Original Research—Head and Neck Surgery Staging Neck Dissection and Transoral Robotic Surgery Treatment Algorithm in Palatine Tonsil Cancer Otolaryngology– Head and Neck Surgery 2018, Vol. 158(3) 479–483 Ó American Academy of Otolaryngology—Head and Neck Surgery Foundation 2017 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599817742615 http://otojournal.org Joseph Spellman, MD 1 , Ryan Sload, MD 1 , Paul Kim, MD 2 , Peter Martin, MD 3 , and Gabriel Calzada, MD 3 No sponsorships or competing interests have been disclosed for this article. Abstract Objective. This study introduces a treatment algorithm based on staging neck dissection to identify patients with palatine tonsil squamous cell carcinoma who can be effectively treated with single-modality transoral robotic surgery while maintain- ing quality of life. Study Design. Retrospective case series. Setting. Kaiser Permanente Southern California Medical Group from 2012 to 2017. Subjects and Methods. Patients with early-stage (T1/2) palatine tonsil squamous cell carcinoma with clinically and radiographi- cally N0 necks underwent staging neck dissection. Those with pN2/3 disease or extracapsular extension on final pathology were triaged to definitive chemoradiation treatment. Patients with confirmed pN0/1 necks without extracapsular extension were treated definitively with transoral robotic surgery. Results. Nineteen patients with cN0 disease underwent selec- tive neck dissection. All were p16 positive. Of these, 14 had pathologically confirmed N0/1 necks without extracapsular extension and were treated with primary surgical resection via transoral robotic surgery. Clear margins were obtained on all patients. There were no significant intra- or postopera- tive complications. No patients required gastrostomy tube or tracheostomy placement. Mean and median follow-up was 28 months with no recurrences to date. Conclusion. Up-front staging neck dissection accurately triages low-risk patients, determining candidates for single-modality definitive treatment with transoral robotic surgery. This approach provides excellent survival outcomes and minimal morbidity and maintains quality of life among appropriately selected patients with palatine tonsil cancer. Keywords transoral robotic surgery, oropharyngeal cancer, squamous cell carcinoma Received August 28, 2017; revised October 17, 2017; accepted October 26, 2017. D ue to the morbidity associated with traditional open surgical approaches, treatment of oropharyngeal squamous cell carcinoma has frequently come to incorporate organ preservation treatment strategies of defini- tive radiotherapy or chemoradiotherapy. Transoral robotic surgery (TORS) was introduced in 2005. 1-3 After its intro- duction, TORS quickly supplanted conventional open surgi- cal techniques in treating oropharyngeal cancers. For appropriately selected patients, TORS has demonstrated excellent oncologic results in addition to favorable functional swallowing outcomes with reduced rates of gastrostomy and tracheostomy placement. 4 Unfortunately, despite complete TORS resection, there is frequent need for adjuvant therapy, which is identified only at the time of final pathologic evaluation. 5 Findings such as perineural or lymphovascular invasion, multiple involved lymph nodes, extracapsular extension, or positive margins require adjuvant therapy with radiotherapy or chemoradia- tion. 6-9 Thus, planned single-modality treatment frequently becomes multimodality with the accompanying increased morbidity and reduction in functional outcomes. However, there is evidence that TORS alone has improved swallowing and quality-of-life outcomes versus definitive chemora- diotherapy or TORS followed by adjuvant therapy. 10-12 Since 2012, Kaiser Permanente Southern California has implemented a surgical treatment algorithm to identify ideal candidates for single-modality treatment with TORS. The goal of this algorithm is one that allows selection of a group of patients who can be effectively treated with TORS alone with minimal morbidity and impact on quality of life. 1 Department Otolaryngology–Head and Neck Surgery, Naval Medical Center San Diego, San Diego, California, USA 2 Department of Head and Neck Surgery, Kaiser Permanente Southern California Medical Group, Fontana, California, USA 3 Department of Head and Neck Surgery, Kaiser Permanente Southern California Medical Group, San Diego, California, USA This article was presented at the 2017 AAO-HNSF Annual Meeting & OTO Experience; September 10-13, 2017; Chicago, Illinois. Corresponding Author: Joseph Spellman, MD, Department Otolaryngology–Head and Neck Surgery, Naval Medical Center San Diego, 34800 Bob Wilson Dr, San Diego, CA 92134, USA. Email: joseph.w.spellman.mil@mail.mil