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Program Number: B218
Session Name: Poster Session

Unilateral vs. Bilateral Transoral Surgery for Tonsillar Squamous Cell Carcinoma: Systematic Review and Meta-Analysis

Andrew M Peterson, MD, MSCI; Lucas Cruz, BA; Michael P Wu, MD; Spencer R Bockover, MA; Dorina Kallogjeri, MD, MPH; Lauren H Yaeger, MLIS; Alex Harbison, MD; Paul Zolkind, MD; Jason T Rich, MD; Patrik Pipkorn, MD, MSCI; Sidharth V Puram, MD, PhD; Ryan S Jackson, MD; Washington University in St. Louis School of Medicine

Introduction: Transoral surgery via radical tonsillectomy followed by pathology-guided adjuvant therapy is standard-of-care for resectable tonsillar SCCa. There is institutional and surgeon-to-surgeon variation on the management of the contralateral tonsil without clinical evidence of disease. Some surgeons recommend routine contralateral extra-capsular tonsillectomy citing an up to 10% synchronous bilateral tonsil second primary rate, while others omit operating on the contralateral tonsil due to the potentially higher complication rate and worsened functional outcomes. The objective of this study was to systematically review the literature and meta-analyze the second primary rates, oncologic survival, functional outcomes, and complications between bilateral (BL) and unilateral (UL) trans-oral surgery for tonsillar SCCa.

Methods: A search of Embase, Ovid Medline, Scopus, Cochrane, and Clinicaltrials.gov from inception to September 11, 2024, was performed. Studies included must have >10 patients, specify their surgical approach, and report at least one of the primary or secondary outcome measures. The primary outcome measures were the synchronous and metachronous contralateral second tonsil primary rates. Secondary outcome measures included between-groups combined proportion differences of post-operative oropharyngeal hemorrhage rates, long-term G-tube dependence rates, and 2-year and 5-year overall survival (OS) and disease-free survival (DFS). Two blinded investigators independently extracted data from each study. Data were pooled using a random-effects model of proportions using the method of DerSimion and Laird.

Results: A total of 135 unique citations were identified, and 10 full texts along with data from an institutional unpublished cohort were included in the final qualitative and quantitative review representing a total of 1486 patients (634 BL and 852 UL). The combined synchronous contralateral tonsil second primary rate in the BL group was 4% (95% CI: 2 to 6%, I2 27.5%) (Figure 1A). The combined estimate of the metachronous contralateral tonsil second primary rate in the UL group was 0.1% (95% CI: 0 to 1%, I2 0%) (Figure 1B). There were no between-groups proportional differences in oropharyngeal bleed rate [-0.2% (95%CI: -5.6 to 5.3%)} or long-term G-tube dependence rate [-0.5% (95%CI: -5.2 to 4.3%)}. The combined BL vs. UL group estimates for 2-year OS (93.4% vs. 95.6%), 5-year OS (80.4% vs. 83.6%), 2-year DFS (94.4% vs 91.2%), and 5-year DFS (75.4% vs. 84.1%) included only HPV+ patients and did not differ between groups.

Discussion: For patients undergoing UL surgery for tonsillar SCCa, the metachronous contralateral tonsil second primary rates are clinically negligible with an estimate far less than 1%. The rate of simultaneous synchronous bilateral tonsillar SCCa for patients undergoing BL surgery is lower than the often-cited rate of 10%. Surgeons can use this data to counsel their patients, while also considering no clinically significant differences in survival, oropharyngeal bleed rate, and G-tube dependence between the two surgical approaches.

Conclusion: Omission of contralateral elective extra-capsular tonsillectomy in tonsillar SCCa is safe with extraordinarily low metachronous contralateral tonsillar second primary rates and no compromise in survival. The decision to perform a simultaneous contralateral extra-capsular tonsillectomy can be addressed via clinician-patient shared decision-making with consideration of its pros and cons.

 

 

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