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Kalavacherla S, Bernard B, Kim SS, Dornisch A, Blumenfeld L, Linnemeyer-Risser K, Sanghvi P, Guo T. Early Improved Functional Outcomes in Head and Neck Cancer Patients with Primary Tumor Detection. Laryngoscope 2024; 134:701-707. [PMID: 37462352 PMCID: PMC10874284 DOI: 10.1002/lary.30903] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 07/05/2023] [Accepted: 07/07/2023] [Indexed: 01/18/2024]
Abstract
OBJECTIVES We characterize functional outcomes in head and neck cancer of unknown primary (CUP) based on primary site identification. METHODS In this retrospective study, CUP cases were categorized as known primaries (KP) if a tumor was localized after diagnostic workup or persisting unknown primaries (UP). Age, sex, HPV status, diagnostic methods, and treatments regimens were collected. Pretreatment and short-term posttreatment (3-6 months after completion of treatment) weights, PHQ-9, Eating Assessment Tool (EAT-10), and Voice Handicap Index (VHI-10) scores were compared between UP and KP. RESULTS Among 67 CUP patients, 35 (52.2%) had identified primaries (91.4% oropharyngeal and 8.6% nasopharyngeal). KP patients were younger (58 vs. 64, p = 0.04) and more likely to be HPV-positive (88.6% vs. 50%, p = 0.002). Overall detection rates were 16.7% for PET/CT, 34.7% for direct laryngoscopy, and 46.6% for transoral robotic oropharyngectomy. Diagnostic workup was not significantly different between groups. Patients with KP received smaller intermediate radiation dose volumes (436.5 vs. 278.9 cc, p = 0.03) and lower doses to the cricopharyngeal muscle (41.6 vs. 24.6 Gy, p = 0.03).Pretreatment weights, PHQ-9, EAT-10, and VHI-10 scores did not differ between groups. However, posttreatment, UP had greater relative weight loss (-14.1% vs. -7.6%, p = 0.032), higher EAT-10 scores (12.5 vs. 3, p = 0.004), and higher PHQ-9 scores (6 vs. 1.4, p = 0.017). Specifically, UP reported more stressful swallowing, difficulty swallowing solids and pills, and swallowing affecting public eating. CONCLUSION KP patients experienced less weight loss, depression, and reduced swallowing dysfunction, highlighting an early functional benefit of primary tumor identification likely driven by reduced radiation treatment volumes. LEVEL OF EVIDENCE 4 Laryngoscope, 134:701-707, 2024.
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Affiliation(s)
- Sandhya Kalavacherla
- School of Medicine, University of California San Diego, La Jolla, California, U.S.A
| | - Benjamin Bernard
- Department of Otolaryngology-Head & Neck Surgery, University of California San Diego, San Diego, California, U.S.A
| | - Sangwoo S Kim
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, California, U.S.A
| | - Anna Dornisch
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, California, U.S.A
| | - Liza Blumenfeld
- Department of Otolaryngology-Head & Neck Surgery, University of California San Diego, San Diego, California, U.S.A
- Gleiberman Head and Neck Cancer Center, Moores Cancer Center, University of California, San Diego, California, U.S.A
| | - Kristen Linnemeyer-Risser
- Department of Otolaryngology-Head & Neck Surgery, University of California San Diego, San Diego, California, U.S.A
- Gleiberman Head and Neck Cancer Center, Moores Cancer Center, University of California, San Diego, California, U.S.A
| | - Parag Sanghvi
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, California, U.S.A
- Gleiberman Head and Neck Cancer Center, Moores Cancer Center, University of California, San Diego, California, U.S.A
| | - Theresa Guo
- Department of Otolaryngology-Head & Neck Surgery, University of California San Diego, San Diego, California, U.S.A
- Gleiberman Head and Neck Cancer Center, Moores Cancer Center, University of California, San Diego, California, U.S.A
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Kalavacherla S, Li V, Voora R, Victor M, Faraji F, Guo T. Factors associated with unknown primary status in head and neck squamous cell carcinoma. Oral Oncol 2024; 148:106650. [PMID: 38039876 DOI: 10.1016/j.oraloncology.2023.106650] [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: 08/25/2023] [Revised: 11/22/2023] [Accepted: 11/25/2023] [Indexed: 12/03/2023]
Abstract
OBJECTIVES Head and neck cancer of unknown primary (CUP) poses significant therapeutic challenges. We compare CUP and oropharyngeal primary (OP) cases to identify factors associated with tumor detection. METHODS The 2004-2019 National Cancer Database was queried to identify CUP and OP cases based on clinical and pathologic TNM staging. Clinical and demographic characteristics were compared by primary detection and HPV status with descriptive statistics. Multivariable logistic regression models to characterize OP detection were constructed. Among HPV-positive and negative patients, respectively, OP and CUP patients were matched by clinical nodal disease. Cox proportional-hazards models were constructed using matched cohorts to characterize survival. RESULTS 81,053 CUP and OP cases were identified; 64.3 % were HPV-positive. OP detection increased over time in HPV-positive and negative disease. HPV-positive status had higher odds of OP detection (odds ratio (OR) = 1.77, p < 0.001), while females (OR = 0.95, p = 0.008), and black (OR = 0.82, p < 0.001) and Asian (OR = 0.7, p < 0.001) patients had lower odds compared to males and whites, respectively. In HPV-positive and negative disease, OP patients had higher 2 and 5-year survival rates than CUP (p < 0.001). Primary detection status conferred lower death risk in HPV-positive (hazard ratio (HR) = 0.85, p < 0.001) and negative disease (HR = 0.87, p < 0.001) when controlling for age, sex, race, comorbidities, insurance, treatment facility, and income. CONCLUSION In the largest cohort of CUP to date, we report a survival benefit in primary tumor detection regardless of HPV status. Groups with higher persistent CUP rates, including non-white, female, HPV-negative, and low income patients, may benefit from increased diagnostic workup to improve detection and treatment.
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Affiliation(s)
| | - Vivienne Li
- School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Rohith Voora
- Department of Otolaryngology-Head and Neck Surgery, UC San Diego Health, La Jolla, CA, USA
| | - Mitchell Victor
- Department of Otolaryngology-Head and Neck Surgery, UC San Diego Health, La Jolla, CA, USA; Gleiberman Head & Neck Cancer Center, Moores Cancer Center, UC San Diego Health, La Jolla, CA, USA
| | - Farhoud Faraji
- Department of Otolaryngology-Head and Neck Surgery, UC San Diego Health, La Jolla, CA, USA; Gleiberman Head & Neck Cancer Center, Moores Cancer Center, UC San Diego Health, La Jolla, CA, USA
| | - Theresa Guo
- Department of Otolaryngology-Head and Neck Surgery, UC San Diego Health, La Jolla, CA, USA; Gleiberman Head & Neck Cancer Center, Moores Cancer Center, UC San Diego Health, La Jolla, CA, USA.
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Chen AM. Management of unknown primary head and neck cancer with radiation therapy in the era of human papillomavirus (HPV): No longer cutting down the tree to get an apple. Radiother Oncol 2023; 189:109952. [PMID: 37844736 DOI: 10.1016/j.radonc.2023.109952] [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: 05/25/2023] [Revised: 10/07/2023] [Accepted: 10/10/2023] [Indexed: 10/18/2023]
Abstract
PURPOSE Given the central role that radiation has in the management of head and neck squamous cell carcinoma of unknown primary origin, it is imperative to review how treatment paradigms have been refined and continue to evolve in the modern era. METHODS AND MATERIALS This study was designed based on the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) statement. A literature search of peer-reviewed publications was undertaken to identify works pertaining to the use of radiation for squamous cell carcinoma of unknown primary origin presenting as cervical lymph node metastases. Articles published from January 2002 to January 2023 with full text available on PubMed and restricted to the English language and human subjects were included. The full bibliographies of identified articles were reviewed and irrelevant studies were removed. RESULTS While such breakthroughs as intensity-modulated radiotherapy, positron emission tomography, biomarker testing with immune-histochemistry, and minimally invasive surgical techniques such as transoral robotic surgery have fundamentally changed the approach to this disease in recent decades, controversies still exist with respect to the manner in which radiation is delivered. Although the incidence of head and neck unknown primary cancer is relatively low, questions regarding the necessity of comprehensive radiation using the age-old standard method of targeting the bilateral necks and entire pharyngeal axis to encompass all putative sites of mucosal disease persist. CONCLUSIONS Prospective evidence is lacking, and the available studies have been complicated by such factors as the relatively limited sample sizes, as well as the variability in work-up, treatment, inclusion criteria, and follow-up. Regardless, advances in science and technology have ushered in more precise approaches with a high degree of customization, particularly given the increased proportion of patients presenting with human papillomavirus-related disease.
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Affiliation(s)
- Allen M Chen
- Department of Radiation Oncology, University of California, Irvine, Chao Family Comprehensive Cancer Center, Orange, CA 92868, USA.
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Kalavacherla S, Sanghvi P, Lin GY, Guo T. Updates in the management of unknown primary of the head and neck. Front Oncol 2022; 12:991838. [PMID: 36185196 PMCID: PMC9521035 DOI: 10.3389/fonc.2022.991838] [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: 07/12/2022] [Accepted: 08/30/2022] [Indexed: 11/25/2022] Open
Abstract
Squamous cell carcinoma (SCC) from an unknown primary tumor (SCCUP) accounts for 2.0%–5.0% of all head and neck cancers. SCCUP presents as enlarged cervical lymph nodes without evidence of a primary tumor upon physical examination. Primary site detection is important to target treatment and avoid treatment-related morbidity. In this review, we discuss updates in SCCUP management. Diagnostic workup should focus on localization of the primary tumor in SCCUP. Initial workup centers on neck biopsy to confirm the presence of SCC. Given the increasing incidence of HPV-related SCC in the oropharynx, HPV testing is crucial. An HPV-positive status can localize the tumor to the oropharynx, a common site for occult tumors. Imaging includes neck CT and/or MRI, and PET/CT. After imaging, panendoscopy, palatine tonsillectomy or diagnostic transoral robotic surgery can facilitate high rates of primary tumor localization. Primary tumor localization influences treatments administered. SCCUP has traditionally been treated aggressively with large treatment fields to all potential disease sites, which can induce weight loss and swallowing dysfunction. As a result, primary localization can reduce radiation fields and provide possible de-escalation to primary surgical management. Advances in intensity-modulated radiation therapy and dose management also have the potential to improve functional outcomes in SCCUP patients. Given the improved prognosis associated with HPV-positive SCCs, HPV tumor status may also inform future treatment de-intensification to reduce treatment-related toxicity.
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Affiliation(s)
- Sandhya Kalavacherla
- School of Medicine, University of California, San Diego, La Jolla, CA, United States
| | - Parag Sanghvi
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, San Diego, CA, United States
| | - Grace Y. Lin
- Department of Pathology, University of California, San Diego, San Diego, CA, United States
| | - Theresa Guo
- Department of Otolaryngology – Head & Neck Surgery, University of California, San Diego, San Diego, CA, United States
- *Correspondence: Theresa Guo,
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Hussain T. Patient Benefit and Quality of Life after Robot-Assisted Head and Neck Surgery. Laryngorhinootologie 2022; 101:S160-S185. [PMID: 35605618 DOI: 10.1055/a-1647-8650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Robotic systems for head and neck surgery are at different stages of technical development and clinical application. Currently, robotic systems are predominantly used for transoral surgery of the pharynx and larynx. Robotic surgery of the neck, the thyroid, and the middle and inner ear is much less common; however, some oncological and functional outcomes have been reported. This article provides an overview of the current state of robot-assisted head and neck surgery with a special emphasis on patient benefit and postoperative quality of life (QoL). The focus is placed on the role of transoral robotic surgery (TORS) for the resection of oropharyngeal carcinomas. For this application, reported long-term outcomes show functional post-operative advantages for selected oropharyngeal cancer patients after TORS compared to open surgery and primary radiotherapy. Since TORS also plays a significant role in the context of potential therapy de-escalation for HPV-positive oropharyngeal cancer patients, ongoing trials are presented. Regarding the evaluation of the therapeutic benefit and the QoL of cancer patients, special attention has to be paid to the large degree of variability of individual patients' preferences. Influencing factors and tools for a detailed assessment of QoL parameters are therefore detailed at the beginning of this article. Notably, while some robotic systems for ear and skull base surgery are being developed in Europe, TORS systems are mainly used in North America and Asia. In Europe and Germany in particular, transoral laser microsurgery (TLM) is a well-established technology for transoral tumor resection. Future trials comparing TORS and TLM with detailed investigation of QoL parameters are therefore warranted and might contribute to identifying suitable fields for the application of the different techniques.
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Affiliation(s)
- Timon Hussain
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Essen, Universität Duisburg-Essen
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Human Papillomavirus and Squamous Cell Carcinoma of Unknown Primary in the Head and Neck Region: A Comprehensive Review on Clinical Implications. Viruses 2021; 13:v13071297. [PMID: 34372502 PMCID: PMC8310239 DOI: 10.3390/v13071297] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 06/28/2021] [Accepted: 06/29/2021] [Indexed: 01/02/2023] Open
Abstract
Squamous cell carcinoma of unknown primary (SCCUP) is a challenging diagnostic subgroup of oropharyngeal squamous cell carcinoma (OPSCC). The incidence of SCCUP is increasing in parallel with the well-documented increase in OPSCC and is likewise driven by the increase in human papillomavirus (HPV). The SCCUP patient often presents with a cystic lymph node metastasis and undergoes an aggressive diagnostic and treatment program. Detection of HPV in cytologic specimens indicates an oropharyngeal primary tumor origin and can guide the further diagnostic strategy. Advances in diagnostic modalities, e.g., transoral robotic surgery and transoral laser microsurgery, have increased the successful identification of the primary tumor site in HPV-induced SCCUP, and this harbors a potential for de-escalation treatment and increased survival. This review provides an overview of HPV-induced SCCUP, diagnostic modalities, and treatment options.
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Sherry AD, Pasalic D, Gunn GB, Fuller CD, Phan J, Rosenthal DI, Morrison WH, Sturgis EM, Gross ND, Gillison ML, Ferrarotto R, El-Naggar AK, Garden AS, Frank SJ. Proton Beam Therapy for Head and Neck Carcinoma of Unknown Primary: Toxicity and Quality of Life. Int J Part Ther 2021; 8:234-247. [PMID: 34285950 PMCID: PMC8270080 DOI: 10.14338/ijpt-20-00034.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 09/21/2020] [Indexed: 12/26/2022] Open
Abstract
Purpose Proton radiation therapy (PRT) may offer dosimetric and clinical benefit in the treatment of head and neck carcinoma of unknown primary (HNCUP). We sought to describe toxicity and quality of life (QOL) in patients with HNCUP treated with PRT. Patients and Methods Toxicity and QOL were prospectively tracked in patients with HNCUP from 2011 to 2019 after institutional review board approval. Patients received PRT to the mucosa of the nasopharynx, oropharynx, and bilateral cervical lymph nodes with sparing of the larynx and hypopharynx. Patient-reported outcomes were tracked with the MD Anderson Symptom Inventory–Head and Neck Module, the Functional Assessment of Cancer Therapy–Head and Neck, the MD Anderson Dysphagia Inventory, and the Xerostomia-Related QOL Scale. Primary study endpoints were the incidence of grade ≥ 3 (G3) toxicity and QOL patterns. Results Fourteen patients (median follow-up, 2 years) were evaluated. Most patients presented with human papillomavirus–positive disease (n = 12, 86%). Rates of G3 oral mucositis, xerostomia, and dermatitis were 7% (n = 1), 21% (n = 3), and 36% (n = 5), respectively. None required a gastrostomy. During PRT, QOL was reduced relative to baseline and recovered shortly after PRT. At 2 years after PRT, the local regional control, disease-free survival, and overall survival were 100% (among 7 patients at risk), 79% (among 6 patients at risk), and 90% (among 7 patients at risk), respectively. Conclusion Therefore, PRT for HNCUP was associated with highly favorable dosimetric and clinical outcomes, including minimal oral mucositis, xerostomia, and dysphagia. Toxicity and QOL may be superior with PRT compared with conventional radiation therapy and PRT maintains equivalent oncologic control. Further prospective studies are needed to evaluate late effects and cost-effectiveness.
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Affiliation(s)
| | - Dario Pasalic
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - G Brandon Gunn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - C David Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jack Phan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David I Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William H Morrison
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Erich M Sturgis
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Neil D Gross
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maura L Gillison
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Renata Ferrarotto
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Adel K El-Naggar
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Adam S Garden
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Carey RM, Brody RM, Shimunov D, Shinn JR, Mady LJ, Rajasekaran K, Cannady SB, Lin A, Lukens JN, Bauml JM, Cohen RB, Basu D, O'Malley BW, Weinstein GS, Newman JG. Locoregional Recurrence in p16-Positive Oropharyngeal Squamous Cell Carcinoma After TORS. Laryngoscope 2021; 131:E2865-E2873. [PMID: 34076275 DOI: 10.1002/lary.29659] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/07/2021] [Accepted: 05/12/2021] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To analyze the patterns, risk factors, and salvage outcomes for locoregional recurrences (LRR) after treatment with transoral robotic surgery (TORS) for HPV-associated oropharyngeal squamous cell carcinoma (HPV+ OPSCC). STUDY DESIGN Retrospective analysis of HPV+ OPSCC patients completing primary TORS, neck dissection, and NCCN-guideline-compliant adjuvant therapy at a single institution from 2007 to 2017. METHODS Features associated with LRR, detailed patterns of LRR, and outcomes of salvage therapy were analyzed. Disease-free survival (DFS) and overall survival (OS) were calculated for subgroups of patients receiving distinct adjuvant treatments. RESULTS Of 541 patients who completed guideline-indicated therapy, the estimated 5-year LRR rate was 4.5%. There were no identifiable clinical or pathologic features associated with LRR. Compared to patients not receiving adjuvant therapy, those who received indicated adjuvant radiation alone had a lower risk of LRR (HR 0.28, 95% CI [0.09-0.83], P = .023), but there was no difference in DFS (P = .21) and OS (P = .86) between adjuvant therapy groups. The 5-year OS for patients who developed LRR was 67.1% vs. 93.9% for those without LRR (P < .001). Patients who initially received adjuvant chemoradiation and those suffering local, in-field, and/or retropharyngeal node recurrences had decreased disease control after salvage therapy. CONCLUSION LRR rates are low for HPV+ OPSCCs completing TORS and guideline-compliant adjuvant therapy. Patients without indication for adjuvant therapy more often suffer LRR, but these recurrences are generally controllable by salvage therapy. Improved understanding of the patterns of recurrence most amenable to salvage therapy may guide treatment decisions, counseling, and adjuvant therapy de-escalation trials. LEVEL OF EVIDENCE 3 Laryngoscope, 2021.
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Affiliation(s)
- Ryan M Carey
- Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Robert M Brody
- Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - David Shimunov
- Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Justin R Shinn
- Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Leila J Mady
- Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Steven B Cannady
- Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Alexander Lin
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - John N Lukens
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Joshua M Bauml
- Department of Internal Medicine, Division of Hematology-Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Roger B Cohen
- Department of Internal Medicine, Division of Hematology-Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Devraj Basu
- Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Bert W O'Malley
- University of Maryland Medical Center, Baltimore, Maryland, U.S.A
| | - Gregory S Weinstein
- Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Jason G Newman
- Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
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9
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Transoral robotic surgery in Ireland: the beginning. Ir J Med Sci 2021; 191:361-365. [PMID: 33559869 DOI: 10.1007/s11845-021-02539-w] [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: 12/05/2020] [Accepted: 02/01/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Transoral robotic surgery (TORS) has shown promising results in the treatment of myriad head and neck pathologies but is now most commonly used in the investigation and management of oropharyngeal squamous cell carcinoma. AIMS The aim of this study was to report our cases of the newly introduced TORS, particularly its role in identifying primary of unknown origin and the potential implications for patients. A literature review and our early experience should begin to debunk some of the criticisms of TORS including setup times and cost. METHODS Prospective data was collected from all patients undergoing transoral robotic surgery including demographics, indication, histology results in primary of unknown origin and complications. RESULTS We have performed 36 TORS procedures in total ranging from intermediate to major complex. Our complication rate is low, and this has improved with the passage of time. Haemorrhage rates remain at 5.6% (n = 2), and the average length of stay is 1 day. Successful identification of a primary tumour in cancer of unknown primary was 80% (n = 8). CONCLUSIONS We anticipate the integration of TORS into routine practice in the investigation and management of a number of ENT pathologies following robust clinical trials.
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Carey RM, Shimunov D, Weinstein GS, Cannady SB, Lukens JN, Lin A, Swisher-McClure S, Bauml JM, Aggarwal C, Cohen RB, Newman JG, Chalian AA, Rassekh CH, Basu D, O'Malley BW, Rajasekaran K, Brody RM. Increased rate of recurrence and high rate of salvage in patients with human papillomavirus-associated oropharyngeal squamous cell carcinoma with adverse features treated with primary surgery without recommended adjuvant therapy. Head Neck 2020; 43:1128-1141. [PMID: 33325579 DOI: 10.1002/hed.26578] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 10/23/2020] [Accepted: 11/30/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Some patients with human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) do not receive guideline-recommended postoperative radiation therapy (PORT) following primary transoral robotic surgery (TORS). METHODS Three-hundred and sixty-four patients with treatment-naïve, HPV-associated OPSCC were recommended to receive PORT based on clinicopathological features following TORS. Patients were stratified based on if they received PORT. Oncologic outcomes were compared. RESULTS The 3-year locoregional failure (LRF) was 32% in patients who did not receive PORT and 4% in patients who received PORT (P < .001). Despite increased LRF, avoiding PORT was not associated with increased 3-year distant metastasis rates (8% vs 4%, P = .56) or worse 3-year survival (95% vs 98%, P = .34). Recurrences in the surgery alone cohort varied between local and regional sites and were often successfully salvaged. CONCLUSIONS Patients with HPV-associated OPSCC who do not receive indicated PORT have an increased risk of LRF but similar survival due to high salvage rates.
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Affiliation(s)
- Ryan M Carey
- Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Shimunov
- Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gregory S Weinstein
- Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Steven B Cannady
- Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John N Lukens
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alexander Lin
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Samuel Swisher-McClure
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua M Bauml
- Department of Internal Medicine, Division of Hematology-Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Charu Aggarwal
- Department of Internal Medicine, Division of Hematology-Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Roger B Cohen
- Department of Internal Medicine, Division of Hematology-Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason G Newman
- Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ara A Chalian
- Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christopher H Rassekh
- Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Devraj Basu
- Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Bert W O'Malley
- Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert M Brody
- Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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11
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Moy J, Li R. Approach to the Patient with Unknown Primary Squamous Cell Carcinoma of the Head and Neck. Curr Treat Options Oncol 2020; 21:93. [DOI: 10.1007/s11864-020-00791-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2020] [Indexed: 12/18/2022]
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12
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de Almeida JR. Role of Transoral Robotic Surgery in the Work-up of the Unknown Primary. Otolaryngol Clin North Am 2020; 53:965-980. [PMID: 32951898 DOI: 10.1016/j.otc.2020.07.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Unknown primary squamous cell carcinoma metastatic to cervical lymph nodes is a relatively rare tumor presentation, although the incidence may be increasing along with the rising incidence of human papilloma virus-mediated oropharyngeal cancers. Traditional diagnostic methods with palatine tonsillectomy and panendoscopy may identify the minority of primary tumors. The addition of a transoral lingual tonsillectomy may improve the diagnostic yield of identifying a primary tumor. Incorporation of transoral robotic surgery may be used for diagnostic purposes to identify a primary site and also for therapeutic purposes, whereby a primary tumor may be completely resected and combined with a neck dissection.
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Affiliation(s)
- John R de Almeida
- Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Centre/University Health Network, University of Toronto, Toronto General Hospital, 200 Elizabeth Street, 8NU-883, Toronto, Ontario, Canada; Department of Surgical Oncology, Princess Margaret Cancer Centre/University Health Network, University of Toronto, Toronto General Hospital, 200 Elizabeth Street, 8NU-883, Toronto, Ontario, Canada.
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13
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Parhar HS, Yver CM, Brody RM. Current Indications for Transoral Robotic Surgery in Oropharyngeal Cancer. Otolaryngol Clin North Am 2020; 53:949-964. [PMID: 32912662 DOI: 10.1016/j.otc.2020.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The incidence of oropharyngeal squamous cell carcinoma (OPSCC) is increasing dramatically and is conclusively linked to increasing rates of human papillomavirus (HPV) infection. HPV-related oropharyngeal cancers have been shown to occur in a unique demographic group and show favorable oncologic outcomes compared with HPV-negative OPSCC. There has been a paradigm shift in the treatment of early-stage OPSCC, with most patients now undergoing primary surgery in the United States. Transoral robotic surgery is associated with excellent oncologic and functional outcomes in the treatment of OPSCC and is increasingly being used for a broader range of oropharyngeal indications.
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Affiliation(s)
- Harman S Parhar
- Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania Health System, 3400 Spruce Street, 5th Floor Silverstein Building, Philadelphia, PA 19104, USA
| | - Christina M Yver
- Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania Health System, 3400 Spruce Street, 5th Floor Silverstein Building, Philadelphia, PA 19104, USA
| | - Robert M Brody
- Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania Health System, 3400 Spruce Street, 5th Floor Silverstein Building, Philadelphia, PA 19104, USA.
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