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Gupta KK, Khan H, Mughal Z, De M, Sharma N, Garas G. Primary Tumour Detection in Carcinoma of Unknown Primary with Transoral Robotic Surgery (TORS) Tongue Base Mucosectomy: A Meta-analysis. Ann Surg Oncol 2024; 31:6065-6076. [PMID: 38980583 DOI: 10.1245/s10434-024-15758-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 06/24/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND Head and neck carcinoma of unknown primary (CUP) represents a challenging diagnostic process when standard work-up fails to identify the primary tumour site. The aim of this systematic review and meta-analysis was to evaluate the diagnostic utility and complication profile of transoral robotic surgery (TORS) tongue base mucosectomy (TBM) in the management of CUP. PATIENTS AND METHODS An electronic database search was performed in the EMBASE, MEDLINE, PubMed and Cochrane databases. A meta-analysis of proportions was performed to obtain an estimate of the overall proportion for the detection and complication rates. RESULTS Nine studies representing 235 patients with CUP who had TORS TBM were included in the final analysis. The overall pooled tumour detection rate was 66.2% [95% confidence interval (CI) 56.1-75.8]. The incidence of tumour detection in human papilloma virus (HPV)-positive cases (81.5%, 95% CI 60.8-96.4) was significantly higher than HPV-negative cases (2.3%, 95% CI 0.00-45.7). Weighted overall complication rate was 11.4% (95% CI 7.2-16.2). The majority were grade I or II (80%) according to the Clavien-Dindo classification. CONCLUSIONS This meta-analysis suggests TORS to be safe and effective in localising the primary tumour site in patients with CUP. While the current data supports the use of TORS in patients who are HPV positive, larger numbers of HPV-negative cases are required to determine the true diagnostic effect with TORS before any valid conclusions can be inferred in this particular subgroup. Further research should focus on high quality prospective trials with stringent methodological work-up to minimise heterogeneity and allow for more accurate statistical analysis.
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Affiliation(s)
- Keshav Kumar Gupta
- Head & Neck Surgical Oncology Unit, Department of Otorhinolaryngology and Head and Neck Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK.
| | - Hamad Khan
- Head & Neck Surgical Oncology Unit, Department of Otorhinolaryngology and Head and Neck Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Zahir Mughal
- Department of Otorhinolaryngology and Head and Neck Surgery, Walsall Manor Hospital, Walsall, UK
| | - Mriganka De
- Head & Neck Surgical Oncology Unit, Department of Otorhinolaryngology and Head and Neck Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Neil Sharma
- Head & Neck Surgical Oncology Unit, Department of Otorhinolaryngology and Head and Neck Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - George Garas
- Head & Neck Surgical Oncology Unit, Department of Otorhinolaryngology and Head and Neck Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
- Department of Surgery and Cancer, Imperial College London, St. Mary's Hospital, London, UK
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2
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Cleere EF, Read C, Prunty S, Duggan E, O'Rourke J, Moore M, Vasquez P, Young O, Subramaniam T, Skinner L, Moran T, O'Duffy F, Hennessy A, Dias A, Sheahan P, Fitzgerald CWR, Kinsella J, Lennon P, Timon CVI, Woods RSR, Shine N, Curley GF, O'Neill JP. Airway decision making in major head and neck surgery: Irish multicenter, multidisciplinary recommendations. Head Neck 2024; 46:2363-2374. [PMID: 38984517 DOI: 10.1002/hed.27868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 06/21/2024] [Accepted: 06/30/2024] [Indexed: 07/11/2024] Open
Abstract
Major head and neck surgery poses a threat to perioperative airway patency. Adverse airway events are associated with significant morbidity, potentially leading to hypoxic brain injury and even death. Following a review of the literature, recommendations regarding airway management in head and neck surgery were developed with multicenter, multidisciplinary agreement among all Irish head and neck units. Immediate extubation is appropriate in many cases where there is a low risk of adverse airway events. Where a prolonged definitive airway is required, elective tracheostomy provides increased airway security postoperatively while delayed extubation may be appropriate in select cases to reduce postoperative morbidity. Local institutional protocols should be developed to care for a tracheostomy once inserted. We provide guidance on decision making surrounding airway management at time of head and neck surgery. All decisions should be agreed between the operating, anesthetic, and critical care teams.
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Affiliation(s)
- Eoin F Cleere
- Department of Otolaryngology - Head and Neck Surgery, Beaumont Hospital, Dublin, Ireland
| | - Christopher Read
- Department of Anaesthesia and Critical Care, Beaumont Hospital, Dublin, Ireland
| | - Sarah Prunty
- Department of Otolaryngology - Head and Neck Surgery, Beaumont Hospital, Dublin, Ireland
| | - Edel Duggan
- Department of Anaesthesia and Critical Care, Beaumont Hospital, Dublin, Ireland
| | - James O'Rourke
- Department of Anaesthesia and Critical Care, Beaumont Hospital, Dublin, Ireland
| | - Michael Moore
- Department of Anaesthesia and Critical Care, Beaumont Hospital, Dublin, Ireland
| | - Pedro Vasquez
- Department of Physiotherapy, Beaumont Hospital, Dublin, Ireland
| | - Orla Young
- Department of Otolaryngology - Head and Neck Surgery, Galway University Hospital, Galway, Ireland
| | - Thavakumar Subramaniam
- Department of Otolaryngology - Head and Neck Surgery, Galway University Hospital, Galway, Ireland
| | - Liam Skinner
- Department of Otolaryngology - Head and Neck Surgery, University Hospital Waterford, Waterford, Ireland
| | - Tom Moran
- Department of Otolaryngology - Head and Neck Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
- Department of Otolaryngology - Head and Neck Surgery, St Vincent's University Hospital, Dublin, Ireland
| | - Fergal O'Duffy
- Department of Otolaryngology - Head and Neck Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
- Department of Otolaryngology - Head and Neck Surgery, St Vincent's University Hospital, Dublin, Ireland
| | - Anthony Hennessy
- Department of Anaesthesiology, South Infirmary Victoria University Hospital, Cork, Ireland
| | - Andrew Dias
- Department of Otolaryngology - Head and Neck Surgery, South Infirmary Victoria University Hospital, Cork, Ireland
| | - Patrick Sheahan
- Department of Otolaryngology - Head and Neck Surgery, South Infirmary Victoria University Hospital, Cork, Ireland
- ENTO Research Unit, College of Medicine and Health, University College Cork, Cork, Ireland
| | - Conall W R Fitzgerald
- Department of Otolaryngology - Head and Neck Surgery, St James's Hospital, Dublin, Ireland
| | - John Kinsella
- Department of Otolaryngology - Head and Neck Surgery, St James's Hospital, Dublin, Ireland
| | - Paul Lennon
- Department of Otolaryngology - Head and Neck Surgery, St James's Hospital, Dublin, Ireland
| | - Conrad V I Timon
- Department of Otolaryngology - Head and Neck Surgery, St James's Hospital, Dublin, Ireland
| | - Robbie S R Woods
- Department of Otolaryngology - Head and Neck Surgery, Beaumont Hospital, Dublin, Ireland
| | - Neville Shine
- Department of Otolaryngology - Head and Neck Surgery, Beaumont Hospital, Dublin, Ireland
| | - Gerard F Curley
- Department of Anaesthesia and Critical Care, Beaumont Hospital, Dublin, Ireland
- Department of Anaesthesia and Critical Care, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - James P O'Neill
- Department of Otolaryngology - Head and Neck Surgery, Beaumont Hospital, Dublin, Ireland
- Department of Otolaryngology - Head and Neck Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
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3
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de Almeida JR, Martino R, Hosni A, Goldstein DP, Bratman SV, Chepeha DB, Waldron JN, Weinreb I, Perez-Ordonez B, Yu E, Metser U, Hansen AR, Xu W, Su SJ, Kim J. Transoral Robotic Surgery and Radiation Volume Deintensification in Unknown Primary Squamous Cell Carcinoma of the Neck: The Phase 2 FIND Nonrandomized Controlled Trial. JAMA Otolaryngol Head Neck Surg 2024; 150:463-471. [PMID: 38602692 PMCID: PMC11009865 DOI: 10.1001/jamaoto.2024.0423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 02/17/2024] [Indexed: 04/12/2024]
Abstract
Importance Patients with unknown primary squamous cell carcinoma (CUP) with cervical metastases typically receive comprehensive radiotherapy (RT) of the pharynx and bilateral neck. Typically, these patients receive comprehensive RT of the pharynx and bilateral neck that may produce treatment-related toxic effects. Objective To determine whether localization of occult oropharyngeal cancers with transoral robotic surgery (TORS) combined with reduced pharyngeal and neck RT volumes provides acceptable disease control. Design, Setting, and Participants This phase 2, single-group nonrandomized controlled trial at a single institution accrued 32 prospective participants with p16-positive CUP without a primary squamous cell carcinoma on examination and imaging from 2017 to 2019, and 24-month follow-up. The data analysis was conducted from January 2021 to June 2022. Intervention Diagnostic- (n = 13) or therapeutic-intent (n = 9) TORS, with pharyngeal-sparing radiotherapy (PSRT) prescribed for negative margins or pT0, and unilateral neck RT (UNRT) prescribed for unilateral lymphadenopathy with lateralized primary tumor or pT0. Main Outcomes and Measures Out-of-radiation treatment volume failure (<15% was hypothesized to be acceptable) and reports of local and regional recurrence, overall survival, toxic effects, swallowing outcomes (per the MD Anderson Dysphagia Inventory), and videofluoroscopic swallow (per Dynamic Imaging Grade of Swallowing Toxic Effects [DIGEST]) ratings. Results The study sample comprised 22 patients (mean [SD] age, 59.1 [5.7] years; 3 [14%] females and 19 [86%] male) with CUP. Of these, 19 patients (86%) had tumor stage cN1; 2 (9%), cN2; and 1 (5%), cN3. Five patients (23%), 14 patients (64%), and 3 patients (13%) had 0, 1, or 2 primary tumors, respectively. Twenty patients received RT; of these, 9 patients (45%) underwent PSRT and 10 patients (50%), UNRT. In the diagnostic-intent group, 8 patients (62%) and 5 patients (38%) underwent RT and RT-concurrent chemotherapy, respectively. In the therapeutic-intent group, 6 patients (67%) and 1 patient (11%) received adjuvant RT-concurrent chemotherapy, respectively; 2 patients declined RT. Two-year out-of-radiation treatment volume failure, locoregional control, distant metastasis control, and overall survival were 0%, 100%, 95%, and 100%, respectively. Grade 3 or 4 surgical, acute, and late toxic effects occurred in 2 (9%), 5 (23%), and 1 (5%) patients, respectively. PSRT was associated with lower RT dose to superior constrictors (37 vs 53 Gy; mean difference, 16 Gy; 95% CI, 6.4, 24.9), smaller decline in swallowing scores during treatment (19.3 vs 39.7; mean difference, -20.4; 95% CI, -34.1 to -6.1), and fewer patients with worsening DIGEST grade on findings of videofluoroscopic swallow studies at 2 years (0% vs 60%; difference, 60%; 95% CI, 30% to 90%). Conclusions and Relevance These findings indicate that TORS for p16-positive CUP allows RT volume deintensification with excellent outcomes and support future investigation in randomized clinical trials. Trial Registration ClinicalTrials.gov Identifier: NCT03281499.
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Affiliation(s)
- John R. de Almeida
- Department of Otolaryngology–Head and Neck Surgery, Princess Margaret Cancer Center/University Health Network, University of Toronto, Toronto, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Canada
| | - Rosemary Martino
- Department of Otolaryngology–Head and Neck Surgery, Princess Margaret Cancer Center/University Health Network, University of Toronto, Toronto, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada
- Department of Speech-Language Pathology, University of Toronto, Toronto, Canada
- The Swallowing Lab, University of Toronto, Toronto, Canada
- Krembil Research Institute, University Health Network, Toronto, Canada
| | - Ali Hosni
- Department of Radiation Oncology, Princess Margaret Cancer Center/University Health Network, University of Toronto, Toronto, Canada
| | - David P. Goldstein
- Department of Otolaryngology–Head and Neck Surgery, Princess Margaret Cancer Center/University Health Network, University of Toronto, Toronto, Canada
| | - Scott V. Bratman
- Department of Radiation Oncology, Princess Margaret Cancer Center/University Health Network, University of Toronto, Toronto, Canada
| | - Douglas B. Chepeha
- Department of Otolaryngology–Head and Neck Surgery, Princess Margaret Cancer Center/University Health Network, University of Toronto, Toronto, Canada
| | - John N. Waldron
- Department of Radiation Oncology, Princess Margaret Cancer Center/University Health Network, University of Toronto, Toronto, Canada
| | - Ilan Weinreb
- Department of Pathology, University Health Network, Toronto, Canada
| | | | - Eugene Yu
- Department of Medical Imaging, University Health Network, Toronto, Canada
| | - Ur Metser
- Department of Medical Imaging, University Health Network, Toronto, Canada
| | - Aaron R. Hansen
- Department of Medical Oncology, Princess Margaret Cancer Center, Toronto, Canada
| | - Wei Xu
- Department of Biostatistics, Princess Margaret Cancer Center, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Susie Jie Su
- Department of Biostatistics, Princess Margaret Cancer Center, Toronto, Canada
| | - John Kim
- Department of Radiation Oncology, Princess Margaret Cancer Center/University Health Network, University of Toronto, Toronto, Canada
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Dewey J, Shaikh N, Al-Asadi Z, Turner M. The influence of perioperative enoxaparin on bleeding after TORS oropharyngectomy. J Robot Surg 2024; 18:203. [PMID: 38713415 DOI: 10.1007/s11701-024-01965-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 04/24/2024] [Indexed: 05/08/2024]
Abstract
Perioperative enoxaparin is often avoided in patients undergoing transoral robotic (TORS) oropharyngectomy. Our goal was to quantify the risk of postoperative hemorrhage (POH) in patients receiving enoxaparin after TORS oropharyngectomy. This was a retrospective database cohort study set up in 89 separate healthcare organizations. The TriNetX electronic database was queried for patients with OPSCC who underwent TORS oropharyngectomy. Propensity-score matching was used to create two cohorts, one receiving and one not receiving perioperative enoxaparin. Outcome measures were the POH rate within 1 day of surgery ("primary") and POH rate within 2-30 days of surgery ("secondary"). 1109 patients undergoing TORS for OPSCC were identified, 400 of which received perioperative enoxaparin. One-to-one propensity score matching resulted in 310 patients per cohort. After matching, the primary POH rates between patients receiving and not receiving enoxaparin were 3.23% for both cohorts (OR 1.000, 95% CI 0.410 to 2.438). The secondary POH rates between those receiving and not receiving enoxaparin were 5.47% vs. 3.54% (OR 1.577, 95% CI 0.726 to 3.424). The number needed to harm (NNH) with perioperative enoxaparin use for secondary POH after TORS was 53; no difference was found in primary POH rates. While not statistically significant, the use of perioperative enoxaparin after TORS is associated with increased odds of secondary POH with a NNH of 53; no difference was found in rates of primary POH. For patients undergoing TORS, enoxaparin use requires careful weighing of the risks and benefits.
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Affiliation(s)
- John Dewey
- Department of Otolaryngology, West Virginia University, PO Box 9100, Morgantown, WV, 26506-9600, USA
| | - Noah Shaikh
- Department of Otolaryngology, West Virginia University, PO Box 9100, Morgantown, WV, 26506-9600, USA
| | - Zayd Al-Asadi
- West Virginia University School of Medicine, Morgantown, WV, USA
| | - Meghan Turner
- Department of Otolaryngology, West Virginia University, PO Box 9100, Morgantown, WV, 26506-9600, USA.
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5
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Jain A, Goldberg ZN, Briggs E, Amin DR, Urdang ZD, Goldman RA, Cognetti DM, Curry JM. Modified Frailty Index Associates With Transoral Robotic Surgery Complications and Survival: A National Database Study. Laryngoscope 2024. [PMID: 38651382 DOI: 10.1002/lary.31458] [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: 01/09/2024] [Revised: 04/02/2024] [Accepted: 04/04/2024] [Indexed: 04/25/2024]
Abstract
OBJECTIVE The modified frailty index (mFI-5) is a National Surgical Quality Improvement Program-derived 5-factor index that has been proven to reflect frailty and predict morbidity and mortality. We hypothesize that mFI-5 is a valid predictive measure in the transoral robotic surgery (TORS) population. METHODS Retrospective study utilizing the TriNetX US-collaborative health records network querying for TORS patients. Cohorts were stratified by mFI-5 score which uses five ICD-10 codes: nonindependent functional status, hypertension, obstructive respiratory disease, heart failure, and diabetes mellitus. Cohorts were matched by age using propensity score matching. Outcome measures included survival, infection, pneumonia, tracheostomy dependence, and percutaneous endoscopic gastrostomy dependence. Reported odds ratios were normalized to mFI-5 = 0. RESULTS A total of 9,081 patients were included in the final analysis. Greater mFI-5 scores predicted decreased survival and increased incidence of postoperative infection and pneumonia. Odds of 5-year mortality were 1.93 (p = 0.0003) for mFI-5 = 2 and 1.90 (p = 0.0002) for mFI-5 = 3. Odds of 2-year mortality were 1.25 (p = 0.0125) for mFI-5 = 1, 1.58 (p = 0.0002) for mFI-5 = 2, and 1.87 (p = 0.003) for mFI-5 = 3. Odds of postoperative infection were 1.51 (p = 0.02) for mFI-5 = 2 and 1.78 (p = 0.05) for mFI-5 = 3. Two-year odds of developing pneumonia were 1.69 (p = 0.0001) for mFI-5 = 2 and 2.84 (p < 0.0001) for mFI-5 = 3. Two-month odds of pneumonia were 1.50 (p = 0.0259) for mFI-5 = 2 and 2.55 (p = 0.0037) for mFI-5 = 3. mFI-5 = 4 or 5 had too few patients to analyze. Using polynomial regression to model age versus incident 5-year post-TORS death (R2 = 0.99), mFI-5 scores better predicted survival than age alone. CONCLUSION This study demonstrates that mFI-5 predicts mortality, pneumonia, and postoperative infection independently of age. LEVEL OF EVIDENCE 4 Laryngoscope, 2024.
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Affiliation(s)
- Amiti Jain
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Zachary N Goldberg
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Erin Briggs
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Dev R Amin
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Zachary D Urdang
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Richard A Goldman
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - David M Cognetti
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Joseph M Curry
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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6
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Plonowska-Hirschfeld KA, Gulati A, Stephens EM, Ochoa E, Xu MJ, Ha PK, Heaton CM, Yom SS, Chan JW, Algazi A, Kang H, Ryan WR. Treatment Modality Impact on Patient-Reported Quality of Life in Human Papilloma Virus-Associated Oropharyngeal Carcinoma. Laryngoscope 2024; 134:1687-1695. [PMID: 37767815 DOI: 10.1002/lary.31065] [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: 03/24/2023] [Revised: 08/11/2023] [Accepted: 09/11/2023] [Indexed: 09/29/2023]
Abstract
OBJECTIVE To prospectively compare the impact of treatment modality on patient-reported quality of life (QOL) in human papillomavirus-associated oropharynx squamous cell carcinoma (HPV + OPSCC). STUDY DESIGN Prospective cohort study. SETTING Academic medical center. METHODS One hundred one patients with American Joint Committee on Cancer (AJCC) 8th edition T1-3 N0-2 HPV + OPSCC completed the European Organization for Research and Treatment of Cancer Quality of Life Core questionnaire and Head and Neck Module pretreatment and 3-month and 1-year posttreatment. Mean score changes were compared to published minimal clinically important differences. RESULTS Patients underwent surgery alone (SA: N = 42, 42%), surgery with adjuvant radiation (S-RT: N = 10, 10%), surgery with adjuvant chemoradiation (S-CRT: N = 8, 8%), definitive radiation (RT: N = 11, 11%), or definitive chemoradiation (CRT: N = 30, 30%). SA, S-[C]RT, and [C]RT patients all reported clinically significant difficulty with sense of taste/smell persisting at 1 year. S-[C]RT and [C]RT patients reported statistically and clinically significant worse salivary dysfunction and problems with social eating at 1 year than SA. S-[C]RT patients reported statistically and clinically significant worse fatigue and head and neck pain compared to [C]RT and SA patients at 3 months, but normalized at 1 year. S-CRT compared to S-RT had statistically and clinically worse physical and role functioning and swallowing difficulties at 3 months but this difference was resolved by 1-year posttreatment. CONCLUSION HPV + OPSCC patients after SA report the lowest posttreatment QOL impact, whereas after S-CRT report the highest symptom burden. Careful selection for definitive surgery is important given the possibility of adjuvant CRT. Patients can experience persistent sense taste and smell difficulties at 1 year with all treatment modalities. LEVEL OF EVIDENCE 3 Laryngoscope, 134:1687-1695, 2024.
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Affiliation(s)
- Karolina A Plonowska-Hirschfeld
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, U.S.A
| | - Arushi Gulati
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, U.S.A
| | - Erika M Stephens
- University of California- San Francisco School of Medicine, San Francisco, California, U.S.A
| | - Edgar Ochoa
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, U.S.A
| | - Mary Jue Xu
- Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, U.S.A
| | - Patrick K Ha
- Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, U.S.A
| | - Chase M Heaton
- Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, U.S.A
| | - Sue S Yom
- Department of Radiation Oncology, University of California-San Francisco, San Francisco, California, U.S.A
| | - Jason W Chan
- Department of Radiation Oncology, University of California-San Francisco, San Francisco, California, U.S.A
| | - Alain Algazi
- Department of Hematology and Oncology, University of California-San Francisco, San Francisco, California, U.S.A
| | - Hyunseok Kang
- Department of Hematology and Oncology, University of California-San Francisco, San Francisco, California, U.S.A
| | - William R Ryan
- Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, U.S.A
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7
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Contrera KJ, Patel MR, Burtness B, Mehra R, Ferris RL. The role of surgery and deescalation for HPV-related oropharyngeal cancer. Cancer 2024. [PMID: 38497569 DOI: 10.1002/cncr.35287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Recently published and ongoing trials are helping to define the role of transoral robotic surgery for oropharyngeal cancer. Evidence to date supports the use of surgery as a valuable tool in the multidisciplinary deescalation of low-risk human papillomavirus-related oropharyngeal squamous cell carcinoma.
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Affiliation(s)
| | - Mihir R Patel
- Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Barbara Burtness
- Yale School of Medicine and Yale Cancer Center, New Haven, Connecticut, USA
| | - Ranee Mehra
- University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, Maryland, USA
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8
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Sano D, Tateya I, Hori R, Ueda T, Mori T, Maruo T, Tsukahara K, Oridate N. Transoral robotic surgery (TORS) in Japan: procedures, advantages and current status. Jpn J Clin Oncol 2024; 54:248-253. [PMID: 38061912 DOI: 10.1093/jjco/hyad168] [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: 09/29/2023] [Accepted: 11/18/2023] [Indexed: 03/12/2024] Open
Abstract
Transoral robotic surgery (TORS), introduced by Weinstein et al. in 2005, has been widely adopted as a minimally invasive procedure, particularly for the treatment of patients with early stage oropharyngeal cancer. TORS is typically performed using the da Vinci Surgical System, similar to robot-assisted surgeries for other malignancies. The main difference between TORS and these other robot-assisted surgeries is that it is performed through the natural orifice of the mouth, which limits the surgical working space, and that it progresses from the lumen of the pharynx to the deeper tissues. The advantages of TORS are mainly due to the benefits of using the da Vinci Surgical System, such as three-dimensional high-definition images, magnification, multiple forceps articulation, tremor-stabilization function and motion scale function. To date, many big data and meta-analyses have shown that TORS is superior to conventional surgeries, such as open surgery, in terms of oncological outcomes, post-operative functionality and quality of life. In Japan, TORS is expected to spread across the country, as it has been covered by health insurance since April 2022. This review highlights the procedures of TORS, its unique aspects, its unparalleled advantages as a minimally invasive surgery for treating laryngeal and pharyngeal cancers, and its current status in Japan.
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Affiliation(s)
- Daisuke Sano
- Department of Otorhinolaryngology, Head and Neck Surgery, Yokohama City University, School of Medicine, Yokohama
| | - Ichiro Tateya
- Department of Otolaryngology, Head and Neck Surgery, Fujita Health University, Toyoake
| | - Ryusuke Hori
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Occupational and Environmental Health, Kitakyushu
| | - Tsutomu Ueda
- Department of Otolaryngology, Head and Neck Surgery, Hiroshima University, Hiroshima
| | - Terushige Mori
- Department of Otolaryngology, Head and Neck Surgery, Kagawa University, Kagawa
| | - Takashi Maruo
- Department of Otolaryngology, Head and Neck Surgery, Aichi Medical University, Nagakute
| | - Kiyoaki Tsukahara
- Department of Otorhinolaryngology, Head and Neck Surgery, Tokyo Medical University, Tokyo, Japan
| | - Nobuhiko Oridate
- Department of Otorhinolaryngology, Head and Neck Surgery, Yokohama City University, School of Medicine, Yokohama
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9
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Maza G, Sharma A. Topical Hemostatic Agents and Risk of Postoperative Hemorrhage After Transoral Robotic Surgery. EAR, NOSE & THROAT JOURNAL 2024:1455613241233097. [PMID: 38380626 DOI: 10.1177/01455613241233097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024] Open
Abstract
Objective: Postoperative hemorrhage is the most common complication of transoral robotic surgery (TORS). The available research literature on topical hemostatic agents is deficient, despite their wide use. This study aims to evaluate the frequency and severity of hemorrhagic events after TORS procedures, performed with various topical hemostatic agents. Methods: This study was planned as a retrospective review to identify postoperative hemorrhage events in a database of all consecutive adult patients who required TORS from January 1, 2015, to April 1, 2020. All procedures were performed in one single institution by the same surgeon. In 2017, bovine gelatin matrix with thrombin (BgMT) was replaced by the porcine gelatin matrix with thrombin (PgMT) for all procedures. Postoperative hemorrhage was identified, along with hemostatic agents employed and other variables. Results: A cohort of 80 TORS procedures was obtained from a population of 78 individuals (60 males:18 females). BgMT was used in 28 procedures (35%), and five cases of postoperative hemorrhage were identified (17.8%), two of them were severe. PgMT was used in 52 procedures (65%) just observing one minor hemorrhagic event (1.92%). Although a significant difference was observed for total events between groups (P = .0183), there was no difference between major or severe hemorrhagic events (P = .1196). The overall rate of major and severe postoperative hemorrhage in the study population was 2.5% (n = 80). Conclusions: This is the first study to evaluate topical hemostatic agents during TORS procedures. The PgMT group had a reduced incidence of total postoperative hemorrhages, although there was no difference in the number of severe hemorrhagic events. The overall simplicity and cost-effectiveness of these agents would support their use, particularly considering the potential risk associated with airway hemorrhage.
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Affiliation(s)
- Guillermo Maza
- Department of Otolaryngology-Head and Neck Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Arun Sharma
- Department of Otolaryngology-Head and Neck Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA
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10
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Virós Porcuna D, Viña Soria C, Vila Poyatos J, Palau Viarnès M, Malagon López P, Gonzàlez Lluch C, Higueras Suñe C, Pollán Guisasola CM, Carrasco López C. Oropharyngeal free flap reconstruction: Transoral robotic surgery versus open approach. Laryngoscope Investig Otolaryngol 2023; 8:1564-1570. [PMID: 38130254 PMCID: PMC10731478 DOI: 10.1002/lio2.1176] [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: 05/25/2023] [Revised: 08/22/2023] [Accepted: 10/15/2023] [Indexed: 12/23/2023] Open
Abstract
Objective Transoral robotic surgery (TORS) has evolved since its 2009 US Food and Drug Administration approval for use in local stage T1-T2 oropharyngeal carcinoma. The ability to resect increasingly larger and more complex lesions has led to the need to introduce reconstructive techniques through this route, avoiding the classic transmandibular or pull-through approach. Few studies have compared the safety, efficacy, and advantages of TORS versus classic open approaches in oropharyngeal salvage surgery with reconstruction using microanastomosed flaps. Here we retrospectively compare our center's experience with the open approach and TORS and describe the technical variations used. Methods Between 2013 and 2021, 30 stage III-IV oropharyngeal cancer patients underwent salvage surgery with reconstruction in our center. From 2013 to 2017, 15 patients underwent surgery with the classic open approach, and from 2018 to 2021, an additional 15 patients underwent TORS. We have compared surgical outcomes, post-surgical results, and survival in the two groups. Results Patient characteristics were similar in the two groups. TORS was associated with shorter surgical time (p < .001), fewer complications (p = .01), shorter hospital stay (p < .001), and lower feeding tube requirements (p = .003). No significant differences were observed between the two groups in the free margin rate or survival. Conclusion Oropharyngeal salvage surgery with TORS with free flap reconstruction reduced associated morbidity compared to the open approach in a patient cohort with poor prognosis. Level of Evidence 4.
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Affiliation(s)
- David Virós Porcuna
- Otolaryngology Section, Head and Neck SurgeryHospital Germans Trias i PujolBadalonaSpain
| | - Constanza Viña Soria
- Otolaryngology Section, Head and Neck SurgeryHospital Germans Trias i PujolBadalonaSpain
| | - Jordi Vila Poyatos
- Plastic and Reconstructive Surgery DepartmentHospital Germans Trias i PujolBadalonaSpain
| | - Mar Palau Viarnès
- Otolaryngology Section, Head and Neck SurgeryHospital Germans Trias i PujolBadalonaSpain
| | - Paloma Malagon López
- Plastic and Reconstructive Surgery DepartmentHospital Germans Trias i PujolBadalonaSpain
| | - Carlota Gonzàlez Lluch
- Otolaryngology Section, Head and Neck SurgeryHospital Germans Trias i PujolBadalonaSpain
| | - Carmen Higueras Suñe
- Plastic and Reconstructive Surgery DepartmentHospital Germans Trias i PujolBadalonaSpain
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11
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Blom M, Zhang H, Tescher A, Dixon B, Magarey M. Staged neck dissection prior to transoral robotic surgery for oropharyngeal cancer: does it reduce post-operative complication rates? A multi-centre study of 104 patients. Eur Arch Otorhinolaryngol 2023; 280:5067-5072. [PMID: 37561189 DOI: 10.1007/s00405-023-08108-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 07/03/2023] [Indexed: 08/11/2023]
Abstract
PURPOSE Transoral robotic surgery (TORS) has become increasingly recognised as a safe and effective treatment for early oropharyngeal squamous cell carcinoma, often performed in conjunction with neck dissection (ND) and vessel ligation. It has been proposed that performing the neck dissection in a staged fashion prior to TORS results in low rates of transoral haemorrhage and pharyngocutaneous fistula, and may aid in TORS patient selection by eliminating patients who would require multi-modality treatment based on nodal pathology. This study aims to assess the effect of staged neck dissection with TORS in mitigating pharyngocutaneous fistulae and post-operative haemorrhage as well as the impact of staged ND on TORS patient selection. METHODS A retrospective cohort analysis was performed of patients undergoing staged ND with intent to proceed to TORS at two Australian hospitals between 2014 and 2022. Incidence of post-operative haemorrhage and pharyngocutaneous fistula and length of inpatient stay was identified. The number of patients who did not proceed to TORS was recorded. RESULTS One hundred and four patients were identified who underwent staged neck dissection with an intention to proceed to TORS. Six patients did not proceed to TORS following pathological assessment of the neck dissection specimen and ninety-eight patients (91 primary, 7 salvage) underwent TORS. There were six cases of secondary haemorrhage (one major, two intermediate and three minor). There were no cases of pharyngocutaneous fistula. CONCLUSION Staged neck dissection prior to TORS results in low rates of haemorrhage and pharyngocutaneous fistula and can improve TORS patient selection.
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Affiliation(s)
- Megan Blom
- Department of Head and Neck Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, 3000, Australia.
| | - Henry Zhang
- Department of Head and Neck Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, 3000, Australia
- Bart's Health NHS Trust, London, United Kingdom
| | - Anne Tescher
- Pinnacle Surgery, Epworth Richmond Hospital, Melbourne, VIC, Australia
| | - Benjamin Dixon
- Department of Head and Neck Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, 3000, Australia
- Pinnacle Surgery, Epworth Richmond Hospital, Melbourne, VIC, Australia
- Department of Surgery, University of Melbourne, Melbourne, VIC, Australia
| | - Matthew Magarey
- Department of Head and Neck Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, 3000, Australia
- Pinnacle Surgery, Epworth Richmond Hospital, Melbourne, VIC, Australia
- Department of Medical Education, University of Melbourne, Melbourne, VIC, Australia
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12
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Godse NR, Snyderman CH. Analysis of Otolaryngologic Readmissions at a High-Volume Quaternary Referral Center. Laryngoscope 2023; 133:2546-2552. [PMID: 36633352 DOI: 10.1002/lary.30563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 11/24/2022] [Accepted: 12/28/2022] [Indexed: 01/13/2023]
Abstract
OBJECTIVES To identify common reasons for readmission following otolaryngologic surgery at a high-volume center and identify possible risk factors for readmission. METHODS Retrospective chart review of readmissions identified by hospital-based electronic medical record reporting mechanism. RESULTS From January 2019 to September 2020, there were 87 readmissions following 808 index surgeries. The most common reason for readmission was for planned surgery (23%), followed by post-operative neck infection, bleeding, or pneumonia. Patients with unplanned readmissions had significantly longer index admission duration than patients who were not readmitted (median 7 days vs. median 5 days, resp.; p = 0.0056). Analysis of cases of unplanned readmission for neck infection and bleeding identified the oral cavity/pharynx as the most common site of initial surgery and that a majority of patients had a history of radiation therapy. CONCLUSION Neck infection, bleeding, and pneumonia were the most common reasons for unplanned readmission following otolaryngologic surgery, and a large portion of patients required additional procedures during readmission. Unplanned readmissions for bleeding were significantly more costly than readmissions for neck infections. Long-index hospitalizations, index surgery involving the oral cavity and pharynx, and a history of radiation therapy may be useful clinical features that could stratify the risk of readmission. LEVEL OF EVIDENCE 4, retrospective chart review Laryngoscope, 133:2546-2552, 2023.
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Affiliation(s)
- Neal R Godse
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Carl H Snyderman
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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13
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Turner MT, Chung J, Noorkbash S, Topf MC, Hardman J, Holsinger FC, Paleri V. Complications following salvage transoral robotic surgery with and without reconstruction: A systematic review of the literature. Oral Oncol 2023; 145:106467. [PMID: 37454544 DOI: 10.1016/j.oraloncology.2023.106467] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 06/03/2023] [Accepted: 06/20/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Transoral robotic surgery (TORS) has been used in the salvage setting for head and neck cancers both with and without reconstruction. The complications of salvage TORS and the effect of reconstruction on complications has not been studied. OBJECTIVE To study the complications of salvage TORS and examine the effect of reconstruction on complication rates. METHOD An electronic search of the English- language literature using PubMed, Medline, and the Cochrane database was conducted and a systematic review performed in accordance with PRISMA guidelines (CRD42020181057). RESULTS A total of 23 studies including 533 patients have been published on salvage TORS.The average patient age was 61.2 years.Prior treatment was described for 420 patients.205 (48.8%) underwent prior definitive radiotherapy (RT).160 (38.1%) underwent definitive chemoradiotherapy (CRT).Only 55 (13.1%) had prior surgery.Overall, there were 158 complications with a pooled rate of 33.6% (95%CI: 25.4-42.3%).77 were major complications requiring surgical intervention with a pooled rate of 18.9% (95% CI: 14.8-23.3%).The number of patients undergoing reconstruction among salvage cases in the literature is 59 (9.19%), with 24 local flaps and 25 microvascular free flaps.Reconstruction was associated with lower overall hemorrhage rates but had no impact on major hemorrhage rates. CONCLUSIONS The pooled incidence rates of major complications, major POH and emergency tracheostomy following salvage TORS are 18.9%, 10.5%, and 4.4%.The rate of death following salvage TORS is 3.6%. Reconstruction was associated with lower overall hemorrhage rate after salvage TORS but had no impact on major postoperative hemorrhage rates.
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Affiliation(s)
- Meghan T Turner
- Division of Head and Neck Surgery, Department of Otolaryngology-Head and Neck Surgery, West Virginia University Health Sciences Center, Morgantown, WV, USA.
| | - Jeffson Chung
- Division of Head and Neck Surgery, Department of Otolaryngology-Head and Neck Surgery, West Virginia University Health Sciences Center, Morgantown, WV, USA
| | - Seth Noorkbash
- West Virginia University School of Medicine, Morgantown, WV, USA
| | - Michael C Topf
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University, Nashville, TN, USA
| | | | - F Christopher Holsinger
- Division of Head and Neck Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University Medical Center, Palo Alto, CA, USA
| | - Vinidh Paleri
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK; Institute of Cancer Research, London, UK
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14
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Larsen MHH, Channir HI, Madsen AKØ, Rubek N, O'Leary P, Kjærgaard T, Kehlet H, von Buchwald C. Why in hospital following transoral robotic lingual tonsillectomy? Acta Otolaryngol 2023; 143:796-800. [PMID: 37897327 DOI: 10.1080/00016489.2023.2265983] [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: 06/05/2023] [Accepted: 09/22/2023] [Indexed: 10/30/2023]
Abstract
BACKGROUND The reported hospital length of stay (LOS) following transoral robotic surgery lingual tonsillectomy (TORS-L) is variable, with limited understanding of the factors requiring hospitalization and no evidence-based criteria for discharge. AIMS/OBJECTIVES This observational cohort study investigated factors hindering discharge following TORS-L in a well-defined postoperative care program. METHODS Patients were included between August 2020 and October 2022. A discharge scheme was filled out twice daily, specifying the factor(s) for hospitalization among patients undergoing TORS-L. This trial was a sub-investigation of a national multicentre randomized clinical trial (RCT) testing the efficiency of high-dose dexamethasone on postoperative pain control. Participation in the RCT demanded admission to the fourth postoperative day as dexamethasone/placebo was given intravenously in repeated dosages till day 4 postoperatively. RESULTS Eighteen patients were included in the analysis. The main factor for hospitalization was nutritional difficulties, while pain was a limiting factor for discharge only on the first postoperative 1-3 days. More than half of the patients could have potentially been discharged on postoperative day 2 when omitting the RCT treatment plan in the analysis. CONCLUSION The study estimates that the majority of patients may be discharged on postoperative day 2 following TORS-L.
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Affiliation(s)
- Mikkel Hjordt Holm Larsen
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Hani Ibrahim Channir
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Anne Kathrine Østergaard Madsen
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Niclas Rubek
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Padraig O'Leary
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Aarhus University Hospital, Copenhagen, Denmark
| | - Thomas Kjærgaard
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Aarhus University Hospital, Copenhagen, Denmark
| | - Henrik Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian von Buchwald
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
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15
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Bruening J. Robotic Surgery in the Head and Neck: Presurgical Considerations and Post-treatment Appearance. Semin Roentgenol 2023; 58:374-383. [PMID: 37507177 DOI: 10.1053/j.ro.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 05/24/2023] [Accepted: 05/30/2023] [Indexed: 07/30/2023]
Affiliation(s)
- Jennifer Bruening
- Department of Otolaryngology and Communication Sciences, Head and Neck Surgical Oncology and Reconstructive Surgery, Medical College of Wisconsin, Milwaukee, WI.
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16
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Cannavicci A, Cioccoloni E, Moretti F, Cammaroto G, Iannella G, De Vito A, Sgarzani R, Gessaroli M, Ciorba A, Bianchini C, Corazzi V, Capaccio P, Vicini C, Meccariello G. Single centre analysis of perioperative complications in trans-oral robotic surgery for oropharyngeal carcinomas. Indian J Otolaryngol Head Neck Surg 2023; 75:842-847. [PMID: 37275059 PMCID: PMC10235366 DOI: 10.1007/s12070-023-03518-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 01/19/2023] [Indexed: 02/07/2023] Open
Abstract
Trans Oral Robotic Surgery (TORS) is a modality in the management of oropharyngeal squamous cell carcinoma(OPSCC). This study was conducted to show the rates of peri-operative complications after TORS for OPSCC in our experience. Single centre retrospective analysis of consecutive OPSCC treated with TORS. The surgical complication severity was recorded according to Clavien-Dindo criteria (CDC). Eighty-seven OPSCC were operated with TORS. According to CDC, grade I, grade II and IIIb were registered in 8%, 4.6% and 11.5% of cases, respectively. The postoperative pain, registered with visual-analogue scale (VAS) score, was 8 ± 1.2 for the secondary healing wounds and 6.2 ± 1.5 for the flap reconstructions (p < 0.01). The impact on swallowing function was not significant between secondary healing and flap reconstructions(p = 0.96). Any major or life-threatening intraoperative complications have not been recorded. Only one patient had postoperative bleeding into the neck whilst 13.3% of patients had postoperative bleeding from the primary tumor. No total local or free flap failure were registered. The mean duration of tracheostomy use was 7.4 ± 2.6 days, and nasogastric tube 14.3 ± 6.9 days. Only one patient, who had also reconstruction with flap, experienced a postoperative severe dysphagia with severe aspiration, needing a permanent tracheostomy tube and percutaneous endoscopic gastrostomy feeding. TORS for OPSCC showed less morbidity, lower risk of severe complication and mortality. Thus, this treatment modality could be offered as first line treatment in selected cases.
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Affiliation(s)
- Angelo Cannavicci
- Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Azienda USL Della Romagna, Viale Forlanini 34, 47100 Forlì, Italy
| | - Eleonora Cioccoloni
- Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Azienda USL Della Romagna, Viale Forlanini 34, 47100 Forlì, Italy
| | | | - Giovanni Cammaroto
- Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Azienda USL Della Romagna, Viale Forlanini 34, 47100 Forlì, Italy
| | | | - Andrea De Vito
- Otolaryngology and Head-Neck Surgery Unit, Department of Surgery, Santa Maria Delle Croci Hospital, Azienda USL Della Romagna, Ravenna, Italy
| | - Rossella Sgarzani
- Burn Unit, Department of Surgery, Bufalini Hospital, Azienda USL Della Romagna, Cesena, Italy
| | - Manlio Gessaroli
- Maxillo-Facial Surgery Unit, Department of Surgery, Bufalini Hospital, Azienda USL Della Romagna, Cesena, Italy
| | - Andrea Ciorba
- Otolaryngology Unit, University of Ferrara, Ferrara, Italy
| | | | | | - Pasquale Capaccio
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Claudio Vicini
- Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Azienda USL Della Romagna, Viale Forlanini 34, 47100 Forlì, Italy
- Otolaryngology Unit, University of Ferrara, Ferrara, Italy
| | - Giuseppe Meccariello
- Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Azienda USL Della Romagna, Viale Forlanini 34, 47100 Forlì, Italy
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17
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Mella MH, Chabrillac E, Dupret-Bories A, Mirallie M, Vergez S. Transoral Robotic Surgery for Head and Neck Cancer: Advances and Residual Knowledge Gaps. J Clin Med 2023; 12:jcm12062303. [PMID: 36983308 PMCID: PMC10056198 DOI: 10.3390/jcm12062303] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 03/11/2023] [Accepted: 03/14/2023] [Indexed: 03/17/2023] Open
Abstract
Minimally invasive surgery is a growing field in surgical oncology. After acquiring its first Food and Drug Administration approval in 2009 for T1–T2 malignancies of the oral cavity, oropharynx, and larynx, transoral robotic surgery (TORS) has gained popularity thanks to its wristed instruments and magnified three-dimensional view, enhancing surgical comfort in remote-access areas. Its indications are expanding in the treatment of head and neck cancer, i.e., resection of tumors of the larynx, hypopharynx, or parapharyngeal space. However, this expansion must remain cautious and based on high-level evidence, in order to guarantee safety and oncological outcomes which are comparable to conventional approaches. This narrative review assesses the current role of TORS in head and neck cancer from an evidence-based perspective, and then identifies what knowledge gaps remain to be addressed.
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Affiliation(s)
- Mariam H. Mella
- Department of Otolaryngology, Head and Neck Surgery, Toulouse University Hospital—Larrey Hospital, 24 Chemin de Pouvourville, CEDEX 9, 31059 Toulouse, France
| | - Emilien Chabrillac
- Department of Surgery, University Cancer Institute of Toulouse—Oncopole, 31100 Toulouse, France
| | - Agnès Dupret-Bories
- Department of Otolaryngology, Head and Neck Surgery, Toulouse University Hospital—Larrey Hospital, 24 Chemin de Pouvourville, CEDEX 9, 31059 Toulouse, France
- Department of Surgery, University Cancer Institute of Toulouse—Oncopole, 31100 Toulouse, France
| | - Mathilde Mirallie
- Department of Otolaryngology, Head and Neck Surgery, Toulouse University Hospital—Larrey Hospital, 24 Chemin de Pouvourville, CEDEX 9, 31059 Toulouse, France
- Department of Surgery, University Cancer Institute of Toulouse—Oncopole, 31100 Toulouse, France
| | - Sébastien Vergez
- Department of Otolaryngology, Head and Neck Surgery, Toulouse University Hospital—Larrey Hospital, 24 Chemin de Pouvourville, CEDEX 9, 31059 Toulouse, France
- Department of Surgery, University Cancer Institute of Toulouse—Oncopole, 31100 Toulouse, France
- Correspondence: ; Tel.: +33-5-67-77-17-32
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Lee YK, Manek R, Hardman J, Ghedia R, Hariri A, Lacey O, Harrington K, Paleri V. Transoral robotic surgery in a modified Trendelenburg position for oropharyngeal squamous cell carcinoma in a patient with severe thoracic kyphosis. Head Neck 2023; 45:E5-E9. [PMID: 36549002 DOI: 10.1002/hed.27271] [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: 10/06/2022] [Accepted: 11/29/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Excessive flexion of the neck and upper back from severe kyphosis of the thoracic spine may limit treatment options for head and neck cancer (HNC). METHODS We describe an innovative approach to transoral robotic surgery (TORS) in a patient with severe thoracic kyphosis and oropharyngeal squamous cell carcinoma (OPSCC) who was unsuitable for definitive radiotherapy. RESULTS Detailed discussion of management pathway, perioperative considerations, and surgical challenges is presented. TORS lateral oropharyngectomy was successfully performed with the robotic system docked from the caudal end in a modified Trendelenburg position. CONCLUSIONS With appropriate surgical and anesthetic planning, TORS for patients with severe thoracic kyphosis is a feasible and suitable treatment.
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Affiliation(s)
- Ying Ki Lee
- Head and Neck Unit, Royal Marsden Hospital NHS Trust, London, UK
| | - Roshni Manek
- Department of Anaesthesia, Imperial College Healthcare NHS Trust, London, UK
| | - John Hardman
- Head and Neck Unit, Royal Marsden Hospital NHS Trust, London, UK
| | - Reshma Ghedia
- Head and Neck Unit, Royal Marsden Hospital NHS Trust, London, UK
| | - Ahmad Hariri
- Head and Neck Unit, Royal Marsden Hospital NHS Trust, London, UK
| | - Orla Lacey
- Anaesthetics, Perioperative Medicine and Pain Department, Royal Marsden Hospital NHS Trust, London, UK
| | - Kevin Harrington
- Head and Neck Unit, Royal Marsden Hospital NHS Trust, London, UK
| | - Vinidh Paleri
- Head and Neck Unit, Royal Marsden Hospital NHS Trust, London, UK
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Surgical Treatment for Advanced Oropharyngeal Cancer: A Narrative Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020304. [PMID: 36837506 PMCID: PMC9961866 DOI: 10.3390/medicina59020304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/30/2022] [Accepted: 01/30/2023] [Indexed: 02/10/2023]
Abstract
Background and Objectives: to describe current scientific knowledge regarding the treatment options in advanced oropharyngeal cancer. The standard care for advanced oropharyngeal cancer (OPSCC) has been chemoradiotherapy, although surgical approaches followed by adjuvant treatment have been proposed. The best therapy for each patient should be decided by an interdisciplinary tumour-board. Different strategies should be considered for the specific patient's treatment: surgery, chemotherapy and radiation therapy or combinations of them. The treatment choice is influenced by tumour variability and prognostic factors, but it also depends on cancer extension, extranodal extension, nervous invasion, human papilloma virus (HPV) presence, making the decisional algorithm not always clear. HPV-related OPSCC is strongly associated with a favourable overall survival (OS) and disease-free survival rate (DSS); by contrast, HPV-negative OPSCC often flags a worse prognosis. Consequently, the American Joint Committee on Cancer (AJCC) differentiates OPSCC treatment and prognosis based on HPV status. Methods: we carried out a review of current scientific literature to analyze the different indications and limitations of surgical treatment options in OPSCC stage III and IV. Conclusion: robotic surgery or open approaches with reconstructive flaps can be considered in advanced stages, resulting in the de-intensification of subsequent systemic therapy and fewer related side effects. Furthermore, in the event of the primary failure of systemic therapy or disease recurrence, the surgical approach constitutes an additional therapeutic option which lengthens patient survival functions.
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20
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Kumar S, Mettias B, Laugharne D, Mortimore S. Morbidity and Mortality Following Transoral Robotic Surgery, a Prospective Single Centre Study. Indian J Otolaryngol Head Neck Surg 2022; 74:422-426. [PMID: 36213486 PMCID: PMC9535068 DOI: 10.1007/s12070-021-03033-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 12/07/2021] [Indexed: 10/19/2022] Open
Abstract
To review complications including mortality after transoral robotic surgery (TORS) for both benign and malignant pathologies. This is a prospective observational study. Postoperative haemorrhage (8.7%) was the most common complication and 2 (1.7%) mortality were seen in this study. Airway complications and tracheostomy (1.7%), aspiration pneumonia (1.7%), swallowing problems and nasogastric feeding (7%), intra-operative pharyngocutaneous fistula (0.9%) and transient nasal regurgitation (3.5%) were also seen. The more tissue is removed the more is the risk of complication. Complications were mainly seen in the first year of starting the service of TORS and it is a reflection of the learning curve. However, secondary haemorrhage did not follow any pattern in our series. The postoperative haemorrhage was more common in patients with T2 oropharyngeal carcinoma. The mortality was seen in 2 patients (1.7%) with T2 oropharyngeal carcinoma due to postoperative haemorrhage. Higher T stage of oropharyngeal squamous cell carcinoma (OPSCC) needs bigger resection with resultant increase in morbidity.
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Affiliation(s)
- S. Kumar
- Department of Otolaryngology & Head and Neck Surgery, University Hospitals of Derby and Burton NHS Trust, Royal Derby Hospital, Uttoxeter New Road, Derby, DE22 3NE UK
| | - B. Mettias
- Department of Otolaryngology & Head and Neck Surgery, University Hospitals of Derby and Burton NHS Trust, Royal Derby Hospital, Uttoxeter New Road, Derby, DE22 3NE UK
| | - D. Laugharne
- Department of Maxillofacial & Head and Neck Surgery, University Hospitals of Derby and Burton NHS Trust, Royal Derby Hospital, Uttoxeter New Road, Derby, DE22 3NE UK
| | - S. Mortimore
- Department of Otolaryngology & Head and Neck Surgery, University Hospitals of Derby and Burton NHS Trust, Royal Derby Hospital, Uttoxeter New Road, Derby, DE22 3NE UK
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21
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Olson B, Cahill E, Imanguli M. Feasibility and safety of the da Vinci Xi surgical robot for transoral robotic surgery. J Robot Surg 2022; 17:571-576. [PMID: 35972598 DOI: 10.1007/s11701-022-01449-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 07/21/2022] [Indexed: 11/28/2022]
Abstract
The collective experience supporting the safety and efficacy of transoral robotic surgery continues to grow. The surgical robot da Vinci Xi has been used successfully off-label for head and neck surgery, including transoral robotic surgery. We evaluated operative outcomes and efficacy of the da Vinci Xi surgical robot for transoral surgery and compared our experience with the da Vinci Si and published da Vinci Xi experiences in transoral surgery. Nineteen total cases were retrospectively reviewed, six with the Si and thirteen with the Xi. Our experience with the da Vinci Xi showed similar peri- and postoperative outcomes to our Si experience the available da Vinci Xi literature. We advocate for careful patient selection while also considering the surgical team's experience with TORS. Transoral robotic surgery with the da Vinci Xi has specific advantages, and support is accumulating for its use in TORS. However, this indication remains off-label, and we do not anticipate the manufacturer will seek approval for this indication given the ongoing development and regulatory approvals of da Vinci Single Port for similar indications.
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Affiliation(s)
- Birk Olson
- Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Ellen Cahill
- Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Matin Imanguli
- Division of Head and Neck Oncologic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
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22
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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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23
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Zorzi SF, Agostini G, Chu F, Tagliabue M, Pietrobon G, Corrao G, Volpe S, Marvaso G, Colombo F, Rocca MC, Gandini S, Gaeta A, Ruju F, Alterio D, Ansarin M. Upfront transoral robotic surgery (TORS) versus intensity-modulated radiation therapy (IMRT) in HPV-positive oropharyngeal cancer: real-world data from a tertiary comprehensive cancer center. ACTA OTORHINOLARYNGOLOGICA ITALICA 2022; 42:334-347. [PMID: 35938555 PMCID: PMC9577690 DOI: 10.14639/0392-100x-n2144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 07/04/2022] [Indexed: 11/23/2022]
Abstract
Objective Methods Results Conclusions
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24
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Wadhavkar N, Jorgensen JB, Bollig CA. Association of comorbidity score with perioperative outcomes following transoral robotic surgery: National analysis. Head Neck 2022; 44:1655-1664. [PMID: 35484962 PMCID: PMC9321542 DOI: 10.1002/hed.27070] [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: 11/28/2021] [Revised: 03/29/2022] [Accepted: 04/19/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The association of comorbidities with perioperative outcomes after transoral robotic surgery (TORS) is not well-defined in the literature. METHODS Using the National Cancer Database, 4004 patients with T1-T2 oropharyngeal cancer between 2010 and 2017 were stratified based on their Charlson-Deyo Comorbidity Class (CDCC). Thirty-day unplanned readmissions, 30-day mortality, and 90-day mortality were compared using chi-square test and logistic regression. Hospital length of stay (LOS) was compared using the Kruskal-Wallis test. RESULTS LOS was greater for patients with CDCC 2 or 3 compared to CDCC 0 or 1 (p < 0.001). Increasing age and CDCC ≥3 were associated with 30-day mortality (CDCC ≥3: odds ratio [OR] 5.55, 95% confidence interval [CI] 1.59-19.45). CDCC ≥3 (OR 2.61, 95%CI 1.09-6.27) was significantly associated with 30-day readmissions. CONCLUSION This national analysis demonstrates greater rates of unplanned 30-day readmissions, longer hospitalizations, and increased 30- and 90-day mortality after TORS in patients with CDCC ≥3.
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Affiliation(s)
- Neha Wadhavkar
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Jeffrey B Jorgensen
- Division of Otolaryngology - Head and Neck Surgery and Communicative Disorders, Prisma Health Upstate, Greenville, South Carolina, USA
| | - Craig A Bollig
- Department of Otolaryngology - Head and Neck Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
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25
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The Many Faces of Head and Neck Surgery in 2022 and Looking Ahead! J Clin Med 2022; 11:jcm11113174. [PMID: 35683558 PMCID: PMC9181701 DOI: 10.3390/jcm11113174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 05/31/2022] [Indexed: 02/01/2023] Open
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26
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Jia J, Zhang J, Zeng Z, Shen H, Wang C, Chen J, Xiao S. Clinical anatomy of superior laryngeal artery via transoral approach. Laryngoscope Investig Otolaryngol 2022; 7:702-706. [PMID: 35734056 PMCID: PMC9194964 DOI: 10.1002/lio2.781] [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: 07/22/2021] [Revised: 02/27/2022] [Accepted: 03/08/2022] [Indexed: 12/05/2022] Open
Abstract
Objective Hemorrhage is the most common complication caused by transoral laryngopharyngeal surgery. It is believed that proper management of the superior laryngeal artery (SLA), the main feeding artery for the larynx and pharynx, may reduce intra- and postoperative hemorrhage incidence. The aim of this study was to illustrate the anatomy of the SLA via transoral endoscopic approach. Methods Fourteen sides of SLA from heads of seven fresh-frozen and silicone-injected cadavers were dissected. Transoral dissections were performed for the intra-laryngeal segment of SLA, and transcervical dissections were performed to confirm the anatomical measurements. Results SLA had a slightly descending course from the origin to the larynx, and there was a major branch supplying the epiglottis, named pharyngo-epiglottic artery (PEA). Parallel with the internal superior laryngeal nerve (ISLN), SLA passed through the thyrohyoid membrane and ended into the hypopharynx. The distance from SLA to the superior horn of thyroid cartilage (SHTC) was (9.11 ± 0.58)mm on the left and (9.01 ± 0.37)mm on the right; the distance from SLA to the inferior margin of the hyoid bone (IMHB) was (2.00 ± 0.11)mm on the left and (1.95 ± 0.08)mm on the right; the distance from SLA to ISLN was (5.98 ± 0.48)mm on the left and (5.78 ± 0.36)mm on the right. No significant difference was found between bilateral sides (p > 0.05). Moreover, the distance from SLA to superior margin of thyroid cartilage (SMTC) was (5.52 ± 0.24)mm on the left and (5.80 ± 0.15)mm on the right. A significant difference was also found between bilateral sides (p = 0.03), which might suggest the SLA is located further from the SMTC on the right side. Conclusion SHTC, SMTC, and IMHB could be regarded as anatomical landmarks to locate SLA when applying a transoral approach. Moreover, a complete understanding of the detailed anatomy of the superior laryngeal artery may improve the detection of hemostasis in transoral laryngeal or hypo-pharyngeal surgery.
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Affiliation(s)
- Junxiao Jia
- Department of Otolaryngology, Head and Neck SurgeryPeking University First HospitalBeijingChina
| | - Junbo Zhang
- Department of Otolaryngology, Head and Neck SurgeryPeking University First HospitalBeijingChina
| | - Zhengang Zeng
- Department of Otolaryngology, Head and Neck SurgeryPeking University First HospitalBeijingChina
| | - Hong Shen
- Department of Otolaryngology, Head and Neck SurgeryPeking University First HospitalBeijingChina
| | - Chengyuan Wang
- Department of Otolaryngology, Head and Neck SurgeryChina‐Japan Friendship HospitalBeijingChina
| | - Jian Chen
- Department of Otolaryngology, Head and Neck SurgeryChina‐Japan Friendship HospitalBeijingChina
| | - Shuifang Xiao
- Department of Otolaryngology, Head and Neck SurgeryPeking University First HospitalBeijingChina
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27
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Sauer AB, Dowling EM, Bauman MM, Moore EJ, Carlson ML, Van Abel KM. Does surgical management still play a role in the management of ectopic lingual thyroid: Institutional experience and systematic review of the literature. Am J Otolaryngol 2022; 43:103461. [PMID: 35427937 DOI: 10.1016/j.amjoto.2022.103461] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 04/04/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Management of ectopic lingual thyroid (ELT) must balance the morbidity of disease with the morbidity of treatment. We investigate clinical outcomes associated with modern treatment options and analyze the role of transoral surgery in the treatment algorithm for ELT. METHODS This was a retrospective chart review of ELT patients treated at a tertiary care center from 1/1/1979 to 12/31/2019. In addition, a systematic review of the literature from 1979 to 2021 for reports of ELT was performed. Symptoms defined as high-risk were dysphagia, dysphonia, dyspnea, neck swelling, bleeding, and obstructive sleep apnea (OSA). RESULTS 36 patients within the institutional cohort (IC) and 224 cases in the systematic review (SRC) met criteria. The most common presenting symptoms for both cohorts were dysphagia, globus sensation, and dysphonia. One third of each cohort were hypothyroid, while 3% (n = 1) and 9% (n = 21) of the IC and SRC, respectively, had clinical suspicion of malignancy at presentation. 27% (n = 10) of the IC and 55% (n = 121) of the SRC underwent surgical therapy. There was a 4% (3/72) transoral bleed rate for all patients undergoing transoral surgery. Other reported complications were minor. There were no tracheostomies, and no deaths. Among observed, medically treated, and surgically treated patients, symptoms improved during follow up for 43% or 68% in the IC and SRC, respectively. Following surgery, symptoms improved or resolved for 86% or 93% in the IC and SRC, respectively. CONCLUSIONS Asymptomatic ELTs with no concern for malignancy can be managed with observation. Patients with mild symptoms or hypothyroidism may trial thyroid suppressive therapy or RAI. RAI can be considered for patients with high-risk symptoms. For patients with symptoms resistant to conservative therapy, concern for malignancy or high-risk symptoms not conducive to RAI, surgery should be considered. Transoral approaches offer acceptable morbidity, and most patients experience resolution of symptoms following this approach.
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28
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Davies JC, Husain Z, Day TA, Graboyes EM, Eskander A. Perioperative Mortality Risk in Patients Undergoing Transoral Robotic Surgery for T1-T2 Oropharyngeal Squamous Cell Carcinoma: A National Cancer Database Study. Front Oncol 2022; 11:808465. [PMID: 35071012 PMCID: PMC8770260 DOI: 10.3389/fonc.2021.808465] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/13/2021] [Indexed: 12/14/2022] Open
Abstract
The National Cancer Database is a joint project of the Commission on Cancer of the American College of Surgeons and the American Cancer Society. The American College of Surgeons and the Commission on Cancer have not verified and are not responsible for the analytic or statistical methods used or for the conclusions drawn from these data by the investigators.
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Affiliation(s)
- Joel C Davies
- Department of Otolaryngology-Head and Neck Surgery, Sinai Health System, University of Toronto, Toronto, ON, Canada
| | - Zain Husain
- Department of Otolaryngology-Head & Neck Surgery, Sunnybrook Health Science Center, Odette Cancer Center, University of Toronto, Toronto, ON, Canada
| | - Terry A Day
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston, SC, United States
| | - Evan M Graboyes
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston, SC, United States.,Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, United States
| | - Antoine Eskander
- Department of Otolaryngology-Head & Neck Surgery, Sunnybrook Health Science Center, Odette Cancer Center, University of Toronto, Toronto, ON, Canada
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29
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Poissonnet V, Chabrillac E, Schultz P, Morinière S, Gorphe P, Baujat B, Garrel R, Lasne-Cardon A, Villeneuve A, Chambon G, Fakhry N, Aubry K, Dufour X, Malard O, Mastronicola R, Vairel B, Gallet P, Ceruse P, Jegoux F, Ton Van J, De Bonnecaze G, Vergez S. Airway management during transoral robotic surgery for head and neck cancers: a French GETTEC group survey. Eur Arch Otorhinolaryngol 2022; 279:3619-3627. [DOI: 10.1007/s00405-021-07188-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 11/15/2021] [Indexed: 11/03/2022]
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30
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Tawk B, Debus J, Abdollahi A. Evolution of a Paradigm Switch in Diagnosis and Treatment of HPV-Driven Head and Neck Cancer—Striking the Balance Between Toxicity and Cure. Front Pharmacol 2022; 12:753387. [PMID: 35126105 PMCID: PMC8810823 DOI: 10.3389/fphar.2021.753387] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 12/09/2021] [Indexed: 11/13/2022] Open
Abstract
More than a decade after the discovery of p16 immunohistochemistry (IHC) as a surrogate for human papilloma virus (HPV)-driven head and neck squamous cell carcinoma (HNSCC), p16-IHC has become a routinely evaluated biomarker to stratify oropharyngeal squamous cell carcinoma (OPSCC) into a molecularly distinct subtype with favorable clinical prognosis. Clinical trials of treatment de-escalation frequently use combinations of biomarkers (p16-IHC, HPV-RNA in situ hybridization, and amplification of HPV-DNA by PCR) to further improve molecular stratification. Implementation of these methods into clinical routine may be limited in the case of RNA by the low RNA quality of formalin-fixed paraffin-embedded tissue blocks (FFPE) or in the case of DNA by cross contamination with HPV-DNA and false PCR amplification errors. Advanced technological developments such as investigation of tumor mutational landscape (NGS), liquid-biopsies (LBx and cell-free cfDNA), and other blood-based HPV immunity surrogates (antibodies in serum) may provide novel venues to further improve diagnostic uncertainties. Moreover, the value of HPV/p16-IHC outside the oropharynx in HNSCC patients needs to be clarified. With regards to therapy, postoperative (adjuvant) or definitive (primary) radiochemotherapy constitutes cornerstones for curative treatment of HNSCC. Side effects of chemotherapy such as bone-marrow suppression could lead to radiotherapy interruption and may compromise the therapy outcome. Therefore, reduction of chemotherapy or its replacement with targeted anticancer agents holds the promise to further optimize the toxicity profile of systemic treatment. Modern radiotherapy gradually adapts the dose. Higher doses are administered to the visible tumor bulk and positive lymph nodes, while a lower dose is prescribed to locoregional volumes empirically suspected to be invaded by tumor cells. Further attempts for radiotherapy de-escalation may improve acute toxicities, for example, the rates for dysphagia and feeding tube requirement, or ameliorate late toxicities like tissue scars (fibrosis) or dry mouth. The main objective of current de-intensification trials is therefore to reduce acute and/or late treatment-associated toxicity while preserving the favorable clinical outcomes. Deep molecular characterization of HPV-driven HNSCC and radiotherapy interactions with the tumor immune microenvironment may be instructive for the development of next-generation de-escalation strategies.
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Affiliation(s)
- Bouchra Tawk
- German Cancer Consortium (DKTK) Core Center Heidelberg, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Clinical Cooperation Units (CCU) Translational Radiation Oncology and Radiation Oncology, National Center for Tumor Diseases (NCT), German Cancer Research Center (DKFZ), Heidelberg University Hospital (UKHD), Heidelberg, Germany
- Division of Molecular and Translational Radiation Oncology, Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg Faculty of Medicine (MFHD), Heidelberg University Hospital (UKHD), Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), German Cancer Research Center (DKFZ), Heidelberg University Hospital (UKHD), Heidelberg, Germany
- *Correspondence: Bouchra Tawk,
| | - Jürgen Debus
- German Cancer Consortium (DKTK) Core Center Heidelberg, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Clinical Cooperation Units (CCU) Translational Radiation Oncology and Radiation Oncology, National Center for Tumor Diseases (NCT), German Cancer Research Center (DKFZ), Heidelberg University Hospital (UKHD), Heidelberg, Germany
- Division of Molecular and Translational Radiation Oncology, Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg Faculty of Medicine (MFHD), Heidelberg University Hospital (UKHD), Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), German Cancer Research Center (DKFZ), Heidelberg University Hospital (UKHD), Heidelberg, Germany
| | - Amir Abdollahi
- German Cancer Consortium (DKTK) Core Center Heidelberg, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Clinical Cooperation Units (CCU) Translational Radiation Oncology and Radiation Oncology, National Center for Tumor Diseases (NCT), German Cancer Research Center (DKFZ), Heidelberg University Hospital (UKHD), Heidelberg, Germany
- Division of Molecular and Translational Radiation Oncology, Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg Faculty of Medicine (MFHD), Heidelberg University Hospital (UKHD), Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), German Cancer Research Center (DKFZ), Heidelberg University Hospital (UKHD), Heidelberg, Germany
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31
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Badaoui JN, Yin LX, Sauer AB, Moore EJ, Lohse CM, Price DL, Kasperbauer JL, Noel DB, Olsen KD, Van Abel KM. Transpharyngeal Approaches for Management of Oropharyngeal Squamous Cell Carcinoma: Mayo Clinic Institution Experience. Otolaryngol Head Neck Surg 2022; 167:509-516. [PMID: 35041566 DOI: 10.1177/01945998211071000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Investigate oncologic and functional outcomes associated with transhyoid and lateral pharyngotomy (transpharyngeal) approaches in the treatment of oropharyngeal squamous cell carcinoma (OPSCC). STUDY DESIGN Retrospective review. SETTING Single institution (tertiary care center). METHODS This is a retrospective case series of patients with OPSCC undergoing transpharyngeal resection from 1990 to 2017 at Mayo Clinic. Oncologic outcomes, postoperative complications, objective swallowing data, and rates of tracheostomy and percutaneous gastrostomy tube dependence were recorded. RESULTS Of 83 patients meeting inclusion criteria, 56 (68%) were human papillomavirus positive. Overall survival rates at 5 and 10 years following surgery were 85% and 80%, respectively. Cancer-specific survival rates at these same time points were 90% and 88%. Following treatment, 35 of 49 patients (71%) had a Functional Oral Intake Scale score ≥5, indicating total oral intake of multiple consistencies; 79 of 82 (96%) were without tracheostomy or laryngectomy; and 71 of 81 (88%) were on a full oral diet. CONCLUSION Transpharyngeal approaches provide adequate functional and oncologic outcomes in the majority of patients with OPSCC. These results may have important implications for patients who are not candidates for, or are unwilling to undergo, nonoperative therapy or for those without access to radiation therapy.
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Affiliation(s)
- Joseph N Badaoui
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Linda X Yin
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Adam B Sauer
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Eric J Moore
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Christine M Lohse
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel L Price
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jan L Kasperbauer
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel B Noel
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kerry D Olsen
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kathryn M Van Abel
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
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32
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Wu X, Pastel DA, Khan R, Eskey CJ, Shi Y, Sramek M, Paydarfar JA, Halter RJ. Quantifying Tumor and Vasculature Deformations during Laryngoscopy. Ann Biomed Eng 2022; 50:94-107. [PMID: 34993696 PMCID: PMC9035291 DOI: 10.1007/s10439-021-02896-8] [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] [Received: 07/26/2021] [Accepted: 11/17/2021] [Indexed: 01/09/2023]
Abstract
Retractors and scopes used in head and neck surgery to provide adequate surgical exposure also deform critical structures in the region. Surgeons typically use preoperative imaging to plan and guide their tumor resections, however the large tissue deformation resulting from placement of retractors and scopes reduces the utility of preoperative imaging as a reliable roadmap. We quantify the extent of tumor and vasculature deformation in patients with tumors of the larynx and pharynx undergoing diagnostic laryngoscopy. A mean tumor displacement of 1.02 cm was observed between the patients' pre- and intra-operative states. Mean vasculature displacement at key bifurcation points was 0.99 cm. Registration to the hyoid bone can reduce tumor displacement to 0.67 cm and improve carotid stem angle deviations but increase overall vasculature displacement. The large deformation results suggest limitations in reliance on preoperative imaging and that using specific landmarks intraoperatively or having more intraoperative information could help to compensate for these deviations and ultimately improve surgical success.
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Affiliation(s)
- Xiaotian Wu
- Gordon Center for Medical Imaging at Massachusetts General Hospital and Harvard Medical School, 13 St, CNY149-5212, Charlestown, MA 02129
| | - David A. Pastel
- Department of Radiology, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr., Lebanon, NH 03756,Geisel School of Medicine at Dartmouth College, 1 Rope Ferry Rd., Hanover, NH 03755
| | - Rihan Khan
- Department of Radiology, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr., Lebanon, NH 03756,Geisel School of Medicine at Dartmouth College, 1 Rope Ferry Rd., Hanover, NH 03755
| | - Clifford J. Eskey
- Department of Radiology, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr., Lebanon, NH 03756,Geisel School of Medicine at Dartmouth College, 1 Rope Ferry Rd., Hanover, NH 03755
| | - Yuan Shi
- Thayer School of Engineering at Dartmouth College, 14 Engineering Dr., Hanover, NH 03755
| | - Michael Sramek
- Geisel School of Medicine at Dartmouth College, 1 Rope Ferry Rd., Hanover, NH 03755
| | - Joseph A. Paydarfar
- Geisel School of Medicine at Dartmouth College, 1 Rope Ferry Rd., Hanover, NH 03755,Thayer School of Engineering at Dartmouth College, 14 Engineering Dr., Hanover, NH 03755,Section of Otolaryngology, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr., Lebanon, NH 03756
| | - Ryan J. Halter
- Geisel School of Medicine at Dartmouth College, 1 Rope Ferry Rd., Hanover, NH 03755,Thayer School of Engineering at Dartmouth College, 14 Engineering Dr., Hanover, NH 03755
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33
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Sano D, Shimizu A, Tateya I, Fujiwara K, Kishimoto Y, Maruo T, Fujimoto Y, Mori T, Kato H, Tsukahara K, Oridate N. Current Status of Transoral Surgery for Patients With Early-Stage Pharyngeal and Laryngeal Cancers in Japan. Front Oncol 2022; 11:804933. [PMID: 34970501 PMCID: PMC8713740 DOI: 10.3389/fonc.2021.804933] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 11/22/2021] [Indexed: 11/13/2022] Open
Abstract
As the laryngopharynx is closely related to swallowing, speech, and phonation, it is necessary to consider not only disease control but also a minimally invasive approach for the treatment of laryngopharyngeal cancer. Transoral surgery has been reported to be a minimally invasive method for treating these diseases. Transoral videolaryngoscopic surgery (TOVS) and endoscopic laryngo-pharyngeal surgery (ELPS) have been developed in Japan and recently emerged as treatments for patients with early stage pharyngeal and laryngeal cancers. However, securing an appropriate field of view and a narrow operating space during TOVS or ELPS are critical issues to be resolved for these surgeries. The clinical significance and safety of transoral robotic surgery (TORS) using the da Vinci Surgical System have been widely reported to provide surgeons with increased visualization and magnification, resulting in precise surgical margins and rapid functional recovery. In this context, a multi-institutional clinical study was conducted to evaluate the treatment outcomes of TORS for the treatment of laryngopharyngeal cancer in Japan, and the da Vinci Surgical System for oral robot-assisted surgery for these diseases was approved by the Pharmaceutical Affairs Agency in August 2018. This review provides an overview of the therapeutic effects of TOVS, ELPS, and TORS, with a particular focus on these therapeutic results in Japan.
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Affiliation(s)
- Daisuke Sano
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Yokohama City University, Yokohama, Japan
| | - Akira Shimizu
- Department of Otorhinolaryngology, Head and Neck Surgery, Tokyo Medical University, Tokyo, Japan
| | - Ichiro Tateya
- Department of Otolaryngology, Head and Neck Surgery, Fujita Health University, Toyoake, Japan
| | - Kazunori Fujiwara
- Department of Otolaryngology, Head and Neck Surgery, Tottori University, Yonago, Japan
| | - Yo Kishimoto
- Department of Otolaryngology-Head and Neck Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takashi Maruo
- Department of Otorhinolaryngology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasushi Fujimoto
- Department of Otolaryngology, Aichi Medical University, Nagakute, Japan
| | - Terushige Mori
- Department of Otolaryngology, Head and Neck Surgery, Kagawa University, Kagawa, Japan
| | - Hisayuki Kato
- Department of Otolaryngology, Head and Neck Surgery, Fujita Health University, Toyoake, Japan
| | - Kiyoaki Tsukahara
- Department of Otorhinolaryngology, Head and Neck Surgery, Tokyo Medical University, Tokyo, Japan
| | - Nobuhiko Oridate
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Yokohama City University, Yokohama, Japan
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Meulemans J, Vanermen M, Goeleven A, Clement P, Nuyts S, Laenen A, Delaere P, Vander Poorten V. Transoral robotic surgery (TORS) using the da Vinci Xi: prospective analysis of feasibility, safety, and outcomes. Head Neck 2021; 44:143-157. [PMID: 34747531 DOI: 10.1002/hed.26902] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/04/2021] [Accepted: 10/13/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The da Vinci Xi system is not Food and Drug Administration approved for transoral robotic surgery (TORS), resulting in limited data. METHODS This prospective study evaluates the feasibility, safety, and outcomes of Xi-TORS in an oncological setting. RESULTS Sixty-one patients with head and neck cancer were consecutively included for Xi-TORS. Adequate exposure and macroscopically complete resection were achieved in 59 patients (success rate = 96.7%). Intraoperative difficulties and complications were encountered in 47.5% and 20.3% of patients, respectively. Postoperative hemorrhage occurred in 11.9%; no treatment-related deaths were encountered. Two-year overall survival and disease-specific survival were 90.5% and 95.6%, respectively. No long-term (>1 month) tracheotomies were necessary, and only two patients remained tube-feeding dependent. The functional baseline level was regained at 12 months for the MD Anderson Dysphagia Inventory and at 24 months for the Swallowing quality-of-life questionnaire. QLQ-H&N35-assessed QOL returned to baseline 6 months postoperatively. CONCLUSIONS Xi-TORS is safe, feasible, and with high oncological and functional effectiveness.
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Affiliation(s)
- Jeroen Meulemans
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Oncology, section Head and Neck Oncology, KU Leuven, Leuven, Belgium
| | - Margaux Vanermen
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Oncology, section Head and Neck Oncology, KU Leuven, Leuven, Belgium
| | - Ann Goeleven
- Otorhinolaryngology, Head and Neck Surgery, Swallowing Clinic, University Hospitals Leuven, Leuven, Belgium
| | - Paul Clement
- Medical Oncology, University Hospitals Leuven, Leuven, Belgium.,Department of Oncology-Section Experimental Oncology, KU Leuven, Leuven, Belgium
| | - Sandra Nuyts
- Radiation Oncology, University Hospitals Leuven, Leuven, Belgium.,Department of Oncology, Section Experimental Radiotherapy, KU Leuven, Leuven, Belgium
| | - Annouschka Laenen
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics, Leuven, Belgium
| | - Pierre Delaere
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Vincent Vander Poorten
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Oncology, section Head and Neck Oncology, KU Leuven, Leuven, Belgium
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Mclean T, Fitzgerald C, Boyle JO. Therapeutic strategies: Surgery for human papillomavirus-associated oropharyngeal carcinoma. J Surg Oncol 2021; 124:935-944. [PMID: 34595753 DOI: 10.1002/jso.26695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 09/20/2021] [Indexed: 12/30/2022]
Abstract
Treatment of oropharyngeal cancer (OPC) has undergone considerable evolution since the discovery of human papillomavirus (HPV)-associated OPC. It is widely understood that HPV OPC affects a younger population and standard treatment offers improved oncologic outcomes compared with non-HPV OPC but can cause significant toxicities and long-term side effects. Surgery for treatment de-escalation is an active area of research. The purpose of this review is to explore surgery as it relates to the treatment of HPV OPC with a focus on the evolution of treatment, rationale for surgery, surgical techniques, outcomes, and the role of surgery in de-escalation of treatment.
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Affiliation(s)
- Timothy Mclean
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Conall Fitzgerald
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jay O Boyle
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Bollig CA, Wang K, Llerena P, Puram SV, Pipkorn PJ, Jackson RS, Stubbs VC. National Analysis of Oropharyngeal Salivary Gland Malignancies Treated With Transoral Robotic Surgery. Otolaryngol Head Neck Surg 2021; 166:886-893. [PMID: 34311621 DOI: 10.1177/01945998211031161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES (1) To compare perioperative outcomes and overall survival of patients with oropharyngeal salivary gland malignancies (OPSGMs) treated with transoral robotic surgery (TORS) versus other approaches. (2) To identify clinical factors associated with a robotic surgical approach. STUDY DESIGN Retrospective analysis of the National Cancer Database (NCDB). SETTING NCDB. METHODS Data obtained from the NCDB were analyzed between 2010 and 2017 for patients with T1-T4a OPSGMs without distant metastases treated surgically. Patients were stratified by surgical approach (TORS vs nonrobotic), and clinicopathologic factors were compared with the t test or chi-square test for continuous or categorical variables, respectively. Overall survival was analyzed by patient demographics and clinical factors according to Kaplan-Meier and Cox proportional hazards models. Factors associated with TORS were assessed with logistic regression. RESULTS A total of 785 patients were analyzed. A non-soft palate primary site (odds ratio, 12.9; 95% CI, 6.6-25.2) and treatment at an academic facility (odds ratio, 2.0; 95% CI, 1.2-3.5) were independently associated with TORS. There were no significant differences in the positive margin rate, 30-day mortality, or overall survival between the groups. The 30-day unplanned readmission rate was higher in patients treated with TORS versus nonrobotic resections (5.8% vs 1.7%, P = .0004). When stratified by tumor subsite, there was a significant decrease in hospital length of stay in patients with tongue base tumors undergoing TORS versus nonrobotic resections (P = .029). CONCLUSION This study suggests that TORS may be a viable treatment modality for appropriately selected patients with OPSGM.
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Affiliation(s)
- Craig A Bollig
- Department of Otolaryngology-Head and Neck Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Kevin Wang
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Pablo Llerena
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Sidharth V Puram
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA.,Department of Genetics, Washington University School of Medicine, St Louis, Missouri, USA
| | - Patrik J Pipkorn
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Ryan S Jackson
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Vanessa C Stubbs
- Department of Otolaryngology-Head and Neck Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
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Gaino F, Gorphe P, Vander Poorten V, Holsinger FC, Lira RB, Duvvuri U, Garrel R, Van Der Vorst S, Cristalli G, Ferreli F, De Virgilio A, Giannitto C, Morenghi E, Colombo G, Malvezzi L, Spriano G, Mercante G. Preoperative predictors of difficult oropharyngeal exposure for transoral robotic surgery: The Pharyngoscore. Head Neck 2021; 43:3010-3021. [PMID: 34132440 DOI: 10.1002/hed.26792] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/28/2021] [Accepted: 06/09/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Insufficient exposure may require termination of procedure in transoral robotic surgery (TORS). The aim of study was to develop a "Pharyngoscore" to quantify the risk of difficult oropharyngeal exposure (DOE) before TORS. METHODS Three-hundred six patients undergoing any surgical procedure at one Academic Hospital were prospectively enrolled. Oropharynx was exposed with Feyh-Kastenbauer retractor. Exposure was evaluated by direct and endoscopic visualization of the four oropharyngeal subsites. Preoperative clinical/anthropometric parameters were studied in good oropharyngeal exposure and DOE groups. Logistic regression was performed to explore association between clinical/anthropometric parameters and DOE. Statistically significant parameters at multivariate analysis were incorporated into a nomogram. RESULTS Sixty-five (21.2%) subjects were characterized by DOE. Variables associated with DOE at univariate analysis were male (p = 0.031), modified Mallampati Class (MMC) ≥ III (p < 0.001), smaller interincisor gap (p < 0.001), and larger neck circumference (p = 0.006). MMC, interincisor gap, and neck circumference were significant at multivariate analysis and were presented with a nomogram for creating the Pharyngoscore. CONCLUSIONS The Pharyngoscore is a promising tool for calculating DOE probability before TORS.
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Affiliation(s)
- Francesca Gaino
- Humanitas University, Department of Biomedical Sciences, Milan, Italy.,Otorhinolaryngology - Head & Neck Surgery Unit, Humanitas Research Hospital - IRCCS, Milan, Italy
| | - Philippe Gorphe
- Department of Head and Neck Oncology, Institute Gustave Roussy, University Paris-Saclay, Villejuif, France
| | - Vincent Vander Poorten
- Otorhinolaryngology-Head and Neck Surgery, Leuven Cancer Institute, University Hospitals Leuven, Leuven, Belgium.,Department of Oncology - Section Head and Neck Oncology, Leuven Cancer Institute, University Hospitals Leuven, Leuven, Belgium
| | - F Christopher Holsinger
- Division of Head and Neck Surgery, School of Medicine, Stanford University, Palo Alto, California, USA
| | - Renan B Lira
- Department of Head and Neck Surgery, AC Camargo Cancer Center, São Paulo, Brazil; Robotic Surgery Program, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Umamaheswar Duvvuri
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Renaud Garrel
- Département ORL CCF et CMF, CHU de Montpellier, Montpellier, France
| | - Sebastien Van Der Vorst
- Department of Head and Neck Surgery, Université catholique de Louvain, CHU UCL Namur-site Godinne, Yvoir, Belgium
| | - Giovanni Cristalli
- Otorhinolaryngology Unit, Ospedali Riuniti Padova Sud "Madre Teresa Di Calcutta", Padua, Italy
| | - Fabio Ferreli
- Humanitas University, Department of Biomedical Sciences, Milan, Italy.,Otorhinolaryngology - Head & Neck Surgery Unit, Humanitas Research Hospital - IRCCS, Milan, Italy
| | - Armando De Virgilio
- Humanitas University, Department of Biomedical Sciences, Milan, Italy.,Otorhinolaryngology - Head & Neck Surgery Unit, Humanitas Research Hospital - IRCCS, Milan, Italy
| | - Caterina Giannitto
- Diagnostic Radiology Unit, Humanitas Clinical and Research Center - IRCCS, Milan, Italy
| | - Emanuela Morenghi
- Biostatistics Unit, Humanitas Clinical and Research Center - IRCCS, Milan, Italy
| | - Giovanni Colombo
- Humanitas University, Department of Biomedical Sciences, Milan, Italy.,Otorhinolaryngology - Head & Neck Surgery Unit, Humanitas Research Hospital - IRCCS, Milan, Italy
| | - Luca Malvezzi
- Humanitas University, Department of Biomedical Sciences, Milan, Italy.,Otorhinolaryngology - Head & Neck Surgery Unit, Humanitas Research Hospital - IRCCS, Milan, Italy
| | - Giuseppe Spriano
- Humanitas University, Department of Biomedical Sciences, Milan, Italy.,Otorhinolaryngology - Head & Neck Surgery Unit, Humanitas Research Hospital - IRCCS, Milan, Italy
| | - Giuseppe Mercante
- Humanitas University, Department of Biomedical Sciences, Milan, Italy.,Otorhinolaryngology - Head & Neck Surgery Unit, Humanitas Research Hospital - IRCCS, Milan, Italy
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38
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Parhar HS, Weinstein GS, O'Malley BW, Shimunov D, Rassekh CH, Chalian AA, Newman JG, Basu D, Cannady SB, Rajasekaran K, Lin A, Lukens JN, Swisher-McClure S, Cohen RB, Bauml JM, Aggrawal C, Brody RM. Oncologic outcomes of transoral robotic surgery for HPV-negative oropharyngeal carcinomas. Head Neck 2021; 43:2923-2934. [PMID: 34101290 DOI: 10.1002/hed.26776] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 02/08/2021] [Accepted: 05/25/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Patients with human papillomavirus (HPV)-negative oropharyngeal squamous cell carcinoma (OPSCC) continue to experience disappointing outcomes following chemoradiotherapy (CRT) and appreciable morbidity following historical surgical approaches. We aimed to investigate the oncologic outcomes and perioperative morbidity of a transoral robotic surgery (TORS) approach to surgically resectable HPV-negative OPSCC. METHODS Retrospective analysis HPV-negative OPSCC patients who underwent TORS, neck dissection and pathology-guided adjuvant therapy (2005-2017). RESULTS Fifty-six patients (91.1% stage III/IV) were included. Three-year overall survival, locoregional control, and disease-free survival were 85.5%, 84.4%, and 73.6%, respectively (median follow-up 30.6 months, interquartile range 18.4-66.6). Eighteen (32.1%) patients underwent adjuvant radiotherapy and 20 (39.3%) underwent adjuvant CRT. Perioperative mortality occurred in one (1.8%) patient and hemorrhage occurred in two (3.6%) patients. Long-term gastrostomy and tracheostomy rates were 5.4% and 0.0%, respectively. CONCLUSION The TORS approach for resectable HPV-negative OPSCC can achieve encouraging oncologic outcomes with infrequent morbidity.
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Affiliation(s)
- Harman S Parhar
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gregory S Weinstein
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Bert W O'Malley
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Shimunov
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christopher H Rassekh
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ara A Chalian
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason G Newman
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Devraj Basu
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Steven B Cannady
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alexander Lin
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John N Lukens
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Samuel Swisher-McClure
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Roger B Cohen
- Department of Medical Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua M Bauml
- Department of Medical Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Charu Aggrawal
- Department of Medical Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert M Brody
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Gorphe P, Temam S, Moya-Plana A, Leymarie N, Kolb F, Bout-Roumazeilles A, Qassemyar Q, Benmoussa N, Honart JF. Indications and Clinical Outcomes of Transoral Robotic Surgery and Free Flap Reconstruction. Cancers (Basel) 2021; 13:cancers13112831. [PMID: 34204149 PMCID: PMC8201082 DOI: 10.3390/cancers13112831] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 06/02/2021] [Accepted: 06/03/2021] [Indexed: 12/21/2022] Open
Abstract
We reviewed the indications, peroperative feasibility, and postoperative clinical outcomes of our first 50 consecutive patients who underwent free flap reconstruction after TORS for complex pharyngeal defects at our institution. We analyzed indications according to previous radiotherapy, the size of the resection, and the transoral exposure of critical structures. We reviewed surgical data, postoperative complications, and functional outcomes comprising tracheostomy and alimentation management. Indications were upfront surgery (34%), a second primary surgery after radiotherapy (28%), or salvage surgery after chemoradiotherapy failure (38%). Localizations were the tongue base (44%), tonsillar fossa (28%), pharyngeal wall (22%), and soft palate (6%). T-classifications were T1 (6%), T2 (52%), T3 (20%), and T4 (22%). The mean length of the surgery was 574 min. Two patients were intraoperatively converted to a conventional approach at the beginning of the learning curve. In conclusion, TORS and free flap reconstruction in complex situations were associated with low rates of postoperative complications and satisfactory functional outcomes. They were, however, associated with a renewed learning curve.
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Affiliation(s)
- Philippe Gorphe
- Department of Head and Neck Oncology, Gustave Roussy Institute, University Paris-Saclay, 94800 Villejuif, France; (S.T.); (A.M.-P.); (N.B.)
- Correspondence:
| | - Stéphane Temam
- Department of Head and Neck Oncology, Gustave Roussy Institute, University Paris-Saclay, 94800 Villejuif, France; (S.T.); (A.M.-P.); (N.B.)
| | - Antoine Moya-Plana
- Department of Head and Neck Oncology, Gustave Roussy Institute, University Paris-Saclay, 94800 Villejuif, France; (S.T.); (A.M.-P.); (N.B.)
| | - Nicolas Leymarie
- Department of Plastic and Reconstructive Surgery, Gustave Roussy Institute, University Paris-Saclay, 94800 Villejuif, France; (N.L.); (A.B.-R.); (J.-F.H.)
| | - Frédéric Kolb
- Plastic and Reconstructive Surgery, UC San Diego, University of California, La Jolla, CA 92121, USA;
| | - Apolline Bout-Roumazeilles
- Department of Plastic and Reconstructive Surgery, Gustave Roussy Institute, University Paris-Saclay, 94800 Villejuif, France; (N.L.); (A.B.-R.); (J.-F.H.)
| | - Quentin Qassemyar
- Department of Plastic Surgery, Tenon Hospital, AP-HP, 75020 Paris, France;
| | - Nadia Benmoussa
- Department of Head and Neck Oncology, Gustave Roussy Institute, University Paris-Saclay, 94800 Villejuif, France; (S.T.); (A.M.-P.); (N.B.)
| | - Jean-François Honart
- Department of Plastic and Reconstructive Surgery, Gustave Roussy Institute, University Paris-Saclay, 94800 Villejuif, France; (N.L.); (A.B.-R.); (J.-F.H.)
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40
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Functional and oncological outcomes of salvage transoral robotic surgery: a comparative study. Eur Arch Otorhinolaryngol 2021; 279:457-466. [PMID: 33880636 DOI: 10.1007/s00405-021-06812-7] [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: 02/26/2021] [Accepted: 04/09/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Transoral robotic surgery (TORS) as a first-line therapy has been well-documented but evidence is missing regarding salvage therapy. The aim of this study is to compare the oncological and functional outcomes of TORS as a primary and salvage therapy. METHODS This retrospective monocentric study included 74 patients operated by a single surgeon and sorted out into two groups: primary treatment (PT) or Salvage treatment (ST) in case of previous history of radiation therapy. Patients were further stratified by tumour location: larynx and pharynx (lST vs lPT and pST vs pPT). RESULTS Forty-eight patients were included in PT group (64.9%) and 26 in ST group (35.1%). ST patients had more frequent cTis/T1 tumours (57.7% vs 29.2%, p = 0.0164) and no clinical lymph disease (3.8% vs 37.5%, p = 0.0016). Tracheostomy was more often performed in the ST group (57.7% vs 16.7%, p = 0.0003) and the lST subgroup (88.9% vs 9.1%, p < 0.0001). Gastric feeding tube placement was more frequent in the ST group (76.9% vs 33.3%, p = 0.0003), the pST subgroup (64.7% vs 15.4%, p = 0.0009) and the lST subgroup (100% vs 54.5%, p = 0.0297). We observed a trend for more postoperative complications in the ST group (69.2% vs 47.9%, p = 0.0783). The overall survival was lower in the ST group (p = 0.0004), and in the pST subgroup (p < 0.0001). The disease-free survival rate was lower in the ST group (p = 0.0001), the pST subgroup (p = 0.0002) and the lST subgroup (p = 0.0328). CONCLUSION This study confirms that survival and functional outcomes after salvage TORS are worse than in first line surgery.
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Treatment outcomes of transoral robotic and non-robotic surgeries to treat oropharyngeal, hypopharyngeal, and supraglottic squamous cell carcinoma: A multi-center retrospective observational study in Japan. Auris Nasus Larynx 2021; 48:502-510. [PMID: 33632582 DOI: 10.1016/j.anl.2021.01.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 01/25/2021] [Accepted: 02/02/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVES The aim of this multicenter retrospective cohort study was to compare efficacy and subsequent postoperative treatment between transoral robotic surgery (TORS) and any non-robotic transoral surgery in Japanese patients with early oropharyngeal squamous cell carcinoma (OPSCC), hypopharyngeal SCC (HPSCC), or supraglottic SCC (SGSCC). MATERIALS AND METHODS Clinical information and surgical outcomes were compared between patients with early-stage OPSCC, HPSCC, and SGSCC who underwent TORS (TORS cohort) and those who underwent non-robotic transoral surgery, including transoral videolaryngoscopic surgery (TOVS), endoscopic laryngopharyngeal surgery (ELPS), and transoral laser microsurgery (TLM) (non-robotic cohort). The data of the Head and Neck Cancer Registry of Japan (registry cohort) were used to validate the comparison. The main outcomes were the presence of positive margins under pathology and the requirement for postoperative therapy, including radiotherapy or chemoradiotherapy. RESULTS Sixty-eight patients in the TORS cohort, 236 patients in the non-robotic cohort, and 1,228 patients in the registry cohort were eligible for this study. Patients in the TORS cohort were more likely to have oropharyngeal tumor disease and T2/3 disease than those in the other cohorts (P<0.001 and P=0.052, respectively). The TORS cohort had significantly fewer patients with positive surgical margins than the non-robotic cohort (P=0.018), as well as fewer patients who underwent postoperative treatment, although the difference was not significant (P=0.069). In the subgroup analysis of patients with OPSCC, a total of 57 patients in the TORS cohort, 73 in the non-robotic cohort, and 171 in the registry cohort were eligible for the present study. Patients with OPSCC who underwent TORS were more likely to have lateral wall lesions than those in the other cohorts (P=0.003). The TORS cohort also had significantly fewer patients with positive surgical margins than the non-robotic cohort (P=0.026), and no patients in the TORS cohort underwent any postoperative treatment for OPSCC, although the difference was not significant (P=0.177). CONCLUSIONS Our results suggest that TORS leads to fewer positive surgical margins than non-robotic transoral surgeries. The clinical significance of TORS may be further validated through the results of all-case surveillance for patients who underwent TORS running in Japan in the future.
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The implementation of TORS for head and neck surgery in Thailand. J Robot Surg 2021; 15:955-961. [PMID: 33532951 DOI: 10.1007/s11701-021-01202-x] [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: 11/16/2020] [Accepted: 01/18/2021] [Indexed: 10/22/2022]
Abstract
Transoral robotic surgery (TORS) is a novel surgical treatment of head and neck cancers, mainly for limited tumor in oropharynx and supraglottis. Despite the major advantage of favorable postoperative functional outcomes, many obstacles exist during the implementation of TORS, especially in a country where financial resources are modest. We demonstrated our experience of initiating this sophisticated technology at the largest tertiary hospital in Thailand. A retrospective review study was conducted in patients with benign or malignant lesions during 2014-2020 at Siriraj Hospital. Different periods of operation time between initial and subsequent cases were compared to evaluate learning-curve improvement. A total of 36 patients underwent TORS, with median follow-up time of 18 months. The average time of room set-up, anesthesia, and positioning was 37 ± 14, 13 ± 7, and 15 ± 7 min, respectively. Whilst, the average robotic procedure time and total time in room were 44 ± 19 and 118 ± 31 min, consecutively. There was no significant difference in any time interval, except the set-up time between initial and subsequent cases. The worthwhile utilization of TORS could be administered cost-effectively despite the complicated and daunting implementation of TORS. Whilst, meticulous planning and sufficient training prior to the initiation of TORS can favorably shorten the learning curve of operative staffs in the TORS team.
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43
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Rao VUS, Subash A, R Bhargavi V, Sinha P, Bagadia RK, Kudpaje A, Arakeri G, Subbanna I. Selective embolization of lingual artery in transoral robotic surgery for the management of recurrent base of tongue carcinomas. Head Neck 2020; 43:1174-1183. [PMID: 33368808 DOI: 10.1002/hed.26585] [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: 05/04/2020] [Revised: 10/15/2020] [Accepted: 12/08/2020] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND The incidence of oropharyngeal carcinoma has been on the rise in recent decades. About 30% of patients who undergo definitive chemoradiation as the initial treatment present with residual/recurrent disease. In such a situation, surgical salvage either in the form of traditional open surgery or transoral robotic surgery (TORS) remains a viable treatment option. However, the extensive vascular supply of the posterior tongue and tonsillar bed increases the risk of perioperative bleeding, which is a key concern. The article describes the technique of selective pre-operative embolization to reduce the risk of perioperative bleeding and enumerate its advantages in providing a bloodless field during surgery. METHODS Prospective study of 5 patients with recurrent or residual midline BOT tumours who underwent TORS after selective lingual artery embolization at our centre. RESULTS AND CONCLUSIONS None of the patients had any major perioperative bleeding or post procedural complications. All the patients after TORS had their tongue vascularity preserved with adequate recovery of tongue functions. Selective embolization of the feeder vessels provides a favorable bloodless surgical field without affecting the vascular integrity of the remnant tongue. This added advantage helps restoring the normal oral phase of swallowing.
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Affiliation(s)
- Vishal U S Rao
- Department of Head and Neck Surgical Oncology and Robotic Surgery, HealthCare Global (HCG) Cancer Center, Bangalore, India
| | - Anand Subash
- Department of Head and Neck Surgical Oncology and Robotic Surgery, HealthCare Global (HCG) Cancer Center, Bangalore, India
| | - Vidya R Bhargavi
- Department of Interventional Radiology, HealthCare Global (HCG) Cancer Center, Bangalore, India
| | - Piyush Sinha
- Department of Head and Neck Surgical Oncology and Robotic Surgery, HealthCare Global (HCG) Cancer Center, Bangalore, India.,Department of Head and Neck Oncology, Medanta Hospital, Lucknow, India
| | - Ritvi K Bagadia
- Department of Head and Neck Surgical Oncology and Robotic Surgery, HealthCare Global (HCG) Cancer Center, Bangalore, India
| | - Akshay Kudpaje
- Department of Head and Neck Surgical Oncology and Robotic Surgery, HealthCare Global (HCG) Cancer Center, Bangalore, India
| | - Gururaj Arakeri
- Department of Head and Neck Surgical Oncology and Robotic Surgery, HealthCare Global (HCG) Cancer Center, Bangalore, India
| | - Indusekhara Subbanna
- Department of Interventional Radiology, HealthCare Global (HCG) Cancer Center, Bangalore, India
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Parhar HS, Shimunov D, Newman JG, Cannady SB, Rajasekaran K, O' Malley BW, Chalian AA, Rassekh CH, Cohen RB, Lin A, Lukens J, Swisher-McClure S, Bauml J, Aggarwal C, Weinstein GS, Brody RM. Oncologic Outcomes Following Transoral Robotic Surgery for Human Papillomavirus-Associated Oropharyngeal Carcinoma in Older Patients. JAMA Otolaryngol Head Neck Surg 2020; 146:1167-1175. [PMID: 33119091 DOI: 10.1001/jamaoto.2020.3787] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance While early epidemiologic studies ascribed increases in the incidence of human papillomavirus-associated oropharyngeal cancers to middle-aged patients, recent analyses have demonstrated an increasing median age of diagnosis. Treatment of patients older than 70 years is controversial as their inclusion in the practice-defining clinical trials has been limited and the survival benefit conferred by chemotherapy may be outweighed by treatment toxic effects. Objective To assess the oncologic outcomes of older adults with human papillomavirus-associated oropharyngeal cancer who underwent upfront transoral robotic surgery and pathologic characteristics-guided adjuvant therapy in a large cohort of patients with close follow-up. Design, Setting, and Participants A retrospective cohort analysis was conducted in a tertiary care academic medical center between January 1, 2010, and December 30, 2017. Patients aged 70 years or older at time of diagnosis with biopsy-proven and surgically resectable p16-positive oropharyngeal cancers were included. Data analysis was conducted from March 1 to June 1, 2020. Exposures Transoral robotic surgery oropharyngeal resection and neck dissection with pathologic characteristic-guided adjuvant therapy. Main Outcomes and Measures Three-year estimates of disease-specific survival, overall survival, and disease-free survival, as well as rates of adjuvant therapy (radiotherapy and chemoradiotherapy) and perioperative complications. Results Seventy-seven patients were included (median age, 73.0; interquartile range, 71.0-76.0; range, 70-89 years); of these, 58 were men (75.3%). Perioperative mortality was 1.3% and the rate of oropharyngeal hemorrhage was 2.6%. Twenty-seven patients (35.1%) underwent postoperative radiotherapy and 20 patients (26.0%) underwent postoperative chemoradiotherapy. The median length of follow-up was 39.6 (range, 0.1-96.2) months, and the 3-year estimates of survival were 92.4% (95% CI, 82.4%-96.9%) for disease-specific survival, 90.0% (95% CI, 79.4%-95.0%) for overall survival, and 84.3% (95% CI, 73.4%-91.0%) for disease-free survival. Conclusions and Relevance The findings of this cohort study suggest that transoral robotic surgery and pathologic characteristic-guided adjuvant therapy can provide beneficial survival outcomes, infrequent perioperative mortality, and, for most carefully selected older adults, obviate the need for chemotherapy.
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Affiliation(s)
- Harman S Parhar
- Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania, Philadelphia
| | - David Shimunov
- Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania, Philadelphia
| | - Jason G Newman
- Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania, Philadelphia
| | - Steven B Cannady
- Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania, Philadelphia
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania, Philadelphia
| | - Bert W O' Malley
- Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania, Philadelphia
| | - Ara A Chalian
- Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania, Philadelphia
| | - Christopher H Rassekh
- Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania, Philadelphia
| | - Roger B Cohen
- Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania, Philadelphia
| | - Alexander Lin
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia
| | - John Lukens
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia
| | | | - Joshua Bauml
- Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania, Philadelphia
| | - Charu Aggarwal
- Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania, Philadelphia
| | - Gregory S Weinstein
- Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania, Philadelphia
| | - Robert M Brody
- Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania, Philadelphia
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Abstract
This article outlines the ways that transoral robotic surgery and transoral laser microsurgery relate to treatment de-escalation in the treatment of head and neck cancer. Treatment de-escalation has particular importance in context of human papillomavirus-related oropharynx squamous cell carcinoma, which responds well to therapy but leaves many survivors with decades of treatment-related sequelae. We compare these less invasive transoral approaches with previously used open approaches to the oropharynx. We discuss the topic of treatment de-escalation in human papillomavirus-related disease and outline completed and ongoing clinical trials investigating the choice of primary treatment modality and de-escalation of adjuvant therapy.
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Affiliation(s)
- Benjamin Wahle
- Division of Head and Neck Surgery, Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8115, St Louis, MO 63110, USA
| | - Jose Zevallos
- Division of Head and Neck Surgery, Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8115, St Louis, MO 63110, USA.
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46
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Enhanced recovery protocol for transoral robotic surgery demonstrates improved analgesia and narcotic use reduction. Am J Otolaryngol 2020; 41:102649. [PMID: 32717682 DOI: 10.1016/j.amjoto.2020.102649] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 06/30/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND No study has evaluated the impact of the Enhanced Recovery After Surgery (ERAS) protocol on opioid usage among patients undergoing transoral robotic surgery (TORS). METHODS In this retrospective study, patients undergoing TORS were enrolled in an ERAS protocol and compared to control patients. Primary outcome measures included postoperative mean morphine equivalent dose (MED), Defense and Veterans Pain Rating Scale (DVPRS) pain scores, and opioid prescriptions on discharge. RESULTS The mean MED administered postoperatively was lower in the ERAS group (17.6 mg) than in the control group (65.0 mg) (p < .001). Average postoperative DVPRS scores were 2.9 in the ERAS group vs. 4.2 in the control group (p = .042). Fewer patients in the ERAS group received opioid prescriptions on discharge (31.6%) than controls (96.2%) (p < .001). CONCLUSION The TORS ERAS protocol is associated with reduced postoperative opioid usage, lower pain scores, and reduced opioid requirements on discharge.
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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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48
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Emergent procedures for oropharyngeal bleeding during the COVID-19 pandemic: Protection of medical staff. Am J Otolaryngol 2020; 41:102583. [PMID: 32516658 PMCID: PMC7832434 DOI: 10.1016/j.amjoto.2020.102583] [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: 05/08/2020] [Accepted: 05/25/2020] [Indexed: 12/02/2022]
Abstract
During an ongoing pandemic of COVID-19, controlling the oropharyngeal bleeding, such as post-tonsillectomy hemorrhage, with cauterization is considered a very vulnerable procedure for medical staff because of high probability of exposure to aerosolized secretion. The authors aimed to introduce an appropriate treatment protocol for oropharyngeal bleeding that provides first aid to patients while protecting medical staff at high-risk of infection such as COVID-19.
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