Transoral robotic surgery for oropharyngeal cancer: patient selection and special considerations

Abstract

The increasing incidence of oropharyngeal squamous cell carcinoma (OPSCC) emphasizes the importance of optimizing treatment for the disease. Historical protocol has utilized definitive radiation and invasive open procedures; these techniques expose the patient to significant risks and morbidity. Transoral robotic surgery (TORS) has emerged as a therapeutic modality with promise. Here, the literature regarding proper patient selection and other considerations for this procedure was reviewed. Multiple patient and tumor-related factors were found to be relevant for successful use of this treatment strategy. Outcomes regarding early and advanced-stage OPSCC were analyzed. Finally, the literature regarding use of TORS in three distinct patient populations, individuals with primary OPSCC, carcinoma of unknown primary and those with recurrent OPSCC, was examined.

MRI-Based Assessment of the Pharyngeal Constrictor Muscle as a Predictor of Surgical Margin after Transoral Robotic Surgery in HPV-Positive Tonsillar Cancer

“…Tonsillar SCC invading the pharyngeal constrictor muscle on a surgical field is known to increase a risk of locoregional recurrence, 26 and tumor invasion of the parapharyngeal fat is likely to leave an insecure surgical margin. 5 These structures can be directly visualized on MR imaging, which is an excellent imaging tool for the head and neck with superb softtissue contrast and high spatial resolution. In this regard, we hypothesized that preoperative MR imaging could predict the surgical margin status by scoring the degree of constrictor and parapharyngeal space invasion by the initial tumor.…”

“…14,15 While avoiding functional deficits from the traditional external approaches, TORS can reduce the need for adjuvant therapy after surgery or can use surgery as a single-technique therapy while preserving oncologic outcomes, particularly when the negative margin is achieved by TORS. 2,3,5,[16][17][18] Despite these advantages, there is still a risk of obtaining an insecure surgical margin (ie, positive margin involvement by the tumor or a close margin of ,1 mm between the tumor and the margin) in TORS, which necessitates adjuvant therapies, even in early T1 and T2 tumors. 3,19 Because oncologic outcomes in such cases are similar to those with chemoradiation alone, 3 it is important to preselect patients who are expected to have an insecure surgical margin to avoid unnecessary dual treatment.…”

“…It has been noted that tumor invasion through the pharyngeal constrictor muscle confirmed in a surgical field will likely have a positive margin related to locoregional recurrence, but data supporting an imaging-based predictor are still lacking. 2,5,20 In our study, we aimed to identify preoperative MR imaging characteristics, particularly with regard to pharyngeal constrictor muscle involvement by the tumor in early stage cancers, that predispose the outcome of TORS toward an insecure surgical margin in HPV-positive tonsillar SCC.…”

Has the time come for de-escalation in the management of oropharyngeal carcinoma?

“…without radiographic ECE) (ref. 48,49 ). The ORATOR, phase II study, if successful, will provide a much-needed randomised comparison of the conventional strategy of primary RT vs the novel strategy of primary TORS.…”

A career in ear, nose, and throat surgery

“…ENT surgeons are innovating and embracing technological advances to improve patients’ quality of life. For example, robotic endoscopic surgery for oropharyngeal cancers is growing in popularity as it can reduce operating time 16. Three dimensional imaging during surgery enables new, safer, less invasive procedures such as surgically removing skull base tumours through nasal passages without disturbing the face or skull 17.…”