Retropharyngeal Lymph Node Dissection Research Articles

Efficacy of surgical comprehensive therapy for 456 cases of hypopharyngeal carcinoma

Objective: To retrospectively analyse the efficacy of surgerical comprehensive treatment for hypopharyngeal cancer. Methods: Four hundred and fifty-six cases of hypopharyngeal squamous cell carcinoma treated from Jan 2014 to Dec 2019 were analyzed retrospectively, including 432 males and 24 females, aged 37-82 years old. There were 328 cases of pyriform sinus carcinoma, 88 cases of posterior pharyngeal wall carcinoma, and 40 cases of postcricoid carcinoma. According to American Joint Committe on Cancer(AJCC) 2018 criteria, 420 cases were of stage Ⅲ or Ⅳ; 325 cases were of T3 or T4 stage. Treatment methods included surgery alone in 84 cases, preoperative planned radiotherapy plus surgery in 49 cases, surgery plus adjuvant radiotherapy or concurrent chemoradiotherapy in 314 cases, and inductive chemotherapy plus surgery and adjuvant radiotherapy in 9 cases. The primary tumor resection methods included transoral laser surgery in 5 cases, partial laryngopharyngectomy in 74 cases, of them 48 cases (64.9%) presented with supracricoid hemilaryngopharyngectomy, total laryngectomy with patial pharyngectomy in 90 cases, total laryngopharyngectomy or with cervical esophagectomy in 226 cases, and total laryngopharyngectomy with total esophagectomy in 61 cases. Among 456 cases, 226 cases received reconstruction surgery with free jejunum transplantation, 61 cases with gastric pull-up, and 32 cases with pectoralis myocutaneous flaps. All patients underwent retropharyngeal lymph node dissection, and high-definition gastroscopy was performed during admission and follow-up. SPSS 24.0 software was used to analyze the data. Results: The 3-year and 5-year overall survival rates were respectively 59.8%, and 49.5%. The 3-year and 5-year disease specific survival rates were respectively 69.0% and 58.8%. Total metastasis rate of retropharyngeal lymph nodes was 12.7%. A total of 132 patients (28.9%) suffered from simultaneous and metachronous multiple primary carcinoma of the hypopharynx. Multivariate Logistic regression analysis showed that T3-4 disease, cervical lymph node metastasis, retropharyngeal lymph node metastasis and postoperative adjuvant radiotherapy were independent factors affecting the prognosis of patients (all P<0.05). As of April 30, 2022, a total of 221 patients died during follow-up, of 109 (49.3%) with distant metastases, which were the main cause of death. Conclusions: The efficacy of comprehensive treatment for hypopharyngeal cancer can be improved by accurate preoperative evaluation, improved surgical resection, active retropharyngeal lymph node dissection and full process intervention of the second primary cancer.

Novel Strategies for Managing Retropharyngeal Lymph Node Metastases in Head and Neck and Thyroid Cancer with Transoral Robotic Surgery (TORS).

Retropharyngeal metastases are encountered in a variety of head and neck malignancies, imposing significant surgical challenges owing to their distinct location and proximity to neurovascular structures. Radiotherapy is the recommended treatment in most cases owing to its oncological efficacy. However, retropharyngeal irradiation affects the superior pharyngeal constrictor muscles and parotid glands, with the potential for long-term dysphagia and xerostomia. A younger oropharyngeal and thyroid cancer patient demographic is trending, fueling interest in treatment de-escalation strategies. Consequently, reducing radiotoxicity and its long-term effects is of special relevance in modern head and neck oncology practice. Through its unique ability to safely extirpate these traditionally difficult-to-access retropharyngeal lymph nodes via a natural orifice, TransOral Robotic Surgery (TORS) can considerably lower the surgical morbidity of retropharyngeal lymph node dissection (RPLND), compared with current existing approaches. This review summarizes the latest developments in the field, exposing current research gaps and discusses specific clinical settings where TORS could enable treatment de-escalation. In early-stage node-negative oropharyngeal cancer, single-modality surgical treatment with TORS RPLND may improve risk stratification of metastasis and recurrence in this region. TORS RPLND is also a potentially viable treatment option in salvage of an isolated retropharyngeal node recurrence or in the primary setting of a thyroid malignancy with a single positive retropharyngeal node. In time, TORS RPLND may provide an alternative de-escalation strategy in these three scenarios. However, with the reported morbidities, further prospective trials with long-term follow-up data are required to prove oncological safety and functional benefits over existing strategies.

Retropharyngeal lymph node dissection in head and neck cancers treated with transoral robotic surgery

Objective: To evaluate the indications, safety, feasibility, and surgical technique for patients with head and neck cancers undergoing transoral robotic retropharyngeal lymph node (RPLN) dissection. Methods: The current study enrolled 12 consecutive head and neck cancer patients (seven males and four females) who underwent transoral robotic RPLN dissection with the da Vinci surgical robotic system at the Sun Yat-sen University Cancer Center from May 2019 to July 2020. Seven patients were diagnosed as nasopharyngeal carcinoma with RPLN metastasis after initial treatments, 4 patients were diagnosed as thyroid carcinoma with RPLN metastasis after initial treatments, and one patient was diagnosed as oropharyngeal carcinoma with RPLN metastasis before initial treatments. The operation procedure and duration time, intraoperative blood loss volume and complications, nasogastric feeding tube dependence, tracheostomy dependence, postoperative complications, and hospitalization time were recorded and analyzed. Results: All patients were successfully treated by transoral robotic dissection of the metastatic RPLNs, none of which was converted to open surgery. RPLNs were completely resected in 10 patients, and partly resected in 2 patients (both were nasopharyngeal carcinoma patients). The mean number of RPLN dissected was 1.7. The operation duration time and intraoperative blood loss volume were (191.3±101.1) min and (150.0±86.6) ml, respectively. There was no severe intraoperative complication such as massive haemorrhage or adjacent organ injury during surgery. Nasogastric tube use was required in all patients with (17.1±10.6) days of dependence, while tracheotomy was performed in 8 patients with (11.6±10.7) days of dependence. The postoperative hospitalization stay was (8.5±5.7) days. Postoperative complications occurred in 4 patients, including 2 of retropharyngeal incision and 2 of dysphagia. During a follow-up of (6.5±5.1) months, disease-free progression was observed in all patients, 10 patients were disease-free survival and other 2 patients were survival with tumor burden. Conclusions: The transoral robotic RPLN dissection is safety and feasible. Compared with the traditional open surgical approach, it is less traumatic and safer, has fewer complications and good clinical application potentiality. The indications for transoral robotic RPLN dissection include thyroid carcinoma, oropharyngeal carcinoma, and some selected nasopharyngeal carcinoma and other head and neck cancers. Metastatic RPLNs from some nasopharyngeal carcinoma with incomplete capsule, unclear border and adhesion to the surrounding vessels are not suitable for transoral robotic RPLN dissection.

Robotic transoral approach for salvage retropharyngeal node dissection: an analysis of functional and oncological outcomes.

Presence of metastatic tumour in the retropharyngeal node has a negative impact on the prognosis. We present here our 5-year experience and the outcomes of transoral robotic retropharyngeal node dissection (RPND) in salvage settings. Hospital database was accessed to extract details of patients with head and neck cancer who developed retropharyngeal (RP) node metastasis. Patients who underwent transoral robotic surgery (TORS) for RPND in salvage settings were included for the study. Patients were first followed-up after 10days of discharge and then on a monthly basis after completion of treatment. At each follow-up, swallow functions and disease status were recorded. A total of 10 patients met the inclusion criteria and underwent salvage transoral robotic RPND. The total number of lymph nodes removed from these patients were 11, with all having malignant tumour deposits. The median follow-up was 20months. Four patients developed distant metastasis. There were no major procedure-related complications. Our experience suggests that TORS as treatment modality is oncologically sound and feasible for salvage RP node dissection.Level of evidence Retrospective Study (3).

Is the retropharyngeal lymph node the first echelon node for carcinoma tonsil? Prospective evaluation and literature review.

Tonsil cancer being predominantly treated by non-surgical means, there is a paucity of data on lymph nodal drainage pathways and histo-pathologically confirmed metastatic rates. This study assesses the retropharyngeal lymph node (RPLN) in N0 squamous cell carcinoma tonsil as a possible first echelon node and a site for occult metastasis. Prospective study involving treatment naïve N0 carcinoma tonsil treated by primary surgery and adjuvant treatment from June 2017 to March 2019. In-vivo lymph nodal drainage patterns were assessed by sentinel node mapping by preoperative SPECT-CT and intra-operative hand-held Gamma probe. All patients had a subsequent Level I-III/IV sampling neck dissection supplemented with RPLN dissection. Histological evaluation of sentinel nodes and RPLN involved step-serial sectioning and pan-cytokeratin immunohistochemistry. A comprehensive literature review was performed with keywords "retropharyngeal lymph node", "oropharynx", "tonsil", "squamous cell carcinoma" to determine the incidence of RPLN positivity in previously published series. Sentinel node was successfully identified by SPECT-CT in all 17 patients (ipsilateral level 2a-13/17, 2b-1/17, 3-1/17; bilateral 2a-1/17; isolated contralateral retropharyngeal node-1/17). 8/17 had occult neck metastasis. In no patient was an ipsilateral RPLN identified as the sentinel node. Histological sampling did not indicate metastatic tumor in the RPLN in any patient (0/17). A systematic literature review further confirmed that RPLN metastasis in oropharyngeal cancer is noted only in the presence of pN + disease at other neck levels, and isolated RPLN metastasis is extremely rare (1.2%). The ipsilateral RPLN is not identified either as the first echelon node or as a site of occult metastatic disease in N0 tonsil cancer. CTRI/2019/06/019551.

Transoral Robotic Retropharyngeal Lymph Node Dissection in Nasopharyngeal Carcinoma With Retropharyngeal Lymph Node Recurrence.

Nasopharyngeal carcinoma (NPC) patients with retropharyngeal lymph node (RPLN) recurrence typically undergo reirradiation and experience severe radiotoxicity. Salvage open surgery is challenging because gaining access to the retropharyngeal space is complex and risky. Thus, only several centers can perform this procedure, and complications are common. We applied transoral robotic surgery RPLN dissection (TORS-RPLND) to NPC patients with RPLN recurrence to address the problem with open surgery. From March 2017 to October 2020, 10 NPC patients with RPLN recurrence underwent TORS-RPLND using the da Vinci Si/Xi Surgical System. We applied the balloon occlusion test to protect the internal carotid artery, induction chemotherapy to shrink large tumors preoperatively, and ultrasound positioning to effectively locate unrecognizable RPLNs during surgery. Clinical characteristics, complications, and survival outcome data were retrospectively collected. Of 10 patients, 8 underwent en bloc resection via TORS-RPLND, and the remaining 2 patients were converted to open surgery because we failed to identify the RPLN during TORS. After introducing intraoperative ultrasound positioning, no such failure occurred. The mean operative time and intraoperative blood loss were 297 ± 120 min and 40 ± 43 ml, respectively. All surgical margins were negative. TORS-related complications were mild, and the most severe one was grade 3 dysphagia in one patient who underwent conversion to open surgery (10%). With a median follow-up of 19 months, only 1 (10%) patient developed cervical recurrence. TORS-RPLND is feasible, safe, and effective in the treatment of NPC patients with RPLN recurrence, especially with the help of intraoperative ultrasound positioning. 4 Laryngoscope, 131:E1895-E1902, 2021.

Transcervical endoscopic retropharyngeal lymph node (RPLN) dissection in nasopharyngeal carcinoma with RPLN recurrence.

Surgical access for retropharyngeal lymph node (RPLN) dissection is difficult. We aimed to examine the efficacy of transcervical endoscopic RPLN dissection (TSE-RPLND) for recurrent RPLN in nasopharyngeal carcinoma (NPC). From April 2013 to February 2019, a total of 31 patients with NPC diagnosed with RPLN recurrence underwent TSE-RPLND. The clinical characteristics, complications, and survival outcomes were retrospectively analyzed. The mean duration of surgery, quantity of bleeding and postoperative hospitalization stay were 347.9 minutes, 107.7 mL, and 8.7 days, respectively. After a median follow-up of 31.0 months, the 2-year locoregional relapse-free survival, distant metastasis-free survival, progression-free survival, and overall survival rates were 63.9%, 95.2%, 59.9%, and 83.3%, respectively. The long-term incidences of swallowing problems, permanent nutrient tube, tongue atrophy, and shoulder problems were 6 (19.4%), 3 (9.7%), 3 (9.7%), and 3 (9.7%), respectively. TSE-RPLND is an effective method to treat RPLN recurrence in NPC, but nerve injury-related complications should not be ignored.

The value of CT, MRI, and PET-CT in detecting retropharyngeal lymph node metastasis of head and neck squamous cell carcinoma

BackgroundThe diagnostic accuracies of the imaging studies should be clearly acknowledged in managing head and neck cancer patients; however, the accuracies of preoperative imaging studies in detecting retropharyngeal lymph node (RPLN) metastasis are still not clarified. This study was to evaluate diagnostic accuracies of computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography-computed tomography (PET-CT) in detecting RPLN metastasis of head and neck squamous cell carcinomas.MethodsFor 123 patients who had performed RPLN dissection during the surgery of their squamous cell carcinoma of the head and neck, preoperative CT, MRI, and/or PET-CT were reviewed for RPLN metastasis in a blinded fashion by one experienced radiologist. Sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of each imaging modality were assessed, by comparing with the histopathologic findings of the resected RPLNs that served as the standard of reference.ResultsRPLNs were pathologically positive for metastasis in 43 of the 123 patients (35%). Sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy in detecting metastasis to RPLN were 65, 94, 85, 83, and 84% for CT; 74, 94, 87, 87 and 87% for MRI; 83, 93, 89, 89 and 89% for PET-CT, respectively. When all the three imaging modalities were considered together (n = 74), they offered sensitivity of 90%, specificity of 91%, positive predictive value of 87%, negative predictive value of 93%, and accuracy of 91%.ConclusionsThe preoperative imaging studies offered relatively high specificity rates, but rather low sensitivity rates. The three imaging modalities altogether increased diagnostic accuracies, which highlights the potential of the three studies when used altogether can minimize missed diagnoses of RPLN metastasis.

Functional and oncological outcomes after retropharyngeal node dissection for papillary thyroid carcinoma.

Papillary thyroid carcinoma frequently metastasizes to central and lateral neck lymph nodes, but metastasis to retropharyngeal lymph nodes (RPLN) is rare. We retrospectively reviewed 16 patients with RPLN metastasis of PTC who underwent therapeutic dissection of RPLN metastases. Among 16 patients, 7 patients underwent RPLN dissection with initial surgery and remaining 9 patients as salvage surgery. RPLN metastasis arose unilaterally in 15 patients and bilaterally in 1 patient. Eleven patients showed temporal dysphagia and four patients showed temporal vocal cord paralysis, but both symptoms eventually recovered in all cases. Two patients with salvage RPLN dissection died of distant metastasis and six patients survived with distant metastasis and/or persistent loco-regional disease. Other eight patients have been alive without disease. Although transcervical approach for RPLN metastases of PTC provided acceptable functional and oncological outcomes, half of the patients with RPLN metastasis have had distant metastasis and/or persistent locoregional disease. Indications of surgery for patients with RPLN metastasis need to be performed carefully in consideration of patients' prognosis and quality of life.

Impact of retropharyngeal lymph node dissection in the surgical treatment of hypopharyngeal cancer.

To evaluate the impact of retropharyngeal lymph node (RPLN) dissection in the surgical treatment of hypopharyngeal cancer. Between 2007 and 2016, 98 previously untreated patients with pathological diagnosed hypopharyngeal squamous cell carcinoma underwent total pharyngolaryngectomy and bilateral neck dissection at Kobe University Hospital. Bilateral dissection of RPLN was simultaneously performed in all patients. Pharynx was reconstructed with free jejunal transfer in 94 patients and primarily closed in 4 patients. Postoperative chemoradiotherapy was performed in patients with high risk factors including metastasis to RPLN, multiple lymph node metastasis, extranodal invasion, and/or positive/close surgical margins. The median follow-up period was 25 months ranging from 1 to 105 months. RPLN adenopathy was preoperatively identified in 9 patients in FDG-positron emission tomography. All of them had pathologically diagnosed RPLN metastases, which had been controlled in all patients during the observation periods. Among the other 89 patients, 7 patients had RPLN metastasis. The 2-year overall survival rates of the patients with and without RPLN metastasis were 65.7% and 69.8% (P = .61), respectively. In the present study, patients with RPLN metastasis showed equally favorable oncological outcome compared with patients without RPLN metastasis. At least, ipsilateral RPLN dissection should be considered in the surgical treatment of advanced hypopharyngeal cancer and multiple neck lymph node metastasis regardless of primary subsite.

Significance of retropharyngeal node dissection in treatment of hypopharyngeal carcinoma

Objective: investigate the incidence of retropharyngeal lymph node (RPLN) metastasis and the risk factors for RPLN metastasis in hypopharyngeal cancer, and the relationship of planned dissection of the RPLN with the survival and tumor control rates in patients with hypopharyngeal cancer. Methods: A total of 203 patients with hypopharyngeal squamous cell carcinoma who underwent radical surgery as initial treatment from February 2011 to July 2015 were analyzed retrospectively. There were 167 cases of pyriform sinus carcinoma, 23 cases of posterior pharyngeal wall carcinoma, and 13 cases of postcricoid carcinoma. Results: The incidence of RPLN metastasis in HPC was 17.7%, with a highest rate of 43.5% in pharyngeal wall carcinoma. The incidence of RPLN metastasis in T3-4 pyriform sinus carcinoma was 18.3%, which significantly higher than 2.8% in T1-2 cases(χ(2)=5.360, P=0.020). The rate of RPLN metastasis was 23.8% in N2b-3 and 8.6% in N0-2a, with a statistically significant difference(χ(2)=7.637, P=0.006). There was no statistically significant difference in overall survival rates between patients with and without RPLN metastasis(P>0.05). Data were analyzed by SPSS 13.0 software. Conclusions: RPLN metastasis is not rare in hypopharyngeal carcinoma. Planned dissection of the RPLN should be performed with the initial surgery in patients with advanced hypopharyngeal cancer, especially posterior pharyngeal wall carcinoma, T3-4 pyriform sinus carcinoma and staged N2b-3 disease, which can reduce the regional recurrence rate and provided with a better prognosis.

Transoral robotic retropharyngeal node dissection in oropharyngeal squamous cell carcinoma: Patterns of metastasis and functional outcomes.

Assessment of the retropharyngeal lymph nodes is essential in the treatment for oropharyngeal squamous cell carcinoma (SCC). Transoral robotic retropharyngeal lymph node dissection (RPLND) may provide valuable staging information and guide selection of adjuvant therapy in a transoral robotic surgery (TORS) treatment paradigm. Outcomes were compared between 30 patients with oropharyngeal SCC with tonsillar primaries undergoing RPLND and 37 stage-matched cases without RPLND. Retropharyngeal metastasis was confirmed in 6 patients undergoing RPLND. Compared with 37 stage-matched controls, there were no differences in length of stay, length of feeding tube dependence, net change in perioperative weight, or rates of hemorrhage and postoperative complications. RPLND altered adjuvant treatment recommendations in 1 of 30 patients. RPLND is technically feasible by a purely transoral robotic approach. Its performance is not associated with worse swallowing outcomes or rates of complication. In select patients, RPLND may provide valuable staging information and guide the selection of adjuvant therapy.

Reconstruction with free jejuna flap for the defect after removal of hypopharyngeal and cervical esophageal caneer: clinical analyses of 103 cases

Objective: To report our experience in reconstruction with free jejunal flap for circumferential defect following resection of hypopharygeal and cervical esophageal carcinoma. Methods: A retrospective analysis was conducted to evaluate the outcomes of reconstruction with free jejunal flaps for circumferential defects in 103 patients treated from Aug 2008 to Mar 2015. Among them, 84 were hypopharyngeal carcinoma and 19 were cervical esophageal carcinoma; 31 patients had total pharyngolaryngectomy, 70 had total pharyngolaryngectomy and cervical esophagectomy and 2 had laryngeal preservation. All patients underwent bilateral neck dissection and 84 underwent retropharyngeal lymph node dissection. Results: The 3 year overall survival rate was 51.6% and disease-specific survival rate was 50%. The 5 year overall survival rate was 39.1%. No in-hospital death, one patient had unsalvageable flap failure and underwent second reconstruction with free jejunal flap. The success rate for the free jejunal flaps was 99% (102/103). Pharyngocutanous fistula occurred in 3 patients and all healed with conservative treatment. Satisfactory oral intake was achieved in all patients. Conclusions: Oncological and functional outcomes of reconstruction with free jejunal flap for circumferential defects of hypopharynx and cervical esophagus were satisfying. Multidisciplinary cooperation is helpful to improve surgical success rate. Free jejunal flap is an ideal method for reconstruction of circumferential hypopharyngeal and cervical esophageal defects after removal of tumor.

The Significance of Retropharyngeal Nodes in Treatment Deintensification.

Treatmentdeintensificationof humanpapillomavirus (HPV) associated oropharyngeal squamous cell cancer (OPSCC) is a topic of active debate. It is well recognized that HPVassociated OPSCC has unique tumor biological characteristics, reflected by a high propensity fornodal involvement and yet more favorable outcomes compared with HPVnegative OPSCC, with significantly improved overall survival and a reduced risk of recurrence. Because patients with HPVassociatedOPSCCareoftenyounger (<60years), healthier, and more likely to outlive their disease than their historical counterparts, efforts to reduce the risk of severe late toxicity, primarily long-term dysphagia, have become a goal of treatment. The primary question now is, which of these patients are candidates for treatment deintensification? The best evidence suggests that patients with HPVassociated OPSCC with low-volume primary site tumors and limited nodal disease (N0-N2a) have lower rates of locoregional recurrence, distant metastatic disease, and improved overall survival.1 These observations have led to the suggestion that these low-risk patients can be targeted for deintensification strategies that omit chemotherapy. The addition of chemotherapy to radiation results in increased mucositis, long-term fibrosis, and late severe dysphagia.2 However, the primary determinant of severe late dysphagia seems to be the radiotherapydose to thesuperiorpharyngeal constrictors,with mean doses greater than 60 Gy to this site associated with a significantly increased risk of long-termdysphagia, aspiration, and gastrostomy dependence.3,4 The retropharyngeal nodes havebeen identifiedasanodalbasinat risk formetastases from OPSCCandareroutinely included inradiationtreatment fields.5 Because the retropharyngeal nodal basin is bound anteriorly by the pharyngeal constrictor muscles and posterior pharyngealwall,deintensificationstrategies that limit treatment tothis site may reduce long-term treatment-related toxicity. The incidence of retropharyngeal metastases from OPSCC is reported to range from10%to27%.6-11Most studies use pretreatment imaging to evaluate retropharyngeal adenopathy with criteria of size greater than 1 cm, central necrosis or cystic degeneration, or fluorodeoxyglucose F 18–avidity on positron emission tomography. The presence of retropharyngeal adenopathy is significantly more likely with advanced T stage, 3 or more involved nodes, contralateral cervical adenopathy, and tonsil or posterior pharyngeal wall subsites.7-9 Retropharyngealmetastases are theonly site ofnodal involvement in 2% to 7%of patients but are nearly always associated with posterior pharyngeal wall primary site involvement.6,10 In patients treated with primary surgery that includes retropharyngeal nodedissection, the incidenceof occult retropharyngealmetastasesnotdetectedby imaging is 7%,andstrongly correlateswithposterior pharyngealwall involvement and/or greater than stageN2adisease.9-11 These data suggest that patients with primary site posterior pharyngeal wall or posterior tonsillarpillar involvement,orwithmultiplecervicalnodes require treatment of the ipsilateral retropharyngeal node basin, whereas patients with low T stage sparing the posterior pharyngeal wall and limited nodal disease could potentially bespared radiation to the retropharyngealnodesandthus limit theeffectsof radiotherapy to thepharyngeal constrictors. This premise is incorporated in the Eastern Cooperative Oncology Group E3311 transoral surgery clinical trial schema, in which low-risk patientswithHPV-associatedOPSCC (<T3, <N2,with clear margins, 0-1 nodes, and no extracapsular spread) are spared radiation therapy. Thus, the findings of Spector et al12 in this issue are important but are not incongruous with the evidence to date. Deintensification strategies require the identification of lowrisk groups who may benefit from less intense therapies—in this case, patients at low risk for retropharyngeal node involvementwho couldbe spared conventional radiotherapy to the pharyngeal constrictors. Patients with clinically detectable retropharyngeal nodes are clearly not suitable for such a strategy. Risk stratification efforts to guide treatment deintensification in patients without clinically detectable retropharyngeal disease will benefit from the results of the E3311 surgical trial, which is actively accruing. Because retropharyngeal node dissection is not performed as part of neck dissection in this trial, thesurvival andrecurrencepatternsofboth low-risk patientswho are spared radiation, and intermediaterisk patients randomized to lower doses of radiation including retropharyngeal nodes, will allow us to better define risk groups and prospectively guide future deintensification efforts in HPV-associated OPSCC care.

Transoral robotic retropharyngeal node dissection.

Surgical access to metastases in the retropharyngeal lymph nodes (RPLNs) could be difficult. Transoral robotic surgery (TORS) can be utilized to access RPLNs. The purpose of this study was to describe a TORS approach to RPLN dissection. A case series of patients undergoing RPLN dissection by TORS was conducted and compared to matched controls (1:2). Twelve patients underwent robotic RPLN dissection. Median age was 63 years (range, 43-73 years). Pathology was oropharyngeal squamous cell carcinoma (SCC) in 9 patients and papillary thyroid cancer (PTC) in 3 patients. The feeding tube dependence duration was 12 days (range, 1-46 days) on average. Complications occurred in 8 patients (66%); most commonly, aspiration pneumonitis in 6 patients. In comparison to the matched controls (24), there was no difference in length of stay or feeding tube dependence. Complications were higher in patients with oropharyngeal SCC. TORS is feasible for accessing RPLNs. The procedure is well tolerated in patients with PTC; whereas patients with oropharyngeal SCC are at increased risk of complications. © 2015 Wiley Periodicals, Inc. Head Neck 38: E981-E986, 2016.

Retropharyngeal lymph node metastasis in 54 patients with oropharyngeal squamous cell carcinoma who underwent surgery-based treatment.

This study aimed to determine the incidence, risk factors, and prognostic significance of retropharyngeal lymph node (RPLN) metastasis from malignancies of the oropharynx. The study retrospectively analyzed 54 patients with oropharyngeal squamous cell carcinoma who underwent primary surgery-based treatment. Most of the patients had advanced stage (stage 3 or 4, 96.3 %) oropharyngeal cancer. Surgery alone was performed for 14 patients. Postoperative radiotherapy was administered to 14 patients and chemoradiation to 26 patients. Genotyping and detection of human papillomavirus (HPV) was available for 52 patients. Using pathologic analysis, RPLN metastasis was confirmed in 22 subjects. The patients with RPLN metastasis had a significantly lower disease-specific survival rate than the non-RPLN metastasis group (54.5 vs 75 %; p = 0.05). The pN+ (RPLN) yield of these cases was 18/22 (81.8 %) for cN+ (RPLN) versus 4/32 (7.4 %) for cN0 (RPLN). Multivariate analysis identified the independent factors associated with RPLN metastasis as radiographically positive retropharyngeal node (p = 0.012; odds ratio [OR] 53.920) and posterior pharyngeal wall invasion (p = 0.021; OR 33.014). A high-risk HPV-positive result was not significantly correlated with RPLN metastasis. Elective RPLN dissection should be considered for patients with advanced neck and primary tumor, particularly those with posterior pharyngeal wall invasion.

Efficacy of retropharyngeal nodes dissection in hypopharyngeal cancer

To investigate the necessity and feasibility of planned dissection of the retropharyngeal lymph nodes (RPLN) in advanced hypopharyngeal cancer. Between February 2011 and December 2012, 54 patients with advanced hypopharyngeal cancer accepted planned dissection of the RPLN during primary surgery. There were 45 cases of pyriform sinus carcinoma, 5 cases of posterior pharyngeal wall carcinoma, and 4 cases of postcricoid carcinoma. All patients underwent surgery and postoperative adjuvant radiotherapy, meanwhile bilateral neck dissection and RPLN dissection were performed. All patients received preoperative CT scanning (with contrast). The results of the radiographic assessment were compared with the postoperative pathologic findings respectively. RPLN were confirmed positive by pathology in 13 cases, and negative in another 43 cases. For the entire treatment group, metastasis to the RPLN was confirmed hispathologically in 12 patients (22.2%). Eight patients were pyriform sinus carcinoma, 4 were posterior pharyngeal wall carcinoma. Among them, seven patients were diagnosed as RPLN metastasis by CT imaging and another 5 patients were not confirmed. The overall accuracy for the radiologist's interpretation was 79.6%, the sensitivity was 58.3%, and the specificity was found to be 85.7%. Eleven patients were N2-3 and 6 patients were N2c. No RPLN metastasis or recurrence was found during more than one year follow-up period. It is not rare for the RPLN metastasis in patients with advanced hypopharyngeal carcinoma. CT imaging is not effective in determining the early presence of RPLN metastasis. The planned dissection of the RPLN is highly recommended during the initial surgery of hypopharyngeal cancer, especially in posterior pharyngeal wall carcinoma, T3-4 pyriform sinus carcinoma and staged N2-3 cases.

Transoral Robotic Retropharyngeal Lymph Node Dissection With or Without Lateral Oropharyngectomy

Retropharyngeal lymph node (RPLN) metastases can occur from advanced head and neck malignancies. Surgical access to RPLNs can be challenging. Considering the more aggressive conventional approach methods, there is an increasing need for minimally invasive techniques. Applying transoral robotic surgery (TORS) to access the RPLN has never been reported in the literature. The purpose of this study was to describe our experience with transoral robotic RPLN dissection for oropharyngeal and hypopharyngeal squamous cell carcinomas. We conducted a retrospective review of TORS cases performed at Severance Hospital, a tertiary care medical center from December 2011 to July 2012. Demographic, clinicopathologic, and treatment characteristics were abstracted from the medical record as well as complications and were analyzed descriptively. A total of 5 TORS procedures with transoral robotic RPLN dissection have been performed at Severance Hospital. Of these, 4 patients were treated for oropharyngeal squamous cell carcinoma and 1 for hypopharyngeal squamous cell carcinoma. The mean operation time for TORS including the robotic RPLN dissection was 84 ± 18.5 minutes. The operation time included time for docking of the robotic arms (4.8 ± 1.3 minutes), console working time for primary tumor removal (50 ± 8.9 minutes), and console working time for RPLN dissection (29.2 ± 9.4 minutes). No patients experienced complications related to the transoral robotic RPLN dissection. Transoral robotic RPLN dissection is a feasible approach for accessing retropharyngeal lymph nodes. This particular operative technique can serve as a minimal invasive surgery in removing pathologic RPLNs.

OP134: Pattern of cervical lymph node metastasis in medial wall pyriform sinus carcinoma: When do contralateral and paratracheal node dissection necessary?

The aim of this study was to analyze the prevalence and distribution of histologic cervical lymph node metastases in medial wall pyriform sinus squamous cell carcinoma (SCC). Sixty-eight medial wall pyriform sinus SCC patients were retrospectively analyzed in this study. All patients underwent bilateral therapeutic/elective neck dissection. Thirty-nine patients underwent central compartment neck dissection. Eleven patients underwent retropharyngeal lymph node (RPLN) dissection. Primary tumor was removed using conservative laryngeal surgery with partial pharyngectomy in 39 cases, near total/total laryngectomy with partial pharyngectomy in 24 cases, and total laryngopharyngectomy in five patients. The overall N-positive contralateral lymph nodes rate on pathology was 14.7%. The rate of contralateral occult cases was 5.2%. Contralateral nodal metastasis was not significantly associated with disease-specific survival. Multivariate analysis revealed that primary lesion across the midline was an independent factor for contralateral neck nodal metastasis. The rate of level VI node metastasis was 16.2%. The disease-specific survival rate was significantly different according to level VI node metastasis (71% vs 40%). In multivariate analysis, pyriform sinus apex invasion was an independent factor for level VI nodal metastasis. RPLN metastasis was confirmed by pathological analysis in two of the 11 (18.2%) subjects. Contralateral nodal metastasis was less frequent than expected. Bilateral neck dissection is mandatory for primary lesion across the midline. Ipsilateral level VI lymph node should be removed in pyriform sinus apex invasion case. We recommend elective RPLN dissection in case with posterior pharyngeal wall invasion.

OP193: Transoral robotic retropharyngeal lymph node dissection with or without lateral oropharyngectomy

Purpose Retropharyngeal lymph node (RPLN) metastases can occur from advanced head and neck malignancies, most commonly in pharyngeal carcinomas. Surgical access to this group of lymph nodes can be challenging. Considering the more aggressive conventional approach methods to access the RPLN, there is an increasing need for lesser invasive approach methods. Applying Transoral robotic surgery (TORS) to access the RPLN has never been reported in the literature. The purpose of this study was to describe our experience with transoral robotic RPLN dissection for oropharyngeal and hypopharyngeal squamous cell carcinomas. Materials and methods We conducted a retrospective review of TORS cases performed at Severance Hospital, a tertiary care medical center from December 2011 to July 2012. Demographic, clinicopathological, and treatment characteristics were abstracted from the medical record as well as complications. The results were analyzed descriptively. Results A total of five TORS procedures with transoral robotic RPLN dissection have been performed at Severance Hospital. Of these, four patients were treated for oropharyngeal squamous cell carcinoma (OPSCC) and one for hypopharyngeal squamous cell carcinoma (HPSCC). The mean operation time for TORS including the robotic RPLN dissection was 84 ± 18.5 min. The operation time included time for docking of the robotic arms (4.8 ± 1.3 min), console working time for primary tumor removal (50 ± 8.9 min) and console working time for RPLN dissection (29.2 ± 9.4 min). Estimated average blood loss during the course of the operation was 11.2 ± 1.5 mL. The median number of retropharyngeal nodes removed was 1 (range 1–2). All but one case revealed positive RPLN. Extracapsular extension was present in 2 (40%) of the specimens. No patients experienced complications related to the transoral robotic RPLN dissection. Conclusion Transoral robotic RPLN dissection is a feasible approach for accessing retropharyngeal lymph nodes. This particular operative technique can serve as a minimal invasive surgery in removing pathologic RPLNs.