Transoral Robotic Surgery for Recurrent Tumors of the Upper Aerodigestive Tract (RECUT): An International Cohort Study

Abstract

Background Transoral robotic surgery (TORS) is an emerging minimally invasive surgical treatment for residual, recurrent, and new primary head and neck cancers in previously irradiated fields, with limited evidence for its oncological effectiveness. Methods A retrospective observational cohort study of consecutive cases performed in 16 high-volume international centers before August 2018 was conducted (registered at clinicaltrials.gov [NCT04673929] as the RECUT study). Overall survival (OS), disease-free survival, disease-specific survivals (DSS), and local control (LC) were calculated using Kaplan-Meier estimates, with subgroups compared using log-rank tests and Cox proportional hazards modeling for multivariable analysis. Maximally selected rank statistics determined the cut point for closest surgical resection margin based on LC. Results Data for 278 eligible patients were analyzed, with median follow-up of 38.5 months. Two-year and 5-year outcomes were 69.0% and 62.2% for LC, 71.8% and 49.8% for OS, 47.2% and 35.7% for disease-free survival, and 78.7% and 59.1% for disease-specific survivals. The most discriminating margin cut point was 1.0 mm; the 2-year LC was 80.9% above and 54.2% below or equal to 1.0 mm. Increasing age, current smoking, primary tumor classification, and narrow surgical margins (≤1.0 mm) were statistically significantly associated with lower OS. Hemorrhage with return to theater was seen in 8.1% (n = 22 of 272), and 30-day mortality was 1.8% (n = 5 of 272). At 1 year, 10.8% (n = 21 of 195) used tracheostomies, 33.8% (n = 66 of 195) used gastrostomies, and 66.3% (n = 53 of 80) had maintained or improved normalcy of diet scores. Conclusions Data from international centers show TORS to treat head and neck cancers in previously irradiated fields yields favorable outcomes for LC and survival. Where feasible, TORS should be considered the preferred surgical treatment in the salvage setting.

Oncological and functional outcomes for transoral robotic surgery following previous radiation treatment for upper aerodigestive tract head and neck cancers. A French multicenter GETTEC group study

“…'s series of 128 patients having undergone transoral excision of a tonsillar cancer, 35 a mean margin width of 1.98 mm led to a 5‐year local control rate of 99%. In the RECUT study, narrow surgical margins (<1.0 mm) were statistically significantly associated with lower overall survival 21 . In the present study, 20.29% of the margins were positive, i.e., ≤ 2 mm.…”

“…Our postoperative complication rate was 26.1%. Hay et al 20 21 The complication rate was significantly lower for Tis, T1, and N0 forms. The extent of the resection (directly correlated with the T stage) therefore appears to be the main predictor of complications.…”

“…27 According to RECUT study at 1 year, 10.8% of patients always required tracheostomies. 21 White et al performed a case-control study comparing transoral and external approaches for 122 patients with a relapsed oropharyngeal tumor, 88% of whom had a history of radiotherapy. 28 TORS was associated with a significantly lower mean LOS (3.8 days, vs. eight for external approaches) and a shorter time to oral refeeding.…”

“…found in a systematic review that the rate of death following salvage TORS was 3.6%, whereas Hardman et al. a 30‐day mortality of 1.8% 21 …”

“…For Hardman et al. in the RECUT study, hemorrhages with return to theater was seen in 8.1% 21 . In the systematic review of Turner et al., major hemorrhage rate (requiring operative intervention) was 10.5% and minor hemorrhage rate (treated with observation and/or transfusion) was 6.3% 25 .…”