Gregory S. Weinstein

Transoral Robotic Surgery (TORS) for Base of Tongue Neoplasms

Objective: To develop a minimally invasive surgical technique for the treatment of base of tongue neoplasms using the optical and technical advantages of robotic surgical instrumentation.

American Society of Clinical Oncology Clinical Practice Guideline for the Use of Larynx-Preservation Strategies in the Treatment of Laryngeal Cancer

PURPOSE To develop a clinical practice guideline for treatment of laryngeal cancer with the intent of preserving the larynx (either the organ itself or its function). This guideline is intended for use by oncologists in the care of patients outside of clinical trials. METHODS A multidisciplinary Expert Panel determined the clinical management questions to be addressed and reviewed the literature available through November 2005, with emphasis given to randomized controlled trials of site-specific disease. Survival, rate of larynx preservation, and toxicities were the principal outcomes assessed. The guideline underwent internal review and approval by the Panel, as well as external review by additional experts, members of the American Society of Clinical Oncology (ASCO) Health Services Committee, and the ASCO Board of Directors. RESULTS Evidence supports the use of larynx-preservation approaches for appropriately selected patients without a compromise in survival; however, no larynx-preservation approach offers a survival advantage compared with total laryngectomy and adjuvant therapy with rehabilitation as indicated. RECOMMENDATIONS All patients with T1 or T2 laryngeal cancer, with rare exception, should be treated initially with intent to preserve the larynx. For most patients with T3 or T4 disease without tumor invasion through cartilage into soft tissues, a larynx-preservation approach is an appropriate, standard treatment option, and concurrent chemoradiotherapy therapy is the most widely applicable approach. To ensure an optimum outcome, special expertise and a multidisciplinary team are necessary, and the team should fully discuss with the patient the advantages and disadvantages of larynx-preservation options compared with treatments that include total laryngectomy.

Transoral Robotic Surgery: Supraglottic Partial Laryngectomy

Objectives: We assessed the feasibility of performing transoral supraglottic partial laryngectomy with robotic instrumentation. Methods: Transoral robotic surgery (TORS) was performed on 3 human patients with supraglottic carcinoma in a prospective human trial. The study was approved by our institutional review board and involved the da Vinci Surgical Robot (Intuitive Surgical, Inc, Sunnyvale, California). Results: All procedures were completed robotically. The median overall operation time to perform the robotic procedure was 120 minutes (range, 1:32:48 to 2:58:18), including 18 minutes (range, 00:6:07 to 00:30:39) for exposure and robotic positioning. There were no intraoperative or postoperative complications or surgical mortality. Conclusions: The preliminary results of our series suggest that application of the da Vinci robotic surgical system for TORS to supraglottic partial laryngectomy is technically feasible and relatively safe. Furthermore, TORS provides excellent surgical exposure that allows complete tumor resection. Most importantly, TORS provides an alternative to open approaches and “conventional” transoral supraglottic partial laryngectomy.

Diffusion-Weighted Magnetic Resonance Imaging for Predicting and Detecting Early Response to Chemoradiation Therapy of Squamous Cell Carcinomas of the Head and Neck

Purpose: The aim of this study was to investigate the utility of apparent diffusion coefficient (ADC) for prediction and early detection of treatment response in head and neck squamous cell carcinomas (HNSCC). Experimental Design: Diffusion-weighted magnetic resonance imaging studies were performed on 40 patients with newly diagnosed HNSCC before, during, and after the end of chemoradiation therapy. Analysis was done on data from 33 patients after exclusion of 7 patients that had incomplete data. Results: Pretreatment ADC value of complete responders (1.04 ± 0.19 × 10−3 mm2/s) was significantly lower (P < 0.05) than that from partial responders (1.35 ± 0.30 × 10−3 mm2/s). A significant increase in ADC was observed in complete responders within 1 week of treatment (P < 0.01), which remained high until the end of the treatment. The complete responders also showed significantly higher increase in ADC than the partial responders by the first week of chemoradiation (P < 0.01). When pretreatment ADC value was used for predicting treatment response, the area under the receiver operating characteristic curve was 0.80 with a sensitivity of 65% and a specificity of 86%. However, change in ADC within the first week of chemoradiation therapy resulted in an area under the receiver operating characteristic curve of 0.88 with 86% sensitivity and 83% specificity for prediction of treatment response. Conclusions: These results suggest that ADC can be used as a marker for prediction and early detection of response to concurrent chemoradiation therapy in HNSCC.

Transoral robotic surgery: A multicenter study to assess feasibility, safety, and surgical margins

Our objective was to determine the safety, feasibility, and the adequacy of surgical margins for transoral robotic surgery (TORS), by reviewing the early results from independent institutional review board‐approved clinical trials in three separate institutions.

Organ Preservation Therapy Using Induction Plus Concurrent Chemoradiation for Advanced Resectable Oropharyngeal Carcinoma: A University of Pennsylvania Phase II Trial

PURPOSE To determine the efficacy, feasibility, and toxicity of a new regimen for locally advanced oropharyngeal carcinoma. PATIENTS AND METHODS Patients had technically resectable stage III/IV squamous cell carcinoma of the oropharynx, exclusive of T1-2N1. Induction chemotherapy consisted of carboplatin (area under the curve formula equal to 6) and paclitaxel 200 mg/m(2) for two cycles, followed by re-evaluation. Patients with major response continued to definitive radiotherapy (70 Gy over 7 weeks) plus concurrent once-weekly paclitaxel (30 mg/m(2)/wk). Patients with advanced neck disease also underwent post-radiation therapy neck dissection and two more chemotherapy cycles. RESULTS Fifty-three patients were enrolled. Median follow-up was 31 months (minimum follow-up for survivors was 18 months). The major response rate to induction chemotherapy was 89%; 90% of patients had a complete response after concurrent chemoradiation. Actuarial survival at 3 years was 70%, and 3-year event-free survival was 59%. The 3-year actuarial locoregional control was 82% and the 3-year actuarial rate of distant metastases was 19%. Organ preservation was achieved in 77% of all patients. One patient (2%) died during therapy. Late grade 3 toxicity occurred in 24% of patients, consisting mainly of chronic dysphagia/aspiration and/or radiation soft tissue ulceration. The treatment-related mortality rate was 4% (two patients died from respiratory failure). CONCLUSION Response to induction chemotherapy as studied in this trial was not useful as a predictive marker for ultimate outcome or organ conservation. Overall, however, this regimen offers good disease control and survival for patients with locally advanced oropharyngeal carcinoma, comparable with other concurrent chemoradiation programs. Further study of similar protocols is indicated.

Transoral Robotic Surgery for Advanced Oropharyngeal Carcinoma

OBJECTIVES To determine the oncologic and functional outcomes in patients undergoing primary transoral robotic surgery followed by adjuvant therapy as indicated with a minimum of 18-month follow-up for advanced oropharyngeal carcinoma. DESIGN Prospective single-center cohort study. SETTING Academic university health system and tertiary referral center. PATIENTS Forty-seven adults with newly diagnosed and previously untreated advanced oropharyngeal carcinoma. INTERVENTION Transoral robotic surgery with staged neck dissection and adjuvant therapy as indicated. MAIN OUTCOME MEASURES Margin status, recurrence, disease-specific and disease-free survival, gastrostomy tube dependence, and safety and efficacy end points. RESULTS In the 47 patients enrolled with stages III and IV advanced oropharyngeal carcinoma, mean follow-up was 26.6 months. There was no intraoperative or postoperative mortality. Resection margins were positive in 1 patient (2%). At last follow-up, local recurrence was identified in 1 patient (2%), regional recurrence in 2 (4%), and distant recurrence in 4 (9%). Disease-specific survival was 98% (45 of 46 patients) at 1 year and 90% (27 of 30 patients) at 2 years. Based on pathologic risk stratification, 18 of 47 patients (38%) avoided chemotherapy, and 5 patients (11%) did not receive adjuvant radiotherapy and concurrent chemotherapy in their treatment regimen. At minimum follow-up of 1 year, only 1 patient required a gastrostomy tube. CONCLUSIONS This novel transoral robotic surgery treatment regimen offers disease control, survival, and safety commensurate with standard treatments and an unexpected beneficial outcome of gastrostomy dependency rates that are markedly lower than those reported with standard nonsurgical therapies.

Supracricoid laryngectomy with cricohyoidopexy: A partial laryngeal procedure for selected supraglottic and transglottic carcinomas

The partial horizontal supracricoid laryngectomy with cricohyoidopexy consists of resection of the whole thyroid cartilage and paraglottic space, as well as the epiglottis and the whole preepiglottic space. The cricoid cartilage, the hyoid bone, and at least one arytenoid cartilage are spared. Sixty‐eight patients with squamous cell carcinoma of the supraglottis who underwent this procedure during the period from 1974 through 1986 are presented. Conventional horizontal supraglottic laryngectomy was contraindicated in all cases. All but three patients (95.4%) recovered physiologic deglutition, and none required a permanent tra‐cheostomy. The 3‐year actuarial survival rate was 71.4%. No local recurrences were encountered. The indications for the procedure are carcinomas of the supraglottis that 1. involve the glottis and anterior commissure, 2. invade the ventricle, 3. present with a marked limitation of true vocal cord mobility (transglottic lesions), and 4. invade the thyroid cartilage. The procedure is presented as a useful alternative to radiation therapy, horizontal supraglottic laryngectomy, and total laryngectomy in select cases of supraglottic carcinoma.

Supracricoid laryngectomy with cricohyoidoepiglottopexy : a partial laryngeal procedure for glottic carcinoma

The partial horizontal supracricoid laryngectomy with cricohyoidoepiglottopexy consists of resection of the whole thyroid cartilage and paraglottic space. The cricoid cartilage, the hyoid bone, most of the epiglottis, and at least one arytenoid cartilage are conserved. Thirty-six patients with squamous cell carcinoma of the glottis who underwent this procedure from 1974 through 1986 are presented. All 36 recovered physiologic deglutition and phonation. None required a permanent tracheotomy. The 3-year actuarial survival rate was 86.5%. The local recurrence rate was 5.5%. The indications for the procedure are carcinomas of the glottis that 1) spread beyond the confines of the membranous portion of the true vocal cord or 2) present with limitation of true vocal cord mobility. The procedure is presented as a useful alternative to radiotherapy, partial vertical laryngectomy, and total laryngectomy in select cases of glottic carcinoma.

Multivariate Predictors of Occult Neck Metastasis in Early Oral Tongue Cancer

OBJECTIVES: The elective dissection of cervical lymph nodes from patients with early oral tongue cancer and a clinically negative neck (T1/T2N0), remains an unsettled issue that continues to be investigated. This study examines clinical and histopathologic factors through univariate and multi-variate analysis to correlate the risk of neck micrometastasis in patients with T1/T2N0 squamous cell carcinoma of the oral tongue. STUDY DESIGN AND METHODS: The clinical files and histologic sections of tumor from 45 clinically determined N0 patients were retrospectively analyzed. The factors examined include degree of tumor cell differentiation, T1/T2 staging, presence of perineural invasion, presence of angiolymphatic invasion, type of invasion front, depth of muscle invasion, and tumor thickness. RESULTS: Independent correlates of positive occult neck metastasis included greater tumor thickness (P = 0.01), greater depth of muscle invasion (P = 0.01), T2 stage (P = 0.01), poorly differentiated tumors (P = 0.007), infiltrating-type invasion front (P = 0.03), presence of perineural invasion (P = 0.001), and presence of angiolymphatic invasion (P = 0.005). The final multivariate model for estimation of an increased probability of occult neck disease included greater tumor thickness, presence of perineural invasion, infiltrating-type invasion front, poorly differentiated tumors, and T2 stage. CONCLUSIONS: The clinical and histopathologic factors studied herein permit greater selectivity and more informed decision-making than does presurgical evaluation, when addressing elective neck treatment for early N0 oral tongue cancer. The multivariate model derived from this study appears to be a more reliable method for determining the patients most likely to benefit from elective neck dissection.