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Hunter CJ, Romaniw NN, Beckham R, Farsi S, Benefield A, Solverson M, Gray EA, Nguyen E, Marshall A, King D, Sunde J, Moreno M, Vural E. Utility of video fluoroscopic swallow study in advancing oral diet post TORS for oropharyngeal malignancies. Am J Otolaryngol 2024; 45:104336. [PMID: 38704947 DOI: 10.1016/j.amjoto.2024.104336] [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: 02/15/2024] [Accepted: 04/21/2024] [Indexed: 05/07/2024]
Abstract
OBJECTIVE TORS is a minimally invasive surgical alternative to chemoradiotherapy for oropharyngeal malignancies. While early postoperative oropharyngeal dysphagia is linked to TORS, this study explores both subjective and objective swallowing outcomes. STUDY DESIGN Retrospective and prospective review of the patients who underwent TORS for oropharyngeal malignancy from 2018 to 2023. SETTING Single tertiary referral center. METHODS Postoperative transnasal feeding tubes were administered to 142 patients undergoing TORS. Data on oncological, clinical, surgical, and pathological parameters, including VFSS records, pain with swallow, and feeding tube removal timing, were collected. Clinical swallow exam (CSE) was conducted on POD-1, with a formal swallow study pursued if inconclusive. Once a safe swallow was confirmed, oral diets were initiated, and the feeding tube removed, with most patients discharged on POD-2. RESULTS At an average age of 59.3 years on the day of operation, the palatine tonsil (N = 101) was the predominant subsite. A dobhoff feeding tube was intraoperatively placed in 98 % of patients (N = 139). On POD-1, CSE was conducted in 119 patients, with 26 % (37/119) cleared for total oral diet (NOMS ≥ 4). Additionally, 30 out of 73 VFSS patients were cleared for total oral diet. A total of 54.9 % (78/142) had the feeding tube removed before discharge on POD-2, with a mean time of 6.5 ± 6.6 days. Overall, 71.1 % (101/142) achieved a total oral diet within one week after TORS. CONCLUSION Early post-TORS swallowing is vital for oropharyngeal malignancies. VFSS assesses post-operative swallowing safety, allowing most patients to resume total oral nutrition shortly after TORS.
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Affiliation(s)
- Courtney J Hunter
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, Little Rock, AR, United States
| | - Natalie N Romaniw
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, Little Rock, AR, United States
| | - Rachel Beckham
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, Little Rock, AR, United States
| | - Soroush Farsi
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, Little Rock, AR, United States
| | - Anna Benefield
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, Little Rock, AR, United States
| | - Matthew Solverson
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, Little Rock, AR, United States
| | - Emily A Gray
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, Little Rock, AR, United States
| | - Emma Nguyen
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, Little Rock, AR, United States
| | - Aubrey Marshall
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, Little Rock, AR, United States
| | - Deanne King
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, Little Rock, AR, United States
| | - Jumin Sunde
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, Little Rock, AR, United States
| | - Mauricio Moreno
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, Little Rock, AR, United States
| | - Emre Vural
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, Little Rock, AR, United States.
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Kaki PC, Lam D, Sangal NR, Rajasekaran K, Chalian AC, Brody RM, Weinstein GS, Cannady SB. Transoral robotic surgery with free flap reconstruction: Functional outcomes of 241 patients at a single institution. Head Neck 2024; 46:1601-1613. [PMID: 38600736 DOI: 10.1002/hed.27761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/18/2024] [Accepted: 03/20/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND Transoral robotic surgery (TORS) for oropharyngeal malignancy optimizes oncologic outcomes while preserving functionality. This study identifies patterns of functional recovery after TORS with free flap reconstruction (FFR). METHODS Retrospective cohort study at a tertiary care center of patients with primary oropharyngeal tumors treated with TORS with FFR between 2010 and 2022. Patients were categorized into: adjuvant chemoradiation or radiation, or no adjuvant therapy (NAT). Functional outcomes were measured by functional oral intake scale (FOIS). RESULTS 241 patients were included. FOIS declined at first postoperative appointment (median = 7.0 to 2.0, IQR = [7.0, 7.0], [2.0, 4.0]), and progressively improved to 6.0 (5.0, 6.0) after 1 year, with NAT having the highest FOIS (7.0, p < 0.05). Predictors of poor long-term FOIS included RT and hypoglossal nerve (CN XII) involvement (p < 0.05). CONCLUSIONS TORS with FFR leads to good long-term function with minimal intake restrictions. Radiation therapy and CN XII involvement increase risk of worse functional outcomes.
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Affiliation(s)
- Praneet C Kaki
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Doreen Lam
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Neel R Sangal
- Department of Otolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Karthik Rajasekaran
- Department of Otolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ara C Chalian
- Department of Otolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert M Brody
- Department of Otolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gregory S Weinstein
- Department of Otolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Steven B Cannady
- Department of Otolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Molteni G, Bassani S, Arsie AE, Zampieri E, Mannelli G, Orlandi E, Bossi P, De Virgilio A. Role of TORS as De-Escalation Strategy in HPV-Related Oropharyngeal Cancer, What We Need to Know. Healthcare (Basel) 2024; 12:1014. [PMID: 38786424 PMCID: PMC11121063 DOI: 10.3390/healthcare12101014] [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: 03/27/2024] [Revised: 05/04/2024] [Accepted: 05/10/2024] [Indexed: 05/25/2024] Open
Abstract
Human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) presents unique challenges and opportunities for treatment, particularly regarding de-escalation strategies to reduce treatment morbidity without compromising oncological outcomes. This paper examines the role of Transoral Robotic Surgery (TORS) as a de-escalation strategy in managing HPV-related OPSCC. We conducted a comprehensive literature review from January 2010 to June 2023, focusing on studies exploring TORS outcomes in patients with HPV-positive OPSCC. These findings highlight TORS's potential to reduce the need for adjuvant therapy, thereby minimizing treatment-related side effects while maintaining high rates of oncological control. TORS offers advantages such as precise tumor resection and the ability to obtain accurate pathological staging, which can guide the tailoring of adjuvant treatments. Some clinical trials provide evidence supporting the use of TORS in specific patient populations. The MC1273 trial demonstrated promising outcomes with lower doses of adjuvant radiotherapy (RT) following TORS, showing high locoregional tumor control rates and favorable survival outcomes with minimal side effects. ECOG 3311 evaluated upfront TORS followed by histopathologically directed adjuvant therapy, revealing good oncological and functional outcomes, particularly in intermediate-risk patients. The SIRS trial emphasized the benefits of upfront surgery with neck dissection followed by de-escalated RT in patients with favorable survival and excellent functional outcomes. At the same time, the PATHOS trial examined the impact of risk-adapted adjuvant treatment on functional outcomes and survival. The ongoing ADEPT trial investigates reduced-dose adjuvant RT, and the DART-HPV study aims to compare standard adjuvant chemoradiotherapy (CRT) with a reduced dose of adjuvant RT in HPV-positive OPSCC patients. These trials collectively underscore the potential of TORS in facilitating treatment de-escalation while maintaining favorable oncological and functional outcomes in selected patients with HPV-related OPSCC. The aim of this scoping review is to discuss the challenges of risk stratification, the importance of HPV status determination, and the implications of smoking on treatment outcomes. It also explores the evolving criteria for adjuvant therapy following TORS, focusing on reducing radiation dosage and volume without compromising treatment efficacy. In conclusion, TORS emerges as a viable upfront treatment option for carefully selected patients with HPV-positive OPSCC, offering a pathway toward treatment de-escalation. However, selecting the optimal candidate for TORS-based de-escalation strategies is crucial to fully leverage the benefits of treatment de-intensification.
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Affiliation(s)
- Gabriele Molteni
- Department of Otolaryngology-Head and Neck Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, 40126 Bologna, Italy
| | - Sara Bassani
- Otolaryngology-Head and Neck Surgery Department, University of Verona, 37129 Verona, Italy; (A.E.A.)
| | - Athena Eliana Arsie
- Otolaryngology-Head and Neck Surgery Department, University of Verona, 37129 Verona, Italy; (A.E.A.)
| | - Erica Zampieri
- Otolaryngology-Head and Neck Surgery Department, University of Verona, 37129 Verona, Italy; (A.E.A.)
| | - Giuditta Mannelli
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Firenze, Italy
| | - Ester Orlandi
- Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy;
- Clinical Department, National Center for Oncological Hadrontherapy (Fondazione CNAO), 27100 Pavia, Italy
| | - Paolo Bossi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, Italy;
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy
| | - Armando De Virgilio
- Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy
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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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Oberhelman N, Bruening J, Jackson RS, Van Abel KM, Sumer B, Holsinger FC, Chan JYK, Gross ND, Clayburgh DR, Andersen PE, Li RJ. Comparison of da Vinci Single Port vs Si Systems for Transoral Robotic-Assisted Surgery: A Review With Technical Insights. JAMA Otolaryngol Head Neck Surg 2024; 150:165-171. [PMID: 38127360 DOI: 10.1001/jamaoto.2023.3994] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Importance Transoral robot-assisted surgery (TORS) continues to have a major role in the treatment of oropharyngeal cancer. As new iterations of robotic technology are increasingly utilized, it is important to share learning experiences and clinical outcomes data, to optimize technical efficiency and clinical care. Observations This was a retrospective review of a large academic institution's initial clinical use of the da Vinci Single Port (SP) compared with the da Vinci Si (Si) system. A total of 205 TORS cases were reviewed: 109 in the SP group (November 22, 2018, through September 30, 2020), and 96 in the Si group (January 1, 2016, through November 12, 2018). Both groups had comparable operative times, rates of postoperative pharyngeal hemorrhage, length of hospital stay, and duration of nasogastric feeding tube use. There was no difference in pathological characteristics, rates of positive margins, or indications for or time to initiation of adjuvant therapy between the groups. The collective experience of 6 faculty members-who have trained 139 TORS surgeons for the SP system rollout-was compiled to provide a summary of learning experiences and technical notes on safe and efficient operation of the SP system. Conclusions and Relevance This Review found that the functional and oncologic outcomes were comparable between TORS cases performed with the Si and SP systems, and they had similar complication rates. Recognized advantages of the SP over the Si system include the availability of bipolar-energized instruments, a usable third surgical arm, and improved camera image quality.
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Affiliation(s)
- Nicholas Oberhelman
- Department of Surgery, Section Otolaryngology-Head and Neck Surgery, University of Chicago, Chicago, Illinois
| | - Jennifer Bruening
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee
| | - Ryan S Jackson
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Kathryn M Van Abel
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
| | - Baran Sumer
- Department of Otolaryngology-Head and Neck Surgery, the University of Texas Southwestern, Dallas
| | - F Christopher Holsinger
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California
| | - Jason Y K Chan
- Department of Otorhinolaryngology-Head and Neck Surgery, Chinese University of Hong Kong, China
| | - Neil D Gross
- Department of Head and Neck Surgery, the University of Texas MD Anderson Cancer Center, Houston
| | - Daniel R Clayburgh
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon
| | - Peter E Andersen
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon
| | - Ryan J Li
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon
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6
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Lu JS, Cao AC, Shimunov D, Sun L, Lukens JN, Lin A, Cohen RB, Basu D, Cannady SB, Rajasekaran K, Weinstein GS, Brody RM. Functional Outcomes in Patients with Human Papillomavirus-Associated Oropharyngeal Squamous Cell Cancer Treated with Trimodality Therapy. Laryngoscope 2023; 133:3013-3020. [PMID: 37129315 DOI: 10.1002/lary.30714] [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: 11/07/2022] [Revised: 03/22/2023] [Accepted: 03/30/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVES To describe swallowing and feeding-tube outcomes in patients with high-risk oropharyngeal cancer treated with trimodality therapy (TMT), including transoral robotic surgery (TORS) and adjuvant chemoradiotherapy. METHODS A chart review was conducted on patients with HPV+ OPSCC receiving TMT with TORS at an academic medical center from March 2010 to March 2021. Data collected included demographics, treatment, feeding tube placement, functional oral intake scale (FOIS) scores, and swallowing-language pathology (SLP) evaluations. RESULTS A total of 255 patients met selection criteria (mean age 61 years, 88% male). Following intraoperative nasogastric tube (NG) placement, 31% remained NG tube dependent after 3 weeks. A gastrostomy tube was placed in 19% of patients, and at 1 year after end-of-treatment (EOT), 3.5% overall remained tube-dependent. Mean FOIS scores were 6.9 (SD = 0.3) at pre-operative visit, 2.6 (1.8) at first post-operative visit, and 5.5 (1.5) after EOT. In the subset of patients with follow-up longer than 2 years (n = 118), the mean FOIS was 6.1 (SD = 1.3) at most recent visit. Clinical signs of aspiration/penetration were suspected on SLP evaluation in 18% of patients. These patients were subsequently evaluated with fiberoptic endoscopic evaluation of swallowing (FEES) and/or barium swallow study, which confirmed signs of aspiration in 2.7% of patients overall. Delayed NG tube removal after 3 weeks was predictive of (1) gastrostomy tube requirement and (2) clinical signs of aspiration on an SLP visit after EOT. CONCLUSIONS Favorable functional and feeding-tube outcomes are demonstrated in patients with HPV-associated OPSCC undergoing TMT. In this single-institution study, we found low rates of long-term feeding tube dependence and high median FOIS following treatment. Review of routine SLP visits provides a detailed and easily accessible means for assessing swallowing function in this cohort. LEVEL OF EVIDENCE 4 Laryngoscope, 133:3013-3020, 2023.
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Affiliation(s)
- Joseph S Lu
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Austin C Cao
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Shimunov
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lova Sun
- Department of Medicine - Medical Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John N Lukens
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alexander Lin
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Roger B Cohen
- Department of Medicine - Medical Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Devraj Basu
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Steven B Cannady
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gregory S Weinstein
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert M Brody
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Douse DM, Yin LX, Olawuni FO, Glasgow AE, Habermann EB, Price DL, Tasche KK, Moore EJ, Van Abel KM. Racial disparities in surgical treatment of oropharyngeal cancer: A Surveillance, Epidemiology, and End Results review. Head Neck 2023; 45:2313-2322. [PMID: 37461323 DOI: 10.1002/hed.27467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 06/03/2023] [Accepted: 07/09/2023] [Indexed: 08/11/2023] Open
Abstract
OBJECTIVES Oropharyngeal squamous cell carcinoma (OPSCC) has been rising. This manuscript looks to explore racial disparities in the surgical management of OPSCC. METHODS A cancer database was queried for patients with OPSCC diagnosed from 2004 to 2017. Univariate and multivariable logistic regressions were used to evaluate associations between patient race/ethnicity, surgical treatment, and reasons for lack of surgery. RESULTS 37 306 (74.3%) patients did not undergo surgery, while 12 901 (25.7%) patients did. Non-Hispanic black (NHB) patients were less likely to undergo surgery than other races (17.9% vs. 26.5%; p < 0.0001). In clinical discussions, the Asian, Native American, Hawaiian, Pacific Islander (ANAHPI), and unknown race group was more likely to directly refuse surgery when recommended (2.5% vs. 1.5%; p = 0.015). CONCLUSION Racial differences exist in treatment for OPSCC. NHB patients are less likely to actually undergo surgical management for OPSCC, while other patients are more likely to directly "refuse" surgery outright when offered.
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Affiliation(s)
- Dontre' M Douse
- Department of Otorhinolaryngology - Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Linda X Yin
- Department of Otorhinolaryngology - Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Felicia O Olawuni
- Department of Otorhinolaryngology - Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Amy E Glasgow
- Division of Health Care Policy and Research and the Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Elizabeth B Habermann
- Division of Health Care Policy and Research and the Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Daniel L Price
- Department of Otorhinolaryngology - Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kendall K Tasche
- Department of Otorhinolaryngology - Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Eric J Moore
- Department of Otorhinolaryngology - Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kathryn M Van Abel
- Department of Otorhinolaryngology - Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
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De Virgilio A, Costantino A, Rizzo D, Crescio C, Gallus R, Spriano G, Mercante G, Festa BM, Accorona R, Pignataro L, Capaccio P, Bussu F. Do We Have Enough Evidence to Specifically Recommend Transoral Robotic Surgery in HPV-Driven Oropharyngeal Cancer? A Systematic Review. Pathogens 2023; 12:pathogens12020160. [PMID: 36839432 PMCID: PMC9959572 DOI: 10.3390/pathogens12020160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/13/2023] [Accepted: 01/17/2023] [Indexed: 01/20/2023] Open
Abstract
Introduction: International guidelines include transoral robotic surgery (TORS) as an option for selected oropharyngeal squamous cell carcinomas (OPSCCs). In the perspective of treatment de-intensification, many surgeons have started recommending and performing TORS preferentially in p16- positive OPSCC in order to reduce the long-term morbidity related to chemoradiotherapy. The aim of the present review is to analyze the current evidence supporting the above-cited strategy. Materials and Methods: The study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results: Twenty-two studies were included in this review, with a total of 3992 patients treated with primary TORS. The majority of patients were classified as HPV+ (n = 3655, 91.6%), and 8.2% (n = 327) as HPV-. The HPV status was unknown in only 10 (0.3%) patients. In particular, only five of the included studies compared survival outcomes of HPV-positive patients with HPV-negative ones treated with primary TORS, and only two of these found a significant improvement in survival in the HPV-driven cohort. Discussion: The current literature does not clarify whether HPV+ OPSCCs treated with TORS, alone or with adjuvant treatments, are associated with a better oncologic and/or functional outcome compared to those treated with radio- or chemoradiotherapy. However, TORS alone obtained good oncological outcomes in a high percentage of cases in the reviewed series. Recent data, on the other hand, suggest that TORS could represent a promising strategy for intensifying treatments in HPV- OPSCC.
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Affiliation(s)
- Armando De Virgilio
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, Pieve Emanuele, 20089 Milan, Italy
- Otorhinolaryngology Unit, Humanitas Clinical and Research Center, IRCCS, Rozzano, 20089 Milan, Italy
| | - Andrea Costantino
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, Pieve Emanuele, 20089 Milan, Italy
- Otorhinolaryngology Unit, Humanitas Clinical and Research Center, IRCCS, Rozzano, 20089 Milan, Italy
| | - Davide Rizzo
- Division of Otolaryngology, Azienda Ospedaliero Universitaria, 07100 Sassari, Italy
| | - Claudia Crescio
- Division of Otolaryngology, Azienda Ospedaliero Universitaria, 07100 Sassari, Italy
| | - Roberto Gallus
- Mater Hospital Olbia, Strada Statale 125 Orientale Sarda, 07026 Olbia, Italy
| | - Giuseppe Spriano
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, Pieve Emanuele, 20089 Milan, Italy
- Otorhinolaryngology Unit, Humanitas Clinical and Research Center, IRCCS, Rozzano, 20089 Milan, Italy
| | - Giuseppe Mercante
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, Pieve Emanuele, 20089 Milan, Italy
- Otorhinolaryngology Unit, Humanitas Clinical and Research Center, IRCCS, Rozzano, 20089 Milan, Italy
| | - Bianca Maria Festa
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, Pieve Emanuele, 20089 Milan, Italy
- Otorhinolaryngology Unit, Humanitas Clinical and Research Center, IRCCS, Rozzano, 20089 Milan, Italy
- Correspondence: ; Tel.: +39-02-8224-7550; Fax: +39-02-8224-7550
| | - Remo Accorona
- Unit of Otorhinolaryngology–Head and Neck Surgery, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milano, Italy
| | - Lorenzo Pignataro
- Unit of Otorhinolaryngology–Head and Neck Surgery, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milano, Italy
| | - Pasquale Capaccio
- Unit of Otorhinolaryngology–Head and Neck Surgery, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milano, Italy
| | - Francesco Bussu
- Division of Otolaryngology, Azienda Ospedaliero Universitaria, 07100 Sassari, Italy
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Viale San Pietro, 07100 Sassari, Italy
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9
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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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10
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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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11
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Charters E, Bogaardt H, Freeman-Sanderson A, Ballard K, Davies S, Oates J, Clark J. Swallowing and communication outcomes following primary transoral robotic surgery for advanced or recurrent oropharyngeal cancer: Case series. INTERNATIONAL JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2022; 24:407-416. [PMID: 34547959 DOI: 10.1080/17549507.2021.1977388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Purpose: Transoral robotic surgery (TORS) is most commonly undertaken as a minimally invasive approach for early staged oropharyngeal cancers (OPC), with good expectations for a functional recovery. A small number of patients, however, require TORS for recurrent or advanced OPC tumours. Their prospects for longer term recovery of communication and swallowing are both unreported and hypothesised to be poorer than the majority of TORS cases. This case-series describes the recovery of swallowing and communication function post-TORS for this unique group of patients.Method: Consecutive recruitment was carried out prospectively at a quaternity oncology referral centre. Participants were aged 18 years and older, with reconstruction involving a free-flap and tracheostomy. Patients were assessed using Fibreoptic Endoscopic Evaluation of Swallowing, and clinician and patient-reported outcomes 12-months post-TORS. Their pre-operative baseline and three-month post-TORS FOIS scores were collated retrospectively.Result: Six participants were recruited over an 18-month period of which three patients underwent TORS for recurrent, and three for advanced OPC. Those with recurrent-OPC did not return to their baseline diet and demonstrated post-swallow silent aspiration of pharyngeal residue. Three of the six were rehabilitated back to their baseline intelligibility (100%).Conclusion: TORS in the recurrent OPC setting appears congruent with high rates of silent aspiration and prolonged reliance on a feeding tube due to oropharyngeal dysphagia, as well as compromised intelligibility. This is the first study that evaluates this instrumentally and provides clinically relevant evidence to inform practice.
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Affiliation(s)
- Emma Charters
- Department of Speech and Language Pathology, Chris O'Brien Lifehouse, Sydney, Australia
| | - Hans Bogaardt
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | | | - Kirrie Ballard
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Sarah Davies
- Department of Head and Neck Surgery, Chris O'Brien Lifehouse, Sydney Head and Neck Cancer Institute, Sydney, Australia
| | - Justine Oates
- Department of Head and Neck Surgery, Chris O'Brien Lifehouse, Sydney Head and Neck Cancer Institute, Sydney, Australia
| | - Jonathan Clark
- Department of Head and Neck Surgery, Chris O'Brien Lifehouse, Sydney Head and Neck Cancer Institute, Sydney, Australia
- Faculty of Medicine and Health, Sydney Medical School, The University of Sydney, Sydney, Australia and
- Royal Prince Alfred Institute of Academic Surgery, Sydney Local Health District, Sydney, Australia
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12
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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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13
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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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14
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Philips R, Topf MC, Vimawala S, Luginbuhl A, Curry JM, Cognetti DM. Risk factors for gastrostomy tube dependence in transoral robotic surgery patients. Am J Otolaryngol 2022; 43:103175. [PMID: 34418824 DOI: 10.1016/j.amjoto.2021.103175] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 06/26/2021] [Accepted: 08/04/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine the rate of gastrostomy tube dependence after transoral robotic surgery (TORS), and to determine which patient or surgical factors increase the likelihood of gastrostomy tube dependence. METHODS Retrospective chart review of all patients who underwent TORS for oropharyngeal squamous cell carcinoma (OPSCC) at a single institution from January 2011 through July 2016. Patients who underwent TORS for recurrent OPSCC were excluded. Primary outcome was gastrostomy tube (g-tube) dependence. Univariable and multivariable logistic regression were performed to identify risk factors for g-tube dependence at 3-months and 1-year. RESULTS A total of 231 patients underwent TORS during the study period. At 3-month follow-up, 58/226 patients (25.7%) required g-tube. At 1-year and 2-year follow-up, 8/203 (3.9%) and 5/176 (2.8%), remained dependent on g-tube, respectively. Advanced T stage (T3) (OR = 6.07; 95% CI, 1.28-28.9) and discharge from the hospital with enteral access (OR = 7.50; 95% CI, 1.37-41.1) were independently associated with increased risk of postoperative gastrostomy tube dependence at 1 year on multivariable analysis. CONCLUSIONS Long-term gastrostomy tube dependence following TORS is rare, particularly in patients that receive surgery alone. Patients with advanced T stage tumors have poorer functional outcomes. Early functional outcomes, as early as discharge from the hospital, are a strong predictor for long-term functional outcomes.
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Affiliation(s)
- Ramez Philips
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, 925 Chestnut Street, 6th Floor, Philadelphia, PA 19107, USA.
| | - Michael C Topf
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, 1215 21st Ave. S. Suite 7209, Nashville, TN 37232, USA
| | - Swar Vimawala
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, 925 Chestnut Street, 6th Floor, Philadelphia, PA 19107, USA
| | - Adam Luginbuhl
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, 925 Chestnut Street, 6th Floor, Philadelphia, PA 19107, USA
| | - Joseph M Curry
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, 925 Chestnut Street, 6th Floor, Philadelphia, PA 19107, USA
| | - David M Cognetti
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, 925 Chestnut Street, 6th Floor, Philadelphia, PA 19107, USA
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15
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Rao KN, Gangiti KK. Transoral Robotic Surgery. Indian J Surg Oncol 2021; 12:847-853. [PMID: 35110913 PMCID: PMC8764010 DOI: 10.1007/s13193-021-01443-0] [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: 12/19/2020] [Accepted: 09/01/2021] [Indexed: 11/21/2022] Open
Abstract
Transoral robotic surgery (TORS) became a valuable new head and neck surgery approach from the past decade since its approval. TORS was initially conceived for oropharyngeal squamous cell carcinoma (OPSCC); now, the indications are gradually extrapolated into other subsites. There have been numerous studies comparing the outcomes following surgical and non-surgical treatment, especially for oropharyngeal cancers. TORS for laryngeal cancers is in its infancy, and only a few reports are describing it. Many report suggestive of better functional outcomes following TORS, but level 1 evidence is still lacking. With the further development of novel, flexible, miniaturized robots, it is highly likely to expand TORS indications further. This article provides an overview of TORS in head and neck cancers.
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Affiliation(s)
- Karthik N. Rao
- Department of Head Neck Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Kranthi Kumar Gangiti
- Department of Head Neck Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
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16
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Ma DJ, Van Abel KM. Treatment De-intensification for HPV-associated Oropharyngeal Cancer: A Definitive Surgery Paradigm. Semin Radiat Oncol 2021; 31:332-338. [PMID: 34455988 DOI: 10.1016/j.semradonc.2021.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Human papillomavirus-associated oropharyngeal squamous cell carcinoma (HPV+OPSCC) constitutes the majority of head and neck diagnoses within the United States. Patients with HPV+OPSCC have biologically and demographically distinct disease, leading to high cure rates after standard treatments. This long survivorship period coupled with the toxicity of standard treatments makes de-intensification strategies an urgent research question. Surgery has generally been avoided for HPV+OPSCC as historical surgical techniques were invasive and morbid. With the advent of minimally invasive transoral techniques, definitive surgical options are becoming more popular. Minimally invasive surgery offers unique opportunities in a de-intensification paradigm, including more detailed patient selection, radiation volume reduction, and radiation dose de-intensification. Nevertheless, careful patient selection must be exercised as surgical defects may lead to quality of life decrements beyond what is gained through de-intensification. Ongoing phase III efforts will help clarify the patient cohorts best suited for surgically oriented de-intensification.
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Affiliation(s)
- Daniel J Ma
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN.
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17
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Miles BA, Posner MR, Gupta V, Teng MS, Bakst RL, Yao M, Misiukiewicz KJ, Chai RL, Sharma S, Westra WH, Kim‐Schulze S, Dayal B, Sobotka S, Sikora AG, Som PM, Genden EM. De-Escalated Adjuvant Therapy After Transoral Robotic Surgery for Human Papillomavirus-Related Oropharyngeal Carcinoma: The Sinai Robotic Surgery (SIRS) Trial. Oncologist 2021; 26:504-513. [PMID: 33675133 PMCID: PMC8176976 DOI: 10.1002/onco.13742] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 02/09/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Treatment of human papillomavirus-related oropharyngeal squamous cell carcinoma (HPVOPC) results in unprecedented high survival rates but possibly unnecessary toxicity. We hypothesized that upfront surgery and neck dissection followed by reduced-dose adjuvant therapy for early and intermediate HPVOPC would ultimately result in equivalent progression-free survival (PFS) and overall survival while reducing toxicity. METHODS This study was a nonrandomized phase II trial for early-stage HPVOPC treated with transoral robotic surgery (TORS) followed by reduced-dose radiotherapy. Patients with previously untreated p16-positive HPVOPC and <20 pack years' smoking history were enrolled. After robotic surgery, patients were assigned to group 1 (no poor risk features; surveillance), group 2 (intermediate pathologic risk factors [perineural invasion, lymphovascular invasion]; 50-Gy radiotherapy), or group 3 (poor prognostic pathologic factors [extranodal extension [ENE], more than three positive lymph nodes and positive margin]; concurrent 56-Gy chemoradiotherapy with weekly cisplatin). RESULTS Fifty-four patients were evaluable; there were 25 in group 1, 15 in group 2, and 14 in group 3. Median follow-up was 43.9 months (9.6-75.8). Disease-specific survival was 98.1%, and PFS was 90.7%. PFS probability via Kaplan-Meier was 91.3% for group 1, 86.7% for group 2, and 93.3% for group 3. There were five locoregional failures (LRFs), including one distant metastasis and one contralateral second primary. Average time to LRF was 18.9 months (9.6-59.0); four LRFs were successfully salvaged, and the patients remain disease free (11.0-42.7 months); one subject remains alive with disease. CONCLUSION The results indicate that upfront surgery with neck dissection with reduced-dose radiation for T1-2, N1 stage (by the eighth edition American Joint Committee on Cancer staging manual) HPVOPC results in favorable survival with excellent function in this population. These results support radiation dose reduction after TORS as a de-escalation strategy in HPVOPC. IMPLICATIONS FOR PRACTICE Transoral robotic surgery can provide a safe platform for de-escalation in carefully selected patients with early-stage human papillomavirus-related oropharyngeal cancer. In this clinical trial, disease-specific survival was 100%, over 90% of the cohort had a reduction of therapy from standard of care with excellent functional results, and the five patients with observed locoregional failures were successfully salvaged.
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Affiliation(s)
- Brett A. Miles
- Tisch Cancer Institute, Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
- Department of Otolaryngology, Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Marshall R. Posner
- Tisch Cancer Institute, Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
- Department of Hematology/Oncology, Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Vishal Gupta
- Department of Radiation Oncology, Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Marita S. Teng
- Department of Otolaryngology, Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Richard L. Bakst
- Tisch Cancer Institute, Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
- Department of Radiation Oncology, Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Mike Yao
- Department of Otolaryngology, Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | | | - Raymond L. Chai
- Department of Otolaryngology, Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Sonam Sharma
- Department of Radiation Oncology, Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - William H. Westra
- Department of Pathology, Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Seunghee Kim‐Schulze
- Department of Immune Monitoring, Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Bheesham Dayal
- Department of Otolaryngology, Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Stanislaw Sobotka
- Department of Otolaryngology, Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
- Department of Biostatistics, Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Andrew G. Sikora
- Department of Otolaryngology, Baylor College of MedicineHoustonTexasUSA
| | - Peter M. Som
- Department of Radiology, Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Eric M. Genden
- Department of Otolaryngology, Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
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18
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Transoral robotic surgery in Ireland: the beginning. Ir J Med Sci 2021; 191:361-365. [PMID: 33559869 DOI: 10.1007/s11845-021-02539-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 02/01/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Transoral robotic surgery (TORS) has shown promising results in the treatment of myriad head and neck pathologies but is now most commonly used in the investigation and management of oropharyngeal squamous cell carcinoma. AIMS The aim of this study was to report our cases of the newly introduced TORS, particularly its role in identifying primary of unknown origin and the potential implications for patients. A literature review and our early experience should begin to debunk some of the criticisms of TORS including setup times and cost. METHODS Prospective data was collected from all patients undergoing transoral robotic surgery including demographics, indication, histology results in primary of unknown origin and complications. RESULTS We have performed 36 TORS procedures in total ranging from intermediate to major complex. Our complication rate is low, and this has improved with the passage of time. Haemorrhage rates remain at 5.6% (n = 2), and the average length of stay is 1 day. Successful identification of a primary tumour in cancer of unknown primary was 80% (n = 8). CONCLUSIONS We anticipate the integration of TORS into routine practice in the investigation and management of a number of ENT pathologies following robust clinical trials.
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19
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Snyder V, Goyal LK, Bowers EMR, Kubik M, Kim S, Ferris RL, Johnson JT, Duvvuri U, Gooding WE, Branstetter BF, Rath TJ, Sridharan SS. PET/CT Poorly Predicts AJCC 8th Edition Pathologic Staging in HPV-Related Oropharyngeal Cancer. Laryngoscope 2021; 131:1535-1541. [PMID: 33428218 DOI: 10.1002/lary.29366] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 12/10/2020] [Accepted: 12/24/2020] [Indexed: 11/10/2022]
Abstract
OBJECTIVE The American Joint Committee on Cancer (AJCC) 8th edition introduced distinct clinical and pathological staging paradigms for human papilloma virus positive (HPV+) oropharyngeal squamous cell carcinoma (OPSCC). Treatment planning for OPSCC often utilizes positron emission tomography/computed tomography (PET/CT) to assess clinical stage. We hypothesize that PET/CT will accurately predict final pathologic AJCC 8th edition staging in patients with HPV+ OPSCC. METHODS All patients with primary HPV+ OPSCC with preoperative PET/CT who underwent transoral robotic surgery and neck dissection between 2011 and 2017 were identified. Data were collected via chart review. Two neuroradiologists performed blinded re-evaluation of all scans. Primary tumor size and cervical nodal disease characteristics were recorded and TNM staging was extrapolated. Cohen's kappa statistic was used to assess interrater reliability. Test for symmetry was performed to analyze discordance between radiologic and pathologic staging. RESULTS Forty-nine patients met inclusion criteria. Interrater reliability was substantial between radiologists for nodal (N) and overall staging (OS) (κ = 0.715 and 0.715). Radiologist A review resulted in identical OS for 67% of patients, overstaging for 31%, and understaging for 2%. Radiologist B review resulted in 61% identical OS, 39% overstaging, and 0% understaging. In misclassified cases, the test of symmetry shows strong bias toward overstaging N stage and OS (P < .001). Radiologic interpretation of extracapsular extension showed poor interrater reliability (κ = 0.403) and poor accuracy. CONCLUSION PET/CT predicts a higher nodal and overall stage than pathologic staging. PET/CT should not be relied upon for initial tumor staging, as increased FDG uptake is not specific for nodal metastases. PET/CT is shown to be a poor predictor of ECE. LEVEL OF EVIDENCE 4 Laryngoscope, 131:1535-1541, 2021.
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Affiliation(s)
- Vusala Snyder
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Lindsey K Goyal
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Eve M R Bowers
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Mark Kubik
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Seungwon Kim
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Robert L Ferris
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Jonas T Johnson
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Umamaheswar Duvvuri
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - William E Gooding
- Department of Epidemiology and Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Barton F Branstetter
- Department of Neuroradiology, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | | | - Shaum S Sridharan
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
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20
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HPV/p16-positive oropharyngeal cancer treated with transoral robotic surgery: The roles of margins, extra-nodal extension and adjuvant treatment. Am J Otolaryngol 2021; 42:102793. [PMID: 33130532 DOI: 10.1016/j.amjoto.2020.102793] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 10/16/2020] [Accepted: 10/19/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE Human papilloma virus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) treatment outcomes are re-defining management. Traditional margins, the role of extranodal extension (ENE) and adjuvant treatment intensity continue to be debated. This study aimed to determine the impact of margins, ENE and adjuvant therapy on survival following transoral robotic surgery (TORS). METHODS Patients treated with TORS at an academic center were retrospectively identified (2013-2019). Survival outcomes were evaluated using Kaplan-Meier curves. RESULTS 48 patients were included. 40 (83%) were male. Mean age was 61.2 years. 43 (90%) were stage I. 22 (45.8%) had ENE. 31 (65%) had margins >1 mm. 38 (79%) had indications for radiation therapy; 9 (24%) refused. Chemotherapy was recommended in 36 (75%) patients; 24 (67%) refused. Locoregional control was 98%, metastasis-free survival was 96%, and disease-specific survival was 100% at 5-years. Overall survival was 95%. CONCLUSIONS Given the high survival rate seen after TORS, it is likely that margins, ENE and adjuvant treatment may not significantly contribute to outcomes.
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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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Abstract
Transoral robotic surgery is a useful minimally invasive technique in the treatment of oropharyngeal squamous cell carcinoma, both human papilloma virus (HPV)-positive and HPV-negative patients in certain instances. This treatment modality often has proven useful for certain tumor persistences or recurrences. Good outcomes are possible given appropriate patient selection, both oncologically and functionally.
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Head and neck robotic surgery combined with sentinel lymph node biopsy. Fascinating, but feasible? Oral Oncol 2020; 111:104939. [PMID: 32745899 DOI: 10.1016/j.oraloncology.2020.104939] [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: 05/21/2020] [Revised: 07/08/2020] [Accepted: 07/27/2020] [Indexed: 02/05/2023]
Abstract
Robotic approaches and sentinel lymph node (SLN) biopsy are both strategies that evolved driven by the need to reduce impact of head and neck oncological surgery in terms of operative timing, morbidity, hospitalization time, and aesthetic results. A comprehensive review of the scientific literature was performed on PubMed, Embase, ResearchGate, Cochrane, and CENTRAL electronic databases with the aim to discuss the role that these two approaches can play together in the management of head and neck cancers (HNCs) of various sites. Dedicated publications on the combined robotics and SLN biopsy approaches resulted, up to now very limited, while their separated application in non-shared fields is gaining strength. However, the possibility to implement and combine technologies to minimize sequelae of head and neck surgery is an interesting and evolving topic.
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