TORS and Transoral Laser Microsurgery for Oropharyngeal Cancer. Baran Sumer MD, FACS Assistant Professor Department of Otolaryngology

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1 TORS and Transoral Laser Microsurgery for Oropharyngeal Cancer Baran Sumer MD, FACS Assistant Professor Department of Otolaryngology

2 1951 Huet described a transoral technique for surgical resection of the oropharynx maintaining continuity of the mandible. N=166 SCCA Tonsil (131 received induction chemotherapy) from year local control 82% 5 year OS 58% Significant surgical complications 6.3%. 7 temporary tracheostomies (3.7%) 59% required NGT. No permanent gastrostomy tube or tracheostomy. Laccourreye O, Arch Otolaryngol Head Neck Surg 2005 Holsinger FC, Arch Otolaryngol Head Neck Surg 2005

3 TORS Radical Tonsillectomy Indications SCCA of the oropharynx Contraindications: Unresectable neck nodes Mandibular invasion Tongue base involvement requiring resection of greater than 50% of the tongue base Pharyngeal involvement necessitating resection of more than 50% of the posterior pharyngeal wall Carotid artery involvement Fixation to prevertebral fascia Previous head and neck surgery Unfavorable anatomy Infection Unable to tolerate anesthesia. Weinstein GS, Arch Otolaryngol Head Neck Surg 2007 Technique is a modification of transoral oropharyngectomy described by Holsinger. 1. Tumor exposed with Crow-Davis 2. Robot docked with patient using 0 endoscope 3. Incision thru buccal mucosa at the pterygomandibular raphe using 5mm spatula cautery 4. 5 mm Maryland used to grasp and retract buccal mucosa medially 5. Constrictors elevated, styloglossus, stylopharyngeous transected. 6. Carotid artery identified 7. Posterior FOM incised to lateral tongue mucosa. (Robotic visualization allow better access to this area and allows resection of more BOT with well visualized margins) 8. If lingual artery transected it is clipped in triplicate to ensure hemostasis. 9. BOT resected to vallecula 10. Posterior pharyngeal wall resected from

4 TORS in Oropharyngeal cancer N=45 patients 100% negative margins. Mean OR time was 71 minutes. 43/45 underwent neck dissection. 14 temporary tracheostomies (all decannulated) 49% NGT (all removed) 18% required PEG tube (all removed) Average hospital stay 3.8 days. Moore EJ, Laryngoscope 2009

5 Principles of TOLS (Transoral Custom Tailored Surgery Strategy is determined by individual spread of tumor adjusting surgical procedure to the intraoperative findings. Blockwise Resection Cutting through larger tumors allows estimation of tumor depth minimizing resection of normal tissue. Cutting through larger tumors allows access to remainder of tumor. Steiner W, Endoscopic Laser Surgery of the Upper Aerodigestive Tract, 2000

6 Principles of TOLS (Transoral Stepwise mosaic exposure Overcomes line of sight limitation. Examples of Surgical Principles superior to inferior lateral to medial Steiner W, Endoscopic Laser Surgery of the Upper Aerodigestive Tract, 2000

7 Increase in Spatial Complexity Volume= Side 3 = View thru laryngoscope; Side=0.5 units = Tumor Volume T1; Side=1 unit T2; Side=2 units Original Views needed for complete resection=8 Increases to the third power. Original Views needed for complete resection=64

8 TOLS Surgery of the Oropharynx 48 patients treated from % were Stage III or Stage IVa. T1-2% T2-25% T3-15% T4-58% 5 year overall local control rate was 85%. There were no local recurrences in T1-T2 lesions. No patients required a tracheostomy. At one year 3 patients (6%) required a feeding tube. Steiner, W et al. Arch Otolaryngol Head Neck Surg Jan, 2003

9 Summary of Some Trials in HPV Era Transoral Surgery (tonsillar), Moore 102 patients, 81% Stage III and IV OS 92% at 2 years. 1 tracheostomy Gastrostomy tubes; 3.9% TORS, Cohen 50 patients, 86% Stage III and IV OS 80-81% at 2 years 1 tracheostomy Gastrostomy tubes; 2.4% TOLS, Haughey 203 patients, 100% Stage III and IV OS 86% at 3 years. 1 tracheostomy Gastrostomy tubes; 3.4%

10 Patient Characteristics

11 Patient Characteristics-

12 Patient Characteristics- Laser(n=16) T1 T2 T3 T4 Total N N N2a N2b N2c N Total Robotic(n=17) T1 T2 T3 T4 Total N N N2a N2b N2c N Total

13 Exposure TORS N=17 1 tongue paresthesia, 1 tongue laceration TOLS N=16 none

14 Exposure The 7 T s of Acces Teeth/Mandible Trismus Tori Tongue Tilt Treatment Tumor Haughey BH

15 Operative Time 11 patients underwent bilateral neck dissections.

16 Blood Loss and Intraoperative Fluids Blood Loss and Fluids Margins All positive margins reresected to negative margins. Complications Robotics One neck hematoma requiring emergent evacuation One MI requiring coronary artery stenting. One patient with accessory nerve injury. Laser One airway obstruction requiring emergent tracheostomy. One episode of aspiration pneumonia 2 patients with accessory nerve injury. One patient with vagus nerve injury and TVC paresis.

17 Functional Outcomes MDADI (MD Anderson Dysphagia Inventory) Score is an average of the four subscales in the inventory: Global, Emotional, Functional, Physical.

18 Oncologic Outcomes One death in laser group from second primary lung cancer 27 months after surgery. Disease free from head and neck cancer. One local recurrence in laser group patient 2 months after surgery who refused adjuvant chemoradiation. Median FU only 8.5 months.

19 Conclusions All transoral techniques highly successful in treating advanced stage oropharyngeal cancer. Excellent oncologic and functional outcomes. Short hospital stay. Similar EBL, fluids, and complications and OR time. Advances in Surgical Therapy Huet s description of transoral resection. Obviates need for disruption of the external superstructure. Allows removal of tumor and margin only. TOLS; technique for resecting more advanced and less accessible tumors Cutting through larger tumors allows access to remainder of tumor and minimizes loss of normal tissue. Custom tailored mosaic resection TORS; is a significant advance that improves access Reduces the spatial complexity of the resection. Allows greater standardization of the surgical approach even for larger, less visible tumors.

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