Skip to main content

Advertisement

SpringerLink
Log in

The Role of Transoral Robotic Surgery in the Management of Oropharyngeal Squamous Cell Carcinoma: a Current Review

  • Head and Neck Cancers (E Hanna, Section Editor)
  • Published:
Current Oncology Reports Aims and scope Submit manuscript

Abstract

The incidence of oropharyngeal squamous cell carcinoma (OPSCC) is increasing in the USA despite a decline in traditional risk factors. This trend is attributed to human papillomavirus (HPV)-associated malignancies and is particularly notable in a younger patient demographic with fewer comorbid diseases and longer life expectancies. Therefore, both oncologic and functional outcomes are important to consider when managing OPSCC in the modern era. The historical management of OPSCC was typically surgical, but traditional open approaches resulted in significant morbidity. As the paradigm shifted, organ-preserving treatment regimens, namely, radiotherapy (RT) and chemoradiation (CRT), replaced surgery as the primary treatment modality. However, these treatment strategies are not without risk of significant sequelae and functional impairment. Transoral robotic surgery (TORS) is a minimally invasive surgical approach that offers surgical access to the oropharynx without the morbidity of open procedures while achieving excellent oncologic and functional outcomes. The appropriate application of this new technology is still being investigated but the current literature supports TORS as a viable option in the management of OPSCC.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Siegel R, Ma J, Zou Z, Jemal A. Cancer statistics, 2014. CA Cancer J Clin. 2014;64(1):9–29.

    Article  PubMed  Google Scholar 

  2. Stein AP, Saha S, Yu M, Kimple RJ, Lambert PF. Prevalence of human papillomavirus in oropharyngeal squamous cell carcinoma in the united states across time. Chem Res Toxicol. 2014;27(4):462–9.

    Article  CAS  PubMed  Google Scholar 

  3. Chaturvedi AK, Engels EA, Anderson WF, Gillison ML. Incidence trends for human papillomavirus-related and -unrelated oral squamous cell carcinomas in the United States. J Clin Oncol. 2008;26(4):612–9.

    Article  PubMed  Google Scholar 

  4. Panwar A, Batra R, Lydiatt WM, Ganti AK. Human papilloma virus positive oropharyngeal squamous cell carcinoma: a growing epidemic. Cancer Treat Rev. 2014;40(2):215–9.

    Article  PubMed  Google Scholar 

  5. Pytynia KB, Dahlstrom KR, Sturgis EM. Epidemiology of HPV-associated oropharyngeal cancer. Oral Oncol. 2014;50(5):380–6.

    Article  PubMed  Google Scholar 

  6. Gayar OH, Ruterbusch JJ, Elshaikh M, Cote M, Ghanem T, Hall F, et al. Oropharyngeal carcinoma in young adults: an alarming national trend. Otolaryngol Head Neck Surg. 2014;150(4):594–601.

    Article  PubMed  Google Scholar 

  7. Benson E, Li R, Eisele D, Fakhry C. The clinical impact of HPV tumor status upon head and neck squamous cell carcinomas. Oral Oncol. 2014;50(6):565–74.

    Article  PubMed  Google Scholar 

  8. Ang KK, Harris J, Wheeler R, Weber R, Rosenthal DI, Nguyen-Tan PF, et al. Human papillomavirus and survival of patients with oropharyngeal cancer. N Engl J Med. 2010;363(1):24–35.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  9. Brickman D, Gross ND. Robotic approaches to the pharynx: tonsil cancer. Otolaryngol Clin North Am. 2014;47(3):359–72.

    Article  PubMed  Google Scholar 

  10. Pfister DG, Harrison LB, Strong EW, Shah JP, Spiro RW, Kraus DH, et al. Organ-function preservation in advanced oropharynx cancer: results with induction chemotherapy and radiation. J Clin Oncol. 1995;13(3):671–80.

    CAS  PubMed  Google Scholar 

  11. Wendt TG. Hazards and risks in oncology: radiation oncology. GMS Curr Top Otorhinolaryngol Head Neck Surg. 2013;12:Doc03.

    PubMed Central  PubMed  Google Scholar 

  12. Forastiere AA, Goepfert H, Maor M, Pajak TF, Weber R, Morrison W, et al. Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer. N Engl J Med. 2003 11/27; 2014/08;349(22):2091-8.

  13. Steiner W, Fierek O, Ambrosch P, Hommerich CP, Kron M. Transoral laser microsurgery for squamous cell carcinoma of the base of the tongue. Arch Otolaryngol Head Neck Surg. 2003;129(1):36–43.

    Article  PubMed  Google Scholar 

  14. Clayburgh DR, Gross N. Surgical innovations. Otolaryngol Clin North Am. 2013;46(4):615–28.

    Article  PubMed  Google Scholar 

  15. Moore EJ, Hinni ML. Critical review: transoral laser microsurgery and robotic-assisted surgery for oropharynx cancer including human papillomavirus–related cancer. Int J Radiat Oncol*Biol*Phys. 2013 4/1;85(5):1163-7.

  16. Hockstein NG, Nolan JP, O’Malley BW, Woo YJ. Robotic microlaryngeal surgery: a technical feasibility study using the daVinci surgical robot and an airway mannequin. Laryngoscope. 2005;115(5):780–5.

    Article  PubMed  Google Scholar 

  17. O’Malley Jr BW, Weinstein GS, Hockstein NG. Transoral robotic surgery (TORS): glottic microsurgery in a canine model. J Voice. 2006;20(2):263–8.

    Article  PubMed  Google Scholar 

  18. O’Malley BW, Weinstein GS, Snyder W, Hockstein NG. Transoral robotic surgery (TORS) for base of tongue neoplasms. Laryngoscope. 2006;116(8):1465–72.

    Article  PubMed  Google Scholar 

  19. Weinstein GS, Quon H, O’Malley BW, Kim GG, Cohen MA. Selective neck dissection and deintensified postoperative radiation and chemotherapy for oropharyngeal cancer: a subset analysis of the University of Pennsylvania transoral robotic surgery trial. Laryngoscope. 2010;120(9):1749–55.

    Article  PubMed  Google Scholar 

  20. Weinstein GS, O’Malley Jr BW, Cohen MA, Quon H. Transoral robotic surgery for advanced oropharyngeal carcinoma. Arch Otolaryngol Head Neck Surg. 2010;136(11):1079–85.

    Article  PubMed  Google Scholar 

  21. Weinstein GS, O’Malley Jr BW, Snyder W, Sherman E, Quon H. Transoral robotic surgery: radical tonsillectomy. Archiv Otolaryngol Head Neck Surg. 2007;133(12):1220–6.

    Article  Google Scholar 

  22. Gunn GB, Debnam JM, Fuller CD, Morrison WH, Frank SJ, Beadle BM, et al. The impact of radiographic retropharyngeal adenopathy in oropharyngeal cancer. Cancer. 2013;119(17):3162–9.

    Article  PubMed Central  PubMed  Google Scholar 

  23. Dirix P, Nuyts S, Bussels B, Hermans R, Van den Bogaert W. Prognostic influence of retropharyngeal lymph node metastasis in squamous cell carcinoma of the oropharynx. Int J Radiat Oncol*Biol*Phys. 2006 7/1;65(3):739-44.

  24. Byeon HK, Duvvuri U, Kim WS, Park YM, Hong HJ, Koh YW, et al. Transoral robotic retropharyngeal lymph node dissection with or without lateral oropharyngectomy. J Craniofac Surg. 2013;24(4):1156–61.

    Article  PubMed  Google Scholar 

  25. Moore MW, Jantharapattana K, Williams MD, Grant DG, Selber JC, Holsinger FC. Retropharyngeal lymphadenectomy with transoral robotic surgery for papillary thyroid cancer. J Robotic Surg. 2011;5:221–6.

    Article  Google Scholar 

  26. Abuzeid WM, Bradford CR, Divi V. Transoral robotic biopsy of the tongue base: a novel paradigm in the evaluation of unknown primary tumors of the head and neck. Head Neck. 2013;35(4):E126–30.

    Article  PubMed  Google Scholar 

  27. Mehta V, Johnson P, Tassler A, Kim S, Ferris RL, Nance M, et al. A new paradigm for the diagnosis and management of unknown primary tumors of the head and neck: a role for transoral robotic surgery. Laryngoscope. 2013;123(1):146–51.

    Article  PubMed  Google Scholar 

  28. Patel SA, Magnuson J, Holsinger F, et al. Robotic surgery for primary head and neck squamous cell carcinoma of unknown site. JAMA Otolaryngol Head Neck Surg. 2013;139(11):1203–11. Retrospective, multi-institution case series that evaluated the utility of TORS for the work-up of an unknown primary tumor site. 47 patients were included and the primary tumor was identified by TORS 72.3% of the time. The primary site was in the base of tongue 58.8% of the time and was located in the palatine tonsil 38.2% of the time. The authors discuss the benefit of being able to simultaneously diagnose and treat an unknown primary using TORS.

    Article  PubMed  Google Scholar 

  29. Cianchetti M, Mancuso AA, Amdur RJ, Werning JW, Kirwan J, Morris CG, et al. Diagnostic evaluation of squamous cell carcinoma metastatic to cervical lymph nodes from an unknown head and neck primary site. Laryngoscope. 2009;119(12):2348–54.

    Article  PubMed  Google Scholar 

  30. Ford SE, Brandwein-Gensler M, Carroll WR, Rosenthal EL, Magnuson JS. Transoral robotic versus open surgical approaches to oropharyngeal squamous cell carcinoma by human papillomavirus status. Otolaryngol Head Neck Surg. 2014. Retrospective review evaluating 130 patients with OPSCC treated at UAB with either an open approach or TORS plus adjuvant therapies as indicated. The data demonstrated no sacrifice of oncologic results regardless of HPV status.

  31. Lawson JD, Otto K, Chen A, Shin DM, Davis L, Johnstone PA. Concurrent platinum-based chemotherapy and simultaneous modulated accelerated radiation therapy for locally advanced squamous cell carcinoma of the tongue base. Head Neck. 2008;30(3):327–35.

    Article  PubMed  Google Scholar 

  32. de Arruda FF, Puri DR, Zhung J, Narayana A, Wolden S, Hunt M, et al. Intensity-modulated radiation therapy for the treatment of oropharyngeal carcinoma: the Memorial Sloan-Kettering Cancer Center experience. Int J Radiat Oncol Biol Phys. 2006;64(2):363–73.

    Article  PubMed  Google Scholar 

  33. Weinstein GS, Quon H, Newman H, et al. Transoral robotic surgery alone for oropharyngeal cancer: an analysis of local control. Archiv Otolaryngol Head Neck Surg. 2012;138(7):628–34. A prospective observational study of 30 patients treated at Penn with TORS alone demonstrated excellent local control after obtaining negative surgical margins. Mean follow-up was 2.7 years (range, 1.5-5.1 years) and local failure occurred in one patient (3%). This study provides further evidence supporting the possibility of de-intensifying adjuvant therapies.

    Article  Google Scholar 

  34. Hurtuk A, Agrawal A, Old M, Teknos TN, Ozer E. Outcomes of transoral robotic surgery: a preliminary clinical experience. Otolaryngol Head Neck Surg. 2011;145(2):248–53.

    Article  PubMed Central  PubMed  Google Scholar 

  35. Iseli TA, Kulbersh BD, Iseli CE, Carroll WR, Rosenthal EL, Magnuson JS. Functional outcomes after transoral robotic surgery for head and neck cancer. Otolaryngol Head Neck Surg. 2009;141(2):166–71.

    Article  PubMed  Google Scholar 

  36. Al-Khudari S, Bendix S, Lindholm J, Simmerman E, Hall F, Ghanem T. Gastrostomy tube use after transoral robotic surgery for oropharyngeal cancer. ISRN Otolaryngol. 2013;2013:190364.

    Article  PubMed Central  PubMed  Google Scholar 

  37. Chen AY, Frankowski R, Bishop-Leone J, et al. The development and validation of a dysphagia-specific quality-of-life questionnaire for patients with head and neck cancer: the M. D. Anderson Dysphagia Inventory. Arch Otolaryngol Head Neck Surg. 2001;127(7):870–6.

    CAS  PubMed  Google Scholar 

  38. Sinclair CF, McColloch NL, Carroll WR, Rosenthal EL, Desmond RA, Magnuson J. Patient-perceived and objective functional outcomes following transoral robotic surgery for early oropharyngeal carcinoma. Arch Otolaryngol Head Neck Surg. 2011;137(11):1112–6.

    Article  PubMed  Google Scholar 

  39. Gillespie M, Brodsky MB, Day TA, Sharma AK, Lee F, Martin-Harris B. Laryngeal penetration and aspiration during swallowing after the treatment of advanced oropharyngeal cancer. Arch Otolaryngol Head Neck Surg. 2005;131(7):615–9.

    Article  PubMed  Google Scholar 

  40. More YI, Tsue TT, Girod DA, et al. Functional swallowing outcomes following transoral robotic surgery vs primary chemoradiotherapy in patients with advanced-stage oropharynx and supraglottis cancers. JAMA Otolaryngol Head Neck Surg. 2013;139(1):43–8.

    Article  PubMed  Google Scholar 

  41. Dziegielewski PT, Teknos TN, Durmus K, et al. Transoral robotic surgery for oropharyngeal cancer: long-term quality of life and functional outcomes. JAMA Otolaryngol Head Neck Surg. 2013;139(11):1099–108.

    Article  PubMed Central  PubMed  Google Scholar 

  42. Levendag PC, Teguh DN, Voet P, van der Est H, Noever I, de Kruijf WJM, et al. Dysphagia disorders in patients with cancer of the oropharynx are significantly affected by the radiation therapy dose to the superior and middle constrictor muscle: a dose-effect relationship. Radiother Oncol. 2007;85(1):64–73.

    Article  PubMed  Google Scholar 

  43. Weinstein GS, O’Malley BW, Magnuson JS, Carroll WR, Olsen KD, Daio L, et al. Transoral robotic surgery: a multicenter study to assess feasibility, safety, and surgical margins. Laryngoscope. 2012;122(8):1701–7. Multicenter study including 177 patients with malignancies of the head and neck demonstrated a low rate of positive surgical margins (4.3%), serious complications (2.3%) and functional outcomes. The authors conclude that TORS should play a significant role in the multidisciplinary management of head and neck malignancies.

    Article  PubMed  Google Scholar 

  44. Gourin CG, Forastiere AA, Sanguineti G, Marur S, Koch WM, Bristow RE. Impact of surgeon and hospital volume on short-term outcomes and cost of oropharyngeal cancer surgical care. Laryngoscope. 2011;121(4):746–52.

    Article  PubMed Central  PubMed  Google Scholar 

  45. Chia SH, Gross ND, Richmon JD. Surgeon experience and complications with transoral robotic surgery (TORS). Otolaryngol Head Neck Surg. 2013;149(6):885–92.

    Article  PubMed  Google Scholar 

  46. Asher SA, White HN, Kejner AE, Rosenthal EL, Carroll WR, Magnuson JS. Hemorrhage after transoral robotic-assisted surgery. Otolaryngol Head Neck Surg. 2013;149(1):112–7.

    Article  PubMed  Google Scholar 

  47. Pollei TR, Hinni ML, Moore EJ, et al. Analysis of postoperative bleeding and risk factors in transoral surgery of the oropharynx. JAMA Otolaryngol Head Neck Surg. 2013;139(11):1212–8.

    Article  PubMed  Google Scholar 

  48. White HN, Moore EJ, Rosenthal EL, Carroll WR, Olsen KD, Desmond RA, et al. Transoral robotic-assisted surgery for head and neck squamous cell carcinoma: one- and 2-year survival analysis. Arch Otolaryngol Head Neck Surg. 2010;136(12):1248–52.

    Article  PubMed  Google Scholar 

  49. Cohen MA, Weinstein GS, O’Malley BW, Feldman M, Quon H. Transoral robotic surgery and human papillomavirus status: oncologic results. Head Neck. 2011;33(4):573–80.

    Article  PubMed  Google Scholar 

  50. Moore EJ, Olsen SM, Laborde RR, García JJ, Walsh FJ, Price DL, et al. Long-term functional and oncologic results of transoral robotic surgery for oropharyngeal squamous cell carcinoma. Mayo Clin Proc. 2012;87(3):219–25.

    Article  PubMed Central  PubMed  Google Scholar 

  51. Hurtuk AM, Marcinow A, Agrawal A, Old M, Teknos TN, Ozer E. Quality-of-life outcomes in transoral robotic surgery. Otolaryngol Head Neck Surg. 2012;146(1):68–73.

    Article  PubMed Central  PubMed  Google Scholar 

  52. Moore EJ, Olsen KD, Kasperbauer JL. Transoral robotic surgery for oropharyngeal squamous cell carcinoma: a prospective study of feasibility and functional outcomes. Laryngoscope. 2009;119(11):2156–64.

    Article  PubMed  Google Scholar 

  53. Olsen SM, Moore EJ, Laborde RR, Garcia JJ, Janus JR, Price DL, et al. Transoral surgery alone for human-papillomavirus-associated oropharyngeal squamous cell carcinoma. Ear Nose Throat J. 2013;92(2):76–83.

    PubMed  Google Scholar 

Download references

Compliance with Ethics Guidelines

Conflict of Interest

E. Ritter Sansoni declares no conflict of interest.

Neil D. Gross has received honoraria from Intuitive Surgical and paid travel expenses from Medrobotics.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Author information

Authors and Affiliations

  1. Department of Otolaryngology - Head and Neck Surgery, Oregon Health & Science University, Portland, OR, USA

    E. Ritter Sansoni

  2. Department Head and Neck Surgery, MD Anderson Cancer Center, 1400 Pressler Street, Unit 1445, Houston, TX, 77030, USA

    Neil D. Gross

Authors
  1. E. Ritter Sansoni
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Neil D. Gross
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Neil D. Gross.

Additional information

This article is part of the Topical Collection on Head and Neck Cancers

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Sansoni, E.R., Gross, N.D. The Role of Transoral Robotic Surgery in the Management of Oropharyngeal Squamous Cell Carcinoma: a Current Review. Curr Oncol Rep 17, 7 (2015). https://doi.org/10.1007/s11912-014-0432-y

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11912-014-0432-y

Keywords

Search

Navigation