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Gupta KK, Khan H, Mughal Z, De M, Sharma N, Garas G. Primary Tumour Detection in Carcinoma of Unknown Primary with Transoral Robotic Surgery (TORS) Tongue Base Mucosectomy: A Meta-analysis. Ann Surg Oncol 2024; 31:6065-6076. [PMID: 38980583 DOI: 10.1245/s10434-024-15758-z] [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: 04/01/2024] [Accepted: 06/24/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND Head and neck carcinoma of unknown primary (CUP) represents a challenging diagnostic process when standard work-up fails to identify the primary tumour site. The aim of this systematic review and meta-analysis was to evaluate the diagnostic utility and complication profile of transoral robotic surgery (TORS) tongue base mucosectomy (TBM) in the management of CUP. PATIENTS AND METHODS An electronic database search was performed in the EMBASE, MEDLINE, PubMed and Cochrane databases. A meta-analysis of proportions was performed to obtain an estimate of the overall proportion for the detection and complication rates. RESULTS Nine studies representing 235 patients with CUP who had TORS TBM were included in the final analysis. The overall pooled tumour detection rate was 66.2% [95% confidence interval (CI) 56.1-75.8]. The incidence of tumour detection in human papilloma virus (HPV)-positive cases (81.5%, 95% CI 60.8-96.4) was significantly higher than HPV-negative cases (2.3%, 95% CI 0.00-45.7). Weighted overall complication rate was 11.4% (95% CI 7.2-16.2). The majority were grade I or II (80%) according to the Clavien-Dindo classification. CONCLUSIONS This meta-analysis suggests TORS to be safe and effective in localising the primary tumour site in patients with CUP. While the current data supports the use of TORS in patients who are HPV positive, larger numbers of HPV-negative cases are required to determine the true diagnostic effect with TORS before any valid conclusions can be inferred in this particular subgroup. Further research should focus on high quality prospective trials with stringent methodological work-up to minimise heterogeneity and allow for more accurate statistical analysis.
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Affiliation(s)
- Keshav Kumar Gupta
- Head & Neck Surgical Oncology Unit, Department of Otorhinolaryngology and Head and Neck Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK.
| | - Hamad Khan
- Head & Neck Surgical Oncology Unit, Department of Otorhinolaryngology and Head and Neck Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Zahir Mughal
- Department of Otorhinolaryngology and Head and Neck Surgery, Walsall Manor Hospital, Walsall, UK
| | - Mriganka De
- Head & Neck Surgical Oncology Unit, Department of Otorhinolaryngology and Head and Neck Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Neil Sharma
- Head & Neck Surgical Oncology Unit, Department of Otorhinolaryngology and Head and Neck Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - George Garas
- Head & Neck Surgical Oncology Unit, Department of Otorhinolaryngology and Head and Neck Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
- Department of Surgery and Cancer, Imperial College London, St. Mary's Hospital, London, UK
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Jeong B, Krishnan G, Foreman A, Aromataris E. Oncological and functional outcomes of transoral surgery compared with non-surgical management in small-volume oropharyngeal cancer: a systematic review protocol. JBI Evid Synth 2023; 21:2099-2106. [PMID: 37246954 DOI: 10.11124/jbies-22-00349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
OBJECTIVE The objective of this systematic review is to investigate oncological and functional outcomes following primary transoral surgery compared with non-surgical management in patients with small-volume (T1-2, N0-2) oropharyngeal cancer. INTRODUCTION The incidence of oropharyngeal cancer is rising. Transoral surgery was introduced to provide a minimally invasive treatment option for patients with small-volume oropharyngeal cancer and to avoid the morbidity that results from open surgery and the potential acute and late toxicities of chemoradiotherapy. INCLUSION CRITERIA The review will include all studies on adult patients with small-volume oropharyngeal cancer managed by transoral surgery or non-surgical management with radiotherapy and/or chemotherapy. All patients must have undergone treatment with curative intent. Participants who underwent palliative treatment will be excluded. METHODS This review will follow the JBI methodology for systematic reviews of effectiveness. Eligible study designs will include randomized controlled trials, quasi-experimental studies, and prospective or retrospective cohort studies. Databases to be searched will include PubMed, Embase, CINAHL, Cochrane CENTRAL, and multiple trial registries from 1972. Titles and abstracts will be reviewed, and full-text articles will be retrieved if they meet the inclusion criteria. All eligible studies will be critically appraised by 2 independent reviewers using the appropriate JBI tools for experimental and observational designs. Where possible, outcome data from studies will be pooled with statistical meta-analysis to compare both oncological and functional outcomes between the two groups. All time to event to data will be converted to a common metric for oncological outcomes. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach will be followed to assess the certainty of findings. REVIEW REGISTRATION PROSPERO CRD4202235209.
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Affiliation(s)
- Bora Jeong
- JBI, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
- Department of Otorhinolaryngology and Head and Neck Surgery, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Giri Krishnan
- Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
- Department of Otorhinolaryngology and Head and Neck Surgery, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Andrew Foreman
- Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
- Department of Otorhinolaryngology and Head and Neck Surgery, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Edoardo Aromataris
- JBI, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
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Brudasca I, Philouze P, Morinière S, Lallemant B, Vergez S, Malard O, Roux PE, Rossello N, Payen C, Céruse P. Transoral Laser Microsurgery versus Robot-Assisted Surgery for Squamous Cell Carcinoma of the Tongue Base (Oncological and Functional Results)-A Retrospective GETTEC Multicenter Study. J Clin Med 2023; 12:4210. [PMID: 37445244 DOI: 10.3390/jcm12134210] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 06/18/2023] [Accepted: 06/20/2023] [Indexed: 07/15/2023] Open
Abstract
The base of the tongue (BOT) is the second most common site for squamous cell carcinoma (SCC) in the oropharynx. There are currently no clear guidelines for the management of BOT SCC. Our main objective was to compare the oncological outcomes of two minimally invasive approaches, transoral laser microsurgery (TLM) and transoral robot-assisted surgery (TORS). This was a retrospective French GETTEC (Groupe d'Études des Tumeurs de la Tête et du Cou) multicenter study of patients with BOT SCC removed surgically either by TLM or TORS between 2005 and 2021. The study group included 16 patients treated by TLM and 38 by TORS, with median follow-up times of 14.4 and 37.2 months, respectively. The overall survival (OS) rates at 2 and 3 years were 67% in the TLM group and 90% at 2 years and 86% at 3 years in the TORS group (p = 0.42, p = 0.20). There was no significant difference in recurrence-free survival (RFS) between the two techniques after 2 and 3 years. The tumors removed by TORS were significantly larger. Operative times were significantly shorter in the TLM group. There were no differences in feeding resumption; none of the patients in the TLM group required a tracheotomy. Postoperative hemorrhagic complication rates were similar in the two groups (12% for TLM and 13% for TORS). Both TORS and TLM showed encouraging oncological, functional, and safety results in BOT SCC even in recurrence or second primary cancer patients, without a technique being found superior in terms of OS or RFS. Tumors removed by TORS were larger without an increase in postoperative bleeding, extending the possibilities of transoral treatment.
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Affiliation(s)
- Ioana Brudasca
- Service d'ORL et de Chirurgie Cervico-Faciale, Centre Hospitalier Croix Rousse, Hospices Civils de Lyon, 69004 Lyon, France
| | - Pierre Philouze
- Service d'ORL et de Chirurgie Cervico-Faciale, Centre Hospitalier Croix Rousse, Hospices Civils de Lyon, 69004 Lyon, France
| | - Sylvain Morinière
- Service d'ORL et Chirurgie Cervico-Faciale, Centre Hospitalier Régional Universitaire Bretonneau, 37000 Tours, France
| | - Benjamin Lallemant
- Service d'ORL et Chirurgie Cervico-Faciale, Centre Hospitalier Universitaire de Nîmes, 30900 Nîmes, France
| | - Sébastien Vergez
- Service d'ORL et Chirurgie Cervico-Faciale, Oncopole, Institut Universitaire du Cancer de Toulouse, 31059 Toulouse, France
| | - Olivier Malard
- Service d'ORL et Chirurgie Cervico-Faciale, Centre Hospitalier Universitaire de Nantes, 44093 Nantes, France
| | - Pierre-Eric Roux
- Service d'ORL et Chirurgie Cervico-Faciale, Centre Léon Bérard, 69008 Lyon, France
| | - Noémie Rossello
- Service d'ORL et de Chirurgie Cervico-Faciale, Centre Hospitalier Croix Rousse, Hospices Civils de Lyon, 69004 Lyon, France
| | - Caroline Payen
- Service d'ORL et Chirurgie Cervico-Faciale, Centre Hospitalier Universitaire de Nîmes, 30900 Nîmes, France
| | - Philippe Céruse
- Service d'ORL et de Chirurgie Cervico-Faciale, Centre Hospitalier Croix Rousse, Hospices Civils de Lyon, 69004 Lyon, France
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Radiofrequency Coblation-Assisted Transoral Surgery for the Treatment of Oropharyngeal Squamous Cell Carcinoma: A Comparative Study with Open Surgery. JOURNAL OF ONCOLOGY 2023; 2023:7487306. [PMID: 36816366 PMCID: PMC9931478 DOI: 10.1155/2023/7487306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 09/17/2022] [Accepted: 01/27/2023] [Indexed: 02/10/2023]
Abstract
Objective Radiofrequency coblation (RFC) is a relatively new method that has opened up new perspectives in treating oropharyngeal squamous cell carcinoma (OPSCC). Our study was designed to explore the feasibility and effectiveness of RFC-assisted transoral surgery (RFC-TOS) for primary OPSCC. Methods Sixty-nine cases of OPSCC from February 2005 to November 2020 were retrospectively analyzed, including 31 in the RFC-TOS group and 38 in the open surgery group. No difference was observed in demographic and oncological characteristics. Results The significance between the RFC-TOS group and the open surgery group was proved in intraoperative bleeding volume (34.10 ± 10.10 ml vs. 193.68 ± 21.00 ml, P < 0.001), durations of surgery (79.58 ± 8.45 min vs. 217.87 ± 17.65 min, P < 0.001), time to resume oral feeding (1.64 ± 0.41 d vs. 11.58 ± 1.41 d, P < 0.001), duration of hospitalization (7.84 ± 0.66 d vs. 15.66 ± 1.62 d, P < 0.001), and the total costs (22846.22 ± 1821.55¥ vs. 41792.24 ± 4150.86¥, P < 0.001). The rates of 5-year overall survival (OS), 5-yeardisease-specific survival (DSS), and 5-year local control rate (LC) were 69.1%, 71.7%, and 75.7%, respectively, in the RFC-TOS group and 71.0%, 73.4%, and 73.7% in the open surgery group (P > 0.05). Conclusions RFC-TOS is a feasible alternative transoral approach for OPSCC. The reported perioperative and oncologic outcomes are satisfactory.
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Gupta KK, Garas G, Idle M, Germain S, De M. Evaluating the role of the self-assembling topical haemostat PuraBond® in Transoral Robotic Surgery (TORS) for oropharyngeal cancer: A case series. Ann Med Surg (Lond) 2022; 80:104302. [PMID: 36045860 PMCID: PMC9422351 DOI: 10.1016/j.amsu.2022.104302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/26/2022] [Accepted: 07/26/2022] [Indexed: 11/24/2022] Open
Abstract
Background Methods Results Conclusion Major haemorrhage is a key concern following transoral robotic surgery (TORS). Purabond® is a synthetic haemostatic agent used in other surgical settings. Our series is the first to evaluate the role of Purabond® in TORS. We demonstrate excellent outcomes in terms of bleeding and swallowing complications. Larger, prospective controlled studies are needed to further assess these outcomes.
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Soldati F, Lambercy K, Simon C. Second primary squamous cell carcinomas treated with trans oral robotic surgery: Oncological and functional results. Laryngoscope Investig Otolaryngol 2022; 7:746-750. [PMID: 35734069 PMCID: PMC9194978 DOI: 10.1002/lio2.795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/13/2022] [Accepted: 03/30/2022] [Indexed: 11/17/2022] Open
Abstract
Background Recovery of swallowing in patients treated with trans-oral robotic surgery (TORS) is in general considered as favorable. However, patients afflicted with a secondary primary carcinoma of the head and neck may be more vulnerable to swallowing dysfunctions after trans-oral surgery as a consequence of previous treatments. Methods This is a retrospective monocentric study on patients undergoing TORS for second primary squamous cell carcinoma between 2013 and 2017 (follow-up until June 2021). Swallowing performance was assessed via the functional outcome swallowing scale (FOSS). Also, overall survival (OS), disease-free survival (DS) and disease-specific survival (DSS) were evaluated. Results Eighteen patients (median 62 years) underwent TORS with curative intent for T1-2 oropharyngeal and supraglottic secondary primaries. The average follow-up was of 52 months. All cases were resected R0 using TORS. 84% of patients had a post-treatment FOSS score equal or better upon last follow-up compared with pre-treatment. Only one patient required a percutaneous gastrostomy long term. DSS/DFS/OS at 5 years was 94%, 60%, and 67%, respectively. The main cause of death was metachronous pulmonary neoplasia. Conclusions Our study demonstrates encouraging results in terms of swallowing recovery in patients undergoing TORS for selected secondary primaries of the oropharynx and supraglottic larynx. Further studies into trans-oral surgery for this condition seem therefore warranted. Level of Evidence: Case series; Level 4.
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Affiliation(s)
- Federico Soldati
- Department of Otolaryngology—Head and Neck SurgeryCHUV, University of LausanneLausanneSwitzerland
| | - Karma Lambercy
- Department of Otolaryngology—Head and Neck SurgeryCHUV, University of LausanneLausanneSwitzerland
| | - Christian Simon
- Department of Otolaryngology—Head and Neck SurgeryCHUV, University of LausanneLausanneSwitzerland
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Badaoui JN, Yin LX, Sauer AB, Moore EJ, Lohse CM, Price DL, Kasperbauer JL, Noel DB, Olsen KD, Van Abel KM. Transpharyngeal Approaches for Management of Oropharyngeal Squamous Cell Carcinoma: Mayo Clinic Institution Experience. Otolaryngol Head Neck Surg 2022; 167:509-516. [PMID: 35041566 DOI: 10.1177/01945998211071000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Investigate oncologic and functional outcomes associated with transhyoid and lateral pharyngotomy (transpharyngeal) approaches in the treatment of oropharyngeal squamous cell carcinoma (OPSCC). STUDY DESIGN Retrospective review. SETTING Single institution (tertiary care center). METHODS This is a retrospective case series of patients with OPSCC undergoing transpharyngeal resection from 1990 to 2017 at Mayo Clinic. Oncologic outcomes, postoperative complications, objective swallowing data, and rates of tracheostomy and percutaneous gastrostomy tube dependence were recorded. RESULTS Of 83 patients meeting inclusion criteria, 56 (68%) were human papillomavirus positive. Overall survival rates at 5 and 10 years following surgery were 85% and 80%, respectively. Cancer-specific survival rates at these same time points were 90% and 88%. Following treatment, 35 of 49 patients (71%) had a Functional Oral Intake Scale score ≥5, indicating total oral intake of multiple consistencies; 79 of 82 (96%) were without tracheostomy or laryngectomy; and 71 of 81 (88%) were on a full oral diet. CONCLUSION Transpharyngeal approaches provide adequate functional and oncologic outcomes in the majority of patients with OPSCC. These results may have important implications for patients who are not candidates for, or are unwilling to undergo, nonoperative therapy or for those without access to radiation therapy.
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Affiliation(s)
- Joseph N Badaoui
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Linda X Yin
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Adam B Sauer
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Eric J Moore
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Christine M Lohse
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel L Price
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jan L Kasperbauer
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel B Noel
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kerry D Olsen
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kathryn M Van Abel
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Mclean T, Fitzgerald C, Boyle JO. Therapeutic strategies: Surgery for human papillomavirus-associated oropharyngeal carcinoma. J Surg Oncol 2021; 124:935-944. [PMID: 34595753 DOI: 10.1002/jso.26695] [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] [Received: 09/20/2021] [Accepted: 09/20/2021] [Indexed: 12/30/2022]
Abstract
Treatment of oropharyngeal cancer (OPC) has undergone considerable evolution since the discovery of human papillomavirus (HPV)-associated OPC. It is widely understood that HPV OPC affects a younger population and standard treatment offers improved oncologic outcomes compared with non-HPV OPC but can cause significant toxicities and long-term side effects. Surgery for treatment de-escalation is an active area of research. The purpose of this review is to explore surgery as it relates to the treatment of HPV OPC with a focus on the evolution of treatment, rationale for surgery, surgical techniques, outcomes, and the role of surgery in de-escalation of treatment.
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Affiliation(s)
- Timothy Mclean
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Conall Fitzgerald
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jay O Boyle
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Dagan R, Galloway TJ. Radiation Treatment Deintensification for HPV-Associated Oropharyngeal Cancer. Semin Radiat Oncol 2021; 31:324-331. [PMID: 34455987 DOI: 10.1016/j.semradonc.2021.02.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Human papillomavirus-associated oropharyngeal cancer (HPV-OPC) is a distinct clinical entity with a favorable prognosis compared with non-HPV-OPC. Surgery and radiotherapy (RT) result in adverse effects, and negative quality of life or functional outcomes, which impact a significant proportion of HPV-OPC survivors. Ongoing studies aim to reduce these negative treatment effects while maintaining high cure rates through deintensified therapy typically use either a primary surgical or RT approach. A single-day curative surgery will remain relevant for many patients with early-stage disease. However, the average patient with HPV-OPC will have indications for adjuvant therapy. A primary RT approach to deintensified therapy has more available data from patients on prospective multi-institutional trials, provides broader patient selection, and may be more cost-effective. Anticipated results from an active phase II/III NCTN trial will help guide the standard of care using primary RT. Next generation trials will help further refine patient selection and/or radical deintensification (30-50 Gy).
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Affiliation(s)
- Roi Dagan
- Department of Radiation Oncology, University of Florida Proton Therapy Institute, Jacksonville, FL.
| | - Thomas J Galloway
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
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Frederiksen JG, Channir HI, Larsen MHH, Christensen A, Friborg J, Charabi BW, Rubek N, von Buchwald C. Long-term survival outcomes after primary transoral robotic surgery (TORS) with concurrent neck dissection for early-stage oropharyngeal squamous cell carcinoma. Acta Otolaryngol 2021; 141:714-718. [PMID: 34191671 DOI: 10.1080/00016489.2021.1939147] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND In 2013, transoral robotic surgery (TORS) was implemented as a protocolled treatment alternative to the traditional radiotherapy (RT) in Denmark for oropharyngeal squamous cell carcinoma (OPSCC). In 2017, we published our first prospective feasibility study, showing that TORS with concurrent neck dissection successfully achieved negative margins in 29 out of 30 patients (97%) with early-stage OPSCC. AIMS/OBJECTIVES This follow-up study aims to evaluate the five-year overall survival (OS), disease-specific survival (DSS) and recurrence-free survival (RFS). METHODS Retrospective follow-up study including 30 patients treated with TORS for early-stage OPSCC (T1-T2, N0-N1, M0, UICC 7th edition) from September 2014 to January 2016 at a single head and neck cancer centre in Denmark. The five-year OS, DSS and RFS, including a detailed analysis of the recurrences, were addressed. RESULTS The five-year OS, DSS and RFS was 90%, 93% and 87%, respectively. Median follow-up was 54.5 months. Four patients developed a recurrence, with one regional, one distant metastatic (M) and two locoregional recurrences. The median time to recurrence was 24 months (range 3-42 months). CONCLUSIONS AND SIGNIFICANCE This follow-up study demonstrates good five-year OS, DSS and RFS in a prospective cohort of patients undergoing TORS and neck dissection for early-stage OPSCC.
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Affiliation(s)
- Joakim Grant Frederiksen
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Hani Ibrahim Channir
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Mikkel Hjordt Holm Larsen
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anders Christensen
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jeppe Friborg
- Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Birgitte Wittenborg Charabi
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Niclas Rubek
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, 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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Jackson R, Ross E, Jose J. Endoscopic video-assisted transoral (EVAT) surgery of the oropharynx: clinical, oncological and functional outcomes. Eur Arch Otorhinolaryngol 2021; 278:4449-4458. [PMID: 33595699 DOI: 10.1007/s00405-021-06671-2] [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: 12/01/2020] [Accepted: 02/01/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Transoral surgery for suspected or proven oropharyngeal malignancies has increased significantly with the practice of transoral laser microsurgery (TLM) and transoral robotic surgery (TORS). An accepted alternative technique is endoscopic video-assisted transoral (EVAT) surgery. Our aim is to review the clinical, oncological and functional outcomes of this technique at our institution. METHODS 56 consecutive patients undergoing EVAT surgery as part of their cancer work up or treatment were reviewed, focusing on clinical, oncological, and functional outcomes. RESULTS Patients had primary oropharyngeal cancer or carcinoma of unknown primary (CUP) staged between T0-T3 and N0-N3. EVAT surgery identified a primary in 47.1% of CUP with p16 positive disease. Major haemorrhage occurred in 1.8%, with eight post-operative complications. 8.9% of patients developed locoregional recurrence. Mean MD Anderson Dysphagia Inventory score was 76.4 following EVAT surgery, 68.8 after EVAT surgery + radiotherapy and 67.1 after EVAT surgery + chemoradiotherapy CONCLUSION: Early clinical, oncological and functional outcomes following EVAT surgery are comparable to TLM and TORS. LEVEL OF EVIDENCE 4 (case series).
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Affiliation(s)
- Richard Jackson
- Department of ENT, Hull Teaching Hospitals, Hull, HU16 5JQ, UK. .,Department of ENT, Castlehill Hospital, Cottingham, HU16 5JQ, UK.
| | - Elizabeth Ross
- Department of ENT, Hull Teaching Hospitals, Hull, HU16 5JQ, UK
| | - Jemy Jose
- Department of ENT, Hull Teaching Hospitals, Hull, HU16 5JQ, UK
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Campbell RG, Harvey RJ. How close are we to anterior robotic skull base surgery? Curr Opin Otolaryngol Head Neck Surg 2021; 29:44-52. [PMID: 33337610 DOI: 10.1097/moo.0000000000000683] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
PURPOSE OF REVIEW The application of robotic surgery to anterior skull base disease has yet to be defined despite the potential for improved tumour resection with less morbidity in this region. Complex anatomy and restricted access have limited the development of robotic anterior skull base surgery. RECENT FINDINGS A limited number of transoral robotic surgical anterior skull base procedures have been undertaken; however, there are significant limitations to the utilization of this technology in the anterior skull base. In this article, the advantages, disadvantages and limitations of robotic anterior skull base surgery are discussed. Currently, the major limitation is the size of the robotic endoscope and of the available instrumentation. Technological advancements that provide promise for the future development of robotic anterior skull base surgery are in development, such as single-port robots, flexible instrument systems and miniaturization and growth of minimally invasive platforms. SUMMARY Although transnasal access to the skull base is not possible with the currently available robotic systems, promising technology does exist and is in development. Robotic anterior skull base surgery promises to provide greater access to skull base disease, improve oncologic results, reduce morbidity and to reduce the ergonomic burden on the surgeon.
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Affiliation(s)
- Raewyn G Campbell
- Faculty of Medicine, Health and Human Sciences, Macquarie University
- Department of Otolaryngology - Head and Neck Surgery, Royal Prince Alfred Hospital
- Rhinology and Skull Base Research Group, St. Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
| | - Richard J Harvey
- Faculty of Medicine, Health and Human Sciences, Macquarie University
- Rhinology and Skull Base Research Group, St. Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
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Dalton CL, Milinis K, Houghton D, Ridley P, Davies K, Williams R, Hamilton D, Wilkie MD, Markey A, Clarke K, Lofthouse M, Helliwell TR, Triantafyllou A, Rodrigues J, Bheemireddy K, Hanlon R, Wieshmann H, Haridass A, Brammer C, Husband D, Shenoy A, Loh C, Roland NJ, Bekiroglu F, Tandon S, Lancaster J, Jones TM. Transoral laser microsurgery and radiotherapy for oropharyngeal squamous cell carcinoma: Equitable survival and enhanced function compared with contemporary standards of care. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2020; 46:2042-2049. [PMID: 32893045 DOI: 10.1016/j.ejso.2020.06.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 06/17/2020] [Accepted: 06/27/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION We describe the 5-year oncological and functional outcomes of transoral laser microsurgery, neck dissection (TLM + ND) and adjuvant radiotherapy (PORT) used to treat patients with oropharyngeal carcinoma. The effectiveness of external carotid artery (ECA) ligation in reducing post-operative bleeding, and fibrin glue following ND in reducing wound drainage and length of hospital stay is reported. MATERIALS AND METHODS This retrospective case review of consecutive patients undergoing TLM between 2006 and 2017 used the Kaplan-Meier Estimator and Log-Rank Test for univariate, time-to-event analyses, and Cox-Proportionate Hazard modelling for multivariate analysis. RESULTS 264 consecutive patients were included. Mean follow-up was 49.4 months. 219 (82.9%) patients received PORT. Five-year overall survival (OS), disease-free survival (DFS), and disease-specific survival (DSS) rates were 74.9%, 73.7%, and 86.2%, respectively. Five-year locoregional control was 89.4%. 65.5% of cases were Human papillomavirus associated (HPV+), for whom OS, DFS and DSS was 85.6%, 84.7% and 92.7%, respectively, and demonstrated significantly higher OS (hazard ratio (HR) 0.28, CI 0.16-0.49, p < 0.0001), DFS (HR 0.28, CI 0.17-0.47, p < 0.0001) and DSS (HR 0.2, CI 0.09-0.44, <0.001). Post-operative oropharyngeal bleeding occurred in 23 patients (8.7%), of which 5 were major/severe, in patients without ECA ligation. Fibrin glue significantly reduced neck drain output (p < 0.001), and length of hospital stay (p < 0.001). One-year gastrostomy dependence rate was 2.3%. CONCLUSIONS TLM + ND + PORT results in favourable 5-year survival and locoregional control rates, and low feeding tube dependency rates. ECA ligation and fibrin glue appear to reduce major post-operative haemorrhage, wound drainage and length of hospital stay.
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Affiliation(s)
- C Lucy Dalton
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - Kristijonas Milinis
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - David Houghton
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; Department of Oral and Maxillofacial Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom
| | - Paul Ridley
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - Katharine Davies
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - Richard Williams
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - David Hamilton
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - Mark D Wilkie
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - Anne Markey
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; Department of Otorhinolaryngology-Head and Neck Surgery, Mid Cheshire Hospitals NHS Foundation Trust, Middlewich Road, Crewe, Cheshire, CW1 4QJ, United Kingdom
| | - Kim Clarke
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - Matthew Lofthouse
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - Timothy R Helliwell
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; Department of Cellular Pathology, Liverpool University Hospitals NHS Foundation Trust, Prescot Street, Liverpool, L7 8XP, United Kingdom
| | - Asterios Triantafyllou
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; Department of Cellular Pathology, Liverpool University Hospitals NHS Foundation Trust, Prescot Street, Liverpool, L7 8XP, United Kingdom
| | - Jennifer Rodrigues
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; Department of Anaesthesia, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom
| | - Krishna Bheemireddy
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; Department of Anaesthesia, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom
| | - Rebecca Hanlon
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; Department of Radiology, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom
| | - Hulya Wieshmann
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; Department of Radiology, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom
| | - Anoop Haridass
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; The Clatterbridge Cancer Centre NHS Foundation Trust, Clatterbridge Road, Wirral, CH63 4JY, United Kingdom
| | - Caroline Brammer
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; The Clatterbridge Cancer Centre NHS Foundation Trust, Clatterbridge Road, Wirral, CH63 4JY, United Kingdom
| | - David Husband
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; The Clatterbridge Cancer Centre NHS Foundation Trust, Clatterbridge Road, Wirral, CH63 4JY, United Kingdom
| | - Aditya Shenoy
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; The Clatterbridge Cancer Centre NHS Foundation Trust, Clatterbridge Road, Wirral, CH63 4JY, United Kingdom
| | - Christopher Loh
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - Nicholas J Roland
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - Fazilet Bekiroglu
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; Department of Oral and Maxillofacial Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom
| | - Sankalap Tandon
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - Jeffrey Lancaster
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - Terence M Jones
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom.
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Robotic Surgery in Oncology. Indian J Surg Oncol 2020; 11:549-551. [PMID: 33299274 DOI: 10.1007/s13193-020-01251-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 09/22/2020] [Accepted: 10/13/2020] [Indexed: 10/23/2022] Open
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Hatten KM, Amin J, Isaiah A. Machine Learning Prediction of Extracapsular Extension in Human Papillomavirus-Associated Oropharyngeal Squamous Cell Carcinoma. Otolaryngol Head Neck Surg 2020; 163:992-999. [PMID: 32600154 DOI: 10.1177/0194599820935446] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To determine whether machine learning (ML) can predict the presence of extracapsular extension (ECE) prior to treatment, using common oncologic variables, in patients with human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC). STUDY DESIGN Retrospective database review. SETTING National Cancer Database study. METHODS All patients with HPV-associated OPSCC treated surgically between January 1, 2010, and December 31, 2015, were selected from the National Cancer Database. Patients were excluded if surgical pathology reports did not include information regarding primary tumor stage, number of metastatic regional lymph nodes, size of largest metastatic regional lymph node, and tumor grade. The data were split into a random distribution of 80% for training and 20% for testing with ML methods. RESULTS A total of 3753 adults with surgically treated HPV-associated OPSCC met criteria for inclusion in the study. Approximately 38% of these patients treated with surgical management demonstrated ECE. ML models demonstrated modest accuracy in predicting ECE, with the areas under the receiver operating characteristic curves ranging from 0.58 to 0.68. The conditional inference tree model (0.66) predicted the metastatic lymph node number to be the most important predictor of ECE. CONCLUSION Despite a large cohort and the use of ML algorithms, the power of clinical and oncologic variables to predict ECE in HPV-associated OPSCC remains limited.
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Affiliation(s)
- Kyle M Hatten
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Julian Amin
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Amal Isaiah
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, University of Maryland, Baltimore, Maryland, USA
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Ross T, Tolley NS, Awad Z. Novel Energy Devices in Head and Neck Robotic Surgery - A Narrative Review. ROBOTIC SURGERY : RESEARCH AND REVIEWS 2020; 7:25-39. [PMID: 32426397 PMCID: PMC7187864 DOI: 10.2147/rsrr.s247455] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/06/2020] [Indexed: 01/06/2023]
Abstract
The advent of trans-oral robotic surgery (TORS) has facilitated removal of tumors previously deemed unresectable, by providing access to the deep structures of the head and neck. Despite this, the wider dissemination of TORS has been restricted due to issues with line of access, as the da Vinci robot was never designed with head and neck surgery in mind. Flexible instruments and novel energy delivery devices offer great potential in overcoming some of the existing challenges surrounding TORS. This review aimed to summarize the existing literature surrounding energy delivery in TORS and highlight areas of future innovation. MEDLINE was searched for studies relating to energy delivery in TORS in November 2019. The existing literature surrounding monopolar and bipolar electrocautery, LASER (CO2, Tm:YAG and blue LASER), Ligasure and Harmonic was reviewed. Additionally, the latest iteration of the da Vinci; the SP, and the FLEX robot were evaluated as novel methods of energy delivery in TORS. Overall, these novel energy devices and robotic systems are predicted to further improve energy delivery to the head and neck. The use of flexible LASER in particular is well substantiated in the literature. This has the potential to achieve treatment de-escalation, based on the excellent outcomes demonstrated for disease-free margins and post-operative morbidity.
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Affiliation(s)
- Talisa Ross
- Department of Ear, Nose and Throat Surgery, London North West University Healthcare NHS Trust, London, UK.,Faculty of Medicine, Imperial College London, London, UK
| | - Neil S Tolley
- Faculty of Medicine, Imperial College London, London, UK.,Department of Ear, Nose and Throat Surgery, Imperial College Healthcare NHS Foundation Trust, London, UK
| | - Zaid Awad
- Faculty of Medicine, Imperial College London, London, UK.,Department of Ear, Nose and Throat Surgery, Imperial College Healthcare NHS Foundation Trust, London, UK
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17
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Campbell RG. Robotic surgery of the anterior skull base. Int Forum Allergy Rhinol 2019; 9:1508-1514. [DOI: 10.1002/alr.22435] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 08/24/2019] [Accepted: 08/29/2019] [Indexed: 02/02/2023]
Affiliation(s)
- Raewyn G. Campbell
- Department of Otorhinolaryngology, Head and Neck SurgeryRoyal Prince Alfred Hospital Sydney NSW Australia
- Department of Otorhinolaryngology, Head and Neck SurgeryMacquarie University Hospital Sydney NSW Australia
- Department of Otorhinolaryngology, Head and Neck SurgeryThe Chris O'Brien Lifehouse Sydney NSW Australia
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18
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Nichols AC, Theurer J, Prisman E, Read N, Berthelet E, Tran E, Fung K, de Almeida JR, Bayley A, Goldstein DP, Hier M, Sultanem K, Richardson K, Mlynarek A, Krishnan S, Le H, Yoo J, MacNeil SD, Winquist E, Hammond JA, Venkatesan V, Kuruvilla S, Warner A, Mitchell S, Chen J, Corsten M, Johnson-Obaseki S, Eapen L, Odell M, Parker C, Wehrli B, Kwan K, Palma DA. Radiotherapy versus transoral robotic surgery and neck dissection for oropharyngeal squamous cell carcinoma (ORATOR): an open-label, phase 2, randomised trial. Lancet Oncol 2019; 20:1349-1359. [PMID: 31416685 DOI: 10.1016/s1470-2045(19)30410-3] [Citation(s) in RCA: 277] [Impact Index Per Article: 55.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 06/05/2019] [Accepted: 06/06/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Transoral robotic surgery (TORS) with concurrent neck dissection has supplanted radiotherapy in the USA as the most common treatment for oropharyngeal squamous cell carcinoma (OPSCC), yet no randomised trials have compared these modalities. We aimed to evaluate differences in quality of life (QOL) 1 year after treatment. METHODS The ORATOR trial was an investigator-initiated, multicentre, international, open-label, parallel-group, phase 2, randomised study. Patients were enrolled at six hospitals in Canada and Australia. We randomly assigned (1:1) patients aged 18 years or older, with Eastern Cooperative Oncology Group scores of 0-2, and with T1-T2, N0-2 (≤4 cm) OPSCC tumour types to radiotherapy (70 Gy, with chemotherapy if N1-2) or TORS plus neck dissection (with or without adjuvant chemoradiotherapy, based on pathology). Following stratification by p16 status, patients were randomly assigned using a computer-generated randomisation list with permuted blocks of four. The primary endpoint was swallowing-related QOL at 1 year as established using the MD Anderson Dysphagia Inventory (MDADI) score, powered to detect a 10-point improvement (a clinically meaningful change) in the TORS plus neck dissection group. All analyses were done by intention to treat. This study is registered with ClinicalTrials.gov (NCT01590355) and is active, but not currently recruiting. FINDINGS 68 patients were randomly assigned (34 per group) between Aug 10, 2012, and June 9, 2017. Median follow-up was 25 months (IQR 20-33) for the radiotherapy group and 29 months (23-43) for the TORS plus neck dissection group. MDADI total scores at 1 year were mean 86·9 (SD 11·4) in the radiotherapy group versus 80·1 (13·0) in the TORS plus neck dissection group (p=0·042). There were more cases of neutropenia (six [18%] of 34 patients vs none of 34), hearing loss (13 [38%] vs five [15%]), and tinnitus (12 [35%] vs two [6%]) reported in the radiotherapy group than in the TORS plus neck dissection group, and more cases of trismus in the TORS plus neck dissection group (nine [26%] vs one [3%]). The most common adverse events in the radiotherapy group were dysphagia (n=6), hearing loss (n=6), and mucositis (n=4), all grade 3, and in the TORS plus neck dissection group, dysphagia (n=9, all grade 3) and there was one death caused by bleeding after TORS. INTERPRETATION Patients treated with radiotherapy showed superior swallowing-related QOL scores 1 year after treatment, although the difference did not represent a clinically meaningful change. Toxicity patterns differed between the groups. Patients with OPSCC should be informed about both treatment options. FUNDING Canadian Cancer Society Research Institute Grant (#701842), Ontario Institute for Cancer Research Clinician-Scientist research grant, and the Wolfe Surgical Research Professorship in the Biology of Head and Neck Cancers grant.
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Affiliation(s)
- Anthony C Nichols
- Department of Otolaryngology-Head and Neck Surgery, Western University, London, ON, Canada.
| | - Julie Theurer
- School of Communication Sciences and Disorders, Western University, London, ON, Canada
| | - Eitan Prisman
- Department of Otolaryngology, University of British Columbia, Vancouver, BC, Canada
| | - Nancy Read
- Department of Radiation Oncology, Western University, London, ON, Canada
| | - Eric Berthelet
- Department of Radiation Oncology, University of British Columbia, Vancouver, BC, Canada
| | - Eric Tran
- Department of Radiation Oncology, University of British Columbia, Vancouver, BC, Canada
| | - Kevin Fung
- Department of Otolaryngology-Head and Neck Surgery, Western University, London, ON, Canada
| | - John R de Almeida
- Department of Otolaryngology-Head and Neck Surgery, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Andrew Bayley
- Department of Radiation Oncology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - David P Goldstein
- Department of Otolaryngology-Head and Neck Surgery, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Michael Hier
- Department of Otolaryngology-Head and Neck Surgery, McGill University, Montreal, QC, Canada
| | - Khalil Sultanem
- Department of Radiation Oncology, McGill University, Montreal, QC, Canada
| | - Keith Richardson
- Department of Otolaryngology-Head and Neck Surgery, McGill University, Montreal, QC, Canada
| | - Alex Mlynarek
- Department of Otolaryngology-Head and Neck Surgery, McGill University, Montreal, QC, Canada
| | - Suren Krishnan
- Department of Otolaryngology-Head and Neck Surgery, Royal Adelaide Hospital, Adelaide, Australia
| | - Hien Le
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, Australia
| | - John Yoo
- Department of Otolaryngology-Head and Neck Surgery, Western University, London, ON, Canada
| | - S Danielle MacNeil
- Department of Otolaryngology-Head and Neck Surgery, Western University, London, ON, Canada
| | - Eric Winquist
- Department of Medical Oncology, Western University, London, ON, Canada
| | - J Alex Hammond
- Department of Radiation Oncology, Western University, London, ON, Canada
| | - Varagur Venkatesan
- Department of Radiation Oncology, Western University, London, ON, Canada
| | - Sara Kuruvilla
- Department of Medical Oncology, Western University, London, ON, Canada
| | - Andrew Warner
- Department of Radiation Oncology, Western University, London, ON, Canada
| | - Sylvia Mitchell
- Department of Radiation Oncology, Western University, London, ON, Canada
| | - Jeff Chen
- Department of Radiation Oncology, Western University, London, ON, Canada
| | - Martin Corsten
- Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, ON, Canada
| | | | - Libni Eapen
- Department of Radiation Oncology, University of Ottawa, Ottawa, ON, Canada
| | - Michael Odell
- Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Christina Parker
- Department of Audiology, London Health Sciences Centre, London, ON, Canada
| | - Bret Wehrli
- Department of Pathology, Western University, London, ON, Canada
| | - Keith Kwan
- Department of Pathology, Western University, London, ON, Canada
| | - David A Palma
- Department of Radiation Oncology, Western University, London, ON, Canada
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Golusiński W, Golusińska-Kardach E. Current Role of Surgery in the Management of Oropharyngeal Cancer. Front Oncol 2019; 9:388. [PMID: 31179239 PMCID: PMC6542993 DOI: 10.3389/fonc.2019.00388] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 04/25/2019] [Indexed: 11/13/2022] Open
Abstract
In the last few decades, the surgical treatment of oropharyngeal squamous cell carcinoma (OPSCC) has undergone enormous changes. Until the 1990s, open surgery was the primary treatment for OPSCC. However, due to the potentially severe functional morbidity of this approach, open surgery was largely displaced by concurrent chemoradiotherapy (CRT) in the 1990s. At the same time, new, less-invasive surgical approaches such as transoral surgery with monopolar cautery began to emerge, with the potential to reduce functional morbidity and avoid the late-onset toxicity of CRT. More recently, the growing incidence of HPV-positive disease has altered the patient profile of OPSCC, as these patients tend to be younger and have a better long-term prognosis. Consequently, this has further bolstered interest in minimally-invasive techniques to de-intensify treatment to reduce long-term toxicity and treatment-related morbidity. In this context, there has been a renewed interest in the primary surgery, which allows for accurate pathologic staging and thus—potentially—de-intensification of postoperative CRT. The continuous advances in minimally-invasive surgical approaches, including transoral laser microsurgery (TLM) and transoral robotic surgery (TORS), have also altered the surgical landscape. These minimally-invasive approaches offer excellent functional outcomes, without the severe toxicity associated with intensive CRT, thus substantially reducing treatment-related morbidity. In short, given the increasing prevalence of HPV-positive OPSCC, together with the severe long-term sequela of aggressive CRT, surgery appears to be recapturing its previous role as the primary treatment modality for this disease. While a growing body of evidence suggests that TLM and TORS offer oncologic outcomes that are comparable to CRT and open surgery, many questions remain due to the lack of prospective data. In the present review, we explore the emerging range of surgical options and discuss future directions in the treatment of OPSCC, including the most relevant clinical trials currently underway.
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Affiliation(s)
- Wojciech Golusiński
- Department of Head and Neck Surgery, Poznan University of Medical Sciences, Poznan, Poland
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