Occult Nodal Disease and Occult Extranodal Extension in Patients With Oropharyngeal Squamous Cell Carcinoma Undergoing Primary Transoral Robotic Surgery With Neck Dissection

McMullen, Caitlin; Garneau, Jonathan; Weimar, Emillie; Ali, Sana; Farinhas, Joaquim M.; Yu, Eugene; Som, Peter M.; Sarta, Catherine; Goldstein, David P.; Su, Susie; Xu, Wei; Smith, Richard V.; Miles, Brett A.; Almeida, John R. de

doi:10.1001/jamaoto.2019.1186

Cited by 22 publications

(19 citation statements)

References 40 publications

(67 reference statements)

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“…Previous analyses of national‐level data suggest unacceptably high rates of both positive surgical margins and a need for adjuvant therapy with upfront surgical approaches, and this highlights the possibility of poor surgical selection nationwide . Notably, the preoperative prediction of adequate margin control and ENE remains challenging despite advances in imaging techniques …”

Section: Introductionmentioning

confidence: 99%

“…14 Notably, the preoperative prediction of adequate margin control and ENE remains challenging despite advances in imaging techniques. 15,16 The objectives of this study were 2-fold: 1) to assess for patient-, hospital-, and disease-specific factors that influence treatment strategies across the United States and 2) to assess predictors of triple-modality therapy in those receiving upfront surgical approaches.…”

Section: Introductionmentioning

confidence: 99%

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National treatment trends in human papillomavirus–positive oropharyngeal squamous cell carcinoma

Zhan

Puram

et al. 2019

Cancer

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Background Human papillomavirus (HPV)–mediated oropharyngeal cancer (OPC) is associated with dramatically improved survival in comparison with HPV‐negative OPC and can be successfully treated with surgical and nonsurgical approaches. National treatment trends for OPC were investigated with the National Cancer Data Base (NCDB). Methods The NCDB was reviewed for primary HPV‐mediated OPC in 2010‐2014. Multivariable regression was used to identify predictors of both nonsurgical therapy and receipt of adjuvant chemoradiation (CRT). Results There were 13,363 patients identified with a median age at diagnosis of 58 years. The incidence of triple‐modality treatment (surgery with adjuvant chemotherapy) decreased from 23.7% in 2010 to 16.9% in 2014 (R2 = 0.96), whereas the incidence of nonsurgical treatment increased from 63.9% to 68.7% (R2 = 0.89). Hospitals in the top treatment volume quartile (quartile 1 [Q1]; n = 29) had a lower rate of positive margins (16.3%) than bottom‐quartile centers (n = 741; rate of positive margins, 36.4%; P < .001); Q1 hospitals used surgical therapy significantly more. Independent predictors of nonsurgical therapy included older age, advanced disease, lower hospital volume, and living closer to the hospital or outside the Pacific United States. In surgically treated patients, younger age, lower hospital volume, nodal disease, positive surgical margins, and extranodal extension (ENE) also predicted more adjuvant CRT use. Conclusions The use of upfront surgical treatment decreased from 2010 to 2014. Hospital volume shows a strong, inverse correlation with the rate of positive surgical margins. The upfront treatment strategy is predicted not only by staging but also by patient‐, geographic‐, and hospital‐specific factors. Lower hospital volume remains independently associated with increased triple‐modality therapy after adjustments for positive margins, ENE, and pathologic staging.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

National treatment trends in human papillomavirus–positive oropharyngeal squamous cell carcinoma

Zhan

Puram

et al. 2019

Cancer

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“…Nevertheless, in this series 13/37 patients had ENE on final pathology the was not identified radiologically. While there remains controversy on the prognostic implication of ENE in HPV‐related OPSCC, this is an important variable that continues to guide primary and adjuvant therapy 17,27 . On the basis of the results of this study, muscle invasion is associated with many known negative prognostic findings on pathology, and therefore warrants further reporting and study to clarify its prognostic utility.…”

Section: Discussionmentioning

confidence: 72%

Muscle invasion in oropharyngeal carcinoma undergoing transoral robotic surgery

McKenzie

Parhar

et al. 2020

Head & Neck

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Backgrounds: Pathologic features of oropharyngeal squamous cell carcinoma (OPSCC) treated with trans-oral robotic surgery predict prognosis and adjuvant therapy. We hypothesized that pathologic muscle invasion (pMI) is associated with poor pathological markers. Methods: Retrospective review of surgically treated OPSCC to identify pMI and its association with poor pathologic markers. Results: pMI was present in 12/37 patients, and compared to non-pMI, was associated with higher rates of lymphovascular invasion (75% vs. 36%, p = 0.03), perineural invasion (16.7% vs. 0%, p = 0.04), extranodal extension (66.7% vs. 20%, p < 0.01), and tumor stage (8.3% vs. 48% pT1, 75% vs. 52% pT2 and 16.7% vs. 0% pT3). pMI was associated with having a positive margin on main specimen (41.7% vs. 12%, p = 0.04) but not after considering additional margins. Conclusions: Muscle invasion was associated with higher pathologic tumor staging, poor pathologic factors, and higher rates of positive margin on main specimen.

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“…Gildener-Leapman et al [ 15 ] performed a retrospective study of TORS-treated patients showing that neck dissection upstaged the nodal status in 36% of patients. McMullen et al [ 16 ] retrospectively reviewed the incidence of occult nodal disease in patients undergoing TORS with neck dissection and demonstrated that 22% of patients were pathologically upstaged from N0/N1 to N2 or greater. Our study provides some encouraging evidence of improved patient selection, with the rate of adjuvant chemoradiation dropping from over 40% in 2010 to less than 30 percent in 2016 ( Figure 4 B).…”

Section: Discussionmentioning

confidence: 99%

“…On univariate analysis, the receipt of adjuvant radiation therapy (Hazard ratio: (HR): 0.65, 95% CI: 0.48, 0.87), adjuvant chemoradiation (HR: 0.81, 95% CI: 0.62, 1.07), HPV status (HR: 0.31, 95% CI: 0.24, 0.42), Charlson comorbidity score (HR: 1.56, 95% CI: 1.18, 2.0), clinical Tumor (T) stage (T3/4 vs. T1, HR: 1.75, 95% CI:1. 16 Figure 3). Figure 3).…”

Section: Survival Analysismentioning

confidence: 99%

Identification of Clinical and Socioeconomic Predictors of Adjuvant Therapy after Trans-Oral Robotic Surgery in Patients with Oropharyngeal Squamous Cell Carcinoma

Baliga

Klamer

Jhawar

et al. 2020

Cancers

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Trans-oral robotic surgery (TORS) has emerged as an important surgical treatment option in the management of human papillomavirus (HPV)-positive and -negative oropharynx cancer. However, treatment selection is paramount to ensure that patients will not require multimodality adjuvant therapy. In this study, we determined predictors of adjuvant therapy in TORS-treated patients. The National Cancer Database (NCDB) was used to identify patients with newly diagnosed clinical T1-T4, N0-N3 oropharyngeal squamous cell carcinoma who underwent TORS between 2010–2016. Kaplan–Meier survival analysis was used to estimate overall survival (OS). A total of 2999 patients were studied, and the five-year OS for the entire cohort was 82.5%, and for HPV-positive and -negative cohorts it was 88.3% and 67.9%, respectively (p < 0.001). Among all patients treated with TORS, 35.1% of patients received no additional treatment, 33.5% received adjuvant radiation alone (RT), and 31.3% received adjuvant chemoradiation. The N stage was pathologically upstaged in 629 (20.9%) patients after TORS. Patients treated at higher-volume centers were more likely to have negative surgical margins (OR: 0.96, 95% CI: 0.94, 0.98, p < 0.001), but this did not influence the receipt of adjuvant therapy. The high rate of adjuvant multimodality treatment after TORS suggests a need for improved patient selection. Limitations of this study, including lack of data on loco-regional control, progression free survival, acute and late toxicities, and utilization of pretreatment PET/CT imaging, should be addressed in future studies.

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Occult Nodal Disease and Occult Extranodal Extension in Patients With Oropharyngeal Squamous Cell Carcinoma Undergoing Primary Transoral Robotic Surgery With Neck Dissection

Cited by 22 publications

References 40 publications

National treatment trends in human papillomavirus–positive oropharyngeal squamous cell carcinoma

National treatment trends in human papillomavirus–positive oropharyngeal squamous cell carcinoma

Muscle invasion in oropharyngeal carcinoma undergoing transoral robotic surgery

Identification of Clinical and Socioeconomic Predictors of Adjuvant Therapy after Trans-Oral Robotic Surgery in Patients with Oropharyngeal Squamous Cell Carcinoma

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