Up-front and Salvage Transoral Robotic Surgery for Head and Neck Cancer: A Belgian Multicenter Retrospective Case Series

Abstract

Introduction/aim: We analyzed the functional and oncologic outcomes of primary and salvage transoral robotic surgery (TORS) procedures, performed in three Belgian institutions with a similar philosophy.

Patients and methods: A total of 86 patients who underwent TORS between 24-12-2009 and 25-09-2015 were retrospectively reviewed. Descriptive statistics, overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS; Kaplan-Meier), and the variation of these outcomes according to whether patients had primary or salvage TORS were evaluated (univariate log-rank analysis).

Results: Of 86 patients, 56 (65.1%) underwent TORS as a primary treatment and 30 (34.9%) as a salvage procedure for recurrent or second primary cancer. Tumor location was mainly oropharynx (N = 63; 73.3%) followed by supraglottic larynx (N = 11; 12.8%), hypopharynx (N = 11; 12.8%), and glottic larynx (N = 1; 1.2%). In the up-front TORS group, most tumors were classified as cT1 (N = 23; 41.1%)/pT1 (N = 24; 42.9%) or cT2 (N = 27; 48.2%)/pT2 (N = 27; 48.2%) and cN0 (N = 18; 32.1%), cN1 (N = 13; 23.2%), or cN2 (N = 25; 44.6%). In the salvage TORS group, most tumors were cT1-rT1 (N = 18; 60.0%)/pT1-rpT1 (N = 18; 60.0%) or cT2-rT2 (N = 12; 40.0%)/pT2-rpT2 (N = 7; 23.3%) and cN0 (N = 25; 83.3%). Neck dissection was performed in 87.5% of primary cases and 30.0% of salvage cases. In the up-front TORS group, patients were postoperatively submitted to follow-up (N = 13; 23.2%) or received adjuvant radiotherapy, either as single modality (N = 26; 46.4%) or with concomitant cisplatin (N = 15; 26.8%). On the other hand, most salvage TORS patients did not receive any adjuvant therapy (N = 19; 63.3%). Mean and median follow-up was 23.1 and 21.2 months, respectively. Functional results were excellent (no definitive tracheostomy, long-term tube feeding in 1.8% of primary cases, and 20% of salvage cases). In the up-front TORS group, estimated 2-year OS was 88.5% (SE = 5.0%), 2-year DSS was 91.8% (SE = 4.6%) and 2-year DFS was 86.1% (SE = 5.3%). In the salvage TORS group, estimated 2-year OS was 73.5% (SE = 10.9%), 2-year DSS was 93.3% (SE = 6.4%), and 2-year DFS was 75.8% (SE = 9.7%). Comparing outcome of primarily treated patients to salvage patients, a non-statistically significant trend toward better OS (p = 0.262) and DFS (p = 0.139) was observed.

Conclusion: This retrospective study confirms favorable oncologic and functional outcomes of TORS for selected head and neck malignancies, both in the primary and in the salvage setting.

Keywords: oropharyngeal cancer; salvage surgery; squamous cell carcinoma; supraglottic cancer; transoral robotic surgery.

Figure 1

Kaplan–Meier curve illustrating overall survival (OS) in patients treated with up-front or primary transoral robotic surgery (TORS) (green) and salvage TORS (blue). A trend toward better OS in the primary group is observed, although this difference is not statistically significant (log-rank test, p = 0.262).

Figure 2

Kaplan–Meier curve illustrating disease-specific survival in patients treated with up-front or primary transoral robotic surgery (TORS) (green) and salvage TORS (blue). No difference between survival curves is observed (log-rank test, p = 0.677).

Figure 3

Kaplan–Meier curve illustrating disease-free survival in patients treated with up-front or primary transoral robotic surgery (TORS) (green) and salvage TORS (blue). A trend toward higher disease control (locoregional and distant) in the primary treated group is observed, though without reaching a level of significance (log-rank test, p = 0.139).