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Single-session, dual-site robotic surgery for synchronous primary malignancies of the oropharynx and thorax.

ABSTRACT: Single-session, dual-site robotic surgery for synchronous malignancies is not widely reported. To our knowledge, there are no previous reports of transoral robotic surgery (TORS) and robot-assisted thoracic surgery (RATS) in a single sitting. A 49-year-old male presented with a neck lump. Biopsies and imaging proved synchronous primaries of the tonsil and lung. The morbidity of primary dual-site chemoradiotherapy, or open surgery, presented a management challenge. We therefore opted for sequential robotic resections, in a single sitting. The patient was discharged on Day 6 post-operatively and was able to start radiotherapy less than 3 weeks post-operatively. Undertaking TORS and RATS in a single sitting is feasible and safe. This approach allowed fast-tracking of adjuvant oncological therapy, arguably conveying the greatest chance of cure. We detail the rationale and utility of this novel approach and describe the surgical and anaesthetic challenges of two teams undertaking sequential robotic procedures in a single sitting.

SUBMITTER: Kelly M

PROVIDER: S-EPMC7449555 | biostudies-literature | 2020 Aug

REPOSITORIES: biostudies-literature

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Single-session, dual-site robotic surgery for synchronous primary malignancies of the oropharynx and thorax.

Kelly Mairead M Oikonomou Georgios G Tornari Chrysostomos C Ahmad Imran I Bille Andrea A Jeannon Jean-Pierre JP Arora Asit A

Journal of surgical case reports 20200826 8

Single-session, dual-site robotic surgery for synchronous malignancies is not widely reported. To our knowledge, there are no previous reports of transoral robotic surgery (TORS) and robot-assisted thoracic surgery (RATS) in a single sitting. A 49-year-old male presented with a neck lump. Biopsies and imaging proved synchronous primaries of the tonsil and lung. The morbidity of primary dual-site chemoradiotherapy, or open surgery, presented a management challenge. We therefore opted for sequenti ...[more]

PMID: 32874542

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Project description:ImportanceUnderstanding patient-specific risk of adverse histopathologic findings after primary surgery for human papillomavirus (HPV)-positive oropharynx squamous cell carcinoma (OPSCC) may help guide patient consultations.ObjectiveTo determine the likelihood of adverse histopathologic features that may indicate adjuvant radiotherapy or chemoradiotherapy after primary surgery for HPV-positive OPSCC according to 2021 National Comprehensive Cancer Network guidelines.Design, setting, and participantsThis retrospective cohort study was performed at a single academic tertiary care center. Of 258 patients who underwent transoral robotic surgery (TORS) from March 1, 2012, to March 1, 2021, 136 consecutive, treatment-naive patients with HPV-positive OPSCC without obvious clinical extranodal extension (ENE) who underwent definitive TORS and neck dissection were included in the analysis. Indications for surgical treatment included non-deeply infiltrative oropharynx tumors, minimal soft palate involvement, and low suspicion for pathologic ENE.ExposuresPrimary site TORS with neck dissection.Main outcomes and measuresThe primary outcomes were the adverse histopathologic features of pathologic ENE and positive surgical margins (PSM) that are indications for possible adjuvant chemoradiotherapy. Outcomes were compared among varying American Joint Committee on Cancer 7th edition (AJCC-7) T and N categories and patient clinical characteristics.ResultsOf the 136 patients included in the analysis (113 men [83.1%]; median age, 63 [interquartile range, 55-70] years), 109 (80.1%) had at least 1 indication for possible adjuvant radiotherapy. Twenty-seven patients (19.9%) had pathologic ENE and 10 (7.3%) had PSM. Thirty-four patients (25.0%) had pathologic ENE and/or PSM, whereas 3 (2.2%) had both. Age, smoking history, history of alcohol consumption, and clinical T category were not associated with pathologic ENE, PSM, lymphovascular invasion, perineural invasion, or pN2 category or greater. The proportion of pathologic ENE varied by clinical N category: 0 of 16 for cN0, 8 of 48 (16.7%) for cN1, 3 of 23 (13.0%) for cN2a, and 16 of 45 (35.6%) for cN2b. Compared with patients with cN1-cN2a disease, patients with cN2b disease had higher odds of pathologic ENE (odds ratio, 3.01; 95% CI, 1.14-8.10). Clinical and pathologic N category were concordant in 77 patients (56.6%), whereas 42 (30.9%) were upstaged and 17 (12.5%) were downstaged.Conclusions and relevanceIn this cohort study, approximately one-quarter of carefully selected patients with HPV-positive OPSCC without obvious clinical ENE undergoing primary surgery had pathologic ENE and/or PSM. Patients with AJCC-7 cT0-cT2 cN0-cN2b disease, especially cN0-cN2a, without signs of clinical ENE may represent appropriate candidates for primary surgery when avoidance of adjuvant chemotherapy and/or reduction of adjuvant radiotherapy dose/extent are the goals.

Project description:The incidence of oropharyngeal squamous cell carcinoma (OPSCC) has markedly increased over the last three decades due to newly found associations with human papillomavirus (HPV) infection. Primary radiotherapy (RT) is the treatment of choice for OPSCC at most centers, and over the last decade, the addition of concurrent chemotherapy has led to a significant improvement in survival, but at the cost of increased acute and late toxicity. Transoral robotic surgery (TORS) has emerged as a promising alternative treatment, with preliminary case series demonstrating encouraging oncologic, functional, and quality of life (QOL) outcomes. However, comparisons of TORS and RT in a non-randomized fashion are susceptible to bias. The goal of this randomized phase II study is to compare QOL, functional outcomes, toxicity profiles, and survival following primary RT (± chemotherapy) vs. TORS (± adjuvant [chemo] RT) in patients with OPSCC.The target patient population comprises OPSCC patients who would be unlikely to require chemotherapy post-resection: Tumor stage T1-T2 with likely negative margins at surgery; Nodal stage N0-2, ?3 cm in size, with no evidence of extranodal extension on imaging. Participants will be randomized in a 1:1 ratio between Arm 1 (RT ± chemotherapy) and Arm 2 (TORS?±?adjuvant [chemo] RT). In Arm 1, patients with N0 disease will receive RT alone, whereas N1-2 patients will receive concurrent chemoradiation. In Arm 2, patients will undergo TORS along with selective neck dissections, which may be staged. Pathologic high-risk features will be used to determine the requirement for adjuvant radiotherapy +/- chemotherapy. The primary endpoint is QOL score using the M.D. Anderson Dysphagia Inventory (MDADI), with secondary endpoints including survival, toxicity, other QOL outcomes, and swallowing function. A sample of 68 patients is required.This study, if successful, will provide a much-needed randomized comparison of the conventional strategy of primary RT vs. the novel strategy of primary TORS. The trial is designed to provide a definitive QOL comparison between the two arms, and to inform the design of an eventual phase III trial for survival outcomes.NCT01590355.

Dataset Information

Single-session, dual-site robotic surgery for synchronous primary malignancies of the oropharynx and thorax.

Publications

Single-session, dual-site robotic surgery for synchronous primary malignancies of the oropharynx and thorax.

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