Introduction/aimWe analyzed the functional and oncologic outcomes of primary and salvage transoral robotic surgery (TORS) procedures, performed in three Belgian institutions with a similar philosophy.Patients and methodsA total of 86 patients who underwent TORS between 24-12-2009 and 25-09-2015 were retrospectively reviewed. Descriptive statistics, overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS; Kaplan–Meier), and the variation of these outcomes according to whether patients had primary or salvage TORS were evaluated (univariate log-rank analysis).ResultsOf 86 patients, 56 (65.1%) underwent TORS as a primary treatment and 30 (34.9%) as a salvage procedure for recurrent or second primary cancer. Tumor location was mainly oropharynx (N = 63; 73.3%) followed by supraglottic larynx (N = 11; 12.8%), hypopharynx (N = 11; 12.8%), and glottic larynx (N = 1; 1.2%). In the up-front TORS group, most tumors were classified as cT1 (N = 23; 41.1%)/pT1 (N = 24; 42.9%) or cT2 (N = 27; 48.2%)/pT2 (N = 27; 48.2%) and cN0 (N = 18; 32.1%), cN1 (N = 13; 23.2%), or cN2 (N = 25; 44.6%). In the salvage TORS group, most tumors were cT1-rT1 (N = 18; 60.0%)/pT1-rpT1 (N = 18; 60.0%) or cT2-rT2 (N = 12; 40.0%)/pT2-rpT2 (N = 7; 23.3%) and cN0 (N = 25; 83.3%). Neck dissection was performed in 87.5% of primary cases and 30.0% of salvage cases. In the up-front TORS group, patients were postoperatively submitted to follow-up (N = 13; 23.2%) or received adjuvant radiotherapy, either as single modality (N = 26; 46.4%) or with concomitant cisplatin (N = 15; 26.8%). On the other hand, most salvage TORS patients did not receive any adjuvant therapy (N = 19; 63.3%). Mean and median follow-up was 23.1 and 21.2 months, respectively. Functional results were excellent (no definitive tracheostomy, long-term tube feeding in 1.8% of primary cases, and 20% of salvage cases). In the up-front TORS group, estimated 2-year OS was 88.5% (SE = 5.0%), 2-year DSS was 91.8% (SE = 4.6%) and 2-year DFS was 86.1% (SE = 5.3%). In the salvage TORS group, estimated 2-year OS was 73.5% (SE = 10.9%), 2-year DSS was 93.3% (SE = 6.4%), and 2-year DFS was 75.8% (SE = 9.7%). Comparing outcome of primarily treated patients to salvage patients, a non-statistically significant trend toward better OS (p = 0.262) and DFS (p = 0.139) was observed.ConclusionThis retrospective study confirms favorable oncologic and functional outcomes of TORS for selected head and neck malignancies, both in the primary and in the salvage setting.

Background/Purpose: We analyzed complications and functional outcomes and aimed at identifying prognostic factors for functional outcomes and complications in patients who underwent salvage total laryngectomy (STL) for residual, recurrent, and second primary squamous cell carcinoma (SCC) of the larynx and hypopharynx after initial (chemo)radiation. Methods: Retrospective cohort study of patients who underwent STL in four major Belgian reference hospitals between 2002 and 2018. Prognostic factors for functional outcomes and complications were identified with uni- and multivariable analysis. Results: A total of 405 patients were included in the final analysis. STL was performed for residual tumor (40.2%), local recurrence (40.5%), or second primary laryngeal or hypopharyngeal SCC (19.4%). Early postoperative complications were experienced by 34.2% of patients: postoperative hemorrhage occurred in 5.4%, wound infection in 16.2%, and clinical pharyngocutaneous fistula (PCF) in 25.5% of patients. Early readmission proved necessary in 15.1% of cases, most often due to late PCF development (72.2%). Patients achieved total peroral intake in 94.2% of cases. However, subjective dysphagia was reported by 31.3% of patients during follow-up. Functional speech, defined as functional communication by speech without additional aids, was reported in 86.7% of cases and was most often achieved by tracheo-esophageal puncture (TEP) (94.1%). In a multivariable model, lower preoperative hemoglobin (<12.5 g/dl) was identified as an independent prognostic factor for higher overall complication rate. No risk factors were found significant for clinical fistula formation. Vascularized tissue augmentation did not significantly prevent clinical PCF. Patients with positive section margins, patients initially treated with surgery combined with adjuvant RT (vs. radiotherapy alone), and those developing PCF after STL were less likely to achieve total peroral intake. Postoperative dysphagia proved more likely in patients who developed a PCF postoperatively, and less likely in patients who underwent STL without partial pharyngectomy and in patients with myocutaneous pectoralis major (PM) flap reconstruction, compared to muscle onlay PM flap. Achieving postoperative functional speech proved most likely in patients with smaller tumors (lower pT classification) and free section margins. Conclusion: Substantial complication rates and favorable functional outcomes are reported after STL.

Functional reconstruction of extensive laryngeal defects can be achieved with an autotransplantation of cervical trachea, with favorable functional results and acceptable morbidity. This technique expands the limits of conservation surgery for selected laryngeal and hypopharyngeal tumors.

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