Oncological outcomes of early glottic carcinoma treated with transoral robotic surgery

Bending the rules: A novel approach to laryngeal surgery in a body donor study

BACKGROUND

Transoral laser microsurgery, the standard surgical approach for early-stage laryngeal cancer, necessitates an unobstructed line of sight to the operating field. However, achieving adequate laryngeal exposure can be challenging, potentially compromising treatment outcomes.

METHODS

We developed a 3D-printed curved laryngoscope (sMAC), designed to match the upper airway anatomy. In a user study (n = 15) with a human body donor we compared the sMAC system to conventional microlaryngoscopy regarding laryngeal exposure and accessibility in a difficult exposure scenario.

RESULTS

All 15 participants achieved complete glottic exposure and successfully manipulated laryngeal landmarks using the sMAC system. Only four participants achieved partial exposure using microlaryngoscopy. Positioning of the sMAC system was significantly faster (p = 0.023). A vocal cord resection was conducted successfully (n = 2) using the sMAC system.

CONCLUSION

The sMAC system effectively addresses challenges associated with transoral laryngeal surgery. Ongoing development aims to overcome current limitations of the system and prepare first clinical trials.

Oncological, Surgical and Functional Outcomes of Transoral Robotic Cordectomy for Early Glottic Carcinoma

OBJECTIVE

To investigate oncological, surgical and functional outcomes of transoral robotic surgery cordectomy (TORS-Co).

METHODS

A retrospective chart review of patients benefiting from TORS-Co for a cT1a vocal fold squamous cell carcinoma was conducted at a single academic medical center. TORS-Co was performed through da Vinci robot. The following outcomes were studied: preoperative and operative exposures; feasibility; conversion rate; average robotic set-up and operative times; margin status; postoperative complications; tracheotomy and feeding tube requirement.

RESULTS

The medical record data of 12 patients were collected. Among them, two patients were excluded because the laryngeal exposition was not adequate. From the 10 included patients, TORS-Co was not performed in three patients. The tumor was not exposable regarding anatomical conditions in two patients, while the size of the robot arms did not allow an adequate exposure in another patient. TORS-Co was performed in the remaining seven patients without transient tracheotomy or feeding tube. The mean estimated blood loss was 20 mL. The average robotic set-up and operative times were 26 minutes and 30 minutes, respectively. The mean hospital stay was 2 days. The margins were not analyzable regarding the use of the monopolar. Two patients reported postoperative complications, while five required class 2 analgesics for postoperative pain. The mean duration of follow-up was 44 months (minimum duration of 36 months). One recurrence occurred 2 years post-surgery. The recurrence was successfully treated by transoral laser CO2 microsurgery.

CONCLUSION

The exposure of the laryngeal surgical field is the primary limitation of TORS-Co. TORS-Co may not report better oncological and functional outcomes than transoral laser CO2 microsurgery, which remains the gold standard surgical approach for early glottic squamous cell carcinoma.

Surgical Treatment of Early Glottic Cancer

The incidence of all head and neck malignancies is rising worldwide, with carcinoma of the larynx constituting approximately 1% of all cancers. Early glottic cancer responds quite favorably to surgical intervention due to its early presentation, coupled with the low rate of regional and distant metastases. This article focuses on various approaches to the surgical treatment of early glottic cancer. Details include the clinical and radiological evaluation of laryngeal cancer, the goals of treatment, current surgical options for early disease, approach to surgical resection margins and management of nodal disease, and complications associated with each treatment modality.

A novel 3D-printed laryngoscope with integrated working channels for laryngeal surgery

Background

For the surgical treatment of early-stage laryngeal cancer, the use of transoral laser microsurgery (TLM) has emerged as the gold standard. However, this procedure requires a straight line of sight to the operating field. Therefore, the patient's neck needs to be brought into a hyperextended position. In a considerable number of patients, this is not possible due to anomalies in the cervical spine anatomy or soft tissue scarring, e.g., after radiation. In these cases, adequate visualization of relevant laryngeal structures cannot be ensured using a conventional rigid operating laryngoscope, which may negatively affect the outcome of these patients.

Methods

We present a system based on a 3D-printed prototype of a curved laryngoscope with three integrated working channels (sMAC). The curved profile of the sMAC-laryngoscope is specifically adapted to the nonlinear anatomy of the upper airway structures. The central working channel provides access for flexible video endoscope imaging of the operating field while the two remaining channels provide access for flexible instrumentation. In a user study (n = 11), visualization and reachability of relevant laryngeal landmarks as well as the feasibility of basic surgical procedures with the proposed system were examined in a patient simulator. In a second setup, the system was evaluated for its applicability in a human body donor.

Results

All participants of the user study were able to visualize, reach and manipulate the relevant laryngeal landmarks. Reaching those took significantly less time in the second attempt compared to the first one (27.5 s ± 5.2 s vs. 39.7 s ± 16.5 s, p = 0.008) indicating a significant learning curve for handling the system. Instrument changes were performed quickly and reliably by all participants (10.9 s ± 1.7 s). All participants were able to bring the bimanual instruments into position for a vocal fold incision. Relevant laryngeal landmarks could be visualized and reached in the human body donor setup.

Conclusion

Possibly, the proposed system may develop into an alternative treatment option for patients with early-stage laryngeal cancer and restricted mobility of the cervical spine in the future. Further improvements of the system could include finer end effectors and a flexible instrument with a laser cutting tool.

Transoral robotic cordectomy for glottic carcinoma: a rapid review

OBJECTIVE

The objective of this study was to investigate feasibility, surgical, oncological, and functional outcomes of transoral robotic cordectomy (TORS-Co) and whether TORS-Co reported comparable outcomes of transoral laser microsurgery (TLM).

METHODS

PubMed, Scopus, and Cochrane Library were searched by three laryngologists for studies investigating feasibility, surgical, oncological, and functional outcomes of patients benefiting from TORS-Co. The following outcomes were investigated according to the PRISMA statements: age; cT stage; types of cordectomy; surgical settings; complications; and functional and feasibility features.

RESULTS

Nine studies published between 2009 and 2021 met our inclusion criteria, accounting for 114 patients. There was no controlled study. TORS-Co was performed in cT1 or cT2 glottic cancer through types II, III, IV, V, or VI cordectomies. The exposure was inadequate in 4% of cases, leading to conversion in transoral laser cordectomy. Margins were positive in 4.5% and local recurrence occurred in 10.7% (N = 8/75). Tracheotomy and feeding tube requirement varied across studies, depending on the types of TORS-Co. The mean duration of robot installation/vocal cord exposure and operative times ranged from 20 to 42 min and 10 to 40 min, respectively. The mean duration of hospital stay ranged from 2 to 7 days. Complications included dyspnea, bleeding, granuloma, synechia, and tongue hematoma and dysesthesia.

CONCLUSION

The current robotic systems do not appear adequate for TORS-Co. TORS-Co was associated with higher rates of complications and tracheotomy than TLM.

Management of clinically node-negative glottic squamous cell carcinoma patients according to risk-scoring model for occult lymph node metastases

Background

Glottic squamous cell carcinoma (GSCC) is the most prevalent type of laryngeal carcinoma. The value of prophylactic lymph node dissection (LND) in resected GSCC remains controversial. This study aims to quantitatively assess the probability of occult lymph node metastasis (LNM) for GSCC patients and devise individualized postoperative radiotherapy strategies.

Methods

A total of 1319 patients with GSCC were retrospectively analyzed.

Results

GSCC patients with T1-T2 stages showed significantly lower LNM rate than those with T3-T4 stages. For patients with T3-T4 GSCC, multivariate logistic analyses indicated that three factors-maximum tumor diameter (MTD) of more than 2.0 cm, relatively low differentiation, and tumor invasive depth of no less than 1.0 cm-were independent risk factors for the existence of LNM. A predictive nomogram was established based on these factors. The accuracy and validity of our model were verified by 0.716 and remained at 0.717 after 1000 bootstrapping. The calibration curve was also plotted and showed a favorable agreement. The patients were stratified into two groups based on their individual LNM risk points. Possible LNM rates for low-risk and high-risk subgroups were 4.7% and 25.2%, respectively.

Conclusions

A new post-operative strategy selection flow chart was established based on our newly created nomogram which can effectively predict the individualized possibility of occult LNM for GSCC patients. For clinical T3-4N0 patients in the high-risk subgroup, prophylactic dose post-operative radiation therapy is recommended. However, for all those clinically diagnosed as T1-2N0 stage, regular follow-up is sufficient in view of the low occult LNM rate.Level of Evidence: 2a.

Patient Benefit and Quality of Life after Robot-Assisted Head and Neck Surgery

Robotic systems for head and neck surgery are at different stages of technical development and clinical application. Currently, robotic systems are predominantly used for transoral surgery of the pharynx and larynx. Robotic surgery of the neck, the thyroid, and the middle and inner ear is much less common; however, some oncological and functional outcomes have been reported. This article provides an overview of the current state of robot-assisted head and neck surgery with a special emphasis on patient benefit and postoperative quality of life (QoL). The focus is placed on the role of transoral robotic surgery (TORS) for the resection of oropharyngeal carcinomas. For this application, reported long-term outcomes show functional post-operative advantages for selected oropharyngeal cancer patients after TORS compared to open surgery and primary radiotherapy. Since TORS also plays a significant role in the context of potential therapy de-escalation for HPV-positive oropharyngeal cancer patients, ongoing trials are presented. Regarding the evaluation of the therapeutic benefit and the QoL of cancer patients, special attention has to be paid to the large degree of variability of individual patients' preferences. Influencing factors and tools for a detailed assessment of QoL parameters are therefore detailed at the beginning of this article. Notably, while some robotic systems for ear and skull base surgery are being developed in Europe, TORS systems are mainly used in North America and Asia. In Europe and Germany in particular, transoral laser microsurgery (TLM) is a well-established technology for transoral tumor resection. Future trials comparing TORS and TLM with detailed investigation of QoL parameters are therefore warranted and might contribute to identifying suitable fields for the application of the different techniques.

Transoral Robotic Surgery for Early-T Stage Glottic Cancer Involving the Anterior Commissure—News and Update

Background

About 20% of all glottic carcinomas involve the anterior commissure (AC), and AC involvement was deemed to be a risk factor of local recurrence and poor prognosis. Transoral robotic surgery (TORS) has been developed for a panoramic view of the AC and en-bloc resection of the tumor by multidirectional dissection with endo-wristed instruments. With satisfactory preliminary results, we would like to update the data with a bigger cohort and present the news on using TORS for salvage treatment of recurrence from irradiation failure.

Methods

From July 2010 to December 2019, 22 patients with early T1 and 2 stage primary (n = 11) or recurrent (n = 11) glottic cancer with AC involvement received TORS without adjuvant therapy. TORS exposure was found to be better than TLM by conventional laryngoscopy in diagnostic biopsy. Seven of the 22 patients had recurrent cancer from irradiation failure. The perioperative factors that may be associated with survival were retrospectively analyzed, and the 5-year overall survival (OS)/disease-specific survival (DSS)/recurrence-free survival (RFS)/and organ preservation survival (OPS) rate were estimated by the Kaplan–Meier Method. Their voice and swallowing functions were evaluated by questionnaires of Voice Handicap Index-10 (VHI-10) and Functional Outcome Swallowing Scale (FOSS).

Results

All 22 TORSs were completed smoothly. After a mean follow-up of 49 ± 35.9 months, the Kaplan–Meier method estimated 5-year OS/DSS/RFS/OPS was 93.8%, 93.8%, 74.6%, and 86.3%, respectively. Our 11 patients with fresh cancer had 100% recurrence-free survival. Although the recurrent rate was higher in patients with history of RT, they could be rescued by further open laryngectomy without compromising the OS and DSS. Only one patient expired. The other 21 patients had satisfactory swallowing function with FOSS of 0.33 ± 0.66. Five patients depended on tracheostomy, but the rest 17 patients had serviceable voice with VHI-10 of 18.41 ± 11.29.

Conclusions

TORS could be used in the primary or salvage management of glottic cancer with AC involvement while TORS was confirmed to have better exposure to TLM. The RFS was good for patients with primary cancer. In patients having irradiation failure, TORS could also be a minimally invasive transoral approach before trying open surgery to preserve the organ.

Early glottic cancer recurrence: A critical review on its current management

INTRODUCTION

Recurrent early glottic cancer (rEGC) poses several issues in terms of timely diagnosis, correct re-staging, and treatment. We want to critically review the latest evidence about rEGC considering its epidemiology, biology, diagnostic challenges, and treatment strategies.

METHODS

A systematic search of the literature using PubMed from 1990 to October 31, 2020 was performed.

RESULTS

There are many different treatment options available (open surgery, transoral mini-invasive surgery, radiotherapy), and many factors related to the patient's status and previous treatments must be considered when planning the best management strategy for rEGC. While its overall prognosis remains satisfactory, it is of the utmost importance to appreciate all the clinical implications derived from the choice of the initial therapeutic modality, and from a correct primary and recurrent staging.

CONCLUSION

The balance between oncological and voice and swallowing functions represents the fundamental principle underlying rEGC management. Future studies should focus on molecular profiling of rEGC, and on the results of the emerging radiation delivery techniques and mini-invasive procedures.

T1b Glottic Tumor and Anterior Commissure Involvement: Is the Transoral CO2 Laser Microsurgery a Safe Option?

OBJECTIVES

Transoral CO₂ laser therapy represents the treatment of choice for early-stage laryngeal tumors. The anterior commissure involvement (ACI) is related to a worse local control and a lower rates of organ preservation. The objective of this study is to analyze the differences in survival, local control, and organ preservation in T1b glottic patients according to the presence of ACI.

METHODS

Observational prospective study in pT1b treated with transoral CO₂ laser between 2009 and 2014.

RESULTS

Forty patients (37 male and 3 female) with a mean age of 66.43 ± 8.16 years were recruited. Anterior commissure involvement was present in 70% of the patients. The 5-year specific cause survival was 91.66%, with 32.50% of local recurrences. Laryngeal preservation was 80%, being lower in the group with local recurrence (P < .000). The involvement of the anterior commissure does not influence the organ preservation (P = .548), the appearance of local recurrences (P = .391), or the survival (P = .33).

CONCLUSIONS

Transoral CO₂ laser therapy is an effective and reproducible treatment for early-stage laryngeal tumors. The results obtained are similar to previous studies, although they present discrepancies in relation to the role of the ACI. Prospective randomized trials are required focusing also on the patients' quality of life and functional outcome in order to clarify the role of the ACI and the need to implement changes in its evaluation, staging, and evolution.