NECTORS and Dissection Compares Favorably to CCRT in Patients with HPV-Related Oropharyngeal Squamous Cell Carcinoma

by Linda Kossof •

CLINICAL QUESTION

How effective is neoadjuvant chemotherapy followed by transoral robotic surgery (NECTORS) and neck dissection compared with standard-of-care concurrent chemoradiation (CCRT) in patients with human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC)?

BOTTOM LINE

Neoadjuvant chemotherapy followed by TORS and neck dissection was shown effective in treating patients with stage III and IVa HPV–OPSCC, reducing the risk of DM and improving overall survival.

BACKGROUND: Distant metastasis (DM) remains the leading cause of death in patients treated for HPV-related OPSCC. Most centers treat advanced-stage OPSCC with CCRT; however, the long-term and late toxic effects of CCRT treatment significantly impact a patient’s quality of life. Surgery or radiotherapy alone is considered for early-stage disease.

STUDY DESIGN: Cohort study

SETTING: Department of Otolaryngology-Head and Neck Surgery, McGill University, Montreal, Québec, Canada

SYNOPSIS: Researchers compared data of 342 patients (82.5% male; mean age 61.4 years) treated for stage III and IVa HPV–OPSCC. Within this cohort, prospectively collected data from patients treated with NECTORS (n=110) were compared with a historical cohort of patients treated with CCRT (n=232). The NECTORS patients were treated with three cycles of neoadjuvant docetaxel and cisplatin followed by TORS and neck dissection. The radiation therapy patients received concurrent high-dose cisplatin and radiotherapy. Findings revealed that within the CCRT arm, 11 patients had locoregional recurrence (LRR), five had LRR plus DM, and 28 developed distant-only metastases. In the NECTORS arm, five patients developed LRR, one developed LRR plus DM, and none developed distant-only metastasis. Mortality was 24.8% in the CCRT group and zero in the NECTORS group. The median follow-up period for the CCRT and NECTORS groups were 5.8 years and 5.1 years, respectively. Authors note that although CCRT provides excellent locoregional control, it is likely that the standard single-agent chemotherapy with cisplatin used with CCRT does not adequately address possible occult micrometastasis. Moreover, the de-escalation of locoregional treatment in the NECTORS paradigm with surgery only avoids potential radiation-induced effects. Study limitations included potential selection bias.

CITATION: Sadeghi N, et al. Neoadjuvant chemotherapy and transoral robotic surgery for human papillomavirus-related oropharyngeal cancer. JAMA Otolaryngol Head Neck Surg. 2024:e243303. doi: 10.1001/jamaoto.2024.3303.