A systematic review on Transoral robotic surgery (TORS) for carcinoma of unknown primary origin: Has tongue base mucosectomy become indispensable?

Abstract

Background Transoral robotic surgery (TORS) is increasingly used in head and neck surgery and in carcinoma of unknown primary (CUP) origin specifically. Due to the rising incidence of human papillomavirus (HPV)‐related oropharyngeal squamous cell carcinoma (OPSCC), there is a rationale for finding ways to de‐escalate treatment strategies. This review aims to test the hypothesis that TORS is a meaningful adjunct in the diagnostic (and therapeutic) pathway in CUP in head and neck. Methods A structured search of the literature was performed with the search terms ‘TORS’ and ‘Carcinoma of Unknown Primary’. Results Two hundred and seventy four cases of CUP in which TORS was used were identified for further analysis. Workup for CUP was comparable in all series with regard to physical examination, fine and/or gross needle examination of cervical nodes, fibre optic endoscopy, imaging and robot assisted mucosectomy of the base of tongue (BOT). Identification rate of the primary tumour was 72% on average (range 17%‐ 90%), and 55%‐ 96% were HPV positive. Clear margins were achieved in 60% (range 0%‐85%) of resected occult tumours. Complication rate of TORS BOT mucosectomy was low with mainly grade I‐III sequelae according to Clavien–Dindo. Conclusions Transoral robotic surgery seems to be a useful and safe adjunct in the diagnostic and therapeutic pathway in case of CUP in an era of increasing incidence of HPV‐positive OPSCC.

Transoral robotic surgery (TORS) using the da Vinci Xi: prospective analysis of feasibility, safety, and outcomes

“…This rate is comparable to 38% as reported by Nilsson et al 24 [24][25][26] A recent review on CUP-TORS reported an average identification of the primary tumor in 72% of cases (range 17%-90%), 55%-96% of these being HPV+ (vs. 42.1% HPV+ in our cohort). 27 The actual benefit of TORS for CUP is possible treatment deintensification by identifying/resecting the primary, as illustrated by Hatten et al 26 Sixty-seven percent of their CUP patients thus avoided chemotherapy and 25% avoided RT, thus reducing the risk of long-term dysphagia, carotid atherosclerosis, and xerostomia in a relatively young patient group. 26,27 Looking at all primarily treated SCC patients in our cohort, adjuvant (C)RT could be avoided in 48.9% of patients (treated with Xi-TORS only).…”

Human Papillomavirus and Squamous Cell Carcinoma of Unknown Primary in the Head and Neck Region: A Comprehensive Review on Clinical Implications

“…In several trials, the identification rate has increased with the addition of TORS and TLM-assisted lingual mucosectomy compared to traditional diagnostic approaches [ 5 , 9 , 34 , 112 ]. The TORS procedure also allows for complete surgical, oncologic lingual mucosectomy with negative margins in 60–80% of the cases [ 87 , 88 ]. One ongoing study from Canada is pursuing the successful identification of SCCUP with TORS among T0, N1-N3, and M0 patients and possible de-intensified adjuvant RT therapy (NCT03281499) but could be limited by its small sample size ( n = 22) and recruitment not limited by HPV status, yet similar designs should be implemented as a research purpose at multiple institutions.…”

“…The utility of TORS and TLM-assisted lingual mucosectomy has also been proven as a new diagnostic modality for SCCUP patients, with successful identification rates of 70–78% of the primary tumor sites [ 34 , 86 , 87 , 88 ]. These diagnostic modalities provide improved visualization and access to an anatomically complex area, and freedom of movement compared to conventional surgical techniques when resecting the superficial part of the tongue base [ 34 ], and are therefore advancing as essential diagnostic tools in SCCUP.…”

“…These diagnostic modalities provide improved visualization and access to an anatomically complex area, and freedom of movement compared to conventional surgical techniques when resecting the superficial part of the tongue base [ 34 ], and are therefore advancing as essential diagnostic tools in SCCUP. The procedure is, as also proven in previous diagnostic steps, highly effective in identifying the primary tumor site in the group of patients with HPV+ lymph node metastasis, as 55–96% of the identified tumors are HPV+ [ 87 , 88 ]. This is contrasted by an identification rate of only 13% in HPV− cases [ 89 ].…”

Salvage surgery in head and neck cancer

“…In case of clear margins of the index tumour and limited nodal involvement (single node without extracapsular spread), surveillance is sufficient.In this group of relatively young patients, toxicity reduction is key to prevent xerostomia, dysphagia, carotid artery atherosclerosis and risk reduction for a radiotherapy-induced tumour. The introduction of TORS has improved the accessibility for oropharyngeal resection and has also taken its role in the unknown primary setting by means of tongue base mucosectomy increasing the identification rate from 40% to 80%(van Weert et al, 2020). Because of possible primary avoidance of toxicity, HPV + OPSCC patients can benefit from (adjuvant)(chemo)radiation in case of locoregional failure.…”