Oncologic Outcomes After Transoral Robotic Surgery

Abstract

IMPORTANCE Large patient cohorts are necessary to validate the efficacy of transoral robotic surgery (TORS) in the management of head and neck cancer. OBJECTIVES To review oncologic outcomes of TORS from a large multi-institutional collaboration and to identify predictors of disease recurrence and disease-specific mortality. DESIGN, SETTING, AND PARTICIPANTS A retrospective review of records from 410 patients undergoing TORS for laryngeal and pharyngeal cancers from January 1, 2007, through December 31, 2012, was performed. Pertinent data were obtained from 11 participating medical institutions. INTERVENTIONS Select patients received radiation therapy and/or chemotherapy before or after TORS. MAIN OUTCOMES AND MEASURES Locoregional control, disease-specific survival, and overall survival were calculated. We used Kaplan-Meier survival analysis with log-rank testing to evaluate individual variable association with these outcomes, followed by multivariate analysis with Cox proportional hazards regression modeling to identify independent predictors. RESULTS Of the 410 patients treated with TORS in this study, 364 (88.8%) had oropharyngeal cancer. Of these 364 patients, information about post-operative adjuvant therapy was known about 338: 106 (31.3) received radiation therapy alone, and 72 (21.3%) received radiation therapy with concurrent chemotherapy. Neck dissection was performed in 323 patients (78.8%). Mean follow-up time was 20 months. Local, regional, and distant recurrence occurred in 18 (4.4%), 15 (3.7%), and 10 (2.4%) of 410 patients, respectively. Seventeen (4.1%) died of disease, and 13 (3.2%) died of other causes. The 2-year locoregional control rate was 91.8% (95% CI, 87.6%-94.7%), disease-specific survival 94.5% (95% CI, 90.6%-96.8%), and overall survival 91% (95% CI, 86.5%-94.0%). Multivariate analysis identified improved survival among women (P = .05) and for patients with tumors arising in tonsil (P = .01). Smoking was associated with worse overall all-cause mortality (P = .01). Although advanced age and tobacco use were associated with locoregional recurrence and disease-specific survival, they, as well as tumor stage and other adverse histopathologic features, did not remain significant on multivariate analysis. CONCLUSIONS AND RELEVANCE This large, multi-institutional study supports the role of TORS within the multidisciplinary treatment paradigm for the treatment of head and neck cancer, especially for patients with oropharyngeal cancer. Favorable oncologic outcomes have been found across institutions. Ongoing comparative clinical trials funded by the National Cancer Institute will further evaluate the role of robotic surgery for patients with head and neck cancers.

Revisiting vascular contraindications for transoral robotic surgery for oropharyngeal cancer

“…The use of the da Vinci Robot for T1 and T2 lesions was approved by the FDA in 2009, and in light of the limited size of the resection in these indications most teams allow the surgical defect to heal by secondary intentions given the good oncologic and functional outcomes that have been reported 2, 7, 8, 9. However, the presence of either a retropharyngeal internal carotid artery (ICA) or a vascular proximity that is likely to result in an intraoperative exposure of the carotid bulb or the ICA were initially proposed to be contraindications for TORS due to the risk of a catastrophic vascular injury 2, 10.…”

Transoral Robotic Surgery for Oropharyngeal Cancer

“…Although explicit HPV testing was not done, the patient cohort with large primary sites and small nodal disease is indicative of HPV-negative tumours. They reported 5-year overall survival (22.4 [19][20][21]; however, the selection bias in these studies is inevitable. A UK-led randomized trial for this group of patients with a surgical arm is ongoing (CompARE; UKCRN 18621).…”

De-intensification of adjuvant therapy in human papillomavirus-associated oropharyngeal cancer

“…Aside from T1-2 disease, eHNS has also been used for locally-advanced OPSCC with acceptable clinical outcomes, suggesting upfront eHNS for selected stage III/IV OPC may also be appropriate [9,19]. Recently, the largest multi-institutional report thus far of 410 head and neck cancer patients treated with eHNS, 89% of which were oropharyngeal primaries, found 2-year and 3-year loco-regional control rates of 91.8 and 88.8% with only 1 surgery-related mortality [20].…”