1
|
Gupta KK, Khan H, Mughal Z, De M, Sharma N, Garas G. Primary Tumour Detection in Carcinoma of Unknown Primary with Transoral Robotic Surgery (TORS) Tongue Base Mucosectomy: A Meta-analysis. Ann Surg Oncol 2024; 31:6065-6076. [PMID: 38980583 DOI: 10.1245/s10434-024-15758-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 06/24/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND Head and neck carcinoma of unknown primary (CUP) represents a challenging diagnostic process when standard work-up fails to identify the primary tumour site. The aim of this systematic review and meta-analysis was to evaluate the diagnostic utility and complication profile of transoral robotic surgery (TORS) tongue base mucosectomy (TBM) in the management of CUP. PATIENTS AND METHODS An electronic database search was performed in the EMBASE, MEDLINE, PubMed and Cochrane databases. A meta-analysis of proportions was performed to obtain an estimate of the overall proportion for the detection and complication rates. RESULTS Nine studies representing 235 patients with CUP who had TORS TBM were included in the final analysis. The overall pooled tumour detection rate was 66.2% [95% confidence interval (CI) 56.1-75.8]. The incidence of tumour detection in human papilloma virus (HPV)-positive cases (81.5%, 95% CI 60.8-96.4) was significantly higher than HPV-negative cases (2.3%, 95% CI 0.00-45.7). Weighted overall complication rate was 11.4% (95% CI 7.2-16.2). The majority were grade I or II (80%) according to the Clavien-Dindo classification. CONCLUSIONS This meta-analysis suggests TORS to be safe and effective in localising the primary tumour site in patients with CUP. While the current data supports the use of TORS in patients who are HPV positive, larger numbers of HPV-negative cases are required to determine the true diagnostic effect with TORS before any valid conclusions can be inferred in this particular subgroup. Further research should focus on high quality prospective trials with stringent methodological work-up to minimise heterogeneity and allow for more accurate statistical analysis.
Collapse
Affiliation(s)
- Keshav Kumar Gupta
- Head & Neck Surgical Oncology Unit, Department of Otorhinolaryngology and Head and Neck Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK.
| | - Hamad Khan
- Head & Neck Surgical Oncology Unit, Department of Otorhinolaryngology and Head and Neck Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Zahir Mughal
- Department of Otorhinolaryngology and Head and Neck Surgery, Walsall Manor Hospital, Walsall, UK
| | - Mriganka De
- Head & Neck Surgical Oncology Unit, Department of Otorhinolaryngology and Head and Neck Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Neil Sharma
- Head & Neck Surgical Oncology Unit, Department of Otorhinolaryngology and Head and Neck Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - George Garas
- Head & Neck Surgical Oncology Unit, Department of Otorhinolaryngology and Head and Neck Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
- Department of Surgery and Cancer, Imperial College London, St. Mary's Hospital, London, UK
| |
Collapse
|
2
|
Ye Z, Tan G, Wang L, Shangguan G, Yao H, Xu X, Ye H, Ding X. Comparison of survival between palliative surgery and no surgery for advanced tongue squamous cell carcinoma: an analysis of SEER data. Int J Oral Maxillofac Surg 2024:S0901-5027(24)00212-1. [PMID: 39025738 DOI: 10.1016/j.ijom.2024.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 06/20/2024] [Accepted: 07/01/2024] [Indexed: 07/20/2024]
Abstract
The aim of this study was to investigate the survival effect of palliative surgery in advanced tongue squamous cell carcinoma (TSCC). A retrospective analysis of data in the SEER database for 6151 patients with stage III/IV TSCC (American Joint Committee on Cancer (AJCC) staging), diagnosed between 2004 and 2015, was performed. The patients were divided into two groups: palliative surgery and no surgery. Kaplan-Meier and Cox proportional hazards regression analyses were applied to determine risk factors for overall survival (OS) and cancer-specific survival (CSS). A further analysis was performed using 1:1 propensity score matching (PSM) to balance 13 patient variables (sex, age at diagnosis, race, marital status, primary tumour site, SEER stage, AJCC stage, pathological differentiation grade, tumour size, lymph node metastasis, previous lymph node removal, radiotherapy, and chemotherapy). Among the 6151 patients, 706 underwent palliative surgery; the other 5445 did not undergo any kind of surgery. Those who underwent palliative surgery had a higher 5-year survival rate. After PSM, 1274 patients were included in the matched cohort. Multivariate Cox regression analysis showed that patients who underwent palliative surgery had a lower risk of death than those who did not (OS: hazard ratio 0.58, 95% confidence interval 0.49-0.69, P < 0.001; CSS: hazard ratio 0.60, 95% confidence interval 0.49-0.74, P < 0.001). In this comparative study it was found that compared with no surgery, palliative surgery has a positive impact on the survival rate of patients with advanced TSCC.
Collapse
Affiliation(s)
- Z Ye
- Department of Maxillofacial Surgery, The People's Hospital of Pingyang (Pingyang Hospital of Wenzhou Medical University), Wenzhou, Zhejiang, PR China
| | - G Tan
- Advanced Neuroimaging Laboratory, Department of Radiology, The Affiliated Yuebei People's Hospital of Shantou University Medical College, Shaoguan, Guangdong, China
| | - L Wang
- School and Hospital of Stomatology, Guangzhou Key Laboratory of Basic and Applied Research of Oral Regenerative Medicine and Optional Institutions, Guangzhou Medical University, Guangzhou, Guangdong, PR China
| | - G Shangguan
- Department of Maxillofacial Surgery, The People's Hospital of Pingyang (Pingyang Hospital of Wenzhou Medical University), Wenzhou, Zhejiang, PR China
| | - H Yao
- Department of Maxillofacial Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, PR China
| | - X Xu
- Department of Maxillofacial Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, PR China
| | - H Ye
- Institute of Digitized Medicine and Intelligent Technology, Wenzhou Medical University, Wenzhou, Zhejiang, PR China
| | - X Ding
- Department of Maxillofacial Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, PR China.
| |
Collapse
|
3
|
de Almeida JR, Martino R, Hosni A, Goldstein DP, Bratman SV, Chepeha DB, Waldron JN, Weinreb I, Perez-Ordonez B, Yu E, Metser U, Hansen AR, Xu W, Su SJ, Kim J. Transoral Robotic Surgery and Radiation Volume Deintensification in Unknown Primary Squamous Cell Carcinoma of the Neck: The Phase 2 FIND Nonrandomized Controlled Trial. JAMA Otolaryngol Head Neck Surg 2024; 150:463-471. [PMID: 38602692 PMCID: PMC11009865 DOI: 10.1001/jamaoto.2024.0423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 02/17/2024] [Indexed: 04/12/2024]
Abstract
Importance Patients with unknown primary squamous cell carcinoma (CUP) with cervical metastases typically receive comprehensive radiotherapy (RT) of the pharynx and bilateral neck. Typically, these patients receive comprehensive RT of the pharynx and bilateral neck that may produce treatment-related toxic effects. Objective To determine whether localization of occult oropharyngeal cancers with transoral robotic surgery (TORS) combined with reduced pharyngeal and neck RT volumes provides acceptable disease control. Design, Setting, and Participants This phase 2, single-group nonrandomized controlled trial at a single institution accrued 32 prospective participants with p16-positive CUP without a primary squamous cell carcinoma on examination and imaging from 2017 to 2019, and 24-month follow-up. The data analysis was conducted from January 2021 to June 2022. Intervention Diagnostic- (n = 13) or therapeutic-intent (n = 9) TORS, with pharyngeal-sparing radiotherapy (PSRT) prescribed for negative margins or pT0, and unilateral neck RT (UNRT) prescribed for unilateral lymphadenopathy with lateralized primary tumor or pT0. Main Outcomes and Measures Out-of-radiation treatment volume failure (<15% was hypothesized to be acceptable) and reports of local and regional recurrence, overall survival, toxic effects, swallowing outcomes (per the MD Anderson Dysphagia Inventory), and videofluoroscopic swallow (per Dynamic Imaging Grade of Swallowing Toxic Effects [DIGEST]) ratings. Results The study sample comprised 22 patients (mean [SD] age, 59.1 [5.7] years; 3 [14%] females and 19 [86%] male) with CUP. Of these, 19 patients (86%) had tumor stage cN1; 2 (9%), cN2; and 1 (5%), cN3. Five patients (23%), 14 patients (64%), and 3 patients (13%) had 0, 1, or 2 primary tumors, respectively. Twenty patients received RT; of these, 9 patients (45%) underwent PSRT and 10 patients (50%), UNRT. In the diagnostic-intent group, 8 patients (62%) and 5 patients (38%) underwent RT and RT-concurrent chemotherapy, respectively. In the therapeutic-intent group, 6 patients (67%) and 1 patient (11%) received adjuvant RT-concurrent chemotherapy, respectively; 2 patients declined RT. Two-year out-of-radiation treatment volume failure, locoregional control, distant metastasis control, and overall survival were 0%, 100%, 95%, and 100%, respectively. Grade 3 or 4 surgical, acute, and late toxic effects occurred in 2 (9%), 5 (23%), and 1 (5%) patients, respectively. PSRT was associated with lower RT dose to superior constrictors (37 vs 53 Gy; mean difference, 16 Gy; 95% CI, 6.4, 24.9), smaller decline in swallowing scores during treatment (19.3 vs 39.7; mean difference, -20.4; 95% CI, -34.1 to -6.1), and fewer patients with worsening DIGEST grade on findings of videofluoroscopic swallow studies at 2 years (0% vs 60%; difference, 60%; 95% CI, 30% to 90%). Conclusions and Relevance These findings indicate that TORS for p16-positive CUP allows RT volume deintensification with excellent outcomes and support future investigation in randomized clinical trials. Trial Registration ClinicalTrials.gov Identifier: NCT03281499.
Collapse
Affiliation(s)
- John R. de Almeida
- Department of Otolaryngology–Head and Neck Surgery, Princess Margaret Cancer Center/University Health Network, University of Toronto, Toronto, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Canada
| | - Rosemary Martino
- Department of Otolaryngology–Head and Neck Surgery, Princess Margaret Cancer Center/University Health Network, University of Toronto, Toronto, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada
- Department of Speech-Language Pathology, University of Toronto, Toronto, Canada
- The Swallowing Lab, University of Toronto, Toronto, Canada
- Krembil Research Institute, University Health Network, Toronto, Canada
| | - Ali Hosni
- Department of Radiation Oncology, Princess Margaret Cancer Center/University Health Network, University of Toronto, Toronto, Canada
| | - David P. Goldstein
- Department of Otolaryngology–Head and Neck Surgery, Princess Margaret Cancer Center/University Health Network, University of Toronto, Toronto, Canada
| | - Scott V. Bratman
- Department of Radiation Oncology, Princess Margaret Cancer Center/University Health Network, University of Toronto, Toronto, Canada
| | - Douglas B. Chepeha
- Department of Otolaryngology–Head and Neck Surgery, Princess Margaret Cancer Center/University Health Network, University of Toronto, Toronto, Canada
| | - John N. Waldron
- Department of Radiation Oncology, Princess Margaret Cancer Center/University Health Network, University of Toronto, Toronto, Canada
| | - Ilan Weinreb
- Department of Pathology, University Health Network, Toronto, Canada
| | | | - Eugene Yu
- Department of Medical Imaging, University Health Network, Toronto, Canada
| | - Ur Metser
- Department of Medical Imaging, University Health Network, Toronto, Canada
| | - Aaron R. Hansen
- Department of Medical Oncology, Princess Margaret Cancer Center, Toronto, Canada
| | - Wei Xu
- Department of Biostatistics, Princess Margaret Cancer Center, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Susie Jie Su
- Department of Biostatistics, Princess Margaret Cancer Center, Toronto, Canada
| | - John Kim
- Department of Radiation Oncology, Princess Margaret Cancer Center/University Health Network, University of Toronto, Toronto, Canada
| |
Collapse
|
4
|
Grasl S, Wassipaul C, Fischer G, Arnoldner C, Janik S. An Unknown Foreign laryngeal Object: an exotic complication of skull base osteoradionecrosis. Eur Arch Otorhinolaryngol 2024; 281:2755-2759. [PMID: 38381152 PMCID: PMC11023982 DOI: 10.1007/s00405-024-08507-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 01/24/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Osteoradionecrosis (ORN) of the skull base is a rare complication after head and neck radiation with a broad variety of subsequent complications. METHODS A 68-year-old woman with a complex oncological history (right-sided sphenoid meningioma; left-sided neck metastasis of a Cancer of Unknown Primary-CUP) was admitted with a right-sided epi-/ oropharyngeal mass and severe pain exacerbations for further evaluation. CT scan revealed an advanced ORN of the skull base with subsequent abruption of the ventral part of the clivus. This dislocated part of the clivus wedged in the oropharynx for 48 h and then moved towards the larynx, resulting in dyspnea and almost complete airway obstruction. RESULTS Due to the dangerous airway situation, an urgent exploration and removal of the dislocated clivus was necessary. After a potential cervical spine instability was ruled out, the patient's airway was initially secured with an awake tracheotomy and the clivus was removed transorally. The tracheostomy tube was removed during the ongoing inpatient stay, and the patient was discharged with significant pain relief. CONCLUSIONS The present case illustrates an orphan complication of skull base ORN resulting in a major airway emergency situation.
Collapse
Affiliation(s)
- Stefan Grasl
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria
| | - Christian Wassipaul
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Gregor Fischer
- Department of Otolaryngology, Karl Landsteiner University Hospital, Krems, Austria
| | - Christoph Arnoldner
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria
| | - Stefan Janik
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria.
| |
Collapse
|
5
|
Hardman JC, Harrington K, O’Leary B, Robinson M, Paleri V. Step Serial Sectioning in Head and Neck Squamous Cell Carcinoma of Unknown Primary. JAMA Otolaryngol Head Neck Surg 2024; 150:118-126. [PMID: 38127339 PMCID: PMC10853833 DOI: 10.1001/jamaoto.2023.3993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 10/26/2023] [Indexed: 12/23/2023]
Abstract
Importance Patients with suspected head and neck squamous cell carcinoma of unknown primary (HNSCCUP) may undergo tonsillectomy and tongue base mucosectomy (TBM) to help identify clinicoradiologically occult primary disease. It is hypothesized that when these diagnostic specimens are analyzed, conventional histopathological (CH) techniques risk missing small primary tumors that may be hidden in the tissue blocks. Objective To establish the outcomes of a step serial sectioning (SSS) histopathological technique vs CH when analyzing diagnostic tissue specimens from TBM and tonsillectomy performed for HNSCCUP. Design, Setting, and Participants The MOSES prospective multicenter noninterventional cohort study was conducted over a 25-month period from November 2019 at secondary and tertiary care ear, nose, and throat departments in the United Kingdom and included adults with clinicoradiologically occult HNSCCUP who were undergoing TBM. Intervention Conventional histopathological techniques performed on TBM and tonsillectomy specimens at participating centers, followed by SSS performed at the central laboratory. Main Outcome Identification of cancer on central histopathological review of TBM and tonsillectomy specimens. Results Tissue from 58 eligible patients was analyzed (median [range] age, 58 [47-82] years; 10 women [17%]), with 20 480 sections cut in the laboratory and 4096 sections directly examined by a pathologist (median [range], 64 [28-135] per patient). The overall identification rate for TBM following SSS according to study protocol was 50.0% (95% CI, 37.5%-62.5%) and by subgroups was 42.9% (95% CI, 21.4%-67.4%) when performed following a negative bilateral tonsillectomy, 46.7% (95% CI, 24.8%-69.9%) at the same time as bilateral tonsillectomy, and 57.1% (95% CI, 36.5%-75.5%) following historic tonsillectomy. Conventional histopathological techniques at central review identified 2 undiagnosed primary tumors and revised the diagnosis of 2 other cases (1 nonmalignant and another down staged). Step serial sectioning identified a single additional tumor: an ipsilateral synchronous tongue base tumor for which a contralateral tumor had been identified on CH. Multifocal disease was seen in 5 (8.6%); all were human papillomavirus-related and in the tongue base. Conclusions and Relevance In this multicenter cohort study of patients undergoing TBM for HNSCCUP, SSS was associated with added considerable histopathological workload with minimal additional diagnostic benefit. A second opinion for conventional histological techniques may be more beneficial. Synchronous primary disease should be considered when planning diagnostic oropharyngeal surgery for these patients.
Collapse
Affiliation(s)
- John C. Hardman
- Head and Neck Unit, The Royal Marsden National Health Service Foundation Trust, London, England
- The Institute of Cancer Research, London, England
| | - Kevin Harrington
- Head and Neck Unit, The Royal Marsden National Health Service Foundation Trust, London, England
- The Institute of Cancer Research, London, England
| | - Ben O’Leary
- Head and Neck Unit, The Royal Marsden National Health Service Foundation Trust, London, England
- The Institute of Cancer Research, London, England
| | - Max Robinson
- Department of Cellular Pathology, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, England
| | - Vinidh Paleri
- Head and Neck Unit, The Royal Marsden National Health Service Foundation Trust, London, England
- The Institute of Cancer Research, London, England
| |
Collapse
|
6
|
Chen AM. Management of unknown primary head and neck cancer with radiation therapy in the era of human papillomavirus (HPV): No longer cutting down the tree to get an apple. Radiother Oncol 2023; 189:109952. [PMID: 37844736 DOI: 10.1016/j.radonc.2023.109952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 10/07/2023] [Accepted: 10/10/2023] [Indexed: 10/18/2023]
Abstract
PURPOSE Given the central role that radiation has in the management of head and neck squamous cell carcinoma of unknown primary origin, it is imperative to review how treatment paradigms have been refined and continue to evolve in the modern era. METHODS AND MATERIALS This study was designed based on the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) statement. A literature search of peer-reviewed publications was undertaken to identify works pertaining to the use of radiation for squamous cell carcinoma of unknown primary origin presenting as cervical lymph node metastases. Articles published from January 2002 to January 2023 with full text available on PubMed and restricted to the English language and human subjects were included. The full bibliographies of identified articles were reviewed and irrelevant studies were removed. RESULTS While such breakthroughs as intensity-modulated radiotherapy, positron emission tomography, biomarker testing with immune-histochemistry, and minimally invasive surgical techniques such as transoral robotic surgery have fundamentally changed the approach to this disease in recent decades, controversies still exist with respect to the manner in which radiation is delivered. Although the incidence of head and neck unknown primary cancer is relatively low, questions regarding the necessity of comprehensive radiation using the age-old standard method of targeting the bilateral necks and entire pharyngeal axis to encompass all putative sites of mucosal disease persist. CONCLUSIONS Prospective evidence is lacking, and the available studies have been complicated by such factors as the relatively limited sample sizes, as well as the variability in work-up, treatment, inclusion criteria, and follow-up. Regardless, advances in science and technology have ushered in more precise approaches with a high degree of customization, particularly given the increased proportion of patients presenting with human papillomavirus-related disease.
Collapse
Affiliation(s)
- Allen M Chen
- Department of Radiation Oncology, University of California, Irvine, Chao Family Comprehensive Cancer Center, Orange, CA 92868, USA.
| |
Collapse
|
7
|
Larsen MHH, Channir HI, Madsen AKØ, Rubek N, O'Leary P, Kjærgaard T, Kehlet H, von Buchwald C. The effect of dexamethasone on functional pain following Transoral Robotic Surgery: a randomized double blinded clinical trial. Acta Otolaryngol 2023; 143:894-901. [PMID: 37902607 DOI: 10.1080/00016489.2023.2269998] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 10/04/2023] [Indexed: 10/31/2023]
Abstract
BACKGROUND Pain is prevalent after most TransOral Robotic Surgery (TORS) procedures and may limit function i.e. swallowing. Currently, there is limited knowledge regarding optimal pain treatment in TORS. AIMS/OBJECTIVES This clinical trial randomized patients to either a high-dose dexamethasone or low-dose dexamethasone treatment in addition to a multimodal basic analgesic protocol. The aim of the trial was to investigate the pain intensity during rest and swallowing using the Visual Analogue Scale (VAS) after TORS lingual tonsillectomy. Secondary outcomes were acceptable food consistency, nausea, vomiting, opioid rescue usage, length of hospitalization, feeding tube placements, readmissions, blood glucose levels and postoperative complications. METHODS The trial was conducted between August 2020 and October 2022. Eligible patients were patients scheduled for TORS-L treatment of obstructive sleep apnea syndrome or as part of the diagnostic work-up of head and neck carcinoma of unknown primary. RESULTS Eighteen patients were and randomized 1:1. There were overall no significant differences between groups in the reported VAS scores during rest or swallowing (p ≥ .05). Overall, there were no differences in the secondary outcomes. CONCLUSION There were no differences in the pain intensity in the two treatment groups allocated to a basic multimodal analgesic package and either high-dose dexamethasone or low-dose dexamethasone treatment. The trial is the first RCT to include pain measurement during a procedure-relevant activity, thus creating a platform for future recovery studies.
Collapse
Affiliation(s)
- Mikkel Hjordt Holm Larsen
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Hani Ibrahim Channir
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Anne Kathrine Østergaard Madsen
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Niclas Rubek
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Padraig O'Leary
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Aarhus University Hospital, Aarhus, Denmark
| | - Thomas Kjærgaard
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian von Buchwald
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| |
Collapse
|
8
|
Lechien JR, Hans S. Are new and young generations of surgeons more aware of transoral robotic surgery than older ones? An international survey. J Robot Surg 2023; 17:2065-2072. [PMID: 37204649 DOI: 10.1007/s11701-023-01619-6] [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: 02/11/2023] [Accepted: 05/13/2023] [Indexed: 05/20/2023]
Abstract
The objective of this study is to investigate adoption, perception, and awareness of otolaryngologist-head neck surgeons (OTO-HNS) toward transoral robotic surgery (TORS) according to the surgeon experience. A total of 1,383 OTO-HNS of YO-IFOS and IFOS received an online survey dedicated to the adoption, perception, and awareness toward TORS. The following outcomes were compared between residents and fellows, young/middle-aged and older OTO-HNS: awareness/perception; indications; advantages; barriers and expected improvements of TORS practice. From the 357 responders (26%), 147 participants were residents and fellows; while 105 and 105 OTO-HNS reported 10 to 19, and more than 20 years of practice. The main barriers of using TORS included the cost and the availability of robot, and the lack of training opportunity. The better view of the operative field and the shorter patient hospital stay were considered as the main advantages. Older surgeons trust more likely in TORS benefits (p = 0.001) and surgical field view advantages (p = 0.037) compared to younger participants. TORS is an important surgical minimal invasive approach for the future for 46% of residents and fellows versus 61% of older OTO-HNS (p = 0.001). Compared to older OTO-HNS, residents and fellows reported more frequently that the lack of training opportunity is the main barrier of TORS (52% versus 12%; p = 0.001). Residents and fellows did not share the same expectations of robot improvement for the future than older OTO-HNS. Experienced OTO-HNS had better perception and trust toward TORS than residents and fellows. Residents and fellows identified the lack of training opportunity as the main barrier to the use of TORS. TORS access and training programs need to be improved in academic hospitals for residents and fellows.
Collapse
Affiliation(s)
- Jerome R Lechien
- Department of Otolaryngology and Head and Neck Surgery, Division of Broncho-Esophagology, EpiCURA Hospital, UMONS Research Institute for Health Sciences and Technology, University of Mons (UMons), Mons, Belgium.
- Department of Otolaryngology and Head and Neck Surgery, Foch Hospital, Paris Saclay University, Paris, France.
- Elsan Polyclinic of Poitiers, Poitiers, France.
- Department of Otolaryngology-Head and Neck Surgery, CHU Saint-Pierre, Brussels, Belgium.
- Laboratory of Anatomy and Cell Biology, UMONS Research Institute for Health Sciences and Technology, University of Mons (UMONS), Avenue du Champ de mars, 6, B7000, Mons, Belgium.
| | - Stephane Hans
- Department of Otolaryngology and Head and Neck Surgery, Foch Hospital, Paris Saclay University, Paris, France
| |
Collapse
|
9
|
Larsen MHH, Channir HI, Madsen AKØ, Rubek N, O'Leary P, Kjærgaard T, Kehlet H, von Buchwald C. Why in hospital following transoral robotic lingual tonsillectomy? Acta Otolaryngol 2023; 143:796-800. [PMID: 37897327 DOI: 10.1080/00016489.2023.2265983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 09/22/2023] [Indexed: 10/30/2023]
Abstract
BACKGROUND The reported hospital length of stay (LOS) following transoral robotic surgery lingual tonsillectomy (TORS-L) is variable, with limited understanding of the factors requiring hospitalization and no evidence-based criteria for discharge. AIMS/OBJECTIVES This observational cohort study investigated factors hindering discharge following TORS-L in a well-defined postoperative care program. METHODS Patients were included between August 2020 and October 2022. A discharge scheme was filled out twice daily, specifying the factor(s) for hospitalization among patients undergoing TORS-L. This trial was a sub-investigation of a national multicentre randomized clinical trial (RCT) testing the efficiency of high-dose dexamethasone on postoperative pain control. Participation in the RCT demanded admission to the fourth postoperative day as dexamethasone/placebo was given intravenously in repeated dosages till day 4 postoperatively. RESULTS Eighteen patients were included in the analysis. The main factor for hospitalization was nutritional difficulties, while pain was a limiting factor for discharge only on the first postoperative 1-3 days. More than half of the patients could have potentially been discharged on postoperative day 2 when omitting the RCT treatment plan in the analysis. CONCLUSION The study estimates that the majority of patients may be discharged on postoperative day 2 following TORS-L.
Collapse
Affiliation(s)
- Mikkel Hjordt Holm Larsen
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Hani Ibrahim Channir
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Anne Kathrine Østergaard Madsen
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Niclas Rubek
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Padraig O'Leary
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Aarhus University Hospital, Copenhagen, Denmark
| | - Thomas Kjærgaard
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Aarhus University Hospital, Copenhagen, Denmark
| | - Henrik Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian von Buchwald
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| |
Collapse
|
10
|
De Virgilio A, Pellini R, Cammaroto G, Sgarzani R, De Vito A, Gessaroli M, Costantino A, Petruzzi G, Festa BM, Campo F, Moretti C, Pichi B, Mercante G, Spriano G, Vicini C, Meccariello G. Trans oral robotic surgery for oropharyngeal cancer: A multi institutional experience. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:106945. [PMID: 37331862 DOI: 10.1016/j.ejso.2023.05.020] [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: 01/11/2023] [Revised: 05/23/2023] [Accepted: 05/30/2023] [Indexed: 06/20/2023]
Abstract
OBJECTIVES Trans Oral Robotic Surgery (TORS) has proved to be a safe and feasible treatment for oropharyngeal squamous cell carcinoma (OPSCC). The aim of this study is to analyse oncological outcomes of OPSCC patients treated with TORS. MATERIALS AND METHODS This study involved 139 patients with OPSCC, treated with TORS between 2008 and 2020. Clinicopathological characteristics, treatment details and oncological outcomes were evaluated retrospectively. RESULTS The management strategies included TORS alone in 42.5%, TORS-RT in 25.2% and TORS-CRT in 30.9%. The ENE was noted in 28.8% of neck dissections. In 19 patients clinically classified as unknown primaries, the primary was found in 73.7%. Rates of local, regional relapses and distant metastasis were 8.6%, 7.2%, and 6.5%, respectively. The 5 year- Overall Survival and Disease Free Survival were 69.6% and 71.3%, respectively. CONCLUSION TORS fits well in the modern management of OPSCC. Although definitive CRT remains a milestone, TORS is proving to be a valid and safe treatment option. The choice of the therapeutic strategy requires evaluation by a multidisciplinary team.
Collapse
Affiliation(s)
- Armando De Virgilio
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20090, Pieve Emanuele, MI, Italy; Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, MI, Italy
| | - Raul Pellini
- Department of Otolaryngology-Head and Neck Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy.
| | - Giovanni Cammaroto
- Otolaryngology and Head-Neck Surgery Unit, Department of Surgery, Morgagni Pierantoni Hospital, Azienda USL della Romagna, Forlì, Italy
| | - Rossella Sgarzani
- Plastic Surgery, DIMES Department, University of Bologna, Bologna, Italy
| | - Andrea De Vito
- Otolaryngology and Head-Neck Surgery Unit, Department of Surgery, Morgagni Pierantoni Hospital, Azienda USL della Romagna, Forlì, Italy
| | - Manlio Gessaroli
- Maxillo-Facial Unit, Department of Surgery, Maurizio Bufalini Hospital, Azienda USL della Romagna, Cesena, Italy
| | - Andrea Costantino
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20090, Pieve Emanuele, MI, Italy; Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, MI, Italy
| | - Gerardo Petruzzi
- Department of Otolaryngology-Head and Neck Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Bianca Maria Festa
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20090, Pieve Emanuele, MI, Italy; Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, MI, Italy
| | - Flaminia Campo
- Department of Otolaryngology-Head and Neck Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Claudio Moretti
- Department of Otolaryngology-Head and Neck Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy; University of Ferrara, Ferrara, Italy
| | - Barbara Pichi
- Department of Otolaryngology-Head and Neck Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Giuseppe Mercante
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20090, Pieve Emanuele, MI, Italy; Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, MI, Italy
| | - Giuseppe Spriano
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20090, Pieve Emanuele, MI, Italy; Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, MI, Italy
| | - Claudio Vicini
- Otolaryngology and Head-Neck Surgery Unit, Department of Surgery, Morgagni Pierantoni Hospital, Azienda USL della Romagna, Forlì, Italy; University of Ferrara, Ferrara, Italy
| | - Giuseppe Meccariello
- Otolaryngology and Head-Neck Surgery Unit, Department of Surgery, Morgagni Pierantoni Hospital, Azienda USL della Romagna, Forlì, Italy
| |
Collapse
|
11
|
The role of transoral surgery in the diagnosis of the carcinoma of unknown origin of the head and neck. Curr Opin Otolaryngol Head Neck Surg 2023; 31:129-133. [PMID: 36912225 DOI: 10.1097/moo.0000000000000880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
PURPOSE OF REVIEW The aim of this article is to update readers on the most recent evidence on the role of trans oral surgery (TOS) in the diagnosis of carcinoma of the unknown primary of the head and neck. RECENT FINDINGS Tongue base mucosectomy has an important role in identifying the primary in patients who have had negative imaging, PET CT scans and ipsilateral tonsillectomy. In patients with bilateral nodal disease, tongue base mucosectomy should precede tonsillectomy. There are several unanswered questions that remain regarding sequencing of operations and use of intraoperative frozen section. SUMMARY An evidence-based approach to diagnosis is important to ensure the highest detection rates, and least morbidity, in patients with head and neck carcinoma of the unknown primary.
Collapse
|