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Albi C, Ciorba A, Bianchini C, Cammaroto G, Pelucchi S, Sgarzani R, Gessaroli M, DE Vito A, Vicini C, Meccariello G. Transoral robotic surgery for oropharyngeal cancer: a systematic review on the role of margin status. Minerva Surg 2024; 79:346-353. [PMID: 38618712 DOI: 10.23736/s2724-5691.24.10235-3] [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: 04/16/2024]
Abstract
INTRODUCTION Nowadays, robotic surgery finds application in the field of head and neck in the treatment of oropharyngeal tumors. The aim of this work is to examine the efficacy of transoral robotic surgery (TORS) in performing safe oncological resections of oropharyngeal squamous cell carcinoma (OPSCC), with particular attention to the status of margins. EVIDENCE ACQUISITION Literature search of English-language studies focused on TORS through PubMed, the Cochrane Library and EMBASE databases. A total of 431 papers returned to search, but only 24 met the inclusion criteria. The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Guidelines. EVIDENCE SYNTHESIS Within the selected studies, the overall rate of OPSCC positive margins following TORS is minimal, especially when patient selection is adequate and when TORS is used by high volume centers. CONCLUSIONS TORS is a very precise and viable therapeutic tool that provides good results in terms of surgical radicality with low positive margin rates and good results in terms of overall survival and disease-free survival; however, there is still a great heterogeneity in margins definition within the available literature. Consequently, even if this surgical approach is very promising, it is still challenging to draw firm conclusions nowadays.
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Affiliation(s)
- Cecilia Albi
- ENT and Audiology Unit, Department of Neurosciences, University Hospital of Ferrara, Ferrara, Italy -
| | - Andrea Ciorba
- ENT and Audiology Unit, Department of Neurosciences, University Hospital of Ferrara, Ferrara, Italy
| | - Chiara Bianchini
- ENT and Audiology Unit, Department of Neurosciences, University Hospital of Ferrara, Ferrara, Italy
| | - Giovanni Cammaroto
- ENT Unit, Morgagni Pierantoni Hospital, Azienda USL della Romagna, Forlì, Forlì-Cesena, Italy
| | - Stefano Pelucchi
- ENT and Audiology Unit, Department of Neurosciences, University Hospital of Ferrara, Ferrara, Italy
| | - Rossella Sgarzani
- Unit of Plastic Surgery, Center of Major Burns, Maurizio Bufalini Hospital, Cesena, Forlì-Cesena, Italy
| | - Manlio Gessaroli
- Unit of Maxillo-Facial Surgery, Maurizio Bufalini Hospital, Cesena, Forlì-Cesena, Italy
| | - Andrea DE Vito
- ENT Unit, Morgagni Pierantoni Hospital, Azienda USL della Romagna, Forlì, Forlì-Cesena, Italy
| | - Claudio Vicini
- ENT and Audiology Unit, Department of Neurosciences, University Hospital of Ferrara, Ferrara, Italy
- ENT Unit, Morgagni Pierantoni Hospital, Azienda USL della Romagna, Forlì, Forlì-Cesena, Italy
| | - Giuseppe Meccariello
- ENT Unit, Morgagni Pierantoni Hospital, Azienda USL della Romagna, Forlì, Forlì-Cesena, Italy
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Matos LL, Kowalski LP, Chaves ALF, de Oliveira TB, Marta GN, Curado MP, de Castro Junior G, Farias TP, Bardales GS, Cabrera MA, Capuzzo RDC, de Carvalho GB, Cernea CR, Dedivitis RA, Dias FL, Estefan AM, Falco AH, Ferraris GA, Gonzalez-Motta A, Gouveia AG, Jacinto AA, Kulcsar MAV, Leite AK, Lira RB, Mak MP, De Marchi P, de Mello ES, de Matos FCM, Montero PH, de Moraes ED, de Moraes FY, Morais DCR, Poenitz FM, Poitevin A, Riveros HO, Sanabria Á, Ticona-Castro M, Vartanian JG, Viani G, Vines EF, William Junior WN, Conway D, Virani S, Brennan P. Latin American Consensus on the Treatment of Head and Neck Cancer. JCO Glob Oncol 2024; 10:e2300343. [PMID: 38603656 DOI: 10.1200/go.23.00343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 12/19/2023] [Accepted: 02/07/2024] [Indexed: 04/13/2024] Open
Abstract
Head and neck squamous cell carcinoma (HNSCC) is well known as a serious health problem worldwide, especially in low-income countries or those with limited resources, such as most countries in Latin America. International guidelines cannot always be applied to a population from a large region with specific conditions. This study established a Latin American guideline for care of patients with head and neck cancer and presented evidence of HNSCC management considering availability and oncologic benefit. A panel composed of 41 head and neck cancer experts systematically worked according to a modified Delphi process on (1) document compilation of evidence-based answers to different questions contextualized by resource availability and oncologic benefit regarding Latin America (region of limited resources and/or without access to all necessary health care system infrastructure), (2) revision of the answers and the classification of levels of evidence and degrees of recommendations of all recommendations, (3) validation of the consensus through two rounds of online surveys, and (4) manuscript composition. The consensus consists of 12 sections: Head and neck cancer staging, Histopathologic evaluation of head and neck cancer, Head and neck surgery-oral cavity, Clinical oncology-oral cavity, Head and neck surgery-oropharynx, Clinical oncology-oropharynx, Head and neck surgery-larynx, Head and neck surgery-larynx/hypopharynx, Clinical oncology-larynx/hypopharynx, Clinical oncology-recurrent and metastatic head and neck cancer, Head and neck surgery-reconstruction and rehabilitation, and Radiation therapy. The present consensus established 48 recommendations on HNSCC patient care considering the availability of resources and focusing on oncologic benefit. These recommendations could also be used to formulate strategies in other regions like Latin America countries.
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Affiliation(s)
- Leandro Luongo Matos
- Head and Neck Surgery, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas, Universidade de São Paulo (Icesp HCFMUSP), São Paulo, Brazil
- Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo, Brazil
| | | | | | | | | | | | - Gilberto de Castro Junior
- Clinical Oncology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas, Universidade de São Paulo (Icesp HCFMUSP), São Paulo, Brazil
| | | | | | | | | | | | | | | | | | - Andrés Munyo Estefan
- Profesor Adjunto Catedra de Otorrinolaringologia del Hospital de Clínicas, Montevidéu, Uruguay
| | | | | | | | - Andre Guimarães Gouveia
- Juravinski Cancer Centre, Department of Oncology, Division of Radiation Oncology, McMaster University, Hamilton, ON, Canada
| | | | - Marco Aurelio Vamondes Kulcsar
- Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas, Universidade de São Paulo (Icesp HCFMUSP), São Paulo, Brazil
| | - Ana Kober Leite
- Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas, Universidade de São Paulo (Icesp HCFMUSP), São Paulo, Brazil
| | - Renan Bezerra Lira
- AC Camargo Cancer Center and Hospital Albert Einstein, São Paulo, Brazil
| | - Milena Perez Mak
- 3Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, Brazil
| | | | | | | | - Pablo H Montero
- Department of Surgical Oncology and Head and Neck Surgery, Division of Surgery, P. Universidad Católica de Chile, Santiago, Chile
| | | | | | | | | | | | | | - Álvaro Sanabria
- 4Department of Surgery, Universidad de Antioquia, Hospital Alma Mater, Medellin, Colombia
| | - Miguel Ticona-Castro
- 5ESMO Member, Peruvian Society of Medical Oncology (S.P.O.M.) Member, La Molina, Peru
| | - José Guilherme Vartanian
- 6Head and Neck Surgery and Otorhinolaryngology Department, A. C. Camargo Cancer Center, São Paulo, Brazil
| | - Gustavo Viani
- 7Ribeirao Preto Medical School, University of Sao Paulo, Ribeirão Preto, Brazil
| | - Eugenio F Vines
- Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | | | | | - Shama Virani
- International Agency for Research on Cancer (IARC/WHO), Genomic Epidemiology Branch, Lyon, France
| | - Paul Brennan
- International Agency for Research on Cancer (IARC/WHO), Genomic Epidemiology Branch, Lyon, France
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Williamson A, Moen CM, Slim MAM, Warner L, O'Leary B, Paleri V. Transoral robotic surgery without adjuvant therapy: A systematic review and meta-analysis of the association between surgical margins and local recurrence. Oral Oncol 2023; 147:106610. [PMID: 37951118 DOI: 10.1016/j.oraloncology.2023.106610] [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: 07/12/2023] [Revised: 10/09/2023] [Accepted: 10/27/2023] [Indexed: 11/13/2023]
Abstract
BACKGROUND Transoral robotic surgery (TORS) is increasingly employed in the management of oropharyngeal cancer without adjuvant treatment. Attaining safe surgical margins is paramount to preventing local recurrence (LR), but the necessary surgical margin dimension remains contentious. METHODS Systematic review and meta-analysis of studies reporting margin status and LR following TORS without adjuvant therapy for primary OPSCC. RESULTS The search identified 269 articles and 11 were selected for inclusion, with 406 patients included in the meta-analysis. Heterogeneity was noted in the definition of "close" margins. Random-effects pooled rate of positive margins was 7 % (95 % CI 0.04-0.12, I2 = 54 %, p = 0.02) and close margins was 7 % (95 % CI 0.02-0.27, I2 = 86 %, p=<0.01). The random-effects overall rate of LR was 6 % (95 % CI 0.04-0.10, I2 = 11 %, p = 0.35), 13 % (95 % CI 0.02-0.620, I2 = 0 %, p = 1.0) after a positive margin, and 3 % (95 % CI 0.03-0.24, I2 = 23 %, p = 0.26) after a close margin. Odds ratio (OR) for LR indicated higher risk of LR for positive compared to close margins (7.5; 95 % CI 1.31-42.91, I2 = 0 %, p = 0.51), and a slightly lower risk of LR between close and negative margins (2.22; 95 % CI 0.67-7.38, I2 = 0 %, p = 0.8). A lack of frozen-section analysis (OR 2.91, p = 0.36) and HPV-negative disease (OR 1.68, p = 0.03) were associated with an elevated risk of LR. CONCLUSIONS TORS as a standalone treatment is associated with low rates of LR; however, the literature is hampered by considerable heterogeneity in margin definitions. Larger multicentre studies are required to determine the precise margin cut-off required for oropharyngeal tumours managed with TORS alone.
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Affiliation(s)
- Andrew Williamson
- International Centre for Recurrent Head and Neck Cancer (IReC), Department of Head and Neck Surgery, The Royal Marsden Hospital, London, UK; Institute for Cancer Research, London, UK.
| | | | | | - Laura Warner
- Department of Head and Neck Surgery, The Freeman Hospital, Newcastle, UK
| | - Ben O'Leary
- International Centre for Recurrent Head and Neck Cancer (IReC), Department of Head and Neck Surgery, The Royal Marsden Hospital, London, UK; Institute for Cancer Research, London, UK
| | - Vinidh Paleri
- International Centre for Recurrent Head and Neck Cancer (IReC), Department of Head and Neck Surgery, The Royal Marsden Hospital, London, UK; Institute for Cancer Research, London, UK.
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Singh R, Song S. Clinical outcomes following observation, post-operative radiation therapy, or post-operative chemoradiation for HPV-associated oropharyngeal squamous cell carcinomas. Oral Oncol 2023; 146:106493. [PMID: 37713768 DOI: 10.1016/j.oraloncology.2023.106493] [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: 01/04/2023] [Revised: 04/14/2023] [Accepted: 07/02/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND Intermediate and high-risk features (IRFs/HRFs) for locoregional recurrence following initial surgery for oropharyngeal SCCs (OP-SCCs) were defined prior to the known association of HPV with OP-SCC. There are limited reports on practice patterns and outcomes associated with post-operative radiation therapy (PORT) or chemoradiation (POCRT) for HPV-associated OP-SCCs. MATERIALS/METHODS The National Cancer Database was queried for patients with HPV-associated OP-SCCs managed initially with surgery with IRFs or HRFs. IRFs were defined as pT3/T4 disease, pN1-3 disease, and lymphovascular space invasion, and HRFs as positive margins and extranodal extension (ENE). Patients were stratified into no adjuvant therapy, PORT, or POCRT arms. Kaplan-Meier analysis was utilized for comparison of overall survival (OS) between treatment arms followed by a Cox multivariate (MVA) proportional-hazards model and propensity score analyses with inverse probability treatment weighting (IPTW). RESULTS We identified 6,301 patients; 51.2% had IRFs only and 48.8% had HRFs. Regarding treatment, 25.5%, 38.2%, and 36.3% of patients received no RT, PORT, and POCRT, respectively. Patients with IRFs who did not receive RT or CRT had inferior 8-year OS (81.1% vs. 87.8%; p < 0.001) that remained significant on IPTW MVA (hazard ratio (HR) = 1.69 (95% CI: 1.27-2.24; p < 0.001). Among patients with HRFs, 8-year OS was not significantly different between patients receiving PORT vs. POCRT (77.3% vs. 79.2%; p = 0.22) that remained insignificant on IPTW MVA (HR = 0.91(0.72-1.17); p = 0.48). CONCLUSION A significant proportion of HPV-associated OP-SCC patients with IRFs or HRFs did not receive PORT, which was associated with inferior OS. We did not demonstrate with statistical power that POCRT vs. PORT was associated with superior OS in patients with HRFs, though prospective studies are warranted.
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Affiliation(s)
- Raj Singh
- Department of Radiation Oncology, The James Cancer Hospital and Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, OH USA
| | - Shiyu Song
- Department of Radiation Oncology, Virginia Commonwealth University Health System, Richmond, VA USA.
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Costantino A, Sampieri C, Pirola F, Kim DH, Lee K, Park YM, De Virgilio A, Kim SH. Prognostic role of surgical margins in patients undergoing transoral robotic surgery after neo-adjuvant chemotherapy. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:1171-1176. [PMID: 36997412 DOI: 10.1016/j.ejso.2023.03.217] [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: 12/21/2022] [Revised: 03/10/2023] [Accepted: 03/13/2023] [Indexed: 03/17/2023]
Abstract
PURPOSE To define if positive and close surgical margins are associated to worse prognosis in patients who underwent transoral robotic surgery (TORS) after neoadjuvant chemotherapy (NCT). METHODS A retrospective cohort study was carried out at a tertiary referral center. The primary outcome was local-regional control (LRC), and the results were summarized with hazard ratios (HR) and 95% confidence intervals (CIs). RESULTS A total of 308 patients (median age: 62.0, IQR: 55.0-68.2) were included. Univariable analysis showed a significant reduced LRC for patients with positive margins (HR = 1.82, 95% CI: 1.02-3.24). However, they were not associated with worse LRC after adjusting for adverse tumor variables (HR = 0.81, 95% CI: 0.40-1.65). ROC analysis was performed on 123 patients with negative margins (AUC: 0.54) measuring an optimal threshold of 1.25 mm (sensitivity = 60.0%; specificity = 50.5%). Univariable analysis showed non-significant differences between close and wide negative margins (HR = 1.44, 95% CI: 0.59-3.54). CONCLUSIONS A positive surgical margin is not an independent predictor of tumor control and survival. A threshold of 1.25 mm was identified as the most appropriate to define close margins, but no difference was measured after distinguishing negative margins in close and wide margins.
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Affiliation(s)
- Andrea Costantino
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20090, Pieve Emanuele, MI, Italy; Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, MI, Italy; Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, South Korea
| | - Claudio Sampieri
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, South Korea; Unit of Otorhinolaryngology - Head and Neck Surgery, IRCCS Ospedale Policlinico San Martino, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Francesca Pirola
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20090, Pieve Emanuele, MI, Italy; Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, MI, Italy; Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, South Korea
| | - Da Hee Kim
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, South Korea
| | - Kyuin Lee
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, South Korea
| | - Young Min Park
- Department of Otorhinolaryngology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Armando De Virgilio
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20090, Pieve Emanuele, MI, Italy; Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, MI, Italy
| | - Se-Heon Kim
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, South Korea.
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Zech HB, Betz CS, Hoffmann TK, Klussmann JP, Deitmer T, Guntinas-Lichius O. [Radiation or Surgery for HPV-positive oropharyngeal cancer? The ORATOR2 Trial - Comparing apples and oranges]. Laryngorhinootologie 2023; 102:169-176. [PMID: 36858059 DOI: 10.1055/a-2014-5733] [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: 03/03/2023]
Abstract
ORATOR2 was a randomized phase II trial aiming to assess an optimal approach for therapy de-escalation in early (T1-T2, N0-N2) human papillomavirus (HPV)-related oropharyngeal squamous cell carcinomas (OPSCC). Radiotherapy (RT) (consisting of a reduced dose of 60 Gy with concurrent weekly cisplatin in N+ patients) was compared to trans-oral surgery (TOS) and neck dissection (ND) (with adjuvant reduced-dose RT depending on pathologic findings) in 61 patients. The primary endpoint, overall survival, favored the radiotherapy approach. This was mainly due to 3 mortality events in the surgery arm (2 surgery-related) which resulted in an early trial termination. The authors, who speak on behalf of the German Society of Otorhinolaryngology, Head & Neck Surgery (working group for oncology) warn to draw conclusions for clinical practice pointing out the main shortages/weaknesses of this trial especially in the surgery arm (at least 1 cm margins, recommending re-operation if not achieved, prohibition of regional or free flaps, high rates of tracheotomy, low rate of TLM). Small patient numbers, a highly selected patient cohort and a short follow-up time further limit this study's relevance. Therefore, patients with HPV-related OPSCC should not receive de-escalating (radiation) therapy outside of clinical trials. When deciding between a surgical or a radio-therapeutical approach, patients should be informed about the pros and cons of both modalities after interdisciplinary consent in a tumor board, as long as clinical trial results` (e. g. EORTC 1420) are pending.
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Affiliation(s)
- H B Zech
- Klinik und Poliklinik für Hals-, Nasen- und Ohrenheilkunde, Universitätsklinikum Hamburg-Eppendorf
- Mildred-Scheel Cancer Career Center HaTriCS4
| | - C S Betz
- Klinik und Poliklinik für Hals-, Nasen- und Ohrenheilkunde, Universitätsklinikum Hamburg-Eppendorf
| | - T K Hoffmann
- Klinik und Poliklinik für Hals-, Nasen- und Ohrenheilkunde, Universitätsklinikum Ulm
| | - J P Klussmann
- Klinik und Poliklinik für Hals-, Nasen- und Ohrenheilkunde, Medizinische Fakultät, Universität zu Köln
| | - T Deitmer
- Deutsche Gesellschaft für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie e. V
| | - O Guntinas-Lichius
- Klinik und Poliklinik für Hals-, Nasen- und Ohrenheilkunde, Universitätsklinikum Jena
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Costantino A, Sampieri C, Pirola F, De Virgilio A, Kim SH. Development of machine learning models for the prediction of positive surgical margins in transoral robotic surgery (TORS). Head Neck 2023; 45:675-684. [PMID: 36541686 DOI: 10.1002/hed.27283] [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: 08/29/2022] [Revised: 11/10/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022] Open
Abstract
PURPOSE To develop machine learning (ML) models for predicting positive margins in patients undergoing transoral robotic surgery (TORS). METHODS Data from 453 patients with laryngeal, hypopharyngeal, and oropharyngeal squamous cell carcinoma were retrospectively collected at a tertiary referral center to train (n = 316) and validate (n = 137) six two-class supervised ML models employing 14 variables available pre-operatively. RESULTS The accuracy of the six ML models ranged between 0.67 and 0.75, while the measured AUC between 0.68 and 0.75. The ML algorithms showed high specificity (range: 0.75-0.89) and low sensitivity (range: 0.26-0.64) in detecting patients with positive margins after TORS. NPV was higher (range: 0.73-0.83) compared to PPV (range: 0.45-0.63). T classification and tumor site were the most important predictors of positive surgical margins. CONCLUSIONS ML algorithms can identify patients with low risk of positive margins and therefore amenable to TORS.
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Affiliation(s)
- Andrea Costantino
- Department of Biomedical Sciences, Humanitas University, Pieve Emanele (MI), Italy.,Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Rozzano (MI), Italy.,Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, Korea
| | - Claudio Sampieri
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, Korea.,Unit of Otorhinolaryngology - Head and Neck Surgery, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Francesca Pirola
- Department of Biomedical Sciences, Humanitas University, Pieve Emanele (MI), Italy.,Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Rozzano (MI), Italy.,Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, Korea
| | - Armando De Virgilio
- Department of Biomedical Sciences, Humanitas University, Pieve Emanele (MI), Italy.,Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Rozzano (MI), Italy
| | - Se-Heon Kim
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, Korea
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8
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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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De Virgilio A, Costantino A, Rizzo D, Crescio C, Gallus R, Spriano G, Mercante G, Festa BM, Accorona R, Pignataro L, Capaccio P, Bussu F. Do We Have Enough Evidence to Specifically Recommend Transoral Robotic Surgery in HPV-Driven Oropharyngeal Cancer? A Systematic Review. Pathogens 2023; 12:pathogens12020160. [PMID: 36839432 PMCID: PMC9959572 DOI: 10.3390/pathogens12020160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/13/2023] [Accepted: 01/17/2023] [Indexed: 01/20/2023] Open
Abstract
Introduction: International guidelines include transoral robotic surgery (TORS) as an option for selected oropharyngeal squamous cell carcinomas (OPSCCs). In the perspective of treatment de-intensification, many surgeons have started recommending and performing TORS preferentially in p16- positive OPSCC in order to reduce the long-term morbidity related to chemoradiotherapy. The aim of the present review is to analyze the current evidence supporting the above-cited strategy. Materials and Methods: The study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results: Twenty-two studies were included in this review, with a total of 3992 patients treated with primary TORS. The majority of patients were classified as HPV+ (n = 3655, 91.6%), and 8.2% (n = 327) as HPV-. The HPV status was unknown in only 10 (0.3%) patients. In particular, only five of the included studies compared survival outcomes of HPV-positive patients with HPV-negative ones treated with primary TORS, and only two of these found a significant improvement in survival in the HPV-driven cohort. Discussion: The current literature does not clarify whether HPV+ OPSCCs treated with TORS, alone or with adjuvant treatments, are associated with a better oncologic and/or functional outcome compared to those treated with radio- or chemoradiotherapy. However, TORS alone obtained good oncological outcomes in a high percentage of cases in the reviewed series. Recent data, on the other hand, suggest that TORS could represent a promising strategy for intensifying treatments in HPV- OPSCC.
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Affiliation(s)
- Armando De Virgilio
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, Pieve Emanuele, 20089 Milan, Italy
- Otorhinolaryngology Unit, Humanitas Clinical and Research Center, IRCCS, Rozzano, 20089 Milan, Italy
| | - Andrea Costantino
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, Pieve Emanuele, 20089 Milan, Italy
- Otorhinolaryngology Unit, Humanitas Clinical and Research Center, IRCCS, Rozzano, 20089 Milan, Italy
| | - Davide Rizzo
- Division of Otolaryngology, Azienda Ospedaliero Universitaria, 07100 Sassari, Italy
| | - Claudia Crescio
- Division of Otolaryngology, Azienda Ospedaliero Universitaria, 07100 Sassari, Italy
| | - Roberto Gallus
- Mater Hospital Olbia, Strada Statale 125 Orientale Sarda, 07026 Olbia, Italy
| | - Giuseppe Spriano
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, Pieve Emanuele, 20089 Milan, Italy
- Otorhinolaryngology Unit, Humanitas Clinical and Research Center, IRCCS, Rozzano, 20089 Milan, Italy
| | - Giuseppe Mercante
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, Pieve Emanuele, 20089 Milan, Italy
- Otorhinolaryngology Unit, Humanitas Clinical and Research Center, IRCCS, Rozzano, 20089 Milan, Italy
| | - Bianca Maria Festa
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, Pieve Emanuele, 20089 Milan, Italy
- Otorhinolaryngology Unit, Humanitas Clinical and Research Center, IRCCS, Rozzano, 20089 Milan, Italy
- Correspondence: ; Tel.: +39-02-8224-7550; Fax: +39-02-8224-7550
| | - Remo Accorona
- Unit of Otorhinolaryngology–Head and Neck Surgery, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milano, Italy
| | - Lorenzo Pignataro
- Unit of Otorhinolaryngology–Head and Neck Surgery, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milano, Italy
| | - Pasquale Capaccio
- Unit of Otorhinolaryngology–Head and Neck Surgery, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milano, Italy
| | - Francesco Bussu
- Division of Otolaryngology, Azienda Ospedaliero Universitaria, 07100 Sassari, Italy
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Viale San Pietro, 07100 Sassari, Italy
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10
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Berlin E, Ma DJ, Bakst RL, Quon H, Lin A, Lukens JN. Close Margins After Transoral Robotic Surgery for Human Papillomavirus-Positive Oropharyngeal Carcinoma: A Review of the Literature and Practical Recommendations. Pract Radiat Oncol 2023; 13:251-255. [PMID: 36599392 DOI: 10.1016/j.prro.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 12/12/2022] [Indexed: 01/02/2023]
Abstract
The purpose of this article is to summarize the literature and practical recommendations from experienced centers for close margins after transoral robotic surgery for human papillomavirus-positive oropharyngeal carcinoma.
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Affiliation(s)
- Eva Berlin
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Pennsylvania
| | - Daniel J Ma
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Richard L Bakst
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Harry Quon
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alexander Lin
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Pennsylvania
| | - J Nicholas Lukens
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Pennsylvania.
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11
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Siddiq S, Stephen S, Lin D, Fox H, Robinson M, Paleri V. Robotic lateral oropharyngectomy following diagnostic tonsillectomy is oncologically safe in patients with human papillomavirus-related squamous cell cancer: Long-term results. Head Neck 2022; 44:2753-2759. [PMID: 36056651 DOI: 10.1002/hed.27186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/19/2022] [Accepted: 08/23/2022] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION To report the long-term oncological and functional outcomes of en bloc TORS lateral oropharyngectomy to address the close/involved margin following diagnostic tonsillectomy in HPV-related SCC of unknown primary. MATERIAL AND METHODS A single tertiary center observational cohort over a 4-year period. Primary outcome measures were disease-specific survival (DSS), overall survival (OS), and PSS NOD (Performance Status Scale-Normalcy of Diet) scores. RESULTS TORS specimens did not evidence residual carcinoma in 93% of patients. Of 14 patients, 50% received surgery alone (median follow-up 57 months; range 46-96), the remainder surgery and adjuvant therapy (median follow-up of 58 months; range 51-69) with 100% DSS, OS and no deterioration of PSS NOD scores. CONCLUSIONS Long-term oncological outcomes confirm TORS lateral oropharyngectomy alone is an oncologically safe treatment. Due consideration of this approach is warranted to mitigate against the morbidity of adjuvant radiotherapy treatment in this group of patients.
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Affiliation(s)
- Somiah Siddiq
- Head and Neck Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Sarah Stephen
- Otolaryngology - Head and Neck Surgery, Newcastle upon Tyne Hospitals, Newcastle upon Tyne, UK
| | - Daniel Lin
- Otolaryngology - Head and Neck Surgery, Newcastle upon Tyne Hospitals, Newcastle upon Tyne, UK
| | - Hannah Fox
- Otolaryngology - Head and Neck Surgery, Newcastle upon Tyne Hospitals, Newcastle upon Tyne, UK
| | - Max Robinson
- Centre for Oral Health Research, Newcastle University, Newcastle upon Tyne, UK
| | - Vinidh Paleri
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
- The Institute of Cancer Research, London, UK
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12
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Lin C, Sharbel DD, Topf MC. Surgical clinical trials for HPV-positive oropharyngeal carcinoma. Front Oncol 2022; 12:992348. [PMID: 36439459 PMCID: PMC9682030 DOI: 10.3389/fonc.2022.992348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 10/21/2022] [Indexed: 07/22/2023] Open
Abstract
The treatment of HPV-positive oropharyngeal squamous cell carcinoma (OPSCC) continues to evolve as multiple ongoing and recently completed clinical trials investigate the role of surgery, radiation therapy, chemotherapy, and immunotherapy. Current trials are investigating transoral robotic surgery (TORS) in treatment de-escalation protocols in an effort to optimize quality of life, while maintaining historical survival rates. The advantage of TORS is its minimally invasive approach to primary resection of the tumor as well as valuable pathologic staging. The ORATOR trial reported poorer quality of life in patients treated with TORS compared to primary radiotherapy though this was not a clinically meaningful difference. The recently published ECOG 3311 trial showed that surgery can be used to safely de-escalate the adjuvant radiation dose to 50 Gy in intermediate-risk patients. In this review, we summarize and discuss the past and current clinical trials involving surgery in the treatment of HPV-positive OPSCC.
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Affiliation(s)
- Chen Lin
- Department of Otolaryngology – Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Otolaryngology – Head and Neck Surgery, University of Illinois at Chicago, Chicago, IL, United States
| | - Daniel D. Sharbel
- Department of Otolaryngology – Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Michael C. Topf
- Department of Otolaryngology – Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
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13
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Poupore NS, Chen T, Nguyen SA, Nathan CAO, Newman JG. Transoral Robotic Surgery for Oropharyngeal Squamous Cell Carcinoma of the Tonsil versus Base of Tongue: A Systematic Review and Meta-Analysis. Cancers (Basel) 2022; 14:cancers14153837. [PMID: 35954500 PMCID: PMC9367622 DOI: 10.3390/cancers14153837] [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: 07/25/2022] [Revised: 08/01/2022] [Accepted: 08/04/2022] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Transoral Robotic Surgery (TORS) has become widely adopted for the surgical removal of oropharyngeal squamous cell carcinoma (OPSCC). However, it is currently unknown if TORS has equal efficacy and outcomes in patients with tonsillar or base of tongue (BOT) OPSCC. Therefore, we performed a systematic review, including articles describing the surgical management of OPSCC with TORS that compared margin status, complications, and recurrence between tonsil and BOT. BOT OPSCC had a higher rate of positive margins compared to tonsillar OPSCC. However, no differences were seen in the recurrence or postoperative hemorrhage rates of BOT and tonsillar OPSCC. While a higher rate of positive margins was seen in BOT OPSCC when compared to tonsillar OPSCC, this did not translate to a higher recurrence rate in the BOT group. Future research on which subset of patients with BOT is more likely to have positive margins is warranted to improve the utility of TORS further. Abstract Transoral Robotic Surgery (TORS) has become widely adopted for the surgical removal of oropharyngeal squamous cell carcinoma (OPSCC), with the most common locations being in the tonsil and base of tongue (BOT). However, it is currently unknown if TORS has equal efficacy and outcomes in patients with tonsillar or BOT OPSCC. Therefore, the aim of this study was to compare the margin status and recurrence rates of tonsillar and BOT OPSCC after TORS. Per PRISMA guidelines, PubMed, Scopus, and CINAHL were systematically searched from inception to 2/28/2022. Articles including the surgical management of OPSCC with TORS that compared margin status, complications, and recurrence between tonsil and BOT were included. Meta-analyses of proportions and odds ratios were performed. A total of 28 studies were included, comprising 1769 patients with tonsillar OPSCC and 1139 patients with BOT OPSCC. HPV positivity was seen in 92.3% of tumors. BOT OPSCC had a higher rate of positive margins compared to tonsillar OPSCC (28.1% [95%CI 15.1–43.3] vs. 7.5% [95%CI 3.3–13.3]). No differences were seen in recurrence between BOT and tonsillar OPSCC (OR 1.1 [95%CI 0.8–1.5], p = 0.480). In addition, no differences in postoperative hemorrhage were seen between tonsillar and BOT OPSCC (10.7% [95%CI 6.1–16.5] vs. 8.8% [95% CI 1.5–21.3]). While a higher rate of positive margins was seen in BOT OPSCC when compared to tonsil OPSCC, this did not translate to a higher recurrence rate in the BOT group. Future research on which subset of patients with BOT is more likely to have positive margins is warranted to improve the utility of TORS further.
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Affiliation(s)
- Nicolas S. Poupore
- Department of Otolaryngology—Head and Neck Surgery, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Tiffany Chen
- Department of Otolaryngology—Head and Neck Surgery, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Shaun A. Nguyen
- Department of Otolaryngology—Head and Neck Surgery, Medical University of South Carolina, Charleston, SC 29425, USA
- Correspondence:
| | - Cherie-Ann O. Nathan
- Department of Otolaryngology—Head and Neck Surgery, Louisiana State University Health Sciences Center, Shreveport, LA 71103, USA
| | - Jason G. Newman
- Department of Otolaryngology—Head and Neck Surgery, Medical University of South Carolina, Charleston, SC 29425, USA
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14
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Practice patterns in transoral robotic surgery: results of an American head and neck society survey. J Robot Surg 2022; 17:549-556. [PMID: 35933632 DOI: 10.1007/s11701-022-01448-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 07/21/2022] [Indexed: 10/15/2022]
Abstract
To understand perioperative practices for transoral robotic surgery (TORS) among academic medical centers. An electronic cross-sectional survey was distributed to fellows and program directors participating in 49 American Head and Neck Society fellowships. Operative decisions, medical and swallowing management, and disposition planning were assessed. Thirty-eight responses were collected (77.6%). Twenty-three centers (60.5%) performed > 25 cases annually with the remainder performing fewer. The da Vinci Si was the most commonly used platform (n = 28, 73.7%). A majority of institutions advocated tailored resection to adequate margins (n = 27, 71.1%) over fixed subunit-based resection (n = 11, 28.9%). Most surgeons (n = 29, 76.3%) performed neck dissection concurrent with TORS, and 89.5% (n = 34) routinely ligated external carotid artery branches. A minority of institutions (n = 17, 45.9%) endorsed a standardized TORS care pathway. Antibiotic choices and duration varied, the most common choice being ampicillin/sulbactam (n = 21, 55.3%), and the most common duration being 24 h or less (n = 22, 57.9%). Multimodal analgesia was used at 36 centers (94.7%), steroids at 31 centers (81.6%), and pharmacologic venous thromboembolic prophylaxis at 29 centers (76.3%). Nasogastric feeding tubes were placed during surgery at 20 institutions (54.1%). Speech-language pathologists routinely performed postoperative swallow evaluations at 29 (78.4%) sites. Practice patterns are variable among institutions performing TORS. While certain surgical and postoperative practices were quite common, many institutions reported no standard TORS care pathway. Further understanding of the impact of individual practices on outcomes is necessary to develop evidence-based perioperative protocols for TORS.
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15
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Warner L, O'Hara JT, Lin DJ, Oozeer N, Fox H, Meikle D, Hamilton D, Iqbal MS, Robinson M, Paleri V. Transoral robotic surgery and neck dissection alone for head and neck squamous cell carcinoma: Influence of resection margins on oncological outcomes. Oral Oncol 2022; 130:105909. [PMID: 35636080 DOI: 10.1016/j.oraloncology.2022.105909] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 05/03/2022] [Accepted: 05/08/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVES This study reports oncological outcomes of transoral robotic surgery (TORS) and neck dissection (ND) alone for head and neck squamous cell carcinoma (HNSCC) and aims to analyse the influence of resection margins on local recurrence rates. MATERIALS AND METHODS Fifty-one patients treated with curative intent for HNSCC, with TORS and ND alone between 2013 and 2019 at two tertiary centres were included in this observational multi-centre prospective cohort study. Oncological outcomes are reported on 47 patients for whom the aim was to treat with TORS and ND alone; this excluded four patients who were recommended adjuvant radiotherapy based on resective pathology but did not receive treatment. Local control is the primary endpoint; disease specific, progression free and overall survival are secondary outcomes. RESULTS With a median follow up of 43 months, estimated outcomes at 3 years (n = 47) were as follows: local control 92%, progression free survival 80%, disease specific survival 94%, and overall survival 84%. Presence of a positive margin on the main specimen was the only statistically significant predictor of local recurrence on univariate Cox regression analysis. Time dependent receiver operating characteristic curve identified margins of 1.1 mm as a threshold for local control, with area under the curve 0.788 (95% CI 0.616-0.960), indicating a good classifier. CONCLUSION This is the first UK surgery alone series reporting mature oncological outcomes following TORS and ND. Positive margins on the resected specimen are the strongest predictor of local recurrence, with conventional definitions of "close margins" having no impact.
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Affiliation(s)
- Laura Warner
- Department of Otolaryngology - Head and Neck Surgery, Newcastle upon Tyne Hospitals, Newcastle upon Tyne NE7 7DN, UK
| | - James T O'Hara
- Department of Otolaryngology - Head and Neck Surgery, Newcastle upon Tyne Hospitals, Newcastle upon Tyne NE7 7DN, UK
| | - Daniel J Lin
- Department of Otolaryngology - Head and Neck Surgery, Sunderland Royal Hospital, Kayll Road, Sunderland SR4 7TP, UK
| | - Nashreen Oozeer
- Department of Otolaryngology - Head and Neck Surgery, Sunderland Royal Hospital, Kayll Road, Sunderland SR4 7TP, UK
| | - Hannah Fox
- Department of Otolaryngology - Head and Neck Surgery, Newcastle upon Tyne Hospitals, Newcastle upon Tyne NE7 7DN, UK
| | - David Meikle
- Department of Otolaryngology - Head and Neck Surgery, Newcastle upon Tyne Hospitals, Newcastle upon Tyne NE7 7DN, UK
| | - David Hamilton
- Department of Otolaryngology - Head and Neck Surgery, Newcastle upon Tyne Hospitals, Newcastle upon Tyne NE7 7DN, UK
| | - Muhammad Shahid Iqbal
- Department of Oncology, Newcastle upon Tyne Hospitals, Newcastle upon Tyne NE7 7DN, UK
| | - Max Robinson
- Department of Cellular Pathology, Newcastle upon Tyne Hospitals, Newcastle upon Tyne NE7 7DN, UK
| | - Vinidh Paleri
- Head and Neck Unit, The Royal Marsden Hospitals NHS Foundation Trust and Institute of Cancer Research, Fulham Road, Chelsea, London SW3 6JJ, UK.
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16
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O’Boyle CJ, Siravegna G, Varmeh S, Queenan N, Michel A, Sing Pang KC, Stein J, Thierauf JC, Sadow PM, Faquin WC, Wang W, Deschler DG, Emerick KS, Varvares MA, Park JC, Clark JR, Chan AW, Busse PM, Corcoran RB, Wirth LJ, Lin DT, Iafrate AJ, Richmon JD, Faden DL. Cell-free human papillomavirus DNA kinetics after surgery for human papillomavirus-associated oropharyngeal cancer. Cancer 2022; 128:2193-2204. [PMID: 35139236 PMCID: PMC10032347 DOI: 10.1002/cncr.34109] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/14/2021] [Accepted: 12/24/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND New ultrasensitive methods for detecting residual disease after surgery are needed in human papillomavirus-associated oropharyngeal squamous cell carcinoma (HPV+OPSCC). METHODS To determine whether the clearance kinetics of circulating tumor human papillomavirus DNA (ctHPVDNA) is associated with postoperative disease status, a prospective observational study was conducted in 33 patients with HPV+OPSCC undergoing surgery. Blood was collected before surgery, postoperative days 1 (POD 1), 7, and 30 and with follow-up. A subcohort of 12 patients underwent frequent blood collections in the first 24 hours after surgery to define early clearance kinetics. Plasma was run on custom droplet digital polymerase chain reaction (ddPCR) assays for HPV genotypes 16, 18, 33, 35, and 45. RESULTS In patients without pathologic risk factors for recurrence who were observed after surgery, ctHPVDNA rapidly decreased to <1 copy/mL by POD 1 (n = 8/8). In patients with risk factors for macroscopic residual disease, ctHPVDNA was markedly elevated on POD 1 (>350 copies/mL) and remained elevated until adjuvant treatment (n = 3/3). Patients with intermediate POD 1 ctHPVDNA levels (1.2-58.4 copies/mL) all possessed pathologic risk factors for microscopic residual disease (n = 9/9). POD 1 ctHPVDNA levels were higher in patients with known adverse pathologic risk factors such as extranodal extension >1 mm (P = .0481) and with increasing lymph nodes involved (P = .0453) and were further associated with adjuvant treatment received (P = .0076). One of 33 patients had a recurrence that was detected by ctHPVDNA 2 months earlier than clinical detection. CONCLUSIONS POD 1 ctHPVDNA levels are associated with the risk of residual disease in patients with HPV+OPSCC undergoing curative intent surgery and thus could be used as a personalized biomarker for selecting adjuvant treatment in the future. LAY SUMMARY Human papillomavirus-associated oropharyngeal squamous cell carcinoma (HPV+OPSCC) is increasing at epidemic proportions and is commonly treated with surgery. This report describes results from a study examining the clearance kinetics of circulating tumor HPV DNA (circulating tumor human papillomavirus DNA [ctHPVDNA]) following surgical treatment of HPV+OPSCC. We found that ctHPVDNA levels 1 day after surgery are associated with the risk of residual disease in patients with HPV+OPSCC and thus could be used as a personalized biomarker for selecting adjuvant treatment in the future. These findings are the first to demonstrate the potential utility of ctHPVDNA in patients with HPV+OPSCC undergoing surgery.
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Affiliation(s)
- Connor J. O’Boyle
- Department of Otolaryngology–Head and Neck Surgery Massachusetts Eye and Ear, Boston, Massachusetts
| | - Giulia Siravegna
- Harvard Medical School, Boston, Massachusetts
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts
| | - Shohreh Varmeh
- Department of Otolaryngology–Head and Neck Surgery Massachusetts Eye and Ear, Boston, Massachusetts
| | - Natalia Queenan
- Department of Otolaryngology–Head and Neck Surgery Massachusetts Eye and Ear, Boston, Massachusetts
| | - Alexa Michel
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts
| | - Kim Chang Sing Pang
- Department of Otolaryngology–Head and Neck Surgery Massachusetts Eye and Ear, Boston, Massachusetts
- Vrije Universiteit of Amsterdam, Amsterdam, the Netherlands
| | - Jarrod Stein
- Department of Otolaryngology–Head and Neck Surgery Massachusetts Eye and Ear, Boston, Massachusetts
| | - Julia C. Thierauf
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Peter M. Sadow
- Department of Otolaryngology–Head and Neck Surgery Massachusetts Eye and Ear, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - William C. Faquin
- Department of Otolaryngology–Head and Neck Surgery Massachusetts Eye and Ear, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Wei Wang
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Neurology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Daniel G. Deschler
- Department of Otolaryngology–Head and Neck Surgery Massachusetts Eye and Ear, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Kevin S. Emerick
- Department of Otolaryngology–Head and Neck Surgery Massachusetts Eye and Ear, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Mark A. Varvares
- Department of Otolaryngology–Head and Neck Surgery Massachusetts Eye and Ear, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Jong C. Park
- Harvard Medical School, Boston, Massachusetts
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - John R. Clark
- Harvard Medical School, Boston, Massachusetts
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Annie W. Chan
- Harvard Medical School, Boston, Massachusetts
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Paul M. Busse
- Harvard Medical School, Boston, Massachusetts
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Ryan B. Corcoran
- Harvard Medical School, Boston, Massachusetts
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Lori J. Wirth
- Harvard Medical School, Boston, Massachusetts
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Derrick T. Lin
- Department of Otolaryngology–Head and Neck Surgery Massachusetts Eye and Ear, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - A. John Iafrate
- Harvard Medical School, Boston, Massachusetts
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jeremy D. Richmon
- Department of Otolaryngology–Head and Neck Surgery Massachusetts Eye and Ear, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Daniel L. Faden
- Department of Otolaryngology–Head and Neck Surgery Massachusetts Eye and Ear, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts
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17
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Robotic vs. transoral laser surgery of malignant oropharyngeal tumors-what is best for the patient? : A contemporary review. HNO 2022; 70:371-379. [PMID: 35419634 DOI: 10.1007/s00106-022-01165-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2022] [Indexed: 12/23/2022]
Abstract
Human papillomavirus (HPV)-associated squamous cell carcinoma of the oropharynx is a malignancy of increasing prevalence. The oncologic community is currently evaluating the safety and efficacy of de-intensifying treatment without compromising oncologic outcomes. Paramount to these treatment algorithms is primary surgery through transoral approaches. This article reviews the literature and concepts pertaining to transoral surgery and describes the two most common techniques, transoral laser microsurgery (TLM) and transoral robotic surgery (TORS).
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18
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Zebolsky AL, George E, Gulati A, Wai KC, Carpenter P, Van Zante A, Ha PK, Heaton CM, Ryan WR. Risk of Pathologic Extranodal Extension and Other Adverse Features After Transoral Robotic Surgery in Patients With HPV-Positive Oropharynx Cancer. JAMA Otolaryngol Head Neck Surg 2021; 147:1080-1088. [PMID: 34673904 DOI: 10.1001/jamaoto.2021.2777] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Importance Understanding patient-specific risk of adverse histopathologic findings after primary surgery for human papillomavirus (HPV)-positive oropharynx squamous cell carcinoma (OPSCC) may help guide patient consultations. Objective To determine the likelihood of adverse histopathologic features that may indicate adjuvant radiotherapy or chemoradiotherapy after primary surgery for HPV-positive OPSCC according to 2021 National Comprehensive Cancer Network guidelines. Design, Setting, and Participants This retrospective cohort study was performed at a single academic tertiary care center. Of 258 patients who underwent transoral robotic surgery (TORS) from March 1, 2012, to March 1, 2021, 136 consecutive, treatment-naive patients with HPV-positive OPSCC without obvious clinical extranodal extension (ENE) who underwent definitive TORS and neck dissection were included in the analysis. Indications for surgical treatment included non-deeply infiltrative oropharynx tumors, minimal soft palate involvement, and low suspicion for pathologic ENE. Exposures Primary site TORS with neck dissection. Main Outcomes and Measures The primary outcomes were the adverse histopathologic features of pathologic ENE and positive surgical margins (PSM) that are indications for possible adjuvant chemoradiotherapy. Outcomes were compared among varying American Joint Committee on Cancer 7th edition (AJCC-7) T and N categories and patient clinical characteristics. Results Of the 136 patients included in the analysis (113 men [83.1%]; median age, 63 [interquartile range, 55-70] years), 109 (80.1%) had at least 1 indication for possible adjuvant radiotherapy. Twenty-seven patients (19.9%) had pathologic ENE and 10 (7.3%) had PSM. Thirty-four patients (25.0%) had pathologic ENE and/or PSM, whereas 3 (2.2%) had both. Age, smoking history, history of alcohol consumption, and clinical T category were not associated with pathologic ENE, PSM, lymphovascular invasion, perineural invasion, or pN2 category or greater. The proportion of pathologic ENE varied by clinical N category: 0 of 16 for cN0, 8 of 48 (16.7%) for cN1, 3 of 23 (13.0%) for cN2a, and 16 of 45 (35.6%) for cN2b. Compared with patients with cN1-cN2a disease, patients with cN2b disease had higher odds of pathologic ENE (odds ratio, 3.01; 95% CI, 1.14-8.10). Clinical and pathologic N category were concordant in 77 patients (56.6%), whereas 42 (30.9%) were upstaged and 17 (12.5%) were downstaged. Conclusions and Relevance In this cohort study, approximately one-quarter of carefully selected patients with HPV-positive OPSCC without obvious clinical ENE undergoing primary surgery had pathologic ENE and/or PSM. Patients with AJCC-7 cT0-cT2 cN0-cN2b disease, especially cN0-cN2a, without signs of clinical ENE may represent appropriate candidates for primary surgery when avoidance of adjuvant chemotherapy and/or reduction of adjuvant radiotherapy dose/extent are the goals.
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Affiliation(s)
- Aaron L Zebolsky
- Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco
| | - Elizabeth George
- Department of Radiology and Biomedical Imaging, University of California, San Francisco
| | - Arushi Gulati
- Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco
| | - Katherine C Wai
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco School of Medicine
| | - Patrick Carpenter
- Section of Otolaryngology, Department of Surgery, Virginia Technical Carilion School of Medicine, Roanoke
| | - Annemieke Van Zante
- Department of Pathology, University of California, San Francisco.,Department of Laboratory Medicine, University of California, San Francisco
| | - Patrick K Ha
- Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco
| | - Chase M Heaton
- Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco
| | - William R Ryan
- Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco
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19
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Shah SB, Malik A. Surgical margins in a single modality transoral robotic surgery-A conundrum. Head Neck 2021; 43:3217-3218. [PMID: 34351026 DOI: 10.1002/hed.26832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 07/26/2021] [Indexed: 11/09/2022] Open
Affiliation(s)
- Snehal B Shah
- Department of Oncosurgery, Balabhai Nanavati Hospital, Mumbai, India
| | - Akshat Malik
- Department of Surgical Oncology, Max Superspecialty Hospital, Saket, New Delhi, India
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20
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Ryan WR, Xu MJ, Ochoa E, Plonowska-Hirschfeld KA, Zebolsky AL, Ha PK, Bewley AF, Mallen-St Clair J, Joshi AS, Coffey CS, Faraji F, MacDonald BV, Houlton JJ, Gobillot TA, Curry JM, Philips R, Hackman TG, Richmon JD, Holcomb AJ, Coughlin AM, Panwar A, Smith RB, Herberg ME, Fakhry C, Cognetti DM. Oncologic outcomes of human papillomavirus-associated oropharynx carcinoma treated with surgery alone: A 12-institution study of 344 patients. Cancer 2021; 127:3092-3106. [PMID: 33957701 DOI: 10.1002/cncr.33611] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 02/11/2021] [Accepted: 02/19/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND The oncologic outcomes of surgery alone for patients with American Joint Committee on Cancer 7th edition (AJCC 7th) pN2a and pN2b human papillomavirus-associated oropharynx squamous cell carcinoma (HPV+OPSCC) are not clear. METHODS The authors performed a 12-institution retrospective study of 344 consecutive patients with HPV+OPSCC (AJCC 7th pT0-3 N3 M0) treated with surgery alone with 6 months or more of follow-up using univariate and multivariate analyses. RESULTS The 2-year outcomes for the entire cohort were 91% (182 of 200) disease-free survival (DFS), 100% (200 of 200) disease-specific survival (DSS), and 98% (200 of 204) overall survival (OS). The 18 recurrences within 2 years were 88.9% (16 of 18) local and/or regional recurrences and 11.1% (2 of 18) distant metastases. Recurrences were not significantly associated with smoking, pT stage, or pN stage. The 16 patients with locoregional recurrences within 2 years all underwent successful salvage treatments (median follow-up after salvage: 13.1 months), 43.8% (7 of 16) of whom underwent salvage surgery alone for a 2-year overall salvage radiation need of 4.5% (9 of 200). The 2-year outcomes for the 59 evaluable patients among the 109 AJCC 7th pT0-2 N2a-N2b patients with 1 to 3 pathologic lymph nodes (LNs) were as follows: local recurrence, 3.4% (2 of 59); regional recurrence, 8.4% (5 of 59); distant metastases, 0%; DFS, 88.1% (52 of 59); DSS, 100% (59 of 59); OS, 96.7% (59 of 61); and salvage radiation, 5.1% (3 of 59). CONCLUSIONS With careful selection, surgery alone for AJCC 7th pT0-T2N0-N2b HPV+OPSCC with zero to 3 pathologic LNs without perineural invasion, extranodal extension, or positive margins results in high DFS, DSS, OS, and salvage treatment success. Because of the short-term follow-up, these data support further investigation of treatment de-escalation in this population.
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Affiliation(s)
- William R Ryan
- Division of Head and Neck Oncologic Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California
| | - Mary J Xu
- Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California
| | - Edgar Ochoa
- School of Medicine, University of California San Francisco, San Francisco, California
| | | | - Aaron L Zebolsky
- Homer Stryker MD School of Medicine, Western Michigan University, Kalamazoo, Michigan
| | - Patrick K Ha
- Division of Head and Neck Oncologic Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California
| | - Arnaud F Bewley
- Department of Otolaryngology-Head and Neck Surgery, University of California Davis Medical Center, Sacramento, California
| | | | - Arjun S Joshi
- Division of Head and Neck Oncologic Surgery, Department of Surgery, George Washington University School of Medicine, Washington, DC
| | - Charles S Coffey
- Division of Otolaryngology/Head and Neck Surgery, Department of Surgery, University of California San Diego, La Jolla, California
| | - Farhoud Faraji
- Division of Otolaryngology/Head and Neck Surgery, Department of Surgery, University of California San Diego, La Jolla, California
| | - Bridget V MacDonald
- School of Medicine, University of California San Diego, La Jolla, California
| | - Jeffrey J Houlton
- Department of Otolaryngology-Head and Neck Surgery, University of Washington Medical Center, Seattle, Washington
| | - Theodore A Gobillot
- School of Medicine, University of Washington Medical Center, Seattle, Washington
| | - Joseph M Curry
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Ramez Philips
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Trevor G Hackman
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Jeremy D Richmon
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts
| | - Andrew J Holcomb
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts.,Head and Neck Surgical Oncology, Nebraska Methodist Health System, Omaha, Nebraska
| | - Andrew M Coughlin
- Head and Neck Surgical Oncology, Nebraska Methodist Health System, Omaha, Nebraska
| | - Aru Panwar
- Head and Neck Surgical Oncology, Nebraska Methodist Health System, Omaha, Nebraska
| | - Russell B Smith
- Section of Head and Neck Surgical Oncology, Baptist MD Anderson Cancer Physicians, Baptist Medical Center, Jacksonville, Florida
| | - Matthew E Herberg
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Carole Fakhry
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland
| | - David M Cognetti
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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