Increased rate of recurrence and high rate of salvage in patients with human papillomavirus–associated oropharyngeal squamous cell carcinoma with adverse features treated with primary surgery without recommended adjuvant therapy

Abstract

Background: Some patients with human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) do not receive guidelinerecommended postoperative radiation therapy (PORT) following primary transoral robotic surgery (TORS). Methods: Three-hundred and sixty-four patients with treatment-naïve, HPVassociated OPSCC were recommended to receive PORT based on clinicopathological features following TORS. Patients were stratified based on if they received PORT. Oncologic outcomes were compared. Results: The 3-year locoregional failure (LRF) was 32% in patients who did not receive PORT and 4% in patients who received PORT (P < .001). Despite increased LRF, avoiding PORT was not associated with increased 3-year distant metastasis rates (8% vs 4%, P = .56) or worse 3-year survival (95% vs 98%, P = .34). Recurrences in the surgery alone cohort varied between local and regional sites and were often successfully salvaged. Conclusions: Patients with HPV-associated OPSCC who do not receive indicated PORT have an increased risk of LRF but similar survival due to high salvage rates.

Locoregional Recurrence in p16‐Positive Oropharyngeal Squamous Cell Carcinoma After TORS

“…HPV status was determined based on p16 immunohistochemistry as previously described. 8,9 A negative margin was defined as a minimum of 2 mm and a close margin was defined as less than 2 mm. All surgeries were performed with curative intent.…”

“…7 We have previously shown that patients with HPV+ OPSCC treated with primary transoral robotic surgery (TORS) who do not receive National Comprehensive Cancer Network (NCCN)-guideline recommended postoperative radiation (PORT) have an increased risk of LRR but high salvage rates and similar survival to patients who receive optimal adjuvant therapy. 8 In the current study, we aimed to describe the outcomes of patients suffering LRR who did receive guideline-compliant adjuvant therapy and evaluate for factors associated with LRR in this population. In addition, we aimed to identify features associated with failure of salvage therapy which might impact patient counseling, clinical management of LRR, and clinical trial design.…”

Surgical margins in a single‐modality transoral robotic surgery: A conundrum—Reply

“…Although this period is relatively limited in duration, multiple studies have demonstrated short median times to local recurrence in surgically treated HPV+OPSCC ranging from 0.7 to 1.6 years. [1][2][3] In our study, no patient experienced local recurrence beyond 18 months of follow-up. While we noted in our study discussion that these patients remain at risk for recurrence, this study duration appears adequate to draw conclusions regarding local control in this patient population.…”

“…Other studies have noted rates of lymphovascular invasion in single-modality surgical patients ranging from 13.4% to 18.2% and rates of perineural invasion ranging from 3.5% to 19.6%. 2,3 We agree that quality of life (QOL) remains a critical area of ongoing research in comparative study of treatment modalities but is beyond the scope of our study. The central impetus of avoiding adjuvant treatment in our patient population is precisely to improve long-term quality of life by minimizing adjuvant treatment sequelae while maintaining superior oncologic outcomes.…”

“…Carey et al identified a significant reduction in locoregional control (68% vs. 96%) in patients refusing recommended adjuvant therapy after TORS but noted no differences in overall survival (95% vs. 98%). 3 Among 15 patients experiencing recurrence, 14 were alive at most recent follow-up and 13 had successful salvage treatment with no evidence of disease at last followup. Ryan et al described 22 locoregional recurrences among 344 single-modality surgery patients, noting no deaths in this subgroup and successful salvage treatment in 21 patients (95.5%).…”