A Retrospective Analysis of Surgery in Prestyloid Parapharyngeal Tumors: Lateral Approaches vs Transoral Robotic Surgery

Abstract Introduction Surgery is the standard treatment for most tumors in the prestyloid parapharyngeal space (PPS) but it can be a challenging procedure because of the anatomical complexity of the area. Prestyloid surgery can be performed with various lateral approaches or with a medial approach using transoral robotic surgery (TORS) – either alone or in combination with a transcervical incision. Here we report our experience in the surgical management of prestyloid PPS tumors. Materials and Methods We have retrospectively compared results with lateral or medial approaches to surgical resection of prestyloid tumors. Between 2015 and 2020, 28 patients with prestyloid PPS tumors underwent surgery at our center: 14 with lateral approaches, including transcervical, transcervical-parotid, and transcervical-mandibular, 12 with TORS, and two with TORS plus a transcervical incision. Surgical time, post-surgical complications, length of hospital stay, need for feeding tube, and relapse-free survival in the two patient groups. Results Pleomorphic adenoma was the most frequent tumor and 60.7% of the tumors were benign. Tumor volume and maximum length were similar in patients undergoing surgery with a lateral approach and in those undergoing TORS. Intraoperative image guidance and ultrasound were used in 33% of TORS. TORS was associated with less surgical time, fewer complications, and shorter hospital stays. Survival rates were similar in the two groups. Conclusion The medial approach by TORS offers better surgical results in prestyloid tumors than the open lateral approach and can be refined by intraoperative guidance.

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Modern Treatment Outcomes for Early T-Stage Oropharyngeal Cancer Treated With Intensity-modulated Radiation Therapy at a Tertiary Care Institution

10.21203/rs.3.rs-83234/v1 ◽

2020 ◽

Author(s):

Eric J. Di Gravio ◽

Pencilla Lang ◽

Hugh Andrew Jinwook Kim ◽

Tricia Chinnery ◽

Neil Mundi ◽

...

Keyword(s):

Robotic Surgery ◽

Oropharyngeal Cancer ◽

Early Stage ◽

Tertiary Care ◽

Feeding Tube ◽

The United States ◽

Transoral Robotic Surgery ◽

Transoral Surgery ◽

Severe Toxicity ◽

T Stage

Abstract BackgroundTransoral surgery (TOS), particularly transoral robotic surgery (TORS) has become the preferred modality in the United States for the treatment of early stage oropharyngeal cancer, largely due to assumptions of fewer toxicities and improved quality of life compared to primary radiotherapy (RT). However, these assumptions are based on retrospective analysis, a subset of which utilize primary RT groups not limited to T1-2 stage tumors for which transoral robotic surgery is FDA approved. Thus, there is potential for underestimating survival and overestimating toxicity, including treatment related mortality, in primary RT.MethodsConsecutive cases of early T stage (T1-T2) oropharyngeal cancer presenting to the London Health Sciences Centre between 2014-2018 treated with RT or chemoradiation (CRT) were reviewed. Patient demographics, treatment details, survival outcomes and toxicity were collected. Toxicities were retrospectively graded using the CTCAE criteria.ResultsA total of 198 patients were identified, of which 82% were male and 73% were HPV-positive. Sixty-eight percent of patients experienced a grade 2 toxicity, 48% a grade 3 and 4% a grade 4. The most frequent toxicities were dysphagia, neutropenia and ototoxicity. The rates of gastrostomy tube dependence at 1 and 2 years were 2.5% and 1% respectively. There were no grade 5 (fatal) toxicities. HPV-positive patients experienced improved 5-year overall survival (86% vs 64%, p=0.0026). ConclusionsPrimary RT or CRT provides outstanding survival for early T-stage HPV-positive disease, with low rates of severe toxicity and feeding tube dependence. This study provides a reference for comparison for patients treated with primary transoral surgery.

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Modern treatment outcomes for early T-stage oropharyngeal cancer treated with intensity-modulated radiation therapy at a tertiary care institution

Radiation Oncology ◽

10.1186/s13014-020-01705-1 ◽

2020 ◽

Vol 15 (1) ◽

Author(s):

Eric J. Di Gravio ◽

Pencilla Lang ◽

Hugh Andrew Jinwook Kim ◽

Tricia Chinnery ◽

Neil Mundi ◽

...

Keyword(s):

Robotic Surgery ◽

Oropharyngeal Cancer ◽

Early Stage ◽

Tertiary Care ◽

Feeding Tube ◽

The United States ◽

Transoral Robotic Surgery ◽

Transoral Surgery ◽

Severe Toxicity ◽

T Stage

Abstract Background Transoral surgery (TOS), particularly transoral robotic surgery (TORS) has become the preferred modality in the United States for the treatment of early stage oropharyngeal cancer, largely due to assumptions of fewer toxicities and improved quality of life compared to primary radiotherapy (RT). However, these assumptions are based on retrospective analysis, a subset of which utilize primary RT groups not limited to T1-2 stage tumors for which transoral robotic surgery is FDA approved. Thus, there is potential for underestimating survival and overestimating toxicity, including treatment related mortality, in primary RT. Methods Consecutive cases of early T-stage (T1–T2) oropharyngeal cancer presenting to the London Health Sciences Centre between 2014 and 2018 treated with RT or chemoradiation (CRT) were reviewed. Patient demographics, treatment details, survival outcomes and toxicity were collected. Toxicities were retrospectively graded using the Common Terminology Criteria for Adverse Events criteria. Results A total of 198 patients were identified, of which 82% were male and 73% were HPV-positive. Sixty-eight percent of patients experienced a grade 2 toxicity, 48% a grade 3 and 4% a grade 4. The most frequent toxicities were dysphagia, neutropenia and ototoxicity. The rates of gastrostomy tube dependence at 1 and 2 years were 2.5% and 1% respectively. There were no grade 5 (fatal) toxicities. HPV-positive patients experienced improved 5-year overall survival (86% vs 64%, p = 0.0026). Conclusions Primary RT or CRT provides outstanding survival for early T-stage disease, with low rates of severe toxicity and feeding tube dependence. This study provides a reference for comparison for patients treated with primary transoral surgery.

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Functional Outcomes after Transoral Robotic Surgery for Head and Neck Cancer

Otolaryngology ◽

10.1016/j.otohns.2009.05.014 ◽

2009 ◽

Vol 141 (2) ◽

pp. 166-171 ◽

Cited By ~ 146

Author(s):

Tim A. Iseli ◽

Brian D. Kulbersh ◽

Claire E. Iseli ◽

William R. Carroll ◽

Eben L. Rosenthal ◽

...

Keyword(s):

Head And Neck Cancer ◽

Robotic Surgery ◽

Head And Neck ◽

Neck Cancer ◽

Functional Outcomes ◽

Case Series ◽

Feeding Tube ◽

Transoral Robotic Surgery ◽

T Stage ◽

Increased Risk

OBJECTIVE: To evaluate functional outcomes following transoral robotic surgery for head and neck cancer. STUDY DESIGN: Case series with planned data collection. SETTING: Academic hospital. SUBJECTS AND METHODS: Between March 2007 and December 2008, 54 of 62 candidate patients underwent transoral robotic tumor resection. Outcomes include airway management, swallowing (MD Anderson Dysphagia Inventory), and enterogastric feeding. RESULTS: Tumors were most commonly oropharynx (61%) or larynx (22%) and T1 (35%) or T2 (44%). Many received radiotherapy (22% preoperatively, 41% postoperatively) and chemotherapy (31%). Endotracheal intubation was retained (22%) for up to 48 hours, tracheostomy less frequently (9%), and all were decannulated by 14 days. Most commenced oral intake prior to discharge (69%) or within two weeks (83%). A worse postoperative Dysphagia Inventory score was associated with retained feeding tube ( P = 0.020), age >60 ( P = 0.017), higher T stage ( P = 0.009), laryngeal site ( P = 0.017), and complications ( P = 0.035). At a mean 12 months' follow-up, 17 percent retained a feeding tube (9.5% among primary cases). Retained feeding tube was associated with preoperative tube requirement ( P = 0.017), higher T stage ( P = 0.043), oropharyngeal/laryngeal site ( P = 0.034), and recurrent/second primary tumor ( P = 0.008). Complications including airway edema (9%), aspiration (6%), bleeding (6%), and salivary fistula (2%) were managed without major sequelae. CONCLUSION: Transoral robotic surgery provides an emerging alternative for selected primary and salvage head and neck tumors with low morbidity and acceptable functional outcomes. Patients with advanced T stage, laryngeal or oropharyngeal site, and preoperative enterogastric feeding may be at increased risk of enterogastric feeding and poor swallowing outcomes.

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Transoral Robotic Surgery: Step-by-Step Radical Tonsillectomy

Case Reports in Otolaryngology ◽

10.1155/2014/497528 ◽

2014 ◽

Vol 2014 ◽

pp. 1-6 ◽

Cited By ~ 2

Author(s):

Jose Granell ◽

Ivan Mendez-Benegassi ◽

Teresa Millas ◽

Laura Garrido ◽

Raimundo Gutierrez-Fonseca

Keyword(s):

Robotic Surgery ◽

Minimally Invasive ◽

Surgical Procedure ◽

Feeding Tube ◽

Transoral Robotic Surgery ◽

Surgical Reconstruction ◽

Case Presentation ◽

Minimally Invasive Surgical Procedure ◽

Patients With Cancer ◽

Minimally Invasive Surgical

Introduction. Transoral robotic surgery (TORS) radical tonsillectomy is an emerging minimally invasive surgical procedure for the treatment of cancer of the tonsil. The detailed surgical technique and claims for its reproducibility have been previously published.Case Presentation. We present a patient with a T2N2bM0 epidermoid carcinoma of the tonsil to illustrate step by step the surgical procedure for TORS radical tonsillectomy. Neck dissection and TORS were staged. No surgical reconstruction of the defect was required. No tracheostomy was necessary. The patient could eat without any feeding tube and was on full oral diet on the fifth postoperative day.Discussion. The transoral approach offers the benefits of minimally invasive surgery to patients with cancer of the tonsil. The excellent exposure and high precision provided by robotic instrumentation allow the surgeon to closely follow and accomplish the surgical steps, which is the best warranty for safety and effectiveness.

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A retrospective analysis of surgery in prestyloid parapharyngeal tumors: Lateral approaches vs transoral robotic surgery

Laryngoscope Investigative Otolaryngology ◽

10.1002/lio2.662 ◽

2021 ◽

Author(s):

David Virós Porcuna ◽

Laura Pardo Muñoz ◽

Constanza Viña Soria ◽

Viviana Nicastro ◽

Mar Palau Viarnès ◽

...

Keyword(s):

Robotic Surgery ◽

Retrospective Analysis ◽

Transoral Robotic Surgery ◽

Parapharyngeal Tumors

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A retrospective analysis of surgery in prestyloid parapharyngeal tumors: lateral approaches vs transoral robotic surgery

10.22541/au.159493252.21751605 ◽

2020 ◽

Author(s):

David Vir s Porcuna ◽

Laura Pardo Mu oz ◽

Constanza Vi a Soria ◽

Viviana Nicastro ◽

Mar Palau Viarn s ◽

...

Keyword(s):

Robotic Surgery ◽

Retrospective Analysis ◽

Transoral Robotic Surgery ◽

Parapharyngeal Tumors

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A phase II randomized trial for early-stage squamous cell carcinoma of the oropharynx: Radiotherapy versus trans-oral robotic surgery (ORATOR).

Journal of Clinical Oncology ◽

10.1200/jco.2019.37.15_suppl.6006 ◽

2019 ◽

Vol 37 (15_suppl) ◽

pp. 6006-6006 ◽

Cited By ~ 5

Author(s):

Anthony Charles Nichols ◽

Julie Theurer ◽

Eitan Prisman ◽

Nancy E Read ◽

Eric Berthelet ◽

...

Keyword(s):

Robotic Surgery ◽

Early Stage ◽

Progression Free Survival ◽

Feeding Tube ◽

Hpv Infection ◽

Transoral Robotic Surgery ◽

Intention To Treat ◽

The Difference ◽

Md Anderson ◽

Anderson Dysphagia Inventory

6006 Background: The incidence of OPSCC has risen rapidly, due to an epidemic of human papillomavirus (HPV) infection. Radiation therapy (RT) has historically been the standard treatment, but transoral robotic surgery (TORS) has surpassed RT in the US as the most common approach, based on assumptions of reduced toxicity or improved quality of life (QOL). No randomized trials have previously compared these treatments. Methods: The ORATOR trial (NCT01590355) enrolled patients with T1-T2 N0-2(≤4 cm) OPSCC amenable to TORS. We randomly assigned patients, stratified by p16 status, to RT (70 Gy/35 fractions, with chemotherapy if N1-2) vs. TORS (± adjuvant [chemo]RT based on pathology). The primary endpoint was a definitive comparison of swallowing QOL at 1-year using the MD Anderson Dysphagia Inventory (MDADI), powered to detect a 10-point improvement (a clinically-meaningful change [CMC]) in the TORS arm. Secondary endpoints included adverse events (AEs), other QOL outcomes [including EORTC scales, the Voice Handicap Index-10, Neck Dissection Impairment Index, and Patient Neurotoxicity Questionnaire], overall- and progression-free survival (OS, PFS). All analyses were pre-specified and intention-to-treat. Results: Between 2012 and 2017, 68 patients were randomized (n = 34 in each arm), in Canada and Australia. Median age was 59 years; 87% were male. Primary tumor sites were palatine tonsil (74%) or base of tongue (26%). Arms were well-balanced for baseline factors, including p16 status (88% in each arm). Median follow-up was 27 months. MDADI scores at 1-year were statistically superior in the RT arm (mean ± SD: 86.9 ± 11.4 vs. 80.1 ± 13.0 in the TORS arm; p = 0.042), but not meeting the definition of a CMC. For the other QOL metrics, outcomes were similar at 1-year. Feeding tube rates at 1-year were 3% (n = 1) vs. 0% respectively. Rates of treatment-related grade ≥2 AEs were similar (91% vs. 100%, p = 0.24), with more neutropenia, constipation and tinnitus in the RT arm and more trismus in the TORS arm (all p < 0.05). There was one TORS bleeding-related death. OS and PFS were similar. Conclusions: RT had superior swallowing QOL scores at 1 year compared to TORS, but the difference was not a CMC. Toxicities differed between the arms. This study provides the first level 1 evidence to inform patients of the QOL impact of both approaches. Clinical trial information: NCT01590355.

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Feeding Tube Placement Following Transoral Robotic Surgery for Oropharyngeal Squamous Cell Carcinoma

Otolaryngology ◽

10.1177/01945998211020302 ◽

2021 ◽

pp. 019459982110203

Author(s):

Allen L. Feng ◽

Andrew J. Holcomb ◽

Nicholas B. Abt ◽

Tara E. Mokhtari ◽

Krish Suresh ◽

...

Keyword(s):

Squamous Cell Carcinoma ◽

Logistic Regression ◽

Robotic Surgery ◽

Cell Carcinoma ◽

Feeding Tube ◽

Transoral Robotic Surgery ◽

Tube Placement ◽

Multiple Logistic Regression ◽

Feeding Tubes ◽

Feeding Tube Placement

Objective To identify factors that may predict the need for feeding tubes in patients undergoing transoral robotic surgery (TORS) in the perioperative setting. Study Design Retrospective chart review. Setting Academic tertiary center. Methods A retrospective series of patients undergoing TORS for oropharyngeal squamous cell carcinoma (OPSCC) was identified between October 2016 and November 2019 at a single tertiary academic center. Patient data were gathered, such as frailty information, tumor characteristics, and treatment, including need for adjuvant therapy. Multiple logistic regression was performed to identify factors associated with feeding tube placement following TORS. Results A total of 138 patients were included in the study. The mean age was 60.2 years (range, 37-88 years) and 81.9% were male. Overall 82.9% of patients had human papilloma virus–associated tumors, while 28.3% were current or former smokers with a smoking history ≥10 pack-years. Eleven patients (8.0%) had a nasogastric or gastrostomy tube placed at some point during their treatment. Five patients (3.6%) had feeding tubes placed perioperatively (<4 weeks after TORS), of which 3 were nasogastric tubes. Six patients (4.3%) had feeding tubes placed in the periadjuvant treatment setting for multifactorial reasons; 5 of which were gastrostomy tubes. Only 1 patient (0.7%) was gastrostomy dependent 1 year after surgery. Multiple logistic regression did not demonstrate any significant predictive variables affecting perioperative feeding tube placement following TORS for OPSCC. Conclusions Feeding tubes are seldom required after TORS for early-stage OPSCC. With appropriate multidisciplinary planning and care, patients may reliably avoid the need for feeding tube placement following TORS for OPSCC.

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