Airway management during transoral robotic surgery for head and neck cancers: a French GETTEC group survey.

PURPOSE: The aim of the survey was to define the indications for preventive tracheostomy in transoral robotic surgery (TORS) for head and neck cancers. METHODS: From October 2019 to January 2020, an online questionnaire was e-mailed to French surgical ENT teams with considerable experience of the TORS procedure (Gettec group). A descriptive analysis of the answers was performed. RESULTS: Eighteen French surgical teams answered the questionnaire. For 77.8% of the surgical teams, a past history of radiotherapy with residual edema was an indication for prophylactic tracheostomy, and for 88.9%, > 75 mg of antiplatelet medication or anticoagulation treatment was an indication. CONCLUSION: Early preventive tracheostomy during TORS can protect airway from uncommon but potentially life-threatening complications, such as transoral hemorrhage or airway edema. We recommend it in high-risk situations, such as a past history of radiotherapy or antiplatelet therapy associated with large resections. Further studies are needed to establish evidence-based recommendations.

Influence of postoperative radiotherapy target volumes in unilateral head and neck carcinoma of unknown primary: A multicentric study using propensity score.

OBJECTIVE: To compare the impact of two radiation modalities on loco-regional control, survival and tumour emergence, after node dissection for an unilateral head and neck carcinoma of unknown primary (HNCUP). MATERIALS AND METHODS: This is a multicentric retrospective study of 138 patients with unilateral HNCUP treated between 2002 and 2017. The absence of primary tumour was assessed by a systematic panendoscopy and positron emission tomography. Neck dissection was initially performed for all patients. Radiation Therapy was delivered on ipsilateral lymph node areas in 62 cases (44%: UL-RT group) and on bilateral lymph node areas and the entire pharyngeal mucosa in 77 cases (56%: COMP-RT group). Impact of radiation modalities on locoregional control and overall survival was assessed using propensity score matching method in order to balance baseline characteristics between the two groups. RESULTS: The population included 80.4% men, 80.4% smokers, 32.6% P16 positive tumours and 71.0% extracapsular extension. After a median follow-up of 5 years, the locoregional control rate was 80.3% in the UL-RT group and 75.3% in the COMP-RT group (p = 0.688). The corresponding rate of contralateral lymph node recurrence was 0% versus 2.6% (p = 0.503) and the rate of tumour emergence was 11.5% versus 9.1% (p = 0.778). No significant difference was observed between the UL-RT and the COMP-RT groups for overall survival (p = 0.9516), specific survival (p = 0.4837) or tumour emergence (p = 0.9034). CONCLUSION: UL-RT seems to provide similar outcomes as COMP-RT in unilateral HNCUP post-operative management.

Management of unilateral head and neck carcinoma of unknown primary: Retrospective analysis of the impact of postoperative radiotherapy target volumes.

BACKGROUND: We compared the outcome of postoperative unilateral cervical nodes radiotherapy (UL-RT) vs bilateral cervical nodes plus total mucosal irradiation (COMP-RT) in the management of head and neck carcinoma of unknown primary (HNCUP). METHODS: HNCUP, defined by the absence of primary despite a PET-CT combined with a panendoscopy, were treated with curative intent by initial ipsilateral neck dissection. Sixty-nine patients with unilateral HNCUP were included: 23 received UL-RT while 46 received COMP-RT. Carcinologic outcomes and long-term quality of life (QOL) according to the QOL Questionnaire for Head and Neck 35 were assessed. RESULTS: Within 6.3 years of median follow-up, there was no significant difference in primary tumor emergence rate (P = .68), cervical node recurrence rate (P = .34), or overall survival (P = .33) between UL-RT and COMP-RT groups. A trend toward QOL improvement was observed in the UL-RT group. CONCLUSION: UL-RT seems to provide similar outcomes as COMP-RT in unilateral HNCUP management.

Oncological and functional outcomes of trans-oral robotic surgery for pyriform sinus carcinoma: A French GETTEC group study.

BACKGROUND: Pyriform sinus carcinomas (SCC) present specific functional and oncological issues. The recent advent of trans-oral robotic surgery (TORS), as a conservative procedure, has opened up new perspectives. OBJECTIVES: To present the oncological and functional outcomes of TORS for pyriform sinus SCC. MATERIALS AND METHODS: We included, retrospectively, all TORS procedures for pyriform sinus SCC performed between 2009 and 2017 in eight French tertiary referral centers. We excluded lesions involving the pyriform sinus that had developed from the oropharynx, larynx, or other anatomic sub-sites of the hypopharynx. RESULTS: We included 57 TORS procedures. Median hospital stay was 10 days. A preventive tracheotomy was performed in seven cases (12%), and all were successfully decannulated. Oral re-feeding was possible for 93%, after a median of 5 days. The main surgical complications were hemorrhages (three cases), all successfully handled, although 2 patients with heavy comorbidities died from blood loss in the days after. Adjuvant therapy was proposed in 31 cases (54%), including two cases of salvage surgery (total pharyngolaryngectomy). After a median follow-up of 23 months, overall and disease-free survival were, respectively, 84% and 74% at 24 months, and 66% and 50% at 48 months. At the end of follow-up, organ preservation rate was 96%. None of the surviving patients needed a tracheotomy and oral diet was possible for 96%. CONCLUSION: The functional and oncological outcomes of TORS for pyriform sinus cancer are encouraging, and this procedure can be considered safe for selected early or moderately advanced cases as a conservative treatment.

Revisiting vascular contraindications for transoral robotic surgery for oropharyngeal cancer.

OBJECTIVE: We analyzed the outcomes for patients with a retropharyngeal internal carotid artery (ICA) who underwent a transoral robotic surgery (TORS) procedure involving a cervical-transoral robotic oropharyngectomy course with free flap reconstruction. METHODS: Patients were included in the prospective multicentric trial NCT02517125. These patients were scheduled to undergo surgery for an oropharyngeal localization. By pre-operative CT scan and MRI it was determined that they had a retropharyngeal internal carotid artery. RESULTS: Three patients had a retropharyngeal ICA: a patient with a 35 mm synovial sarcoma of the tonsillar fossa, a patient with a T2N2b squamous-cell carcinoma (SCC) of the glossotonsillar sulcus, and a patient with a T3N0 SCC of the tonsillar fossa in a previously irradiated field. These patients encountered neither preoperative nor postoperative complications. CONCLUSIONS: In our experience, TORS for oropharyngeal cancers appears to be feasible in patients with a retropharyngeal ICA, provided that the procedure has been adapted for complex situations. LEVEL OF EVIDENCE: 4.

Head and neck soft tissue sarcomas of adult: prognostic value of surgery in multimodal therapeutic approach.

Adult head and neck soft tissue sarcomas (AHNSTS) are rare, and data concerning treatment results are spare. To assess clinico-pathological characteristics, management prognostic factors, and survival of AHNSTS, we reviewed our experience of 28 recent successive new cases. Data were collected from a retrospective database (1997-2002). Aggressive fibromatosis, dermatofibrosarcoma, Kaposi sarcoma, chondrosarcoma and osteogenic sarcoma were excluded. Univariate analysis for prognostic factors was performed with chi2 test with Yates correction. The median age was 45.7 years (range: 18-86). The male/female ratio was 15/13. The most common subtypes was rhabdomyosarcoma (seven cases). Twenty-two patients presented with previous inadequate resection performed elsewhere before admission. The most common location was neck muscles (11 cases). Nineteen patients had surgery (complete resection in 13 cases). Associated treatments were neoadjuvant chemotherapy, adjuvant chemotherapy and postoperative radiotherapy in respectively, 4, 3 and 10 cases. The 2-year overall survival was 56%. Rhabdomyosarcomas (p = 0.005) and inadequate resection (p = 0.04) were associated with poor outcome. Large resection of AHNSTS in a multimodality approach may afford the best chance of disease control.

Functional and sensitive outcomes after tongue reconstruction: about a series of 30 patients.

Few studies reported both functional and sensitive long-term evaluations after tongue reconstruction. The aim of this study was to assess functional outcomes and sensitive recovery after tongue reconstruction with fasciocutaneous free flap (FCFF) or musculocutaneous pedicled flap (MCPF) without nerve anastomosis. We enrolled 30 patients having no recurrence from a consecutive series of 79 tongue reconstructions as part of a cancer treatment. All patients were submitted to functional and sensitive tests. The functional study included intelligibility, tongue motility, food, and swallowing scores. Flap sensibility was evaluated too. Male-to-female sex ratio was 6.5 with a mean age of 52 years old. The lesions were mainly advanced (T3-T4 73%). Mobile tongue and base of tongue resection was carried out in 43% of cases, and resection was limited to the oral tongue for 53%. Twenty-one FCFF and nine MCPF were performed. The mean follow-up was 2 years and 11 months. Swallowing (slightly impaired 63%), food (normal 40%), and intelligibility (excellent 77%) assessments were satisfactory. Spontaneous sensory recovery was regularly observed (mean response 62%). The two groups FCFF and MCPF were similar regarding population and tumors characteristics. Functional results were higher in case of FCFF (food score p=0.05; intelligibility p=0.04). No difference was observed on sensitive recovery. This study emphasizes good functional results either for swallowing or intelligibility, with higher scores for the FCFF, strengthening the opinion that FCFF is the best choice for tongue reconstruction whenever possible.

Treatment of laryngeal cancer: the permanent challenge.

There are many options to treat larynx cancers. Throughout the 20th century, surgical research has provided many partial surgery techniques (either open surgery or endoscopic CO2 surgery). In parallel, the modification of radiotherapy schedules has notably improved the local control with definitive irradiation. The appearance of active chemotherapy regimens has also modified the concept of treatment for advanced disease, allowing a decrease in the total indications of laryngectomy, although this remains the treatment of choice in some cases. The selection of the most appropriate treatment is based on a multidisciplinary approach. Early diseases may be treated by open surgery, endoscopic laser CO2 surgery or irradiation. Some advanced diseases may be treated by partial surgery, but the majority are theoretically candidates for radical surgery when resectable. In many instances, but not in all, chemotherapy-based larynx-preserving protocols may avoid performing such mutilating surgery. When inoperable, larynx cancers are better treated by combined chemotherapy and irradiation when the performance status of the patient is compatible with such an intensive regimen.