Achim Virginie, Bolognone Rachel K, Palmer Andrew D, Graville Donna J, Light Tyler J, Li Ryan, Gross Neil, Andersen Peter E, Clayburgh Daniel
Department of Head and Neck Surgery, Oregon Health and Science University, Portland.
The Northwest Clinic for Voice and Swallowing, Oregon Health and Science University, Portland.
JAMA Otolaryngol Head Neck Surg. 2018 Jan 1;144(1):18-27. doi: 10.1001/jamaoto.2017.1790.
In recent years, transoral robotic surgery (TORS) has emerged as a useful treatment for oropharyngeal squamous cell carcinoma (OPSCC). In appropriately selected patients, the use of TORS may allow avoidance of adjuvant chemotherapy and/or radiotherapy, thereby avoiding the long-term adverse effects of these therapies.
To compare functional speech, swallowing, and quality-of-life outcomes longitudinally between those undergoing TORS only and those undergoing TORS and adjuvant radiotherapy (TORS+RT) or TORS and chemoradiotherapy (TORS+CRT).
DESIGN, SETTING, AND PARTICIPANTS: This prospective, longitudinal cohort study performed from June 1, 2013, through November 31, 2015, included 74 patients undergoing TORS for initial treatment of OPSCC at a single tertiary academic hospital.
Data were collected at baseline, postoperatively (7-21 days), at short-term follow-up (6-12 months), and at long-term follow-up (>12 months). The quality-of-life metrics included the 10-item Eating Assessment Tool and the University of Michigan Head and Neck Quality of Life instrument. Data were also collected on tumor staging, surgical and adjuvant therapy details, patient comorbidities, tracheostomy and feeding tube use, and functional speech and swallowing status using the Performance Status Scale for Head and Neck Cancer Patients.
Seventy-four patients were enrolled in the study (mean [SD] age, 61.39 [7.99] years; 68 [92%] male). Median long-term follow-up was 21 months (range, 12-36 months). The response rates were 86% (n = 64) postoperatively, 88% (n = 65) at short-term follow-up, and 86% (n = 64) at long-term follow-up. In all 3 groups, there was a significant worsening in pain and all swallowing-related measures postoperatively. There was subsequent improvement over time, with different trajectories observed across the 3 intervention groups. Postoperative dysphagia improved significantly more quickly in the TORS-only group. At long-term follow-up, weight loss differed between the TORS-only and TORS+RT groups (mean difference, -16.1; 97.5% CI, -29.8 to -2.4) and the TORS-only and TORS+CRT groups (mean difference, -14.6; 97.5% CI, -29.2 to 0) in a clinically meaningful way. In addition, the TORS-only group had significantly better scores than the TORS+CRT group on the Performance Status Scale-Eating in Public scale (mean difference, 21.8; 97.5% CI, 4.3-39.2) and Head and Neck Quality of Life-Eating scale (mean difference, 21.2; 97.5% CI, 4.0-38.3).
Patients who underwent TORS+CRT demonstrated poorer long-term outcomes, with continued dysphagia more than 1 year after surgery. These findings support the investigation of adjuvant de-escalation therapies to reduce the long-term adverse effects of treatment.
近年来，经口机器人手术（TORS）已成为口咽鳞状细胞癌（OPSCC）的一种有效治疗方法。在适当选择的患者中，使用TORS可能避免辅助化疗和/或放疗，从而避免这些治疗的长期不良反应。
纵向比较仅接受TORS治疗的患者与接受TORS联合辅助放疗（TORS+RT）或TORS联合放化疗（TORS+CRT）的患者在功能性言语、吞咽和生活质量方面的结果。
设计、设置和参与者：这项前瞻性纵向队列研究于2013年6月1日至2015年11月31日进行，纳入了一家三级学术医院中74例接受TORS进行OPSCC初始治疗的患者。
在基线、术后（7-21天）、短期随访（6-12个月）和长期随访（>12个月）时收集数据。生活质量指标包括10项饮食评估工具和密歇根大学头颈生活质量量表。还收集了肿瘤分期、手术和辅助治疗细节、患者合并症、气管切开术和饲管使用情况，以及使用头颈癌患者功能状态量表评估的功能性言语和吞咽状态的数据。
74例患者纳入研究（平均[标准差]年龄，61.39[7.99]岁；68例[92%]为男性）。长期随访的中位数为21个月（范围，12-36个月）。术后应答率为86%（n = 64），短期随访时为88%（n = 65），长期随访时为86%（n = 64）。在所有3组中，术后疼痛和所有与吞咽相关的指标均有显著恶化。随后随时间有所改善，3个干预组观察到不同的变化轨迹。仅接受TORS治疗的组术后吞咽困难改善明显更快。在长期随访中，仅接受TORS治疗的组与TORS+RT组（平均差异，-16.1；97.5%CI，-29.8至-2.4）以及仅接受TORS治疗的组与TORS+CRT组（平均差异，-14.6；97.5%CI，-29.2至0）之间的体重减轻在临床上具有显著差异。此外，仅接受TORS治疗的组在公共场合进食功能状态量表（平均差异，21.8；97.5%CI，4.3-39.2）和头颈生活质量饮食量表（平均差异，21.2；97.5%CI，4.0-38.3）上的得分显著高于TORS+CRT组。
接受TORS+CRT治疗的患者长期结局较差，术后1年多仍持续存在吞咽困难。这些发现支持对辅助降阶梯治疗进行研究，以减少治疗的长期不良反应。
