Robotic approaches to the pharynx: tonsil cancer

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

4 Laryngoscope, 2024.

Presentation and outcomes of patients with clinically T1-2, N0 oropharynx squamous cell carcinoma: The interplay of primary treatment modality and human papillomavirus status

BACKGROUND

To examine the pattern of utilization and outcomes of definitive radiotherapy (RT) versus primary robotic-assisted surgery in patients with early-stage oropharyngeal squamous cell carcinoma (OPSCC).

METHODS

A retrospective cohort analysis of patients with clinically T1-2, N0 OPSCC was performed using the National Cancer Database, 2010-2016.

RESULTS

A total of 1451 patients were included. Prevalence of human papillomavirus (HPV)-positive tumors was 58.30%. Primary surgery was performed in 30.25% of the sample. Tongue base and clinically T1 tumors were each associated with a higher likelihood of undergoing surgery (p < 0.05). Histopathology of patients who underwent surgery demonstrated a prevalence of 15.95% with lymphovascular invasion, 16.67% with extranodal extension, 19.36% were T updated, and 30.00% were N upstaged. Improved survival was observed in the surgery + adjuvant RT group compared to RT alone for HPV-positive tumors (HR: 0.27; 95%CI: 0.12, 0.62; p = 0.002).

CONCLUSION

This study provides epidemiological perspective regarding management pattern and outcomes of patients with early-stage OPSCC.

Swallowing After Primary TORS and Unilateral or Bilateral Radiation for Low- to Intermediate-Risk Tonsil Cancer

OBJECTIVE

The primary course of treatment for patients with low- to intermediate-risk tonsil cancer has evolved with a shift toward primary transoral robotic surgery (TORS) or radiation therapy (RT). While favorable outcomes have been reported after deintensification via unilateral TORS or RT (uniRT), comparisons of functional outcomes between these treatments are lacking. We compared clinical outcomes (Dynamic Imaging Grade of Swallowing Toxicity [DIGEST] and feeding tube [FT]) and patient-reported swallowing outcomes (MD Anderson Dysphagia Inventory [MDADI]) based on primary treatment strategy: TORS, uniRT, or bilateral RT (biRT).

STUDY DESIGN

Secondary analysis of prospective cohort.

SETTING

Single institution.

METHODS

The study sample comprised 135 patients with HPV/p16+ T1-T3, N0-2b (American Joint Committee on Cancer, seventh edition), N0-1 (eighth edition) squamous cell carcinoma of the tonsil were sampled from a prospective registry. Modified barium swallow studies graded per DIGEST, FT placement and duration, and MDADI were collected.

RESULTS

Baseline DIGEST grade significantly differed among treatment groups, with higher dysphagia prevalence in the TORS group (34%) vs the biRT group (12%, P = .04). No significant group differences were found in DIGEST grade or dysphagia prevalence at subacute and longitudinal time points (P = .41). Mean MDADI scores were similar among groups at baseline (TORS, 92; uniRT, 93; biRT, 93; P = .90), subacute (TORS, 83; uniRT, 88; biRT, 82; P = .38) and late time points (TORS, 86; uniRT, 86; biRT, 87; P = .99). FT placement and duration significantly differed among primary treatment groups (FT [median days]: TORS, 89% [3]; uniRT, 8% [82]; biRT, 37% [104]; P < .001).

CONCLUSION

While TORS and uniRT offer optimal functional outcomes related to dysphagia, results suggest that no measurable clinician-graded or patient-reported differences in swallow outcomes exist among these primary treatment strategies and biRT. Aside from baseline differences that drive treatment selection, differences in FT rate and duration by primary treatment strategy likely reflect diverse toxicities beyond dysphagia.

Infectivity of murine papillomavirus in the surgical byproducts of treated tail warts

OBJECTIVES/HYPOTHESIS

Human papillomavirus (HPV) is a highly stable DNA virus that causes disease in human organ systems, including the larynx and oropharynx. The treatment of HPV-associated diseases with scalpels, lasers, and other surgical instruments has the potential to release infectious particles, placing healthcare workers at risk. The objectives of this study were to create a reproducible in vivo animal model of papillomavirus infectivity and to compare the infectivity of byproducts of surgically treated mouse papillomavirus (MmuPV1) warts.

STUDY DESIGN

Animal study.

METHODS

Nude laboratory mice (Mus musculus) with established MmuPV1 tail warts were treated with scalpel excision, potassium titanyl phosphate (KTP) laser ablation, and coblator treatment. Uninfected nude mice were challenged with surgical byproducts, including ablated and heated tissue, and surgical smoke products. The incidence and time course of the appearance of warts was recorded.

RESULTS

There was rapid transmission of virus in mice challenged with scalpel-treated warts, with 50% penetrance of infection at day 13 and 100% at day 32. For KTP-treated warts, there was the slower development of infection (50% by day 35) but 100% penetrance by day 52. Coblator-treated tissue reached 50% penetrance at day 59 and a maximum of 73% penetrance. Smoke plume captured during treatment with the KTP laser and coblator was highly infectious, as was the material captured in a laser filter.

CONCLUSIONS

MmuPV1 remains infectious in all modes of surgically treated tissue, and the smoke plume is capable of transmitting infection. Healthcare workers should use appropriate precautions to lower their risk of infection when treating papillomavirus-associated diseases.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:712-717, 2020.

The Role of Surgery in the Management of Recurrent Oropharyngeal Cancer

The incidence of oropharyngeal squamous cell carcinoma (OPSCC) continues to rise worldwide at a dramatic pace, buoyed by the predominance of human papilloma virus (HPV) driven disease (Panwar et al. 2014). While the outcomes of patients with HPV-positive OPSCC are dramatically improved compared to HPV-negative OPSCC, treatment failures do occur. The result is an inevitable rise in the incidence of recurrent OPSCC. Since the majority of incident OPSCC cases are treated with some form of radiation therapy (primary or adjuvant), surgery remains the backbone of treatment for recurrent OPSCC. This section will focus on options for surgical management of recurrent OPSCC.

The role of transoral robotic surgery in the management of oropharyngeal squamous cell carcinoma: a current review

The incidence of oropharyngeal squamous cell carcinoma (OPSCC) is increasing in the USA despite a decline in traditional risk factors. This trend is attributed to human papillomavirus (HPV)-associated malignancies and is particularly notable in a younger patient demographic with fewer comorbid diseases and longer life expectancies. Therefore, both oncologic and functional outcomes are important to consider when managing OPSCC in the modern era. The historical management of OPSCC was typically surgical, but traditional open approaches resulted in significant morbidity. As the paradigm shifted, organ-preserving treatment regimens, namely, radiotherapy (RT) and chemoradiation (CRT), replaced surgery as the primary treatment modality. However, these treatment strategies are not without risk of significant sequelae and functional impairment. Transoral robotic surgery (TORS) is a minimally invasive surgical approach that offers surgical access to the oropharynx without the morbidity of open procedures while achieving excellent oncologic and functional outcomes. The appropriate application of this new technology is still being investigated but the current literature supports TORS as a viable option in the management of OPSCC.