The Lack of Standardized Outcomes for Surgical Salvage of HPV-Positive Recurrent Oropharyngeal Squamous Cell Carcinoma: A Systematic Scoping Review

Although HPV status is known to provide an improved prognosis in initial treatments of HPV-positive oropharyngeal squamous cell carcinoma (OPSCC), it is unclear how it affects patients who receive salvage surgery (SS), which has historically poor survival rates. The purpose of this study was to evaluate the role of SS for patients with locoregional recurrence (LRR) of HPV-positive OPSCC and its impact survival rates. We conducted a scoping review of literature through October 2022 and included 995 individuals. Survival endpoints, such as overall survival (OS), Kaplan-Meier curves, and median post-recurrence survival, were analyzed in addition to demographics. Of all studies, 18.8% (6/32) reported any survival data for SS patients, with the most prevalent reporting 2- and 5-year OS in two studies. Median post-recurrence survival was not reported for SS. These findings reveal the limited and unpredictable reporting of survival-specific data on SS for HPV-positive OPSCC. With limited survival assessment, it is difficult to assess the potential advantages and disadvantages of this therapy to guide clinical decision-making.

The Inconsistent Assessment of Quality of Life in Patients Treated for Head and Neck Cancer with Anti-EGFR Inhibitors: A Systematic Scoping Review

In patients receiving treatment for head and neck cancer (HNC), there is a correlation between quality of life (QoL) scores and treatment outcomes. Higher QoL scores have been associated with improved survival. Despite this, the assessment of QoL in clinical trials varies considerably. Three databases (Scopus, PubMed, and Cinahl) were queried for articles published in English between 2006 and 2022. Two reviewers (SRS and ANT) performed study screening, data extraction, and risk of bias assessment. The authors identified 21 articles that met the inclusion criteria. A total of 5961 patients were evaluated. QoL was reported as average scores for specific variables across five different surveys in 12 included articles. Supplemental QoL data were available in 10 included studies. Critical appraisal of studies indicated a high risk of bias due to the inclusion of trials. There is no standard method for reporting QoL data in clinical trials for HNC patients undergoing treatment with anti-EGFR inhibitors. Future clinical trials should standardize their method for assessing and reporting quality-of-life data to increase patient-centered care and refine treatment choices to optimize survival.

The Body Mass Index Paradox in Head and Neck Cancer: A Systematic Review and Meta-Analysis

The body mass index (BMI) paradox describes that among patients with certain cancers, higher pretreatment BMI may be associated with improved survival. We examine the impact of BMI on overall survival (OS) in head and neck squamous cell carcinoma (HNSCC) patients. A literature search was performed, and articles using hazard ratios to describe the prognostic impact of BMI on OS in HNSCC were included. Random-effects DerSimonian and Laird methods were employed for meta-analysis. Meta-analysis of OS indicated a lower hazards of death in the overweight (BMI: 25 kg/m2-30 kg/m2) compared to the normal weight (BMI: 18.5 kg/m2-25 kg/m2). This protective relationship loses significance when BMI exceeds 30 kg/m². Underweight patients (BMI < 18.5 kg/m2) demonstrate higher hazards of death compared to normal weight patients. Compared to HNSCC patients with normal weight, being overweight up to a BMI of 30 kg/m² is a positive predictor of OS, while being underweight confers a prognostic disadvantage. Further studies are needed to determine the mechanisms by which increased body mass influences survival outcomes in HNSCC.

Transcervical arterial ligation for prevention of postoperative hemorrhage in transoral oropharyngectomy: Systematic review and meta-analysis

BACKGROUND

Transcervical arterial ligation has been studied as a useful procedure to prevent bleeding events after transoral robotic surgery (TORS).

METHODS

A systematic review of English-language literature on arterial ligation in TORS from 2005 to 2019 was conducted using Cochrane, PubMed, Web of Science (WoS), and ScienceDirect databases. Studies evaluating ligation and rates of postoperative hemorrhage were included. Meta-analysis of included studies was performed to assess impact of ligation on postoperative hemorrhage.

RESULTS

Five studies with 2008 patients were included. History of radiation (odds ratio [OR] = 2.26, P = .02) and advanced tumor stage (OR = 1.93, P = .02) were found to predispose patients to postoperative hemorrhage. Arterial ligation was protective against severe hemorrhage in the mixed primary surgical modality cohort (OR = 0.33, P = .03) and in the TORS-only subgroup (OR = 0.21, P = .02), but did not significantly impact overall odds of postoperative hemorrhage.

CONCLUSION

Transcervical arterial ligation offers protection against major/severe postoperative hemorrhage in patients undergoing TORS.

LEVEL OF EVIDENCE

II.

Occult Metastasis in Laryngeal Squamous Cell Carcinoma: A Systematic Review and Meta-Analysis

OBJECTIVE

The incidence of occult metastasis (OM) in laryngeal squamous cell carcinoma (SCC) is still widely debated. In this systematic review, we aim to determine the rate of OM in laryngeal SCC, its impact on recurrence, and the role of elective neck dissection (END) in the management of the clinically negative neck.

METHODS

A systematic review of the English-language literature in Web of Science, PubMed, MEDLINE, and Cochrane Library databases on occult metastasis in laryngeal SCC from 1977 to 2018 was conducted. Studies evaluating occult metastasis (OM) in patients with laryngeal SCC with clinically negative necks undergoing surgery were included. Studies evaluating other head and neck subsites, clinically node positive, and salvage patients were excluded.

RESULTS

Twenty-one articles with a total of 5630 patients were included. The overall rate of OM was 20.5% and was 23% and 12.2% in supraglottic and glottic tumors, respectively. The OM rate in T1-T2 tumors was 13% and 25% in T3-T4 tumors. T3-T4 tumors had significantly greater odds of developing OM compared to T1-T2 tumors (Odds Ratio [OR] = 2.61, 95% Confidence Interval [CI] = 1.92-3.55, P < .00001). Patients with OM were more likely to develop distant metastasis (OR = 5.65, 95% CI = 3.36-9.51, P < .00001).

CONCLUSIONS

Patients with advanced T-stage laryngeal SCC should undergo elective neck treatment. More aggressive treatment for patients with history of OM should be considered due to the risk of subsequent regional and distant metastasis.

LEVEL OF EVIDENCE

II.

Salivary Clear Cell Carcinoma Clinicopathologic Characteristics and Outcomes: A Population-Based Analysis

Background:

Salivary clear cell carcinoma is an uncommon, low-grade malignancy for which limited data describing predictive clinicopathologic factors and treatment outcomes exist because of rarity.

Methods:

The authors queried the Surveillance, Epidemiology, and End Results database from 1982 to 2014. Multivariate Cox and Kaplan-Meier analyses were performed to determine disease-specific survival (DSS) and predictive clinicopathologic factors.

Results:

One hundred ninety-eight patients with salivary clear cell carcinoma were included. Overall incidence was 0.011 per 100 000 individuals, with no significant annual percentage change across years (−0.93%, P = .632). Five-, 10-, and 20-year DSS rates were 81.3% (n = 117), 69.6% (n = 94), and 55.3% (n = 68), respectively. Men (hazard ratio, 4.74; P = .0087) and patients with regional (hazard ratio, 5.59; P = .018) or distant (hazard ratio, 8.9; P = .01) metastases carried a worse prognosis. Five-year DSS was greater in patients with localized disease (96.36%, P < .0001) than those with regional or distant metastases. Treatment with surgery alone had better 10-year DSS (86.3%) compared with treatment with combination radiation and surgery (57.6%) or radiation monotherapy (18.75%, P < .0001).

Conclusions:

Salivary clear cell carcinoma carries an overall good prognosis. Patients with localized disease and those treated with surgery alone have more favorable prognoses. Male patients and those with regional or distant metastatic disease at time of presentation carry a worse prognosis.

Level of Evidence:

N/A

Oligometastatic status as predictor of survival in metastatic human papillomavirus-positive oropharyngeal carcinoma

BACKGROUND

Oligometastasis is a good prognostic indicator when compared to widely metastatic disease in malignancies of other organ systems. We hypothesized that oligometastasis in human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (SCC) would be associated with better overall survival.

METHODS

This is a retrospective review of all HPV-positive oropharyngeal SCC treated at one center with at least 1-year of follow-up. Patients were stratified into 2 cohorts: oligometastasis (1-2 metastases, confined to 1 organ system) or polymetastasis (>2 metastases or multiple organ involvement) with cohorts compared for time to distant metastasis and overall survival after metastasis.

RESULTS

Thirty-eight of 506 patients (7.5%) developed metachronous distant metastasis; 12 developed oligometastasis and 26 developed polymetastasis. Median overall survival after oligometastasis was significantly longer than polymetastasis at 45 months (95% confidence interval [CI] 19 months - not reached) and 10 months (95% CI 5-24 months; P = .00028).

CONCLUSION

Oligometastasis in metastatic HPV-positive oropharyngeal SCC portends a better prognosis than polymetastasis.

Positive Margins by Oropharyngeal Subsite in Transoral Robotic Surgery for T1/T2 Squamous Cell Carcinoma

Objective To compare positive margin rates between the 2 most common subsites of oropharyngeal transoral robotic surgery (TORS), the base of tongue (BOT) and the tonsil, as well as identify preoperative imaging characteristics that predispose toward positive margins. Study Design Case series with chart review. Setting Tertiary care referral center. Subjects and Methods We compared the final and intraoperative positive margin rate between TORS resections for tonsil and BOT oropharyngeal squamous cell carcinoma (OPSCC), as well as the effect of margins on treatment. A blinded neuroradiologist examined the preoperative imaging of BOT tumors to measure their dimensions and patterns of spread and provided a prediction of final margin results. Results Between January 2010 and May 2016, a total of 254 patients underwent TORS for OPSCC. A total of 140 patients who underwent TORS for T1/T2 OPSCC met inclusion criteria. A final positive margin is significantly more likely for BOT tumors than tonsil tumors (19.6% vs 4.5%, respectively, P = .004) and likewise for intraoperative margins of BOT and tonsil tumors (35.3% vs 12.4%, respectively; P = .002). A positive final margin is 10 times more likely to receive chemoradiation compared to a negative margin, controlling for extracapsular spread and nodal status (odds ratio, 9.6; 95% confidence interval, 1.6-59.6; P = .02). Preoperative imaging characteristics and subjective radiologic examination of BOT tumors did not correlate with final margin status. Conclusion Positive margins are significantly more likely during TORS BOT resections compared to tonsil resections. More research is needed to help surgeons predict which T1/T2 tumors will be difficult to completely extirpate.

Assessment of Surgical Learning Curves in Transoral Robotic Surgery for Squamous Cell Carcinoma of the Oropharynx

Importance

Transoral robotic surgery (TORS) is increasingly employed as a treatment option for squamous cell carcinoma of the oropharynx (OPSCC). Measures of surgical learning curves are needed particularly as clinical trials using this technology continue to evolve.

Objective

To assess learning curves for the oncologic TORS surgeon and to identify the number of cases needed to identify the learning phase.

Design, Setting, and Participants

A retrospective review of all patients who underwent TORS for OPSCC at the University of Pittsburgh Medical Center between March 2010 and March 2016. Cases were excluded for involvement of a subsite outside of the oropharynx, for nonmalignant abnormality or nonsquamous histology, unknown primary, no tumor in the main specimen, free flap reconstruction, and for an inability to define margin status.

Exposures

Transoral robotic surgery for OPSCC.

Main Outcomes and Measures

Primary learning measures defined by the authors include the initial and final margin status and time to resection of main surgical specimen. A cumulative sum learning curve was developed for each surgeon for each of the study variables. The inflection point of each surgeon's curve was considered to be the point signaling the completion of the learning phase.

Results

There were 382 transoral robotic procedures identified. Of 382 cases, 160 met our inclusion criteria: 68 for surgeon A, 37 for surgeon B, and 55 for surgeon C. Of the 160 included patients, 125 were men and 35 were women. The mean (SD) age of participants was 59.4 (9.5) years. Mean (SD) time to resection including robot set-up was 79 (36) minutes. The inflection points for the final margin status learning curves were 27 cases (surgeon A) and 25 cases (surgeon C). There was no inflection point for surgeon B for final margin status. Inflection points for mean time to resection were: 39 cases (surgeon A), 30 cases (surgeon B), and 27 cases (surgeon C).

Conclusions and Relevance

Using metrics of positive margin rate and time to resection of the main surgical specimen, the learning curve for TORS for OPSCC is surgeon-specific. Inflection points for most learning curves peak between 20 and 30 cases.

A prospective evaluation of short-term dysphagia after transoral robotic surgery for squamous cell carcinoma of the oropharynx

BACKGROUND

Transoral robotic surgery (TORS) for oropharyngeal squamous cell carcinoma (OPSCC) has been associated with improved long-term dysphagia symptomatology compared with chemoradiation. Dysphagia in the perioperative period has been inadequately characterized. The objective of this study was to characterize short-term swallowing outcomes after TORS for OPSCC.

METHODS

Patients undergoing TORS for OPSCC were enrolled prospectively. The Eating Assessment Tool 10 (EAT-10) was used as a measure of swallowing dysfunction (score >2) and was administered on postoperative day (POD) 1, 7, and 30. Patient demographics, weight, pain level, and clinical outcomes were recorded prospectively and focused on time to oral diet, feeding tube placement, and dysphagia-related readmissions.

RESULTS

A total of 51 patients were included with pathologic T stages of T1 (n = 24), T2 (n = 20), T3 (n = 3), and Tx (n = 4). Self-reported preoperative dysphagia was unusual (13.7%). The mean EAT-10 score on POD 1 was lower than on POD 7 (21.5 vs 26.6; P = .005) but decreased by POD 30 (26.1 to 12.2; P < .001). Forty-seven (92.1%) patients were discharged on an oral diet, but 57.4% required compensatory strategies or modification of liquid consistency. Ninety-eight percent of patients were taking an oral diet by POD 30. There were no dysphagia-related readmissions.

CONCLUSION

This prospective study shows that most patients who undergo TORS experience dysphagia for at least the first month postoperatively, but nearly all can be started on an oral diet. The dysphagia-associated complication profile is acceptable after TORS with a minority of patients requiring temporary feeding tube placement. Aggressive evaluation and management of postoperative dysphagia in TORS patients may help prevent dysphagia-associated readmissions. Cancer 2017;123:3132-40. © 2017 American Cancer Society.

Association of pretreatment body mass index and survival in human papillomavirus positive oropharyngeal squamous cell carcinoma

BACKGROUND

Pretreatment body mass index (BMI) >25kg/m(2) is a positive prognostic factor in patients with head and neck cancer. Previous studies have not been adequately stratified by human papilloma virus (HPV) status or subsite. Our objective is to determine prognostic significance of pretreatment BMI on overall survival in HPV+ oropharyngeal squamous cell carcinoma (OPSCC).

METHODS

This is a retrospective review of patients with HPV+ OPSCC treated between 8/1/2006 and 8/31/2014. Patients were stratified by BMI status (>/<25kg/m(2)). Univariate and multivariate analyses of survival were performed.

RESULTS

300 patients met our inclusion/exclusion criteria. Patients with a BMI >25kg/m(2) had a longer overall survival (HR=0.49, P=0.01) as well as a longer disease-specific survival (HR=0.43, P=0.02). Overall survival remained significantly associated with high BMI on multivariate analysis (HR=0.54, P=0.04).

CONCLUSIONS

Pre-treatment normal or underweight BMI status is associated with worse overall survival in HPV+ OPSCC.

Selection of Ideal Candidates for Surgical Salvage of Head and Neck Squamous Cell Carcinoma: Effect of the Charlson-Age Comorbidity Index and Oncologic Characteristics on 1-Year Survival and Hospital Course

IMPORTANCE

Salvage surgery for recurrent head and neck squamous cell carcinoma (HNSCC) carries substantial risks of morbidity and mortality. Risk factors for death within 1 year should be better defined.

OBJECTIVES

To report preoperative oncologic prognostic factors predictive of short-term (<1 year) survival after salvage surgery in patients with HNSCC, to assess whether preoperative age and comorbidity predicts 1-year mortality, and to report hospital courses after salvage surgery within 1 year.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective medical record review of 191 patients with recurrent HNSCC treated with salvage surgery from January 1, 2003, through December 31, 2013, at a tertiary academic center.

INTERVENTIONS

Surgical salvage of HNSCC (larynx, oral cavity, oropharynx, or hypopharynx) with curative intent.

MAIN OUTCOMES AND MEASURES

Primary outcome was survival 1 year after salvage surgery. Secondary outcomes were length of inpatient hospital stay, days of admissions, and skilled nursing facility disposition within 1 year stratified by survival status. Presalvage Charlson-Age Comorbidity Index (CACI) was calculated. Associations among CACI, oncologic risk factors, and risk of death within 1 year after salvage surgery are investigated using multivariable analysis.

RESULTS

Of 191 patients studied, 53 (27.7%) died within 1 year after salvage surgery. Patients who died within 1 year had more total inpatient admissions (P < .001), longer total length of stay (P < .001), and higher risk of discharge to a skilled nursing facility (P < .001) and spent 17.3% (interquartile range, 5.2-36.3) of their remaining days in the hospital. Independent risk factors for death within 1 year are CACI (relative risk [RR], 1.43; 95% CI, 1.16-1.76), primary T3 or T4 stage (RR, 2.34; 95% CI, 1.27-4.31), and disease-free interval of less than 6 months (RR, 5.61; 95% CI, 1.78-16.7).

CONCLUSIONS AND RELEVANCE

Medical comorbidity and age as measured by the CACI, primary T3 or T4 stage, and short disease-free interval must be considered in selecting patients ideal for surgical salvage surgery for recurrent HNSCC. Patients with these risk factors should be more strongly considered for palliative measures.

Respiratory epithelial adenomatoid hamartoma of the olfactory groove: A report of 4 cases and a review of the literature

Respiratory epithelial adenomatoid hamartoma (REAH) is a rare benign lesion that affects the nasal cavity and paranasal sinuses. We present 4 cases of REAH that involved the olfactory clefts; 1 case was bilateral. Each of the cases was treated surgically, and no recurrence was observed. Most reports have indicated that REAH occurs in the presence of sinonasal inflammation, particularly nasal polyposis, yet all 4 of our cases occurred in the absence of concurrent rhinosinusitis. This suggests that the etiology of REAH is multifactorial. In addition, we review the literature on REAH, and we discuss its presentation, differential diagnosis, radiology, histopathology, and underlying treatment principles.

Predictors of Intensive Care Unit Stay After Pediatric Supraglottoplasty

IMPORTANCE

Supraglottoplasty is a common procedure performed without evidence-based postoperative management plans. Patients are routinely admitted to the intensive care unit (ICU) postoperatively, but this may not be necessary in all cases.

OBJECTIVE

To determine (1) whether routine admission to the ICU after supraglottoplasty is warranted in all patients who undergo this procedure and (2) which factors predict requirement for ICU-level care.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective case series and analysis of immediate postoperative outcomes of all children aged 1 month to 18 years who underwent supraglottoplasty at 1 tertiary-care children's hospital from January 1, 2008, through January 31, 2014. Exclusion criteria included preoperative admission to the ICU, preoperative need for positive-pressure ventilation, history of major airway reconstruction, or any concomitant other major procedure.

EXPOSURE

Supraglottoplasty.

MAIN OUTCOMES AND MEASURES

Need for ICU-level care as defined by need for intubation, positive-pressure ventilation, multiple doses of racemic epinephrine, or oxygen via nasal cannula at greater than 4 L/min within the first 24 hours.

RESULTS

Of 223 patients identified, 25 (11.2%) met our criteria for ICU-level care. Nine patients required intubation. Twenty of the 25 patients met ICU criteria within 4 hours of surgery. Univariate analysis was performed on 38 risk factors. Risk factors for ICU requirement that remained statistically significant on multivariable analysis (P < .05) included surgical duration longer than 30 minutes (odds ratio [OR], 4.48 [95% CI, 1.51-13.19]; P = .007), nonwhite race (OR, 4.42 [95% CI, 1.54-12.66]; P = .006), and a preoperative diagnosis of gastroesophageal reflux disease (OR, 0.10 [95% CI, 0.09-0.36]; P < .001).

CONCLUSIONS AND RELEVANCE

Our study suggests that most children undergoing supraglottoplasty do not require ICU-level care postoperatively. Those who require ICU-level care are likely to be identified within the first 4 hours after surgery. Consideration for routine ICU admission should be given to those with longer surgical duration and those of nonwhite race.

Robot-Assisted Neck Dissection Through a Modified Facelift Incision

Objectives:

The aim of this study is to describe the feasibility as well as oncologic outcomes of robot-assisted neck dissection (RAND) through a modified facelift incision in an American population.

Study Design:

Retrospective case series.

Setting:

University tertiary care hospital.

Methods:

All patients who underwent RAND between November 2012 and December 2014 were included. Medical records were reviewed for demographics, medical histories, staging, operative information, postoperative hospital course and complications, and oncologic outcomes.

Results:

There were 11 RANDs identified among 10 patients. Five patients had known nodal metastasis at the time of surgery. Two patients had been previously irradiated. The average time of surgery was 284.4 ± 72.3 minutes, including other associated procedures. The average lymph node yield was 28.5 ± 9.3 nodes. There were no major complications. Average follow-up was 19.4 months. There was 1 supraclavicular recurrence in a previously irradiated patient. All patients are currently alive and without evidence of disease.

Conclusions:

Robot-assisted neck dissection is a safe and feasible procedure that can be performed by surgeons with familiarity with neck dissection and robot-assisted surgery and who have been trained in RAND. Appropriate oncologic outcomes can be obtained in a patient wishing to avoid a noticeable scar.

Accuracy of computed tomography to predict extracapsular spread in p16-positive squamous cell carcinoma

OBJECTIVE

To determine the accuracy of pretreatment, contrast-enhanced computed tomography (CT) in the diagnosis of extracapsular spread (ECS) in cervical lymph node metastases from p16-positive head-and-neck squamous cell carcinoma (HNSCC).

STUDY DESIGN

Retrospective observational study.

METHODS

Sixty-five (n = 65) patients diagnosed between 2004 and 2013 with p16-positive HNSCC and with cervical lymph node metastases measuring at least 1 centimeter in diameter on pathological assessment were included. All patients underwent primary surgical treatment. Subjects' preoperative contrast-enhanced neck CT scans were independently assigned a score for the likelihood of ECS (5-point scale) by two board-certified neuroradiologists. Receiver-operating characteristic curves were generated, and optimal sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated for each radiologist.

RESULTS

On histological analysis, the majority of patients (58%; 38/65) were found to have ECS, and 29% (19/65) of patients had ≥ three metastatic lymph nodes. For radiologist 1, PPV and NPV for ECS detection were 72% (95% confidence interval (CI), 53%-87%) and 53% (95% CI, 36%-70%), respectively. For radiologist 2, PPV and NPV for ECS detection were 82% (95% CI, 60 %-95%) and 53% (95% CI, 38%-69%), respectively.

CONCLUSION

CT is not a reliable method for determining the presence of ECS in p16-positive HNSCC patients.

Measurement of Nasal Polyp Patient Symptomatology over Time Using the Sinonasogram: Initial Validation

Objectives:

Chronic rhinosinusitis with nasal polyps is a common disorder that requires multiple methods to monitor disease burden. There is no validated questionnaire to monitor nasal polyp patient symptoms over time. We describe a novel 10-item questionnaire (Sinonasogram) which is currently used in clinical practice to evaluate current and 4-week symptoms that are common to patients with chronic rhinosinusitis.

Methods:

Twenty-five consecutive patients with nasal polyps seen in a university setting were included in this retrospective review. Patients were included if they had multiple visits to clinic and filled out the Sinonasogram questionnaire at each visit. Nasal polyp score was graded on a (0-5) scale. Statistical analysis was performed to determine correlation between changes in current, 4-week, and total Sinonasogram score and changes in nasal polyp score and to determine internal consistency.

Results:

Twenty-five patients were included for analysis with a total of 81 clinic visits. Changes in total and current Sinonasogram scores were significantly correlated with changes in nasal polyp scores ( P = .004, P = .002). Individual symptom scores best predicting nasal polyp size were nasal obstruction, hyposmia, and anterior rhinorrhea ( P < .001, P < .001, P < .001). Cronbach’s alpha test for internal consistency was 0.8244 for current Sinonasogram score and 0.8878 for 4-week Sinonasogram score.

Conclusions:

The Sinonasogram is a valid tool for monitoring nasal polyp symptoms and can predict changes in nasal polyp size. Symptoms that were found to be most associated with nasal polyps were nasal obstruction, hyposmia, and anterior rhinorrhea.

Robotic-Assisted Neck Dissection via Facelift Incision: Preliminary Findings in North American Patients

Objectives:

Describe the technique and lymph node yield of robotic-assisted neck dissection (RAND) via facelift incision in a North American cohort.

Methods:

Patients with squamous cell carcinoma of the head and neck at a tertiary hospital in 2012 were offered selective neck dissection via facelift incision. Operative time, estimated blood loss, complications, and lymph node yield were collected. Additionally, seven sequential open selective neck dissections were retrospectively reviewed for lymph node yield. A two-tailed t-test was used to compare nodal yield between the two groups (RAND vs open).

Results:

Four patients underwent five RANDs, including a simultaneous transoral robotic surgery base of tongue resection and one partial glossectomy. Four lateral neck dissections and one supraomohyoid neck dissection were performed. Mean operative time for the cohort was 4:29 +/- 1:33 (including extirpation); the average time for the three RAND only was 3:29 +/- 0:55. Average blood loss was 77 +/- 68 ml. The only complication was an intraoperative internal jugular vein injury, which was repaired with surgical clipping and suturing. The average number of lymph nodes removed was 29 in patients undergoing level 2-4 RAND, compared to 35.9 in the open group ( P = 0.28).

Conclusions:

Our preliminary experience suggests that RAND is feasible and safe in the North American population. Our data is also the first to demonstrate that nodal yield is the same between robotic-assisted and open lymphadenectomy. Further study will determine the learning curve for the procedure, and long-term oncologic follow up is needed.

Transoral Robotic Surgery and the Unknown Primary: A Highly Effective Technique for Identifying the Tumor

Objectives:

1) Describe the use of transoral robotic surgery (TORS) in the management of patients with unknown primary carcinoma of the head and neck. 2) Report the efficacy of TORS for patients with unknown primaries in our updated series, the largest reported series of such patients.

Methods:

A retrospective chart review was performed on patients with new occult primary squamous cell carcinoma of the head and neck with non-diagnostic imaging and/or endoscopy who were treated with TORS at a tertiary hospital between 2009 and 2012. Tumor identification rate and characteristics were analyzed.

Results:

206 head and neck robotic cases were performed at our institution between December 2009 and December 2012. Three surgeons performed TORS on 22 patients for occult primary squamous cell carcinoma. Of these, 11 had bilateral base of tongue resection, 3 had unilateral base of tongue resection, and the remainder had a combination of base of tongue procedures and tonsillectomy. The primary tumor was located in 19/22 (86.4%) patients. Mean tumor size was 1.03 cm +/- 0.66 cm and 9/22 (40.9%) patients had negative resection margins after the primary procedure.

Conclusions:

TORS is an effective procedure to locate the primary tumor in patients with cervical lymph node metastases and no obvious source. Bilateral base of tongue resection should be considered as part of the exam under anesthesia for these patients, particularly if the palatine tonsils have already been removed.