Results of transoral laser microsurgery in 102 patients with squamous cell carcinoma of the tonsil

Ten-Year Efficacy of Transoral Surgery for Squamous Carcinoma of the Lateral Oropharynx

OBJECTIVES

To document the 10-year results of transoral mandibular preservation surgery for patients with T1-2 squamous cell carcinoma (SCC) arising from the lateral oropharynx.

METHODS

This was a retrospective 30-year review using STROBE guidelines at an academic, tertiary referral center. A total of 294 patients with T1-2 SCC of the lateral oropharynx were reviewed. Only 19% of patients were never-smokers, suggesting a predominantly HPV-negative population. All patients had transoral mandibular preservation surgery. Follow-up therapy included neck dissection (76.5%), induction chemotherapy (57.8%), and postoperative radiation therapy (31.6%) Local control, survival, and functional endpoints, as well as the consequences of local recurrence, were analyzed.

RESULTS

The 10-year local disease control was 88.3%. Local recurrence was salvaged in 50% of cases, resulting in an overall 94.5% local control rate. The overall 10-year survival was 50%. Mortality was related to metachronous second primary cancer (MSPC) (29.2%), medical comorbidities (25.7%), uncontrolled local recurrence (10%), and complications following transoral resection (4.2%). In multivariate analysis, the development of an MSPC significantly increased (p < 0.005) the risk of death. Overall, 95.2% of patients achieved mandibular preservation. However, gastrostomy and tracheostomy dependence occurred in 1% and 0.3% of cases, respectively.

CONCLUSIONS

For a patient population with a significant percentage of tobacco-associated oropharyngeal cancer (OPC), transoral surgery was associated with long-term minimal postoperative complications and a high rate of local control. MSPC was the main cause of death during the first 10 postoperative years. Such long-term figures support transoral surgery as an effective first-line treatment for early-stage predominantly tobacco-related OPC.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:4564-4572, 2024.

Epidemiological and clinical description of patients with oropharyngeal cancer treated in a public oncology referral hospital in Chile

Introduction

The incidence of squamous carcinoma of the oropharynx (OPSCC) has presented an increase worldwide, a fact that occurs along with a phenomenon of epidemiological transition, whose pathogenesis is linked to human papilloma virus (HPV) in a significant part of the cases. Published evidence at the Latin American level is scarce. The present study aims to evaluate the epidemiological and clinical characteristics of patients with oropharyngeal cancer treated in a public oncology reference centre in Chile.

Methodology

A cross-sectional study was carried out. Patients with histological confirmation of OPSCC aged 18 years or older, referred to the National Cancer Institute of Chile between 2012 and 2023 were included. The association with HPV was determined by immunohistochemistry for p16.

Results

178 patients were analysed, most of them in locoregionally advanced stages involving the palatine tonsil. Seventy-seven percent were male, with a median age of 60 years. Sixty-seven percent of patients were positive for p16, with a progressive increase to 85% in the last 2 years of the study. The p16(+) patients were younger and had fewer classical risk factors. Primary treatment was radiotherapy in 94% of patients.

Conclusion

The epidemiological profile of patients with OPSCC treated in a Chilean public oncology referral centre reflects the epidemiological transition observed in developed countries. This change justifies the need to adapt health policies and conduct research that considers the characteristics of this new epidemiological profile.

Robotic vs. transoral laser surgery of malignant oropharyngeal tumors-what is best for the patient? : A contemporary review

Human papillomavirus (HPV)-associated squamous cell carcinoma of the oropharynx is a malignancy of increasing prevalence. The oncologic community is currently evaluating the safety and efficacy of de-intensifying treatment without compromising oncologic outcomes. Paramount to these treatment algorithms is primary surgery through transoral approaches. This article reviews the literature and concepts pertaining to transoral surgery and describes the two most common techniques, transoral laser microsurgery (TLM) and transoral robotic surgery (TORS).

Post-operative outcomes of different surgical approaches to oropharyngeal squamous cell cancer: a case-matched study

OBJECTIVE

To compare the post-operative outcomes of transoral laser microsurgery, lateral pharyngotomy and transmandibular surgery in oropharyngeal cancer management.

METHODS

Records of 162 patients treated with transmandibular surgery, transoral laser microsurgery or lateral pharyngotomy were reviewed. The transoral laser microsurgery cohort was matched with the lateral pharyngotomy and transmandibular surgery cohorts for tumour stage, tumour subsite and human papilloma virus status, and the intra- and post-operative outcomes were compared.

RESULTS

Duration of surgery and hospital stay were significantly longer for transmandibular surgery. Tracheostomy and nasogastric feeding tube rates were similar, but time to decannulation and to oral feeding were longer in the transmandibular surgery group. Transmandibular surgery more frequently required flap reconstruction and had a greater complication rate. Negative margins were fewer in the lateral pharyngotomy group than in the transoral laser microsurgery and transmandibular surgery groups.

CONCLUSION

In comparison with transmandibular surgery, transoral laser microsurgery and lateral pharyngotomy were associated with fewer complications and faster functional recovery. Lateral pharyngotomy had a higher rate of positive margins than transoral laser microsurgery, with a consequently greater need for adjuvant therapy. Many patients are nonetheless unsuitable for transoral surgery. All these factors should be considered when deciding on oropharyngeal cancer surgical treatment.

Acceptance and adoption of transoral robotic surgery in Germany

PURPOSE

Since its introduction over a decade ago, the use of robotic surgery (RS) in head and neck surgery has widely spread around the globe, with very differential adoption of this novel surgical technique in different parts of the world. In this study, we analyze the acceptance and adoption of robotic surgery in the head and neck in Germany.

MATERIALS AND METHODS

A cross-sectional analysis using a questionnaire evaluating the acceptance and adoption of RS was performed. Questionnaires were distributed to all chairmen /-women of Otorhinolaryngology, Head and Neck Surgery Departments in Germany.

RESULTS

A total of 107 respondents completed the questionnaire (65.2%). At university hospitals, 71.4% of the respondents indicated that a robotic system was available, and 21.4% responded that robotic surgery was performed at their institution; 22.7% and 0.04%, respectively, at non-university hospitals. The overall adoption rate was 0.8%. The most common cases performed were TORS resection in the oropharynx. Main reasons for not adopting this technique were costs, lack of interest and available co-operations.

CONCLUSION

This study provides evidence of the extent of adoption of TORS in Germany; main perceived barriers to adoption are costs with lack of cost-covering reimbursement and insufficient co-operations with other disciplines as well as hospital administration resulting in a very low adoption rate of this technique over the past decade. Results from this study may assist in decision-making processes on adopting this technique in the future.

Transoral laser microsurgery and radiotherapy for oropharyngeal squamous cell carcinoma: Equitable survival and enhanced function compared with contemporary standards of care

INTRODUCTION

We describe the 5-year oncological and functional outcomes of transoral laser microsurgery, neck dissection (TLM + ND) and adjuvant radiotherapy (PORT) used to treat patients with oropharyngeal carcinoma. The effectiveness of external carotid artery (ECA) ligation in reducing post-operative bleeding, and fibrin glue following ND in reducing wound drainage and length of hospital stay is reported.

MATERIALS AND METHODS

This retrospective case review of consecutive patients undergoing TLM between 2006 and 2017 used the Kaplan-Meier Estimator and Log-Rank Test for univariate, time-to-event analyses, and Cox-Proportionate Hazard modelling for multivariate analysis.

RESULTS

264 consecutive patients were included. Mean follow-up was 49.4 months. 219 (82.9%) patients received PORT. Five-year overall survival (OS), disease-free survival (DFS), and disease-specific survival (DSS) rates were 74.9%, 73.7%, and 86.2%, respectively. Five-year locoregional control was 89.4%. 65.5% of cases were Human papillomavirus associated (HPV+), for whom OS, DFS and DSS was 85.6%, 84.7% and 92.7%, respectively, and demonstrated significantly higher OS (hazard ratio (HR) 0.28, CI 0.16-0.49, p < 0.0001), DFS (HR 0.28, CI 0.17-0.47, p < 0.0001) and DSS (HR 0.2, CI 0.09-0.44, <0.001). Post-operative oropharyngeal bleeding occurred in 23 patients (8.7%), of which 5 were major/severe, in patients without ECA ligation. Fibrin glue significantly reduced neck drain output (p < 0.001), and length of hospital stay (p < 0.001). One-year gastrostomy dependence rate was 2.3%.

CONCLUSIONS

TLM + ND + PORT results in favourable 5-year survival and locoregional control rates, and low feeding tube dependency rates. ECA ligation and fibrin glue appear to reduce major post-operative haemorrhage, wound drainage and length of hospital stay.

Evaluation of robotic surgery for transoral resection of T1-2 squamous cell carcinoma of the tonsillar fossa

GOAL

To evaluate transoral robotic surgery (TORS) for isolated previously untreated squamous cell carcinoma (SCC) of the tonsillar fossa classified as T1-2.

METHOD

Retrospective analysis of two cohorts of isolated untreated T1-2 tonsillar fossa SCC consecutively operated on by a transoral approach, with (R=21) and without (NR=24) robotic assistance, in the period 2006-2014. Three main (survival, local control, and operative morbidity) and three secondary (pathologic data, incidence and duration of tracheotomy and nasogastric intubation, and hospital stay) endpoints were compared between groups. The significance threshold was set at P< .005.

RESULTS

Three- and five-year actuarial survival estimates were 80.2% and 74.5% respectively in group R, and 91.5% and 82.5% respectively in group NR (NS: P=.34). Three- and five-year actuarial local control estimates were 90% and 90% respectively in group R, and 95.8% and 91% respectively in group NR (NS: P=.81). There were no significant differences in morbidity, tracheotomy/nasogastric intubation time, or hospital stay. Positive resection margins (R1) were noted in 38.1% and 16.7% in groups R and NR, respectively (NS: P=.05) without significant impact on 5-year actuarial local control (P=0.78).

CONCLUSION

Robotic assistance in transoral lateral oropharyngectomy for T1-2 tonsillar fossa SCC did not significantly impact oncologic or functional outcome.

Styloglossus muscle: a critical landmark in head and neck oncology

GOAL

To document the role of the styloglossus muscle (SG) in head and neck oncology and at the time of surgical treatment and mandibular preservation surgery for squamous cell carcinoma of the lateral oropharynx (SCCLO).

METHOD

Based on a search conducted within the Pubmed, Embase, and Cochrane databases, using the key words SG muscle, parapharyngeal space and oropharynx, the authors discuss the embryology, physiology, anatomy and radiology of this muscle as well as its role in the oncologic staging surgery of SCCLO.

RESULTS

The most specific radiologic exam to evaluate the involvement of SG muscle in SCCLO is magnetic resonance imaging (MRI). According to the eigth international staging classification systems, radiologic invasion of the SG muscle, at the time of MRI, leads to reclassify as T4a many tumors considered as T1-3 at the time of clinical and/or on computerized tomography evaluation. This must lead to extreme care when comparing oncologic results from series published prior and after the MRI era. When transoral resection of the SG muscle is advocated for SCCLO, one must know that this maneuver brings numerous arterial and venous structures within the operative field. If difficulties to achieve safe margins of resection and/or to control bleeding are encountered, a simple trans cervical maneuver described herein is most useful.

CONCLUSION

The importance of the SG muscle should be emphasized as a touchstone for staging and surgeon's guide to mandibular preservation surgery of SCCLO. The various approaches allowing the control of this muscle and its vascular environment must be taught at the time of initial training.

Outcomes of transoral laser microsurgery for oropharyngeal squamous cell carcinoma in Ireland and review of the literature on transoral approaches

BACKGROUND

The optimal treatment for oropharyngeal squamous cell carcinoma (OPSCC) is controversial. There is increasing evidence that, in selected cases, minimally invasive transoral surgery can offer improved functional outcomes, with equivalent oncologic outcomes, compared to chemoradiotherapy.

AIMS

We report the outcomes of transoral laser microsurgery (TLM) for treatment of OPSCC at our institution.

METHODS

Patients with OPSCC undergoing TLM at the South Infirmary Victoria University Hospital, Cork, between 2010 and 2016, were identified from an institutional database. Human papillomavirus (HPV) status was determined by p16 immunohistochemistry. Survival outcomes were analysed using the Kaplan-Meier method. Complications following surgery and gastrostomy tube dependence were evaluated.

RESULTS

The study cohort consisted of 26 patients, with mean age of 56 years (range 29-71). Primary tumours were located in the tonsil (18), base of tongue (4) and other subsites (4). Seventeen cases were p16-positive. Complications included haemorrhage necessitating return to theatre (1) and aspiration pneumonia (1). Four patients underwent tracheostomy, all of whom were successfully decannulated. One patient underwent gastrostomy tube insertion during postoperative radiotherapy. No patient was gastrostomy dependent at latest follow-up. Twenty-two patients received adjuvant treatment, with radiation alone (21) or chemoradiotherapy (2). Mean follow-up was 27 months. Five-year locoregional control was 92% and disease-specific survival was 81%.

CONCLUSIONS

In selected patients with OPSCC, TLM offers excellent functional and survival outcomes, and as such offers an alternative approach to chemoradiotherapy as primary treatment. We compare TLM to other transoral approaches and discuss its potential use in the Irish healthcare system.

Current Role of Surgery in the Management of Oropharyngeal Cancer

The 1990s saw an increased use of chemoradiotherapy protocols, commonly referred to as organ-sparing therapy, for the treatment of oropharyngeal cancer after the Groupe d'Oncologie Radiothérapie Tête et Cou trial. Since that time, human papillomavirus-associated oropharyngeal squamous cell carcinoma has been identified as a unique disease, with improved survival regardless of treatment modality. The improved outcomes of this population has led to re-evaluation of treatment paradigms in the past decade, with a desire to spare young, human papillomavirus-positive patients the treatment-related toxicities of chemoradiotherapy and to use new minimally invasive surgical techniques to improve outcomes. Numerous retrospective and prospective studies have investigated the role of surgery in treatment of oropharyngeal carcinoma and have demonstrated equivalent oncologic outcomes and improved functional outcomes compared with chemoradiotherapy protocols. Ongoing and future clinical trials may help delineate the role of surgery in the future.

Transoral robotic surgery for the base of tongue squamous cell carcinoma: a preliminary comparison between da Vinci Xi and Si

Considering the emerging advantages related to da Vinci Xi robotic platform, the aim of this study is to compare for the first time the operative outcomes of this tool to the previous da Vinci Si during transoral robotic surgery (TORS), both performed for squamous cell carcinomas (SCC) of the base of tongue (BOT). Intra- and peri-operative outcomes of eight patients with early stage (T1-T2) of the BOT carcinoma and undergoing TORS by means of the da Vinci Xi robotic platform (Xi-TORS) are compared with the da Vinci Si group ones (Si-TORS). With respect to Si-TORS group, Xi-TORS group demonstrated a significantly shorter overall operative time, console time, and intraoperative blood loss, as well as peri-operative pain intensity and length of mean hospital stays and nasogastric tube positioning. Considering recent advantages offered by surgical robotic techniques, the da Vinci Xi Surgical System preliminary outcomes could suggest its possible future routine implementation in BOT squamous cell carcinoma procedures.

Chemoradiotherapy versus surgery followed by postoperative radiotherapy in tonsil cancer: Korean Radiation Oncology Group (KROG) study

Background

Treatment of tonsil cancer, a subset of oropahryngeal cancer, varies between surgery and radiotherapy. Well-designed studies in tonsil cancer have been rare and it is still controversial which treatment is optimal. This study aimed to assess the outcome and failure patterns in tonsil cancer patients treated with either approaches.

Methods

We retrospectively reviewed medical records of 586 patients with tonsil cancer, treated between 1998 and 2010 at 16 hospitals in Korea. Two hundred and one patients received radiotherapy and chemotherapy (CRT), while 385 patients received surgery followed by radiotherapy and/or chemotherapy (SRT). Compared with the SRT group, patients receiving CRT were older, with more advanced T stage and received higher radiotherapy dose given by intensity modulation techniques. Overall survival (OS), disease-free survival (DFS), locoregional recurrence-free survival (LRRFS), distant metastasis-free survival (DMFS), and clinicopathologic factors were analyzed.

Results

At follow-up, the 5-year OS, DFS, LRRFS and DMFS rates in the CRT group were 82, 78, 89, and 94%, respectively, and in the SRT group were 81, 73, 87, and 89%, respectively. Old age, current smoking, poor performance status, advanced T stage, nodal involvement, and induction chemotherapy were associated with poor OS. Induction chemotherapy had a negative prognostic impact on OS in both treatment groups (p = 0.001 and p = 0.033 in the CRT and SRT groups, respectively).

Conclusions

In our multicenter, retrospective study of tonsil cancer patients, the combined use of radiotherapy and chemotherapy resulted in comparable oncologic outcome to surgery followed by postoperative radiotherapy, despite higher-risk patients having been treated with the definitive radiotherapy. Induction chemotherapy approaches combined with either surgery or definitive radiotherapy were associated with unfavorable outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12885-017-3571-3) contains supplementary material, which is available to authorized users.

Should We De-escalate the Treatment for HPV-Positive Tumors?

De-escalation or de-intensification of therapy is discussed since many retrospective analyses of former trials demonstrated significantly better outcome for patients suffering from p16/HPV16-positive oropharyngeal squamous cell carcinoma of head and neck (OHNSCC). These observations are comprehensively addressed, but the reader has to keep in mind that none of the currently discussed data result from prospective controlled trials addressing the HPV-discrimination in the primary endpoint design. Identification of the true HPV16-related tumors is still challenging and in addition with different clinical reports and lack of data of prospective trials not mature for routine clinical decision making in 2016. Independent of the currently lacking evidence for HPV-dependent treatment de-escalation, there are some relevant arguments to address this question in ongoing and future trials.

Considerations in surgical versus non-surgical management of HPV positive oropharyngeal cancer

Given the marked difference in clinical presentation and treatment response based on human papilloma virus (HPV) status, HPV-associated oropharyngeal squamous cell carcinoma is now viewed as a distinct biologic and clinical entity. HPV-associated oropharyngeal squamous cell carcinoma has increased by nearly 7.5 % per year, from approximately 16 % in the early 1980′s to nearly 70 % today, and is believed will continue to increase dramatically in the coming years. Currently, a myriad of treatment options exist for these patients as many active clinical trials are underway which aim to identify the most appropriate interventions for this unique group of patients. This review aims to provide considerations between surgical and non-surgical management for HPV-associated oropharyngeal squamous cell carcinoma.

Oncologic outcomes of surgically treated early-stage oropharyngeal squamous cell carcinoma

BACKGROUND

The purpose of this study was to characterize oncologic outcomes in early (T1-T2, N0) and intermediate (T1-T2, N1) oropharyngeal squamous cell carcinoma (SCC) after surgery.

METHODS

Patients with oropharyngeal SCC treated with surgery were identified from 2 academic institutions.

RESULTS

Of 188 patients, 143 met the inclusion criteria. Eighty-six (60%) had T1 to T2 N0 and 57 (40%) had T1 to T2 N1 disease. Sixty-five patients (45%) underwent a robotic-assisted resection, whereas the remaining had transoral (n = 60; 42%), mandible-splitting (n = 11; 8%), or transhyoid approaches (n = 7; 5%). Human papillomavirus (HPV) status was known for 97 patients (68%), and 54 (55%) were HPV positive. Three-year recurrence-free survival (RFS) was 82% (95% confidence interval [CI] = 0.75-0.89). Since 2008, HPV infection was protective of recurrence (log-rank p = .0334). A single node did not increase the risk of recurrence (p = .467) or chance of a second primary (p = .175).

CONCLUSION

Complete surgical resection is effective therapy for early and intermediate oropharyngeal SCC. HPV-negative patients were at increased risk for locoregional recurrence or second primary disease. © 2016 Wiley Periodicals, Inc. Head Neck 38: First-1471, 2016.

Transoral Endoscopic Head and Neck Surgery: The Contemporary Treatment of Head and Neck Cancer

Traditional open surgical approaches are indicated for treatment of select tumor subsites of head and neck cancer, but can also result in major cosmetic and functional morbidity. Transoral surgical approaches have been used for head and neck cancer since the 1960s, with their application continuing to evolve with the changing landscape of this disease and recent innovations in surgical instrumentation. The potential to further reduce treatment morbidity with transoral surgery, while optimizing oncologic outcomes, continues to be investigated. This review examines current literature evaluating oncologic and quality-of-life outcomes achieved through transoral head and neck surgery.

Transoral ultrasonic total laryngectomy (TOUSS-TL): description of a new endoscopic approach and report of two cases

The minimally invasive total laryngectomy avoids a wide surgical field and so it has the potential benefit of reducing the local morbidity, especially on radiated patients. This approach has been previously described on a robotic basis, the transoral robotic total laryngectomy (TORS-TL). We have designed a minimally invasive approach for total laryngectomy (TL) using the transoral ultrasonic surgery technique (TOUSS). TOUSS is a transoral, endoscopic, non-robotic approach for laryngeal and pharyngeal tumors, based on the ultrasonic scalpel as a resection tool. Two patients with a laryngeal squamous cell carcinoma with indication for total laryngectomy were surgically treated: one primary TL for a subglottic carcinoma and one salvage TL with partial pharyngectomy for a local relapse after chemoradiotherapy of a glottic carcinoma. The tumors were completely removed with free surgical margin in both patients. The functional recovery was satisfactory in terms of swallowing and speech (a tracheoesophageal puncture and voice prosthesis placement were done in the same procedure). No intraoperative complications were observed. The patient with previous chemoradiotherapy had a pharyngocutaneous fistula which closed spontaneously without additional surgery. We have demonstrated that transoral endoscopic approach to the larynx and pharynx is feasible without a robotic platform. TOUSS-TL can easily spread the transoral endoscopic philosophy as well as the benefits of a minimally invasive way to remove the entire larynx. Further research will show the advantages in terms of complications and functional outcomes.

Transoral Robotic Surgery in Oropharyngeal Carcinoma

Context

The incidence of oropharyngeal squamous cell carcinoma has increased during the past decade and is related primarily to the human papillomavirus. This change in etiology, from tobacco and alcohol to human papillomavirus, has resulted in improved survival for the disease. In the United States, open resection had largely been replaced by concurrent chemotherapy and/or radiotherapy by the early 2000s. The advent of transoral surgery has led to an increase in surgery as the primary treatment for both early- and advanced-stage oropharyngeal squamous cell carcinoma because it has potential advantages over open surgery and nonsurgical modalities.

Objective

To provide an overview of transoral robotic surgery for oropharyngeal squamous cell carcinoma and contrast it with other surgical and nonsurgical modalities.

Data Sources

Articles from 2000 to 2014 were accessioned on PubMed and reviewed for utility by the primary authors.

Conclusions

Transoral surgery has become more commonly used as a minimally invasive approach to treat oropharyngeal tumors. Other strategies, including radiation, chemotherapy with radiation, and open surgery, are still important treatment approaches. The treatment options for an individual patient rely on multiple factors, including the tumor location and size, features of the tumor, and patient comorbidities. The continued study of these techniques is important to match the patient with the most appropriate treatment.

Postoperative Hemorrhage After Transoral Oropharyngectomy for Cancer of the Lateral Oropharynx

Objective:

Assessment of incidence, risk factors, management, and outcome of postoperative hemorrhage after transoral oropharyngectomy for cancer of the lateral oropharynx.

Methods:

Retrospective review of a cohort of 514 cancers of the lateral oropharynx consecutively resected.

Results:

Incidence of postoperative hemorrhage was 3.6%. In 31.5% of cases, onset was after hospital discharge. No hemorrhages occurred after the end of the fourth postoperative week. Variables associated with increased risk of hemorrhage were advanced age ( P = .004), antithrombotic treatment ( P = .012), and robotic assistance ( P = .009). When the source of hemorrhage could be identified, hemostasis, performed transorally in most cases, was highly effective; no patients in this subgroup showed recurrence. In spontaneously resolved hemorrhage under observation or when no active site of bleeding was found on exploration under general anesthesia, the recurrence rate was 18.1%. Overall, hemorrhage resulted in death in 2 patients.

Conclusion:

Exploration under general anesthesia in case of active bleeding and observation with discussion of arterial exploration of the ipsilateral external carotid system in patients in whom no source of bleeding can be identified are the keys to successful management of this potentially lethal complication.

Transoral robotic surgery for oropharyngeal cancer: long-term quality of life and functional outcomes

IMPORTANCE

Because treatment for oropharyngeal squamous cell carcinoma (OPSCC), especially in patients of older age, is associated with decreased patient quality of life (QOL) after surgery, demonstration of a less QOL-impairing treatment technique would improve patient satisfaction substantially.

OBJECTIVE

To determine swallowing, speech, and QOL outcomes following transoral robotic surgery (TORS) for OPSCC.

DESIGN, PARTICIPANTS, AND SETTING

This prospective cohort study of 81 patients with previously untreated OPSCC was conducted at a tertiary care academic comprehensive cancer center.

INTERVENTIONS

Primary surgical resection via TORS and neck dissection as indicated.

MAIN OUTCOMES AND MEASURES

Patients were asked to complete the Head and Neck Cancer Inventory (HNCI) preoperatively and at 3 weeks as well as 3, 6, and 12 months postoperatively. Swallowing ability was assessed by independence from a gastrostomy tube (G-tube). Clinicopathologic and follow-up data were also collected.

RESULTS

Mean follow-up time was 22.7 months. The HNCI response rates at 3 weeks and 3, 6, and 12 months were 79%, 60%, 63%, and 67% respectively. There were overall declines in speech, eating, aesthetic, social, and overall QOL domains in the early postoperative periods. However, at 1 year post TORS, scores for aesthetic, social, and overall QOL remained high. Radiation therapy was negatively correlated with multiple QOL domains (P < .05 for all comparisons), while age older than 55 years correlated with lower speech and aesthetic scores (P < .05 for both). Human papillomavirus status did not correlate with any QOL domain. G-tube rates at 6 and 12 months were 24% and 9%, respectively. Greater extent of TORS (>1 oropharyngeal site resected) and age older than 55 years predicted the need for a G-tube at any point after TORS (P < .05 for both).

CONCLUSIONS AND RELEVANCE

Patients with OPSCC treated with TORS maintain a high QOL at 1 year after surgery. Adjuvant treatment and older age tend to decrease QOL. Patients meeting these criteria should be counseled appropriately.

Surgery in the HPV era: the role of robotics and microsurgical techniques

Retrospective studies suggested that head and neck cancers associated with human papilloma virus (HPV) are more frequently cured than those caused by substance use. The Eastern Cooperative Oncology Group (ECOG) subsequently confirmed the observation in a prospective trial. Most HPV-initiated cancers arise in the oropharynx. Survival differences between patients with cancers caused by HPV and those caused by alcohol and tobacco use persist despite modern treatment. The impression that treatment intensification has resulted in improved survivorship may well be attributable to an increasing proportion of patients with cancers caused by HPV infection. Unsatisfactory results for cancers attributable to substance use and encouraging improvements in tumor control for patients with HPV-initiated cancers have led to dissatisfaction with the current nonsurgical management paradigm. Ongoing advances in surgical techniques permit transoral resection of oropharyngeal cancers, thus limiting exposure-related morbidity and permitting ready recovery in terms of speech and swallowing. Transoral laser microsurgery (TLM) is increasingly employed and transoral robotic surgery (TORS) has dramatically popularized surgical treatment of oropharyngeal cancers. Resection affords the opportunity to increase local control at the primary site and surgical management of neck allows risk-based stratification of postoperative radiation therapy. Case series from several institutions show encouraging results. Transoral surgical resection is safe, can be undertaken with acceptable morbidity, and provides comparable locoregional control to that achieved with chemoradiation. Prospective trials for patients with HPV-initiated cancers, as well as those referable to substance use, are underway.