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Program Number: B219
Session Name: Poster Session

Outcomes of Unilateral vs. Bilateral Transoral Robotic Surgery for HPV+ Tonsillar Squamous Cell Carcinoma

Andrew M Peterson, MD, MSCI¹; Spencer R Bockover, MA¹; Dorina Kallogjeri, MD, MPH¹; Katherine Chang, MD²; Theresa Tharakan, MD, MSCI¹; R. Alex Harbison, MD¹; Paul Zolkind, MD¹; Jason T Rich, MD¹; Patrik Pipkorn, MD, MSCI¹; Sidharth V Puram, MD, PhD¹; Ryan Jackson, MD¹; ¹Washington University in St. Louis School of Medicine; ²Emory University School of Medicine

Introduction: The palatine tonsil is the most common subsite of human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (SCCa). With increasing use of transoral robotic surgery (TORS), primary surgical management followed by pathology-driven adjuvant therapy has become a mainstay of treatment. There is significant debate on how to manage the contralateral clinically-uninvolved tonsil. Some surgeons routinely perform a contralateral elective extra-capsular tonsillectomy. More recent studies have advocated for leaving the contralateral tonsil unoperated given no apparent impact on oncologic outcomes and the increased potential for complications. The objective of this study was to assess functional outcomes, survival, and complications between unilateral and bilateral TORS for tonsillar SCCa. 

Methods: This retrospective cohort study assessed all consecutive patients with unilateral primary HPV-associated tonsillar SCCa undergoing TORS from 6/2016 through 7/2023 at an academic medical center. The primary outcome measure was oropharyngeal hemorrhage. Secondary outcome measures included post-operative ED visit/hospitalization rate, severity of oropharyngeal hemorrhage based on the Mayo Clinic classification system, time-to-nasogastric tube (NGT) removal, rate of discharge with an NGT tube, change in MD Anderson Dysphagia Inventory (MDADI) scores, rate of contralateral second tonsillar primary SCCa, length-of-stay, and 2-year and 5-year disease-free survival (DFS) and overall survival (OS).

Results: A total of 158 (106 unilateral and 52 bilateral TORS) patients with HPV-associated tonsillar SCCa were evaluated, including 139 men with a mean (SD) age of 60 years (10). There were clinically meaningful differences in oropharyngeal hemorrhage rate (7% vs. 15%, percent difference: -7.8 [-18.8 to 3.2]), 30-day ED visit/hospitalization rate (9% vs 21%, percent difference: -11.7% [-24.1 to 0.7]), and median length-of-stay (2 vs. 3 days) for unilateral and bilateral TORS, respectively. Swallowing outcomes, DFS, and OS were not significantly different between the two groups (Figure 1). A total of 3 patients (1.9%) had a second primary in the contralateral tonsil, including 2 metachronous primaries in the unilateral TORS group (1.8%) and 1 synchronous primary incidentally removed at the time of surgery in the bilateral TORS group (1.9%).

Discussion: This study assessed the major considerations when determining unilateral vs. bilateral TORS for tonsillar SCCa, including post-operative complications, swallowing outcomes, risk of second primary, and oncologic survival. There was no trade-off in disease-free and overall survival in those patients undergoing unilateral TORS. The overall rate of incidental contralateral synchronous or metachronous second primaries is very low, consistent with more recent larger studies reporting a metachronous primary rate of 0.3% and incidental synchronous primary rate of 2.7%.

Conclusions: Omission of contralateral elective extra-capsular tonsillectomy in HPV+ SCCa is associated with a trend towards lower post-tonsillectomy hemorrhage, post-operative ED visits for pain control, and hospital length-of-stay without compromising survival. These data support the safety of omitting elective contralateral tonsillectomy, though further work is warranted to elucidate the potential benefits on post-operative complications and patient-reported outcomes. The decision to perform a simultaneous contralateral extra-capsular tonsillectomy can be addressed via clinician-patient shared decision-making with consideration of its added risks.

 

 

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