Abstract
BackgroundThe purpose of this study was to identify preoperative patient characteristics associated with the incidence of positive surgical margins or lymph node extracapsular extension (ECE), which necessitate adjuvant chemoradiation after transoral robotic surgery (TORS).MethodsWe conducted a single institution retrospective study of 34 consecutive patients with primary oropharyngeal cancer who underwent TORS. All imaging was reviewed by a single neuroradiologist. Surgical margins and ECE status were determined by a single head and neck pathologist. Associations of preoperative patient characteristics with positive surgical margins and lymph node ECE were examined using univariate analysis. Independent predictors of these outcomes were determined using logistic regression.ResultsPreoperatively, the majority of patients had early-stage disease (7 cT1 and 21 cT2; 10 cN0). Positive margins occurred in 4 (12 %) patients. A clinically positive lymph node was seen in 23 (68 %) patients. Neck dissection was performed in 29 (85 %) patients, among whom 19 had a pathologically positive lymph node and 15 had nodal ECE. Logistic regression showed that larger preoperative lymph node size was an independent predictor of ECE (odds ratio, 13.32 [95 % CI, 1.46–121.43]). Among the 21 patients with a clinically positive lymph node who underwent neck dissection, ECE was present more often in patients with a preoperative node size ≥ 3.0 vs. < 3.0 cm (92 % vs. 44 %, P = 0.046). There was no patient characteristic associated with positive margins.ConclusionsPatients with a larger preoperative lymph node appear more likely to have ECE, and thus be treated with chemoradiation after TORS, with a potentially higher rate of toxicity. Lymph node size should be taken into account when deciding upon treatment approaches. Further research is needed to validate these results.Electronic supplementary materialThe online version of this article (doi:10.1186/s41199-016-0008-7) contains supplementary material, which is available to authorized users.
Highlights
The purpose of this study was to identify preoperative patient characteristics associated with the incidence of positive surgical margins or lymph node extracapsular extension (ECE), which necessitate adjuvant chemoradiation after transoral robotic surgery (TORS)
Patients were selected for TORS if there was a consensus at tumor board that there was a high likelihood of achieving negative margins and if the lymph nodes did not demonstrate obvious radiographic evidence of ECE on preoperative examination and imaging
No clinical features predicted positive margins in this single institution study of predominantly T1 and T2 cancers, but nodal size emerged as a significant predictor of ECE
Summary
The purpose of this study was to identify preoperative patient characteristics associated with the incidence of positive surgical margins or lymph node extracapsular extension (ECE), which necessitate adjuvant chemoradiation after transoral robotic surgery (TORS). The use of adjuvant therapy after TORS remains high [4]. Based on the landmark studies by the RTOG and EORTC, the addition of cisplatin chemotherapy is indicated in patients with extracapsular extension (ECE) of metastatic lymph nodes or positive surgical margins [5,6,7]. Recent analysis has called into question the validity of these guidelines [8], adjuvant chemoradiation remains the standard of care for these high-risk patients, pending further clinical trials. Positive margins and nodal ECE are indications for dose escalation of radiation therapy [9]
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