Dysphagia After Primary Transoral Robotic Surgery With Neck Dissection vs Nonsurgical Therapy in Patients With Low- to Intermediate-Risk Oropharyngeal Cancer

Abstract

for the MD Anderson Head and Neck Cancer Symptom Working Group IMPORTANCE A major goal of primary transoral robotic surgery (TORS) for oropharyngeal cancer is to optimize swallowing outcomes by personalized treatment based on pathologic staging. However, swallowing outcomes after TORS are uncertain, as are the outcomes compared with nonsurgical options. OBJECTIVES To estimate rates of acute dysphagia and recovery after TORS and to compare swallowing outcomes by primary treatment modality (TORS or radiotherapy). DESIGN, SETTING, AND PARTICIPANTSThis case series study was a secondary analysis of prospective registry data from 257 patients enrolled from March 1, 2015, to February 28, 2018, at a single academic institution who, according to the AJCC Staging Manual, 7th edition TNM classification, had low-to intermediate-risk human papillomavirus-related oropharyngeal squamous cell carcinoma possibly resectable by TORS. EXPOSURE Patients were stratified by primary treatment (75 underwent TORS and 182 received radiotherapy). MAIN OUTCOMES AND MEASURESModified barium swallow (MBS) studies graded per Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) and the MD Anderson Symptom Inventory-Head and Neck Module (MDASI-HN) questionnaires were administered at standard intervals. Prevalence and severity of dysphagia were estimated per DIGEST before and after TORS and 3 to 6 months after treatment. Moderate-severe dysphagia (DIGEST grade Ն2) was assessed using logistic regression and compared by primary treatment group. The MDASI swallowing symptom severity item scores during and after radiotherapy were compared using generalized estimating equations by treatment status at the start of radiotherapy, after induction, and after TORS. RESULTS A total of 257 patients (mean [SD] age, 59.54 [9.07] years; 222 [86.4%] male) were included in the study. Dysphagia severity (per DIGEST) was significantly worse after TORS (r = −0.63; 95% CI, −0.78 to −0.44): 17 patients (22.7%; 95% CI, 13.8%-33.8%) had moderate-severe (DIGEST grade Ն2) acute post-TORS dysphagia significantly associated with primary tumor volume (odds ratio, 1.43; 95% CI, 1.11-1.84). DIGEST improved by 3 to 6 months but remained worse than that at baseline; at 3 to 6 months, the number of patients with DIGEST grade 2 or higher dysphagia was 5 (6.7%; 95% CI, 2.2%-14.9%) after primary TORS and 29 (15.9%; 95% CI, 10.9%-22.1%) after radiotherapy. At the start of radiotherapy, MDASI swallowing symptom severity item scores were significantly worse in the post-TORS group compared with postinduction (mean [SD] change, 2.6 [1.1]) and treatment-naive (mean [SD] change, 1.7 [0.3]) patients. This result inverted at radiotherapy end, and all groups converged at 3 to 6 months.CONCLUSIONS AND RELEVANCE Subacute swallowing outcomes were similar regardless of primary treatment modality among patients with low-to intermediate-risk oropharyngeal squamous cell carcinoma.

Transoral robotic salvage oropharyngectomy with submental artery island flap reconstruction

“…Oropharyngeal squamous cell carcinoma (SCC) may be treated in the primary setting with both surgical and nonsurgical strategies, with comparable oncologic and functional outcomes between primary radiation and transoral robotic surgery (TORS). [6][7][8][9] In the salvage setting after radiation or chemoradiation, the treatment of oropharyngeal SCC becomes far more complex. Reirradiation is typically not an optimal choice due to intolerable toxicity.…”

A new endoscopic surgical approach to the larynx, hypopharynx, and neck lymphatics: The robotic‐assisted extended “Sistrunk” approach (RESA)

“…Transoral robotic surgery is a well-established treatment strategy for oropharyngeal cancers with excellent oncological and functional outcomes. [1][2][3][4][5] Further applications have been described for supraglottic, [6][7][8][9] partial, 10 and total laryngectomies [11][12][13] with promising initial results.…”

Early fiberoptic endoscopic evaluation of swallow in transoral robotic surgery: Description of swallow function and recovery in the acute postoperative period for oropharyngeal squamous cell carcinoma

“…Recent studies have used the MD Anderson Dysphagia Inventory (MDADI), 10,11,13,14 Functional Oral Intake Scale, 15 Eating Assessment Tool (EAT-10), 16 Performance Status Scale-Head and Neck (PSSHN), 15,17,18 and Functional Oral Swallowing Scale. 19 Comparative studies have demonstrated similar patient rated severity of dysphagia at 3 and 6 months for both definitive CRT and TORS, 10,14 however, potentially superior swallowing function for CRT at 12 months. 11 In those patients where adjuvant treatment can be avoided, TORS can result in minimal dysphagia, depending on baseline function and tumor classification.…”

“…22 Despite this, only four studies have examined swallowing in the OPC TORS population using instrumental assessment. 10,[13][14][15] These cohorts involved patients with a mean age of 55 to 61 years, majority males and varied participant numbers ranging between 10 and 257. To the best of our knowledge, a study reporting on acute dysphagia after TORS evaluated by FEES has not been published.…”

“…Despite this, only four studies have examined swallowing in the OPC TORS population using instrumental assessment 10,13‐15 . These cohorts involved patients with a mean age of 55 to 61 years, majority males and varied participant numbers ranging between 10 and 257.…”