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Original Investigation
June 20, 2019

Occult Nodal Disease and Occult Extranodal Extension in Patients With Oropharyngeal Squamous Cell Carcinoma Undergoing Primary Transoral Robotic Surgery With Neck Dissection

Author Affiliations
  • 1Department of Otolaryngology–Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
  • 2Department of Otolaryngology–Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
  • 3Princess Margaret Cancer Center, Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
  • 4Montefiore Medical Center, Department of Radiology, Albert Einstein College of Medicine, Bronx, New York
  • 5Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
  • 6Montefiore Medical Center, Department of Otolaryngology–Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, New York
  • 7Princess Margaret Cancer Centre and Dalla Lana School of Public Health, Biostatistics Department, University of Toronto, Toronto, Ontario, Canada
JAMA Otolaryngol Head Neck Surg. 2019;145(8):701-707. doi:10.1001/jamaoto.2019.1186
Key Points

Question  What is the rate of occult extranodal extension and postoperative nodal upstaging in patients with pathologic T1-2 oropharyngeal squamous cell carcinoma treated by transoral robotic surgery and neck dissection?

Findings  In this cohort study of 92 patients with oropharyngeal squamous cell carcinoma from 3 different centers, the rate of occult extranodal extension on final pathologic findings was 13%. In the entire cohort, the nodal category of 12 patients (13%) was upstaged postoperatively, and the nodal category of 12 (13%) was downstaged postoperatively.

Meaning  These results suggest that preoperative prediction of nodal disease and extranodal extension remains a challenge for patients with localized oropharyngeal squamous cell cancer.

Abstract

Importance  The historically reported rates of subclinical cervical nodal metastases in oropharyngeal squamous cell carcinoma (OPSCC) predate the emergence of human papillomavirus as the predominant causative agent. The rate of occult nodal disease with changing etiology of OPSCC is not known, and it is challenging to anticipate which patients will be upstaged postoperatively and will require adjuvant therapy.

Objective  To assess the rate of nodal upstaging and occult extranodal extension (ENE) in a multi-institutional population of patients with pathologic (p)T1-2 OPSCC treated by transoral robotic surgery and neck dissection.

Design, Setting and Participants  This retrospective, multicenter cohort study of 92 participants at 2 US institutions (Albert Einstein College of Medicine, Bronx, New York [n = 38], and Icahn School of Medicine at Mount Sinai, New York, New York [n = 39]) and 1 Canadian institution (Princess Margaret Hospital, Toronto [n = 15]) examined the rate of postoperative pathologic upstaging for 92 patients with pT1-2 OPSCC undergoing transoral robotic surgery with neck dissection from August 2007 to December 2016. A neuroradiologist at each site blinded to final pathologic diagnosis reviewed preoperative imaging; these findings were compared with operative pathology and applied for tumor staging using the eighth edition of the American Joint Committee on Cancer Cancer Staging Manual. The statistical analysis was performed on December 18, 2018.

Main Outcomes and Measures  Occult pathologic nodal disease and change in nodal category postoperatively.

Results  Of 92 patients who met the inclusion criteria, 76 (83%) were male, and they had a mean (SD) age at surgery of 59.5 (10.5) years; 70 patients (84%) with available p16 status were positive. Five of 18 patients (28%) who had no evidence of nodal disease on imaging had occult pathologic nodal disease. Seven of 32 patients (22%) presenting with no nodal disease or with a single metastatic node on imaging received pathologic upstaging because of multiple positive nodes, indicating implementation of additional adjuvant treatment not anticipated after a priori imaging. Changes included 12 patients (13%) who had pathologic nodal upstaging and 12 (13%) with pathologic nodal downstaging in the eighth edition of staging. In the cohort, 24 patients (27%) had pathologic ENE, and 5 of 39 patients (13%) had occult ENE in the absence of radiographic evidence.

Conclusions and Relevance  Predicting pathologic staging preoperatively for patients with OPSCC undergoing transoral robotic surgery and neck dissection remains a challenge. Although nodal size, tumor size, and location do not help predict ENE, the presence of nodes on imaging and nodal category may help predict ENE. Our findings suggest a small proportion of patients might benefit from further adjuvant therapies not predicted by preoperative imaging based on occult nodal upstaging and ENE.

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