Transoral robotic surgery and neck dissection for HPV-positive oropharyngeal carcinoma: Importance of nodal count in survival

Chi T Viet; Eric J Dierks; Allen C Cheng; Ashish A Patel; Shu-Ching Chang; Marcus A Couey; Amber L Watters; Thien Hoang; Hong D Xiao; Marka R Crittenden; Rom S Leidner; Steven K Seung; Kristina H Young; R Bryan Bell

doi:10.1016/j.oraloncology.2020.104770

Transoral robotic surgery and neck dissection for HPV-positive oropharyngeal carcinoma: Importance of nodal count in survival

Oral Oncol. 2020 Jun 26:109:104770. doi: 10.1016/j.oraloncology.2020.104770. Online ahead of print.

Authors

Affiliations

¹ Oral and Maxillofacial Surgery Department, Loma Linda University School of Dentistry, Loma Linda, CA, United States; Head and Neck Cancer Program, Providence Cancer Institute, Portland, OR, United States; Head and Neck Cancer Program, Legacy Cancer Center, Portland, OR, United States.
² Head and Neck Cancer Program, Providence Cancer Institute, Portland, OR, United States; Head and Neck Cancer Program, Legacy Cancer Center, Portland, OR, United States.
³ Medical Data Research Center, Providence St. Joseph Health, Portland, OR, United States.
⁴ Oral Oncology and Medicine, Providence Cancer Institute, Portland, OR, United States.
⁵ Head and Neck Cancer Program, Providence Cancer Institute, Portland, OR, United States.
⁶ Head and Neck Cancer Program, Providence Cancer Institute, Portland, OR, United States; Earle A. Chiles Research Institute at Robert W. Franz Cancer Center, Providence Cancer Institute, Portland, OR, United States; The Oregon Clinic, Portland, OR, United States.
⁷ Head and Neck Cancer Program, Providence Cancer Institute, Portland, OR, United States; Earle A. Chiles Research Institute at Robert W. Franz Cancer Center, Providence Cancer Institute, Portland, OR, United States.
⁸ Head and Neck Cancer Program, Providence Cancer Institute, Portland, OR, United States; The Oregon Clinic, Portland, OR, United States.
⁹ Head and Neck Cancer Program, Providence Cancer Institute, Portland, OR, United States; Earle A. Chiles Research Institute at Robert W. Franz Cancer Center, Providence Cancer Institute, Portland, OR, United States. Electronic address: richard.bell@providence.org.

PMID: 32599498
DOI: 10.1016/j.oraloncology.2020.104770

Abstract

Background: In this study we determine the survival in patients with HPV-positive oropharyngeal carcinoma treated with transoral robotic surgery (TORS), neck dissection and risk-adapted adjuvant therapy.

Methods: We retrospectively identified 122 patients with HPV-positive oropharyngeal carcinoma treated with TORS and neck dissection between 2011 and 2018. Survival probability was calculated. We determined the effect of the type of neck dissection performed (modified radical neck dissection-MRND vs. selective neck dissection - SND), extranodal extension (ENE), margin status, and presence of ≥ 5 metastatic nodes on survival.

Results: Our patient population had a five-year overall survival of 91.0% (95% C.I. 85-97%). The five-year probability of recurrence or cancer-associated death was 0.0977 (95% C.I. 0.0927-0.1027). The five-year probability of cancer-associated death was 0.0528 (95% C.I. 0.048-0.0570). All patients who died of their disease had distant metastasis. Our PEG dependence rate was 0%. Patients with ENE and positive margins who underwent adjuvant chemoradiation did not have worse survival. Presence of ≥ 5 metastatic nodes portended worse survival after controlling for age, positive ENE and margins. Low yield (<18 nodes) on neck dissection worsened DFS on multivariable analysis. Furthermore, patients who underwent SND did not have worse OS than those who underwent MRND.

Conclusion: Our study demonstrates that surgery could be simplified by performing TORS with SND rather than MRND. The one true poor prognostic factor in HPV-positive oropharyngeal carcinoma patients who undergo surgery is high nodal burden. Patients with high nodal burden are much more likely to die from their disease.

Keywords: De-escalate; HPV; Head and neck cancer; Human papilloma virus; Oral cancer; Oropharyngeal cancer; Radiation; Surgery; TORS; Transoral robotic surgery.