Transoral Robotic Surgery Patients Research Articles

Interim Phase II Results Using Panitumumab-IRDye800CW During Transoral Robotic Surgery in Patients with Oropharyngeal Cancer.

The incidence of oropharyngeal squamous cell carcinoma (OPSCC) has continually increased during the past several decades. Using transoral robotic surgery (TORS) significantly improves functional outcomes relative to open surgery for OPSCC. However, TORS limits tactile feedback, which is often the most important element of cancer surgery. Fluorescence guided surgery (FGS) strategies to aid surgeon assessment of malignancy for resection are in various phases of clinical research but have the greatest potential impact for improving patient care when the surgeon has limited tactile feedback, such as during TORS. Here, we assessed the feasibility of intraoperative fluorescence imaging using panitumumab-IRDye800CW (PAN800) during TORS in OPSCC patients. 12 consecutive patients with OPSCC were enrolled as part of a non-randomized, prospective, phase II FGS clinical trial using PAN800. TORS was performed with an integrated robot camera for surgeon assessment of fluorescence. Intraoperative and ex vivo fluorescence signals in tumors and normal tissue were quantified and correlated with histopathology. Intraoperative robot fluorescence views delineated OPSCC from normal tissue throughout the TORS procedure (10.7 mean tumor-to-background ratio), including in tumors with low expression of the molecular target. Tumor-specific fluorescence was consistent with surgeon-defined tumor borders requiring resection. Intraoperative robot fluorescence imaging revealed an OPSCC fragment initially overlooked during TORS based on brightfield views, further substantiating the clinical benefit of this FGS approach. Results from this OPSCC patient cohort support further clinical assessment of FGS during TORS to aid resection of solid tumors.

Primary Tumour Detection in Carcinoma of Unknown Primary with Transoral Robotic Surgery (TORS) Tongue Base Mucosectomy: A Meta-analysis.

Head and neck carcinoma of unknown primary (CUP) represents a challenging diagnostic process when standard work-up fails to identify the primary tumour site. The aim of this systematic review and meta-analysis was to evaluate the diagnostic utility and complication profile of transoral robotic surgery (TORS) tongue base mucosectomy (TBM) in the management of CUP. An electronic database search was performed in the EMBASE, MEDLINE, PubMed and Cochrane databases. A meta-analysis of proportions was performed to obtain an estimate of the overall proportion for the detection and complication rates. Nine studies representing 235 patients with CUP who had TORS TBM were included in the final analysis. The overall pooled tumour detection rate was 66.2% [95% confidence interval (CI) 56.1-75.8]. The incidence of tumour detection in human papilloma virus (HPV)-positive cases (81.5%, 95% CI 60.8-96.4) was significantly higher than HPV-negative cases (2.3%, 95% CI 0.00-45.7). Weighted overall complication rate was 11.4% (95% CI 7.2-16.2). The majority were grade I or II (80%) according to the Clavien-Dindo classification. This meta-analysis suggests TORS to be safe and effective in localising the primary tumour site in patients with CUP. While the current data supports the use of TORS in patients who are HPV positive, larger numbers of HPV-negative cases are required to determine the true diagnostic effect with TORS before any valid conclusions can be inferred in this particular subgroup. Further research should focus on high quality prospective trials with stringent methodological work-up to minimise heterogeneity and allow for more accurate statistical analysis.

Modified Frailty Index Associates With Transoral Robotic Surgery Complications and Survival: A National Database Study.

The modified frailty index (mFI-5) is a National Surgical Quality Improvement Program-derived 5-factor index that has been proven to reflect frailty and predict morbidity and mortality. We hypothesize that mFI-5 is a valid predictive measure in the transoral robotic surgery (TORS) population. Retrospective study utilizing the TriNetX US-collaborative health records network querying for TORS patients. Cohorts were stratified by mFI-5 score which uses five ICD-10 codes: nonindependent functional status, hypertension, obstructive respiratory disease, heart failure, and diabetes mellitus. Cohorts were matched by age using propensity score matching. Outcome measures included survival, infection, pneumonia, tracheostomy dependence, and percutaneous endoscopic gastrostomy dependence. Reported odds ratios were normalized to mFI-5 = 0. A total of 9,081 patients were included in the final analysis. Greater mFI-5 scores predicted decreased survival and increased incidence of postoperative infection and pneumonia. Odds of 5-year mortality were 1.93 (p = 0.0003) for mFI-5 = 2 and 1.90 (p = 0.0002) for mFI-5 = 3. Odds of 2-year mortality were 1.25 (p = 0.0125) for mFI-5 = 1, 1.58 (p = 0.0002) for mFI-5 = 2, and 1.87 (p = 0.003) for mFI-5 = 3. Odds of postoperative infection were 1.51 (p = 0.02) for mFI-5 = 2 and 1.78 (p = 0.05) for mFI-5 = 3. Two-year odds of developing pneumonia were 1.69 (p = 0.0001) for mFI-5 = 2 and 2.84 (p < 0.0001) for mFI-5 = 3. Two-month odds of pneumonia were 1.50 (p = 0.0259) for mFI-5 = 2 and 2.55 (p = 0.0037) for mFI-5 = 3. mFI-5 = 4 or 5 had too few patients to analyze. Using polynomial regression to model age versus incident 5-year post-TORS death (R2 = 0.99), mFI-5 scores better predicted survival than age alone. This study demonstrates that mFI-5 predicts mortality, pneumonia, and postoperative infection independently of age. 4 Laryngoscope, 2024.

0616 Effects of Oropharyngeal Rehabilitation After Transoral Robotic Surgery in Patients with Obstructive Sleep Apnea

0616 Effects of Oropharyngeal Rehabilitation After Transoral Robotic Surgery in Patients with Obstructive Sleep Apnea

A randomized clinical trial to evaluate transoral head and neck surgery using a single-port flexible robotic system

This randomized IDEAL stage 2 clinical trials examined the safety and efficacy of a novel single-port flexible robot for transoral robotic surgery in patients with benign and malignant head and neck tumors. Rates of conversion and perioperative problems within a month of surgery were the main objectives. The Fisher's exact test and the Mann-Whitney U test were used in the statistical analysis, which used a p-value of 0.05 or less to determine significance. With the use of the da Vinci SP technology, 25 participants got TORS that allowed them to swiftly enter their nasopharynx, oropharynx, and hypopharynx. Notably, there were no serious complications or unfavorable robot-related occurrences throughout the 30-day follow-up period or any modifications to the robotic surgical equipment. The novel single-port flexible automated device demonstrates both security and practicality for carrying out transoral endoscopic procedures for head and neck conditions; based on this possible IDEAL stage 2 clinical trials, allowing accessibility to several anatomical regions, such as the larynx, oropharynx, nasopharynx, and hypopharynx.

Acute Taste Dysfunction in Oropharyngeal Cancer Patients after Transoral Robotic Surgery.

To compare taste changes after transoral robotic surgery (TORS) to taste changes in healthy controls. Oropharyngeal cancer patients receiving TORS and healthy controls were recruited. Participants underwent posterolateral and whole-mouth psychophysical taste testing (identification, intensity, and hedonics) at baseline and at 2 weeks postoperatively (patients) or follow-up (controls). Surgeons reported suspension time and glossopharyngeal nerve injury (GNI) based on the identification and sacrifice of the nerve. A Clinical Global Impression (CGI) of taste symptoms was completed at each session ("My sense of taste bothers me" on a 5-point scale from Never [1] to Always [5]). A taste disorder (TD) was a CGI of 3 (Sometimes) or worse. Within-subject changes in CGI and psychophysical scores were computed. "Worsened taste" was a CGI increase by ≥1 point at follow-up. Of 69 participants, most (33/37 tumor, 31/32 controls) had normal baseline taste (CGI < 3). 14/33 (42%) TORS patients and no controls developed new TDs at follow-up. More smokers (7/9) had worsened taste than nonsmokers (19/60, difference = 46% [95% CI 16%-76%]). More patients without GNI (6/22) than with GNI (0/15) had postoperative phantogeusia (difference = 27% [95% CI 9-45%]). Tumor-ipsilateral taste identification (TI) decreased more in patients (-11.3%) than controls (0.8%, difference = 12.2% [95% CI 5.0-19.3%]). Suspension time was not associated with worsened taste symptoms or psychophysical changes. Patient-reported taste changes after TORS are frequent. Compared to healthy controls, TORS patients have decreased tumor-ipsilateral TI. Suspension time and GNI are unlikely to cause symptomatic TDs. Further investigations of the etiology and long-term symptom burden of TORS-associated TDs will aid in the management of oropharyngeal cancer patients. 3 (non-randomized controlled cohort study) Laryngoscope, 133:3520-3528, 2023.

Transoral robotic surgery vs. non-robotic surgeries for oropharyngeal squamous cell carcinoma: systematic review and meta-analysis.

To compare the effectiveness of transoral robotic surgery (TORS) and non-robotic surgeries (NRES) in patients with oropharyngeal squamous cell carcinoma (OPSCC), medical databases were searched including PubMed, Web of Science, Medline, Embase, and Cochrane Library up to January 2023. The methodology follows PRISMA guidelines, including the PRISMA flow diagram. Data from the included studies were extracted independently by two researchers. Seven studies involving five hundred seventy-seven patients were included. Of these, 275 underwent TORS and 302 underwent NRES. The disease-free survival rate was significantly higher in the TORS group than in the NRES group (OR = 3.43, 95% CI 1.92-6.15, P < 0.0001). However, there were no significant differences in positive surgical margins, hospital stays, operation time, blood loss, postoperative bleeding rate, perioperative tracheostomy, perioperative feeding tube, and overall survival rate. These findings can initially guide the preoperative counseling of TORS in patients with OPSCC, and preliminarily confirm that the adoption of TORS deserves careful consideration.

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

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

Role of local flaps in the prevention of soft tissue necrosis after transoral robotic surgery for tonsillar cancer

ObjectiveSoft tissue necrosis (STN) can occur after transoral robotic surgery (TORS) with radiation therapy (RT). We investigated the usefulness of local flap reconstruction for preventing STN after TORS in patients with tonsillar cancer. MethodsThis case-control study retrospectively reviewed clinicopathological data of patients who underwent TORS for tonsillar cancer at a tertiary referral center. The incidence of STN was compared in patients who underwent secondary intention healing or local flap reconstruction, and factors predicting STN were identified. ResultsSTN occurred in 20 (25%) of 80 patients in the study. The incidence of STN was higher in the secondary intention healing than the flap reconstruction group. Mucositis grade (odds ratio [OR] 3.694, p = 0.02), RT dose (OR 4.667, p = 0.001), and secondary intention healing (OR 14.985, p = 0.035) were predictive factors for STN. ConclusionFlap reconstruction can prevent STN after TORS with RT in patients with tonsillar cancer. The use of local flaps preserves the minimally invasive nature of TORS.

Effects of Transoral Robotic Surgery for Patients with Obstructive Sleep Apnea on Sexual Functions

Effects of Transoral Robotic Surgery for Patients with Obstructive Sleep Apnea on Sexual Functions

Association of comorbidity score with perioperative outcomes following transoral robotic surgery: National analysis.

BackgroundThe association of comorbidities with perioperative outcomes after transoral robotic surgery (TORS) is not well‐defined in the literature.MethodsUsing the National Cancer Database, 4004 patients with T1‐T2 oropharyngeal cancer between 2010 and 2017 were stratified based on their Charlson–Deyo Comorbidity Class (CDCC). Thirty‐day unplanned readmissions, 30‐day mortality, and 90‐day mortality were compared using chi‐square test and logistic regression. Hospital length of stay (LOS) was compared using the Kruskal–Wallis test.ResultsLOS was greater for patients with CDCC 2 or 3 compared to CDCC 0 or 1 (p < 0.001). Increasing age and CDCC ≥3 were associated with 30‐day mortality (CDCC ≥3: odds ratio [OR] 5.55, 95% confidence interval [CI] 1.59–19.45). CDCC ≥3 (OR 2.61, 95%CI 1.09–6.27) was significantly associated with 30‐day readmissions.ConclusionThis national analysis demonstrates greater rates of unplanned 30‐day readmissions, longer hospitalizations, and increased 30‐ and 90‐day mortality after TORS in patients with CDCC ≥3.

Risk of Pathologic Extranodal Extension and Other Adverse Features After Transoral Robotic Surgery in Patients With HPV-Positive Oropharynx Cancer

Understanding patient-specific risk of adverse histopathologic findings after primary surgery for human papillomavirus (HPV)-positive oropharynx squamous cell carcinoma (OPSCC) may help guide patient consultations. To determine the likelihood of adverse histopathologic features that may indicate adjuvant radiotherapy or chemoradiotherapy after primary surgery for HPV-positive OPSCC according to 2021 National Comprehensive Cancer Network guidelines. This retrospective cohort study was performed at a single academic tertiary care center. Of 258 patients who underwent transoral robotic surgery (TORS) from March 1, 2012, to March 1, 2021, 136 consecutive, treatment-naive patients with HPV-positive OPSCC without obvious clinical extranodal extension (ENE) who underwent definitive TORS and neck dissection were included in the analysis. Indications for surgical treatment included non-deeply infiltrative oropharynx tumors, minimal soft palate involvement, and low suspicion for pathologic ENE. Primary site TORS with neck dissection. The primary outcomes were the adverse histopathologic features of pathologic ENE and positive surgical margins (PSM) that are indications for possible adjuvant chemoradiotherapy. Outcomes were compared among varying American Joint Committee on Cancer 7th edition (AJCC-7) T and N categories and patient clinical characteristics. Of the 136 patients included in the analysis (113 men [83.1%]; median age, 63 [interquartile range, 55-70] years), 109 (80.1%) had at least 1 indication for possible adjuvant radiotherapy. Twenty-seven patients (19.9%) had pathologic ENE and 10 (7.3%) had PSM. Thirty-four patients (25.0%) had pathologic ENE and/or PSM, whereas 3 (2.2%) had both. Age, smoking history, history of alcohol consumption, and clinical T category were not associated with pathologic ENE, PSM, lymphovascular invasion, perineural invasion, or pN2 category or greater. The proportion of pathologic ENE varied by clinical N category: 0 of 16 for cN0, 8 of 48 (16.7%) for cN1, 3 of 23 (13.0%) for cN2a, and 16 of 45 (35.6%) for cN2b. Compared with patients with cN1-cN2a disease, patients with cN2b disease had higher odds of pathologic ENE (odds ratio, 3.01; 95% CI, 1.14-8.10). Clinical and pathologic N category were concordant in 77 patients (56.6%), whereas 42 (30.9%) were upstaged and 17 (12.5%) were downstaged. In this cohort study, approximately one-quarter of carefully selected patients with HPV-positive OPSCC without obvious clinical ENE undergoing primary surgery had pathologic ENE and/or PSM. Patients with AJCC-7 cT0-cT2 cN0-cN2b disease, especially cN0-cN2a, without signs of clinical ENE may represent appropriate candidates for primary surgery when avoidance of adjuvant chemotherapy and/or reduction of adjuvant radiotherapy dose/extent are the goals.

Evaluating dysphagia and xerostomia outcomes following transoral robotic surgery for patients with oropharyngeal cancer

We assessed long-term patient-reported dysphagia and xerostomia outcomes following definitive surgical management with transoral robotic surgery (TORS) in patients with oropharyngeal cancer (OPC) via a cross-sectional survey study. Patients with OPC managed with primary oropharyngeal surgery as definitive treatment at least 1year ago between 2015 and 2019 were identified. The M. D. Anderson Dysphagia Inventory (MDADI) and Xerostomia Inventory (XI) scores were compared across treatment types (i.e., no adjuvant therapy [TORS-A] vs. adjuvant radiotherapy [TORS+RT] vs. adjuvant chemoradiotherapy [TORS+CT/RT]). The sample had 62 patients (10 TORS-A, 30 TORS+RT, 22 TORS+CT/RT). TORS-A had clinically and statistically significantly better MDADI scores than TORS+RT (p=0.03) and TORS+CT/RT (p=0.02), but TORS+RT and TORS+CT/RT were not significantly different. TORS-A had clinically and statistically significantly less XI than TORS+RT (p < 0.01) and TORS+CT/RT (p < 0.01). Patients with OPC who have undergone TORS+RT or TORS+CT/RT following surgery face clinically worse dysphagia and xerostomia outcomes relative to patients who undergo TORS-A.

Risk factors for gastrostomy tube dependence in transoral robotic surgery patients

ObjectivesTo determine the rate of gastrostomy tube dependence after transoral robotic surgery (TORS), and to determine which patient or surgical factors increase the likelihood of gastrostomy tube dependence. MethodsRetrospective chart review of all patients who underwent TORS for oropharyngeal squamous cell carcinoma (OPSCC) at a single institution from January 2011 through July 2016. Patients who underwent TORS for recurrent OPSCC were excluded. Primary outcome was gastrostomy tube (g-tube) dependence. Univariable and multivariable logistic regression were performed to identify risk factors for g-tube dependence at 3-months and 1-year. ResultsA total of 231 patients underwent TORS during the study period. At 3-month follow-up, 58/226 patients (25.7%) required g-tube. At 1-year and 2-year follow-up, 8/203 (3.9%) and 5/176 (2.8%), remained dependent on g-tube, respectively. Advanced T stage (T3) (OR = 6.07; 95% CI, 1.28–28.9) and discharge from the hospital with enteral access (OR = 7.50; 95% CI, 1.37–41.1) were independently associated with increased risk of postoperative gastrostomy tube dependence at 1 year on multivariable analysis. ConclusionsLong-term gastrostomy tube dependence following TORS is rare, particularly in patients that receive surgery alone. Patients with advanced T stage tumors have poorer functional outcomes. Early functional outcomes, as early as discharge from the hospital, are a strong predictor for long-term functional outcomes.

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.

Opioid Usage and Prescribing Predictors Following Transoral Robotic Surgery for Oropharyngeal Cancer.

Pain management following transoral robotic surgery (TORS) varies widely. We aim to quantify opioid usage following TORS for oropharyngeal squamous cell carcinoma (OPSCC) and identify prescribing predictors. Retrospective cohort study. A consecutive series of 138 patients undergoing TORS for OPSCC were reviewed from 2016 to 2019. Opioid usage (standardized to morphine milligram equivalents [MME]) was gathered for 12 months post-surgery via prescribing record cross-check with the Massachusetts Prescription Awareness Tool. Of 138 OPSCC TORS patients, 92.8% were human papillomavirus (HPV) positive. Adjuvant therapy included radiation (XRT;67.4%) and chemoradiation (cXRT;6.5%). Total MME usage from start of treatment averaged 1395.7 MMEs with 76.4% receiving three prescriptions or less. Categorical analysis showed age <65, male sex, overweight BMI, lower frailty, former smokers, HPV+, higher T stage, and BOT subsite to be associated with increased MMEs. Adjuvant therapy significantly increased MMEs (TORS+XRT:1646.2; TORS+cXRT:2385.0; TORS alone:554.7 [P < .001]) and 12-month opioid prescription totals (TORS+XRT:3.2; TORS+cXRT:5.5; TORS alone:1.6 [P < .001]). Adjuvant therapy increased time to taper (total MME in TORS alone versus TORS+XRT/cXRT: 0 to 3 months:428.2 versus 845.5, 4 to 6 months:46.8 versus 541.8, 7 to 9 months:12.4 versus 178.6, 10 to 12 months:11.0 versus 4.4,[P < .001]). Positive predictors of opioid prescribing at the 4- to 6-month and 4- to 12-month intervals included adjuvant therapy (odds ratio [OR]:5.56 and 4.51) and mFI-5 score ≥3 (OR:36.67 and 31.94). Following TORS at 6-, 9-, and 12-month, 15.7%, 6.6%, and 4.1% were still using opioids. In OPSCC treated with TORS, opioid use tapers faster for surgery alone versus with adjuvant therapy. Opioid prescribing risks include adjuvant therapy and higher frailty index. 4 Laryngoscope, 131:E1888-E1894, 2021.

Prognostic Factors for Adjuvant Therapy after Trans-Oral Robotic Surgery in Patients with Oropharyngeal Squamous Cell Carcinoma

To identify predictors of adjuvant therapy after Trans-Oral Robotic Surgery (TORS) for Oropharyngeal Squamous Cell Carcinoma (OPSCC). We used the National Cancer Database (NCDB) registry to identify patients with newly diagnosed clinical (AJCC 7th edition) T1-T4 N0-N3 OPSCC treated with TORS between 2010 and 2016. Exclusion criteria were patients with metastatic disease (n = 1,997), biopsy only disease (n = 227), unknown stage (n = 771), and unknown surgical margin status (n = 78). A multivariable logistic regression was performed to determine predictors of adjuvant chemotherapy use after TORS. Variables included in the multivariable analysis include T stage, N stage, HPV status, margin status, performance status, age, case year surgery was performed (2010-2013 vs 2014-2016), and case volume. Case volume was divided into quintiles to assess the impact of case volume per institution with need for adjuvant therapy. Kaplan Meier Survival analysis was used to estimate overall survival (OS). We identified 3,337 patients who underwent TORS between 2010-2016. 3,232 patients (95.03%) underwent a lymph node dissection and the median number of lymph nodes removed was 31. 82.0% of patients were HPV positive and 18.0% were HPV negative. 2,940 patients (88%) were T1/T2 and 397 patients (12%) were T3/T4. Only 44 patients (1.3%) had N3 disease. The percentage of patients with positive and negative margins was 14.9% and 86.1% percent, respectively. The 5-year OS for the entire cohort was 80.8%. The 5-year OS for the HPV+ versus HPV- cohort was 85.2% and 63.5%, respectively (log-rank, p<0.001). Of all patients who received TORS, 1,166 (35.6%) received no further adjuvant therapy, 1,088 (33.2%) received adjuvant RT alone and 1,022 (31.2%) received adjuvant chemotherapy in addition to radiation. Among patients with only T1-T2 disease (n = 3050), 929 (29.6%) required adjuvant chemoradiation. For patients treated at institutions with the highest quintile for case volume, 27.2% required adjuvant radiotherapy and 35.0% required adjuvant chemotherapy. On multivariable logistic regression, patients with higher T stage (OR: 1.28, p<0.001), N stage (OR: 2.32, p<0.001), and positive margins (OR:1.64, p<0.001) were more likely to receive adjuvant chemotherapy. Patients who were treated between 2014-2016 were less likely to receive adjuvant chemotherapy compared to those treated between 2010-2013 (OR: 0.80, p = 0.029). The utilization of adjuvant therapy after TORS remains high, even in high volume centers, which suggests better patient selection is needed to identify a subset of patients that can be treated with TORS alone and undergo treatment de-escalation.

Identification of Clinical and Socioeconomic Predictors of Adjuvant Therapy after Trans-Oral Robotic Surgery in Patients with Oropharyngeal Squamous Cell Carcinoma.

Simple SummaryTreatment of oropharynx cancers usually requires radiation, chemotherapy, surgery, or a combination of all three. Although these treatments are effective, they can cause both short- and long-term side effects, particularly when more than one treatment option is used. Robotic surgery is now an option for patients with oropharynx cancers, but it is not clear how many patients will require additional treatment with radiation, or combined chemotherapy and radiation, after surgical treatment. In this study we used a large national database of oropharynx cancer patients and found that two-thirds of patients who were treated with robotic surgery required radiation therapy and one-third required chemotherapy with radiation. In addition, we found that the true tumor stage of the patients in this study was often higher than was initially thought prior to surgery. Finally, patients treated at high volume surgical centers were more likely to have more of their tumor removed compared to those at low volume facilities. Better survival quality of oropharynx cancer patients could be achieved by improving pre-surgical selection of patients so that the number of treatment modalities is reduced. Trans-oral robotic surgery (TORS) has emerged as an important surgical treatment option in the management of human papillomavirus (HPV)-positive and -negative oropharynx cancer. However, treatment selection is paramount to ensure that patients will not require multimodality adjuvant therapy. In this study, we determined predictors of adjuvant therapy in TORS-treated patients. The National Cancer Database (NCDB) was used to identify patients with newly diagnosed clinical T1-T4, N0-N3 oropharyngeal squamous cell carcinoma who underwent TORS between 2010–2016. Kaplan–Meier survival analysis was used to estimate overall survival (OS). A total of 2999 patients were studied, and the five-year OS for the entire cohort was 82.5%, and for HPV-positive and -negative cohorts it was 88.3% and 67.9%, respectively (p < 0.001). Among all patients treated with TORS, 35.1% of patients received no additional treatment, 33.5% received adjuvant radiation alone (RT), and 31.3% received adjuvant chemoradiation. The N stage was pathologically upstaged in 629 (20.9%) patients after TORS. Patients treated at higher-volume centers were more likely to have negative surgical margins (OR: 0.96, 95% CI: 0.94, 0.98, p < 0.001), but this did not influence the receipt of adjuvant therapy. The high rate of adjuvant multimodality treatment after TORS suggests a need for improved patient selection. Limitations of this study, including lack of data on loco-regional control, progression free survival, acute and late toxicities, and utilization of pretreatment PET/CT imaging, should be addressed in future studies.

The difficult airway and transoral robotic surgery

A systematic approach to airway management for transoral robotic surgery (TORS) will translate to a high-reliability system capable of handling anticipated and unexpected difficult airway situations. Intubation and glottic exposure for surgery need to be considered as distinct but critical components. Preoperative team briefings can contribute to effective planning and preparedness. Management options for TORS difficult airway should include formal consideration of awake tracheostomy and surgical microdirect laryngoscopy to facilitate intubation. Preinduction airway assessment by flexible fiberoptic exam or videolaryngoscopy can be helpful to inform shared decision making. Ideally in all facilities that perform TORS, a difficult airway ID and structured, multidisciplinary airway rapid response system is in place. A high risk extubation identification and formal extubation and/or reintubation planning process may further promote safety for TORS patients who remained intubated postoperatively. A team and instrument focused protocol for the management of emergent bring backs for bleeding or other complications is critical.

Functional Swallowing Outcomes in Transoral Robotic Surgery Patients With and Without Adjuvant Treatment

Dysphagia is an important consequence of cancer treatment and has overarching implications on quality of life. Using the FOIS, we demonstrated that swallowing function may be worse in the long term in patients with OPSCC undergoing triple therapy, although this finding did not reach statistical significance. This study emphasizes the importance of diligent selection in patients undergoing TORS to avoid poor functional swallowing outcomes, particularly in those that may need adjuvant chemoradiation therapy. A study with a larger sample size may determine the significance of these trends.