Oncological outcomes post transoral robotic surgery (TORS) for HPV-associated oropharyngeal squamous cell carcinoma, a single-centre retrospective Australian study.

We present a cohort review of TORS resection for HPV-associated oropharyngeal squamous cell carcinoma (OPSCC) and its associated oncological outcomes spanning a 10-year period. A retrospective case series review was performed of patients undergoing primary surgical treatment for HPV-associated OPSCC through the St. Vincent's Head and Neck Cancer service from 2011 to 2022. The primary outcomes were to investigate complete resection of the primary tumour, rates of recurrence, and survival analysis. Secondary outcomes included complications, rates of adjuvant therapy, sites of recurrence and rates of percutaneous endoscopic gastrostomy (PEG). 184 patients underwent TORS-based therapy with neck dissection, and guideline-directed adjuvant therapy for HPV-associated OPSCC. Our median follow-up was 46 months. The positive margin rate on final histopathology analysis was 10.9%. Adjuvant therapy was indicated in 85 patients (46%). The local recurrence rate was 10.9% with the majority (80%) of patients recurring in the first 3 years since treatment. The disease-specific survival at 3 years was 98.6% and at 5 years was 94.4%. The 3-year and 5-year OS for the cohort was 96.7% and 92.5%, respectively. The presence of extranodal extension and positive margins were associated with increased risk of recurrence, whereas adjuvant therapy was found to be a protective factor for both overall recurrence and survival. Major complications occurred in 12 patients (6.5%), resulting in one death. This study has demonstrated that primary surgical therapy for HPV-associated OPSCC is a safe and effective treatment modality with low local recurrence and complication rates, and overall survival benefits.

Transoral Robotic Surgery for Recurrent Tumors of the Upper Aerodigestive Tract (RECUT): An International Cohort Study.

BACKGROUND: Transoral robotic surgery (TORS) is an emerging minimally invasive surgical treatment for residual, recurrent, and new primary head and neck cancers in previously irradiated fields, with limited evidence for its oncological effectiveness. METHODS: A retrospective observational cohort study of consecutive cases performed in 16 high-volume international centers before August 2018 was conducted (registered at clinicaltrials.gov [NCT04673929] as the RECUT study). Overall survival (OS), disease-free survival, disease-specific survivals (DSS), and local control (LC) were calculated using Kaplan-Meier estimates, with subgroups compared using log-rank tests and Cox proportional hazards modeling for multivariable analysis. Maximally selected rank statistics determined the cut point for closest surgical resection margin based on LC. RESULTS: Data for 278 eligible patients were analyzed, with median follow-up of 38.5 months. Two-year and 5-year outcomes were 69.0% and 62.2% for LC, 71.8% and 49.8% for OS, 47.2% and 35.7% for disease-free survival, and 78.7% and 59.1% for disease-specific survivals. The most discriminating margin cut point was 1.0 mm; the 2-year LC was 80.9% above and 54.2% below or equal to 1.0 mm. Increasing age, current smoking, primary tumor classification, and narrow surgical margins (≤1.0 mm) were statistically significantly associated with lower OS. Hemorrhage with return to theater was seen in 8.1% (n = 22 of 272), and 30-day mortality was 1.8% (n = 5 of 272). At 1 year, 10.8% (n = 21 of 195) used tracheostomies, 33.8% (n = 66 of 195) used gastrostomies, and 66.3% (n = 53 of 80) had maintained or improved normalcy of diet scores. CONCLUSIONS: Data from international centers show TORS to treat head and neck cancers in previously irradiated fields yields favorable outcomes for LC and survival. Where feasible, TORS should be considered the preferred surgical treatment in the salvage setting.

Altered presentation of oropharyngeal cancer, a 6-year review.

BACKGROUND: Human papilloma virus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) continues to increase in incidence. Patients are younger, non-smokers and most commonly present with a neck mass often with no other symptoms. This altered presentation compared with non-HPV OPSCC may not be recognized by medical practitioners, leading to delayed diagnosis. METHODS: Patients with histopathological confirmation of OPSCC and known HPV and/or P16 status who presented to our institution between 2012-2017 inclusive were included in the study. Demographic data, tumour characteristics and presenting symptoms were retrospectivxely obtained from both electronic- and paper-based records. Descriptive statistics were used to report demographic data and the two sample t-test and Fisher's exact test were used to compare groups based on HPV status. Time to diagnosis was also reported. RESULTS: A total of 184 patients were included in the study. The majority of patients were male (85.4%) and HPV + (85.3%). The tonsillar complex (53.8%) and tongue base (42.4%) were the most common primary sites. HPV+ patients were less likely to smoke (17.8%) and they commonly presented with a neck mass (39.5% alone or with other symptoms 61.2%). Time to diagnosis in the HPV+ group was longer (15 weeks). CONCLUSION: Our review has highlighted the altered presentation of OPSCC due to the increased incidence of HPV infection. We showed a delayed time to diagnosis in HPV+ OPSCC compared with non-HPV disease. This confirms the importance of focusing our efforts on educating medical practitioners and creating further awareness to facilitate early detection and treatment.

Transoral robotic parapharyngeal approach to the submandibular space.

The aim of the study was to demonstrate a novel transoral parapharyngeal approach to the submandibular space. The method used was the clinical case of a patient presenting with an anteriorly based tumor in the left submandibular space. The video shows the transoral robotic technique for access to the submandibular space through the parapharyngeal space for removal of the tumor. This approach allows for high definition visibility and complete access to structures in the submandibular space including the submandibular gland. For robotic head and neck surgeons performing lateral oropharyngectomies, the anatomy is familiar, and the technique avoids potential access issues with traditional floor of mouth incisions. Furthermore, it provides a novel technique for identification of the hypoglossal nerve for potential preservation in oropharyngeal malignancy. The transoral robotic parapharyngeal approach to the submandibular space is safe, reproducible, and avoids unnecessary cervical incisions.

Frontal Sinus Osteoma: From Direct Excision to Endoscopic Removal.

Frontal sinus osteomas are benign bone-forming neoplasms. Ongoing advancements in endoscopic surgery have allowed less invasive surgical approaches to be adopted for removal. The authors systematically reviewed the literature to provide analysis and recommendations for management.One hundred ninety-three publications encompassing 1399 patients met inclusion, with mean age 42.1 ±â€Š13.8 years and a male predominance (59.2%). Symptoms included pain (70.8%); orbital/ocular (20.7%); sinonasal (36.4%); neurologic (6.0%); other (14.5%); and asymptomatic (4.8%). Osteoma was isolated to the frontal sinus (82.9%) or extended into the ethmoid (16.6%), maxillary (0.3%), and sphenoid sinuses (0.2%). There was intracranial extension in 9.5% and intraorbital extension in 18.7%. Of those proceeding to surgery, majority (59.8%) underwent open approaches, followed by endoscopic (25.0%) and combined (11.5%). A significant (P < 0.01) increase in proportion of cases utilizing endoscopic approaches versus open/combined was observed over the period studied. Seventy-one postoperative complications were reported, in 7.5% of endoscopic cases, 27% of open, and 8.8% of combined. Complications were more likely in open/combined surgery, compared with endoscopic (22.3% versus 7.5%, P < 0.001). In 181 patients, completeness of resection was reported (complete resection; 87.8%) and found to be a significant predictor (P < 0.01) for disease recurrence/progression. Mean length of stay for the endoscopic group was 3.1 ±â€Š1.3 days, compared with 7.9 ±â€Š3.1 for open/combined (P < 0.0001).In the management of frontal sinus osteoma, indications for selecting endoscopic versus open approaches have expanded over the past 30 years, as techniques, equipment, and understanding of pathophysiology have evolved. Where endoscopic approaches are possible, they are associated with reduced morbidity and length of stay compared with open approaches.

Bilateral stage I chronic maxillary atelectasis: A case report.

INTRODUCTION: Chronic maxillary atelectasis (CMA) is a rare acquired condition of persistent and progressive reduction in maxillary sinus volume and antral wall collapse secondary to ostiomeatal obstruction and development of negative intra-sinus pressure gradients. CASE PRESENTATION: A 32-year old male was referred with a 6 week history of persistent and worsening sinonasal symptoms, following a significant upper respiratory tract infection. Imaging confirmed bilateral stage I CMA and successful treatment entailed bilateral endoscopic uncinectomy and maxillary antrostomy. DISCUSSION: Review of the literature has demonstrated CMA to describe an all-encompassing disease process of ostiomeatal obstruction and atelectatic maxillary sinus remodelling that overcomes early variations in taxonomy ('silent sinus syndrome', 'imploding antrum syndrome', 'acquired maxillary sinus hypoplasia') and inconsistencies in reporting. Unilateral CMA is well documented, however a systematic search of the literature reveals only six bilateral cases. To the best of our knowledge, this is the first individual report of bilateral stage I CMA in which the inciting event is established and a uniquely rapid progress of disease followed. CONCLUSION: The present literature regarding CMA is incomplete and further investigation is required to provide greater insight into its aetiology and pathogenesis. Minimally invasive endoscopic approaches can be employed to re-establish aeration to the affected maxillary sinus for symptomatic relief, to halt disease progression and facilitate antral remodelling and sinus re-expansion.

Risk factors and management approach for deep sternal wound infection after cardiac surgery at a tertiary medical centre.

BACKGROUND: Deep sternal wound infection (DSWI) is a rare but severe complication following cardiac surgery. Our study investigated the risk factors and treatment options for patients who developed DSWI at our institution between May 1988 and April 2008. METHOD: Data was collected prospectively in a database and information on demographics reviewed retrospectively on 5649 patients who underwent cardiac surgery during this period. RESULTS: The incidence of DSWI was 34/5649 (0.6%). These patients were older (mean age 66.1 vs. 64.5), more likely to die (in hospital mortality 11.8% vs. non DSWI group 1.8%) and had longer hospital stays (DSWI group mean stay 25 days vs. non DSWI group 9 days). Using Fisher's exact test the risk predictors for DSWI determined at our institution included diabetes managed with oral medications (p=0.021), previous cardiac surgery (p=0.038), BMI≥30 (p=0.041), LVEF≤30 (p=0.010), IABP usage (p=0.028) and homologous blood usage (p<0.001). Most commonly bilateral pectoralis major muscle flap (BPMMF) was used for treatment of DSWI (11/30, 36.7%). CONCLUSION: Ultimately our data was comparable to published data in the literature on known risk predictors.