Faculty Bibliography

Retropharyngeal lymph node (RPLN) metastases can occur from advanced head and neck malignancies. Surgical access to RPLNs can be challenging. Considering the more aggressive conventional approach methods, there is an increasing need for minimally invasive techniques. Applying transoral robotic surgery (TORS) to access the RPLN has never been reported in the literature. The purpose of this study was to describe our experience with transoral robotic RPLN dissection for oropharyngeal and hypopharyngeal squamous cell carcinomas. We conducted a retrospective review of TORS cases performed at Severance Hospital, a tertiary care medical center from December 2011 to July 2012. Demographic, clinicopathologic, and treatment characteristics were abstracted from the medical record as well as complications and were analyzed descriptively. A total of 5 TORS procedures with transoral robotic RPLN dissection have been performed at Severance Hospital. Of these, 4 patients were treated for oropharyngeal squamous cell carcinoma and 1 for hypopharyngeal squamous cell carcinoma. The mean operation time for TORS including the robotic RPLN dissection was 84 ± 18.5 minutes. The operation time included time for docking of the robotic arms (4.8 ± 1.3 minutes), console working time for primary tumor removal (50 ± 8.9 minutes), and console working time for RPLN dissection (29.2 ± 9.4 minutes). No patients experienced complications related to the transoral robotic RPLN dissection. Transoral robotic RPLN dissection is a feasible approach for accessing retropharyngeal lymph nodes. This particular operative technique can serve as a minimal invasive surgery in removing pathologic RPLNs.

OBJECTIVES/OBJECTIVE:To evaluate the impact of margin sampling on local recurrence in patients with pT1-2 pN0 conventional squamous cell carcinoma of the oral tongue. MATERIALS AND METHODS/METHODS:Based on margin sampling, 126 cases were divided into group 1 (margins sampled from the glossectomy specimen only), group 2 (with revision of glossectomy margins), and group 3 (margins primarily sampled from the tumor bed). RESULTS:The probability of local progression-free survival at 3years was .90, .76 and .73 (p=.0389) in groups 1, 2, and 3, respectively. Groups differed by frequency of positive glossectomy specimen margins (p=<.0001) and by the average distance from carcinoma to the closest margin (4.5, 2.4, and 3.0mm for Groups 1, 2, and 3, respectively; p=.0009). Tumor bed margin status (positive vs. negative) and other parameters (e.g., pattern and depth of invasion) did not correlate with local recurrence. Status of the glossectomy specimen margins did correlate with outcome. A positive glossectomy margin conferred a relative risk of 2.5 (95% confidence interval, CI, 1 - 6.3) for local recurrence. A proportional hazards regression model for margin width found a hazard ratio of 0.67 (95% CI=.57-.98) comparable to a 33% decrease in risk of local recurrence for an increase of 1mm of margin width (p=.0271). CONCLUSIONS:Status of the glossectomy specimen margins rather than that of tumor bed margins was prognostically relevant. Reliance on tumor bed margins appears to be associated with worse local control, perhaps due to the narrower initial resection.

As minimally invasive surgery has become common in head and neck surgery, the role of robotic surgery has expanded from thyroid surgery and transoral robotic surgery (TORS) of the oropharynx and supraglottic to other areas. Surgeons have advanced the limits of TORS, adapting lasers to the Da Vinci robot for glottic cancer, and combining existing techniques for transoral supraglottic laryngectomy and hypopharyngectomy to perform transoral total laryngectomy. Skull base approaches have been reported with some success in case reports and cadaver models, but the current instrument size and configuration limit the applicability of the current robotic system. Surgeons have reported reconstruction of the head and neck via local and free flaps. Using the previously reported approaches for thyroidectomy via modified facelift incision, neck dissection has also been reported. Future applications of robotic surgery in otolaryngology may be additionally expanded, as several new robotic technologies are under development for endolaryngeal work and neurotology.

IMPORTANCE/OBJECTIVE:At many institutions, computed tomography with iodinated intravenous contrast medium is the preferred imaging modality for staging of the neck in squamous cell carcinoma of the head and neck. However, few studies have specifically assessed the diagnostic accuracy of computed tomography for determining the presence or absence of extracapsular spread (ECS). OBJECTIVE:To determine the accuracy of modern, contrast-enhanced, multidetector computed tomography in the diagnosis of ECS of cervical lymph node metastases from squamous cell carcinoma of the head and neck. DESIGN, SETTING, AND PARTICIPANTS/METHODS:Retrospective observational study at an academic tertiary referral center among 100 consecutive patients between May 1, 2007, and February 1, 2012, who underwent a lateral cervical neck dissection for squamous cell carcinoma of the head and neck with neck metastases of at least 1 cm in diameter on pathologic assessment. Exclusion criteria included malignant neoplasms other than squamous cell carcinoma, a delay in surgery longer than 6 weeks from the time of staging computed tomography, and prior treatment of the neck or recurrent disease or a second primary. MAIN OUTCOMES AND MEASURES/METHODS:Each patient was independently assigned a subjective score for the presence of ECS by 2 Certificate of Added Qualification-certified neuroradiologists according to a 5-point scale. Receiver operating characteristic curves were generated, and sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were calculated for each observer. RESULTS:The areas under the receiver operating characteristic curve for observers 1 and 2 are 0.678 (95% CI, 0.578-0.768) and 0.621 (95% CI, 0.518-0.716), respectively. For observer 1, the positive and negative predictive values for the detection of ECS were 84% (95% CI, 68%-93%) and 49% (95% CI, 36%-62%), respectively. For observer 2, the positive and negative predictive values for the detection of ECS were 71% (95% CI, 57%-82%) and 48% (95% CI, 32%-64%), respectively. CONCLUSIONS AND RELEVANCE/CONCLUSIONS:Computed tomography cannot be used to reliably determine the presence of pathologic ECS. Radiologic findings suggestive of ECS should not be relied on for treatment planning in squamous cell carcinoma of the head and neck.

OBJECTIVES/HYPOTHESIS/OBJECTIVE:To evaluate the transoral anatomy of the tonsillar fossa and lateral pharyngeal wall and to correlate these findings with radiographic measurements and transoral robotic surgery (TORS) of patients with early tonsillar tumor. STUDY DESIGN/METHODS:Preclinical cadaveric study and patient cohort. METHODS:Six complete cadaveric dissections were performed to identify key anatomic landmarks, and these landmarks were validated in two consecutive patients with T1 human papillomavirus-positive squamous cell carcinoma of the tonsil treated by TORS. For radiographic landmark analysis, 25 patients who underwent contrast-enhanced computed tomography (CT) of the neck for a variety of endoscopic skull base procedures were selected. Measurements were taken from the lateral pharyngeal wall at C2-C3 interspace and greater horn of hyoid (C6) to the external carotid artery (ECA). RESULTS:The glossopharyngeal (IX) nerve was consistently identified deep to the superior constrictor musculature and at the intersection of the posterior tonsillar pillar with the base of tongue. The styloglossus muscle forms the deep plane medial to the ECA. The mean measurements for left C2-C3 interspace to the ECA and right C2-C3 interspace to ECA were 17.6 ± 0.8 mm and 18.4 ± 0.8 mm, respectively. Similarly, the mean measurements for left hyoid to ECA and right hyoid to ECA were 3.4 ± 0.8 mm and 4.3 ± 0.6 mm, respectively. CONCLUSIONS:A systematic approach to dissect the tonsillar fossa and lateral pharyngeal wall can be performed using key anatomic landmarks. CT measurements taken at the C2-C3 interspace and greater horn of hyoid bone (C6 level) to the ECA are consistently and reliably achieved.

IMPORTANCE/OBJECTIVE:Since technologic advances allow the use of robotic assistance in various surgical interventions performed to treat pediatric otolaryngology patients, the feasibility and outcomes of potential procedures must be assessed. OBJECTIVE:To assess the feasibility and outcomes of robotic-assisted lingual tonsillectomy in the pediatric population. DESIGN, SETTING, AND PARTICIPANTS/METHODS:Retrospective medical record review in a tertiary care children's hospital of 16 pediatric patients who underwent robotic-assisted lingual tonsillectomy from March 1, 2011, through December 31, 2012. INTERVENTION/METHODS:All patients underwent robotic-assisted lingual tonsillectomy using the da Vinci Surgical System (Intuitive Surgical, Inc) at the Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center. MAIN OUTCOMES AND MEASURES/METHODS:Demographic data, comorbidities, robot docking time, operative time, estimated blood loss, and postoperative course, including complications in the immediate and longer-term postoperative period, were collected and analyzed. RESULTS:All patients successfully underwent lingual tonsillectomy using the da Vinci Surgical System. Endotracheal intubation was performed in all patients and did not interfere with visualization of the oropharynx. Optimal retraction allowed visualization of pertinent structures and maximized transoral access. A significant learning curve from the first 5 surgical cases to subsequent cases with respect to robot docking time was observed (9 vs 3 minutes, respectively; P < .05). Operative time, estimated blood loss, and postoperative complication profiles are within the expected and acceptable limitations for performing lingual tonsillectomy in the pediatric population. CONCLUSIONS AND RELEVANCE/CONCLUSIONS:Technologic advances have allowed miniaturization of robotic instrumentation and have expanded the scope of surgical options for the pediatric airway. Robotic-assisted lingual tonsillectomy is well tolerated and can be performed in the pediatric population with excellent success. It should be considered a feasible option for implementation at an institution-based level.

The development of robotic surgery has brought new levels of precision and control to minimally invasive surgical techniques. Its effectiveness, well established in urologic and gynecologic surgery applications, has also been demonstrated in cardiac, endocrine and general surgery. Recently, trans-oral robotic approaches to oropharyngeal tumor resection have been reported and, by eliminating the need for morbid lip and mandible splitting approaches, trans-oral robotic surgery (TORS) has allowed a re-assessment of surgical options for early stage tumors which have until recently been treated primarily with chemoradiation. The application of the TORS approach to malignant and non-malignant conditions affecting the oropharynx has created the need to develop robotic-assisted methods of managing the resultant tissue defects and to assess and compare the effectiveness of these procedures. This report details our early experience with the use of robotic surgery for management of soft tissue defects of the oropharynx in 12 patients.

BACKGROUND: Typically, thyroid follicular neoplasm/suspicious for follicular neoplasm (FN/SFN) cases show moderate to marked cellularity and scant or absent colloid. Recently, cases have been noted with microfollicular cellularity in the background of moderate to abundant amount of colloid. The purpose of this study was to compare these "colloid-rich" FN/SFN cases to the typical FN/SFN cases. METHODS: Thyroid cytology specimens with the features of FN/SFN were searched in cytopathology files from September 2008 to June 2012. Cases with absent or minimal colloid were designated "typical colloid-poor" FN/SFN and cases with moderate to abundant colloid were designated "colloid-rich" FN/SFN. From these cases, those with surgical pathology resection follow-up were identified. Cytologic, surgical pathology resection, and molecular features (BRAF, RAS, RET/PTC, and PAX8-PPARgamma) were investigated for the typical colloid-poor FN/SFN cases and were compared with those of the colloid-rich FN/SFN cases. RESULTS: Of 431 FN/SFN cases with surgical pathology resection follow-up, 360 (83.5%) cases showed features of typical colloid-poor FN/SFN and 71 (16.5%) cases showed features of colloid-rich FN/SFN. Papillary carcinoma was the most common malignant outcome for the 2 groups. Although the proportion of malignant outcome was similar for the 2 groups, the "colloid-rich" FN/SFN cases showed a greater proportion of nodular hyperplasia among the cases with benign outcome. In addition, the "colloid-rich" FN/SFN cases demonstrated a greater proportion of cases with a mutation. CONCLUSIONS: Approximately one-sixth of cases of FN/SFN show "colloid-rich" features. Comparison to the typical colloid-poor FN/SFN demonstrated similar risk for malignancy but contrasting resection outcome and molecular characteristics.

OBJECTIVES/HYPOTHESIS/OBJECTIVE:Organ preservation surgery is a major focus in head and neck oncology. Current approaches are aimed toward improving quality of life and decreasing treatment-related morbidity. Transoral robotic surgery was developed to overcome the limitations of traditional surgical approaches. The most widely used robotic system is the da Vinci Surgical System. Although the da Vinci offers clear surgical advantages over traditional approaches, its rigid operative arms prevent complex maneuverability in three-dimensional space. The ideal surgical robot would configure to the anatomy of the patient and maneuver in narrow spaces. We present the first cadaveric trials of the use of a highly flexible robot able to traverse the nonlinear upper aerodigestive tract and gain physical and visual access to important anatomical landmarks without laryngeal suspension. STUDY DESIGN/METHODS:Feasibility. METHODS:Using human cadavers, we investigated the feasibility of visualizing the endolarynx transorally with a highly flexible robot without performing suspension of the larynx. Two fresh and four preserved human specimens were used. RESULTS:Unhampered visualization of the endolarynx was achieved in all specimens without performing laryngeal suspension. Standard mouth retractors facilitated the delivery of the robot into the endolarynx. CONCLUSIONS:The flexible robot technology mitigates laryngeal suspension and the limitations of current robotic surgery with rigid line-of-sight-directed instruments. Having demonstrated the feasibility of physical and visual access to the endolarynx, future work will study the feasibility of using the highly flexible robot in transoral robotic procedures with flexible instrumentation placed in the robot's available working ports.