H&N Robotic Surgery Update. August 14, 2022

What´s new in PubMed this week

Poupore NS, Chen T, Nguyen SA, Nathan CO, Newman JG. Transoral Robotic Surgery for Oropharyngeal Squamous Cell Carcinoma of the Tonsil versus Base of Tongue: A Systematic Review and Meta-Analysis. Cancers (Basel). 2022 Aug 8;14(15):3837. doi: 10.3390/cancers14153837. PMID: 35954500

An interesting approach, since every surgeon knows that is is harder to get free marging on the base of the tongue compared to the lateral wall of the oropharynx. However, some remarks.

  1. Tumors on the base of the tongue arise from the lingual tonsil, so better use either palatine tonsil / lingual tonsil or lateral pharyngeal wall / base of the tongue.
  2. Over 90% of the cases are HPV+. Obviously, even in the US, the prevalence of HPV in oropahyngeal cancer is not that high. Why still that reluctance to perform surgery on HPV- patients?
  3. Even though positive margins are more frequent in the base of the tongue, still there is not a higher recurrence rate. We should probably reconsider the management of the surgical margins for HPV+ orapharyngeal cancer.

Cadena-Piñeros E, Moreno-Torres A, Correa-Marin J, Melo-Uribe MA. Transoral robotic surgery for parapharyngeal carcinoma ex-pleomorphic adenoma: A case report. Cancer Rep (Hoboken). 2022 Aug 9:e1692. doi: 10.1002/cnr2.1692. Epub ahead of print. PMID: 35945155

TORS is a powerfull resource for paraphayngeal tumors that highlights the advantages of the minimally invasive surgical approach. However cases should be selected with extreme care, even in patients with benign tumors. For the most usual finding, pleomorphic adenoma of the deep lobe of the parotid gland, the risk of tumor rupture should be carefully considered. Unexpected malignant findings in the pathology report also happen. In this last situation asssesment of the surgical margins is critical, as TORS is not an appropriate technique for malignant tumors in this region. If recurrence occurs it might be uncontrollable.

Hardman JC, Holsinger FC, Brady GC, Beharry A, Bonifer AT, D’Andréa G, Dabas SK, de Almeida JR, Duvvuri U, Floros P, Ghanem TA, Gorphe P, Gross ND, Hamilton D, Kurukulasuriya C, Larsen MHH, Lin DJ, Magnuson JS, Meulemans J, Miles BA, Moore EJ, Pantvaidya G, Roof S, Rubek N, Simon C, Subash A, Topf MC, Van Abel KM, Vander Poorten V, Walgama ES, Greenlay E, Potts L, Balaji A, Starmer HM, Stephen S, Roe J, Harrington K, Paleri V. Transoral Robotic Surgery for Recurrent Tumors of the Upper Aerodigestive Tract (RECUT): An International Cohort Study. J Natl Cancer Inst. 2022 Aug 10:djac130. doi: 10.1093/jnci/djac130. Epub ahead of print. PMID: 35944904.

Relevant evidence adding to the indication of TORS fos salvage surgery.

Garas G, Roland NJ, Lancaster J, Zammit M, Manon VA, Davies K, Jones TM, De M, Holsinger FC, Prestwich RJD, Fleming JC. ASO Visual Abstract: Novel Strategies for Managing Retropharyngeal Lymph Node Metastases in Head and Neck and Thyroid Cancer with TransOral Robotic Surgery (TORS). Ann Surg Oncol. 2022 Aug 8. doi: 10.1245/s10434-022-12371-w. Epub ahead of print. PMID: 35941346

Zorzi SF, Agostini G, Chu F, Tagliabue M, Pietrobon G, Corrao G, Volpe S, Marvaso G, Colombo F, Rocca MC, Gandini S, Gaeta A, Ruju F, Alterio D, Ansarin M. Upfront transoral robotic surgery (TORS) versus intensity-modulated radiation therapy (IMRT) in HPV-positive oropharyngeal cancer: real-world data from a tertiary comprehensive cancer center. Acta Otorhinolaryngol Ital. 2022 Aug 8. doi: 10.14639/0392-100X-N2144. Epub ahead of print. PMID: 35938555

Still we need to further analize toxicities and long term sequelae. TORS-alone patiens might be absolutely free of them while radiochemoteraphy patients will at best have permanent xerostomy and a variable degree of neck fibrosys.

However at the first reading I was surprised with the numbers of advanced stage HPV+ oropharyngeal carcinomas. In the last review or a Spanish multicenter series there were 137 cases, 47 HPV+. As it was a surgical series, p stage was avaible for every case. NONE of the HPV+ patients was clasified as an advanced stage according to pTNM 8th edition. This study design is a retrospective cohort study (year 2015 thorugh 2020) on advanced stage (III and IV) oropharyngel cancer according to TNM 7th edition. Results are therefore absurd. Considering p stage (TNM 8th edition) there are also no advanced stages in the HPV+ group. So cohorts are not comparable. Or may be they are, but we do not know about clinical TNM 8th staging in group B. it is absurd to discuss about oropahyngeal cancer without considering the HPV status in the staging (that is, aplying TNM 8th). As a a reviewer I would have never accepted the paper to be published without a prior re-staging to TNM 8th.

Holcomb AJ, Kammer R, Holman A, Goldsmith T, Divi V, Starmer HM, Zenga J, Li R, Patel UA, Richmon JD. Practice patterns in transoral robotic surgery: results of an American head and neck society survey. J Robot Surg. 2022 Aug 7. doi: 10.1007/s11701-022-01448-z. Epub ahead of print. PMID: 35933632

Towards a standarized perioperative care in TORS.

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