Do We Have Enough Evidence to Specifically Recommend Transoral Robotic Surgery in HPV−Driven Oropharyngeal Cancer? A Systematic Review

SIMPLE SUMMARY: The aim of the present study is to summarize the current evidence published in the literature concerning the role of transoral robotic surgery in HPV+ oropharyngeal squamous cell carcinoma. Recently, in order to reduce the side-effects related to chemo-radiotherapy, the use of transoral robotic surgery has increased, especially for oropharyngeal tumors related to HPV. Our review highlights that we do not have enough evidence for specifically recommending TORS in HPV−driven oropharyngeal cancer. However, transoral robotic surgery shows good oncological and functional outcomes in general. Moreover, based on the current evidence, transoral robotic surgery could potentially represent a promising strategy for intensifying treatments in HPV−negative oropharyngeal cancer. ABSTRACT: Introduction: International guidelines include transoral robotic surgery (TORS) as an option for selected oropharyngeal squamous cell carcinomas (OPSCCs). In the perspective of treatment de-intensification, many surgeons have started recommending and performing TORS preferentially in p16- positive OPSCC in order to reduce the long-term morbidity related to chemoradiotherapy. The aim of the present review is to analyze the current evidence supporting the above-cited strategy. Materials and Methods: The study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results: Twenty-two studies were included in this review, with a total of 3992 patients treated with primary TORS. The majority of patients were classified as HPV+ (n = 3655, 91.6%), and 8.2% (n = 327) as HPV−. The HPV status was unknown in only 10 (0.3%) patients. In particular, only five of the included studies compared survival outcomes of HPV−positive patients with HPV−negative ones treated with primary TORS, and only two of these found a significant improvement in survival in the HPV−driven cohort. Discussion: The current literature does not clarify whether HPV+ OPSCCs treated with TORS, alone or with adjuvant treatments, are associated with a better oncologic and/or functional outcome compared to those treated with radio- or chemoradiotherapy. However, TORS alone obtained good oncological outcomes in a high percentage of cases in the reviewed series. Recent data, on the other hand, suggest that TORS could represent a promising strategy for intensifying treatments in HPV− OPSCC.