Abstract
Purpose
We present our experience with the use of transoral robotic surgery (TORS) for treatment of supraglottic squamous cell carcinoma.
Materials and Methods
We studied all patients who underwent TORS for supraglottic squamous cell carcinoma, with or without adjuvant therapy, from March 2007 through June 2009, who had a minimum of 2 years of follow-up. Primary functional outcomes included dysphonia, tracheostomy dependence, and gastrostomy tube dependence. Disease control and survival were estimated with the Kaplan-Meier method.
Results
Of 9 patients in the study group, 7 (78%) had advanced-stage disease. All 9 patients had negative margins after TORS, with no perioperative complications. Regional recurrence and local recurrence developed in 1 patient each. One patient died of disease. At last follow-up, 7 patients (78%) were tracheostomy free, and 7 (78%) were gastrostomy tube free.
Conclusions
Transoral robotic surgery is a promising modality for resection of supraglottic squamous cell carcinoma. Transoral robotic surgery achieved functional laryngeal preservation in most patients with no complications.
1
Introduction
Treatment options for supraglottic squamous cell carcinoma (SG SCC) include operative therapy (open surgical procedures and transoral procedures), radiotherapy, chemoradiotherapy, or combinations of these. The optimal treatment is individualized to the patient, tumor subsite, and stage. The main goals of treatment include optimizing disease control and survival while minimizing functional morbidity . Primary surgical options for SG SCC range from minimally invasive transoral approaches to total laryngectomy. Most SG SCCs that do not extend onto the vocal cords or cause cord fixation can be successfully treated with transoral or open partial laryngectomy. Oncologic outcomes for laryngeal cancer are equivalent for transoral approaches and open approaches . The surgical approach is selected based on surgeon skill and training; patient factors including body habitus, pulmonary function, and oral and neck compliance; and tumor factors including location and extent. Surgeons are increasingly performing minimally invasive transoral laser microsurgery in an attempt to preserve laryngeal function without sacrificing disease control and survival. In appropriately selected patients, transoral laser microsurgery achieves oncologic outcomes comparable with those with open surgical approaches, with shorter hospitalizations, decreased morbidity, and improved functional outcomes . A promising new modality to improve on the limitations of transoral laser microsurgery is transoral robotic surgery (TORS).
We have used TORS for the treatment of select head and neck cancers since March 2007. The advantages of using TORS for resection of SG SCC include improved visualization, improved manual dexterity, tremor reduction, and the availability of many types of instruments including laser and cautery options and angulated instruments and endoscopes capable of working around corners. Several small case series have demonstrated that TORS is a feasible modality for resection of cancers of the larynx, but oncologic and functional outcomes are lacking . Because TORS represents a new technique in head and neck cancer treatment, careful analysis of treatment-related morbidity, functional results, and oncologic outcomes is essential to ensure that results are comparable or superior to current widely accepted treatment options. Here, we describe disease control, survival, and functional outcomes in patients treated with TORS for SG SCC to justify continuation of this new treatment modality.
2
Materials and methods
2.1
Study design
This study was approved by and conducted in compliance with the Mayo Clinic Institutional Review Board. All patients who underwent TORS as primary treatment for SG SCC from March 2007 through June 2009 at Mayo Clinic, Rochester, Minnesota, were included in this series. The time frame chosen ensured that patients were followed up for a minimum of 24 months after surgery. Data on patient demographics, tumor stage, histopathologic characteristics, treatment modalities, and functional and oncologic outcomes were collected from a prospectively compiled database.
2.2
Patient candidacy for TORS
Patients were considered for TORS if they had a supraglottic tumor estimated to be resectable via the transoral route based on preoperative imaging and physical examination. Patients with retrognathia, narrow mandibular arch, macroglossia, or limited neck extension were considered poor candidates for TORS because of the difficulty of exposing the tumor and were offered alternative operative or nonoperative treatment. Patients with tumors that caused vocal cord fixation or those that extended transglottically, into the deep tongue musculature, hyoid, or lateral neck soft tissue were not considered candidates for TORS.
2.3
Surgical technique
After securing the airway by standard endotracheal intubation with a laser-safe tube or tracheostomy placement, the patient was positioned for TORS, and the teeth and alveolar ridge were protected with a thermoplastic mouthguard. The larynx was exposed using a Feyh-Kastenbauer laryngeal retractor (Gyrus ACMI, Southborough, MA). Instrumentation used included a 30° binocular endoscope, a 5-mm EndoWrist Schertel grasper, and a 5-mm spatula cautery (Intuitive Surgical, Inc, Sunnyvale, CA). A surgical assistant was positioned at the patient’s head, aiding with suction, application of vascular clips (superior laryngeal vessels), and surgical specimen retrieval and pathologic orientation. Tumors were resected en block when possible. After removing the tumor, peripheral margins were examined in the frozen section pathology laboratory, and positive margins were reexcised until clear margins were achieved. After margins were cleared, the surgical site was checked for hemostasis, and a nasogastric tube was placed. Neck dissections were performed in all cases at the time of TORS.
2.4
Postoperative care
Patients had their tracheostomy tube removed when they could tolerate corking for 48 continuous hours. All patients underwent repeat examination and speech-language pathology evaluation with a video swallow study within 30 days of surgery. If swallowing function was deemed adequate, the nasogastric tube was removed, and the patient was allowed to resume an oral diet. Patients with persistent dysphagia were considered for additional swallowing therapy or gastrostomy tube (G-tube) placement, depending on dysphagia severity and adjuvant therapy requirements. Functional speech outcomes were determined from the patient’s most recent speech-language pathology evaluation. Speech quality was recorded for 3 general parameters: phonation, resonance, and articulation. Only phonation was affected in this series. Phonation characteristics including hoarseness, strain, pitch, wetness, and breathiness were scored on a 0 (normal) to 4 (profoundly impaired) scale by a speech-language pathologist. Scores from each category were then added, and the patient’s speech was categorized as follows: 0, normal speech; 1 to 2, mild dysphonia; 3 to 5, moderate dysphonia; or 6 or greater, severe dysphonia.
2.5
Adjuvant therapy
Adjuvant therapy included intensity-modulated radiotherapy with or without chemotherapy. Indications for adjuvant therapy were usually determined by neck disease and included extracapsular spread, desmoplasia, multiple positive lymph nodes, or atypical metastatic patterns. Indications for adjuvant therapy based on the primary tumor included lymphovascular invasion, perineural invasion, grade 4/4 disease, and positive resection margins. The decision to pursue adjuvant therapy was based on the final pathology report and consultation with medical and radiation oncologists.
2.6
Statistics
Data are summarized as number of patients (percentage). Commercially available statistical software was used (JMP; SAS Institute, Inc, Cary, NC). Oncologic outcomes were estimated using Kaplan-Meier regression analysis. Patients were censored on the date of death or the date of last contact.
2
Materials and methods
2.1
Study design
This study was approved by and conducted in compliance with the Mayo Clinic Institutional Review Board. All patients who underwent TORS as primary treatment for SG SCC from March 2007 through June 2009 at Mayo Clinic, Rochester, Minnesota, were included in this series. The time frame chosen ensured that patients were followed up for a minimum of 24 months after surgery. Data on patient demographics, tumor stage, histopathologic characteristics, treatment modalities, and functional and oncologic outcomes were collected from a prospectively compiled database.
2.2
Patient candidacy for TORS
Patients were considered for TORS if they had a supraglottic tumor estimated to be resectable via the transoral route based on preoperative imaging and physical examination. Patients with retrognathia, narrow mandibular arch, macroglossia, or limited neck extension were considered poor candidates for TORS because of the difficulty of exposing the tumor and were offered alternative operative or nonoperative treatment. Patients with tumors that caused vocal cord fixation or those that extended transglottically, into the deep tongue musculature, hyoid, or lateral neck soft tissue were not considered candidates for TORS.
2.3
Surgical technique
After securing the airway by standard endotracheal intubation with a laser-safe tube or tracheostomy placement, the patient was positioned for TORS, and the teeth and alveolar ridge were protected with a thermoplastic mouthguard. The larynx was exposed using a Feyh-Kastenbauer laryngeal retractor (Gyrus ACMI, Southborough, MA). Instrumentation used included a 30° binocular endoscope, a 5-mm EndoWrist Schertel grasper, and a 5-mm spatula cautery (Intuitive Surgical, Inc, Sunnyvale, CA). A surgical assistant was positioned at the patient’s head, aiding with suction, application of vascular clips (superior laryngeal vessels), and surgical specimen retrieval and pathologic orientation. Tumors were resected en block when possible. After removing the tumor, peripheral margins were examined in the frozen section pathology laboratory, and positive margins were reexcised until clear margins were achieved. After margins were cleared, the surgical site was checked for hemostasis, and a nasogastric tube was placed. Neck dissections were performed in all cases at the time of TORS.
2.4
Postoperative care
Patients had their tracheostomy tube removed when they could tolerate corking for 48 continuous hours. All patients underwent repeat examination and speech-language pathology evaluation with a video swallow study within 30 days of surgery. If swallowing function was deemed adequate, the nasogastric tube was removed, and the patient was allowed to resume an oral diet. Patients with persistent dysphagia were considered for additional swallowing therapy or gastrostomy tube (G-tube) placement, depending on dysphagia severity and adjuvant therapy requirements. Functional speech outcomes were determined from the patient’s most recent speech-language pathology evaluation. Speech quality was recorded for 3 general parameters: phonation, resonance, and articulation. Only phonation was affected in this series. Phonation characteristics including hoarseness, strain, pitch, wetness, and breathiness were scored on a 0 (normal) to 4 (profoundly impaired) scale by a speech-language pathologist. Scores from each category were then added, and the patient’s speech was categorized as follows: 0, normal speech; 1 to 2, mild dysphonia; 3 to 5, moderate dysphonia; or 6 or greater, severe dysphonia.
2.5
Adjuvant therapy
Adjuvant therapy included intensity-modulated radiotherapy with or without chemotherapy. Indications for adjuvant therapy were usually determined by neck disease and included extracapsular spread, desmoplasia, multiple positive lymph nodes, or atypical metastatic patterns. Indications for adjuvant therapy based on the primary tumor included lymphovascular invasion, perineural invasion, grade 4/4 disease, and positive resection margins. The decision to pursue adjuvant therapy was based on the final pathology report and consultation with medical and radiation oncologists.
2.6
Statistics
Data are summarized as number of patients (percentage). Commercially available statistical software was used (JMP; SAS Institute, Inc, Cary, NC). Oncologic outcomes were estimated using Kaplan-Meier regression analysis. Patients were censored on the date of death or the date of last contact.
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