Oncologic outcomes of human papillomavirus–associated oropharynx carcinoma treated with surgery alone: A 12‐institution study of 344 patients

Abstract

Background The oncologic outcomes of surgery alone for patients with American Joint Committee on Cancer 7th edition (AJCC 7th) pN2a and pN2b human papillomavirus–associated oropharynx squamous cell carcinoma (HPV+OPSCC) are not clear. Methods The authors performed a 12‐institution retrospective study of 344 consecutive patients with HPV+OPSCC (AJCC 7th pT0‐3 N3 M0) treated with surgery alone with 6 months or more of follow‐up using univariate and multivariate analyses. Results The 2‐year outcomes for the entire cohort were 91% (182 of 200) disease‐free survival (DFS), 100% (200 of 200) disease‐specific survival (DSS), and 98% (200 of 204) overall survival (OS). The 18 recurrences within 2 years were 88.9% (16 of 18) local and/or regional recurrences and 11.1% (2 of 18) distant metastases. Recurrences were not significantly associated with smoking, pT stage, or pN stage. The 16 patients with locoregional recurrences within 2 years all underwent successful salvage treatments (median follow‐up after salvage: 13.1 months), 43.8% (7 of 16) of whom underwent salvage surgery alone for a 2‐year overall salvage radiation need of 4.5% (9 of 200). The 2‐year outcomes for the 59 evaluable patients among the 109 AJCC 7th pT0‐2 N2a‐N2b patients with 1 to 3 pathologic lymph nodes (LNs) were as follows: local recurrence, 3.4% (2 of 59); regional recurrence, 8.4% (5 of 59); distant metastases, 0%; DFS, 88.1% (52 of 59); DSS, 100% (59 of 59); OS, 96.7% (59 of 61); and salvage radiation, 5.1% (3 of 59). Conclusions With careful selection, surgery alone for AJCC 7th pT0‐T2N0‐N2b HPV+OPSCC with zero to 3 pathologic LNs without perineural invasion, extranodal extension, or positive margins results in high DFS, DSS, OS, and salvage treatment success. Because of the short‐term follow‐up, these data support further investigation of treatment de‐escalation in this population.

The accuracy of clinical neck staging for p16-positive and negative oropharyngeal cancer and its therapeutic implications

“…Our results, which confirm superior disease-free survival for p16-positive vs. p16-negative patients fall in line with multiple retrospective studies from recent years showing excellent disease control in HPV-positive patients after primary surgery-notably with patients undergoing un-adjusted treatment regimens, i.e. regular dose adjuvant therapy where warranted [1,15]. Preliminary results of deintensification trials for adjuvant treatment after primary surgery have been promising, however, deintensification was carefully adjusted to pathological results, for example excluding patients with high burden metastatic neck disease, extranodal extension or other potential risk factors which were determined by pathology [16].…”

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.…”

“…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%). 2 Given the clear decrement in QOL associated with adding adjuvant therapy after TORS, [10][11][12][13][14] identifying the precise intensity of such treatment remains a challenge in situations where indications for adjuvant therapy are equivocal and when recurrence, should it occur, can be readily salvaged.…”

Patienten-Benefit und Lebensqualität nach Roboter-assistierten Operationen im Kopf-Hals-Bereich

“…The goal of any surgical therapy for OPSCC is a complete resection of the tumor with adequate safety margins. This improves the overall prognosis of the patient, and the dose of adjuvant therapy administered depending on other risk factors can possibly be reduced [135]. HPV-positive OPSCC are particularly amenable to TORS because of their predominant localization in the tonsils or base of the tongue and their tendency towards lower T-stages at initial diagnosis compared with HPV-negative carcinomas [136].…”