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Program Number: B232
Session Name: Poster Session

Resection Beyond Initial Incisions in Transoral Robotic Surgery is Associated with Adverse Pathologic Features in Oropharyngeal Cancer

Hannah L Kenny, MD; Kelly M Bridgham, MD; Eric V Mastrolonardo, MD; Praneet Kaki, BS; Joseph M Curry, MD; Thomas Jefferson University Hospital

Introduction: Positive surgical margins is a well-established poor prognosticator in oropharyngeal squamous cell carcinoma (OPSCC); transoral robotic surgery (TORS) has improved visualization and access in the oropharynx, facilitating adequate resection; however, reduced haptic feedback may increase the likelihood of initial incisions being within or close to tumor margins. The relationship between initial incision margins (IIM) and outcomes in OPSCC is not well-defined; one retrospective study found that positive or close deep IIMs on pathology review was associated with worse disease-specific survival and recurrence in HPV+ OPSCC. This study aims to evaluate the association between resection beyond IIMs in OPSCC and adverse pathologic features. 

Methods: All patients with OPSCC undergoing TORS between 1/1/2018 and 12/31/2023 at a single institution were included in this retrospective study. Pathology reports were reviewed to collect tumor data including subsite, p16 status, staging and adverse features; operative reports were reviewed to determine if patients underwent additional resection of tissue beyond IIMs, and reason for re-resection (whether prompted by surgeons’ gross tumor analysis versus close or positive margins on intra-operative pathology review). Chi-squared analyses were performed to evaluate association between additional resection and adverse pathologic features including lymphovascular invasion (LVI) and perineural invasion (PNI). 

Results: 361 cases met inclusion criteria for this study; there were 124 (34.3%) tonsil primary sites, 189 (52.4%) base of tongue primary sites, and 39 (10.8%) glossotonsillar sulcus primary sites. 334 (92.5%) were p16+; 24 (6.63%) were p16-. 187 (51.8%) were staged as T1, 147 (40.7%) were T2, 23 were (6.4%) T3, and 2 (0.5%) were T4. 157 (43.8%) patients underwent resection beyond IIMs, whereas 203 (56.2%) did not. 88 of 157 (55.7%) who underwent additional resection had LVI on final pathology, whereas 58 of 203 (28.6%) who did not undergo additional resection had LVI (x^2=27.1395, p<0.00001). 44 (27.8%) of those who underwent additional resection had PNI; 30 (14.8%) of those who did not undergo additional resection had PNI (x^2=9.319, p=0.00227). The association between additional resection and adverse features remained significant when evaluating only those prompted by surgeons’ gross tumor analysis; the association was not significant when evaluating only those prompted by close or positive margins on intra-operative pathology review. 

Conclusion: In this retrospective review study, resection beyond initial incisions in TORS for OPSCC was associated with LVI and PNI, which are known risk factors for worse overall and disease-free survival; this association remained significant when evaluating additional resections prompted by surgeons’ gross tumor analysis, prior to pathology review. This association warrants further study to better-delineate factors impacting surgeons’ planning of initial incisions and decision to resect further tissue prior to pathology consultation, which could identify any variables confounding the association between IIM and adverse pathologic features. If future evidence continues to support this association, this might prompt consideration of planning initial incisions based on findings from initial tumor biopsy.

 

 

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