Transoral Robotic Surgery: A Population-Level Analysis

Transoral non-robotic surgery for oropharyngeal squamous cell carcinoma

PURPOSE

This retrospective cohort study aims to evaluate the clinical, oncological, and functional outcomes of transoral non-robotic surgery for oropharyngeal squamous cell carcinoma (OPSCC).

MATERIALS AND METHODS

Data from 131 patients with surgically treated OPSCC (2010-2022) were analyzed. Patients who underwent exclusively transoral surgery were included in the study. The surgeries were performed under microscopic or endoscopic guidance and either a CO2 laser or an ultrasound/radiofrequency scalpel was used as a cutting instrument, depending on the characteristics and location of the tumor. Functional outcomes were assessed in terms of length of hospital stay, tracheostomy rate, duration of feeding tube dependency and complications. Survival outcomes were assessed in terms of overall survival (OS), disease-free survival (DFS) and disease-specific survival (DSS).

RESULTS

Of 74 included patients, transoral surgery demonstrated safety with no major complications. Tracheotomy was performed in 51.4 % of cases, and was maintained for a median of 10 days. Complete swallowing recovery was restored in 97.3 % of cases, after a median of 5 days. The median length of hospital stay was 12 days. At 5 years, OS was 68.2 %, PFS was 58.2 % and DSS was 83.6 %.

CONCLUSION

The study confirms the safety and efficacy of a transoral approach for OPSCC. Having the capability to utilize and access a variety of tools provides the opportunity to tailor the technique to the individual patient and specific circumstances.

Effectiveness and outcomes of endoscopic resection for superficial pharyngeal squamous cell carcinomas

BACKGROUND

With the development of endoscopic imaging, superficial pharyngeal squamous cell carcinoma can now be detected during routine endoscopy. Recently, the effectiveness of endoscopic resection for superficial pharyngeal squamous cell carcinoma have been reported.

METHODS

This study had a retrospective single-center design that included patients with superficial pharyngeal squamous cell carcinoma who underwent endoscopic resection. A total 47 patients with 53 lesions were analyzed.

RESULTS

En bloc and R0 resection rates were 83.0% and 56.6%. Local recurrence and cervical lymph node metastasis (CLNM) were detected in 1 and 3 patients during follow-up. The macroscopic type 0-I was an independent factor for CLNM. The 3-year cumulative incidence of metachronous pharyngeal squamous cell carcinoma following endoscopic resection was 33.0%, and the 5-year overall survival rate was 89.2%.

CONCLUSIONS

Endoscopic resection is an effective treatment for superficial pharyngeal squamous cell carcinomas, and the macroscopic type 0-I is a useful predictor of CLNM.

Perception of Young European Otolaryngologists toward Transoral Robotic Surgery in Head and Neck Oncology and Surgery

Background: To investigate the perception of young European otolaryngologists (OTOs), i.e., head and neck surgeons, toward transoral robotic surgery (TORS). Methods: Members of the Young Confederation of European Otorhinolaryngology-Head and Neck Surgery and Young Otolaryngologists of International Federation of Otorhinolaryngological Societies were surveyed about TORS perception and practice. Results: The survey was completed by 120 young OTOS (26%). The most important barriers to TORS were robot availability (73%), cost (69%), and lack of training (37%). The participants believed that the main benefits include better surgical filed view (64%), shorter hospital stay (62%), and better postoperative outcomes (61%) than the conventional approach. Head and neck surgeons considered cT1-T2 oropharyngeal cancers (94%), resection of base of tongue for sleep apnea (86%), or primary unknown cancer (76%) as the most appropriate indications. A total of 67% of TORS surgeons assessed themselves as adequately trained in TORS. Conclusions: Young European OTOs report positive perception, adoption, and knowledge of TORS. The cost-related unavailability and the lack of training or access are reported to be the most important barriers for the spread of TORS.

Oncological and functional outcomes for transoral robotic surgery following previous radiation treatment for upper aerodigestive tract head and neck cancers. A French multicenter GETTEC group study

BACKGROUND

Transoral robotic surgery (TORS) opens new perspectives. We evaluated the outcomes for patients having undergone TORS after previous radiotherapy.

METHODS

A retrospective multicenter study (n = 138) in a previously irradiated area between 2009 and 2020. Survival was assessed with the Kaplan-Meier method. Prognostic factors were evaluated using a chi-squared test, Fisher's test, or Wilcoxon's test.

RESULTS

The median length of hospital stay was 12.5 days. Bleeding was the most frequent postoperative complication (15.2%, n = 22). Prophylactic vessel ligation did not significantly decrease bleeding. Complications were significantly lower for Tis, T1, and N0 tumors. 91.6% (n = 120) of the patients with a perioperative tracheotomy could be decannulated. Larynx was functional for 65.94% of the patients. The median length of follow-up was 26 months. The 5-year overall and relapse-free survival rates were respectively 59.9% and 43.4%.

CONCLUSION

Oncological and functional results confirmed the value of TORS as a treatment in previously irradiated area.

Identification of new head and neck squamous cell carcinoma molecular imaging targets

OBJECTIVES

Intraoperative fluorescence imaging (FI) of head and neck squamous cell carcinoma (HNSCC) is performed to identify tumour-positive surgical margins, currently using epidermal growth factor receptor (EGFR) as imaging target. EGFR, not exclusively present in HNSCC, may result in non-specific tracer accumulation in normal tissues. We aimed to identify new potential HNSCC FI targets.

MATERIALS AND METHODS

Publicly available transcriptomic data were collected, and a biostatistical method (Transcriptional Adaptation to Copy Number Alterations (TACNA)-profiling) was applied. TACNA-profiling captures downstream effects of CNAs on mRNA levels, which may translate to protein-level overexpression. Overexpressed genes were identified by comparing HNSCC versus healthy oral mucosa. Potential targets, selected based on overexpression and plasma membrane expression, were immunohistochemically stained. Expression was compared to EGFR on paired biopsies of HNSCC, adjacent macroscopically suspicious mucosa, and healthy mucosa.

RESULTS

TACNA-profiling was applied on 111 healthy oral mucosa and 410 HNSCC samples, comparing expression levels of 19,635 genes. The newly identified targets were glucose transporter-1 (GLUT-1), placental cadherin (P-cadherin), monocarboxylate transporter-1 (MCT-1), and neural/glial antigen-2 (NG2), and were evaluated by IHC on samples of 31 patients. GLUT-1 was expressed in 100 % (median; range: 60-100 %) of tumour cells, P-cadherin in 100 % (50-100 %), EGFR in 70 % (0-100 %), MCT-1 in 30 % (0-100 %), and NG2 in 10 % (0-70 %). GLUT-1 and P-cadherin showed higher expression than EGFR (p < 0.001 and p = 0.015).

CONCLUSIONS

The immunohistochemical confirmation of TACNA-profiling results showed significantly higher GLUT-1 and P-cadherin expression than EGFR, warranting further investigation as HNSCC FI targets.

Transoral Surgery in HPV-Positive Oropharyngeal Carcinoma: Oncologic Outcomes in the Veterans Affairs System

OBJECTIVES

Most transoral robotic surgery (TORS) literature for HPV-positive oropharyngeal squamous cell carcinoma (HPV-OPC) derives from high-volume tertiary-care centers. This study aims to describe long-term recurrence and survival outcomes among Veterans Health Administration patients.

MATERIALS AND METHODS

Using the US Veterans Affairs database, we identified patients with HPV-OPC treated with TORS between January 2010 and December 2016. Patients were stratified in risk categories: low (0-1 metastatic nodes, negative margins), intermediate (close margins, 2-4 metastatic nodes, lymphovascular or perineural invasion, pT3-pT4 tumor), or high (positive margins, extranodal extension (ENE), and/or ≥5 metastatic nodes). Primary outcomes included overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS).

RESULTS

The cohort included 161 patients of which 29 (18%) were low-risk, 45 (28%) intermediate-risk, and 87 (54%) high-risk. ENE was present in 41% of node-positive cases and 24% had positive margins. Median follow-up was 5.6 years (95% CI, 3.0-9.3). The 5-year DSS for low, intermediate, and high-risk groups were: 100%, 90.0% (95% CI, 75.4-96.1%), and 88.7% (95% CI, 78.3-94.2%). Pathologic features associated with poor DSS on univariable analysis included pT3-T4 tumors (HR 3.81, 95% CI, 1.31-11; p = 0.01), ≥5 metastatic nodes (HR 3.41, 95% CI, 1.20-11; p = 0.02), and ENE (HR 3.53, 95% CI, 1.06-12; p = 0.04). Higher 5-year cumulative incidences of recurrence were observed in more advanced tumors (pT3-T4, 33% [95% CI, 14-54%] versus pT1-T2, 13% [95% CI, 8-19%]; p = 0.01).

CONCLUSIONS

In this nationwide study, patients with HPV-OPC treated with TORS followed by adjuvant therapy at Veterans Affairs Medical Centers demonstrated favorable survival outcomes comparable to those reported in high-volume academic centers and clinical trials.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:207-214, 2024.

Are new and young generations of surgeons more aware of transoral robotic surgery than older ones? An international survey

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.

Why in hospital following transoral robotic lingual tonsillectomy?

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.

Single centre analysis of perioperative complications in trans-oral robotic surgery for oropharyngeal carcinomas

Trans Oral Robotic Surgery (TORS) is a modality in the management of oropharyngeal squamous cell carcinoma(OPSCC). This study was conducted to show the rates of peri-operative complications after TORS for OPSCC in our experience. Single centre retrospective analysis of consecutive OPSCC treated with TORS. The surgical complication severity was recorded according to Clavien-Dindo criteria (CDC). Eighty-seven OPSCC were operated with TORS. According to CDC, grade I, grade II and IIIb were registered in 8%, 4.6% and 11.5% of cases, respectively. The postoperative pain, registered with visual-analogue scale (VAS) score, was 8 ± 1.2 for the secondary healing wounds and 6.2 ± 1.5 for the flap reconstructions (p < 0.01). The impact on swallowing function was not significant between secondary healing and flap reconstructions(p = 0.96). Any major or life-threatening intraoperative complications have not been recorded. Only one patient had postoperative bleeding into the neck whilst 13.3% of patients had postoperative bleeding from the primary tumor. No total local or free flap failure were registered. The mean duration of tracheostomy use was 7.4 ± 2.6 days, and nasogastric tube 14.3 ± 6.9 days. Only one patient, who had also reconstruction with flap, experienced a postoperative severe dysphagia with severe aspiration, needing a permanent tracheostomy tube and percutaneous endoscopic gastrostomy feeding. TORS for OPSCC showed less morbidity, lower risk of severe complication and mortality. Thus, this treatment modality could be offered as first line treatment in selected cases.

Role of transoral robotic surgery in surgical treatment of early-stage supraglottic larynx carcinoma

BACKGROUND

There are several options for primary surgical treatment of early-stage supraglottic squamous cell carcinoma (SCC), including transoral robotic surgery (TORS). The purpose of this study was to compare outcomes of TORS to open partial laryngectomy and transoral laser microsurgery (TLM).

METHODS

Patients with clinical classification T1-2 supraglottic SCC diagnosed 2010-2019, treated with TORS, open partial laryngectomy, or TLM in the National Cancer Database were selected.

RESULTS

One thousand six hundred three patients were included: 17% TORS, 26.5% TLM, 56.5% open. TORS patients had the lowest rates of adjuvant treatment (28.4% vs. TLM: 45.0%, open: 38.5%, p < 0.001), and lower positive margin rates than TLM (16.9% vs. 30.5%, p < 0.001). Thirty-day and ninety-day post-operative mortality did not differ between the approaches. Five-year survival was higher following TORS compared to open surgery (77.8% vs. 66.1%, p = 0.01); this difference persisted following matched-pair analysis.

CONCLUSIONS

TORS may be a safe and effective surgical approach for early-stage supraglottic SCC in appropriate patients.

Adoption of otolaryngologist-head neck surgeons toward transoral robotic surgery: An international survey

Objective

To investigate perception, adoption and awareness of otolaryngologist-head neck surgeons (OTO-HNS) toward transoral robotic surgery (TORS).

Methods

An online survey was sent to 1383 OTO-HNS on the perception, adoption and awareness about TORS to members of many otolaryngological societies. The following aspects were assessed: TORS access; training; awareness/perception; indications and advantages/barriers to TORS practice. The responses were presented for the entire cohort and regarding the TORS experience of OTO-HNS.

Results

A total of 359 completed the survey (26%); including 115 TORS surgeons. TORS-surgeons carry out a mean number of 34.4 annual TORS procedures. The primary barriers to TORS were the cost of the robot (74%) and disposable accessories (69%), and the lack of training opportunity (38%). The 3D view of the surgical field (66%), the postoperative quality of life outcomes (63%) and the shorter hospital stay (56%) were the most important benefits of TORS. TORS-surgeons believed more frequently that TORS is indicated for cT1-T2 oropharyngeal and supraglottic cancers than non-TORS surgeons (p < .005). Participants believed that the priorities for the future consisted of the reduction of the robot arm size and the incorporation of flexible instruments (28%); the integration of laser (25%) or GPS tracking based on imaging (18%), all of them to improve accesses to hypopharynx (24%), supraglottic larynx (23%) and vocal folds (22%).

Conclusions

The perception, adoption and knowledges toward TORS depend on the access to robot. The findings of this survey may help guide decisions on how improve the dissemination of TORS interest and awareness.

Intraoperative Imaging Techniques to Improve Surgical Resection Margins of Oropharyngeal Squamous Cell Cancer: A Comprehensive Review of Current Literature

Inadequate resection margins in head and neck squamous cell carcinoma surgery necessitate adjuvant therapies such as re-resection and radiotherapy with or without chemotherapy and imply increasing morbidity and worse prognosis. On the other hand, taking larger margins by extending the resection also leads to avoidable increased morbidity. Oropharyngeal squamous cell carcinomas (OPSCCs) are often difficult to access; resections are limited by anatomy and functionality and thus carry an increased risk for close or positive margins. Therefore, there is a need to improve intraoperative assessment of resection margins. Several intraoperative techniques are available, but these often lead to prolonged operative time and are only suitable for a subgroup of patients. In recent years, new diagnostic tools have been the subject of investigation. This study reviews the available literature on intraoperative techniques to improve resection margins for OPSCCs. A literature search was performed in Embase, PubMed, and Cochrane. Narrow band imaging (NBI), high-resolution microendoscopic imaging, confocal laser endomicroscopy, frozen section analysis (FSA), ultrasound (US), computed tomography scan (CT), (auto) fluorescence imaging (FI), and augmented reality (AR) have all been used for OPSCC. NBI, FSA, and US are most commonly used and increase the rate of negative margins. Other techniques will become available in the future, of which fluorescence imaging has high potential for use with OPSCC.

Transoral Robotic Surgery for Oropharyngeal Squamous Cell Carcinoma of the Tonsil versus Base of Tongue: A Systematic Review and Meta-Analysis

Simple Summary

Transoral Robotic Surgery (TORS) has become widely adopted for the surgical removal of oropharyngeal squamous cell carcinoma (OPSCC). However, it is currently unknown if TORS has equal efficacy and outcomes in patients with tonsillar or base of tongue (BOT) OPSCC. Therefore, we performed a systematic review, including articles describing the surgical management of OPSCC with TORS that compared margin status, complications, and recurrence between tonsil and BOT. BOT OPSCC had a higher rate of positive margins compared to tonsillar OPSCC. However, no differences were seen in the recurrence or postoperative hemorrhage rates of BOT and tonsillar OPSCC. While a higher rate of positive margins was seen in BOT OPSCC when compared to tonsillar OPSCC, this did not translate to a higher recurrence rate in the BOT group. Future research on which subset of patients with BOT is more likely to have positive margins is warranted to improve the utility of TORS further.

Abstract

Transoral Robotic Surgery (TORS) has become widely adopted for the surgical removal of oropharyngeal squamous cell carcinoma (OPSCC), with the most common locations being in the tonsil and base of tongue (BOT). However, it is currently unknown if TORS has equal efficacy and outcomes in patients with tonsillar or BOT OPSCC. Therefore, the aim of this study was to compare the margin status and recurrence rates of tonsillar and BOT OPSCC after TORS. Per PRISMA guidelines, PubMed, Scopus, and CINAHL were systematically searched from inception to 2/28/2022. Articles including the surgical management of OPSCC with TORS that compared margin status, complications, and recurrence between tonsil and BOT were included. Meta-analyses of proportions and odds ratios were performed. A total of 28 studies were included, comprising 1769 patients with tonsillar OPSCC and 1139 patients with BOT OPSCC. HPV positivity was seen in 92.3% of tumors. BOT OPSCC had a higher rate of positive margins compared to tonsillar OPSCC (28.1% [95%CI 15.1–43.3] vs. 7.5% [95%CI 3.3–13.3]). No differences were seen in recurrence between BOT and tonsillar OPSCC (OR 1.1 [95%CI 0.8–1.5], p = 0.480). In addition, no differences in postoperative hemorrhage were seen between tonsillar and BOT OPSCC (10.7% [95%CI 6.1–16.5] vs. 8.8% [95% CI 1.5–21.3]). While a higher rate of positive margins was seen in BOT OPSCC when compared to tonsil OPSCC, this did not translate to a higher recurrence rate in the BOT group. Future research on which subset of patients with BOT is more likely to have positive margins is warranted to improve the utility of TORS further.

The effect of human papillomavirus status on prognosis and local treatment strategies of T1-2N0 oropharyngeal squamous cell cancer

Purpose

To explore the effect of human papillomavirus (HPV) status on prognosis and further investigate whether human papillomavirus (HPV) status has an impact on the local treatment strategies for T1-2N0 oropharyngeal squamous cell cancer (OPSCC) patients.

Methods

Patients diagnosed with T1-2N0 OPSCC between 2010 and 2015 were included from the Surveillance, Epidemiology, and End Results database. Data were analyzed using propensity score matching (PSM), Chi-square test, Kaplan-Meier survival analysis, and Cox multivariable analyses.

Results

A total of 1,004 patients were identified, of whom 595 (59.3%) had HPV-related tumors. Of all the patients, 386 (38.4%) and 618 (61.6%) received definitive radiotherapy and radical surgery, respectively. HPV status had no significant effect on local treatment strategies for early-stage OPSCC (P = 0.817). The 3-year cancer-specific survival (CSS) and overall survival (OS) were 89.6 and 80.1%, respectively. Compared to those with HPV-negative diseases, patients with HPV-positive diseases had better CSS and OS. A total of 222 pairs of patients were completely matched after PSM. The results of multivariate Cox regression analysis showed that patients with HPV-positive disease had significantly better CSS (P = 0.001) and OS (P < 0.001) compared to those with HPV-negative tumors. However, local treatment strategy was not associated with survival outcomes after PSM (CSS, P = 0.771; OS, P = 0.440). The subgroup analysis showed comparable CSS and OS between those treated with radical surgery and definitive radiotherapy regardless of HPV status.

Conclusions

HPV status is an independent prognostic factor for the survival of stage T1-2N0 OPSCC patients. Local treatment strategies had no significant effect on the survival of early-stage OPSCC regardless of HPV status. Patients with early-stage OPSCC should be informed regarding the pros and cons of definitive radiotherapy or radical surgery.

Transoral robotic surgery adoption and safety in treatment of oropharyngeal cancers

BACKGROUND

Transoral robotic surgery (TORS) was approved by the Food and Drug Administration in 2009 for the treatment of oropharyngeal cancers (oropharyngeal squamous cell carcinoma [OPSCC]). This study investigated the adoption and safety of TORS.

METHODS

All patients who underwent TORS for OPSCC in the National Cancer Data Base from 2010 to 2016 were selected. Trends in the positive margin rate (PMR), 30-day unplanned readmission, and early postoperative mortality were evaluated. Outcomes after TORS, nonrobotic surgery (NRS), and nonsurgical treatment were compared with matched-pair survival analyses.

RESULTS

From 2010 to 2016, among 73,661 patients with OPSCC, 50,643 were treated nonsurgically, 18,024 were treated with NRS, and 4994 were treated with TORS. TORS utilization increased every year from 2010 (n = 363; 4.2%) to 2016 (n = 994; 8.3%). The TORS PMR for base of tongue malignancies decreased significantly over the study period (21.6% in 2010-2011 vs 15.8% in 2015-2016; P = .03). The TORS PMR at high-volume centers (≥10 cases per year; 11.2%) was almost half that of low-volume centers (<10 cases per year; 19.3%; P < .001). The rates of 30-day unplanned readmission (4.1%) and 30-day postoperative mortality (1.0%) after TORS were low and did not vary over time. High-volume TORS centers had significantly lower rates of 30-day postoperative mortality than low-volume centers (0.5% vs 1.5%; P = .006). In matched-pair analyses controlling for clinicopathologic cofactors, 30-, 60-, and 90-day posttreatment mortality did not vary among patients with OPSCC treated with TORS, NRS, or nonsurgical treatment.

CONCLUSIONS

TORS has become widely adopted and remains safe across the country with a very low risk of severe complications comparable to the risk with NRS. Although safety is excellent nationally, high-volume TORS centers have superior outcomes with lower rates of positive margins and early postoperative mortality.

Current Status of Transoral Surgery for Patients With Early-Stage Pharyngeal and Laryngeal Cancers in Japan

As the laryngopharynx is closely related to swallowing, speech, and phonation, it is necessary to consider not only disease control but also a minimally invasive approach for the treatment of laryngopharyngeal cancer. Transoral surgery has been reported to be a minimally invasive method for treating these diseases. Transoral videolaryngoscopic surgery (TOVS) and endoscopic laryngo-pharyngeal surgery (ELPS) have been developed in Japan and recently emerged as treatments for patients with early stage pharyngeal and laryngeal cancers. However, securing an appropriate field of view and a narrow operating space during TOVS or ELPS are critical issues to be resolved for these surgeries. The clinical significance and safety of transoral robotic surgery (TORS) using the da Vinci Surgical System have been widely reported to provide surgeons with increased visualization and magnification, resulting in precise surgical margins and rapid functional recovery. In this context, a multi-institutional clinical study was conducted to evaluate the treatment outcomes of TORS for the treatment of laryngopharyngeal cancer in Japan, and the da Vinci Surgical System for oral robot-assisted surgery for these diseases was approved by the Pharmaceutical Affairs Agency in August 2018. This review provides an overview of the therapeutic effects of TOVS, ELPS, and TORS, with a particular focus on these therapeutic results in Japan.

Human Papillomavirus and Squamous Cell Carcinoma of Unknown Primary in the Head and Neck Region: A Comprehensive Review on Clinical Implications

Squamous cell carcinoma of unknown primary (SCCUP) is a challenging diagnostic subgroup of oropharyngeal squamous cell carcinoma (OPSCC). The incidence of SCCUP is increasing in parallel with the well-documented increase in OPSCC and is likewise driven by the increase in human papillomavirus (HPV). The SCCUP patient often presents with a cystic lymph node metastasis and undergoes an aggressive diagnostic and treatment program. Detection of HPV in cytologic specimens indicates an oropharyngeal primary tumor origin and can guide the further diagnostic strategy. Advances in diagnostic modalities, e.g., transoral robotic surgery and transoral laser microsurgery, have increased the successful identification of the primary tumor site in HPV-induced SCCUP, and this harbors a potential for de-escalation treatment and increased survival. This review provides an overview of HPV-induced SCCUP, diagnostic modalities, and treatment options.

Robotic and Endoscopic Approaches to Head and Neck Surgery

Technological developments have disrupted the practice of medicine throughout history. Endoscopic and robotic techniques in head and neck surgery have emerged over the past half-century and have been incrementally adapted to expanding indications within otolaryngology. Robotic and endoscopic surgery have an established role in treatment of oropharyngeal and laryngeal cancers, reducing surgical morbidity and improving survival relative to traditional open approaches. Surgical treatment of human papillomavirus-mediated oropharyngeal cancer via transoral robotic surgery offers equivalent oncologic and functional outcomes relative to radiotherapy. Newer iterations of single-port robotic systems continue to expand the scope of robotics in head and neck surgery.

Oropharyngeal Carcinoma Treated with Surgery Alone: Outcomes and Predictors of Failure

OBJECTIVE

To analyze the oncologic outcomes and risk factors for recurrence in patients who underwent surgery for oropharyngeal squamous cell carcinoma (OPSCC), and in whom adjuvant therapy was not recommended or was declined.

METHODS

Retrospective cohort study of patients with OPSCC who were treated with transoral surgery only at a tertiary care academic medical center from April 2010 to March 2019.

RESULTS

Seventy-four patients met inclusion criteria. In 16, adjuvant therapy was recommended but declined. There were 8 recurrences, of which 6 had been given recommendations for adjuvant therapy. Of the 8 recurrences, 2 died, 2 are alive with disease, and 4 were successfully salvaged. Five patients died of unrelated causes. Lymphovascular invasion (LVI, P = .016) had a significant impact on recurrence, while other pathologic features of the primary tumor such as size, location, human papillomavirus (HPV) status, and margin status did not. Margins were classified as "positive" in 4 patients, "close" in 54, and "negative" in 16. There were 3 local recurrences (4.1%), each of whom had declined adjuvant therapy. Lymph node features such as N-stage (P = .0004), number of positive nodes (P = .0005), and presence of extra-nodal extension (ENE, P = .0042) had a statistically significant impact on relapse. Smoking history and surgical approach showed no significant impact on recurrence.

CONCLUSION

Patients who undergo surgery for HPV-positive OPSCC with negative margins, no PNI, no LVI, and ≤1 positive lymph node without ENE have low risk for recurrence. These patients can likely be safely treated with surgery alone. Patients with these risk factors who decline adjuvant therapy are at risk for recurrence, and should be monitored.

Transoral robotic surgery versus nonrobotic resection of oropharyngeal squamous cell carcinoma

The aim of this study is to evaluate the impact of transoral robotic surgery (TORS) compared to nonrobotic surgery (NRS) on overall survival in oropharyngeal squamous cell carcinoma (OPSCC). We performed a retrospective study of patients with HPV+ and HPV- OPSCC undergoing TORS or NRS with neck dissection using the National Cancer Database from the years 2010-2016. Among patients with OPSCC in our cohort, 3167 (58.1%) patients underwent NRS and 2288 (41.9%) underwent TORS. TORS patients demonstrated better overall survival than NRS patients (HPV+ patients: aHR 0.74, p = 0.02; HPV- patients: aHR 0.58, p < 0.01). Subsite analysis showed TORS was correlated with improved survival in base of tongue (BoT) primaries for both HPV+ (aHR 0.46, p = 0.01) and HPV- (aHR 0.42, p = 0.01) OPSCC. Compared to NRS, TORS is associated with improved overall survival for HPV+ and HPV- OPSCC, as well as greater overall survival for BoT primaries.

Machine Learning to Predict Treatment in Oropharyngeal Squamous Cell Carcinoma

OBJECTIVES

This study seeks to (1) demonstrate how machine learning (ML) can be used for prediction modeling by predicting the treatment patients with T1-2, N0-N1 oropharyngeal squamous cell carcinoma (OPSCC) receive and (2) assess the impact patient, socioeconomic, regional, and institutional factors have in the treatment of this population.

METHODS

A retrospective cohort of adults diagnosed with T1-2, N0-N1 OPSCC from 2004 to 2013 was obtained using the National Cancer Database. The data was split into 80/20 distribution for training and testing, respectively. Various ML algorithms were explored for development. Area under the curve (AUC), accuracy, precision, and recall were calculated for the final model.

RESULTS

Among the 19,111 patients in the study, the mean (standard deviation) age was 61.3 (10.8) years, 14,034 (73%) were male, and 17,292 (91%) were white. Surgery was the primary treatment in 9,533 (50%) cases and radiation in 9,578 (50%) cases. The model heavily utilized T-stage, primary site, N-stage, grade, and type of treatment facility to predict the primary treatment modality. The final model yielded an AUC of 78% (95% CI, 77-79%), accuracy of 71%, precision of 72%, and recall of 71%.

CONCLUSION

This study created a ML model utilizing clinical variables to predict primary treatment modality for T1-2, N0-N1 OPSCC. This study demonstrates how ML can be used for prediction modeling while also highlighting that tumor and facility realted variables impact the decision making process on a national level.

Acceptance and adoption of transoral robotic surgery in Germany

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Comparison of Survival After Transoral Robotic Surgery vs Nonrobotic Surgery in Patients With Early-Stage Oropharyngeal Squamous Cell Carcinoma

Importance

Transoral robotic surgery has been widely adopted since approval by the US Food and Drug Administration in December 2009, despite limited comparative data.

Objective

To compare the long-term outcomes of transoral robotic surgery with those of nonrobotic surgery for patients with early-stage oropharyngeal cancer.

Design, Setting, and Participants

A retrospective cohort comparative effectiveness analysis was performed of patients in the National Cancer Database with clinical T1 and T2 oropharyngeal squamous cell carcinoma diagnosed between January 1, 2010, and December 31, 2015, who underwent definitive robotic and nonrobotic surgery. Multivariable Cox proportional hazards regression analysis and propensity score matching were performed in patients with known human papillomavirus status to adjust for patient- and disease-related covariates. Survival after robotic and nonrobotic surgery was also compared in 3 unrelated cancers: prostate, endometrial, and cervical cancer. Statistical analysis was performed from April 10, 2019, to May 21, 2020.

Main Outcomes and Measures

Overall survival.

Results

Of 9745 patients (7652 men [78.5%]; mean [SD] age, 58.8 [9.6] years) who met inclusion criteria, 2694 (27.6%) underwent transoral robotic surgery. There was a significant increase in the use of robotic surgery from 18.3% (240 of 1309) to 35.5% (654 of 1841) of all surgical procedures for T1 and T2 oropharyngeal cancers from 2010 to 2015 (P = .003). Robotic surgery was associated with lower rates of positive surgical margins (12.5% [218 of 1746] vs 20.3% [471 of 2325]; P < .001) and lower use of adjuvant chemoradiotherapy (28.6% [500 of 1746] vs 35.7% [831 of 2325]; P < .001). Among 4071 patients with known human papillomavirus status, robotic surgery was associated with improved overall survival compared with nonrobotic surgery in multivariable Cox proportional hazards regression (hazard ratio [HR], 0.74; 95 CI, 0.61-0.90; P = .002). Similar results were seen when analyzing only the subset of facilities offering both robotic and nonrobotic surgery. The 5-year overall survival was 84.8% vs 80.3% among patients undergoing robotic vs nonrobotic surgery in propensity score-matched cohorts (P = .001). By contrast, there was no evidence that robotic surgery was associated with improved survival in other cancers, such as prostate cancer (HR, 0.92; 95% CI, 0.79-1.07; P = .26), endometrial cancer (HR, 0.97; 95% CI, 0.90-1.04; P = .36), and cervical cancer (HR, 1.27; 95% CI, 0.96-1.69; P = .10).

Conclusions and Relevance

This study suggests that transoral robotic surgery was associated with improved surgical outcomes and survival compared with nonrobotic surgery in patients with early-stage oropharyngeal cancer. Evaluation in comparative randomized trials is warranted.

Evaluating the risks and benefits of ketorolac in transoral robotic surgery

Transoral Robotic Surgery (TORS) is increasingly used for oropharyngeal neoplasms and obstructive sleep apnea. Post-operative pain and bleeding remain concerns. Ketorolac has proved to be a safe alternative or addition to narcotics in other operations, but has not been thoroughly evaluated in TORS. A retrospective review was carried out on all TORS cases at our institution between April 2012 and March 2019, with the vast majority of cases performed starting in 2017. Post-operative bleed rates were compared between those who received Ketorolac and those who did not. Secondary outcomes evaluated included post-operative pain scores and need for feeding tube upon discharge. A total of 81 TORS cases were evaluated, with 37 patients receiving Ketorolac. Six (7.4%) patients reported post-operative bleeding, with one major and five minor bleeds. The patient with major bleeding requiring operative intervention did not receive Ketorolac. All five patients with minor bleeding received Ketorolac, but no bleeds occurred in the immediate post-operative setting while receiving Ketorolac. The average time of bleeding was 8 days post-operative. There were no significant differences in pain scores or time to feeding tube removal. This preliminary study shows that Ketorolac use in the postoperative pain management after TORS does not increase major bleeding risk without benefits in pain management. There was increased risk of minor bleeding not requiring intervention, but this was not significant. Future prospective studies are needed to determine if it improves pain and swallowing and decreases narcotic requirements following TORS.

Days alive and out of hospital a validated patient-centred outcome to be used for patients undergoing transoral robotic surgery: protocol and perspectives

BACKGROUND

Days Alive and Out of Hospital (DAOH) has been validated as a suitable clinical trial outcome. It can be used as a proxy for surgical quality and reflects both procedure specific morbidity and mortality.

AIMS/OBJECTIVES

We propose DAOH as a supplement to established patient-related and objective outcomes, since it adds information on health care burden. Two upcoming studies incorporating DAOH are planned and will report DAOH for patients undergoing transoral robotic surgery.

METHODS

Firstly, a multicentre national prospective cohort study investigating DAOH with a 1-year follow-up after TORS is planned. Secondly a retrospective study of DAOH with a 1-year follow-up period will be performed using our institute's, the largest TORS center in Scandinavia, transoral robotic surgery (TORS) database. The database consists of more than 250 patients with more than 300 procedures performed between 2013 and 2018.

CONCLUSION AND SIGNIFICANCE

The planned studies of DAOH may, when applied to TORS, contribute to a better interpretation of post-treatment morbidity and provide a basis for further interventional studies to enhance recovery, perioperative optimization, and serve as a comparison tool between treatment modalities.

MRI-Based Assessment of the Pharyngeal Constrictor Muscle as a Predictor of Surgical Margin after Transoral Robotic Surgery in HPV-Positive Tonsillar Cancer

BACKGROUND AND PURPOSE

Transoral robotic surgery is an emerging strategy for treating human papillomavirus-positive cancers, but the role of MR imaging in predicting the surgical outcome has not been established. We aimed to identify preoperative MR imaging characteristics that predispose the outcome of transoral robotic surgery toward an insecure (positive or close) surgical margin in human papillomavirus-positive tonsillar squamous cell carcinoma.

MATERIALS AND METHODS

Between December 2012 and May 2019, sixty-nine patients underwent transoral robotic surgery at our institution. Among these, 29 who were diagnosed with human papillomavirus-positive tonsillar squamous cell carcinoma, did not receive neoadjuvant treatment, underwent preoperative 3T MR imaging, and had postoperative pathologic reports and were included in this retrospective study. Two neuroradiologists evaluated the preoperative MR imaging scans to determine the tumor spread through the pharyngeal constrictor muscle using a 5-point scale: 1, normal constrictor; 2, bulging constrictor; 3, thinning constrictor; 4, obscured constrictor; and 5, tumor protrusion into the parapharyngeal fat. The risk of an insecure surgical margin (involved or <1 mm) according to the MR imaging scores was predicted using logistic regression with the Firth correction.

RESULTS

The interobserver agreement for the MR imaging scores was excellent (κ = 0.955, P < .001). A score of ≥4 could predict an insecure margin with 87.5% sensitivity and 92.3% specificity (area under the curve = 0.899) and was the only significant factor associated with an insecure margin in the multivariable analysis (OR, 6.59; 95% CI, 3.11-22.28; P < .001).

CONCLUSIONS

The pre-transoral robotic surgery MR imaging scoring system for the pharyngeal constrictor muscle is a promising predictor of the surgical margin in human papillomavirus-positive tonsillar squamous cell carcinoma.

Cost Considerations for Robotic Surgery

Transoral robotic surgery (TORS) is a rapidly growing diagnostic and therapeutic modality in otolaryngology-head and neck surgery, having already made a large impact in the short time since its inception. Cost-effectiveness analysis is complex, and a thorough cost-effectiveness inquiry should analyze not only financial consequences but also impact on the health state of the patient. The cost-effectiveness of TORS is still under scrutiny, but the early data suggest that TORS is a cost-effective method compared with other available options when used in appropriately selected patients.

Transoral Robotic Surgical Proficiency Via Real-Time Tactile Collision Awareness System

OBJECTIVES

In 2009, the Food and Drug Administration approved the use of the surgical robotic system for removal of benign and malignant conditions of the upper aerodigestive tract. This novel application of robotic-assisted surgery, termed transoral robotic surgery (TORS), places robotic instruments and camera system through the mouth to reach recessed areas of the pharynx and larynx. Over the successive decade, there was a rapid adoption of TORS with a surgical growth rate that continues to increase. Despite the rapid clinical acceptance, the field of TORS has not yet seen substantive changes or advances in the technical shortcomings, the lack of which has restricted objective TORS-specific surgical skills assessment as well as subsequent skills improvement efforts. One of the primary technical challenges of TORS is operating in a confined space, where the robotic system is maneuvered within the restrictive boundaries of the mouth and throat. Due to these confined boundaries of the pharynx, instruments can frequently collide with anatomic structures such as teeth and bone, producing anatomic collisions. Therefore, we hypothesized that anatomic collisions negatively impact TORS surgical performance. Secondarily, we hypothesized that avoidance of unwanted anatomic collisions could improve TORS surgical proficiency.

METHODS

Design and fidelity testing for a custom TORS training platform with an integrated anatomic collision-sensing system providing real-time tactile feedback is described. Following successful platform assembly and testing, validation study using the platform was carried through prospective surgical training with trial randomization. Twenty otolaryngology-head and neck surgery residents, each trainee performing three discrete mock surgical trials (n = 60), performed the initial system validation. Ten of the 20 residents were randomized to perform the surgical trials utilizing the real-time feedback system. The remaining 10 residents were randomized to perform the surgical trials without the feedback system, although the system still could record collision data. Surgical proficiency was measured by Global Evaluative Assessment of Robotic Skills (GEARS) score, time to completion, and tumor resection scores (categorical scale ranging 0-3, describing the adequacy of resection).

RESULTS

Major anatomic collisions (greater than 5N of force) negatively affected GEARS robotic skills. A mixed model analysis demonstrated that for every additional occurrence of a major collision, GEARS robotic skills assessment score would decrease by 0.29 points (P = .04). Real-time collision awareness created significantly fewer major (> 5 N) anatomic collisions with the tactile feedback system active (n = 30, mean collisions = 2.9 ± 4.2) as compared with trials without tactile feedback (n = 30, mean collisions = 12.53 ± 23.23) (P < .001). The second assessment measure of time to completion was unaffected by the presence of collisions or by the use of tactile feedback system. The third proficiency assessment was measured with tumor resection grading. Tumor resection scores was significantly (P = .02) improved with collision awareness system activated than trials without collision awareness.

CONCLUSION

In order to test our primary hypothesis, a novel TORS training platform was successfully developed that provides collision force measurements including frequency, severity, and duration of anatomic collisions. Additionally, the platform was modulated to provide real-time tactile feedback of the occurrence of out-of-field collisions. Utilizing this custom platform, our hypothesis that anatomic collisions during TORS diminishes surgical performance was supported. Additionally, our secondary hypothesis that subsequent reduction of anatomic collisions improves TORS proficiency was supported by the surgical trial. Dedicated investigation to characterize the effect size and clinical impact is required in order to translate this finding into training curriculums and into clinical utilization.

LEVEL OF EVIDENCE

II (Randomized trial) Laryngoscope, 130:S1-S17, 2020.

Insurance Status as a Predictor of Treatment in Human Papillomavirus Positive Oropharyngeal Cancer

OBJECTIVES

The link between human papillomavirus (HPV) and oropharyngeal cancer (OPC) is well known. Locally advanced, HPV-positive OPC (HPV OPC) can be treated with either chemoradiation or primary surgery with or without adjuvant therapy. Head and neck cancer patients with government insurance or uninsured have been shown to have worse prognosis than similar patients with private insurance. In this study, we aimed to determine if insurance status would predict treatment modality in patients with HPV OPC.

STUDY DESIGN

A retrospective analysis using the National Cancer Database (NCDB).

METHODS

The National Cancer Database was used to identify patients with HPV OPC who underwent primary surgery or primary chemoradiation from 2010-2015. Insurance status was categorized as government, private, or no insurance. The relationship between insurance status and treatment was investigated using Chi square and multivariate regression models. Kaplan-Meier analyses were performed comparing overall survival (OS) by insurance status.

RESULTS

There were 10,606 patients were included. There was a statistically significant correlation between insurance status and primary treatment modality for HPV OPC (P < .001). Patients with government insurance were 19.3% less likely to undergo surgery and uninsured patients were 36.9% less likely to undergo primary surgery when compared to those with private insurance (P < .001), even after correcting for TNM stage in multivariate analysis. There was an improved 5-year OS for patients with private insurance (86.6%) versus both government insurance (68.4%) and no insurance (69.9%) (P < .001).

CONCLUSIONS

Patients with private insurance are more likely to undergo primary surgery in HPV OPC and have improved overall survival.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:776-781, 2021.

Margins in Laryngeal Squamous Cell Carcinoma Treated with Transoral Laser Microsurgery: A National Database Study

Objectives

To determine national positive margin rates in transoral laser microsurgery, to compare patients with positive and negative margins, and to identify factors associated with positive margins.

Study Design

Retrospective review of the National Cancer Database.

Setting

Population based.

Subjects/Methods

Patients included those with TIS-T3 laryngeal squamous cell carcinoma (2004-2014). Univariable and multivariable logistic regression were used to identify predictors.

Results

A total of 1959 patients met inclusion criteria. The national positive margin rate was 22.3%. Sixty-five percent of patients had T1 disease; 94.3% were N-negative; and 74.0% had glottic tumors. Fifty-eight percent of patients were treated at academic centers, and 60.6% were treated at facilities performing <2 cases per year. On multivariable analysis, factors associated with margin status included facility volume (odds ratio [95% CI]; in cases per year: 0.93 [0.89-0.97], P = .001), academic status (vs nonacademic; academic: 0.70 [0.54-0.90], P = .008), T-stage (vs T1; T2: 2.74 [2.05-3.65], T3: 5.53 [3.55-8.63], TIS: 0.59 [0.38-0.92], P < .001), and N-stage (vs N0; N1: 3.42 [1.79-6.54], N2: 2.01 [1.09-3.69], P < .001). Tumor subsite was not associated with margin status.

Conclusion

The national positive margin rate for laryngeal laser surgery is 22%, which is concerning given the equivalent survival benefit offered by surgery and primary radiation and the increased likelihood of bimodal therapy in the situation of positive margins. Cases treated at nonacademic centers and those with lower caseloads had a higher likelihood of positive margins. There was a linear association between T-stage and likelihood of positive margins, with T3 tumors being 5 times as likely as T1 to yield positive margins. This study highlights the importance of proper patient selection for transoral laser microsurgery resections.

Role of Treatment Deintensification in the Management of p16+ Oropharyngeal Cancer: ASCO Provisional Clinical Opinion

PURPOSE

An ASCO provisional clinical opinion offers timely clinical direction to ASCO’s membership after publication or presentation of potentially practice-changing data from major studies. This provisional clinical opinion addresses the role of treatment deintensification in the management of p16+ oropharyngeal cancer (OPC).

CLINICAL CONTEXT

For patients with p16+ OPC, current treatment approaches are well established. In the good-prognosis subset of nonsmoking p16+ patients with early-stage disease, these treatments have been highly successful, albeit with significant associated acute and late toxicity. Deintensification of surgical, radiation, and medical treatment in an effort to reduce toxicity while preserving high survival rates is an appropriate therapeutic objective currently being explored in patients who are experiencing the best treatment results. However, careful delineation of this good-risk subset is essential. While the current eighth edition of the American Joint Committee on Cancer staging system is prognostically robust, it should not be interpreted as reason to alter therapeutic decisions or justify treatment deintensification. The development of transoral surgical techniques and the adoption of intensity-modulated radiation therapy planning have been transformative in disease management and suggest potentially beneficial approaches. Recent advances in systemic treatments have been notable. The optimal integration and modification of these modalities to ameliorate toxicity has not been defined and remains an important focus of current investigation.

PROVISIONAL CLINICAL OPINION

The hypothesis that de-escalation of treatment intensity for patients with p16+ OPC can reduce long-term toxicity without compromising survival is compelling and necessitates careful study and the analysis of well-designed clinical trials before changing current treatment standards. Treatment deintensification for these patients should only be undertaken in a clinical trial. Additional information is available at www.asco.org/head-neck-cancer-guidelines .

Current Concepts in Chemotherapy for Head and Neck Cancer

This article highlights the evidence-based data to support systemic treatment options for patients with head and neck squamous cell carcinoma (HNSCC). The discovery of the human papillomavirus epidemic in HNSCC and its favorable prognosis has led to a major focus of research. Patients are stratified into clinical or pathologic risk categories and enrolled in trials comparing standard treatment paradigms with deintensification, in low-risk disease, or to intensification, in intermediate-risk or high-risk disease. Immunotherapy has proven beneficial in second-line palliative therapy and is under investigation in first-line palliative therapy and as a component of definitive, multimodality therapy for high-risk patients.

The interplay of IMRT and transoral surgery in HPV-mediated oropharyngeal cancer: Getting the balance right

Transoral surgery (TOS) and IMRT represent two primary local ablative treatment modalities for oropharyngeal cancer (OPC). The choice of one over the other represents an interplay between the chance of cure vs risk of late sequelae. HPV-mediated (HPV+) OPC patients generally have excellent outcomes, especially in TNM-8 stage I disease. Controversies exist over which treatment has a more favorable toxicity profile and equal efficacy in the management of this population. Non-randomized retrospective data show comparable oncological and functional outcomes between TOS-based vs IMRT-based treatment for this disease. Several de-intensification concepts have been explored in this subset in both primary surgery-based vs primary radiotherapy-based trials. However, no robust mature trial data are available to convincingly guide treatment selection. TOS is often presented as one of the de-intensification options although the majority of series also describe the use of adjuvant treatments which inevitably result in non-negligible toxicities. Patient selection and surgeons' training are paramount. Understanding tumor biology and the prognostic value of traditional 'adverse' features will further guide trial design for refinement of risk tailored approach. In conclusion, comparative data suggests TOS and IMRT are both effective treatment for TNM-8 stage I HPV+ OPC with similar oncological and functional outcomes. TOS as a single modality has potential advantages in mitigating radiation included toxicities. TOS should be avoided in the presence of clinically overt extranodal extension or when negative margins are unlikely to be achieved. TOS is also less ideal for cases with radiological features predicting a high risk of distant metastasis.

[Surgery or radiotherapy for oropharyngeal HPV-positive tumours?]

Oropharyngeal carcinomas related to the human papilloma virus (HPV; usually HPV16) exhibit biological differences in terms of carcinogenesis and are of relatively better prognosis (in the absence of tobacco consumption) compared to tobacco-related cancers. The therapeutic strategies between these two forms of cancers of the upper aerodigestive tract related to different risk factors are however identical, except therapeutic trial. In the absence of a sufficient level of evidence to define a specific strategy for induced HPV carcinomas, the analysis of the recent literature nonetheless allows us to suggest ways to guide the clinician in his therapeutic choice. Given the relative good prognosis HPV+ oropharyngeal cancers, an important goal is to avoid if possible a multimodal treatment that increases the sequelae and could degrade the quality of life. For the early stages I/II, it may be desirable to propose minimally invasive surgery if radiotherapy is avoidable or an exclusive conformal radiation therapy by intensity modulation in the opposite case. For the advanced stages III/IV, the recommendations are similar to those of cancers not related to HPV. Current trials should provide answers on the relevance of therapeutic deflation (absence of chemotherapy in the event of capsular rupture, dose reduction or irradiation volumes, etc.).

Initial and Long-term Retention of Robotic Technical Skills in an Otolaryngology Residency Program

OBJECTIVES/HYPOTHESIS

To objectively assess the initial and long-term retention of robotic surgical skills of otolaryngology residents.

STUDY DESIGN

This study was performed in an academic otolaryngology residency training program. Between October 2015 and November 2016, residents were invited to complete a prospective, multiphase robotic surgical skills training course: 1) online da Vinci Surgical System Assessment and didactic, 2) faculty-supervised robotic simulator training, 3) robotic docking and draping training, 4) robotic dry-lab exercises. To optimize surgical skill retention, the training laboratory was repeated 2 weeks after the initial training session.

METHODS

Twenty otolaryngology residents were included. Primary outcome was measured as robotic skill assessment scores on three tasks: camera targeting, peg board, and needle targeting. Skill assessments were completed prior to training, between the two training sessions, and at 1 month and 6 months after training. Residents were also asked to complete a self-assessment questionnaire.

RESULTS

Camera targeting scores were improved at midtraining (P < .001) and 1-month posttraining (P = .010). Peg board scores were improved at 1 month training (P = .043). Needle targeting scores were improved at midtraining (P = .002), 1 month (P = .002), and 6 months posttraining (P < .001). Resident self-assessment scores demonstrating comfort with using the robotic console (P < .01) and docking/draping (P < .01) improved significantly following the training.

CONCLUSIONS

Following a multiphase robotic training program, otolaryngology residents demonstrated significant, objective skill acquisition and retention at 1 month and 6 months follow-up. Although the proposed training strategy may be considered an important step in otolaryngology residency training, additional innovations are being designed toward a formal robotic training curriculum.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:1380-1385, 2019.

Transoral Robotic Surgery in the Nordic Countries: Current Status and Perspectives

Background: The five Nordic countries with a population of 27 M people form a rather homogenous region in terms of health care. The management of head and neck cancer is centralized to the 21 university hospitals in these countries. Our aim was to gain an overview of the volume and role of transoral robotic surgery (TORS) and to evaluate the need to centralize it in this area as the field is rapidly developing.

Materials and Methods: A structured questionnaire was sent to all 10 Departments of Otorhinolaryngology—Head and Neck Surgery in the Nordic countries having an active programme for TORS in December 2017.

Results: The total cumulative number of performed robotic surgeries at these 10 Nordic centers was 528 and varied between 5 and 240 per center. The median annual number of robotic surgeries was 38 (range, 5–60). The observed number of annually operated cases remained fairly low (<25) at most of the centers.

Conclusions: The present results showing a limited volume of performed surgeries call for considerations to further centralize TORS in the Nordic countries.

Extracapsular extension is not a significant prognostic indicator in non-squamous cancers of the major salivary glands

Background

Extracapsular extension (ECE) is a well-established prognostic feature in squamous cell cancers of the head and neck. Although some extrapolate data from mucosal head and neck cancer to include ECE as a high-risk feature in salivary gland cancers, data is lacking about ECE’s prognostic value for these malignancies. We investigate whether ECE is a significant prognostic indicator in pathologic node-positive cancers of the major salivary glands.

Methods

A retrospective study of adult salivary gland cancer cases diagnosed from 2004 to 2013 in the NCDB was conducted. Demographic, tumor, treatment, and survival variables were included in the study. Univariate Kaplan-Meier analyses, as well as multivariate Cox survival regressions were performed.

Results

Positive ECE status was associated with significantly worse survival in salivary SCC (HR 1.687; p = 0.002) but not non-squamous salivary cancers (HR 1.000; p = 0.998) on multivariate analysis. While post-operative radiotherapy was not associated with improved survival for patients without high-risk adverse features (high grade or positive surgical margins), its use was associated with better survival for ECE-positive salivary SCC patients without one of these additional adverse features (HR 0.064; p = 0.010).

Conclusions

Although ECE is a significant prognostic indicator in salivary SCC, its prognostic significance for non-squamous salivary cancers may be limited. Radiotherapy may improve survival in cases with at least one high-risk adverse feature: high grade; positive surgical margins; and for salivary SCC specifically, positive ECE status.

Financial outcomes of transoral robotic surgery: A narrative review

OBJECTIVE

To determine the current cost impact and financial outcomes of transoral robotic surgery in Otolaryngology.

DATA SOURCES

A narrative review of the literature with a defined search strategy using Pubmed, MEDLINE, CINAHL, and Web of Science.

REVIEW METHODS

Using keywords ENT or otolaryngology, cost or economic, transoral robotic surgery or TORs, searches were performed in Pubmed, MEDLINE, CINAHL, and Web of Science and reviewed by the authors for inclusion and analysis.

RESULTS

Six total papers were deemed appropriate for analysis. All addressed cost impact of transoral robotic surgery (TORs) as compared to open surgical methods in treating oropharyngeal cancer and/or the identification of the primary tumor within unknown primary squamous cell carcinoma. Results showed TORs to be cost-effective.

CONCLUSION

Transoral robotic surgery is currently largely cost effective for both treatment and diagnostic procedures. However, further studies are needed to qualify long-term data.