Transoral Robotic Surgery, Intensity-Modulated Radiotherapy Offer Comparable Survival Estimates for Early T-Stage Oropharyngeal Cancer

Clinical Question

How do survival estimates for transoral robotic surgery (TORS) compare to intensity-modulated radiotherapy (IMRT) for early T-stage oropharyngeal cancer?

Background: There have been concerns regarding the effectiveness of TORS as a treatment for early T-stage oropharyngeal carcinoma compared to existing treatment. Newer nonsurgical techniques have improved on traditional three-dimensional conformal radiotherapy by limiting the toxicity burden while offering similar disease control. One challenge in interpreting the literature is the patient heterogeneity reported.

Study design: Retrospective study of 20 cases reported through September 2012, including patients treated for early T-stage oropharynx cancer with TORS or IMRT.

Setting: MEDLINE, EMBASE, CENTRAL, PsychINFO, CINAHL, and bibliographies of relevant studies.

Synopsis: For early T-stage tumors, 350 of 794 patients received chemotherapy in addition to IMRT. Three studies reported that 57 of 152 patients (38%) received neck dissections for possible residual disease following treatment. The incidence of N2c or N3 metastases was always less than 16% among TORS studies and less than 17% among IMRT studies. All TORS patients were treated with transoral robotic resection of an oropharyngeal primary cancer. IMRT studies reported a two-year disease-specific survival ranging from 82% to 97.7%. TORS studies reported a two-year disease-specific survival ranging from 79% to 98%. Five IMRT studies reported adverse event outcomes, including osteoradionecrosis of the mandible (2.6%) and esophageal stenosis (4.8%). Nine TORS studies reported adverse event outcomes, including post-operative bleeding (2.4%), neck hematomas (0.4%), and a cumulative pharyngocutaneous fistula rate of 2.5%. Limitations included a lack of meta-analysis and patient-reported subjective outcomes due to the retrospective, heterogeneous, and noncomparative nature of the studies.

Bottom line: Survival estimates are similar for TORS and IMRT; the differences lie in adverse events and are likely based on the specifics of their toxicity and complication profiles.

Citation: De Almeida JR, Byrd JK, Wu R, et. al. A systematic review of transoral robotic surgery and radiotherapy for early oropharynx cancer: a systematic review. Laryngoscope. 2014;124:2096-2102.

—Reviewed by Amy Eckner