Predictors and outcomes of pathologic retropharyngeal lymph nodes in HPV-related oropharyngeal cancer.

OBJECTIVES

To determine the incidence of pathologic retropharyngeal lymph node (RPLN) metastases, evaluate the accuracy of preoperative imaging, identify predictors for RPLN involvement, and assess the impact of pathologic RPLN metastases on survival in patients with human papillomavirus-positive (HPV + ) oropharyngeal squamous cell carcinoma (OPSCC) undergoing primary transoral robotic surgery (TORS).

MATERIALS AND

METHODS

This retrospective cohort study included consecutive patients with HPV + OPSCC treated with primary TORS and concurrent RPLN dissection at a single tertiary academic medical center between 2007 and 2024. The primary outcome was the presence of pathologic RPLN. Secondary outcomes included the diagnostic accuracy of preoperative imaging, predictors of RPLN positivity, 5-year disease-free survival (DFS), and overall survival (OS).

RESULTS

Among 107 patients undergoing TORS and RPLN dissection, 27 (25.2%) had pathologic RPLN. Preoperative imaging had a pooled sensitivity of 53.8% and specificity of 91.8% for detecting pathologic RPLNs; and, on multivariate analysis, positive imaging was the only independent predictor of cancerous RPLNs. The 5-year DFS for the cohort was 84.4%, and the 5-year OS was 86.3%. The presence of RPLN metastases trended toward but was not significantly associated with worse DFS (P = 0.10) or OS (P = 0.09).

CONCLUSION AND RELEVANCE: Cancerous RPLN were found in a quarter of patients undergoing TORS and RPLN dissection for HPV + OPSCC. While preoperative imaging has low sensitivity for identifying RPLN, it was the strongest predictor of pathologic RPLN involvement. With comprehensive management, including RPLN dissection and appropriate adjuvant therapy, RPLN metastasis did not significantly diminish patient survival.