Transoral Robotic Surgery for Head and Neck Pathology: A Series of 37 cases

Introduction:Traditionally, oropharyngeal cancer treatment composed of en bloc resection of the tumor via lip-split mandibulotomy approach followed by potential adjuvant therapy. With advance of technology, Transoral robotic surgery (TORS) in head and neck cancer has shown acceptable surgical outcome with low morbidity and improved postoperative recovery.¹ TORS and neckdissection followed by deintensified adjuvant therapy has shown promise for lowering comorbidity from adjuvant therapy and improving the outcome of patient with oropharyngeal carcinoma.²In this study, we will review surgical outcomes in resection of head and neck cancer as well as benign pathology with TORS

Patients and Methods:Medical records of 34 consecutive patients who underwent transoral robotic surgery for head and neck pathology between March 2010 and March 2012 were retrospectively reviewed

Results:A total of 37transoral robotic surgery for head and neck pathology cases among 34 patients were identified.  Among the 37 cases, 25 cases were for malignant tumor and 12 cases were for benign pathology.Malignant tumor sites were tonsillar fossa (n=11), base of the tongue (n=12), posterior pharyngeal wall (n=1), and retromolar trigone (n=1). Ten patients (40%) had simultaneous neck dissection with TORS.  Three patients underwent re-resection of positive margins by TORS yielding negative final margins. 10 of 22 patients had concurrent neck dissection with TORS

Primary Tumor staging (T) include ten T1 stage (40%), twelve T2 stage (48%), and two T3 stage (12%).  Final surgical margins found to be negative for cancer in 9 of 10 patient with T1 (90%), 9 of 12 with T2 (75%), and 1 of 3 with T3 tumor (33%). Subtotal resection performed on 2 of 5 T2 tumors due to significant growth of tumor noted at the time of surgery.

13of 22 patients who underwent malignant tumor resection, treated with adjuvant therapy. 10 patients treated with postoperative radiation therapy (RT), 3 patients with concurrent chemoradiation therapy. 5 of 13 (38%) patients received deescalated postoperative RT

Benign pathology cases include seven tonsillectomies, two submandibular sialoadnectomies, two lateral pharyngeal space pleomorphic adenoma, and one periglottic branchial cleft cyst, one lingual tonsil hypertrophy with obstructive sleep apnea.

No major intraoperative or postoperative complications encountered in all cases.  One case with periglottic mass was aborted due to severe retrognathic mandible limiting adequate retraction for TORS

Conclusions:Transoral robotic surgery demonstrated alternative surgical options for effective resection of selected head and neck cancer by offering unobstructed access for oropharyngeal cancer. In our experiences, for T1 and T2 oropharyngeal cancer, it is feasible to obtain excellent surgical outcome with TORS while the patients benefit from low morbidity and improved postoperative recovery. With concurrent neck dissection, patient may avoid delayed operative treatment and necessary adjuvant therapy. Role of TORS combined with deescalated adjuvant therapy will be investigated in future. TORS has limited role in benign pathology cases.

References:

1. Leonhardt FD, Quon H, Weinstein GS et al. Tranoral robotic surgery for oropharyngeal carcinoma and its impact on patient-reported quality of life and function. Head & Neck February 2012: 146-154

2. Weinstein GS, Quon, H, O'Malley BW et al. Selective neck dissection and deintensified postoperative radiation and chemotherapy for oropharyngeal cancer: A subset analysis of the University of Pennsylvania Transoral Robotic Surgery Trial. Laryngoscope2010; 120:1749-1755