Innovatieve Chirurgische Technieken in Hoofd-en Hals Oncologische Heelkunde: Huidige Technologieën en Applicaties en Ontwikkelingen voor de Toekomst

Innovative Surgical Techniques in Head and Neck Oncologic Surgery: Current Technologies and Applications and Developments for the Future Introduction Surgical treatment of head and neck malignancies are often associated with considerable esthetic and functional (regarding speech, swallowing and respiration) mutilation. Due to this, a shift towards organsparing treatments with curative intent (radiotherapy or radiochemotherapy) has developed over the last decades. These non-surgical treatments are associated with less esthetic mutilation when compared with classic open en bloc surgical resection of head and neck malignancies. Unfortunately, these treatment strategies frequently result in major functional complications, e.g. dysphagia, xerostomy, dyspnoea and stridor due to bilateral arytenoidankylosis etc. However, in recent years, the introduction of innovative, minimal invasive surgical technologies, such as transoral laser microsurgery (TLM) or transoral robotic surgery (TORS) has revived the interest to treat a selection of head and neck malignancies surgically. The underlying idea is to pursue a disease control rate comparable to radio(chemo)therapy, but with optimal functional results. Apart from their introduction in the primary treatment of a selection of head and neck malignancies, these minimal invasive strategies are also of interest in the salvage setting, when local or locoregional recurrence after prior radio(chemo)therapy necessitates surgical resection. In this setting, these minimal invasive techniques can be a valuable alternative for the more mutilating classic open en-bloc resections. The main goals of this PhD thesis are: retrospective evaluation of oncological and functional outcome of patients treated in the University Hospital Leuven (UZL) using one or a combination of these new surgical techniques, setup of several prospective studies which will evaluate the clinical application and value of new technologies and finally, development and implementation of a new innovative minimal invasive technique or tool. This last part of the thesis will be achieved in collaboration with the RAS-group (robot-assisted surgery) of the department of mechanical engineering (KU Leuven) and the LMTC (Leuven Medical Technology Centre). Content of PhD thesis 1.Review In the first chapter of the thesis, an overview will be given of the current scientifical evidence concerning transoral robotic surgery (TORS). In particular, a literature review entitled 'Early experience of transoral robotic surgery in the treatment of non-oropharyngeal head and neck malignancies" will be incorporated in the text. Furthermore, the role of TORS in the managment of unknown primary head and neck cancer will be discussed and finally, a summary of the most recent technological innovations will be given and limitations of current technologies will be discussed. 2. Retrospective evaluation of the clinical application of minimal invasive surgical techniques for the treatment of head and neck malignancies in UZ Leuven (UZL) In this chapter, outcome of the minimal invasive techniques implemented in UZ Leuven (and affiliated centres) for the treatment of head and neck malignancies will be retrospectively analysed. - Oncological and functional outcome of TORS in the primary and salvage treatment of head and neck malignancies (mainly oropharynx or supraglottic squamous cell carcinoma (SCC)) (1). In this retrospective case series, patients treated in UZL and patients treated in AZ Sint-Lucas (Ghent) will be included. After retrospective analysis of oncological outcomes, the UZL patients will be prospectively evaluated regarding quality of life and swallowing function. - Retrospective evaluation of oncological and functional outcome of TLM in the salvage treatment of glottis SCC. - Retrospective evaluation of oncological and functional ouctome of TLM in the primary treatment of glottis SCC, possibly followed by comparison of these results with the oncological and functional results of a matched control population treated with radiotherapy for glottic SCC. - Retrospective evaluation of oncological and functional ouctome after the combined treatment with TORS and postoperative photodynamic therapy (PDT). 3. Prospective evaluation of the application of minimal invasive techniques in the field of head and neck oncological surgery In this chapter, minimal invasive or innovative techniques will be prospectively assessed and evaluated. Ideally, these prospective studies will be multicentric. - Development and prospective evaluation of a new method and standardised protocol concerning the pathological assessment of specimens removed by means of TLM or TORS, in particular regarding the analysis of section margins. This will be achieved in colllaboration with the deparment of pathology (Prof. Dr. E. Hauben). Oncological variables (e.g. % positive section margins, incidence of local recurrence etc.) and variables related to the pathological analysis (e.g. duration of pathological assessment etc.) will be evaluated. After achievement of a standardized protocol, this will be validated and restrospectively compared to the earlier technique. If this proves beneficial, the new pathology protocol will be used in the subsequent prospective studies. - Prospective trial assessing the feasibility of TORS procedures using the new generation Intuitive robot platform (Da Vinci Xi©), in the primary setting as well as in the salvage setting for tumours of the oropharynx, hypopharynx and supraglottis. This trial will probably be multicentric, with UZ Leuven and Institut Gustave Roussy (Paris, France) as the main centres. Feasibility, tumor control, postoperative functionality and postoperative quality of life will be evaluated (2,3). Afterwards, the results obtained in the primary treatment group can be compared to the oncological and functional outcome of a matched population treated with primary radio(chemo)therapy. - If feasibility of TORS procedures using the Da Vinci Xi© is confirmed, a randomized controlled trial (RCT) comparing primary radiochemotherapy with primary TORS + possible adjuvant therapy for treating stage I/II oropharynx or supraglottis SCC, will be organized. This RCT demands a multicenter setting, to gain sufficient statistical power in analysing the outcome results. If possible, this trial will be performed in the larger framework of the upcoming phase III EORTC study ("best of" trial). - Prospective trial concerning the management of CUP (cervical adenopathy with unknown primary). Using TORS or TLM, a bilateral resection of the palatine and lingual tonsils can be achieved in CUP patients. After pathological examination of the resection specimens, the primary tumor site detection rate can be calculated. If the primary site is detected following TLM or TORS, deintensification of the adjuvant radiotherapeutic treatment is possible (4). Oncological and functional results of these patients can be compared with those of a matched control CUP population with no identification of the primary site after classic palatine tonsillectomy and subsequently treated with total pahrynx irradiation. Within the framework of this prospective trial, the added value of NBI (Narrow Band Imaging) in the detection and localisation of the primary tumor site can be assessed. Mucosal abnormalities as seen on NBI can be compared to and correlated with the pathologic findings on the resection specimen obtained by TORS or TLM. - Prospective evaluation of the value of NBI and videokymography in the pre-operative assessment of suspected premalign or malign glottic lesions. Perceived abberant findings on NBI and videokymography will be compared with intraoperative findings and the results of the pathologic examination of the resection specimen. We hypothesize that preoperative videokymography could possibly tell the surgeon something about invasiveness of glottic lesions, while NBI could give more information about the superficial mucosal extension of a suspect lesion. NBI can also be performed intraoperatively during TLM in order to determine safer resection margins (e.g. RCT comparing section margins of specimens obtained during TLM with peroperative NBI, TLM with preoperative NBI or TLM without NBI). 4. Development and clinical implementation of new innovative minimal invasive techniques or tools (in collaboration with the RAS-group (robot-assisted surgery) of the department of mechanical engineering (KU Leuven) and the LMTC (Leuven Medical Technology Centre)) The goal of this part of the PhD thesis is to develop and implement new innovative minimal invasive techniques or tools. - Development of a da Vinci Xi © compatible flexible laser carrier to allow simultaneous intraoperative use of a flexible carbon dioxide laser and a monopolar spatula during TORS procedures. - Development of a flexible actuator with incorporated microcamera to allow retrograde visualisation of caudal margins of glottic tumors during "combined approach laryngoscopy/TLM" References: (1)White H, Ford B, Bush B, Holsinger C. Salvage surgery for recurrent cancers of the oropharynx: comparing TORS with standard open surgical approaches. JAMA otolaryngol Head Neck Surg. 2013;139(8):773-778 (2)Van Loon JWL, Smeele LE, Hilgers FJM, van den Brekel MWM. Outcome of transoral robotic surgery for stage I-II oropharyngeal cancer. Eur Arch Otorhinolaryngol. 2014, epub ahead of print (3)Lörincz B, Möckelmann N, Busch CJ, Knecht R. Functional outcomes, feasibility, and safety of resection of transoral robotic surgery: single-institution series of 35 consecutive cases of transoral robotic surgery for oropharyngeal squamous cell carcinoma. Head Neck.2014, epub ahead of print (4) Mehta V, Johnson P, Tassler A, Kim S et al. A new paradigm for the diagnosis and management of unknown primary tumors of the head and neck: a role for transoral robotic surgery. Laryngoscope. 2013;123:146-451

Publication year:2021

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