Prognostic role of surgical margins in patients undergoing transoral robotic surgery after neo-adjuvant chemotherapy

Adjuvant treatment in elderly patients undergoing transoral surgery for HPV-related oropharyngeal cancer

OBJECTIVES

Older adults are an increasing proportion of patients with HPV-related oropharyngeal squamous cell carcinoma (OPSCC), and transoral surgery (TOS) remains a valid treatment option for this population. This study aimed to evaluate the impact of adjuvant therapy on survival outcomes in this group.

METHODS

This retrospective study analyzed data from the National Cancer Database (NCDB) for older adults (≥65 years) diagnosed with OPSCC and treated with primary TOS. Patients were stratified into low, intermediate, and high-risk groups according to specific pathological criteria. The survival benefit of adjuvant therapy was assessed using a multivariable Cox regression model.

RESULTS

A total of 998 patients undergoing primary TOS for HPV-related OPSCC were classified in low (N = 347, 34.8 %), intermediate (N = 261, 26.1 %) and high (N = 390, 39.1 %) risk groups. Adjuvant treatment showed no significant benefit in the low (adjusted HR: 0.70; 95 % CI: 0.33-1.47) and intermediate (HR: 0.73; 95 % CI: 0.36-1.48) risk groups. Adjuvant treatment was beneficial in the high risk group (adjusted HR: 0.40, 95 % CI: 0.25-0.62), with adjuvant chemoradiotherapy (adjusted HR: 0.28 95 % CI: 0.16-0.48; p < 0.001) showing a slight advantage compared to radiotherapy alone (adjusted HR: 0.61, 95 % CI: 0.36-1.03).

CONCLUSION

The findings suggest that adjuvant therapy should be selectively applied in older adults with OPSCC, with a significant survival benefit observed primarily in high-risk patients. Future studies are needed to confirm the safety and efficacy of treatment de-escalation strategies in this population.

Adjuvant Radiation Sparing after Neoadjuvant Chemotherapy and TORS in Selected HPV-Positive Oropharyngeal Cancer

OBJECTIVE

Transoral robotic surgery (TORS) has shown promising results in treating human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC), and there has been increasing interest in incorporating neoadjuvant chemotherapy (NCT) prior to TORS. This study aimed to assess the feasibility and safety of sparing adjuvant RT following NCT and TORS.

METHODS

A retrospective cohort study included consecutive patients with HPV-positive OPSCC who underwent NCT followed by TORS without adjuvant RT. Disease-free survival (DFS) was the primary outcome. Pattern of recurrence (local, regional, and distant), salvage treatment outcomes, and predictors of tumor recurrence were also assessed.

RESULTS

A total of 84 patients were included in the analysis. No patients died during the study period. DFS rates (95% Confidence Interval, CI) at 1, 2, and 3 years were 92.8% (87.4-98.5), 87.0% (79.7-94.9), and 84.4% (76.0-93.8), respectively. Local, regional, and distant recurrence rates were 7.0%, 9.5%, and 3.6%, respectively. Salvage treatment achieved a 100% salvage rate. Predictors of tumor recurrence included the number of positive lymph nodes (hazard ratio: 2.66; 95% CI: 1.19-5.92) and clinical stage III at diagnosis (hazard ratio: 7.65; 95% CI: 1.97-29.7).

CONCLUSIONS

Recommendation of adjuvant treatment based on pathologic adverse features appears to be associated with favorable outcomes in selected HPV-positive OPSCC cases treated with NCT and TORS. Future studies should focus on refining criteria for recommending adjuvant RT to further reduce recurrence rates and minimize treatment-related toxicity, contributing to personalized treatment strategies for HPV-related OPSCC.

LEVEL OF EVIDENCE

4 Laryngoscope, 135:1401-1408, 2025.

Neoadjuvant chemotherapy followed by transoral robotic surgery versus upfront surgery for locoregionally advanced oropharyngeal carcinoma: A propensity score matched analysis

BACKGROUND

Transoral robotic surgery (TORS) performed after neoadjuvant chemotherapy (NAC) is a promising treatment for advanced-stage oropharyngeal carcinoma (OPSCC) able to reduce the adjuvant therapy administration rate.

METHODS

A retrospective bi-centric study was conducted to analyze NAC + TORS versus upfront TORS patients. A 1:1 propensity score matching was used to compare the two groups.

RESULTS

Among the 300 patients with stage III-IV OPSCC, 204 patients were matched for comparing NAC + TORS versus upfront TORS. Between the two groups, no significant difference was observed in recurrences and in survival for RFS, OS, and DSS. In the NAC + TORS p16-positive population, adjuvant therapy could be spared in 51% versus 16% in the upfront surgery cohort (p < 0.001) due to the lower frequency of pathological risk factors after NAC.

CONCLUSIONS

NAC followed by TORS for locoregionally advanced OPSCC demonstrated to achieve non-inferior survival outcomes to upfront surgery, while in the p16-positive population allowed to significantly spare adjuvant therapy.

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.

Transoral robotic surgery in oropharyngeal squamous cell carcinoma: A comparative study between da Vinci Single-Port and da Vinci Xi systems

BACKGROUND

The recently developed da Vinci single-port (SP) system offers potential advantages in maneuverability within narrower surgical spaces. This study aims to compare intra- and post-operative outcomes, technical advantages, and limitations of transoral resections using the da Vinci SP and da Vinci Xi systems for oropharyngeal squamous cell carcinoma (OPSCC).

METHODS

A single-center retrospective cohort study included patients with OPSCC who underwent transoral robotic surgery (TORS) after neoadjuvant chemotherapy (NCT). Data on pre-operative variables, intraoperative data, postoperative complications, and functional outcomes were collected.

RESULTS

A total of 209 patients (males: 175; mean age: 59.0 ± 9.3) were included (SP: n = 136; Xi: n = 73). A significantly lower docking time was measured for the SP group (5.7 ± 2.5 min vs. 10.0 ± 4.4 min; p <.001). Similarly, the console time was reduced for the SP group though not reaching statistical significance (76.3 ± 30.7 min vs. 88.1 ± 36.9 min; p =.06). A greater proportion of patients showed wide negative resection margins in the SP group (71 % vs. 56 %; p =.10), although not statistically significant. No significant differences were observed in complication rates or postoperative functional outcomes.

DISCUSSION

This study demonstrates the safety and efficacy of the da Vinci SP system in oropharyngeal surgery, with potential advantages in terms of reduced docking and console times. The findings suggest that the SP system offers improved maneuverability and instrument placement compared to the da Vinci Xi system.

Neo-adjuvant chemotherapy and transoral robotic surgery in locoregionally advanced oropharyngeal cancer

PURPOSE

To analyze the oncological outcomes and patterns of recurrence of patients with locoregionally advanced oropharyngeal squamous cell carcinoma (OPSCC) who underwent neo-adjuvant chemotherapy (NCT) with subsequent transoral robotic surgery (TORS).

METHODS

A single-center retrospective cohort study was performed, including 198 patients (mean age: 58.6, SD: 9.2). The primary outcome was disease-free survival (DFS).

RESULTS

The median follow-up time was 26.5 months (IQR: 16.0-52.0). Estimated DFS rates (95 % CI) at 1 and 3 years were 86.6 % (81.9-91.7), and 81.4 % (75.7-87.6), respectively. Estimated DSS rates (95 % CI) at 1 and 3 years were 96.7 % (94.1-99.3), and 92.6 % (88.4-97.0), respectively. Estimated OS rates (95 % CI) at 1 and 3 years were 96.2 % (93.4-99.0), and 88.7 % (83.4-94.2), respectively. A total of 31 (15.6 %) patients showed a disease relapse after a median time of 8 months (IQR: 4.0-12.0), but only 12 (6 %) patients died of the disease during the study period.

CONCLUSIONS

This study demonstrates that NCT and TORS can obtain excellent tumor control and survival in locoregionally advanced OPSCC. NCT might reduce the need for adjuvant treatments, and randomized clinical trials should be conducted to better define this aspect.

Compartmental Transoral Robotic Lateral Oropharyngectomy with the da Vinci Single-Port System: Surgical Technique

BACKGROUND

Transoral robotic surgery (TORS) has renovated the surgical management of oropharyngeal squamous cell carcinoma (OPSCC), allowing a minimally invasive surgical approach with optimal oncological outcomes. The recent introduction of the da Vinci Single Port (SP) system resulted in a considerable improvement of TORS technique.

METHODS

In this video, we illustrate the transoral robotic lateral oropharyngectomy performed with the da Vinci SP system in a 50-year-old male patient suffering from a p16+ oropharyngeal squamous cell carcinoma cT4N1M0.

RESULTS

The transoral robotic lateral oropharyngectomy is illustrated step by step. The structures encountered during the resection are described, and the surgical margins are defined based on anatomical landmarks. The most critical regions encountered during resection are pointed out, and the tip and tricks of this surgery are reported.

CONCLUSIONS

A step-by-step transoral lateral oropharyngectomy is described to increase its reproducibility. The da Vinci SP system owns various benefits for performing transoral lateral oropharyngectomy due to the increased maneuverability in the narrower oral cavity working spaces.