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Original Investigation |

Oncologic Outcomes After Transoral Robotic Surgery  A Multi-institutional Study

John R. de Almeida, MD, MSc1; Ryan Li, MD2; J. Scott Magnuson, MD3; Richard V. Smith, MD4; Eric Moore, MD5; Georges Lawson, MD6; Marc Remacle, MD6; Ian Ganly, MD7; Dennis H. Kraus, MD8; Marita S. Teng, MD9; Brett A. Miles, MD9; Hilliary White, MD3; Umamaheswar Duvvuri, MD, PhD10; Robert L. Ferris, MD, PhD10; Vikas Mehta, MD10; Krista Kiyosaki, MD2; Edward J. Damrose, MD2; Steven J. Wang, MD11; Michael E. Kupferman, MD12; Yoon Woo Koh, MD13; Eric M. Genden, MD9; F. Christopher Holsinger, MD2,12
[+] Author Affiliations
1Department of Otolaryngology–Head and Neck Surgery, Princess Margaret Cancer Center, Toronto, Ontario, Canada
2Division of Head and Neck Surgery, Department of Otolaryngology–Head and Neck Surgery, Stanford University, Palo Alto, California
3Department of Otolaryngology–Head and Neck Surgery, University of Alabama at Birmingham
4Department of Otorhinolaryngology–Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York
5Department of Otolaryngology–Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
6Catholic University of Louvain at Mont-Godinne, Yvoir, Belgium
7Department of Surgery, Head and Neck Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
8New York Head and Neck Institute, North Shore Health System, New York, New York
9Department of Otolaryngology Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
10Department of Otolaryngology–Head and Neck Surgery, University of Pittsburgh Medical Center, Veterans Affairs Pittsburgh HealthCare System, Pittsburgh, Pennsylvania
11Department of Otolaryngology–Head and Neck Surgery, University of California, San Francisco
12Department of Head and Neck Surgery, MD Anderson Cancer Center, Houston, Texas
13Severance Hospital, Yonsei University School of Medicine, Seoul, Korea
JAMA Otolaryngol Head Neck Surg. 2015;141(12):1043-1051. doi:10.1001/jamaoto.2015.1508.
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Importance  Large patient cohorts are necessary to validate the efficacy of transoral robotic surgery (TORS) in the management of head and neck cancer.

Objectives  To review oncologic outcomes of TORS from a large multi-institutional collaboration and to identify predictors of disease recurrence and disease-specific mortality.

Design, Setting, and Participants  A retrospective review of records from 410 patients undergoing TORS for laryngeal and pharyngeal cancers from January 1, 2007, through December 31, 2012, was performed. Pertinent data were obtained from 11 participating medical institutions.

Interventions  Select patients received radiation therapy and/or chemotherapy before or after TORS.

Main Outcomes and Measures  Locoregional control, disease-specific survival, and overall survival were calculated. We used Kaplan-Meier survival analysis with log-rank testing to evaluate individual variable association with these outcomes, followed by multivariate analysis with Cox proportional hazards regression modeling to identify independent predictors.

Results  Of the 410 patients treated with TORS in this study, 364 (88.8%) had oropharyngeal cancer. Of these 364 patients, information about post-operative adjuvant therapy was known about 338: 106 (31.3) received radiation therapy alone, and 72 (21.3%) received radiation therapy with concurrent chemotherapy. Neck dissection was performed in 323 patients (78.8%). Mean follow-up time was 20 months. Local, regional, and distant recurrence occurred in 18 (4.4%), 15 (3.7%), and 10 (2.4%) of 410 patients, respectively. Seventeen (4.1%) died of disease, and 13 (3.2%) died of other causes. The 2-year locoregional control rate was 91.8% (95% CI, 87.6%-94.7%), disease-specific survival 94.5% (95% CI, 90.6%-96.8%), and overall survival 91% (95% CI, 86.5%-94.0%). Multivariate analysis identified improved survival among women (P = .05) and for patients with tumors arising in tonsil (P = .01). Smoking was associated with worse overall all-cause mortality (P = .01). Although advanced age and tobacco use were associated with locoregional recurrence and disease-specific survival, they, as well as tumor stage and other adverse histopathologic features, did not remain significant on multivariate analysis.

Conclusions and Relevance  This large, multi-institutional study supports the role of TORS within the multidisciplinary treatment paradigm for the treatment of head and neck cancer, especially for patients with oropharyngeal cancer. Favorable oncologic outcomes have been found across institutions. Ongoing comparative clinical trials funded by the National Cancer Institute will further evaluate the role of robotic surgery for patients with head and neck cancers.

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Figure 1.
Locoregional Control (LRC) for Patients Treated With Transoral Robotic Surgery (TORS)

Locoregional control by oropharyngeal subsite in all patients and pathologic margin status, human papillomavirus (HPV) status, and p16 status in patients with oropharyngeal primary tumors.

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Figure 2.
Overall Survival (OS) and Disease-Specific Survival (DSS) for Patients Treated With Transoral Robotic Surgery (TORS)

Overall survival and DSS in all 396 study patients with head and neck cancer.

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