M. Ménard

Transoral robotic surgery in head and neck cancer

Robots have invaded industry and, more recently, the field of medicine. Following the development of various prototypes, Intuitive Surgical® has developed the Da Vinci surgical robot. This robot, designed for abdominal surgery, has been widely used in urology since 2000. The many advantages of this transoral robotic surgery (TORS) are described in this article. Its disadvantages are essentially its high cost and the absence of tactile feedback. The first feasibility studies in head and neck cancer, conducted in animals, dummies and cadavers, were performed in 2005, followed by the first publications in patients in 2006. The first series including more than 20 patients treated by TORS demonstrated the feasibility for the following sites: oropharynx, supraglottic larynx and hypopharynx. However, these studies did not validate the oncological results of the TORS technique. TORS decreases the number of tracheotomies, and allows more rapid swallowing rehabilitation and a shorter length of hospital stay. Technical improvements are expected. Smaller, more ergonomic, new generation robots, therefore more adapted to the head and neck, will probably be available in the future.

Postoperative Hemorrhage after Transoral Oropharyngectomy for Cancer of the Lateral Oropharynx

Objective: Assessment of incidence, risk factors, management, and outcome of postoperative hemorrhage after transoral oropharyngectomy for cancer of the lateral oropharynx. Methods: Retrospective review of a cohort of 514 cancers of the lateral oropharynx consecutively resected. Results: Incidence of postoperative hemorrhage was 3.6%. In 31.5% of cases, onset was after hospital discharge. No hemorrhages occurred after the end of the fourth postoperative week. Variables associated with increased risk of hemorrhage were advanced age (P = .004), antithrombotic treatment (P = .012), and robotic assistance (P = .009). When the source of hemorrhage could be identified, hemostasis, performed transorally in most cases, was highly effective; no patients in this subgroup showed recurrence. In spontaneously resolved hemorrhage under observation or when no active site of bleeding was found on exploration under general anesthesia, the recurrence rate was 18.1%. Overall, hemorrhage resulted in death in 2 patients. Conclusion: Exploration under general anesthesia in case of active bleeding and observation with discussion of arterial exploration of the ipsilateral external carotid system in patients in whom no source of bleeding can be identified are the keys to successful management of this potentially lethal complication.

Total laryngectomy or laryngeal preservation for advanced laryngeal cancer. Impact of the functional risk upon the patient's preferences.

OBJECTIVEnTo analyse, based on an anonymous questionnaire, the treatment decision envisaged and the impact of the medical information delivered in patients facing the diagnosis of an advanced laryngeal cancer amenable to total laryngectomy or a laryngeal preservation protocol.nnnMATERIAL AND METHODSnProspective study conducted in a French teaching hospital based on questionnaires filled in by 269 patients attending the otorhinolaryngology clinic.nnnRESULTSnA total of 28.6% of patients would not consider any trade-off of cure to preserve their larynx; 1.4% of patients were willing to trade all chances of cure in order to avoid total laryngectomy. The median percentage of cure that patients were ready to loose in order to preserve their larynx was 33% (range: 5 to 100%); 47.9% of patients wanted to receive additional information before making their decision with a significant increase among patients with a level of education beyond secondary school (P=0.0006) and among patients with a family history of cancer (P=0.038). The additional information most frequently requested concerned the complications related to the laryngeal preservation protocol (34.1%) and the cure rate (28.6%). After receiving information about the risk of tracheostomy and permanent gastrostomy following the laryngeal preservation protocol, the percentage of subjects who would not consider any trade-off in order to preserve their larynx increased to 31.2% and 56.1%, respectively.nnnCONCLUSIONnLaryngeal preservation is not a major objective of treatment shared by patients filling a questionnaire devoted to the choice of treatment when facing an advanced laryngeal cancer. Specific information concerning the expected results and the inherent risks involved in the various treatment options must be provided in every case.

Value and limits of non-robotic transoral oropharyngectomy for local control of T1-2 invasive squamous cell carcinoma of the tonsillar fossa.

BACKGROUNDnAn analysis of the value and limits of non-robotic transoral oropharyngectomy for local control of T1-2 squamous cell carcinoma of the tonsillar fossa.nnnMETHODSnA retrospective series of 111 T1 and 133 T2 (N0: 129; N1: 52; N2: 53; N3: 10). Induction chemotherapy and postoperative radiation therapy were used in 63.5% and 29.5% of cases, respectively. Actuarial analysis of local failure, impact of various variables upon local failure and consequences of local failure upon other oncological events and survival are documented.nnnRESULTSnThe 5-year actuarial local failure estimate was 10.4% and 14.2% for T1 and T2 tumors, respectively. The 5-year actuarial local failure estimate was significantly reduced when resection margins were safe or yielded dysplasia (P=0.008) and when induction chemotherapy achieved complete histologic regression (P=0.013). Salvage treatment achieved a 97.2% and 93.2% overall local control rate in T1 and T2 tumors, respectively. The 5-year actuarial nodal failure estimate was 35.1% in patients with local failure versus 10.8% without (P=0.0001). The 5-year actuarial metachronous second primary estimate was 7% in patients with local failure versus 33.2% without (P=0.016). The impact of local failure on survival (5-year actuarial survival estimate: 67.3% without and 46.4% with local failure) was not significant.nnnCONCLUSIONnIn T1-2 squamous cell carcinoma of the tonsillar fossa, non-robotic transoral oropharyngectomy appeared to be highly effective in terms of local control. The high incidence of head and neck metachronous second primaries further advocates the use of this treatment option in order to reserve radiation therapy to such cases.

Otorhinolaryngologists' personal treatment preferences (total laryngectomy or laryngeal preservation) when faced with advanced stage laryngeal cancer.

OBJECTIVEnTo analyse the treatment options that otorhinolaryngologists would consider if faced with advanced stage laryngeal cancer amenable to total laryngectomy or an organ preservation protocol.nnnMATERIAL AND METHODSnProspective study conducted in a French Teaching Hospital based on questionnaires filled in by 163 otorhinolaryngologists in 2012, studying the percentage chance of cure that they would be prepared to trade-off to preserve their larynx, defining the additional information that they would like to receive and identifying any statistical associations between these parameters and various medical and socioeconomic variables.nnnRESULTSnA total of 42.3% of otorhinolaryngologists would not consider the slightest trade-off to preserve their larynx and preferred to undergo total laryngectomy. In the group of otorhinolaryngologists who would consider a larynx preservation protocol (57.6%), the percentage chance of cure that they would be willing to trade-off to preserve their larynx ranged between 5 to 100% (median: 15%) and 4.2% of them were willing to trade-off all chances of cure (100%) to avoid total laryngectomy. The percentage of otorhinolaryngologists who would not consider trading off the slightest chance of survival to preserve their larynx increased from 29.3 to 49.5% (P=0.01) when they participated in multidisciplinary consultation meetings. In the group of otorhinolaryngologists who would consider a larynx preservation protocol, the median percentage survival trade-off that they would consider in order to preserve their larynx (i) decreased from 20 to 10% (P=0.004) when they participated in multidisciplinary consultation meetings and (ii) increased regularly with their number of years of practice (P=0.03) and their age (P=0.025). Finally, 25.1% of otorhinolaryngologists wanted to receive additional information, although none of the variables analysed affected this desire for more information.nnnCONCLUSIONnTreatment options considered by otorhinolaryngologists faced with advanced stage laryngeal cancer were almost equally divided between total laryngectomy and larynx preservation. Number of years of practice and regular participation in head and neck cancer multidisciplinary consultation meetings were variables that significantly influenced this choice.

Quel choix pour l’oncologue radiothérapeute atteint d’un cancer du larynx localement évolué ?

PURPOSEnTo analyse the therapeutic decision considered by radiation oncologists put in a position of being diagnosed with an advanced stage cancer of the larynx accessible either to a total laryngectomy or to an organ preservation protocol.nnnMATERIALS AND METHODSnProspective analysis based on an anonymous survey filled by 104 radiation oncologists.nnnRESULTSnA total of 30.7% of radiation oncologists surveyed did not consider any trade in their cure rate to preserve their larynx. The median percentage of cure that they were willing to trade was 10% (2-100%); and 0.9% of them were willing to trade 100% of their chance for cure in order to avoid total laryngectomy. A total of 16.3% of radiation oncologists would like to receive more information before making their decision. The additional information most frequently requested concerned the precise stage of the tumour and the potential remedial treatment in case of failure of the laryngeal preservation protocol. None of the analysed demographic variables influenced the choice to trade or not survival chance to preserve the larynx, the percentage of chance that radiation oncologists would consider exchanging, and/or the wish to receive additional information.nnnCONCLUSIONnThis prospective study highlights that larynx preservation protocol is not the main therapeutic goal shared by all radiation oncologists put in a position of being diagnosed with an advanced stage cancer of the larynx. Total laryngectomy should remain a treatment option that as organ preservation protocols to be proposed and discussed.

Survival and laryngeal preservation tradeoff in advanced laryngeal cancer: From the otorhinolaryngology patient to the managing physician

The purpose of this study was to document the tradeoff between survival and laryngeal preservation in advanced‐stage laryngeal cancer amenable to chemoradiation or total laryngectomy.