Transoral laser microsurgery for treatment of oropharyngeal cancer in 368 patients

[Radiation or Surgery for HPV-positive oropharyngeal cancer? The ORATOR2 Trial - Comparing apples and oranges]

ORATOR2 was a randomized phase II trial aiming to assess an optimal approach for therapy de-escalation in early (T1-T2, N0-N2) human papillomavirus (HPV)-related oropharyngeal squamous cell carcinomas (OPSCC). Radiotherapy (RT) (consisting of a reduced dose of 60 Gy with concurrent weekly cisplatin in N+ patients) was compared to trans-oral surgery (TOS) and neck dissection (ND) (with adjuvant reduced-dose RT depending on pathologic findings) in 61 patients. The primary endpoint, overall survival, favored the radiotherapy approach. This was mainly due to 3 mortality events in the surgery arm (2 surgery-related) which resulted in an early trial termination. The authors, who speak on behalf of the German Society of Otorhinolaryngology, Head & Neck Surgery (working group for oncology) warn to draw conclusions for clinical practice pointing out the main shortages/weaknesses of this trial especially in the surgery arm (at least 1 cm margins, recommending re-operation if not achieved, prohibition of regional or free flaps, high rates of tracheotomy, low rate of TLM). Small patient numbers, a highly selected patient cohort and a short follow-up time further limit this study's relevance. Therefore, patients with HPV-related OPSCC should not receive de-escalating (radiation) therapy outside of clinical trials. When deciding between a surgical or a radio-therapeutical approach, patients should be informed about the pros and cons of both modalities after interdisciplinary consent in a tumor board, as long as clinical trial results` (e. g. EORTC 1420) are pending.

Radiofrequency Coblation-Assisted Transoral Surgery for the Treatment of Oropharyngeal Squamous Cell Carcinoma: A Comparative Study with Open Surgery

Objective

Radiofrequency coblation (RFC) is a relatively new method that has opened up new perspectives in treating oropharyngeal squamous cell carcinoma (OPSCC). Our study was designed to explore the feasibility and effectiveness of RFC-assisted transoral surgery (RFC-TOS) for primary OPSCC.

Methods

Sixty-nine cases of OPSCC from February 2005 to November 2020 were retrospectively analyzed, including 31 in the RFC-TOS group and 38 in the open surgery group. No difference was observed in demographic and oncological characteristics.

Results

The significance between the RFC-TOS group and the open surgery group was proved in intraoperative bleeding volume (34.10 ± 10.10 ml vs. 193.68 ± 21.00 ml, P < 0.001), durations of surgery (79.58 ± 8.45 min vs. 217.87 ± 17.65 min, P < 0.001), time to resume oral feeding (1.64 ± 0.41 d vs. 11.58 ± 1.41 d, P < 0.001), duration of hospitalization (7.84 ± 0.66 d vs. 15.66 ± 1.62 d, P < 0.001), and the total costs (22846.22 ± 1821.55¥ vs. 41792.24 ± 4150.86¥, P < 0.001). The rates of 5-year overall survival (OS), 5-yeardisease-specific survival (DSS), and 5-year local control rate (LC) were 69.1%, 71.7%, and 75.7%, respectively, in the RFC-TOS group and 71.0%, 73.4%, and 73.7% in the open surgery group (P > 0.05).

Conclusions

RFC-TOS is a feasible alternative transoral approach for OPSCC. The reported perioperative and oncologic outcomes are satisfactory.

Factors influencing outcomes in selective neck dissection in 661 patients with head and neck squamous cell carcinoma

Background

Selective neck dissection (SND) is the surgical treatment of choice in squamous cell carcinoma of the head and neck (HNSCC) with suspected or manifest metastases in the cervical lymph nodes. For SND to be successful, treated lymph node levels should be selected according to anatomic considerations and the extent of the disease. Aim of this study was to identify neck dissection levels that had an impact on individual prognosis.

Methods

We conducted a retrospective review of SND as part of primary treatment of HNSCC. Overall survival (OS) and regional control rates (RCR) were calculated for all patients treated at one academic tertiary referral center.

Results

661 patients with HNSCC were included, 644 underwent ipsilateral and 319 contralateral SND. Average follow-up was 78.9 ± 106.4 months. 67 (10.1%) patients eventually developed nodal recurrence. Tumor sites were oral cavity (135), oropharynx (179), hypopharynx (118) and larynx (229). Tumor categories pT1–pT4a, and all clinical and pathological nodal categories were included. Multivariate analysis indicated improved OS rates for patients undergoing SND in ipsilateral levels I and V as well as level III contralaterally. Analysis for tumor origin showed that SND in ipsilateral level I showed significantly improved OS in HNSCC of the oral cavity.

Conclusion

The dissection of ipsilateral level I in oral cavity cancer was of particular relevance in our exploratory, retrospective analysis. To clarify the relevance for the determination of the extent of SND, this should be investigated prospectively in a more homogenous patient cohort.

Robotic vs. transoral laser surgery of malignant oropharyngeal tumors-what is best for the patient? : A contemporary review

Human papillomavirus (HPV)-associated squamous cell carcinoma of the oropharynx is a malignancy of increasing prevalence. The oncologic community is currently evaluating the safety and efficacy of de-intensifying treatment without compromising oncologic outcomes. Paramount to these treatment algorithms is primary surgery through transoral approaches. This article reviews the literature and concepts pertaining to transoral surgery and describes the two most common techniques, transoral laser microsurgery (TLM) and transoral robotic surgery (TORS).

Flexible transoral robotic surgery: the Italian experience

Objective

This prospective, non-randomised study documents our initial experience using the Flex^® Surgical System for transoral surgery in Italy.

Methods

All patients who underwent transoral robotic surgery using the Medrobotics^® Flex^® Robotic System (Raynham, MA, USA) between March 2018 and April 2019 were reviewed. Rates of successful surgery, surgical time and complications were evaluated. 43 surgical procedures were performed in the study. The average age was 62.56 years (range 36-90 years). The Flex^® system was used successfully in surgery of the base of the tongue, palatine tonsils, supraglottis, hypopharynx and glottis, which was the most frequent target.

Results

All procedures were successfully completed. There were no intraoperative or serious postoperative complications, with no cases of intraoperative haemorrhage.

Conclusions

This is the first study in Italy evaluating the use of the Flex^® system to safely resect lesions in the oral cavity, larynx and pharynx.

High-resolution spatiotemporal pHe and pO2 imaging in head and neck and oesophageal carcinoma cells

Background

pO₂ and pH are physiological parameters relevant for different processes in health and disease, including wound healing and cancer progression. Head and neck squamous cell carcinomas (HNSCC) and oesophageal squamous cell carcinomas (ESCC) have a high rate of local recurrence that is partly related to treatment-resistant residual tumour cells. Hence, novel diagnostic tools are required to visualise potential residual tumour cells and thereby improve treatment outcome for HNSCC and ESCC patients. We developed a device to spatiotemporally measure oxygen consumption rates (OCR) and extracellular acidification rates (ECAR) to distinguish HNSCC and ESCC cells from healthy cells in vitro, exploiting general metabolic differences between cancer cells and healthy cells.

Methods

OCR and ECAR were measured via a newly developed device named STO₂p-Q (SpatioTemporal O₂ and pH Quantification) using the VisiSens technology based on ratiometric fluorescence imaging, facilitating spatiotemporal resolution. Results were confirmed using extracellular flux analyses (Seahorse technology).

Results

STO₂p-Q is described and used to measure OCR and ECAR in HNSCC and ESCC cell lines and normal fibroblast and epithelial cells as components of the tumour microenvironment. OCR measurements showed differences amongst HNSCC and ESCC cell lines and between HNSCC/ESCC and normal cells, which on average had lower OCR than HNSCC/ESCC cells. Both OCR and ECAR measurements were independently verified using the Seahorse technology. Additionally, using STO₂p-Q, HNSCC/ESCC, and normal cells could be spatially resolved with a resolution in the low millimetre range.

Conclusions

We developed a method to spatiotemporally measure OCR and ECAR of cells, which has many potential in vitro applications and lays the foundation for the development of novel diagnostic tools for the detection of cancerous tissue in HNSCC and ESCC patients in vivo.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40170-021-00257-6.

Post-operative outcomes of different surgical approaches to oropharyngeal squamous cell cancer: a case-matched study

OBJECTIVE

To compare the post-operative outcomes of transoral laser microsurgery, lateral pharyngotomy and transmandibular surgery in oropharyngeal cancer management.

METHODS

Records of 162 patients treated with transmandibular surgery, transoral laser microsurgery or lateral pharyngotomy were reviewed. The transoral laser microsurgery cohort was matched with the lateral pharyngotomy and transmandibular surgery cohorts for tumour stage, tumour subsite and human papilloma virus status, and the intra- and post-operative outcomes were compared.

RESULTS

Duration of surgery and hospital stay were significantly longer for transmandibular surgery. Tracheostomy and nasogastric feeding tube rates were similar, but time to decannulation and to oral feeding were longer in the transmandibular surgery group. Transmandibular surgery more frequently required flap reconstruction and had a greater complication rate. Negative margins were fewer in the lateral pharyngotomy group than in the transoral laser microsurgery and transmandibular surgery groups.

CONCLUSION

In comparison with transmandibular surgery, transoral laser microsurgery and lateral pharyngotomy were associated with fewer complications and faster functional recovery. Lateral pharyngotomy had a higher rate of positive margins than transoral laser microsurgery, with a consequently greater need for adjuvant therapy. Many patients are nonetheless unsuitable for transoral surgery. All these factors should be considered when deciding on oropharyngeal cancer surgical treatment.

Transoral Robotic Surgery for Pharyngeal and Laryngeal Cancers-A Prospective Medium-Term Study

Transoral robotic surgery (TORS) has been used for treating pharyngeal and laryngeal cancers for many years. However, the application of neoadjuvant chemotherapy (NACT) before TORS, the sparing rate of adjuvant irradiation after TORS, and the long-term oncologic/functional outcomes of TORS are seldom reported. From September 2014 to May 2018, 30 patients with clinical T1 to T3 cancers of oropharynx (7), larynx (3), and hypopharynx (20) were prospectively recruited for TORS in a tertiary referral medical center. Twelve (40%) patients had clinical early stage (I or II) disease, and 18 (60%) patients had late-stage (III or IV) disease. All 30 patients were suggested to receive TORS with neck dissection. Cisplatin-based NACT was given to 11 patients before the surgery, and it led to a 100% reduction in tumor size. Only 40% of patients needed adjuvant irradiation with a mean dosage of 5933 cGY after TORS. After a mean follow up of 38.9± 14.7 months, the Kaplan-Meier method estimated 5-year disease-specific survival, and organ preservation was 86.3% and 96.2%, respectively. Twenty-five patients were alive without tracheostomy and tube feeding. We found that NACT is a potential method for facilitating tumor resection and TORS effectively de-escalated adjuvant irradiation with a satisfactory 5-year survival and functional outcomes.

[Functional outcomes after surgical treatment of oropharyngeal carcinomas]

INTRODUCTION

The primary goal of surgical resection of oropharyngeal carcinoma (OPSCC) is an R0 resection. The extension of the primary tumor is decisive for selection of access route, which should be as circumscribed as possible but as radical as necessary. To date, there are no prospective comparative studies that compared functional outcome in terms of surgical access route.

MATERIALS AND METHODS

A selective literature search was carried out for the period from 01/01/2000 to 12/31/2019 to assess the functional result after different surgical approaches in the treatment of OPSCC. The search strategy aimed to identify publications that investigated the functional result of transoral approaches, robot-assisted transoral resections (TORS), and surgical resection using pharyngotomies or transmandibular approaches.

RESULTS

Various measures were identified which enable subjective and objective assessment of swallowing and speaking restrictions. For all surgical access routes, studies were identified that examined the functional aspects of the respective access, but there are no direct comparisons between the individual approaches.

CONCLUSION

There are various surgical approaches available for resection of OPSCC, each of which has been examined in various studies with regard to its oncological and functional results.

Endonasal endoscopic surgery for sinonasal squamous cell carcinoma from an oncological perspective

Endonasal endoscopic surgery (EES) has been applied to the management of sinonasal (SN) tumors based on recent advances in endoscopic surgical techniques and technologies over the past three decades. EES has been mainly indicated for benign tumors and less aggressive malignant tumors. Notwithstanding this, EES has been gradually adopted for squamous cell carcinoma (SCC), which is the most common histology among SN malignancies. However, an analysis of the outcomes of EES for patients with SCC is difficult because most articles included SCC a wide range of different tumor histologies. Therefore, we herein review and clarify the current status of EES focusing on SCC from an oncological perspective. The oncologic outcomes and the ability to achieve a histologically complete resection are similar between endoscopic and open approaches in highly selected patients with SN-SCC. Surgical complications associated with EES are likely similar for SN-SCC compared to other sinonasal malignancies. The indications for a minimally invasive approach such as EES in the management of patients with SN-SCC should be stricter than those for less aggressive malignant tumors because of the aggressive nature of SCC. Also, it is important to achieve negative surgical margins with EES in patients with SCC. We believe that the indications for EES for SN-SCC are widening due to advances in diagnostic imaging, and endoscopic surgical techniques and technologies. However, while expanding the indications for EES for SN-SCC we must carefully confirm that the outcomes support this strategy.

Prognostic impact of additional HPV diagnostics in 102 patients with p16-stratified advanced oropharyngeal squamous cell carcinoma

Purpose

p16 overexpression was considered as surrogate marker to identify human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCCs).

Methods

102 patients with advanced stage OPSCCs treated primarily by transoral lasermicrosurgery were included. Prognostic associations of p16- and HPV-status were analyzed separately and combined.

Results

In contrast to p16, the HPV-status resulted in no significant survival discrepancies (5-year overall survival (OS) HPV-positive 64.9%, HPV-negative 78.7%). Combining both markers, p16-positive (p16-positive/HPV-positive, p16-positive/HPV-negative) and p16-negative/HPV-negative groups demonstrated comparable high survival (OS 78.1% vs. 85.6% vs. 73.6%). Lowest survival was observed for patients with p16-negative/HPV-positive OPSCCs (OS 40.8%).

Never smoking patients with p16-positive OPSCCs demonstrated the highest survival, whereas within former/current smokers with p16-positive and p16-negative disease it was comparable low (OS 90.0% vs. 63.0% vs. 57.4%).

Conclusions

p16- and HPV-status should not be considered as equivalent markers for a better prognosis. Furthermore, they should not generally predominate patient associated factors like smoking.

Electronic supplementary material

The online version of this article (10.1007/s00405-020-06262-7) contains supplementary material, which is available to authorized users.

Benefit of postoperative radiotherapy for early tumors with single ipsilateral lymph node metastasis

OBJECTIVES/HYPOTHESIS

Indication for postoperative radiotherapy in patients with locally circumscribed tumors (pT1-pT2) and a single ipsilateral lymph node metastasis (pN1) is debatable. The aim of this study was to evaluate the oncological long-term outcome of patients with pT1-pT2 pN1 squamous cell carcinoma (SCC) of the oral cavity, the oropharynx, and the hypopharynx without extracapsular spread (ECS) after a margin-negative surgical resection, who either received or did not receive postoperative (chemo)radiotherapy.

STUDY DESIGN

Retrospective case series.

METHODS

The oncological outcome of patients with pT1-pT2 pN1 SCC without ECS was evaluated retrospectively. All patients underwent primary tumor resection that included transoral laser microsurgery and neck dissection at an academic tertiary referral center.

RESULTS

Of 65 identified patients treated between 1986 and 2015 (18 oral cavity, 30 oropharynx, 17 hypopharynx), 21 (32%) received postoperative radiotherapy, and 44 (68%) were treated by surgery alone. The group of patients receiving postoperative treatment showed a significantly superior 5-year disease-specific (94.4% vs. 73.2%, P = .029) and recurrence-free survival (85.2% vs. 43.2%, P = .002), as well as a higher local control rate (90.2% vs. 64.9%, P = .042). The overall survival was 71.4% vs. 62.6% (P = .53). The mean follow-up was 80.7 months.

CONCLUSIONS

Patients with locally circumscribed carcinomas and a single ipsilateral ECS-negative lymph node metastasis seem to benefit from postoperative radiotherapy.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:E530-E538, 2020.