Introduction
The Transoral Neck Surgery (TONS) Study Group was established at the 1st International Thyroid NOTES Conference in February 2016 with the intention of standardizing and refining thyroid ...NOTES techniques, including both transoral endoscopic and robotic thyroidectomy approaches. Herein, the authors report the modification of indications, preparation, and step-by-step explanations for operative techniques, as well as results and postoperative care for transoral endoscopic thyroidectomy vestibular approach (TOETVA).
Methods
Between February 2015 and December 2015, a total of 200 patients comprising 8 males (4%) and 192 females (96%) underwent TOETVA using 3 laparoscopic ports inserted at the oral vestibule. Of these patients, 111 presented with single thyroid nodules (55.5%), while 66 patients had multinodular goiters (33%), 12 had Graves’ disease (6%) and 11 had papillary microcarcinoma (5.5%). The CO
2
insufflation pressure was maintained at 6 mmHg. Each surgery was performed using laparoscopic instruments and ultrasonic devices.
Results
TOETVA was performed on 200 consecutive patients. No conversion to conventional open surgery was necessary. Average tumor size was 4.1 ± 1.78 cm (1–10 cm). Median operative time was 97 ± 40.5 min (45–300 min). Median blood loss was 30 ± 46.25 mL (6–300 mL). Mean visual analog scale measurements were 2.41 ± 2.04 (2–7), 1.17 ± 1.4 (0–5), and 0.47 ± 0.83 (0–3) on the first, second, and third days, respectively. Temporary hoarseness and hypoparathyroidism occurred in 8 patients (4%) and 35 patients (17.5%), respectively. No permanent hoarseness or hypoparathyroidism occurred. Mental nerve injury occurred in 3 patients (1.5%). One patient (0.5%) developed a post-operative hematoma that required open surgery. No infection was identified.
Conclusion
TOETVA was shown to be safe and feasible with a reasonable surgical duration and minimal pain scores. This approach shows promise for those patients who are motivated to avoid a neck scar.
Background
Transoral thyroid surgery is an ideal method for minimally invasive thyroidectomy, as there is less flap dissection during the procedure and no postoperative scars. Nonetheless, technical ...obstacles have precluded the wide dissemination of this procedure. We present the surgical procedures and outcomes of transoral robotic thyroidectomy (TORT).
Methods
From September 2012 to June 2016, we performed TORT at Korea University Hospital. We used three intraoral ports and a single axillary port for the system’s four robotic arms. The surgical outcomes were retrospectively reviewed.
Results
Twenty-four female patients (mean age 39.6 ± 11.6 years; mean tumor size 1.0 ± 1.3 cm) underwent unilateral thyroid lobectomies with or without ipsilateral central neck dissection. Twenty patients had papillary thyroid carcinomas (PTC), three had benign nodules, and one had a follicular thyroid carcinoma. The mean surgical time was 232 ± 41 min; the mean hospital stay was 3.3 ± 0.8 days. The number of retrieved central lymph nodes in the PTC patients was 4.7 ± 3.2. There were no reports of transient or permanent vocal cord palsy, recurrence, or mortality during the median follow-up period of 16.8 months. Paresthesia of the lower lip and the chin due to mental nerve injury was observed in nine of the first 12 patients (six transient, three permanent), but no further reports of paresthesia were recorded after patient 12, when the locations of the intraoral incisions were modified.
Conclusions
TORT is feasible and safe for selected patients after technical refinements, and can be a potential alternative approach for scarless thyroid surgery.
Human papillomavirus-associated head and neck squamous cell carcinomas (HPV-HNSCC) originate in the tonsils, the major lymphoid organ that orchestrates immunity to oral infections. Despite its ...location, the virus escapes immune elimination during malignant transformation and progression. Here, we provide evidence for the role of the PD-1:PD-L1 pathway in HPV-HNSCC immune resistance. We show membranous expression of PD-L1 in the tonsillar crypts, the site of initial HPV infection. In HPV-HNSCCs that are highly infiltrated with lymphocytes, PD-L1 expression on both tumor cells and CD68+ tumor-associated macrophages is geographically localized to sites of lymphocyte fronts, whereas the majority of CD8+ tumor-infiltrating lymphocytes express high levels of PD-1, the inhibitory PD-L1 receptor. Significant levels of mRNA for IFN-γ, a major cytokine inducer of PD-L1 expression, were found in HPV+ PD-L1(+) tumors. Our findings support the role of the PD-1:PD-L1 interaction in creating an "immune-privileged" site for initial viral infection and subsequent adaptive immune resistance once tumors are established and suggest a rationale for therapeutic blockade of this pathway in patients with HPV-HNSCC.
The presence of human papillomavirus (HPV) in unknown primary squamous cell carcinoma (UPSCC) of the head and neck at initial presentation focuses the investigation for the primary tumor on the ...oropharynx. The trends, frequency, and detection rate of UPSCCs have not been evaluated in the context of HPV tumor status.
To determine the frequency of UPSCC over time and to evaluate the proportion of HPV-positive UPSCCs.
Retrospective, single-institutional case series of patients diagnosed with UPSCC and evaluated at the Johns Hopkins Hospital from January 1, 2005, to June 1, 2014. Human papillomavirus tumor status was determined by p16 immunohistochemical analysis and/or high-risk HPV DNA by in situ hybridization as clinically available.
Number and clinical characteristics of UPSCC cases over time.
Eighty-four UPSCC cases were eligible for analysis. The mean age of the patients was 57.3 years (range 29-80 years), and 88.1% (n = 74) were male. The frequency of UPSCC increased significantly over time (P for trend = .01) and was significantly higher during later calendar periods (14 cases during 2005-2008 vs 39 cases during 2012-2014, P = .03). A total of 69 cases (90.7%) with available HPV tumor status were HPV-positive. The patients with HPV-positive UPSCC were significantly more likely to be male (91% vs 42.9%, P = .005) and younger (56.1 vs 67.7 years, P = .002) than the HPV-negative patients with UPSCC. The overall primary tumor site detection rate was 59.3% (n = 48). There was a nonsignificant increase in the detection rate from calendar periods 2005-2008 to 2012-2014 (50.0% vs 64.9%, P = .38). Since transoral robotic surgery was adopted in the diagnostic evaluation of UPSCC in 2011, a nonsignificant increase in the detection of primary tumors was observed (53.8% vs 64.3%, P = .34).
The frequency of UPSCC has increased significantly in recent calendar periods, and most cases are HPV-positive. As expected, patients with HPV-positive UPSCC tend to be male and younger.
Technological developments have disrupted the practice of medicine throughout history. Endoscopic and robotic techniques in head and neck surgery have emerged over the past half-century and have been ...incrementally adapted to expanding indications within otolaryngology. Robotic and endoscopic surgery have an established role in treatment of oropharyngeal and laryngeal cancers, reducing surgical morbidity and improving survival relative to traditional open approaches. Surgical treatment of human papillomavirus-mediated oropharyngeal cancer via transoral robotic surgery offers equivalent oncologic and functional outcomes relative to radiotherapy. Newer iterations of single-port robotic systems continue to expand the scope of robotics in head and neck surgery.
To investigate surgeon preferences for perioperative management of transoral robotic surgery (TORS) and explore the frequency of postoperative complications.
Retrospective survey.
...Multi-institutional.
An electronic survey was sent to over 300 TORS-trained surgeons in the United States identified by Intuitive Surgical, Inc. Participation was voluntary and solicited by email invitations to participate 3 times over a 1-month period.
A total of 2015 procedures were reported by 45 respondent TORS-trained surgeons: 67% academic, 33% nonacademic. A minority of TORS procedures (n = 214, 10.6%) were performed on previously irradiated patients. Neck dissections were performed concurrently (58%) or staged (42%). Fewer than 6% of TORS procedures required tracheotomy or reconstruction. Most surgeons (62%) initiated oral intake on postoperative day 0-1. Of the patients who required readmission, bleeding (n = 62, 3.1%) was the most common cause followed by dehydration (n = 26, 1.3%). Other complications of surgery included tooth injury (n = 29, 1.4%), percutaneous endoscopic gastrostomy (PEG) dependency >6 months (n = 21, 1.0%), temporary hypoglossal nerve injury (n = 18, 0.9%), and lingual nerve injury (n = 11, 0.6%). A total of 6 deaths (0.3%) were reported within 30 days of TORS. All reported deaths were due to postoperative hemorrhage. The complication rate decreased significantly with higher surgeon case volume (>50 cases).
TORS is associated with a low major complication rate, early initiation of oral intake, and a low rate of long-term PEG dependency. Postoperative hemorrhage was the most common cause of hospital readmission and postoperative mortality.
Objectives/Hypothesis
The nasopharynx remains one of the most challenging areas to surgically access given its deep location, narrow confines, and surrounding critical neurovascular anatomy. Various ...open and endoscopic approaches have been developed, all of which have been limited to some degree in their ability to bimanually instrument and visualize in this area.
Study Design
Cadaveric dissection.
Methods
Study using one fresh human cadaver. A novel, highly articulated endoscope with flexible instrumentation, the Flex System, was placed in the oral cavity and advanced around the soft palate into the nasopharynx to perform a nasopharyngectomy.
Results
A complete nasopharyngectomy was accomplished with the Flex System without palatal incisions or extended‐access approaches.
Conclusions
The Flex System is a novel computer‐assisted flexible endoscope with a highly articulated scope and flexible instruments that was successfully used to perform a nasopharyngectomy while avoiding any additional incisions. This system holds promise in minimally invasive skull base surgery.
Level of Evidence
NA Laryngoscope, 125:318–322, 2015
Objectives/Hypothesis
Transoral surgery is an increasingly frequent treatment modality for tumors of the upper aerodigestive tract. This is in large part related to the introduction of transoral ...robotic surgery (TORS) for oropharyngeal cancer resection, which has demonstrated excellent oncologic and functional outcomes. There is limited data, however, on how TORS compares to traditional open surgery in overall costs and length of hospitalization. With increasing pressure to contain and reduce the costs of medical care, we sought to evaluate the impact of TORS on a national sample of patients undergoing surgery for oropharyngeal cancer.
Study Design
Retrospective cross‐sectional study.
Methods
A cross‐sectional analysis of 9,601 patients who underwent an extirpative procedure for a malignant oropharyngeal neoplasm in 2008 to 2009 was performed using discharge data from the Nationwide Inpatient Sample.
Results
TORS was performed in 116 (1.2%) of cases. TORS patients had a lower rate of gastrostomy tube placement (0% vs. 19%), tracheotomy tube placement (0% vs. 36%), and nonroutine discharge (0% vs. 44%) compared to patients undergoing non‐TORS procedures. After controlling for all other variables, including comorbidity, extent of surgery, and teaching hospital status, TORS was associated with significantly decreased length of hospitalization (mean, −1.5 days) and hospital‐related costs (mean, −$4,285).
Conclusions
TORS is becoming an increasingly frequent technique to treat tumors of the upper aerodigestive tract. These data demonstrate that TORS is associated with a decreased length of hospitalization and hospital‐related costs compared to other surgical techniques.
Level of Evidence
2c. Laryngoscope, 124:165–171, 2014
Background
New ultrasensitive methods for detecting residual disease after surgery are needed in human papillomavirus–associated oropharyngeal squamous cell carcinoma (HPV+OPSCC).
Methods
To ...determine whether the clearance kinetics of circulating tumor human papillomavirus DNA (ctHPVDNA) is associated with postoperative disease status, a prospective observational study was conducted in 33 patients with HPV+OPSCC undergoing surgery. Blood was collected before surgery, postoperative days 1 (POD 1), 7, and 30 and with follow‐up. A subcohort of 12 patients underwent frequent blood collections in the first 24 hours after surgery to define early clearance kinetics. Plasma was run on custom droplet digital polymerase chain reaction (ddPCR) assays for HPV genotypes 16, 18, 33, 35, and 45.
Results
In patients without pathologic risk factors for recurrence who were observed after surgery, ctHPVDNA rapidly decreased to <1 copy/mL by POD 1 (n = 8/8). In patients with risk factors for macroscopic residual disease, ctHPVDNA was markedly elevated on POD 1 (>350 copies/mL) and remained elevated until adjuvant treatment (n = 3/3). Patients with intermediate POD 1 ctHPVDNA levels (1.2‐58.4 copies/mL) all possessed pathologic risk factors for microscopic residual disease (n = 9/9). POD 1 ctHPVDNA levels were higher in patients with known adverse pathologic risk factors such as extranodal extension >1 mm (P = .0481) and with increasing lymph nodes involved (P = .0453) and were further associated with adjuvant treatment received (P = .0076). One of 33 patients had a recurrence that was detected by ctHPVDNA 2 months earlier than clinical detection.
Conclusions
POD 1 ctHPVDNA levels are associated with the risk of residual disease in patients with HPV+OPSCC undergoing curative intent surgery and thus could be used as a personalized biomarker for selecting adjuvant treatment in the future.
Lay Summary
Human papillomavirus–associated oropharyngeal squamous cell carcinoma (HPV+OPSCC) is increasing at epidemic proportions and is commonly treated with surgery.
This report describes results from a study examining the clearance kinetics of circulating tumor HPV DNA (circulating tumor human papillomavirus DNA ctHPVDNA) following surgical treatment of HPV+OPSCC.
We found that ctHPVDNA levels 1 day after surgery are associated with the risk of residual disease in patients with HPV+OPSCC and thus could be used as a personalized biomarker for selecting adjuvant treatment in the future.
These findings are the first to demonstrate the potential utility of ctHPVDNA in patients with HPV+OPSCC undergoing surgery.
This report describes results from a study examining the clearance kinetics of circulating tumor human papillomavirus (HPV) DNA after surgical treatment of HPV+ head and neck cancer. It is the first report across HPV‐associated cancers to show that HPV liquid biopsy after surgery could be used as a marker of residual disease status.
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