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BACKGROUND: Transoral robotic surgery (TORS) performed after neoadjuvant chemotherapy (NAC) is a promising treatment for advanced-stage oropharyngeal carcinoma (OPSCC) able to reduce the adjuvant therapy administration rate. METHODS: A retrospective bi-centric study was conducted to analyze NAC + TORS versus upfront TORS patients. A 1:1 propensity score matching was used to compare the two groups. RESULTS: Among the 300 patients with stage III-IV OPSCC, 204 patients were matched for comparing NAC + TORS versus upfront TORS. Between the two groups, no significant difference was observed in recurrences and in survival for RFS, OS, and DSS. In the NAC + TORS p16-positive population, adjuvant therapy could be spared in 51% versus 16% in the upfront surgery cohort (p < 0.001) due to the lower frequency of pathological risk factors after NAC. CONCLUSIONS: NAC followed by TORS for locoregionally advanced OPSCC demonstrated to achieve non-inferior survival outcomes to upfront surgery, while in the p16-positive population allowed to significantly spare adjuvant therapy.
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PURPOSE: Clinical implications of neoadjuvant immunotherapy in patients with locally advanced but resectable head and neck squamous cell carcinoma (HNSCC) remain largely unexplored. PATIENTS AND METHODS: Patients with resectable HNSCC were randomized to receive a single dose of preoperative durvalumab (D) with or without tremelimumab (T) before resection, followed by postoperative (chemo)radiotherapy based on multidisciplinary discretion and 1-year D treatment. Artificial intelligence (AI)-powered spatial distribution analysis of tumor-infiltrating lymphocytes and high-dimensional profiling of circulating immune cells tracked dynamic intratumoral and systemic immune responses. RESULTS: Of the 48 patients enrolled (D, 24 patients; D+T, 24 patients), 45 underwent surgical resection per protocol (D, 21 patients; D+T, 24 patients). D±T had a favorable safety profile and did not delay surgery. Distant recurrence-free survival (DRFS) was significantly better in patients treated with D+T than in those treated with D monotherapy. AI-powered whole-slide image analysis demonstrated that D+T significantly reshaped the tumor microenvironment toward immune-inflamed phenotypes, in contrast with the D monotherapy or cytotoxic chemotherapy. High-dimensional profiling of circulating immune cells revealed a significant expansion of T-cell subsets characterized by proliferation and activation in response to D+T therapy, which was rare following D monotherapy. Importantly, expansion of specific clusters in CD8+ T cells and non-regulatory CD4+ T cells with activation and exhaustion programs was associated with prolonged DRFS in patients treated with D+T. CONCLUSIONS: Preoperative D±T is feasible and may benefit patients with resectable HNSCC. Distinct changes in the tumor microenvironment and circulating immune cells were induced by each treatment regimen, warranting further investigation.
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Anticorpos Monoclonais Humanizados , Anticorpos Monoclonais , Protocolos de Quimioterapia Combinada Antineoplásica , Neoplasias de Cabeça e Pescoço , Terapia Neoadjuvante , Carcinoma de Células Escamosas de Cabeça e Pescoço , Humanos , Masculino , Carcinoma de Células Escamosas de Cabeça e Pescoço/tratamento farmacológico , Carcinoma de Células Escamosas de Cabeça e Pescoço/terapia , Carcinoma de Células Escamosas de Cabeça e Pescoço/patologia , Pessoa de Meia-Idade , Feminino , Anticorpos Monoclonais Humanizados/administração & dosagem , Anticorpos Monoclonais Humanizados/uso terapêutico , Idoso , Anticorpos Monoclonais/administração & dosagem , Anticorpos Monoclonais/uso terapêutico , Neoplasias de Cabeça e Pescoço/terapia , Neoplasias de Cabeça e Pescoço/tratamento farmacológico , Neoplasias de Cabeça e Pescoço/patologia , Neoplasias de Cabeça e Pescoço/imunologia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Protocolos de Quimioterapia Combinada Antineoplásica/efeitos adversos , Terapia Neoadjuvante/métodos , Linfócitos do Interstício Tumoral/imunologia , Linfócitos do Interstício Tumoral/efeitos dos fármacos , Adulto , Microambiente Tumoral/imunologia , Microambiente Tumoral/efeitos dos fármacosRESUMO
Locally advanced laryngeal cancers treatment often involves total laryngectomy, which some patients are unwilling to undergo, even if this choice reduces their survival probability. Therefore, the objective of laryngeal oncologic surgery is not only to remove the tumor, but also to preserve the organ and its functions. To overcome these concerns, several partial laryngectomy techniques have been developed. This article describes the surgical technique and a case study of a 64-year-old male patient with locally advanced laryngeal squamous cell carcinoma who underwent vertical partial laryngectomy extending to the subglottis and hypopharynx using transoral robotic surgery (TORS) with a da Vinci Single Port surgical robot. The video and article provide a detailed description of the surgical technique, which resulted in successful tumor removal with excellent oncological and functional outcomes.
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Neoplasias de Cabeça e Pescoço , Neoplasias Laríngeas , Procedimentos Cirúrgicos Robóticos , Robótica , Masculino , Humanos , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Robóticos/métodos , Laringectomia/métodos , Hipofaringe/cirurgia , Hipofaringe/patologia , Neoplasias Laríngeas/cirurgia , Neoplasias Laríngeas/patologia , Neoplasias de Cabeça e Pescoço/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: The recently developed da Vinci single-port (SP) system offers potential advantages in maneuverability within narrower surgical spaces. This study aims to compare intra- and post-operative outcomes, technical advantages, and limitations of transoral resections using the da Vinci SP and da Vinci Xi systems for oropharyngeal squamous cell carcinoma (OPSCC). METHODS: A single-center retrospective cohort study included patients with OPSCC who underwent transoral robotic surgery (TORS) after neoadjuvant chemotherapy (NCT). Data on pre-operative variables, intraoperative data, postoperative complications, and functional outcomes were collected. RESULTS: A total of 209 patients (males: 175; mean age: 59.0 ± 9.3) were included (SP: n = 136; Xi: n = 73). A significantly lower docking time was measured for the SP group (5.7 ± 2.5 min vs. 10.0 ± 4.4 min; p <.001). Similarly, the console time was reduced for the SP group though not reaching statistical significance (76.3 ± 30.7 min vs. 88.1 ± 36.9 min; p =.06). A greater proportion of patients showed wide negative resection margins in the SP group (71 % vs. 56 %; p =.10), although not statistically significant. No significant differences were observed in complication rates or postoperative functional outcomes. DISCUSSION: This study demonstrates the safety and efficacy of the da Vinci SP system in oropharyngeal surgery, with potential advantages in terms of reduced docking and console times. The findings suggest that the SP system offers improved maneuverability and instrument placement compared to the da Vinci Xi system.
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Neoplasias de Cabeça e Pescoço , Procedimentos Cirúrgicos Robóticos , Masculino , Humanos , Pessoa de Meia-Idade , Idoso , Carcinoma de Células Escamosas de Cabeça e Pescoço , Estudos Retrospectivos , Complicações Pós-Operatórias , Resultado do TratamentoRESUMO
Flail chest is a severe injury to the chest wall and is related to adverse outcomes. A flail chest is classified as the physiologic, paradoxical motion of a chest wall or flail segment of rib fracture (RFX). We hypothesized that patients with paradoxical chest wall movement would present different clinical features from patients with a flail segment. This retrospective observational study included patients with blunt chest trauma who visited our level 1 trauma center between January 2019 and October 2022 and were diagnosed with one or more flail segments by computed tomography. The primary outcome of our study was a clinically diagnosed visible, paradoxical chest wall motion. We used the least absolute shrinkage and selection operator (LASSO) logistic regression model to minimize overfitting. After a feature selection using the LASSO regression model, we constructed a multivariable logistic regression (MLR) model and nomogram. A total of five risk factors were selected in the LASSO model and applied to the multivariable logistic regression model. Of these, four risk factors were statistically significant: the total number of RFX (adjusted OR [aOR], 1.28; 95% confidence interval [CI], 1.09-1.49; p = 0.002), number of segmental RFX including Grade III fractures (aOR, 1.78; 95% CI, 1.14-2.79; p = 0.012), laterally located primary fracture lines (aOR, 4.00; 95% CI, 1.69-9.43; p = 0.002), and anterior-lateral flail segments (aOR, 4.20; 95% CI, 1.60-10.99; p = 0.004). We constructed a nomogram to predict the personalized probability of the flail motion. A novel nomogram was developed in patients with flail segments of traumatic RFX to predict paradoxical chest wall motion. The number of RFX, Grade III segmental RFX, and the location of the RFX were significant risk factors.
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Tórax Fundido , Fraturas das Costelas , Traumatismos Torácicos , Parede Torácica , Ferimentos não Penetrantes , Humanos , Fraturas das Costelas/diagnóstico por imagem , Estudos Retrospectivos , Nomogramas , Fixação Interna de Fraturas/métodosRESUMO
PURPOSE: To analyze the oncological outcomes and patterns of recurrence of patients with locoregionally advanced oropharyngeal squamous cell carcinoma (OPSCC) who underwent neo-adjuvant chemotherapy (NCT) with subsequent transoral robotic surgery (TORS). METHODS: A single-center retrospective cohort study was performed, including 198 patients (mean age: 58.6, SD: 9.2). The primary outcome was disease-free survival (DFS). RESULTS: The median follow-up time was 26.5 months (IQR: 16.0-52.0). Estimated DFS rates (95 % CI) at 1 and 3 years were 86.6 % (81.9-91.7), and 81.4 % (75.7-87.6), respectively. Estimated DSS rates (95 % CI) at 1 and 3 years were 96.7 % (94.1-99.3), and 92.6 % (88.4-97.0), respectively. Estimated OS rates (95 % CI) at 1 and 3 years were 96.2 % (93.4-99.0), and 88.7 % (83.4-94.2), respectively. A total of 31 (15.6 %) patients showed a disease relapse after a median time of 8 months (IQR: 4.0-12.0), but only 12 (6 %) patients died of the disease during the study period. CONCLUSIONS: This study demonstrates that NCT and TORS can obtain excellent tumor control and survival in locoregionally advanced OPSCC. NCT might reduce the need for adjuvant treatments, and randomized clinical trials should be conducted to better define this aspect.
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Carcinoma de Células Escamosas , Neoplasias de Cabeça e Pescoço , Neoplasias Orofaríngeas , Procedimentos Cirúrgicos Robóticos , Humanos , Pessoa de Meia-Idade , Carcinoma de Células Escamosas/tratamento farmacológico , Carcinoma de Células Escamosas/cirurgia , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/métodos , Terapia Neoadjuvante , Recidiva Local de Neoplasia , Carcinoma de Células Escamosas de Cabeça e Pescoço , Neoplasias Orofaríngeas/tratamento farmacológico , Neoplasias Orofaríngeas/cirurgiaRESUMO
Acute kidney injury (AKI) is common in patients with trauma and is associated with poor outcomes. Therefore, early prediction of AKI in patients with trauma is important for risk stratification and the provision of optimal intensive care unit treatment. This study aimed to compare 2 models, machine learning (ML) techniques and logistic regression, in predicting AKI in patients with trauma. We retrospectively reviewed the charts of 400 patients who sustained torso injuries between January 2016 and June 2020. Patients were included if they were aged > 15 years, admitted to the intensive care unit, survived for > 48 hours, had thoracic and/or abdominal injuries, had no end-stage renal disease, and had no missing data. AKI was defined in accordance with the Kidney Disease Improving Global Outcomes definition and staging system. The patients were divided into 2 groups: AKI (n = 78) and non-AKI (n = 322). We divided the original dataset into a training (80%) and a test set (20%), and the logistic regression with stepwise selection and ML (decision tree with hyperparameter optimization using grid search and cross-validation) was used to build a model for predicting AKI. The models established using the training dataset were evaluated using a confusion matrix receiver operating characteristic curve with the test dataset. We included 400 patients with torso injury, of whom 78 (19.5%) progressed to AKI. Age, intestinal injury, cumulative fluid balance within 24 hours, and the use of vasopressors were independent risk factors for AKI in the logistic regression model. In the ML model, vasopressors were the most important feature, followed by cumulative fluid balance within 24 hours and packed red blood cell transfusion within 4 hours. The accuracy score showed no differences between the 2 groups; however, the recall and F1 score were significantly higher in the ML model (.94 vs 56 and.75 vs 64, respectively). The ML model performed better than the logistic regression model in predicting AKI in patients with trauma. ML techniques can aid in risk stratification and the provision of optimal care.
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Traumatismos Abdominais , Injúria Renal Aguda , Humanos , Modelos Logísticos , Estudos Retrospectivos , Injúria Renal Aguda/diagnóstico , Injúria Renal Aguda/etiologia , Aprendizado de MáquinaRESUMO
BACKGROUND: Transoral robotic surgery (TORS) has renovated the surgical management of oropharyngeal squamous cell carcinoma (OPSCC), allowing a minimally invasive surgical approach with optimal oncological outcomes. The recent introduction of the da Vinci Single Port (SP) system resulted in a considerable improvement of TORS technique. METHODS: In this video, we illustrate the transoral robotic lateral oropharyngectomy performed with the da Vinci SP system in a 50-year-old male patient suffering from a p16+ oropharyngeal squamous cell carcinoma cT4N1M0. RESULTS: The transoral robotic lateral oropharyngectomy is illustrated step by step. The structures encountered during the resection are described, and the surgical margins are defined based on anatomical landmarks. The most critical regions encountered during resection are pointed out, and the tip and tricks of this surgery are reported. CONCLUSIONS: A step-by-step transoral lateral oropharyngectomy is described to increase its reproducibility. The da Vinci SP system owns various benefits for performing transoral lateral oropharyngectomy due to the increased maneuverability in the narrower oral cavity working spaces.
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Neoplasias de Cabeça e Pescoço , Neoplasias Orofaríngeas , Procedimentos Cirúrgicos Robóticos , Masculino , Humanos , Pessoa de Meia-Idade , Carcinoma de Células Escamosas de Cabeça e Pescoço , Procedimentos Cirúrgicos Robóticos/métodos , Reprodutibilidade dos Testes , Boca/cirurgia , Boca/patologia , Neoplasias Orofaríngeas/cirurgia , Neoplasias Orofaríngeas/patologiaRESUMO
INTRODUCTION: Indications for elective treatment of the neck in patients with major salivary gland cancers are still debated. Our purpose was to develop a machine learning (ML) model able to generate a predictive algorithm to identify lymph node metastases (LNM) in patients with major salivary gland cancer (SGC). METHODS: A Retrospective study was performed with data obtained from the Surveillance, Epidemiology, and End Results (SEER) program. Patients diagnosed with a major SGC between 1988 and 2019 were included. Two 2-class supervised ML decision models (random forest, RF; extreme gradient boosting, XGB) were used to predict the presence of LNM, implementing thirteen demographics and clinical variables collected from the SEER database. A permutation feature importance (PFI) score was computed using the testing dataset to identify the most important variables used in model prediction. RESULTS: A total of 10 350 patients (males: 52%; mean age: 59.9 ± 17.2 years) were included in the study. The RF and the XGB prediction models showed an overall accuracy of 0.68. Both models showed a high specificity (RF: 0.90; XGB: 0.83) and low sensitivity (RF: 0.27; XGB: 0.38) in identifying LNM. According, a high negative predictive value (RF: 0.70; XGB: 0.72) and a low positive predictive value (RF: 0.58; XGB: 0.56) were measured. T classification and tumor size were the most important features in the construction of the prediction algorithms. CONCLUSIONS: Classification performance of the ML algorithms showed high specificity and negative predictive value that allow to preoperatively identify patients with a lower risk of LNM. LAY SUMMARY: Based on data from the Surveillance, Epidemiology, and End Results (SEER) program, our study showed that machine learning algorithms owns a high specificity and negative predictive value, allowing to preoperatively identify patients with a lower risk of lymph node metastasis.
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Aprendizado de Máquina , Neoplasias das Glândulas Salivares , Masculino , Humanos , Adulto , Pessoa de Meia-Idade , Idoso , Metástase Linfática , Estudos Retrospectivos , AlgoritmosRESUMO
BACKGROUND: The squamous cell carcinoma (SCC) of the posterior pharyngeal wall (PPW) is associated with poor oncological outcomes based on current literature data. We reported the preliminary outcomes of a potential new treatment protocol based on neoadjuvant chemotherapy (NCT) and transoral robotic surgery (TORS). METHODS: A retrospective single-center case series was performed including a total of 20 patients diagnosed with a SCC of the PPW between October 2010 and September 2021. All patients successfully completed TORS with neck dissection after NCT. Adjuvant treatment was performed in the presence of adverse pathologic features. Loco-regional control (LRC), overall survival (OS), and disease-specific survival (DSS) were defined as the time from surgery to tumor recurrence or death, as appropriate. Survival estimates were calculated by Kaplan-Meier analysis. Surgical data and post-operative functional outcomes were also reported. RESULTS: Estimated 3-year LRC, OS, and DSS rates (95% Confidence interval) were 59.7% (39.7-89.6), 58.6% (38.7-88.8), and 69.4% (49.9-96.6). The median hospital stay was 21 days (IQR 17.0-23.5). Oral diet and decannulation were achieved after a median of 14 days (IQR 12.0-15.0). Feeding tube and tracheostomy dependence after 6 months was observed in 3 (15%) and 2 (10%) patients, respectively. CONCLUSIONS: The use of NCT followed by TORS for PPW SCC treatment appears to have good oncological and functional outcomes for both early and locally advanced cancers. Further randomized trials and site-specific guidelines are needed.
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Carcinoma de Células Escamosas , Neoplasias de Cabeça e Pescoço , Neoplasias Orofaríngeas , Neoplasias Faríngeas , Procedimentos Cirúrgicos Robóticos , Humanos , Estudos Retrospectivos , Terapia Neoadjuvante , Procedimentos Cirúrgicos Robóticos/métodos , Recidiva Local de Neoplasia/etiologia , Neoplasias Faríngeas/cirurgia , Carcinoma de Células Escamosas/tratamento farmacológico , Carcinoma de Células Escamosas/cirurgia , Neoplasias de Cabeça e Pescoço/etiologia , Neoplasias Orofaríngeas/patologia , Resultado do TratamentoRESUMO
BACKGROUND: We analyzed the difference in treatment results according to safety margin range and studied the role of adjuvant therapy in patients with human papillomavirus-positive (HPV+) oropharyngeal squamous cell carcinoma (OPSCC). MATERIALS AND METHODS: A total of 279 patients with HPV+ OPSCC were included in this study. RESULTS: Surgical margin and T classification were significant prognostic factors related to death. The difference in locoregional recurrence was analyzed by dividing the safety margin into groups of <1, 1-5, and >5 mm. There was no significant difference in local-regional recurrence for T1-T2 lesions between the three groups. Adjuvant therapy can significantly reduce disease recurrence in HPV+ OPSCC patients with risk factors. CONCLUSIONS: In T1-T2 lesions without other risk factors, even with a safety margin ≥1 mm, adjuvant therapy can potentially be omitted. Adjuvant therapy can significantly reduce disease recurrence in HPV+ OPSCC patients with risk factors.
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Carcinoma de Células Escamosas , Neoplasias de Cabeça e Pescoço , Neoplasias Orofaríngeas , Infecções por Papillomavirus , Humanos , Papillomavirus Humano , Carcinoma de Células Escamosas/patologia , Infecções por Papillomavirus/complicações , Infecções por Papillomavirus/patologia , Margens de Excisão , Recidiva Local de Neoplasia/cirurgia , Neoplasias Orofaríngeas/cirurgia , Neoplasias Orofaríngeas/patologia , Carcinoma de Células Escamosas de Cabeça e Pescoço , Prognóstico , Papillomaviridae , Estudos RetrospectivosRESUMO
The direct consequences of chest trauma may cause adverse outcomes. Therefore, the early detection of high-risk patients and appropriate interventions can improve patient outcomes. This study aimed to investigate the risk factor for overall pulmonary complications in patients with blunt traumatic rib fractures. Prospectively recorded data of patients with blunt chest trauma in a level 1 trauma center between January 2019 and October 2022 were retrospectively analyzed. The primary outcomes were one or more pulmonary complications. To minimize the overfitting of the prediction model, we used the least absolute shrinkage and selection operator (LASSO) logistic regression. We input selected features using LASSO regression into the multivariable logistic regression model (MLR). We also constructed a nomogram to calculate approximate individual probability. Altogether, 542 patients were included. The LASSO regression model identified age, injury severity score (ISS), and flail motion of the chest wall as significant risk factors. In the MLR analysis, age (adjusted OR [aOR] 1.06; 95% confidence interval [CI] 1.03-1.08; p < 0.001), ISS (aOR 1.10; 95% CI 1.05-1.16; p < 0.001), and flail motion (aOR 8.82; 95% CI 4.13-18.83; p < 0.001) were significant. An MLR-based nomogram predicted the individual risk, and the area under the receiver operating characteristic curve was 0.826. We suggest a novel nomogram with good performance for predicting adverse pulmonary outcomes. The flail motion of the chest wall may be the most significant risk factor for pulmonary complications.
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Fraturas das Costelas , Traumatismos Torácicos , Ferimentos não Penetrantes , Humanos , Fraturas das Costelas/complicações , Traumatismos Torácicos/complicações , Estudos Retrospectivos , Nomogramas , Ferimentos não Penetrantes/complicaçõesRESUMO
OBJECTIVE: Da Vinci single port (SP) has been recently approved for transoral robotic surgery (TORS). Its characteristics make it particularly feasible for laryngeal and hypopharyngeal surgery. We report our experience comparing intra- and postoperative outcomes, technical advantages, and shortcomings of transoral laryngeal and hypopharyngeal resections performed with the da Vinci SP and the da Vinci Si/Xi systems. STUDY DESIGN: Retrospective database review. SETTING: Single academic tertiary care hospital. METHODS: Subjects included adult patients with laryngeal and hypopharyngeal carcinoma who underwent TORS between 2008 and 2022. The SP and multiport (MP) systems were compared in terms of intraoperative times, short-term postoperative outcomes, and TORS-related complications after a propensity score matching. RESULTS: A total of 185 patients were enrolled (56 SP vs 129 MP patients), and a cohort of 112 patients was analyzed after matching. The docking time was reduced in the SP group (8.84 ± 4.67 vs 6.45 ± 3.11 minutes; p = .003), as well as console time (53.91 ± 29.38 vs 42.70 ± 13.72 minutes; p = .035). Positive margins were more frequent in the MP group (52% vs 43%; p = .34). The mean decannulation time was 1.86 days longer in the SP group (p = .046). No significant differences emerged from the analysis of the duration of hospitalization, enteral feeding, and TORS-related complications. CONCLUSION: SP safety profile is comparable to that of previous models, while it showed advantages in terms of reduced docking times. Console times were also shortened due to improved maneuverability and field visualization.
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Carcinoma , Neoplasias Laríngeas , Procedimentos Cirúrgicos Robóticos , Adulto , Humanos , Estudos Retrospectivos , Neoplasias Laríngeas/cirurgia , Hipofaringe/cirurgiaRESUMO
OBJECTIVES: To analyze the oncological and functional outcomes of patients with stage III-IV laryngo-hypopharyngeal cancer who underwent neoadjuvant chemotherapy (NAC) with subsequent transoral robotic surgery (TORS). MATERIALS AND METHODS: A single-center retrospective cohort study included a total of 100 patients (median age of 67.0) affected by stage III-IV supraglottic or hypopharyngeal cancer. All patients underwent NAC followed by TORS and risk-adjusted adjuvant therapy. The primary outcome was recurrence-free survival (RFS). RESULTS: The median follow-up time was 24.0 months. Estimated 2-year (95% CI) OS, DSS, and RFS were 75% (66% - 85%), 84% (76% - 92%), and 65% (56% - 76%), respectively. Among the 11 patients who relapsed on the primary site, 3 underwent salvage total laryngectomy, 3 underwent salvage CRT, and the others receive palliation or supportive care. At 6 months from surgery, 17 patients were still tracheostomized or had a stoma retainer, while 15 were gastrostomy dependent. At the Cox multivariable analysis, the clinical stage at presentation, the number of NAC cycles, and the presence of LVI were found to be independently correlated with the RFS. CONCLUSION: This study demonstrates that NAC followed by TORS can obtain good tumor control, survival, and organ preservation rates in stage III-IV laryngo-hypopharyngeal cancer.
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Carcinoma de Células Escamosas , Neoplasias Hipofaríngeas , Neoplasias Laríngeas , Procedimentos Cirúrgicos Robóticos , Humanos , Neoplasias Hipofaríngeas/cirurgia , Carcinoma de Células Escamosas/cirurgia , Carcinoma de Células Escamosas/patologia , Neoplasias Laríngeas/cirurgia , Terapia Neoadjuvante , Estudos Retrospectivos , Laringectomia , Resultado do TratamentoRESUMO
PURPOSE: To define if positive and close surgical margins are associated to worse prognosis in patients who underwent transoral robotic surgery (TORS) after neoadjuvant chemotherapy (NCT). METHODS: A retrospective cohort study was carried out at a tertiary referral center. The primary outcome was local-regional control (LRC), and the results were summarized with hazard ratios (HR) and 95% confidence intervals (CIs). RESULTS: A total of 308 patients (median age: 62.0, IQR: 55.0-68.2) were included. Univariable analysis showed a significant reduced LRC for patients with positive margins (HR = 1.82, 95% CI: 1.02-3.24). However, they were not associated with worse LRC after adjusting for adverse tumor variables (HR = 0.81, 95% CI: 0.40-1.65). ROC analysis was performed on 123 patients with negative margins (AUC: 0.54) measuring an optimal threshold of 1.25 mm (sensitivity = 60.0%; specificity = 50.5%). Univariable analysis showed non-significant differences between close and wide negative margins (HR = 1.44, 95% CI: 0.59-3.54). CONCLUSIONS: A positive surgical margin is not an independent predictor of tumor control and survival. A threshold of 1.25 mm was identified as the most appropriate to define close margins, but no difference was measured after distinguishing negative margins in close and wide margins.
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Carcinoma de Células Escamosas , Neoplasias Orofaríngeas , Procedimentos Cirúrgicos Robóticos , Humanos , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Robóticos/métodos , Prognóstico , Terapia Neoadjuvante , Margens de Excisão , Estudos Retrospectivos , Carcinoma de Células Escamosas/patologia , Neoplasias Orofaríngeas/patologiaRESUMO
Lymph node (LN) metastasis is an important factor in determining the treatment and prognosis of oropharyngeal squamous cell carcinoma (OPSCC). Here, we compared the somatic mutational profiles and clonal evolution of primary and metastatic LNs using multiregion sequencing of human papilloma virus (HPV)-positive OPSCC and HPV-negative OPSCC. We performed high-depth whole-exome sequencing (200×) of 76 samples from 18 patients with OPSCC (10 HPV-positive and 8 HPV-negative), including 18 primary tumor samples, 40 metastatic LN samples, and 18 normal tissue samples. Among 40 metastatic LNs, 22 showed extranodal extension (ENE). Mutation profiles of HPV-positive OPSCC and HPV-negative OPSCC were similar to those reported previously. Somatic mutations in CDKN2A and TP53 were frequently detected in HPV-negative OPSCC. Somatic mutations in HPV-positive OPSCC samples showed APOBEC-related signatures. Somatic mutations from metastatic LNs showed a different pattern than the primary tumor. Somatic mutations acquired in the WNT pathway during metastasis showed a significant relationship with ENE. Clonal evolution analysis of primary and metastatic LNs showed that, in some cases, each metastatic LN originated from a different primary tumor sub-clone.
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Carcinoma de Células Escamosas , Neoplasias de Cabeça e Pescoço , Neoplasias Orofaríngeas , Infecções por Papillomavirus , Humanos , Neoplasias Orofaríngeas/genética , Neoplasias Orofaríngeas/patologia , Metástase Linfática , Sequenciamento do Exoma , Infecções por Papillomavirus/complicações , Infecções por Papillomavirus/genética , Infecções por Papillomavirus/patologia , Carcinoma de Células Escamosas/genética , Carcinoma de Células Escamosas/patologia , Carcinoma de Células Escamosas de Cabeça e Pescoço , Mutação/genéticaRESUMO
BACKGROUND: No consensus exists regarding the most effective reconstruction after total laryngectomy with partial pharyngectomy (TLwPP). This study aims to compare different reconstructive techniques (pectoralis major myo-cutaneous flap, PMMCF; anterolateral thigh flap, ALTF; radial forearm free flap, RFFF) after TLwPP in terms of pharyngocutaneous fistula (PCF), stenosis and feeding tube dependence (FTD) incidence. METHODS: The Scopus, PubMed/MEDLINE, Cochrane Library, and Google Scholar databases were searched. A single-arm meta-analysis was performed for PCF incidence, stenosis incidence, and FTD incidence on the entire cohort. An arm-based network analysis was conducted to compare three different surgical interventions (PMMCF, ALTF, RFFF). RESULTS: A total of 13 studies and 232 patients were included in the network meta-analysis. The lowest PCF absolute risk was measured for the RFFF (11.7%, 95% CI: 2.8%-33.4%), compared to the ALTF (13.4%, 95% CI: 4.5%-32.1%) and the PMMC (49.0%, 95% CI: 19.2%-79.3%). The RFFF showed a stenosis absolute risk of 0.0% (95% CI: 0.0%-1.1%), while a higher stenosis incidence was measured for the ALTF (5.7%, 95% CI: 0.8%-25.2%) and the PMMCF (11.6%, 95% CI: 0.8%-55.1%). The RFFF showed the lowest absolute risk of FTD incidence (6.8%, 95% CI: 0.5%-28.1%) compared to the other reconstructive techniques (PMMCF: 12.4%, 95% CI: 2.4%-42.1%; ALTF: 17.5%, 95% CI: 6.4%-38.9%). CONCLUSIONS: The RFFF seems the best choice for reconstruction of partial pharyngeal defects after TLwPP due to the lower incidence of PCF, stenosis and FTD compared to the ALTF and the PMMCF.
Assuntos
Fístula Cutânea , Retalhos de Tecido Biológico , Demência Frontotemporal , Doenças Faríngeas , Humanos , Faringectomia/efeitos adversos , Laringectomia/efeitos adversos , Coxa da Perna/cirurgia , Metanálise em Rede , Constrição Patológica/cirurgia , Músculos Peitorais , Demência Frontotemporal/complicações , Demência Frontotemporal/cirurgia , Estudos Retrospectivos , Fístula Cutânea/cirurgia , Doenças Faríngeas/etiologiaRESUMO
PURPOSE: To develop machine learning (ML) models for predicting positive margins in patients undergoing transoral robotic surgery (TORS). METHODS: Data from 453 patients with laryngeal, hypopharyngeal, and oropharyngeal squamous cell carcinoma were retrospectively collected at a tertiary referral center to train (n = 316) and validate (n = 137) six two-class supervised ML models employing 14 variables available pre-operatively. RESULTS: The accuracy of the six ML models ranged between 0.67 and 0.75, while the measured AUC between 0.68 and 0.75. The ML algorithms showed high specificity (range: 0.75-0.89) and low sensitivity (range: 0.26-0.64) in detecting patients with positive margins after TORS. NPV was higher (range: 0.73-0.83) compared to PPV (range: 0.45-0.63). T classification and tumor site were the most important predictors of positive surgical margins. CONCLUSIONS: ML algorithms can identify patients with low risk of positive margins and therefore amenable to TORS.
Assuntos
Carcinoma de Células Escamosas , Neoplasias de Cabeça e Pescoço , Neoplasias Orofaríngeas , Procedimentos Cirúrgicos Robóticos , Humanos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Carcinoma de Células Escamosas/patologia , Margens de Excisão , Estudos Retrospectivos , Resultado do Tratamento , Aprendizado de Máquina , Neoplasias de Cabeça e Pescoço/cirurgia , Neoplasias de Cabeça e Pescoço/etiologia , Neoplasias Orofaríngeas/cirurgia , Neoplasias Orofaríngeas/etiologiaRESUMO
PURPOSE: Although postoperative radiotherapy (PORT) is demonstrably effective in local control of head and neck adenoid cystic carcinoma (HNACC), its application is controversial and the subset of patients who would benefit most from PORT is unknown. Herein, we analyzed the data of HNACC patients to clarify the role of PORT. METHODS: We retrospectively reviewed 187 patients with nonmetastatic HNACC who underwent surgical resection between 2005 and 2019. The study endpoints were locoregional failure-free survival (LRFFS), progression-free survival (PFS), and overall survival (OS). Subgroup analysis and recursive partitioning analysis (RPA) were performed to identify patients most likely to benefit from PORT. RESULTS: With a median follow-up of 84.7 months, the 5-year LRFFS, PFS, and OS were 70.0%, 52.6%, and 86.4%, respectively. Survival was significantly shorter in patients who experienced local failure than in those who did not (5-year OS: 88.1% vs. 80.5%, P = 0.001). The local failure rate was significantly lower in patients who underwent PORT (16.9% vs. 31.0%, P = 0.021), despite the high frequency of adverse factors. Especially, significant decreases in local failure and similar OS rates could be obtained after PORT among patients with positive margins, T2-4 stage disease, and minor salivary gland tumors. The RPA model for PFS categorized patients into four groups according to three prognostic factors (T-stage, location, and sex). The RPA model for LRFFS and OS suggested three groups based on two factors (T-stage, margin for LRFFS; T-stage, grade 3 for OS). CONCLUSION: PORT could prevent dismal survival, while significantly reducing local failures in high-risk HNACC patients.