Transoral robotic surgery adoption and safety in treatment of oropharyngeal cancers

Abstract

Background Transoral robotic surgery (TORS) was approved by the Food and Drug Administration in 2009 for the treatment of oropharyngeal cancers (oropharyngeal squamous cell carcinoma [OPSCC]). This study investigated the adoption and safety of TORS. Methods All patients who underwent TORS for OPSCC in the National Cancer Data Base from 2010 to 2016 were selected. Trends in the positive margin rate (PMR), 30‐day unplanned readmission, and early postoperative mortality were evaluated. Outcomes after TORS, nonrobotic surgery (NRS), and nonsurgical treatment were compared with matched‐pair survival analyses. Results From 2010 to 2016, among 73,661 patients with OPSCC, 50,643 were treated nonsurgically, 18,024 were treated with NRS, and 4994 were treated with TORS. TORS utilization increased every year from 2010 (n = 363; 4.2%) to 2016 (n = 994; 8.3%). The TORS PMR for base of tongue malignancies decreased significantly over the study period (21.6% in 2010‐2011 vs 15.8% in 2015‐2016; P = .03). The TORS PMR at high‐volume centers (≥10 cases per year; 11.2%) was almost half that of low‐volume centers (<10 cases per year; 19.3%; P < .001). The rates of 30‐day unplanned readmission (4.1%) and 30‐day postoperative mortality (1.0%) after TORS were low and did not vary over time. High‐volume TORS centers had significantly lower rates of 30‐day postoperative mortality than low‐volume centers (0.5% vs 1.5%; P = .006). In matched‐pair analyses controlling for clinicopathologic cofactors, 30‐, 60‐, and 90‐day posttreatment mortality did not vary among patients with OPSCC treated with TORS, NRS, or nonsurgical treatment. Conclusions TORS has become widely adopted and remains safe across the country with a very low risk of severe complications comparable to the risk with NRS. Although safety is excellent nationally, high‐volume TORS centers have superior outcomes with lower rates of positive margins and early postoperative mortality.

Perioperative Mortality Risk in Patients Undergoing Transoral Robotic Surgery for T1-T2 Oropharyngeal Squamous Cell Carcinoma: A National Cancer Database Study

“…Studies comparing mortality in the non-surgical group for chemoradiation or radiation only groups will help determine if surgical complications or non-surgical issues contributed to mortality. Although the exact cause underlying this association is unknown, one recently published study found a similar association due to younger patients presenting with more advanced nodal disease ( 30 ). In agreement with this study, we found that younger patients (<65 years) were observed to have higher N-category (N2/3) disease (<65 years: 1920/2563 vs ≥65 years: 643/2563; p<0.01) and therefore this association may be a reflection of the previously addressed impact of age on perioperative mortality.…”

Transoral Robotic Surgery for Oropharyngeal Squamous Cell Carcinoma of the Tonsil versus Base of Tongue: A Systematic Review and Meta-Analysis

“…When considering outcomes after TORS, another NCDB study by Hanna et al found the rate of BOT OPSCC positive margins was higher than tonsillar OPSCC, but this was nonsignificant [ 55 ]. Interestingly, Hanna et al and another more recent NCDB review from Oliver et al found that high volume cancer centers reduced their positive margin rates by almost half compared to low volume centers (12.7% versus 21.9% and 11.2% to 19.3%) [ 55 , 58 ]. Furthermore, Oliver et al found that BOT positive margins were reduced by around 6% when comparing rates from 2011 to 2016 [ 58 ].…”

“…Interestingly, Hanna et al and another more recent NCDB review from Oliver et al found that high volume cancer centers reduced their positive margin rates by almost half compared to low volume centers (12.7% versus 21.9% and 11.2% to 19.3%) [ 55 , 58 ]. Furthermore, Oliver et al found that BOT positive margins were reduced by around 6% when comparing rates from 2011 to 2016 [ 58 ]. A systematic review on TORS found that specific procedures were more difficult due to the structural components of the robot, with BOT resections being more likely to undergo conversion to an open approach [ 59 ].…”

“…Some studies reported on their first implementations of TORS at their institution, while others performed recent retrospective reviews after a decade of use. As increased experience with TORS can decrease postoperative positive margins, the length of institutional experience with TORS may have been a confounding factor in these analyses [ 58 ]. Moreover, while most studies included upfront TORS for OPSCC, some included salvage procedures that were unable to be factored out of the analysis, therefore, potentially elevating rates of positive margin, recurrence, and hemorrhage for that particular study.…”

Second window indocyanine green for oropharyngeal tumours: A case series and comparison of near‐infrared camera systems

“…This can be magnified in transoral robotic surgery (TORS) due to limited haptic feedback and anatomic constraints preventing palpation of the tumour during resection. Positive margin rates have improved with increased experience with TORS, but remain high at nearly 16% nationally 2 and 26% at low‐volume centres 3,4 . The ability to obtain favourable oncologic outcomes with TORS on even locally advanced tumours has been demonstrated, 5,6 but avoidance of postoperative adjuvant therapy is dependent on ability to obtain negative margins amongst other factors 7,8 .…”