What are the safety, toxicity and oncologic outcomes of patients undergoing transoral robotic surgery (TORS), neck dissection and adjuvant therapy for advanced oropharyngeal squamous cell carcinoma (AOC)?
Explore this issue:April 2011
Background: Most patients with AOC in the U.S. are treated with definitive chemoradiation therapy. The U.S. Food and Drug Administration recently approved TORS for surgical treatment of AOC.
Study design: Retrospective cohort study of 47 patients with stage III-IV AOC undergoing TORS, all with minimum 18 months of follow-up. Reasons for exclusion included distant metastases, T4a disease (except for deep tongue muscle invasion), T4b disease, trismus or unresectable nodal metastases. The decision for adjuvant therapy was based on pathologic analysis.
Setting: Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania, Pennsylvania.
Synopsis: Of 47 patients with advanced AOC, the majority of tumors were classified T1 (n=13) or T2 (n=23); fewer were T3 (n=9) or T4a (n=2). Tumors originated from the base of the tongue (n=23), tonsil (n=23) or soft palate (n=1). All patients had Karnofsky performance scores ≥ 80. Surgical margins were negative in 46 patients (98 percent). Neck dissections were performed within three weeks of TORS. Radiation therapy to a postoperative dose of 60 Gy was recommended in 46 patients (98 percent), four of whom refused. Chemotherapy was administered in 29 patients (62 percent).
The actuarial two-year rate of overall survival was 82 percent; disease-specific survival, 90 percent; local control, 98 percent; regional control, 96 percent; distant control, 91 percent. The overall rates of PEG- and tracheotomy-dependence were not reported, but 2.4 percent of surviving patients were PEG-dependent, and none were tracheotomy-dependent. Mean operative blood loss was 220 ml.
These results compare favorably to disease control and survival rates in AOC patients treated with definitive chemoradiotherapy. The rate of PEG-dependence was lower than in most chemoradiation series. The authors acknowledge that the TORS cohort included a higher proportion of T1/T2 tumors, fewer T4 tumors, and fewer patients with bulky neck disease, than most chemoradiation cohorts.
Bottom line: A selected group of patients with AOC experienced excellent oncologic and functional outcomes after TORS, neck dissection and adjuvant therapy. These data cannot be directly compared to patients receiving chemoradiation due to the selection process inherent in candidacy for TORS. Multi-institutional prospective trials are necessary for a rigorous demonstration of safety and efficacy.
Citation: Weinstein GS, O’Malley BW II, Cohen MA, et al. Transoral robotic surgery for advanced oropharyngeal carcinoma. Arch Otolaryngol Head Neck Surg. 2010;136(11):1079-1085.
—Reviewed by Dennis H. Kraus, MD, and Luc Morris, MD