 1.64; 95% CI, 1.09-2.46; P = .02), and this difference persisted after adjusting for other factors associated with prognosis (ie, age, tumor subsite, histological grade, and T and N classification) (HR, 1.72; 95% CI, 1.12-2.66; P = .01).

CONCLUSIONS AND RELEVANCE

This study found that definitive chemoradiotherapy was associated with effectiveness that was comparable with that of upfront surgical treatment when adjusted for baseline factors associated with prognosis. These findings suggest that definitive chemoradiotherapy should be considered to avoid accumulating toxic effects associated with surgical treatment and chemoradiotherapy.

Establishment and Validation of a Nomogram for Tonsil Squamous Cell Carcinoma: A Retrospective Study Based on the SEER Database

This study aimed to establish and validate a comprehensive nomogram for predicting the cause-specific survival (CSS) probability in tonsillar squamous cell carcinoma (TSCC). We screened and extracted data from the SEER (Surveillance, Epidemiology, and End Results) database for the period 2004 to 2016. We randomly divided the 7243 identified patients into a training cohort (70%) for constructing the model and a validation cohort (30%) for evaluating the model using R software. Multivariate Cox stepwise regression was used to select predictive variables. The concordance index (C-index), the area under the time-dependent receiver operating characteristics curve (AUC), the net reclassification improvement (NRI), the integrated discrimination improvement (IDI), calibration plotting, and decision-curve analysis (DCA) were used to evaluate the model. The multivariate Cox stepwise regression analysis successfully established a nomogram for the 1-, 3-, and 5-year CSS probabilities for TSCC patients. The C-index, AUC, NRI, and IDI were all showed that the model has good discrimination. The calibration plots were very close to the standard lines, indicating that the model has a good degree of calibration, and the DCA curve further illustrated that the model has good clinical validity. We have established the first nomogram for predicting the 1-, 3-, and 5-year CSS probabilities for TSCC based on a large retrospective sample. Our rigorous validation and evaluation indicated that the model can provide useful guidance to clinical workers making clinical decisions about individual patients.

A matched pair analysis of oncological outcomes in human papillomavirus-negative oropharyngeal squamous cell carcinoma: Transoral surgery versus radiotherapy or concurrent chemoradiation

BACKGROUND

With the termination of RTOG 1221, there remains a lacuna regarding the optimal treatment for human papillomavirus (HPV)-negative oropharyngeal squamous cell carcinoma (OPSCC).

METHODS

Matched pair analysis with propensity score matching (PSM) between Arm I (transoral surgery [TOS] + risk-stratified adjuvant treatment) and Arm II (nonsurgical treatment - radiation/chemoradiation) in HPV(-) OPSCC.

RESULTS

Unmatched comparison of Arm I (n = 57) and Arm II (n = 89) indicated significantly better overall survival (OS) and disease-free survival (DFS) for Arm I. PSM by matched pairs (n = 48, 24 each arm) indicated 5-year OS at 80% and 72.1%, respectively, for Arm I and II (p > 0.05) and corresponding DFS at 65.3% and 33.4% (p > 0.05). Subgroup analysis did not demonstrate statistical difference in outcomes in stage II and III, but stage IV tumors had significantly better outcomes in Arm I than Arm II (4-year OS: 100% vs. 21%, p = 0.04; DFS: 75% vs. 14.3%, p = 0.04).

CONCLUSIONS

TOS +/- adjuvant was found to have oncological outcomes at par with nonsurgical modalities in stage I-III OPSCC, whereas a distinct survival advantage was noted in case of stage IV tumors.

Functional outcomes of soft palate free flap reconstruction following oropharyngeal cancer surgery

INTRODUCTION

The objective of this study was to assess the impact of surgical resection and free flap reconstruction of soft palate cancer on speech, swallowing and quality of life, and to identify the factors influencing functional outcomes and quality of life.

MATERIAL AND METHODS

Patients treated with surgical resection of squamous cell carcinoma and free-flap reconstruction of the soft palate were reviewed at least 12 months after surgery. Speech was assessed using the Hirose intelligibility scoring system, nasalance scoring, GRBAS scoring and the Voice Handicap Index 30 (VHI30) questionnaire. Swallowing was assessed by fiberoptic endoscopy and the Deglutition Handicap Index (DHI). Quality of life was assessed using EORTC QLQ-C30 and QLQ-H&N35 questionnaires.

RESULTS

29 patients were included. Speech outcomes were satisfactory, demonstrating normal or slightly below normal speech intelligibility in 75.9% of the patients, moderate or no rhinolalia in 72.4% of the patients and mean overall VHI30 scores indicative of slight or no handicap in 86.2% of the patients. Swallowing outcomes were satisfactory, with mean overall DHI scores indicative of slight or no handicap in 82.8% of the patients. Patient quality of life was preserved as demonstrated by mean quality of life and functioning scales scores all superior to 80%.

CONCLUSION

The sequelae arising from surgical resection and free-flap reconstruction of soft palate cancer are tolerable, involving slight handicap in terms of speech and swallowing and relatively little impact on quality of life.

Oncologic outcomes of human papillomavirus-associated oropharynx carcinoma treated with surgery alone: A 12-institution study of 344 patients

BACKGROUND

The oncologic outcomes of surgery alone for patients with American Joint Committee on Cancer 7th edition (AJCC 7th) pN2a and pN2b human papillomavirus-associated oropharynx squamous cell carcinoma (HPV+OPSCC) are not clear.

METHODS

The authors performed a 12-institution retrospective study of 344 consecutive patients with HPV+OPSCC (AJCC 7th pT0-3 N3 M0) treated with surgery alone with 6 months or more of follow-up using univariate and multivariate analyses.

RESULTS

The 2-year outcomes for the entire cohort were 91% (182 of 200) disease-free survival (DFS), 100% (200 of 200) disease-specific survival (DSS), and 98% (200 of 204) overall survival (OS). The 18 recurrences within 2 years were 88.9% (16 of 18) local and/or regional recurrences and 11.1% (2 of 18) distant metastases. Recurrences were not significantly associated with smoking, pT stage, or pN stage. The 16 patients with locoregional recurrences within 2 years all underwent successful salvage treatments (median follow-up after salvage: 13.1 months), 43.8% (7 of 16) of whom underwent salvage surgery alone for a 2-year overall salvage radiation need of 4.5% (9 of 200). The 2-year outcomes for the 59 evaluable patients among the 109 AJCC 7th pT0-2 N2a-N2b patients with 1 to 3 pathologic lymph nodes (LNs) were as follows: local recurrence, 3.4% (2 of 59); regional recurrence, 8.4% (5 of 59); distant metastases, 0%; DFS, 88.1% (52 of 59); DSS, 100% (59 of 59); OS, 96.7% (59 of 61); and salvage radiation, 5.1% (3 of 59).

CONCLUSIONS

With careful selection, surgery alone for AJCC 7th pT0-T2N0-N2b HPV+OPSCC with zero to 3 pathologic LNs without perineural invasion, extranodal extension, or positive margins results in high DFS, DSS, OS, and salvage treatment success. Because of the short-term follow-up, these data support further investigation of treatment de-escalation in this population.

Patient Selection for Transoral Robotic Surgery (TORS) in Oropharyngeal Squamous Cell Carcinoma: What the Surgeon Wants to Know

ABSTRACT

Transoral robotic surgery (TORS) is an excellent treatment strategy for well-selected patients with oropharyngeal squamous cell carcinoma. Potential benefits of TORS are greatest among patients for whom surgical resection will reduce or eliminate the need for adjuvant therapy. Proper patient selection largely depends on imaging, which is used to determine tumor resectability, to inform expected morbidity and functional outcome, to assess the potential need for adjuvant therapy, to evaluate for vascular or other anatomic contraindications, and to gauge adequacy of transoral access to the tumor. This article provides the radiologist with a practical and accessible approach to interpreting preoperative imaging among patients with oropharyngeal cancer, emphasizing what the surgeon wants to know to inform the determination of whether the patient is a TORS candidate and why this information is important. By accurately reporting this information, the radiologist facilitates the multidisciplinary care team's selection of a treatment regimen optimized for the circumstances of the individual patient.

Outcomes of HPV-Negative Oropharyngeal Cancer Treated With Transoral Robotic Surgery

OBJECTIVE

The incidence of oropharyngeal squamous cell carcinoma (OPSCC) is increasing secondary to human papillomavirus (HPV)-related disease. Despite this, outcomes of patients with HPV-negative OPSCC undergoing transoral robotic surgery (TORS) are largely unknown.

STUDY DESIGN

Analysis of the National Cancer Database (NCDB).

SETTING

Not applicable.

METHODS

The 2015 participant user file from the NCDB was analyzed between 2010 and 2015 for patients with OPSCC who underwent TORS and neck dissection. Kaplan-Meier survival analysis was used to estimate overall survival of the study population. Univariable Cox survival analyses was used to determine significant associations between demographic, tumor, and treatment characteristics and overall survival (OS).

RESULTS

There were 164 patients (124 male and 40 female) with a mean age of 58 years (30-89 years). Median follow-up was 34 months. Five-year OS was 78% (95% CI, 70%-86%). Patients with early stage disease (pT1-2, N0-1) had significantly improved OS compared to patients with advanced T- or N-stage disease (log-rank 0.011; 5-year OS: 88% [95% CI, 78%-98%] vs 66% [95% CI, 50%-82%]).

CONCLUSION

Very few patients in the NCDB underwent TORS for HPV-negative OPSCC, but those who did had favorable outcomes, especially in early stage disease. Based on these findings, TORS may be considered in the treatment algorithm for patients with HPV-negative OPSCC.

LEVEL OF EVIDENCE

Level IV.

Machine Learning to Predict Treatment in Oropharyngeal Squamous Cell Carcinoma

OBJECTIVES

This study seeks to (1) demonstrate how machine learning (ML) can be used for prediction modeling by predicting the treatment patients with T1-2, N0-N1 oropharyngeal squamous cell carcinoma (OPSCC) receive and (2) assess the impact patient, socioeconomic, regional, and institutional factors have in the treatment of this population.

METHODS

A retrospective cohort of adults diagnosed with T1-2, N0-N1 OPSCC from 2004 to 2013 was obtained using the National Cancer Database. The data was split into 80/20 distribution for training and testing, respectively. Various ML algorithms were explored for development. Area under the curve (AUC), accuracy, precision, and recall were calculated for the final model.

RESULTS

Among the 19,111 patients in the study, the mean (standard deviation) age was 61.3 (10.8) years, 14,034 (73%) were male, and 17,292 (91%) were white. Surgery was the primary treatment in 9,533 (50%) cases and radiation in 9,578 (50%) cases. The model heavily utilized T-stage, primary site, N-stage, grade, and type of treatment facility to predict the primary treatment modality. The final model yielded an AUC of 78% (95% CI, 77-79%), accuracy of 71%, precision of 72%, and recall of 71%.

CONCLUSION

This study created a ML model utilizing clinical variables to predict primary treatment modality for T1-2, N0-N1 OPSCC. This study demonstrates how ML can be used for prediction modeling while also highlighting that tumor and facility realted variables impact the decision making process on a national level.

Assessment Criteria and Clinical Implications of Extranodal Extension in Head and Neck Cancer

Tumor breaching the capsule of a lymph node is termed extranodal extension (ENE). It reflects aggressiveness of a tumor, creates anatomic challenges for disease clearance, and increases the risk of distant metastasis. Extranodal extension can be assessed on a pathology specimen, by radiology studies, and by clinical examination. Presence of ENE in a pathology specimen has long been considered a high-risk feature of disease progression and would ordinarily benefit from the addition of chemotherapy to adjuvant radiotherapy. Although the eighth edition of the Union for International Cancer Control/American Joint Committee on Cancer stage classification dichotomizes pathologic ENE according to its presence or absence, emerging evidence suggests that the extent of a pathologic ENE may provide additional value for risk stratification to guide adjuvant therapy. Recent data suggest that the prognostic importance of pathologic ENE is also applicable for HPV-associated head and neck squamous cell carcinoma. In addition, compelling data demonstrate that indisputable radiologic ENE is a powerful risk stratification tool to identify patients at high risk for treatment failure, especially distant metastasis, applicable for both HPV-positive and HPV-negative head and neck squamous cell carcinoma. However, the definition and taxonomy of radiologic ENE requires standardization. The goal of this review is to clarify the contemporary understanding of the prognostic implications of ENE in head and neck squamous cell carcinoma, present the nuances of what is presently known and unknown, and elucidate how to classify ENE pathologically and radiologically with an understanding of the strengths and weaknesses of each approach. Finally, with the development of several risk stratification methods, the relative role of ENE and other prognostic schema will be explored.

Comparison of Survival After Transoral Robotic Surgery vs Nonrobotic Surgery in Patients With Early-Stage Oropharyngeal Squamous Cell Carcinoma

Importance

Transoral robotic surgery has been widely adopted since approval by the US Food and Drug Administration in December 2009, despite limited comparative data.

Objective

To compare the long-term outcomes of transoral robotic surgery with those of nonrobotic surgery for patients with early-stage oropharyngeal cancer.

Design, Setting, and Participants

A retrospective cohort comparative effectiveness analysis was performed of patients in the National Cancer Database with clinical T1 and T2 oropharyngeal squamous cell carcinoma diagnosed between January 1, 2010, and December 31, 2015, who underwent definitive robotic and nonrobotic surgery. Multivariable Cox proportional hazards regression analysis and propensity score matching were performed in patients with known human papillomavirus status to adjust for patient- and disease-related covariates. Survival after robotic and nonrobotic surgery was also compared in 3 unrelated cancers: prostate, endometrial, and cervical cancer. Statistical analysis was performed from April 10, 2019, to May 21, 2020.

Main Outcomes and Measures

Overall survival.

Results

Of 9745 patients (7652 men [78.5%]; mean [SD] age, 58.8 [9.6] years) who met inclusion criteria, 2694 (27.6%) underwent transoral robotic surgery. There was a significant increase in the use of robotic surgery from 18.3% (240 of 1309) to 35.5% (654 of 1841) of all surgical procedures for T1 and T2 oropharyngeal cancers from 2010 to 2015 (P = .003). Robotic surgery was associated with lower rates of positive surgical margins (12.5% [218 of 1746] vs 20.3% [471 of 2325]; P < .001) and lower use of adjuvant chemoradiotherapy (28.6% [500 of 1746] vs 35.7% [831 of 2325]; P < .001). Among 4071 patients with known human papillomavirus status, robotic surgery was associated with improved overall survival compared with nonrobotic surgery in multivariable Cox proportional hazards regression (hazard ratio [HR], 0.74; 95 CI, 0.61-0.90; P = .002). Similar results were seen when analyzing only the subset of facilities offering both robotic and nonrobotic surgery. The 5-year overall survival was 84.8% vs 80.3% among patients undergoing robotic vs nonrobotic surgery in propensity score-matched cohorts (P = .001). By contrast, there was no evidence that robotic surgery was associated with improved survival in other cancers, such as prostate cancer (HR, 0.92; 95% CI, 0.79-1.07; P = .26), endometrial cancer (HR, 0.97; 95% CI, 0.90-1.04; P = .36), and cervical cancer (HR, 1.27; 95% CI, 0.96-1.69; P = .10).

Conclusions and Relevance

This study suggests that transoral robotic surgery was associated with improved surgical outcomes and survival compared with nonrobotic surgery in patients with early-stage oropharyngeal cancer. Evaluation in comparative randomized trials is warranted.

Transoral robotic submandibular gland transposition to reconstruct radical tonsillar resection defects

Significant dysphagia, pain, and risk of bleeding occur after transoral robotic surgery (TORS) radical tonsillectomy. We present a novel surgical technique utilizing robotically assisted submandibular gland transposition (SMGT) to reconstruct the radical tonsillar defect. A 48-year-old male with p16+ tonsillar squamous cell carcinoma underwent deep TORS radical tonsillectomy, contralateral tonsillectomy, ipsilateral neck dissection, and TORS-assisted reconstruction of the radical defect with ipsilateral SMGT. Postoperatively, the patient experienced minimal pain and was discharged on postoperative day (POD) 3 tolerating a soft diet. There were no episodes of postoperative bleeding. This procedure was performed in five other cases as well. Transoral robotic SMGT can be used successfully to repair deep TORS radical tonsillectomy defects and may theoretically reduce dysphagia, pain, and the risk of hemorrhage.