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Hunter CJ, Romaniw NN, Beckham R, Farsi S, Benefield A, Solverson M, Gray EA, Nguyen E, Marshall A, King D, Sunde J, Moreno M, Vural E. Utility of video fluoroscopic swallow study in advancing oral diet post TORS for oropharyngeal malignancies. Am J Otolaryngol 2024; 45:104336. [PMID: 38704947 DOI: 10.1016/j.amjoto.2024.104336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 04/21/2024] [Indexed: 05/07/2024]
Abstract
OBJECTIVE TORS is a minimally invasive surgical alternative to chemoradiotherapy for oropharyngeal malignancies. While early postoperative oropharyngeal dysphagia is linked to TORS, this study explores both subjective and objective swallowing outcomes. STUDY DESIGN Retrospective and prospective review of the patients who underwent TORS for oropharyngeal malignancy from 2018 to 2023. SETTING Single tertiary referral center. METHODS Postoperative transnasal feeding tubes were administered to 142 patients undergoing TORS. Data on oncological, clinical, surgical, and pathological parameters, including VFSS records, pain with swallow, and feeding tube removal timing, were collected. Clinical swallow exam (CSE) was conducted on POD-1, with a formal swallow study pursued if inconclusive. Once a safe swallow was confirmed, oral diets were initiated, and the feeding tube removed, with most patients discharged on POD-2. RESULTS At an average age of 59.3 years on the day of operation, the palatine tonsil (N = 101) was the predominant subsite. A dobhoff feeding tube was intraoperatively placed in 98 % of patients (N = 139). On POD-1, CSE was conducted in 119 patients, with 26 % (37/119) cleared for total oral diet (NOMS ≥ 4). Additionally, 30 out of 73 VFSS patients were cleared for total oral diet. A total of 54.9 % (78/142) had the feeding tube removed before discharge on POD-2, with a mean time of 6.5 ± 6.6 days. Overall, 71.1 % (101/142) achieved a total oral diet within one week after TORS. CONCLUSION Early post-TORS swallowing is vital for oropharyngeal malignancies. VFSS assesses post-operative swallowing safety, allowing most patients to resume total oral nutrition shortly after TORS.
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Affiliation(s)
- Courtney J Hunter
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, Little Rock, AR, United States
| | - Natalie N Romaniw
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, Little Rock, AR, United States
| | - Rachel Beckham
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, Little Rock, AR, United States
| | - Soroush Farsi
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, Little Rock, AR, United States
| | - Anna Benefield
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, Little Rock, AR, United States
| | - Matthew Solverson
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, Little Rock, AR, United States
| | - Emily A Gray
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, Little Rock, AR, United States
| | - Emma Nguyen
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, Little Rock, AR, United States
| | - Aubrey Marshall
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, Little Rock, AR, United States
| | - Deanne King
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, Little Rock, AR, United States
| | - Jumin Sunde
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, Little Rock, AR, United States
| | - Mauricio Moreno
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, Little Rock, AR, United States
| | - Emre Vural
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, Little Rock, AR, United States.
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Snyder V, Kraft DO, Creamer A, Spector ME, Sridharan SS. A Scoping Review of Pain Management After Transoral Robotic Surgery. Otolaryngol Head Neck Surg 2024. [PMID: 39031715 DOI: 10.1002/ohn.871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Revised: 06/04/2024] [Accepted: 06/05/2024] [Indexed: 07/22/2024]
Abstract
OBJECTIVE Pain following transoral robotic surgery (TORS) is a driver of adverse outcomes and can lead to readmission and treatment delays. A scoping review was conducted to characterize TORS-related pain and identify key management strategies utilized in the literature. DATA SOURCES OVID Medline, CINAHL, Cochrane, Pubmed, and Embase databases were queried. REVIEW METHODS Two team members independently screened titles and abstracts and completed full-text reviews. Studies examining TORS for OPSCC with quantitative pain data were included. The study followed the PRISMA guidelines. RESULTS A total of 1467 studies were imported for screening and 25 studies were ultimately included. The average study sample size was 89 participants. 68% were conducted in a single-center academic setting. Pain was assessed on varying timelines up to 3 years using 13 different metrics. Pain peaks days-weeks postoperatively and returns to baseline thereafter. Postoperative pain is a significant cause of morbidity and limited data exist about optimal management. CONCLUSION Prospective studies are needed to characterize and address TORS-related pain.
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Affiliation(s)
- Vusala Snyder
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Daniel O Kraft
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai New York, New York, New York, USA
| | - Andrew Creamer
- Brown University Library, School of Medicine, Providence, Rhode Island, USA
| | - Matthew E Spector
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Shaum S Sridharan
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Ushiro K, Watanabe Y, Kishimoto Y, Kawai Y, Fujimura S, Asato R, Tsujimura T, Hori R, Kumabe Y, Yasuda K, Tamaki H, Iki T, Kitani Y, Kurata K, Kojima T, Takata K, Kada S, Takebayashi S, Shinohara S, Hamaguchi K, Miyazaki M, Ikenaga T, Maetani T, Harada H, Haji T, Omori K. Complications including dysphagia following transoral non-robotic surgery for pharyngeal and laryngeal squamous cell carcinoma: A retrospective multicenter study. Auris Nasus Larynx 2024; 51:575-582. [PMID: 38547566 DOI: 10.1016/j.anl.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 02/19/2024] [Accepted: 03/14/2024] [Indexed: 05/12/2024]
Abstract
OBJECTIVE Transoral surgery is a minimally invasive treatment but may cause severe dysphagia at a lower rate than chemoradiotherapy. METHODS We compared clinical information, surgical complications, and swallowing function in patients who underwent transoral nonrobotic surgery for laryngo-pharyngeal squamous cell carcinoma between 2015 and 2021 in a multicenter retrospective study. RESULTS Six hundred and forty patients were included. Postoperative bleeding was observed in 20 cases (3.1%), and the risk factor was advanced T category. Postoperative laryngeal edema was observed in 13 cases (2.0%), and the risk factors were prior radiotherapy, advanced T stage, and concurrent neck dissection in patients with resected HPC. Dysphagia requiring nutritional support was observed in 29 cases (4.5%) at 1 month postoperatively and in 19 cases (3.0%) at 1 year postoperatively, respectively. The risk factors for long-term dysphagia were prior radiotherapy and advanced T category. Short-term risk factors for dysphagia were prior radiotherapy, advanced T category, and concurrent neck dissection, while long-term risk factors for dysphagia were only prior radiotherapy and advanced T category. CONCLUSION Prior radiotherapy, advanced T stage, and concurrent neck dissection increased the incidence of postoperative laryngeal edema and short-term dysphagia, but concurrent neck dissection did not affect long-term dysphagia. Such features should be considered when considering the indication for transoral surgery and postoperative management.
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Affiliation(s)
- Koji Ushiro
- Department of Otolaryngology-Head & Neck Surgery, National Hospital Organization Kyoto Medical Center, 1-1 Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto 612-8555, Japan.
| | - Yoshiki Watanabe
- Department of Otolaryngology-Head & Neck Surgery, Japanese Red Cross Osaka Hospital, Osaka, Japan
| | - Yo Kishimoto
- Department of Otolaryngology-Head & Neck Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yoshitaka Kawai
- Department of Otolaryngology-Head & Neck Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shintaro Fujimura
- Department of Otolaryngology-Head & Neck Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ryo Asato
- Department of Otolaryngology-Head & Neck Surgery, National Hospital Organization Kyoto Medical Center, 1-1 Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto 612-8555, Japan
| | - Takashi Tsujimura
- Department of Otolaryngology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Ryusuke Hori
- Department of Otolaryngology-Head and Neck Surgery, University of Occupational and Environmental Health, Kitakyushu, Japan; Department of Otolaryngology-Head & Neck Surgery, Fujita Health University, Toyoake, Japan; Department of Otolaryngology-Head & Neck Surgery, Tenri Hospital, Tenri, Japan
| | - Yohei Kumabe
- Department of Otolaryngology-Head & Neck Surgery, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Kaori Yasuda
- Department of Otolaryngology-Head & Neck Surgery, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Hisanobu Tamaki
- Department of Otolaryngology-Head & Neck Surgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Takehiro Iki
- Department of Otolaryngology-Head & Neck Surgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Yoshiharu Kitani
- Department of Otolaryngology-Head & Neck Surgery, Shizuoka General Hospital, Shizuoka, Japan
| | - Keisuke Kurata
- Department of Otolaryngology-Head & Neck Surgery, Shizuoka General Hospital, Shizuoka, Japan
| | - Tsuyoshi Kojima
- Department of Otolaryngology-Head & Neck Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan; Department of Otolaryngology-Head & Neck Surgery, Tenri Hospital, Tenri, Japan
| | - Kuniaki Takata
- Department of Otolaryngology-Head & Neck Surgery, Tenri Hospital, Tenri, Japan
| | - Shinpei Kada
- Department of Otolaryngology-Head & Neck Surgery, Japanese Red Cross Otsu Hospital, Otsu, Japan
| | - Shinji Takebayashi
- Department of Otolaryngology-Head & Neck Surgery, Shiga General Hospital, Moriyama, Japan
| | - Shogo Shinohara
- Department of Otolaryngology-Head & Neck Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Kiyomi Hamaguchi
- Department of Otolaryngology-Head & Neck Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan; Department of Otolaryngology-Head & Neck Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Masakazu Miyazaki
- Department of Otolaryngology-Head & Neck Surgery, Nara Prefecture General Medical Center, Nara, Japan
| | - Tadashi Ikenaga
- Department of Otolaryngology-Head & Neck Surgery, Nara Prefecture General Medical Center, Nara, Japan
| | - Toshiki Maetani
- Department of Otolaryngology-Head & Neck Surgery, Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Hiroyuki Harada
- Department of Otolaryngology-Head & Neck Surgery, Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Tomoyuki Haji
- Department of Otolaryngology-Head & Neck Surgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Koichi Omori
- Department of Otolaryngology-Head & Neck Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Molteni G, Bassani S, Arsie AE, Zampieri E, Mannelli G, Orlandi E, Bossi P, De Virgilio A. Role of TORS as De-Escalation Strategy in HPV-Related Oropharyngeal Cancer, What We Need to Know. Healthcare (Basel) 2024; 12:1014. [PMID: 38786424 PMCID: PMC11121063 DOI: 10.3390/healthcare12101014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 05/04/2024] [Accepted: 05/10/2024] [Indexed: 05/25/2024] Open
Abstract
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.
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Affiliation(s)
- Gabriele Molteni
- Department of Otolaryngology-Head and Neck Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, 40126 Bologna, Italy
| | - Sara Bassani
- Otolaryngology-Head and Neck Surgery Department, University of Verona, 37129 Verona, Italy; (A.E.A.)
| | - Athena Eliana Arsie
- Otolaryngology-Head and Neck Surgery Department, University of Verona, 37129 Verona, Italy; (A.E.A.)
| | - Erica Zampieri
- Otolaryngology-Head and Neck Surgery Department, University of Verona, 37129 Verona, Italy; (A.E.A.)
| | - Giuditta Mannelli
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Firenze, Italy
| | - Ester Orlandi
- Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy;
- Clinical Department, National Center for Oncological Hadrontherapy (Fondazione CNAO), 27100 Pavia, Italy
| | - Paolo Bossi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, Italy;
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy
| | - Armando De Virgilio
- Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy
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Larsen MHH, Kehlet H, von Buchwald C. Transoral robotic surgery - time for consensus on pain assessment. A review. Acta Otolaryngol 2023; 143:902-911. [PMID: 37991140 DOI: 10.1080/00016489.2023.2282149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 11/02/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND In Head and Neck surgery Transoral Robotic Surgery (TORS) is evolving as a key treatment option for benign and malignant lesions in the oropharynx. Even so, postoperative pain is one of the primary early complaints following TORS. Well established evidence-based procedure specific pain treatment guidelines are available for a variety of other surgical specialties. However, there are no guidelines for TORS. AIM This review describes the available data of early pain intensity following TORS during rest and procedure related activity. METHODS Literature concerning pain in the immediate postoperative phase following TORS were obtained from two literature databases. RESULTS Most data on pain intensity following TORS are based upon a numeric rating scale, e.g. the Visual Analogue Scale and/or analgesic demands. Only one randomized clinical trial is available reflecting that the literature is mainly based on retrospective and a few prospective studies. Only one study analyzed pain during relevant functionality, i.e. swallowing. Overall, the studies suffer from a non-standardized approach and there is a need for transparent information concerning the timing of pain ratings and methodology. CONCLUSIONS The evidence for optimal pain control is limited, particularly during surgical relevant activity. Postoperative pain rating during activity is a fundamental element in pain trials in order to enhance recovery thereby calling for future consensus on assessment methodology.
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Affiliation(s)
- Mikkel Hjordt Holm Larsen
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Henrik Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian von Buchwald
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
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Cannavicci A, Cioccoloni E, Moretti F, Cammaroto G, Iannella G, De Vito A, Sgarzani R, Gessaroli M, Ciorba A, Bianchini C, Corazzi V, Capaccio P, Vicini C, Meccariello G. Single centre analysis of perioperative complications in trans-oral robotic surgery for oropharyngeal carcinomas. Indian J Otolaryngol Head Neck Surg 2023; 75:842-847. [PMID: 37275059 PMCID: PMC10235366 DOI: 10.1007/s12070-023-03518-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 01/19/2023] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Angelo Cannavicci
- Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Azienda USL Della Romagna, Viale Forlanini 34, 47100 Forlì, Italy
| | - Eleonora Cioccoloni
- Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Azienda USL Della Romagna, Viale Forlanini 34, 47100 Forlì, Italy
| | | | - Giovanni Cammaroto
- Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Azienda USL Della Romagna, Viale Forlanini 34, 47100 Forlì, Italy
| | | | - Andrea De Vito
- Otolaryngology and Head-Neck Surgery Unit, Department of Surgery, Santa Maria Delle Croci Hospital, Azienda USL Della Romagna, Ravenna, Italy
| | - Rossella Sgarzani
- Burn Unit, Department of Surgery, Bufalini Hospital, Azienda USL Della Romagna, Cesena, Italy
| | - Manlio Gessaroli
- Maxillo-Facial Surgery Unit, Department of Surgery, Bufalini Hospital, Azienda USL Della Romagna, Cesena, Italy
| | - Andrea Ciorba
- Otolaryngology Unit, University of Ferrara, Ferrara, Italy
| | | | | | - Pasquale Capaccio
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Claudio Vicini
- Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Azienda USL Della Romagna, Viale Forlanini 34, 47100 Forlì, Italy
- Otolaryngology Unit, University of Ferrara, Ferrara, Italy
| | - Giuseppe Meccariello
- Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Azienda USL Della Romagna, Viale Forlanini 34, 47100 Forlì, Italy
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Surgical Treatment for Advanced Oropharyngeal Cancer: A Narrative Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020304. [PMID: 36837506 PMCID: PMC9961866 DOI: 10.3390/medicina59020304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/30/2022] [Accepted: 01/30/2023] [Indexed: 02/10/2023]
Abstract
Background and Objectives: to describe current scientific knowledge regarding the treatment options in advanced oropharyngeal cancer. The standard care for advanced oropharyngeal cancer (OPSCC) has been chemoradiotherapy, although surgical approaches followed by adjuvant treatment have been proposed. The best therapy for each patient should be decided by an interdisciplinary tumour-board. Different strategies should be considered for the specific patient's treatment: surgery, chemotherapy and radiation therapy or combinations of them. The treatment choice is influenced by tumour variability and prognostic factors, but it also depends on cancer extension, extranodal extension, nervous invasion, human papilloma virus (HPV) presence, making the decisional algorithm not always clear. HPV-related OPSCC is strongly associated with a favourable overall survival (OS) and disease-free survival rate (DSS); by contrast, HPV-negative OPSCC often flags a worse prognosis. Consequently, the American Joint Committee on Cancer (AJCC) differentiates OPSCC treatment and prognosis based on HPV status. Methods: we carried out a review of current scientific literature to analyze the different indications and limitations of surgical treatment options in OPSCC stage III and IV. Conclusion: robotic surgery or open approaches with reconstructive flaps can be considered in advanced stages, resulting in the de-intensification of subsequent systemic therapy and fewer related side effects. Furthermore, in the event of the primary failure of systemic therapy or disease recurrence, the surgical approach constitutes an additional therapeutic option which lengthens patient survival functions.
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30-day morbidity and mortality after transoral robotic surgery for human papillomavirus (HPV) associated oropharyngeal squamous cell carcinoma: A retrospective analysis of two prospective adjuvant de-escalation trials (MC1273 & MC1675). Oral Oncol 2023; 137:106248. [PMID: 36603364 DOI: 10.1016/j.oraloncology.2022.106248] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/17/2022] [Accepted: 11/10/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Dose de-escalation of adjuvant therapy (DART) in patients with HPV(+)OPSCC was investigated in two prospective Phase II and III clinical trials (MC1273 and MC1675). We report the 30-day morbidity and mortality associated with primary TORS resection in patients enrolled in these trials. MATERIALS AND METHODS Patients with HPV(+)OPSCC, who underwent TORS resection between 2013 and 2020 were considered in this analysis. The severity of postoperative transoral bleeding was graded using both the Hinni Grade (HG) transoral surgery bleeding scale and the Common Terminology for Adverse Events (CTCAE) v5.0. Post-surgical complications within 30 days of surgery, as well as rates of tracheostomy, PEG and nasogastric tube placement. RESULTS 219 patients were included. A total of 7 (3.2 %) patients had a tracheostomy placed at the time of surgery, and all were decannulated within 26 days (median: 5, range: 2-26). There were 33 (15.1 %) returns to the emergency department (ED) with 10 (4.6 %) patients requiring readmission. Using the HG scale, 10 (4.6 %) patients experienced ≥ Grade 3 bleeding with no Grade 5 or 6 bleeds. In contrast, using the CTCAE scale, 15 patients (6.8 %) experienced ≥ Grade 3 bleeding with no Grade 5 bleeds. There was one post-operative death in a patient withdrawn from the trial, and no deaths related to hemorrhage. CONCLUSION AND RELEVANCE TORS for HPV(+)OPSCC in carefully selected patients at a high volume center was associated with low morbidity and mortality.
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Ferris RL, Westra W. Oropharyngeal Carcinoma with a Special Focus on HPV-Related Squamous Cell Carcinoma. ANNUAL REVIEW OF PATHOLOGY 2023; 18:515-535. [PMID: 36693202 PMCID: PMC11227657 DOI: 10.1146/annurev-pathmechdis-031521-041424] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Human papillomavirus-positive oropharyngeal squamous cell carcinoma (HPV-OPSCC) has one of the most rapidly increasing incidences of any cancer in high-income countries. The most recent (8th) edition of the Union for International Cancer Control/American Joint Committee on Cancer staging system separates HPV-OPSCC from its HPV-negative counterpart to account for the improved prognosis seen in the former. Indeed, owing to its improved prognosis and greater prevalence in younger individuals, numerous ongoing trials are examining the potential for treatment deintensification as a means to improve quality of life while maintaining acceptable survival outcomes. Owing to the distinct biology of HPV-OPSCCs, targeted therapies and immunotherapies have become an area of particular interest. Importantly, OPSCC is often detected at an advanced stage, highlighting the need for diagnostic biomarkers to aid in earlier detection. In this review, we highlight important advances in the epidemiology, pathology, diagnosis, and clinical management of HPV-OPSCC and underscore the need for a progressive understanding of the molecular basis of this disease toward early detection and precision care.
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Affiliation(s)
| | - William Westra
- Department of Pathology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
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10
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Non-opioid analgesics and post-operative pain following transoral robotic surgery for oropharyngeal cancer. The Journal of Laryngology & Otology 2022; 136:527-534. [DOI: 10.1017/s0022215121004734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractObjectiveTo investigate associations between multimodal analgesia and post-operative pain among patients undergoing transoral robotic surgery for oropharyngeal squamous cell carcinoma.MethodsRecords of patients who underwent surgery from 5 September 2012 to 30 November 2016 were abstracted. Associations were assessed using multivariable analysis.ResultsA total of 216 patients (mean age of 59.1 years, 89.4 per cent male) underwent transoral robotic surgery (92.6 per cent were human papilloma virus positive, 87.5 per cent had stage T1–T2 tumours, and 82.9 per cent had stage N0–N1 nodes). Gabapentin (n = 86) was not associated with a reduction in severe pain. Ibuprofen (n = 72) was administered less often in patients with severe pain. Gabapentin was not associated with increased post-operative sedation (p = 0.624) and ibuprofen was not associated with increased bleeding (p = 0.221). Post-operative opioid usage was not associated with surgical duration, pharyngotomy, bilateral neck dissections, tumour stage, tumour size, subsite or gabapentin.ConclusionScheduled low-dose gabapentin was not associated with improved pain control or increased respiratory depression. Ibuprofen was not associated with an increased risk of bleeding and may be under-utilised.
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11
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Hussain T. Patient Benefit and Quality of Life after Robot-Assisted Head and Neck Surgery. Laryngorhinootologie 2022; 101:S160-S185. [PMID: 35605618 DOI: 10.1055/a-1647-8650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Timon Hussain
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Essen, Universität Duisburg-Essen
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12
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Ferris RL, Flamand Y, Weinstein GS, Li S, Quon H, Mehra R, Garcia JJ, Chung CH, Gillison ML, Duvvuri U, O'Malley BW, Ozer E, Thomas GR, Koch WM, Gross ND, Bell RB, Saba NF, Lango M, Méndez E, Burtness B. Phase II Randomized Trial of Transoral Surgery and Low-Dose Intensity Modulated Radiation Therapy in Resectable p16+ Locally Advanced Oropharynx Cancer: An ECOG-ACRIN Cancer Research Group Trial (E3311). J Clin Oncol 2022; 40:138-149. [PMID: 34699271 PMCID: PMC8718241 DOI: 10.1200/jco.21.01752] [Citation(s) in RCA: 152] [Impact Index Per Article: 76.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 07/30/2021] [Accepted: 09/17/2021] [Indexed: 01/12/2023] Open
Abstract
PURPOSE Definitive or postoperative chemoradiation (CRT) is curative for human papillomavirus-associated (HPV+) oropharynx cancer (OPC) but induces significant toxicity. As a deintensification strategy, we studied primary transoral surgery (TOS) and reduced postoperative radiation therapy (RT) in intermediate-risk HPV+ OPC. METHODS E3311 is a phase II randomized trial of reduced- or standard-dose postoperative RT for resected stage III-IVa (American Joint Committee on Cancer-seventh edition) HPV+ OPC, determined by pathologic parameters. Primary goals were feasibility of prospective multi-institutional study of TOS for HPV+ OPC, and oncologic efficacy (2-year progression-free survival) of TOS and adjuvant therapy in intermediate-risk patients after resection. TOS plus 50 Gy was considered promising if the lower limit of the exact 90% binomial confidence intervals exceeded 85%. Quality of life and swallowing were measured by functional assessment of cancer therapy-head and neck and MD Anderson Dysphagia Index. RESULTS Credentialed surgeons performed TOS for 495 patients. Eligible and treated patients were assigned as follows: arm A (low risk, n = 38) enrolled 11%, intermediate risk arms B (50 Gy, n = 100) or C (60 Gy, n = 108) randomly allocated 58%, and arm D (high risk, n = 113) enrolled 31%. With a median 35.2-month follow-up for 359 evaluable (eligible and treated) patients, 2-year progression-free survival Kaplan-Meier estimate is 96.9% (90% CI, 91.9 to 100) for arm A (observation), 94.9% (90% CI, 91.3 to 98.6]) for arm B (50 Gy), 96.0% (90% CI, 92.8 to 99.3) for arm C (60 Gy), and 90.7% (90% CI, 86.2 to 95.4) for arm D (66 Gy plus weekly cisplatin). Treatment arm distribution and oncologic outcome for ineligible or step 2 untreated patients (n = 136) mirrored the 359 evaluable patients. Exploratory comparison of functional assessment of cancer therapy-head and neck total scores between arms B and C is presented. CONCLUSION Primary TOS and reduced postoperative RT result in outstanding oncologic outcome and favorable functional outcomes in intermediate-risk HPV+ OPC.
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Affiliation(s)
| | - Yael Flamand
- Dana Farber Cancer Institute-ECOG-ACRIN Biostatistics Center, Boston, MA
| | | | - Shuli Li
- Dana Farber Cancer Institute-ECOG-ACRIN Biostatistics Center, Boston, MA
| | | | | | | | | | | | | | | | | | | | | | - Neil D. Gross
- The University of Texas, MD Anderson Cancer Center, Houston, TX
| | | | - Nabil F. Saba
- Winship Cancer Institute at Emory University, Atlanta, GA
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13
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Stephen SE, Murphy JM, Beyer FR, Sellstrom D, Paleri V, Patterson JM. Early postoperative functional outcomes following transoral surgery for oropharyngeal cancer: A systematic review. Head Neck 2021; 44:530-547. [PMID: 34882886 DOI: 10.1002/hed.26938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 11/02/2021] [Accepted: 11/08/2021] [Indexed: 11/11/2022] Open
Abstract
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.
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Affiliation(s)
- Sarah E Stephen
- Speech, Voice and Swallow Department, Freeman Hospital, Newcastle upon Tyne, UK
| | - Jennifer M Murphy
- Speech, Voice and Swallow Department, Freeman Hospital, Newcastle upon Tyne, UK
| | - Fiona R Beyer
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Diane Sellstrom
- Speech, Voice and Swallow Department, Freeman Hospital, Newcastle upon Tyne, UK
| | - Vinidh Paleri
- Head and Neck Unit, Royal Marsden Hospital, London, UK
| | - Joanne M Patterson
- School of Health Sciences, Liverpool Head and Neck Cancer Centre, University of Liverpool, Liverpool, UK
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14
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Larsen MHH, Scott SI, Channir HI, Madsen AKØ, Charabi BW, Rubek N, Tvedskov JF, Kehlet H, von Buchwald C. Days alive and out of hospital following transoral robotic surgery: Cohort study of 262 patients with head and neck cancer. Head Neck 2021; 43:3866-3874. [PMID: 34605110 DOI: 10.1002/hed.26880] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 07/20/2021] [Accepted: 09/13/2021] [Indexed: 12/09/2022] Open
Abstract
BACKGROUND Days alive and out of hospital (DAOH) is a validated outcome in clinical trials, since it reflects procedure-associated morbidity and mortality. Transoral robotic surgery (TORS) has become a widely adopted procedure with increasing demand for knowledge and data on morbidity. METHODS Retrospective single-center assessment of a prospective TORS database comprising patients treated for malignancy between 2013 and 2018 using DAOH to describe procedure- and disease-related morbidity the first 12-postoperative months. RESULTS For 262 patients, median DAOH365 was 357 days (IQR 351-360). Indications for TORS were (i) primary curative resection (61%), (ii) salvage resection (15%), and (iii) diagnostic work-up of cancer of unknown primary in the head and neck (24%). Median DAOH365 was 359 days (IQR 351-361 days), 348 days (IQR 233-355), and 357 days (351-361), respectively. Pneumonia had the highest impact in DAOH365 reduction. CONCLUSION Total median DAOH365 after TORS was 357 days. The main cause leading to DAOH365 reduction was pneumonia.
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Affiliation(s)
- Mikkel H H Larsen
- Department of Otorhinolaryngology - Head and Neck Surgery & Audiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Susanne I Scott
- Department of Otorhinolaryngology - Head and Neck Surgery & Audiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Hani I Channir
- Department of Otorhinolaryngology - Head and Neck Surgery & Audiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anne K Ø Madsen
- Department of Otorhinolaryngology - Head and Neck Surgery & Audiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Birgitte W Charabi
- Department of Otorhinolaryngology - Head and Neck Surgery & Audiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Niclas Rubek
- Department of Otorhinolaryngology - Head and Neck Surgery & Audiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jesper F Tvedskov
- Department of Otorhinolaryngology - Head and Neck Surgery & Audiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Henrik Kehlet
- Department of Surgical Pathophysiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian von Buchwald
- Department of Otorhinolaryngology - Head and Neck Surgery & Audiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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15
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Feng AL, Holcomb AJ, Abt NB, Mokhtari TE, Suresh K, McHugh CI, Parikh AS, Holman A, Kammer RE, Goldsmith TA, Faden DL, Deschler DG, Varvares MA, Lin DT, Richmon JD. Feeding Tube Placement Following Transoral Robotic Surgery for Oropharyngeal Squamous Cell Carcinoma. Otolaryngol Head Neck Surg 2021; 166:696-703. [PMID: 34154449 DOI: 10.1177/01945998211020302] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To identify factors that may predict the need for feeding tubes in patients undergoing transoral robotic surgery (TORS) in the perioperative setting. STUDY DESIGN Retrospective chart review. SETTING Academic tertiary center. METHODS A retrospective series of patients undergoing TORS for oropharyngeal squamous cell carcinoma (OPSCC) was identified between October 2016 and November 2019 at a single tertiary academic center. Patient data were gathered, such as frailty information, tumor characteristics, and treatment, including need for adjuvant therapy. Multiple logistic regression was performed to identify factors associated with feeding tube placement following TORS. RESULTS A total of 138 patients were included in the study. The mean age was 60.2 years (range, 37-88 years) and 81.9% were male. Overall 82.9% of patients had human papilloma virus-associated tumors, while 28.3% were current or former smokers with a smoking history ≥10 pack-years. Eleven patients (8.0%) had a nasogastric or gastrostomy tube placed at some point during their treatment. Five patients (3.6%) had feeding tubes placed perioperatively (<4 weeks after TORS), of which 3 were nasogastric tubes. Six patients (4.3%) had feeding tubes placed in the periadjuvant treatment setting for multifactorial reasons; 5 of which were gastrostomy tubes. Only 1 patient (0.7%) was gastrostomy dependent 1 year after surgery. Multiple logistic regression did not demonstrate any significant predictive variables affecting perioperative feeding tube placement following TORS for OPSCC. CONCLUSIONS Feeding tubes are seldom required after TORS for early-stage OPSCC. With appropriate multidisciplinary planning and care, patients may reliably avoid the need for feeding tube placement following TORS for OPSCC.
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Affiliation(s)
- Allen L Feng
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew J Holcomb
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Nicholas B Abt
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Tara E Mokhtari
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Krish Suresh
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher I McHugh
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Anuraag S Parikh
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Allison Holman
- Department of Speech, Language, and Swallowing Disorders, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Rachael E Kammer
- Department of Speech, Language, and Swallowing Disorders, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Tessa A Goldsmith
- Department of Speech, Language, and Swallowing Disorders, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Daniel L Faden
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel G Deschler
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark A Varvares
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Derrick T Lin
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeremy D Richmon
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
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16
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Plonowska KA, Ochoa E, Zebolsky AL, Patel N, Hoppe KR, Ha PK, Heaton CM, Ryan WR. Nasogastric tube feeding after transoral robotic surgery for oropharynx carcinoma. Am J Otolaryngol 2021; 42:102857. [PMID: 33513477 DOI: 10.1016/j.amjoto.2020.102857] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 11/13/2020] [Accepted: 12/22/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE To determine the need for and predictors of nasogastric tube feeding (NGTF) use and duration after transoral robotic surgery (TORS) for oropharynx squamous cell carcinoma (OPSCC). MATERIALS AND METHODS This is a retrospective cohort study. For 95 OPSCC patients undergoing TORS with or without concurrent unilateral or bilateral neck dissections (ND), we evaluated NGTF use and duration, along with demographic, clinical, histopathologic, and treatment risk factors. RESULTS 23.2% (22/95) of patients received NGTF. Univariate analysis found that NGTF was significantly more likely in larger tumor specimens (mean: 2.32 cm vs. 1.84 cm; p = 0.043) and after concurrent bilateral (46.7%) compared to unilateral (17.4%) ND (p = 0.043). Multivariable analysis also found increased tumor size (p = 0.035) and concurrent bilateral ND (p = 0.04) to be significant risk factors for NGTF. The following were not statistically significantly associated with NGTF use: sex, age, smoking history, HPV status, base of tongue (BOT) resection (20%) vs. radical tonsillectomy (25.9%), pT2 (27.0%) vs. pT1 (20.4%) vs pT0 (16.7%), BOT with (28.6%) vs. without epiglottis resection (22.2%), and surgery for additional margins the same day (27.3%) (all p > 0.1). Patients who underwent NGTF had a mean duration of 18 days (2-96, SD: 20.7 days) with 12 (55.6%) having over 2 weeks of use. No significant predictors of longer duration of NGTF were identified. CONCLUSIONS A majority of patients undergoing TORS do not need NGTF. When NGTF is needed, the duration of use is usually longer than 14 days. Larger tumor size and concurrent bilateral ND are risk factors for NGTF.
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17
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Ottenstein L, Cornett H, Switchenko JM, Nathan M, Thomas S, Gillespie AI, McColloch N, Barrett T, Studer MB, Brinkman M, Kaka AS, Boyce BJ, Ferris RL, Aiken AH, El-Deiry M, Beitler JJ, Patel MR. Characterizing postoperative physiologic swallow function following transoral robotic surgery for early stage tonsil, base of tongue, and unknown primary human papillomavirus-associated squamous cell carcinoma. Head Neck 2021; 43:1629-1640. [PMID: 33547716 PMCID: PMC8046724 DOI: 10.1002/hed.26632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 12/23/2020] [Accepted: 01/21/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Data objectively evaluating acute post-transoral robotic surgery (TORS) swallow function are limited. Our goal was to characterize and identify clinical variables that may impact swallow function components 3 weeks post-TORS. METHODS Retrospective cohort study. Pre/postoperative use of the Modified Barium Swallow Impairment Profile (MBSImP) and Penetration-Aspiration Scale (PAS) was completed on 125 of 139 TORS patients (2016-2019) with human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma. Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) scores were retrospectively calculated. Uni/multivariate analysis was performed. RESULTS Dysfunctional pre-TORS DIGEST scores were predictive of post-TORS dysphagia (p = 0.015). Pre-TORS MBSImP deficits in pharyngeal stripping wave, swallow initiation, and clearing pharyngeal residue correlated with airway invasion post-TORS based on PAS scores (p = 0.012, 0.027, 0.048, respectively). Multivariate analysis of DIGEST safety scores declined with older age (p = 0.044). Odds ratios (ORs) for objective swallow function components after TORS were better for unknown primary and tonsil primaries compared to base of tongue (BOT) (OR 0.35-0.91). CONCLUSIONS Preoperative impairments in specific MBSImP components, older patients, and BOT primaries may predict more extensive recovery in swallow function after TORS.
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Affiliation(s)
- Lauren Ottenstein
- Department of Otolaryngology – Head & Neck Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Hannah Cornett
- Department of Otolaryngology – Head & Neck Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jeffrey M. Switchenko
- Department of Biostatistics & Bioinformatics, Winship Cancer Institute, Atlanta, Georgia, USA
| | - Meghana Nathan
- Department of Otolaryngology – Head & Neck Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Susan Thomas
- Department of Otolaryngology – Head & Neck Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Amanda I. Gillespie
- Department of Otolaryngology – Head & Neck Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Nancy McColloch
- Department of Otolaryngology – Head & Neck Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | | | - Meghan Brinkman
- Department of Otolaryngology – Head & Neck Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Azeem S. Kaka
- Department of Otolaryngology – Head & Neck Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Winship Cancer Institute, Atlanta, Georgia, USA
| | - Brian J. Boyce
- Department of Otolaryngology – Head & Neck Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Winship Cancer Institute, Atlanta, Georgia, USA
| | - Robert L. Ferris
- Department of Otolaryngology – Head & Neck Surgery, Hillman Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ashley H. Aiken
- Department of Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Mark El-Deiry
- Department of Otolaryngology – Head & Neck Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Winship Cancer Institute, Atlanta, Georgia, USA
| | - Jonathan J. Beitler
- Department of Otolaryngology – Head & Neck Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Winship Cancer Institute, Atlanta, Georgia, USA
- Department of Radiation Oncology, Winship Cancer Institute, Atlanta, Georgia, USA
| | - Mihir R. Patel
- Department of Otolaryngology – Head & Neck Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Winship Cancer Institute, Atlanta, Georgia, USA
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18
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Jackson RS, Stepan K, Bollig C, Sharma RK, Patel M, Massa S, Puram SV, Zevallos JP, Pipkorn P, Zenga J. Outcomes of HPV-Negative Oropharyngeal Cancer Treated With Transoral Robotic Surgery. Otolaryngol Head Neck Surg 2021; 165:682-689. [PMID: 33752484 DOI: 10.1177/0194599821996647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Ryan S Jackson
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Katelyn Stepan
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Craig Bollig
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Rahul K Sharma
- Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Mihir Patel
- Department of Otolaryngology-Head and Neck Surgery, Winship Cancer Institute at Emory, Atlanta, Georgia, USA
| | - Sean Massa
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Sidharth V Puram
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Jose P Zevallos
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Patrik Pipkorn
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Joseph Zenga
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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19
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Baijens LWJ, Walshe M, Aaltonen LM, Arens C, Cordier R, Cras P, Crevier-Buchman L, Curtis C, Golusinski W, Govender R, Eriksen JG, Hansen K, Heathcote K, Hess MM, Hosal S, Klussmann JP, Leemans CR, MacCarthy D, Manduchi B, Marie JP, Nouraei R, Parkes C, Pflug C, Pilz W, Regan J, Rommel N, Schindler A, Schols AMWJ, Speyer R, Succo G, Wessel I, Willemsen ACH, Yilmaz T, Clavé P. European white paper: oropharyngeal dysphagia in head and neck cancer. Eur Arch Otorhinolaryngol 2021; 278:577-616. [PMID: 33341909 PMCID: PMC7826315 DOI: 10.1007/s00405-020-06507-5] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 11/17/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE To develop a European White Paper document on oropharyngeal dysphagia (OD) in head and neck cancer (HNC). There are wide variations in the management of OD associated with HNC across Europe. METHODS Experts in the management of specific aspects of OD in HNC across Europe were delegated by their professional medical and multidisciplinary societies to contribute to this document. Evidence is based on systematic reviews, consensus-based position statements, and expert opinion. RESULTS Twenty-four sections on HNC-specific OD topics. CONCLUSION This European White Paper summarizes current best practice on management of OD in HNC, providing recommendations to support patients and health professionals. The body of literature and its level of evidence on diagnostics and treatment for OD in HNC remain poor. This is in the context of an expected increase in the prevalence of OD due to HNC in the near future. Contributing factors to increased prevalence include aging of our European population (including HNC patients) and an increase in human papillomavirus (HPV) related cancer, despite the introduction of HPV vaccination in various countries. We recommend timely implementation of OD screening in HNC patients while emphasizing the need for robust scientific research on the treatment of OD in HNC. Meanwhile, its management remains a challenge for European professional associations and policymakers.
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Affiliation(s)
- Laura W J Baijens
- Department of Otorhinolaryngology, Head and Neck Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.
- GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - Margaret Walshe
- Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin, Ireland
| | - Leena-Maija Aaltonen
- Department of Otorhinolaryngology, Head and Neck Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Christoph Arens
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Magdeburg, Otto-von-Guericke University, Magdeburg, Germany
| | - Reinie Cordier
- Department of Special Needs Education, University of Oslo, Oslo, Norway
- School of Occupational Therapy, Social Work and Speech Pathology, Curtin University, Perth, Australia
| | - Patrick Cras
- Department of Neurology, Born Bunge Institute, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Lise Crevier-Buchman
- Voice, Speech, Swallowing Lab, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital UVSQ and Research lab CNRS-UMR7018, Hôpital Foch, Suresnes, France
| | - Chris Curtis
- Swallows Head and Neck Cancer Charity, Blackpool, UK
| | - Wojciech Golusinski
- Department of Head and Neck Surgery, The Greater Poland Cancer Centre, Poznan University of Medical Sciences, Poznan, Poland
| | - Roganie Govender
- Head and Neck Cancer Centre, University College London Hospital, London, UK
| | - Jesper Grau Eriksen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Kevin Hansen
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical Faculty, University of Cologne, Cologne, Germany
| | - Kate Heathcote
- Robert White Centre for Airway, Voice and Swallow, Poole Hospital NHS Foundation Trust, Dorset, UK
| | - Markus M Hess
- Deutsche Stimmklinik, Hamburg, Germany
- Departement of Voice, Speech and Hearing Disorders, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sefik Hosal
- Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine, Atılım University, Medicana International Ankara, Ankara, Turkey
| | - Jens Peter Klussmann
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical Faculty, University of Cologne, Cologne, Germany
| | - C René Leemans
- Department of Otolaryngology, Head and Neck Surgery, Amsterdam University Medical Centres, Vrije Universiteit, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam University Medical Centres, Vrije Universiteit, Amsterdam, The Netherlands
| | - Denise MacCarthy
- Division of Restorative Dentistry and Periodontology, Faculty of Health Sciences, Trinity College Dublin, Dublin Dental University Hospital, Dublin, Ireland
| | - Beatrice Manduchi
- Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin, Ireland
| | - Jean-Paul Marie
- Department of Otorhinolaryngology, Head and Neck Surgery, Rouen University Hospital, Rouen, France
| | - Reza Nouraei
- Department of Ear Nose and Throat Surgery, The Robert White Centre for Airway Voice and Swallowing, Poole Hospital NHS Foundation Trust, University of Southampton, Southampton, UK
| | - Claire Parkes
- Department of Speech and Language Therapy, St. James's Hospital, Dublin, Ireland
| | - Christina Pflug
- Departement of Voice, Speech and Hearing Disorders, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Walmari Pilz
- Department of Otorhinolaryngology, Head and Neck Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
- MHeNs School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Julie Regan
- Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin, Ireland
| | - Nathalie Rommel
- Department Neurosciences, Experimental Otorhinolaryngology, Deglutology, University of Leuven, Leuven, Belgium
| | - Antonio Schindler
- Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan, Milan, Italy
| | - Annemie M W J Schols
- Department of Respiratory Medicine, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Renee Speyer
- Department of Special Needs Education, University of Oslo, Oslo, Norway
- School of Occupational Therapy, Social Work and Speech Pathology, Curtin University, Perth, Australia
- Department of Otorhinolaryngology and Head and Neck Surgery, Leiden University Medical Centre, Leiden, The Netherlands
- Faculty of Health, School of Health and Social Development, Victoria, Australia
| | - Giovanni Succo
- Head and Neck Oncology Service, Candiolo Cancer Institute, FPO - IRCCS, Candiolo, TO, Italy
- Department of Oncology, University of Turin, Orbassano, TO, Italy
| | - Irene Wessel
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Anna C H Willemsen
- GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Respiratory Medicine, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, The Netherlands
- Division of Medical Oncology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Taner Yilmaz
- Department of Otorhinolaryngology, Head and Neck Surgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Pere Clavé
- Gastrointestinal Physiology Laboratory, Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
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20
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Fujiwara K, Taira K, Donishi R, Koyama S, Morisaki T, Fukuhara T, Takeuchi H. Preoperative predictors of dysphagia after transoral surgery. Int J Clin Oncol 2021; 26:835-840. [PMID: 33459899 PMCID: PMC8055620 DOI: 10.1007/s10147-021-01860-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 12/20/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Transoral surgery (TOS) has been used to remove pharyngeal and laryngeal cancers with the objective of improving functional without worsening survival. However, there is a risk of postoperative dysphagia, which can severely impair quality of life. The aim of this study was to evaluate the preoperative predictive factors for postoperative dysphagia in patients undergoing TOS. METHODS One hundred and twenty patients who underwent TOS were evaluated in this study. The degree of dysphagia was evaluated using the Functional Outcome Swallowing Scale (FOSS) both preoperatively and 3 months postoperatively. Those whose FOSS stage was maintained postoperatively were classified into the FOSS-M group, while those with increased FOSS stage postopratively were classified into the FOSS-I group. The following parameters were assessed before surgery: age, weight, height, body mass index (BMI), forced expiratory volume in 1 s, and history of head and neck radiotherapy. Videofluoroscopy (VF) was performed preoperatively to evaluate swallowing function using the Penetration-Aspiration Scale (PAS). RESULTS The BMI of the FOSS-M group was significantly higher than that of the FOSS-I group. A history of radiotherapy was significantly more common in the FOSS-I group than in the FOSS-M group. Finally, preoperative PAS in the FOSS-M group was lower than that in the FOSS-I group. CONCLUSION This study suggested that patients with preoperative aspiration detected using VF might develop postoperative dysphagia severely. In addition, preoperative low BMI and a history of previous radiotherapy for head and neck cancer were associated with postoperative dysphagia. Objective examinations such as VF should be performed preoperatively.
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Affiliation(s)
- Kazunori Fujiwara
- Division of Otolaryngology, Head and Neck Surgery, Department of Sensory and Motor Organs, School of Medicine, Tottori University Faculty of Medicine, Yonago, 683-8504, Japan.
| | - Kenkichiro Taira
- Division of Otolaryngology, Head and Neck Surgery, Department of Sensory and Motor Organs, School of Medicine, Tottori University Faculty of Medicine, Yonago, 683-8504, Japan
| | - Ryohei Donishi
- Division of Otolaryngology, Head and Neck Surgery, Department of Sensory and Motor Organs, School of Medicine, Tottori University Faculty of Medicine, Yonago, 683-8504, Japan
| | - Satoshi Koyama
- Division of Otolaryngology, Head and Neck Surgery, Department of Sensory and Motor Organs, School of Medicine, Tottori University Faculty of Medicine, Yonago, 683-8504, Japan
| | - Tsuyoshi Morisaki
- Division of Otolaryngology, Head and Neck Surgery, Department of Sensory and Motor Organs, School of Medicine, Tottori University Faculty of Medicine, Yonago, 683-8504, Japan
| | - Takahiro Fukuhara
- Division of Otolaryngology, Head and Neck Surgery, Department of Sensory and Motor Organs, School of Medicine, Tottori University Faculty of Medicine, Yonago, 683-8504, Japan
| | - Hiromi Takeuchi
- Division of Otolaryngology, Head and Neck Surgery, Department of Sensory and Motor Organs, School of Medicine, Tottori University Faculty of Medicine, Yonago, 683-8504, Japan
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21
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Sethi RK, Chen MM, Malloy KM. Complications of Transoral Robotic Surgery. Otolaryngol Clin North Am 2020; 53:1109-1115. [DOI: 10.1016/j.otc.2020.07.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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22
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Tamer R, Chen Y, Xu X, Xie C, Swai J. Short-Term Quality of Life, Functional Status, and Their Predictors in Tongue Cancer Patients After Anterolateral Thigh Free Flap Reconstruction: A Single-Center, Prospective, Comparative Study. Cancer Manag Res 2020; 12:11663-11673. [PMID: 33235497 PMCID: PMC7678467 DOI: 10.2147/cmar.s268912] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 09/28/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose To assess the quality of life, functional status, and their predictors in tongue cancer patients up to three months after anterolateral thigh free flap (ALTFF) reconstruction. Patients and Methods Tongue cancer patients were examined before and one and three months after ALTFF reconstruction using three validated questionnaires: the MD Anderson Dysphagia Inventory (MDADI), Eating Assessment Tool (EAT-10), and Functional Assessment of Cancer Therapy-Head and Neck (FACT-H&N). Mean scores were compared using the Friedman test. Forward selection and backward elimination methods of multiple linear regression analysis were used to identify the predictors of quality of life and functional status using SPSS at a 95% significance level. Results The present study included 265 participants (88.68% males, mean age 46.7 ± 11.05 years). The mean MDADI and EAT-10 scores were highest at one month after the surgery and lowest at three months after the surgery (p < 0.05). The mean FACT-H&N score was lowest at one month after the surgery (p < 0.05); however, post hoc analysis revealed that the difference in the scores before and three months after the surgery was non significant (p > 0.05). Denture use, occupation, age, tumor site, illness duration, drinking habit, and diet predicted the patients' quality of life, while denture use, betel nut consumption, age, marital status, and diet predicted their functional status. Conclusion Although tongue cancer patients have a poor quality of life and functional status in the first month after ALTFF reconstruction, their quality of life and functional status improve thereafter. We recommend the implementation of swallowing training programs and case-oriented psychological interventions to assist patients in coping with temporary deterioration during the first month after the surgery.
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Affiliation(s)
- Roba Tamer
- Xiangya School of Nursing, Central South University, Changsha City, Hunan Province, People's Republic of China.,Department of Nursing, Hama University, Hama City, Syria
| | - Yongyi Chen
- Xiangya School of Nursing, Central South University, Changsha City, Hunan Province, People's Republic of China.,Department of Hospital Administration, Hunan Cancer Hospital/The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha City, Hunan Province, People's Republic of China
| | - Xianghua Xu
- Department of Nursing, Hunan Cancer Hospital/The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha City, Hunan Province, People's Republic of China
| | - Chanjuan Xie
- Department of Nursing, Hunan Cancer Hospital/The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha City, Hunan Province, People's Republic of China
| | - Joel Swai
- Department of Nephrology and Rheumatology, The Third Xiangya Hospital of Central South University, Changsha City, Hunan Province, People's Republic of China
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23
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Charters EK, Bogaardt H, Freeman-Sanderson AL, Ballard KJ, Davies S, Oates J, Clark J. Early fiberoptic endoscopic evaluation of swallow in transoral robotic surgery: Description of swallow function and recovery in the acute postoperative period for oropharyngeal squamous cell carcinoma. Head Neck 2020; 43:116-127. [PMID: 32964561 DOI: 10.1002/hed.26458] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 07/20/2020] [Accepted: 08/26/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Transoral robotic surgery (TORS) is a minimally invasive approach for the treatment of oropharyngeal cancer. The effects on swallowing and speech need to be comprehensively evaluated to understand the associated morbidity. METHODS A prospective cohort of 21 patients was recruited to undergo pre-TORS and post-TORS swallowing and communication assessment. Fiberoptic endoscopic evaluation of swallowing (FEES) was used in the first postoperative week. RESULTS Sixteen participants (76.2%) had penetration-aspiration scores ≥3 or higher, seven (33.3%) aspirated on thin liquids, three (14.3%) did so silently. Prolonged recovery trajectory occurred for the majority of the cohort, particularly if TORS was followed by adjuvant radiotherapy. Swallowing and communication scores were significantly worse in base of tongue primary tumors and with advanced age. CONCLUSION Early FEES demonstrates a significant decline in swallowing function, including increased secretion load, pharyngeal residue, laryngeal penetration, and aspiration. Silent aspiration occurred in 14% and thus highlights the necessity for instrumental assessment to ascertain aspiration risk.
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Affiliation(s)
- Emma K Charters
- Department of Speech Pathology, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
| | - Hans Bogaardt
- Faculty of Medicine and Health, The University of Sydney, Australia
| | | | - Kirrie J Ballard
- Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
| | - Sarah Davies
- Department of Speech Pathology, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
| | - Justine Oates
- Department of Speech Pathology, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
| | - Jonathan Clark
- Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
- Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
- Royal Prince Alfred Institute of Academic Surgery, Sydney, New South Wales, Australia
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24
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Yao CMKL, Hutcheson KA. Quality of Life Implications After Transoral Robotic Surgery for Oropharyngeal Cancers. Otolaryngol Clin North Am 2020; 53:1117-1129. [PMID: 32917421 DOI: 10.1016/j.otc.2020.07.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Oropharyngeal cancers and their treatment can exquisitely affect a patient's quality of life and functional outcome. Transoral robotic surgery offers a minimally invasive surgical approach that mitigates injury from traditional open surgical approaches and offers a treatment more likely to have short-term side effects compared with nonsurgical treatment. Feeding tube dependence, oral intake, and swallowing questionnaires, in addition to swallowing evaluations provide a snapshot of a patient's current swallowing function. Investigation of patient-reported quality-of-life outcomes allows for understanding of their symptomatology and the comparison of different treatment strategies.
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Affiliation(s)
- Christopher M K L Yao
- Advanced Head and Neck Surgical Oncology and Microvascular Reconstruction, Department of Head and Neck Surgery, The University of Texas at MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1445, Houston, TX 77030, USA
| | - Katherine A Hutcheson
- Department of Head and Neck Surgery, The University of Texas at MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1445, Houston, TX 77030, USA; Division of Radiation Oncology, The University of Texas at MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1445, Houston, TX 77030, USA.
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25
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Functional and survival outcomes in elderly patients undergoing transoral robotic surgery. Oral Oncol 2020; 111:104954. [PMID: 32827931 DOI: 10.1016/j.oraloncology.2020.104954] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/18/2020] [Accepted: 08/03/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To determine if elderly patients (≥70 years) have differences in functional and survival outcomes compared to non-elderly patients (<70 years) following transoral robotic surgery. MATERIALS AND METHODS A retrospective cohort study was conducted on patients undergoing robotic surgery for head and neck cancer at a tertiary institution from 2011 to 2016. Functional status was evaluated with diet, enteric feeding status, Functional Oral Intake Scale (FOIS), tracheostomy tube placement, and unplanned readmission. Kaplan Meier method and Cox proportional hazard model were used to assess overall survival (OS) and disease-free survival (DFS) between elderly and non-elderly patients. RESULTS Two hundred and forty-six patients met inclusion criteria. The mean age of the cohort was 63.5 ± 9.74 years. There were 64 patients (26.0%) that were ≥70 years. Elderly patients were more likely to be discharged with enteric access (p < 0.002). As early as 3 months, there was no significant difference in need for enteric feeds, diet, or FOIS score. There was no difference in tracheostomy tube rates and unplanned readmission between both cohorts. There was no significant difference in OS and DFS between age groups when stratified by p16 status. CONCLUSIONS Elderly patients are more likely to require perioperative enteric feeding, but 3-month, 1-year, and 2-year functional outcomes are comparable to younger patients. Survival outcomes are similar in both populations.
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26
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Ferris RL, Flamand Y, Holsinger FC, Weinstein GS, Quon H, Mehra R, Garcia JJ, Hinni ML, Gross ND, Sturgis EM, Duvvuri U, Méndez E, Ridge JA, Magnuson JS, Higgins KA, Patel MR, Smith RB, Karakla DW, Kupferman ME, Malone JP, Judson BL, Richmon J, Boyle JO, Bayon R, O'Malley BW, Ozer E, Thomas GR, Koch WM, Bell RB, Saba NF, Li S, Sigurdson ER, Burtness B. A novel surgeon credentialing and quality assurance process using transoral surgery for oropharyngeal cancer in ECOG-ACRIN Cancer Research Group Trial E3311. Oral Oncol 2020; 110:104797. [PMID: 32679405 DOI: 10.1016/j.oraloncology.2020.104797] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/01/2020] [Accepted: 05/08/2020] [Indexed: 01/22/2023]
Abstract
PURPOSE Understanding the role of transoral surgery in oropharyngeal cancer (OPC) requires prospective, randomized multi-institutional data. Meticulous evaluation of surgeon expertise and surgical quality assurance (QA) will be critical to the validity of such trials. We describe a novel surgeon credentialing and QA process developed to support the ECOG-ACRIN Cancer Research Group E3311 (E3311) and report outcomes related to QA. PATIENTS AND METHODS E3311 was a phase II randomized clinical trial of transoral surgery followed by low- or standard-dose, risk-adjusted post-operative therapy with stage III-IVa (AJCC 7th edition) HPV-associated OPC. In order to be credentialed to accrue to this trial, surgeons were required to demonstrate active hospital credentials and technique-specific surgical expertise with ≥20 cases of transoral resection for OPC. In addition, 10 paired operative and surgical pathology reports from the preceding 24 months were reviewed by an expert panel. Ongoing QA required <10% rate of positive margins, low oropharyngeal bleeding rates, and accrual of at least one patient per 12 months. Otherwise surgeons were placed on hold and not permitted to accrue until re-credentialed using a new series of transoral resections. RESULTS 120 surgeons trained in transoral minimally invasive surgery applied for credentialing for E3311 and after peer-review, 87 (73%) were approved from 59 centers. During QA on E3311, positive final pathologic margins were reported in 19 (3.8%) patients. Grade III/IV and grade V oropharyngeal bleeding was reported in 29 (5.9%) and 1 (0.2%) of patients. CONCLUSIONS We provide proof of concept that a comprehensive credentialing process can support multicenter transoral head and neck surgical oncology trials, with low incidence of positive margins and *grade III/V oropharyngeal bleeding.
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Affiliation(s)
| | - Yael Flamand
- Dana Farber Cancer Institute-ECOG-ACRIN Biostatistics Center, Boston, MA, United States
| | | | | | - Harry Quon
- Johns Hopkins University, Baltimore, MD, United States
| | - Ranee Mehra
- University of Maryland, Baltimore, MD, United States
| | | | | | - Neil D Gross
- The University of Texas, M.D. Anderson Cancer Center, Houston, TX, United States
| | - Erich M Sturgis
- The University of Texas, M.D. Anderson Cancer Center, Houston, TX, United States
| | | | | | - John A Ridge
- Fox Chase Cancer Center, Philadelphia, PA, United States
| | | | | | - Mihir R Patel
- Winship Cancer Institute at Emory University, Atlanta, GA, United States
| | | | | | - Michael E Kupferman
- The University of Texas, M.D. Anderson Cancer Center, Houston, TX, United States
| | - James P Malone
- UPMC Pinnacle Cancer Center, Harrisburg, PA, United States
| | - Benjamin L Judson
- Yale School of Medicine and Yale Cancer Center, New Haven, CT, United States
| | - Jeremy Richmon
- Massachusetts Eye and Ear, Harvard University, Boston, MA, United States
| | - Jay O Boyle
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | | | | | - Enver Ozer
- The Ohio State University, Columbus, OH, United States
| | - Giovana R Thomas
- University of Miami Leonard Miller School of Medicine, Miami, FL, United States
| | - Wayne M Koch
- Johns Hopkins University, Baltimore, MD, United States
| | - R Bryan Bell
- Providence Cancer Institute, Portland, OR, United States
| | - Nabil F Saba
- Winship Cancer Institute at Emory University, Atlanta, GA, United States
| | - Shuli Li
- Dana Farber Cancer Institute-ECOG-ACRIN Biostatistics Center, Boston, MA, United States
| | | | - Barbara Burtness
- Yale School of Medicine and Yale Cancer Center, New Haven, CT, United States
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27
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Harris A, Lyu L, Wasserman-Winko T, George S, Johnson JT, Nilsen ML. Neck Disability and Swallowing Function in Posttreatment Head and Neck Cancer Patients. Otolaryngol Head Neck Surg 2020; 163:763-770. [DOI: 10.1177/0194599820923630] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Objective To examine the relationship between symptoms of neck disability and swallowing dysfunction among head and neck cancer (HNC) survivors. Study Design Cross-sectional analysis. Setting Single-center, university-affiliated HNC survivorship clinic. Subjects and Methods Survivors’ patient-reported symptoms of neck disability and swallowing dysfunction were prospectively collected from March 2017 to May 2018. Neck disability and swallowing dysfunction were measured using the Neck Disability Index and Eating Assessment Tool (EAT-10), respectively. Linear regression was used to analyze the association between neck disability and swallowing dysfunction. Results A total of 179 survivors, predominantly male (n = 130, 72.6%) with an average age of 64.64 ± 9.91 years, were included in the analysis. Primary cancer sites were oropharynx (n = 85, 47.5%), oral cavity (n = 59, 33.0%), and larynx/hypopharynx (n = 35, 19.5%). Mean EAT-10 score was 10.07 ± 10.89 (range = 0-40; >2 indicative of swallowing dysfunction). Survivors treated for early stage cancer had lower EAT-10 scores than those with advanced stage (early = 3.55 ± 7.46; advanced = 11.95 ± 11.02, P < .001). After controlling for age, time since treatment, American Joint Committee on Cancer stage, and treatment modality, the EAT-10 score for patients with mild neck disability was 6.88 (95% confidence interval [CI], 3.71-10.06; P < .001) points higher than those without neck disability, and the score for those with moderate-complete neck disability was 13.65 (95% CI, 9.47-17.83; P < .001) points higher than those without neck disability. Conclusions Swallowing dysfunction is a commonly recognized effect of HNC treatment. The prevalence and burden of neck disability are shown to be highly correlated with swallowing dysfunction. These results support the need for comprehensive, multidisciplinary rehabilitation interventions for patients with HNC.
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Affiliation(s)
- Alexandria Harris
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lingyun Lyu
- Department of Biostatistics, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Tamara Wasserman-Winko
- Department of Otolaryngology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Susan George
- Centers for Rehab Services, UPMC, Pittsburgh, Pennsylvania, USA
| | - Jonas T. Johnson
- Department of Otolaryngology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Marci Lee Nilsen
- Department of Otolaryngology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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28
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Cramer JD, Burtness B, Le QT, Ferris RL. The changing therapeutic landscape of head and neck cancer. Nat Rev Clin Oncol 2019; 16:669-683. [PMID: 31189965 DOI: 10.1038/s41571-019-0227-z] [Citation(s) in RCA: 429] [Impact Index Per Article: 85.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2019] [Indexed: 12/27/2022]
Abstract
Head and neck cancers are a heterogeneous collection of malignancies of the upper aerodigestive tract, salivary glands and thyroid. In this Review, we primarily focus on the changing therapeutic landscape of head and neck squamous cell carcinomas (HNSCCs) that can arise in the oral cavity, oropharynx, hypopharynx and larynx. We highlight developments in surgical and non-surgical therapies (mainly involving the combination of radiotherapy and chemotherapy), outlining how these treatments are being used in the current era of widespread testing for the presence of human papillomavirus infection in patients with HNSCC. Finally, we describe the clinical trials that led to the approval of the first immunotherapeutic agents for HNSCC, and discuss the development of strategies to decrease the toxicity of different treatment modalities.
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Affiliation(s)
- John D Cramer
- Department of Otolaryngology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Barbara Burtness
- Department of Medicine and Yale Cancer Center, Yale School of Medicine, New Haven, CT, USA
| | - Quynh Thu Le
- Department of Radiation Oncology, Stanford University, Palo Alto, CA, USA
| | - Robert L Ferris
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, PA, USA.
- Department of Immunology, University of Pittsburgh, Pittsburgh, PA, USA.
- UPMC Hillman Cancer Center, Pittsburgh, PA, USA.
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29
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Patient-reported outcomes of symptom burden in patients receiving surgical or nonsurgical treatment for low-intermediate risk oropharyngeal squamous cell carcinoma: A comparative analysis of a prospective registry. Oral Oncol 2019; 91:13-20. [DOI: 10.1016/j.oraloncology.2019.01.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 01/22/2019] [Accepted: 01/25/2019] [Indexed: 11/22/2022]
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30
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Cramer JD, Ferris RL, Kim S, Duvvuri U. Primary surgery for human papillomavirus-associated oropharyngeal cancer: Survival outcomes with or without adjuvant treatment. Oral Oncol 2018; 87:170-176. [PMID: 30527235 DOI: 10.1016/j.oraloncology.2018.10.039] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 10/26/2018] [Accepted: 10/30/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Human papillomavirus-associated (HPV+) oropharyngeal squamous cell carcinoma (OPSCC) is a unique form of head and neck cancer with improved prognosis. We assessed survival for stage I patients with low- or intermediate-risk pathologic features with surgery alone compared with surgery with adjuvant radiation (RT) or chemoradiation (CRT). MATERIALS AND METHODS We identified patients with stage I HPV+ OPSCC (after restaging with 8th edition staging system) treated with surgery alone, adjuvant RT or CRT in the National Cancer Data Base from 2010 to 2013. We compared survival for low-risk patients (≤1 metastatic lymph nodes with no adverse features) and intermediate-risk patients (2-4 metastatic lymph nodes, microscopic extranodal extension (ENE) or lymphovascular invasion). RESULTS We examined 1677 patients with median follow-up of 43.9 months. In the intermediate-risk group, 4-year overall survival was 94.0% with surgery alone, 91.5% with adjuvant RT and 92.0% with adjuvant CRT (p = 0.72). There were similar rates of overall survival in the low-risk group. In multivariable models accounting for clinicopathologic differences the dose of adjuvant RT was not associated with mortality. On Cox proportional hazard modeling, adjuvant RT (HR 0.94; CI 0.43-2.08) or CRT (HR 0.96; CI 0.45-2.11) did not significantly improved survival compared with surgery alone in the intermediate-risk group (reference). Similar results were seen in the low-risk group. The composite number of pathologic risk features significantly improved risk stratification. CONCLUSION We provide observational evidence that adjuvant RT or CRT does not provide a survival benefit for stage I HPV+ OPSCC with low- or intermediate-risk pathologic features.
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Affiliation(s)
- John D Cramer
- Department of Otolaryngology - Head and Neck Surgery, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; Department of Otolaryngology - Head and Neck Surgery, Wayne State University School of Medicine, Detroit, MI, United States.
| | - Robert L Ferris
- Department of Otolaryngology - Head and Neck Surgery, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Seungwon Kim
- Department of Otolaryngology - Head and Neck Surgery, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Umamaheswar Duvvuri
- Department of Otolaryngology - Head and Neck Surgery, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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Parhar HS, Gausden E, Patel J, Prisman E, Anderson DW, Durham JS, Rush B. Analysis of readmissions after transoral robotic surgery for oropharyngeal squamous cell carcinoma. Head Neck 2018; 40:2416-2423. [PMID: 30102813 DOI: 10.1002/hed.25362] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Revised: 03/03/2018] [Accepted: 05/16/2018] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND As transoral robotic surgery (TORS) is being increasingly used to treat patients with oropharyngeal squamous cell carcinoma (OPSCC), there is an interest in determining contributors to readmission. METHODS We conducted this retrospective multivariate analysis modeling 30-day readmission using the Nationwide Readmissions Database (2012-2014). RESULTS Of 950 patients, 117 (12.3%) were readmitted. Hemorrhage and diet/aspiration accounted for 32.5% and 19.7% of readmissions, respectively. Of those readmitted, 23.1% required operative bleeding control, 11.1% required transfusion, 1.7% required tracheostomy, and 18.8% required gastrostomies. Those readmitted were older (mean 63.2 years, SD 9.5 vs 60.9 mean years, SD 10.3) and had longer hospitalizations (mean 5.7 days, SD 6.8 vs mean 4.3 days, SD 4.1) and higher rates of aspiration/pneumonia (9.4% vs 2.4%, P < .01) on index admission. Multivariate analysis demonstrated that aspiration/pneumonia on index admission was independently associated with readmission (OR 3.128, 95% CI 1.178-8.302). CONCLUSIONS Of the patients 12.3% were readmitted within 30 days with hemorrhage and diet complications as significant contributors.
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Affiliation(s)
- Harman S Parhar
- Division of Otolaryngology - Head & Neck Surgery, University of British Columbia, Vancouver, Canada.,T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Elizabeth Gausden
- T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Jayendrakumar Patel
- T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Eitan Prisman
- Division of Otolaryngology - Head & Neck Surgery, University of British Columbia, Vancouver, Canada
| | - Donald W Anderson
- Division of Otolaryngology - Head & Neck Surgery, University of British Columbia, Vancouver, Canada
| | - J Scott Durham
- Division of Otolaryngology - Head & Neck Surgery, University of British Columbia, Vancouver, Canada
| | - Barret Rush
- T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts.,Division of Critical Care Medicine, University of British Columbia, Vancouver, Canada
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Koch W. Dysphagia in oropharyngeal squamous cell carcinoma in perspective. Cancer 2017; 123:3003-3004. [PMID: 28467594 DOI: 10.1002/cncr.30710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 03/08/2017] [Indexed: 11/10/2022]
Affiliation(s)
- Wayne Koch
- Department of Otolaryngology, Johns Hopkins Outpatient Center, 601 N. Caroline Street, Room 6254, Baltimore, Maryland
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