Taiwan Head and Neck Society

Video

• 楊吉川講座 KS01

Field of Research

Head & Neck Surgical Oncology

Topic

Transcending the Limitation of Transoral Robotic Surgery

Abstract

Background. The purpose of this study was to evaluate the feasibility and safety of the single port surgical robotic system (da Vinci SP system) for performing transoral robotic surgery (TORS) in head and neck cancer patients.

Methods. From October 2018 to Dec 2022, we retrospectively reviewed the medical records of 277 patients who underwent TORS using the da Vinci SP system.

Results. During TORS, three robotic arms could be used to perform a geometric resection of the lesion in a narrow working space. The mean total operation time was 60 minutes and the average time required to set up the robotic system was within 10 minutes. All patients successfully underwent TORS. All robotic arms were inserted through a single port, which widened the working space around the patient's head and allowed for the operative assistant to easily approach the patient during operation. The joggle joint of the robotic arms aided in easy manipulation within the confined working space. Joggle joints of the endoscopic arm were controlled through the navigation system, which was very helpful in securing the superior visualization of the surgical site, especially in the area of larynx and hypopharynx.

Conclusions. We confirmed that da Vinci SP provided us technical advantages above the Si/Xi systems for performing TORS. Especially, it was helpful to ensure proper visualization of the surgical field and to perform precise surgery when operating the tongue-base or the laryngo-hypopharyngeal cancer.

Field of Research

Head and Neck Oncology/Microvascular Reconstruction/Skull Base Surgery

Publications (the latest 5 articles)

1. Lin DT, Lin B, Abt N, Bhanot H, Rajagopal J, Saladi SV. RUVBL1 (Tip49a) is an Amplified Epigenetic Factor Inhibiting Differentiation Program in Head and Neck Squamous Cancers.” Oral Oncology. 2020 Dec;111:104930.
2. Parikh AS, Fuller JC, Lehmann AE, Goyal N, Gray ST, Lin DT. Prognostic Impact of Adverse Pathologic Features in Sinonasal Squamous Cell Carcinoma. J Neurol Surg B Skull Base. 2019 Nov 13; 4(6):632-639.
3. Parikh AS, Puram SV, Faquin WC, Richmon JD, Emerick KS, Deschler DG, Varvares MA, Tirosh I, Bernstein BE, Lin DT. Immunohistochemical Quantification of Partial-EMT in Oral Cavity Squamous Cell Carcinoma Primary Tumors is Associated with Nodal Metastasis. Oral Oncol. 2019 Dec;99:104458.
4. Puram SV, Tirosh I, Parikh AS, Patel AP, Yizhak K, Gillespie S, Rodman C, Luo CL, Mroz EA, Emerick KS, Deschler DG, Varvares MA, Mylvaganam R, Rozenblatt-Rosen O, Rocco JW, Faquin WC, *Lin DT, *Regev A, *Bernstein BE. Single-Cell Transcriptomic Analysis of Primary and Metastatic Tumor Ecosystems in Head and Neck Cancer. Cell. 2017 Dec 14;171(7):1611-1624. *Co-Senior Authors
5. Sinha S, Dedmon MM, Naunheim MR, Fuller JC, Gray ST, Lin DT. Update on Surgical Outcomes of Lateral Temporal Bone Resection for Ear and Temporal Bone Malignancies. J Neurol Surg B Skull Base. 2017 Feb;78(1):37-42.

Video

• Extent of Surgical Resection in the Management of Sinonasal and Skull Base Malignancies: Is there a Role for Structure Preservation.

Topic

Strategies for combating therapeutic resistance of advanced head and neck cancer

Abstract

The recent progress in the treatment of recurrent/metastatic head and neck cancer (R/M HNSCC) significantly improves the outcome of these patients. The major treatment strategies for R/M HNSCC include platinum-based chemotherapy, anti-EGFR target therapy, and immune checkpoint inhibitors (ICI). However, resistance for these treatments compromises the outcome of patients and development of strategies for combating resistance is an urgent need. Regarding the resistance to the anti-EGFR monoclonal antibody cetuximab, it emerges rapidly after initial success of the treatment and the mechanisms for acquired resistance to cetuximab remains not totally clear. For ICI treatment in R/M HNSCC, the great success in second and first line treatments encourages the clinicians greatly. Emerging evidence indicates different strategies for overcoming ICI resistance, which includes combinatory therapy of ICI and tyrosine kinase inhibitors or other agents and application of different immunotherapeutic agents with distinct mechanisms. In the presentation, I would like to review the progress of R/M HNSCC treatment, the updated data of ICI in HNSCC, and the potential strategies for overcoming the resistance to target therapies and immunotherapies.

Topic

Annual meeting is cancelled due to pandemic of COVID-19.

Topic

Seminal research papers from Tata Memorial Hospital - The future of Head and Neck oncology lies in India

Abstract

TMH has been offering excellent services in the Head & Neck Oncology for several decades now. The high quality of work is not only limited to clinics but also extends to research. Majority of publications have been related to oral cancers. Management of neck in early node negative oral cancers has always been controversial. First prospective randomized trial for this was conducted by Fakih et el way back in 1980s. The controversy was laid to rest by the RCT by D’cruz et al where elective neck dissection showed a benefit in overall and disease free survival of 12.5 and 23.6% respectively. Another prospective study by Pantvaidya et al, found no skip metastasis at level IV and further found that level V positivity was determined by level II and III positivity. In another prospective study, Malik et al have shown the feasibility of preserving submandibular gland during neck dissection as it is very rarely involved per se and there is a very small chance of having nodes deep to the gland. Through a multicenter study by ICOR, importance of depth of invasion was recognized and it was included by AJCC in its 8th staging system. Coming onto the primary tumor, Mistry et al showed that mucosal shrinkage is noted post-surgery. Chaturvedi et al showed that if gross tumor margin was more than 7 mm then there was no additional advantage of doing frozen section. In two other papers, Chaturvedi et al demonstrated that oral cancers associated with oral sub mucous fibrosis had better clinico-pathological profile and had better survival too. Mair et al found that node negative T4b oral cancers had survival similar to node positive T4a tumors. Mishra et al proved that a margin of over 5 mm on final histopathology report should be aimed for and that there was no added survival advantage of margins beyond 7 mm. Survival advantage of neo-adjuvant chemotherapy in borderline resectable tumors has been demonstrated by Patil et al. Ghosh-Laskar et al chemoradiation achieved better locoregional control compared to conventional and accelerated radiotherapy.

Topic

2018 Ji-Chuan Yang International Lecture on Head and Neck Oncology Robotic surgery in Head & Neck : from the Da Vinci to the Medrobotics Flex system

Abstract

The main difficulty with laryngeal application of the da Vinci robot was getting a good visualization and exposure of the larynx due to the bend around the tongue base. The rigid endoscope of the da Vinci cannot do so and hence a complete appreciation of lesions of the larynx is not always possible. Over the last two years, a novel single-port operator-controlled computer assisted semi-rigid transoral ‘robotic’ system-the Medrobotics Flex was initially trialed in several centres in Western Europe and therefore in the USA Controversy sur rounding the use of the term ‘robot-assisted surgery’ does exist. This system is essentially an endoscopic system that is steered using a joystick ‘robotically’ by the operating surgeon who negotiates the curvilinear anatomy of the upper aerodigestive tract. It is therefore not a ‘line-of-sight’ system requiring angled endoscopes to ‘see’ around corners and does not utilize rigid ‘straight’ instrumentation.

The system is therefore ‘robotic’ in the manipulation of the flexible endoscope to the site of surgery but should not be confused as ‘robotic assisted’. The instruments are not ‘wristed’ like the da Vinci but are rotatable using flexible wire technology.

Additionally, the use of flexible instrumentation is manual and there are no robotic enhancements in surgical precision, tremor reduction and scaling of motion. Visualization is provided by a high definition digital camera incorporated in the distal end of the scope. The endoscope can currently extend as far as 17 cm hence access to the larynx and subglottis is well within reach. The instruments are 3.5mm and can project through the two side instrument ports 20mm beyond the tip of the endoscope.

The aim of this study was to assess the feasibility and ease of use of this system with a particular emphasis on visualization and resection procedures of laryngeal lesions.

Topic

Thyroid Molecular Testing Using Ultrasound

Abstract

1. Surgeon Performed Thyroid Ultrasound Guided FNAC with On-Site Cytopathology improves adequacy and accuracy.
2. Ultrasound Risk Stratification
3. Bethesda Cytology Classification for fine needle aspiration.
4. Molecular alteration testing for Indeterminate thyroid nodules improves specificity analysis and may reduce the number of completion thyroidectomies
5. Molecular alteration testing for Indeterminate thyroid nodules improves sensitivity analysis and may reduce surgery on benign nodules.
6. Commercially Available Molecular Testing for Thyroid Cancer:
7. Gene Mutation Panel: miRInform (Asuragen), now ThyGenX (Interpace)-Rule in cancer
8. Gene Expression Classifier (Afirma, Veracyte)-Rule out cancer
9. ThyroSeq v2.1 (CBL Path)- Rule in cancer/rule out cancer
10. ThyGenX + ThyraMIR (Interpace)-Rule in cancer/rule out cancer
11. Are Molecular Alteration tests valid predictors of false positives and negatives?
12. Genetics overview-BRAF, RAS, RET/PTC, PAX8/PPARg, mRNA panels, miRNA panels
13. Clinical Utility: Do Commercially available tests change management?
14. Factors that may mute the power of a rule in test and positive predictive value- and impact of new diagnostic category NIFTP
15. Incorporation of American Thyroid Association Guidelines and Molecular testing.
16. Algorithm to rule out cancer with molecular testing: prevalence and negative predictive value.
17. Prognostication with Multiple Mutations
18. Case examples
19. Indications favoring rule in testing: FLUS/FN, High Prevalence of cancer at your institution for Indeterminates FNAC, High risk ultrasound features, Highly specific mutation for cancer, Surgeon favoring total thyroidectomy for DTC <4cm.
20. Indications favoring rule out testing: FLUS/FN, Low prevalence of cancer at your institution for DTC on Indeterminates, Nodules < 4cm, No high risk history, physical or ultrasound features.
21. Conclusions.

Topic

Management of the Neck in the Era of "Organ Preservation"

Abstract

The treatment of advanced carcinomas of the larynx and pharynx has evolved from surgery and postoperative radiation to “organ preservation” strategies with various combinations of radiation and chemotherapy and more recently to tissue-sparing transoral endoscopic and robotic surgery. This has brought up several dilemmas in the management of the cervical lymph nodes, both electively and therapeutically.

The first dilemmas to be addressed in this presentation concern the timing and extent of elective node dissection, as well as the need to address the retropharyngeal lymph nodes, in patients with oropharyngeal tumors treated transorally with endoscopic or robotic assisted resection.

The second dilemma concerns the management of the clinically N0 neck in patients undergoing “salvage”, particularly laryngectomy after failure of treatment with radiation alone or in combination with chemotherapy.

The third set of dilemmas concern the management of patients with clinically obvious lymph node metastases, particularly those with advanced neck disease (N2 – N3), who are initially treated with radiation with or without chemotherapy. Issues to be discussed are whether or not a planned neck dissection should be performed, irrespective of the response of the tumor in the neck, the timing of the decision to dissect the neck nodes and the role of CT and PET scanning in identifying the subset of patients who need a neck dissection and in the decisions about the extent of the node dissection.

Topic

Debating issues for the management of tongue squamous cell carcinoma

Abstract

Oral cancer is the eighth most common cancer in worldwide and tongue squamous cell carcinoma(TSCC) is a common cancer in oral cavity. There were several issues of the treatment option for tongue squamous cell carcinoma. Elective neck dissection in patients with the clinical negative neck in early TSCC, safe surgical resection margin, and reconstruction method for TSCC will be discussed.

The treatment of patients with clinical negative neck (cN0) in T1-2 TSCC remains controversial. A conservative trend in the treatment OSCC N0 patients has encouraged the sentinel lymph node biopsy(SLNB). Our study SLNB for cN0 oral tongue SCC provides acceptable oncological outcomes by long-term observation. Despite the false positive rate of 11.7% in the SLNB application group, phase did not affect neck control rate, stringent strategy of follow-up and salvage treatment is mandatory to maintain acceptable outcomes.

Current NCCN Clinical Practice Guideline recommend the adjuvant treatment in case with close resection margins(~5mm) in patients with oral squamous cell carcinoma in spite of tumor size or stage. In our recent study, when the patients were stratified into small (T1-2) and large (T3-4) tumors, close margin was a significant risk factor for local recurrence in T3-4 OSCC(p=0.036, HR=11.079, 95% CI=1.170-104.863), but not in T1-2 OSCC. Close margin was not an independent risk factor of local recurrence in T1-2 OSCC while it significantly increased local recurrence rates in T3-4 OSCC.

Generally, a variety of different methods such as radial forearm free flap(RFFF) and anterolateral thigh free flap(ALTFF) have been used in tongue reconstruction according to the defect size and site. However, RFFF and ALTFF show various features in the donor site morbidity such as tendon exposure, skin graft loss and sensory deficits. Recently, we developed facial artery musculomucosal island flap (FAMMI) to reconstruct small and medium sized defects in tongue and mouth floor. FAMMI flap transferred to the neck through a paramandibular tunnel and transposed to the intraoral area for primary reconstruction of partial glossectomy defects. Intraoral donor site could be closed primarily or secondary with minimal scarring.