Robotic assisted surgical platforms that are currently in use for resections of colorectal cancer and liver metastasis, sphincter-preservation in rectal cancer, surgery of endometrial cancer, and for head and neck cancer resections were discussed at the ESMO Asia 2017 in Singapore, an Annual Congress organised by the European Society for Medical Oncology. Investigators reported improved short and long-term patient outcomes following robot assisted surgical platforms in comparison with conventional surgical approaches.
Robotic surgery may be an option in simultaneous resection of colorectal cancer and liver metastases
Jianmin Xu, Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China discussed whether robotic surgery could be used in simultaneous resection of colorectal cancer and liver metastases, which has been found to be safe and effective in patients with colorectal cancer patients and liver metastases (CRCLM). Dr. Xu and colleagues conducted a study (NCT02642978) to compare a robot-assisted procedure with open surgery, and to identify the patients with CRCLM most likely to benefit from each method. Patients with confirmed CRCLM were randomised equally into a robotic arm or an open arm of 60 patients each. The primary endpoint was disease-free survival (DFS) at 3 years and the secondary endpoints were short-term surgical outcomes, complications, and safety.
Of the 60 patients undergoing robotic surgery, one patient converted to open surgery due to a drop of blood pressure induced by oppressing inferior vena cava during hepatectomy. The remaining patients in the robotic arm demonstrated more favourable short-term outcomes and fewer complications than patients in the open surgery arm. Although operating times were longer in the robotic arm these patients experienced significantly less blood loss of 99.3 ml compared to 205.1 ml in patients receiving open surgery (p < 0.001). Patients in the robotic arm also had a shorter time to pass first flatus of mean (standard deviation) 63.0 (±28.2) hours compared to 93.6 (±35.5) hours in the open surgery arm (p < 0.001), and were able to return to a fluid diet sooner, at 83.2 (±34.1) hours versus 113.2 (±64.5) hours, respectively (p = 0.002). Patients in the robotic arm had shorter hospital stays of 8.1 (±2.1) days compared to 10.6 (±4.9) days with open surgery. Urinary function was improved and faster recovery of stress response, as indicated by lower C-reactive protein levels and better liver function, indicated by lower ALT/AST levels were observed. Dindo grade III/IV complication was decreased with robotic surgery to 6.7% compared to 20.0% with open surgery (p = 0.032).
Meta-analysis shows comparable to improved outcomes with robotic over laparoscopic intersphincteric resection for rectal cancer
S.W. Lim, Colorectal Surgery, Hallym University Sacred Heart Hospital, Anyang, Korea, Republic of Korea and colleagues conducted a meta-analysis of 5 studies contained in the Pubmed, MEDLINE, Embase, and the Cochrane library databases comparing robotic to laparoscopic intersphincteric resection (ISR) in low rectal cancer. The analysis consisted of data from 273 patients that underwent robotic ISR and 237 patients that had conventional laparoscopic ISR.
This analysis also pointed out that surgery time was longer with robotic ISR than with laparoscopic ISR (mean difference [MD] 41.25, 95% confidence interval [CI] 15.62, 66.89 (p = 0.002), blood loss was lower (MD -23.30, 95% CI -41.96, -4.64; p = 0.01), and the postoperative hospital stay was shorter, respectively, (MD 0.37, 95% CI -2.57, 3.31; p < 0.0001). However, with robotic ISR fewer lymph nodes could be harvested than with laparoscopic ISR (MD-2.01, 95% CI -3.86, -0.16; p = 0.03).
The analysis found no significant differences between the robotic and laparoscopic ISR for time to diet (p = 0.61), postoperative morbidity (p = 0.20), morbidity of Dindo-Klavien classification> 3 (p = 0.42), anastomotic leakage (p = 0.89), distal resection margin (p = 0.83) and in circumferential resection margin (p = 0.34).
Sentinel lymph node mapping associated with improved nodal metastasis detection following robotic assisted techniques in endometrial cancer
Sentinel lymph node (SLN) mapping strategies can improve the detection of nodal metastasis following robotic-assisted surgical staging for early stage endometrial cancer, according to Dr Tien Le of the Division of Gynaecologic Oncology, The Ottawa Hospital Regional Cancer Centre, Ottawa, Ontario, Canada. Dr Le reported local SLN mapping experience using blue dye compared to full lymphadenectomy under the robotic DaVinci platform. This retrospective analysis reviewed data from all clinical stage I endometrial carcinoma patients from November 2011 to May 2016. Robotic assisted staging was done in 469 patients. Staging full lymphadenectomy was done in 409 patients, with SLN mapping performed in 60 patients. No significant association was apparent between the use of SLN mapping and tumour grade, depth of invasion, lymph-vascular space invasion (LVSI), or cervical stromal invasion. Grade 1 tumour was documented in preoperative biopsy for 372 (79%) patients with 290 (78%) patients had confirmed grade 1 based on the hysterectomy pathology.
Sentinel node dissection
Nodal metastasis was detected in 5 (1.2%) patients treated with full lymphadenectomy versus 5 (8.3%) of the 60 patients underwent SLN mapping (p < 0.001). A logistic regression model including: grade (1 versus 2/3), histology (endometroids versus non endometroids), cervix stromal involvement (yes versus no), myometrial invasion (none versus less than 50% versus > 50%), and SLN mapping application showed only two significant predicting factors of nodal metastasis being: final non-endometroids histology, OR 5.02; 95% CI 1.26, 19.96 (p = 0.02) and the use of SLN mapping, OR 7.80; 95% CI 2.06, 29.58 (p = 0.002). In patients with endometroids histology and negative SLN, application of SLN mapping protocol did not result in a significant increased risk for recurrence.
Lymphadenectomy
Prospective trial shows high survival rates following intensification of treatment by transoral robotic surgery in HPV-negative stage IV oropharyngeal cancer
K. Gupta, Department of Head-Neck and Thoracic Surgical Oncology, Fortis Memorial Research Institute, Gurgaon, India reported patient outcome following treatment intensification using transoral robotic surgery (TORS) in addition to adjuvant radiotherapy/chemoradiotherapy in 86 patients with stage IV (cT1-3N2) HPV-negative oropharyngeal carcinoma. TORS and neck dissection was performed using daVinci® surgical system and patients received adjuvant radiation (60-64 Gy) or chemoradiation at the same dose with weekly cisplatin following this procedure. The TORS cohort included 69 males and 17 females who were evaluated for disease-free survival (DFS) and overall survival (OS). The patients’ mean age at presentation was 57.4 years (range, 32 to 83 years).
DFS was 76.7% and OS was 88.4% in the overall cohort of 86 patients with stage IVa oropharyngeal carcinoma after escalation of treatment with TORS followed by adjuvant radiotherapy or chemoradiotherapy at a mean follow-up of 34 months (range, 21 to 51 months).
Patient outcome according to disease stage was as follows: All patients underwent TORS. Of 12 patients with T1-3N2a disease, 7 patients received subsequent radiotherapy and 5 patients received chemoradiotherapy. At an average follow-up of 29 months, all patients were alive; 10 remained disease free and two patients developed nodal recurrence and received salvage surgery. Of 56 T1-3N2b stage patients, radiotherapy was subsequently administered in 16 patients and chemoradiotherapy in 40 patients. Of the overall population, 46 (82.1%) patients are living and disease free, 4 patients died due to metastasis, and 6 patients developed loco-regional recurrence, with 4 patients receiving salvage surgery and remaining disease free. Of the 18 patients with 3N2c status receiving TORS, 5 received subsequent radiotherapy and 13 received adjuvant chemoradiotherapy; all but 3 patients who died due to disease progression are living. Ten (55.6%) patients remained disease free and 7 patients developed locoregional recurrence, with 4 patients remaining disease free after salvage surgery.
Conclusions
The research team headed by Dr. Xu identified patients with CRCLM and fewer than 3 liver metastases, with a lesion maximal size of less than 5 cm as the patients most likely to benefit from robot-assisted surgery, which was found to offer improved short-term post surgical outcomes in these patients. The meta-analysis done by Lim and colleagues confirmed most of these results and found that robotic ISR provided comparable perioperative outcomes with a laparoscopic approach plus less blood loss and shorter postoperative hospital stays, despite longer operation time. They recommend further investigation of the potential oncologic and functional benefits of robotic ISR in larger, randomised trials.
Le et al. commented that SLN mapping can improve the sensitivity of detection of nodal metastasis with no increased risk for recurrence in patients with low risk endometrial cancer.
The Gupta’s team recommended transoral robotic surgery (TORS) as a good option for cure in relatively radio-resistant HPV-negative resectable oropharyngeal malignancies. They noted that TORS was successfully used to intensify treatment of stage IV oropharyngeal carcinoma to achieve better oncological outcome, while avoiding early and late toxicities due to higher doses of radiotherapy or chemoradiotherapy.
Disclosure
None of these studies reported external funding.
References
143O – Xu J, et al. Robot-assisted Procedure versus Open Surgery for Simultaneous Resection of Colorectal Cancer with Liver Metastases: Short-term Outcomes of a Randomized Controlled Study.
168P - Lim SW, et al. Robotic Versus Laparoscopic Intersphincteric Resection for Low Rectal Cancer: systemic review and meta-analysis.
290O – Le T, et al. Effect of sentinel node mapping strategy in robotic surgical treatment of endometrial cancers.
338O – Gupta K, et al. Oncological outcome following intensification of treatment by Transoral robotic surgery (TORS) for HPV negative Stage IV Oropharyngeal cancer: A prospective trial.