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Thomas R, Kelemen N, Molena E, Lester S. Indications for oropharyngeal biopsy in head and neck squamous cell carcinoma of unknown primary: A systematic review (HNSCCUP). Clin Otolaryngol 2024; 49:552-566. [PMID: 38773941 DOI: 10.1111/coa.14168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 04/07/2024] [Accepted: 04/13/2024] [Indexed: 05/24/2024]
Abstract
INTRODUCTION Patients presenting with head and neck squamous cell carcinoma of unknown primary (HNSCCUP) remain challenging clinical scenarios as large variation exists in practices used to locate the primary. OBJECTIVE The objective of this systematic review is to review of the literature and offer recommendations for oropharyngeal biopsies in HNSCCUP. METHOD Pubmed, Medline and Embase were searched to identify studies from inception to October 2021. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. RESULTS A total of 483 articles were included and screened, 41 studies met the inclusion criteria, including over 3400 patients from the original articles (122 of these patients were reported on in two sequential articles by a single author - table 1) and 4 large metaanalyses including 1852 patients. The primary site identification rate following random biopsies or deep tissue biopsies is less than 5% in most studies. The mean detection rate following ipsilateral tonsillectomy is 34%; two pooled analyses indicate that the mean detection rate following tongue base mucosectomy is 64%, with this figure rising when the tonsils are negative. CONCLUSIONS High level evidence is lacking, with heterogeneity in the reported studies. Published meta-analyses are based on retrospective data. There is little evidence supporting the practice of random/non-directed oropharyngeal biopsies. Available evidence supports palatine tonsillectomy and tongue base mucosectomy compared to deep tissue biopsies.
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Affiliation(s)
- Rachael Thomas
- Department of Plastic Surgery, St John's Hospital, Edinburgh, Scotland
| | - Noemi Kelemen
- Department of Plastic Surgery, Hull University Teaching Hospitals NHS Trust, UK
| | - Emma Molena
- Department of Plastic Surgery, Hull University Teaching Hospitals NHS Trust, UK
| | - Shane Lester
- Department of Ear Nose and Throat Surgery, James Cook University Hospital, Middlesborough, UK
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2
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Olaleye O, Nassif R, Fleming B, Burrows S. Laser tongue base mucosectomy is a useful diagnostic tool in the management of unknown primary cancers of the head and neck region. J Laryngol Otol 2023; 137:438-441. [PMID: 35674061 DOI: 10.1017/s0022215122001311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Tongue base mucosectomy identified cancer in 78 per cent of cancers of unknown primary in a recent meta-analysis. The carbon dioxide laser is an alternative technique if there is no access to a robot. This study aimed to describe the steps for undertaking tongue base mucosectomy using the carbon dioxide laser and its diagnostic utility in cancers of unknown primary. METHOD This was a prospective feasibility study utilising carbon dioxide laser for tongue base mucosectomy in cancers of unknown primary. Data collected included demographic data and p16 status. RESULTS There were 14 cancers of unknown primary with 86 per cent p16 positivity on immunohistochemistry. Laser tongue base mucosectomy alone identified the cancer primary in 7 of 12 (58 per cent) cancers of unknown primary among p16 positive tumours and 0 of 2 (0 per cent) among p16 negative tumours. Combining bilateral tonsillectomy with laser tongue base mucosectomy resulted in identification of the primary cancer in 8 of 12 (67 per cent) p16 positive tumours. CONCLUSION In centres without a robot, tongue base mucosectomy using the carbon dioxide laser is a viable alternative, especially in combination with bilateral tonsillectomy in p16 positive cases.
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Affiliation(s)
- O Olaleye
- ENT & Audiology, Norfolk & Norwich University Hospitals NHS Trust, Norwich, UK
| | - R Nassif
- ENT & Audiology, Norfolk & Norwich University Hospitals NHS Trust, Norwich, UK
| | - B Fleming
- Anaesthesia, Norfolk & Norwich University Hospitals NHS Trust, Norwich, UK
| | - S Burrows
- ENT & Audiology, Norfolk & Norwich University Hospitals NHS Trust, Norwich, UK
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Kanodia A, Singh CA, Sakthivel P, Shamim SA, Sikka K, Kumar R, Kakkar A, Kumar R, Gupta SD, Bhalla AS, Thakar A, Sharma SC. Role of Whole body PET/CT and Examination under anesthesia with multi-site biopsy in evaluating CUP. Indian J Otolaryngol Head Neck Surg 2022; 74:2656-2662. [PMID: 36452568 PMCID: PMC9702410 DOI: 10.1007/s12070-020-02268-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 11/03/2020] [Indexed: 10/22/2022] Open
Abstract
To evaluate the role of 18FDG-WBPET-CT, Examination under anesthesia (EUA), and multiple-site biopsy in detecting the occult site in head & neck carcinoma of unknown primary (HN-CUP). In this prospective study, 22 patients with diagnosed CUP, after a thorough outpatient endoscopic evaluation of upper airway and radiological evaluation (CT/MRI) that ruled out a primary lesion were included. These patients subsequently underwent whole-body PET-CT and EUA. Based on the presence of suspicious findings ( +) or their absence (-) on 18FDG-WBPET-CT (P) and EUA (E), we divided the patients into 5 groups: P-E-, P-E + , P + E-, P + E + , and P + or E + . All these patients underwent bilateral palatine tonsillectomy, bilateral nasopharyngeal biopsy, and ipsilateral lingual tonsillectomy for identification of occult primary. Out of 22 patients, the primary could be detected in 4 patients (18%) after the workup (three in the oropharynx and one in the hypopharynx, all ipsilateral). 18FDG-PET-CT suspected primaries in 7 patients; biopsy was positive for three (sensitivity-75%, specificity-77%, PPV-43%, NPV-93%). Out of 5 patients, who had suspicious findings on EUA, 3 of the biopsies revealed malignancy (sensitivity-75%, specificity-88%, PPV-60%, NPV-94%). Both PET-CT and EUA when combined, yield a NPV of 100% if both are negative and PPV of 100% when both are positive for suspicious findings. No primary was identified in the absence of a suspicion by PET-CT or EUA. Without a suspicion on 18FDG-WBPET-CT and EUA, there is a limited role of multiple-site biopsies in patients of HN-CUP.
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Affiliation(s)
- Anupam Kanodia
- Department of Otorhinolaryngology and Head–Neck Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi India
| | - Chirom Amit Singh
- Department of Otorhinolaryngology and Head–Neck Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi India
| | - Pirabu Sakthivel
- Department of Otorhinolaryngology and Head–Neck Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi India
| | - Shamim Ahmad Shamim
- Department of Nuclear Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi India
| | - Kapil Sikka
- Department of Otorhinolaryngology and Head–Neck Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi India
| | - Rajeev Kumar
- Department of Otorhinolaryngology and Head–Neck Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi India
| | - Aanchal Kakkar
- Department of Pathology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi India
| | - Rakesh Kumar
- Department of Otorhinolaryngology and Head–Neck Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi India
| | - Siddhartha Datta Gupta
- Department of Pathology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi India
| | - Ashu Seith Bhalla
- Department of Radiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi India
| | - Alok Thakar
- Department of Otorhinolaryngology and Head–Neck Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi India
| | - Suresh C. Sharma
- Department of Otorhinolaryngology and Head–Neck Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi India
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Advancement in the Oropharyngeal Primary Unknown Cancer Diagnostic and Current Treatments Pathway: A Narrative Review. SURGERIES 2022. [DOI: 10.3390/surgeries3030022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: The objective of this article is to define a correct diagnostic pathway for oropharyngeal cancer of unknown primary (OPCUP) identification. Background: OPCUP represents one of the most frequent causes of neck metastases onset without the identification of the primary tumor. Therefore, there is a high percentage of late or missing diagnoses, resulting in treatment delay or in a wrong therapeutic process. The up-to-date diagnostic procedures can help us to begin therapies at the right time. Methods: This is a review of the latest articles about diagnostic pathways in the OPCUP. A selection of the references was carried out in PubMed, EMBASE, Cochrane, and CENTRAL electronic databases. Conclusion: The oropharynx represents the most common site of primary unknown head and neck cancer (HNCUP). Recent epidemiologic data reported an increasing incidence of HNCUP related to human papilloma virus positive squamous cell carcinoma. Positron emission tomography combined with computerized tomography scanning or magnetic resonance imaging allows for improving the detection of primary unknown tumors and distant and locoregional metastases. Finally, the introduction of the trans-oral robotic surgical approach has introduced a new role of surgery in the HNCUP diagnosis and treatment. Hence, the new technological improvement allows reaching in most HNCUP patients an early diagnosis, achieving targeted management and better treatment outcomes, as well as decreasing toxicity and the side effects of treatment options.
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Reducing the unknowns: A systematic review & meta-analysis of the effectiveness of trans-oral surgical techniques in identifying head and neck primary cancer in carcinoma unknown primary. Oral Oncol 2022; 126:105748. [PMID: 35144209 DOI: 10.1016/j.oraloncology.2022.105748] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 01/17/2022] [Accepted: 01/24/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The use of transoral robotic surgery (TORS), transoral laser microsurgery (TLM) and more recently reported transoral endoscopic electrocautery (TOEC) in identifying the primary cancer in head and neck Carcinoma Unknown Primary (CUP) patients have gained popularity. This review aims to assess the effectiveness of TORS, TLM and TOEC. MATERIALS & METHODS A systematic review and meta-analysis was carried out. EMBASE, MEDLINE and CINAHL databases were searched from inception to September 2020. All primary studies were considered for inclusion. Primary outcome measure was detection rates of primary cancer of the different techniques. Secondary outcome measures were complications and length of hospital stay. RESULTS 289 studies were identified of which 30 met the inclusion criteria. The primary cancer was identified in 567 /777 patients (pooled results was 64% (95% CI 54-73). The primary identification rates were 45% and 32% in lingual (n = 273) and palatine tonsillectomy (n = 118) respectively. The primary cancer identification rates by surgical techniques are: TORS was 60% (95% CI 49-70), TLM was 80% (95% CI 0.58, 1.01), TOEC was 41% (95% CI 0.05, 0.76). 529/777 (68%) tumours were Human Papilloma Virus (HPV) related. The pooled data of studies that reported on detection rates relating to HPV status were 178/216 (82%) for HPV +ve and 7/59 (12%) for HPV -ve tumours. Coefficient of variation results suggest heterogenous data for TORS and TLM. The commonest complication was haemorrhage (5.3%). The length of reported hospital stay ranged from 1.4 to 7 days. CONCLUSIONS This is the largest systematic review in the subject. The quality of studies and heterogeneity of data limit conclusive findings. Lingual tonsillectomy is an effective procedure in CUP work up. Further larger, multicentre, prospective studies of PET CT negative CUP patients is needed to draw conclusive results.
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Gupta M, Gupta A, Singh I, Puri I. Evaluation of metastatic neck nodes search for primary and subsequent management. J Cancer Res Ther 2022; 18:119-123. [DOI: 10.4103/jcrt.jcrt_1083_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Rao KN, Gangiti KK. Transoral Robotic Surgery. Indian J Surg Oncol 2021; 12:847-853. [PMID: 35110913 PMCID: PMC8764010 DOI: 10.1007/s13193-021-01443-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 09/01/2021] [Indexed: 11/21/2022] Open
Abstract
Transoral robotic surgery (TORS) became a valuable new head and neck surgery approach from the past decade since its approval. TORS was initially conceived for oropharyngeal squamous cell carcinoma (OPSCC); now, the indications are gradually extrapolated into other subsites. There have been numerous studies comparing the outcomes following surgical and non-surgical treatment, especially for oropharyngeal cancers. TORS for laryngeal cancers is in its infancy, and only a few reports are describing it. Many report suggestive of better functional outcomes following TORS, but level 1 evidence is still lacking. With the further development of novel, flexible, miniaturized robots, it is highly likely to expand TORS indications further. This article provides an overview of TORS in head and neck cancers.
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Affiliation(s)
- Karthik N. Rao
- Department of Head Neck Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Kranthi Kumar Gangiti
- Department of Head Neck Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
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Mclean T, Fitzgerald C, Boyle JO. Therapeutic strategies: Surgery for human papillomavirus-associated oropharyngeal carcinoma. J Surg Oncol 2021; 124:935-944. [PMID: 34595753 DOI: 10.1002/jso.26695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 09/20/2021] [Indexed: 12/30/2022]
Abstract
Treatment of oropharyngeal cancer (OPC) has undergone considerable evolution since the discovery of human papillomavirus (HPV)-associated OPC. It is widely understood that HPV OPC affects a younger population and standard treatment offers improved oncologic outcomes compared with non-HPV OPC but can cause significant toxicities and long-term side effects. Surgery for treatment de-escalation is an active area of research. The purpose of this review is to explore surgery as it relates to the treatment of HPV OPC with a focus on the evolution of treatment, rationale for surgery, surgical techniques, outcomes, and the role of surgery in de-escalation of treatment.
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Affiliation(s)
- Timothy Mclean
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Conall Fitzgerald
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jay O Boyle
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Rettig EM, Sethi RKV. Cancer of the Oropharynx and the Association with Human Papillomavirus. Hematol Oncol Clin North Am 2021; 35:913-931. [PMID: 34244016 DOI: 10.1016/j.hoc.2021.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Squamous cell carcinoma of the oropharynx (OPC) consists of human papillomavirus (HPV)-negative disease caused by tobacco and alcohol use, and HPV-positive disease caused by the sexually transmitted infection HPV. These entities have unique but overlapping risk factors, epidemiologic trends, staging systems, and survival outcomes. HPV-positive tumor status confers a significant survival benefit compared with HPV-negative disease. OPC treatment entails a combination of surgery, radiation, and chemotherapy. Ongoing trials will determine whether treatment of HPV-related disease may be safely deintensified to decrease morbidity. Emerging HPV-related biomarkers are under study as tools to inform screening, diagnosis, treatment, and surveillance for HPV-positive OPC.
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Affiliation(s)
- Eleni M Rettig
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Brigham and Women's Hospital, 45 Francis Street, ASB-2, Boston, MA 02115, USA; Center for Head and Neck Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Department of Otolaryngology Head and Neck Surgery, Harvard Medical School, Boston, MA, USA.
| | - Rosh K V Sethi
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Brigham and Women's Hospital, 45 Francis Street, ASB-2, Boston, MA 02115, USA; Center for Head and Neck Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Department of Otolaryngology Head and Neck Surgery, Harvard Medical School, Boston, MA, USA
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10
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Park KS, Lim HR, Jeong SH, Lee DH, Lim SC. Treatment Outcomes of Patients with Head and Neck Squamous Cell Carcinoma of Unknown Primary. Chonnam Med J 2021; 57:58-61. [PMID: 33537220 PMCID: PMC7840340 DOI: 10.4068/cmj.2021.57.1.58] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/01/2020] [Accepted: 11/02/2020] [Indexed: 12/18/2022] Open
Abstract
The purpose of this study was to evaluate clinical characteristics and treatment outcome of patients with head and neck squamous cell carcinoma of unknown primary (HNSCCUP), treated according to the method of our hospital. Six patients with histopathologically and radiologically confirmed HNSCCUP January 2010-December 2016 were enrolled in this study. All patients underwent radical neck dissection involving level I-V, bilateral tonsillectomy, and diagnostic esophagoscopy and postoperative radiotherapy (RT), with or without concurrent chemotherapy. There were no major complications resulting from surgical intervention. Duration of follow-up was 56.3±20.2 months (range, 28-82 months). There was no recurrence or late detection of primary site of HNSCCUP. All patients with HNSCCUP except one were alive, at the time of the last follow-up. The other patient had no recurrence of HNSCCUP, but died of colon cancer at 58 months postoperatively. We have successfully treated patients with HNSCCUP by performing radical neck dissection, bilateral tonsillectomy, and diagnostic esophagoscopy and postoperative RT with concurrent chemotherapy, and recommend using this method as the main treatment method.
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Affiliation(s)
- Kyeong Suk Park
- Department of Otolaryngology-Head and Neck Surgery, Chonnam National University Medical School & Hwasun Hospital, Hwasun, Korea
| | - Hye Rin Lim
- Department of Otolaryngology-Head and Neck Surgery, Chonnam National University Medical School & Hwasun Hospital, Hwasun, Korea
| | - Se Hyun Jeong
- Department of Otolaryngology-Head and Neck Surgery, Chonnam National University Medical School & Hwasun Hospital, Hwasun, Korea
| | - Dong Hoon Lee
- Department of Otolaryngology-Head and Neck Surgery, Chonnam National University Medical School & Hwasun Hospital, Hwasun, Korea
| | - Sang Chul Lim
- Department of Otolaryngology-Head and Neck Surgery, Chonnam National University Medical School & Hwasun Hospital, Hwasun, Korea
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Civantos FJ, Vermorken JB, Shah JP, Rinaldo A, Suárez C, Kowalski LP, Rodrigo JP, Olsen K, Strojan P, Mäkitie AA, Takes RP, de Bree R, Corry J, Paleri V, Shaha AR, Hartl DM, Mendenhall W, Piazza C, Hinni M, Robbins KT, Tong NW, Sanabria A, Coca-Pelaz A, Langendijk JA, Hernandez-Prera J, Ferlito A. Metastatic Squamous Cell Carcinoma to the Cervical Lymph Nodes From an Unknown Primary Cancer: Management in the HPV Era. Front Oncol 2020; 10:593164. [PMID: 33244460 PMCID: PMC7685177 DOI: 10.3389/fonc.2020.593164] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 09/30/2020] [Indexed: 12/20/2022] Open
Abstract
Background Patients with metastases in the lymph nodes of the neck and no obvious primary tumor, neck cancer with unknown primary (NCUP), represent a management challenge. A majority of patients have metastatic squamous cell carcinoma (SCC), although other histologies do occur. Methods We comprehensively reviewed the literature, compared available guidelines, and conferred with an international team of experts. Results Positron emission tomography-computed tomography (PET-CT) and fine needle aspiration (FNA) under ultrasound guidance increase accuracy of diagnosis. Immunohistochemistry (IHC), determination of human papilloma virus (HPV) status, by p16 staining or by in situ hybridization (ISH), and next-generation gene sequencing can guide us regarding probable primary sites and tumor biology. Narrow Band Imaging (NBI) has been introduced for the early detection of subtle mucosal lesions. Direct laryngoscopy (DL) and tonsillectomy have long been procedures used in the search for a primary site. More recently, TransOral Robotic Surgery (TORS) or Transoral LASER Microsurgery (TLM) have been introduced for lingual tonsillectomy. Conclusions New technologies have been developed which can better detect, diagnose, and treat occult primary tumors. Decisions regarding therapy are based on the primary tumor site (if discovered) and N stage. Options include neck dissection with or without postoperative adjuvant therapy, primary irradiation, or combined chemotherapy with irradiation. The preferred treatment of patients whose primary remains unidentified is controversial.
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Affiliation(s)
- Francisco J Civantos
- Department of Otolaryngology, Sylvester Cancer Center, University of Miami, Miami, FL, United States
| | - Jan B Vermorken
- Department of Medical Oncology, Antwerp University Hospital, Edegem, Belgium
| | - Jatin P Shah
- Department of Surgery, Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | | | - Carlos Suárez
- Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
| | - Luiz P Kowalski
- Department of Head and Neck Surgery and Otorhinolaryngology, A.C. Camargo Cancer Center, Sao Paolo, Brazil.,Head and Neck Surgery Department, University of São Paulo Medical School, São Paulo, Brazil
| | - Juan P Rodrigo
- Department of Otolaryngology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Kerry Olsen
- Department of Otorhinolaryngology, Mayo Clinic, Rochester, MN, United States
| | - Primoz Strojan
- Department of Radiation Oncology Institute of Oncology, University of Ljubljana, Ljubljana, Slovenia
| | - Antti A Mäkitie
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Helsinki and HUS Helsinki University Hospital, Helsinki, Finland
| | - Robert P Takes
- Department of Otolaryngology/Head and Neck Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Remco de Bree
- Department of Head and Neck Surgical Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - June Corry
- Department of Medicine Division Radiation Oncology, St. Vincent's Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - Vinidh Paleri
- Head and Neck Unit, The Royal Marsden Hospitals NHS Foundation Trust, London, United Kingdom
| | - Ashok R Shaha
- Department of Surgery, Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Dana M Hartl
- Division of Surgical Oncology, Gustave Roussy Cancer Center and Paris-Sud University, Paris, France
| | - William Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, United States
| | - Cesare Piazza
- Department of Otorhinolaryngology, Maxillofacial and Thyroid Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Michael Hinni
- Department of Otolaryngology, Mayo Clinic, Phoenix, AZ, United States
| | - K Thomas Robbins
- Southern Illinois University School of Medicine, Department of Otolaryngology, Springfield, IL, United States
| | - Ng Wai Tong
- Department of Clinical Oncology, Pamela Youde Nethersole Eastern Hospital, Hong Kong, Hong Kong
| | - Alvaro Sanabria
- Department of Surgery, School of Medicine, Hospital Universitario San Vicente Fundacion. CEXCA Centro de Excelencia en Enfermedades de Cabeza y Cuello, Universidad de Antioquia, Medellín, Colombia
| | - Andres Coca-Pelaz
- Department of Otolaryngology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Johannes A Langendijk
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | | | - Alfio Ferlito
- International Head and Neck Scientific Group, Padua, Italy
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de Almeida JR. Role of Transoral Robotic Surgery in the Work-up of the Unknown Primary. Otolaryngol Clin North Am 2020; 53:965-980. [PMID: 32951898 DOI: 10.1016/j.otc.2020.07.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Unknown primary squamous cell carcinoma metastatic to cervical lymph nodes is a relatively rare tumor presentation, although the incidence may be increasing along with the rising incidence of human papilloma virus-mediated oropharyngeal cancers. Traditional diagnostic methods with palatine tonsillectomy and panendoscopy may identify the minority of primary tumors. The addition of a transoral lingual tonsillectomy may improve the diagnostic yield of identifying a primary tumor. Incorporation of transoral robotic surgery may be used for diagnostic purposes to identify a primary site and also for therapeutic purposes, whereby a primary tumor may be completely resected and combined with a neck dissection.
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Affiliation(s)
- John R de Almeida
- Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Centre/University Health Network, University of Toronto, Toronto General Hospital, 200 Elizabeth Street, 8NU-883, Toronto, Ontario, Canada; Department of Surgical Oncology, Princess Margaret Cancer Centre/University Health Network, University of Toronto, Toronto General Hospital, 200 Elizabeth Street, 8NU-883, Toronto, Ontario, Canada.
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13
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Maghami E, Ismaila N, Alvarez A, Chernock R, Duvvuri U, Geiger J, Gross N, Haughey B, Paul D, Rodriguez C, Sher D, Stambuk HE, Waldron J, Witek M, Caudell J. Diagnosis and Management of Squamous Cell Carcinoma of Unknown Primary in the Head and Neck: ASCO Guideline. J Clin Oncol 2020; 38:2570-2596. [PMID: 32324430 DOI: 10.1200/jco.20.00275] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
PURPOSE To provide evidence-based recommendations to practicing physicians and other health care providers on the diagnosis and management of squamous cell carcinoma of unknown primary in the head and neck (SCCUP). METHODS The American Society of Clinical Oncology convened an Expert Panel of medical oncology, surgery, radiation oncology, radiology, pathology, and advocacy experts to conduct a literature search, which included systematic reviews, meta-analyses, randomized controlled trials, and prospective and retrospective comparative observational studies published from 2008 through 2019. Outcomes of interest included survival, local and regional disease control, and quality of life. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations. RESULTS The literature search identified 100 relevant studies to inform the evidence base for this guideline. Four main clinical questions were addressed, which included subquestions on preoperative evaluations, surgical diagnostic and therapeutic procedures, appropriate pathology techniques, and adjuvant therapy. RECOMMENDATIONS Evidence-based recommendations were developed to address preoperative evaluation for patients with a neck mass, surgical diagnostic and therapeutic procedures, appropriate treatment options in unilateral versus bilateral SCCUP.Additional information is available at www.asco.org/head-neck-cancer-guidelines.
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Affiliation(s)
| | | | | | | | | | | | | | - Bruce Haughey
- Advent Health Medical Group, Otolaryngology, Head and Neck Surgery, Celebration, FL, and University of South Florida, Tampa, FL
| | - Doru Paul
- Weill Cornell Medical College, New York, NY
| | | | - David Sher
- University of Texas Southwestern, Dallas, TX
| | | | - John Waldron
- Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Matt Witek
- University of Wisconsin School of Medicine and Public Health, Madison, WI
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Di Luca M, Iannella G, Montevecchi F, Magliulo G, De Vito A, Cocuzza S, Maniaci A, Meccariello G, Cammaroto G, Sgarzani R, Ferlito S, Vicini C. Use of the transoral robotic surgery to treat patients with recurrent lingual tonsillitis. Int J Med Robot 2020; 16:e2106. [PMID: 32223059 DOI: 10.1002/rcs.2106] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/19/2020] [Accepted: 03/19/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND This study evaluates the efficacy of lingual tonsil resection by transoral robotic surgery (TORS) in a large group of patients with recurrent lingual tonsillitis (RLT). METHODS Eighty-four patients with RLT treated with a lingual tonsil surgical resection using TORS were analyzed in terms of their postoperative results, disease recurrence, postoperative dysphagia, and quality of life. RESULTS A reduction of the mean number/year of acute lingual tonsillitis (LT) episodes emerged after surgery (5.17 vs 0.54 events), comparing the mean number of preoperative and postoperative LT episodes, a statistical significance emerged (P = .0001). The postoperative endoscopic evaluation showed 94.1% of patients with absent or poor lymphatic tissue on the tongue base. Evaluation of postoperative dysphagia showed good results with an average score of 85.9 ± 7.5. CONCLUSION This article explains how in patients with chronic LT with medical therapy failure and impaired quality of life, TORS could represent a valid therapeutic option.
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Affiliation(s)
- Milena Di Luca
- Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia," ENT Section, University of Catania, Catania, Italy
| | - Giannicola Iannella
- Department of 'Organi di Senso', University "Sapienza", Rome, Italy.,Department of Head-Neck Surgery, Otolaryngology, Head-Neck, and Oral Surgery Unit, Morgagni Pierantoni Hospital, Forlì, Italy
| | | | | | - Andrea De Vito
- Department of Head-Neck Surgery, Otolaryngology, Head-Neck, and Oral Surgery Unit, Morgagni Pierantoni Hospital, Forlì, Italy
| | - Salvatore Cocuzza
- Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia," ENT Section, University of Catania, Catania, Italy
| | - Antonino Maniaci
- Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia," ENT Section, University of Catania, Catania, Italy
| | - Giuseppe Meccariello
- Department of Head-Neck Surgery, Otolaryngology, Head-Neck, and Oral Surgery Unit, Morgagni Pierantoni Hospital, Forlì, Italy
| | - Giovanni Cammaroto
- Department of Head-Neck Surgery, Otolaryngology, Head-Neck, and Oral Surgery Unit, Morgagni Pierantoni Hospital, Forlì, Italy
| | | | - Salvatore Ferlito
- Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia," ENT Section, University of Catania, Catania, Italy
| | - Claudio Vicini
- Department of Head-Neck Surgery, Otolaryngology, Head-Neck, and Oral Surgery Unit, Morgagni Pierantoni Hospital, Forlì, Italy.,Department ENT and Audiology, University of Ferrara, Ferrara, Italy
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15
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de Almeida JR, Noel CW, Veigas M, Martino R, Chepeha DB, Bratman SV, Goldstein DP, Hansen AR, Yu E, Metser U, Weinreb I, Perez-Ordonez B, Xu W, Kim J. Finding/identifying primaries with neck disease (FIND) clinical trial protocol: a study integrating transoral robotic surgery, histopathological localisation and tailored deintensification of radiotherapy for unknown primary and small oropharyngeal head and neck squamous cell carcinoma. BMJ Open 2019; 9:e035431. [PMID: 31892671 PMCID: PMC6955504 DOI: 10.1136/bmjopen-2019-035431] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
INTRODUCTION Carcinomas of unknown primary site (CUP) of the head and neck have historically been worked up and managed heterogeneously. Failure to identify a primary site may result in large radiotherapy mucosal volumes. Transoral approaches such as Transoral Robotic Surgery (TORS) may improve the yield of identifying hidden primaries. We aim to assess the oncological and functional outcomes of a combined treatment approach with TORS and tailored radiotherapy. METHODS AND ANALYSIS Twenty-five patients with metastatic squamous cell carcinoma to the neck without clinical or radiographic evidence of a primary site will be enrolled in a phase II trial. Patients will undergo a diagnostic or therapeutic approach with TORS based on specific algorithms incorporating tailored radiotherapy according to the location and laterality of the primary tumour. The primary outcome is to evaluate the out-of-field failure rate over a 2-year period. Secondary outcomes include identification rates, survival outcomes, patient reported outcomes and functional swallowing outcomes. ETHICS AND DISSEMINATION The University Health Network Research Ethics Board approved this study (ID 15-9767). The results will be published in an open access journal. TRIAL REGISTRATION NUMBER NCT03281499.
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Affiliation(s)
- John R de Almeida
- Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Christopher W Noel
- Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Maria Veigas
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Rosemary Martino
- Department of Speech Language Pathology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Douglas B Chepeha
- Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Scott V Bratman
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - David P Goldstein
- Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Aaron R Hansen
- Department of Medical Oncology, Princess Margaret Hospital Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Eugene Yu
- Department of Neuroradiology and Head and Neck Imaging, Princess Margaret Cancer Cenre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Ur Metser
- Department of Neuroradiology and Head and Neck Imaging, Princess Margaret Cancer Cenre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Ilan Weinreb
- Department of Pathology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Bayardo Perez-Ordonez
- Department of Pathology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Wei Xu
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - John Kim
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
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16
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Dorobisz K, Wlodarska-Polinska I, Pazdro-Zastawny K, Rutkowski T, Palka P, Dworzecki T, Zatonski T. The impact of the patient's condition, diagnostic procedures and treatment on the survival of carcinoma of unknown primary site patients. Cancer Manag Res 2019; 11:6603-6614. [PMID: 31406475 PMCID: PMC6642654 DOI: 10.2147/cmar.s204346] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 05/10/2019] [Indexed: 11/26/2022] Open
Abstract
Introduction Carcinoma of unknown primary site (CUP) refers to 1–5% of all head and neck neoplasms. Very often, the primary site remains difficult to determine. Squamous cell carcinoma is the most frequent histopathological type diagnosed in the head and neck region. According to statistics, a primary site is usually located in the oropharynx. Study objective The study presents diagnostic difficulties and the methods of diagnosing and the therapy of CUP and primary sites in patients treated in the region of Lower Silesia and Silesia. The aim of the study was to show a retrospective analysis of 233 CUP patients to assess how clinical features, diagnosis and treatment affect the survival of patients. Material and methods The diagnostics of patients included panendoscopy with specimen collection (nasoendoscopy, laryngoscopy, esophagoscopy, brochoscopy), computed tomography examination of the neck, chest, abdomen and pelvis minor, as well as positron emission tomography examination. Tonsilletomy was performed in 37 patients. Neck dissection was carried out in 109 subjects and 165 patients were treated bt radiotherapy, and 135 by chemotherapy. Conclusions Tonsillectomy is required in CUP patients with the negative results of biopsy and imaging tests. It gives a possibility of detecting the primary site and improves the results of treatment and survival of CUP patients.Combination therapy, including surgical treatment and chemoradiotherapy, gives the best therapeutic results in CUP patients. The general condition of patient and younger age have an impact on prognosis and survival.
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Affiliation(s)
- Karolina Dorobisz
- Department of Otolaryngology, Head and Neck Surgery, Wroclaw Medical University, Wrocław, Poland
| | | | | | - Tomasz Rutkowski
- Department of Radiation and Clinical Oncology, Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice, Poland
| | - Piotr Palka
- Department of Radiation and Clinical Oncology, Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice, Poland
| | - Tomasz Dworzecki
- Department of Radiotherapy, Oncotherapy International Center, Walbrzych, Poland
| | - Tomasz Zatonski
- Department of Otolaryngology, Head and Neck Surgery, Wroclaw Medical University, Wrocław, Poland
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Meccariello G, Cammaroto G, Ofo E, Calpona S, Parisi E, D'Agostino G, Gobbi R, Firinu E, Bellini C, De Vito A, Montevecchi F, Costantini M, Amadori E, Nuzzo S, Pelucchi S, Vicini C. The emerging role of trans-oral robotic surgery for the detection of the primary tumour site in patients with head-neck unknown primary cancers: A meta-analysis. Auris Nasus Larynx 2019; 46:663-671. [PMID: 31064689 DOI: 10.1016/j.anl.2019.04.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 04/16/2019] [Accepted: 04/23/2019] [Indexed: 12/29/2022]
Abstract
The identification of the site in head neck unknown primary (HNUP) tumour is of utmost importance to help select best treatment while decreasing treatment-related morbidity and mortality. The primary purpose of this study is to demonstrate that TORS may be a valuable tool in detecting primary tumour. Studies were systematically searched in the PubMed, EMBASE, the Cochrane Library and CENTRAL electronic databases. A total of 12 selected studies (349 patients) were analyzed. The primary tumour detection and positive surgical margins rates were 70.8% and 19.4%, respectively. The rate of HPV-related tumour was 71.3%. The primary tumour was mainly in base of tongue (64%). In conclusion, TORS seems to be an effective surgical approach both in terms of detection of primary tumour site and in terms of therapeutic perspective for HNUP. In particular, a subset of HPV-related tumours might benefits all advantages from this surgical modality.
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Affiliation(s)
- Giuseppe Meccariello
- Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Azienda USL della Romagna, Forlì, Italy.
| | - Giovanni Cammaroto
- Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Azienda USL della Romagna, Forlì, Italy; Department of Otolaryngology and Head-Neck Surgery, University of Messina, Italy
| | - Enyinnaya Ofo
- St George's University Hospital, Kingston Hospital NHS Foundation Trusts, London, UK
| | - Sebastiano Calpona
- Osteoncology and Rare Tumors Center, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori(IRST), IRCCS, Meldola, Italy
| | - Elisabetta Parisi
- Radiotherapy Department, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori(IRST), IRCCS, Meldola, Italy
| | - Giovanni D'Agostino
- Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Azienda USL della Romagna, Forlì, Italy
| | - Riccardo Gobbi
- Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Azienda USL della Romagna, Forlì, Italy
| | - Elisabetta Firinu
- Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Azienda USL della Romagna, Forlì, Italy
| | - Chiara Bellini
- Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Azienda USL della Romagna, Forlì, Italy
| | - Andrea De Vito
- Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Azienda USL della Romagna, Forlì, Italy
| | - Filippo Montevecchi
- Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Azienda USL della Romagna, Forlì, Italy
| | - Matteo Costantini
- Department of Surgical Pathology, Morgagni Pierantoni Hospital, Azienda USL della Romagna, Forlì, Italy
| | - Elena Amadori
- Radiology Department, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori(IRST), IRCCS, Meldola, Italy
| | - Simona Nuzzo
- Department of Biostatistics, Azienda USL della Romagna, Forlì, Italy
| | | | - Claudio Vicini
- Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Azienda USL della Romagna, Forlì, Italy
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18
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Unknown primary of the head and neck: a new entry in the TNM staging system with old dilemmas for everyday practice. Curr Opin Otolaryngol Head Neck Surg 2019; 27:73-79. [DOI: 10.1097/moo.0000000000000528] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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19
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Transoral tongue base mucosectomy for the identification of the primary site in the work-up of cancers of unknown origin: Systematic review and meta-analysis. Oral Oncol 2019; 91:97-106. [PMID: 30926070 DOI: 10.1016/j.oraloncology.2019.02.018] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 02/17/2019] [Accepted: 02/20/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND The use of transoral robotic surgery (TORS) and laser microsurgery (TLM) in the diagnosis and identification of the site of the unknown primary has become increasingly common. This systematic review and meta-analysis aims to assess the use and efficacy of TORS and TLM for this indication. METHOD Systematic review and meta-analysis of studies employing TORS or TLM in diagnosis of the unknown primary tumor site in patients with cervical nodal metastases of squamous cell origin. MEDLINE, EMBASE and CINHAL were searched from inception to July 2018 for all studies that used TORS and or TLM in identifying the unknown primary. RESULTS 251 studies were identified, of which 21 were eligible for inclusion. The primary tumour was identified by TORS/TLM in 78% of patients (433 out of 556). Tongue base mucosectomy (TBM) identified the primary in 222 of 427 cases (53%). In patients with negative physical examination, diagnostic imaging and PETCT, TBM identified the primary in 64% (95% CI 50, 79) cases. In patients who had negative CT/MRI imaging, negative PETCT and negative EUA and tonsillectomy, TBM identified a tongue base primary in 78% (95% CI 41, 92) cases. Haemorrhage, the commonest complication, was reported in 4.9% cases. Mean length of stay varied between 1.4 and 6.3 days. CONCLUSION Tongue base mucosectomy, performed by TORS or TLM, is highly efficacious in identifying the unknown primary in the head and neck region.
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20
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Chan JW, Yeh I, El‐Sayed IH, Algazi AP, Glastonbury CM, Ha PK, Yom SS, Zante A. Ultraviolet light‐related DNA damage mutation signature distinguishes cutaneous from mucosal or other origin for head and neck squamous cell carcinoma of unknown primary site. Head Neck 2019; 41:E82-E85. [DOI: 10.1002/hed.25613] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 12/12/2018] [Indexed: 01/01/2023] Open
Affiliation(s)
- Jason W. Chan
- Department of Radiation OncologyUniversity of California San Francisco San Francisco California
| | - Iwei Yeh
- Departments of Dermatology and PathologyUniversity of California San Francisco San Francisco California
| | - Ivan H. El‐Sayed
- Department of Otolaryngology – Head and Neck SurgeryUniversity of California San Francisco San Francisco California
| | - Alain P. Algazi
- Department of Medicine – Hematology/OncologyUniversity of California San Francisco San Francisco California
| | - Christine M. Glastonbury
- Department of Radiology and Biomedical ImagingUniversity of California San Francisco San Francisco California
| | - Patrick K. Ha
- Department of Otolaryngology – Head and Neck SurgeryUniversity of California San Francisco San Francisco California
| | - Sue S. Yom
- Department of Radiation OncologyUniversity of California San Francisco San Francisco California
| | - Annemieke Zante
- Department of Anatomic PathologyUniversity of California San Francisco San Francisco California
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21
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Golusinski P, Di Maio P, Pehlivan B, Colley S, Nankivell P, Kong A, Hartley A, Mehanna H. Evidence for the approach to the diagnostic evaluation of squamous cell carcinoma occult primary tumors of the head and neck. Oral Oncol 2019; 88:145-152. [DOI: 10.1016/j.oraloncology.2018.11.020] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 11/11/2018] [Accepted: 11/15/2018] [Indexed: 02/08/2023]
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22
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Iannella G, Magliulo G, Montevecchi F, De Vito A, Polimeni A, De Vincentiis M, Meccariello G, D'Agostino G, Gobbi R, Cammaroto G, Stomeo F, Pang KP, Rotenberg B, Vicini C. Lingual tonsil lymphatic tissue regrowth in patients undergoing transoral robotic surgery. Laryngoscope 2018; 129:2652-2657. [PMID: 30582182 DOI: 10.1002/lary.27775] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2018] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS To evaluate a possible regrowth of lingual tonsil lymphatic tissue in patients submitted to lingual tonsil resection with transoral robotic surgery (TORS). STUDY DESIGN Retrospective Study. METHODS Medical records of patients surgically treated by means of TORS to remove excessive lymphatic tissue of the lingual tonsil were retrospectively reviewed. Postoperative endoscopic data after long-term follow-up were analyzed to investigate possible lymphatic tissue regrowth. Preoperative and postoperative lingual tonsil lymphatic tissue were classified according to the standardized Friedman's grading scale ranging from 0 to 4. RESULTS Sixty-eight patients (41 male and 27 female; mean age = 51.3 years) were considered suitable for the study analysis. Clinical regrowth was observed in six (8.8%) patients: four (5.9%) and two (2.9%) patients with grade 2 and 3 lymphatic hypertrophy, respectively. No correlation between the grade of regrowth, the time interval from surgery, and the volume of lymphatic tissue removed was found. CONCLUSIONS The lymphatic tissue regrowth after TORS resection appears to be very low. LEVEL OF EVIDENCE 4 Laryngoscope, 129:2652-2657, 2019.
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Affiliation(s)
| | - Giuseppe Magliulo
- Department of Sensory Organs, University "Sapienza", Rome, Italy.,Otolaryngology-Head and Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Forlì, Italy
| | - Filippo Montevecchi
- Otolaryngology-Head and Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Forlì, Italy
| | - Andrea De Vito
- Otolaryngology-Head and Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Forlì, Italy
| | - Antonella Polimeni
- Department of Oral and Maxillofacial Sciences, University "Sapienza", Rome, Italy
| | | | | | - Giovanni D'Agostino
- Otolaryngology-Head and Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Forlì, Italy
| | - Riccardo Gobbi
- Otolaryngology-Head and Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Forlì, Italy
| | - Giovanni Cammaroto
- Otolaryngology-Head and Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Forlì, Italy
| | - Francesco Stomeo
- Department of ENT and Audiology, University of Ferrara, Ferrara, Italy
| | - Kenny P Pang
- Department of Otolaryngology, Asia Sleep Centre, Paragon, Singapore
| | - Brian Rotenberg
- Department of Otolaryngology, Western University, London, Ontario, Canada
| | - Claudio Vicini
- Department of ENT and Audiology, University of Ferrara, Ferrara, Italy
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23
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Di Maio P, Iocca O, De Virgilio A, Ferreli F, Cristalli G, Pellini R, Golusinski P, Ricci G, Spriano G. Role of palatine tonsillectomy in the diagnostic workup of head and neck squamous cell carcinoma of unknown primary origin: A systematic review and meta‐analysis. Head Neck 2018; 41:1112-1121. [DOI: 10.1002/hed.25522] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 08/21/2018] [Accepted: 09/28/2018] [Indexed: 12/17/2022] Open
Affiliation(s)
- Pasquale Di Maio
- Section of Otolaryngology—Head and Neck Surgery, Department of Surgical and Biomedical SciencesUniversity of Perugia Perugia Italy
- Department of Otolaryngology—Head & Neck SurgeryRegina Elena National Cancer Institute Rome Italy
| | - Oreste Iocca
- Department of Otolaryngology—Head & Neck SurgeryRegina Elena National Cancer Institute Rome Italy
| | | | - Fabio Ferreli
- Department of Otolaryngology—Head & Neck SurgeryRegina Elena National Cancer Institute Rome Italy
| | - Giovanni Cristalli
- Department of Otolaryngology—Head & Neck SurgeryRegina Elena National Cancer Institute Rome Italy
| | - Raul Pellini
- Department of Otolaryngology—Head & Neck SurgeryRegina Elena National Cancer Institute Rome Italy
| | - Pawel Golusinski
- Department of Head and Neck SurgeryPoznan University of Medical Sciences, The Greater Poland Cancer Centre Poznan Poland
- Department of Biology and Environmental StudiesPoznan University of Medical Sciences Poznan Poland
| | - Giampietro Ricci
- Section of Otolaryngology—Head and Neck Surgery, Department of Surgical and Biomedical SciencesUniversity of Perugia Perugia Italy
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Lingual Tonsillectomy Likely Does Not Improve Outcomes for Squamous Cell Carcinoma of the Head and Neck From an Unknown Primary Site. Am J Clin Oncol 2018; 41:1216-1219. [DOI: 10.1097/coc.0000000000000461] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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25
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Tongue base mucosectomy for carcinoma of unknown primary using endoscopic electrocautery: rationale for wider implementation of an institutionally restricted technique. The Journal of Laryngology & Otology 2018; 132:1138-1142. [PMID: 30457073 DOI: 10.1017/s0022215118002062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Cervical metastasis from an unknown primary site invariably results in pan-mucosal irradiation if a primary tumour is not identified. Transoral robotic and laser-assisted mucosectomy are valid techniques to increase diagnostic rates, but these remain restricted to certain centres. This paper describes, in detail, a technique in which mucosectomy is performed via endoscopic electrocautery. METHODS Patients were prospectively recruited between May 2017 and June 2018. Inclusion criteria stipulated biopsy-proven metastatic cervical squamous cell carcinoma, with negative findings on magnetic resonance imaging and positron emission tomography/computed tomography, in addition to examination under anaesthetic, tonsillectomy and 'blind' tongue base biopsies without tumour identification, prior to mucosectomy. RESULTS Of nine patients, a mucosal primary was identified in four (44.4 per cent), for which ipsilateral intensity-modulated radiotherapy was advocated in three and completion tongue base resection in the fourth. Dysplasia was demonstrated in two further patients, which provided information relevant to radiotherapy fields and post-treatment surveillance. No surgical complications were identified. CONCLUSION Tongue base mucosectomy using electrocautery and conventional tonsillectomy equipment is a safe, effective technique in the identification of cervical metastasis from an unknown primary site. It expands the potential breadth of use, quickens prolonged diagnostic pathways and obviates the necessity for pan-mucosal irradiation.
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26
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Prevalence, prognosis, and treatment implications of retropharyngeal nodes in unknown primary head and neck carcinoma. Oral Oncol 2018; 82:162-167. [DOI: 10.1016/j.oraloncology.2018.05.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 05/01/2018] [Accepted: 05/25/2018] [Indexed: 12/24/2022]
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27
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Sudoko CK, Polacco MA, Gosselin BJ, Paydarfar JA. Diagnostic Value of Lingual Tonsillectomy in Unknown Primary Head and Neck Carcinoma Identification After a Negative Clinical Workup and Positron Emission Tomography-Computed Tomography. Front Oncol 2018; 8:118. [PMID: 29732318 PMCID: PMC5919999 DOI: 10.3389/fonc.2018.00118] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 04/03/2018] [Indexed: 01/15/2023] Open
Abstract
Objective Diagnostic rates of unknown primary head and neck carcinoma (UPHNC) using lingual tonsillectomy (LT) are highly variable. This study sought to determine the diagnostic value of LT in UPHNC identification using strict inclusion criteria and definitions to produce a more accurate estimate of diagnosis rate. Methods In this retrospective chart review, records of patients who underwent LT for UPHNC were reviewed. Inclusion criteria included absence of suspicious findings on physical exam and positron emission tomography-computed tomography as well as negative biopsies after panendoscopy and palatine tonsillectomy. Following inclusion criteria, 16 patients were reviewed. A systematic literature review on LT for the workup of CUP was also performed. Results LT was performed using transoral robotic surgery (TORS), transoral laser microsurgery (TLM), or transoral microsurgery with cautery (TMC). Following LT, primary tumor was identified in 4 patients out of 16. Detection rate by technique was 1/6, 2/7, and 1/3 for TORS, TLM, and TMC respectively. Postoperative bleeding occurred in three patients (19%); however, this was not related to the LT. Following literature review, 12 studies were identified; however, only 3 had enough data to compare against. All three studies had a cohort with suspicious findings on clinical exam. A total of 34 patients had a negative workup, with no suspicious findings on clinical exam and subsequently received an LT. Conclusion This study suggests that LT should be considered initially in the diagnostic algorithm for UPHNC. This study can increase the patient size in this cohort by approximately 47%.
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Affiliation(s)
- Chad K Sudoko
- Geisel School of Medicine at Dartmouth College, Hanover, NH, United States
| | - Marc A Polacco
- Section of Otolaryngology, Audiology & Maxillofacial Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States
| | - Benoit J Gosselin
- Section of Otolaryngology, Audiology & Maxillofacial Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States.,Norris Cotton Cancer Center, Lebanon, NH, United States
| | - Joseph A Paydarfar
- Section of Otolaryngology, Audiology & Maxillofacial Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States.,Norris Cotton Cancer Center, Lebanon, NH, United States
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Tiong A, Rischin D, Young RJ, Herschtal A, Solomon B, D'Costa I, Fua T, Liu C, Coleman A, Kleid S, Dixon BJ, Corry J. Unilateral radiotherapy treatment for p16/human papillomavirus-positive squamous cell carcinoma of unknown primary in the head and neck. Laryngoscope 2018; 128:2076-2083. [PMID: 29481710 DOI: 10.1002/lary.27131] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 12/01/2017] [Accepted: 01/04/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS The outcomes of unilateral radiotherapy treatment for patients with p16/HPV-positive squamous cell carcinomas of unknown primary (SCCUP) affecting cervical lymph nodes are under-reported. Compared to radiating large volumes of the pharyngeal axis (the more common approach), this is potentially a much less toxic treatment for a good prognosis group. STUDY DESIGN Retrospective cohort study. METHODS We identified patients with SCCUP who were treated radically at our center and did not have parotid or isolated level IV or V nodal involvement. Failure-free and overall survivals were calculated using Kaplan-Meier methods. RESULTS From 2004 to 2012, there were 49 radically treated patients with SCCUP. Fourteen patients had bilateral neck treatment (they had bilateral nodal disease or suspected lesions in the base of tongue, though not proven with biopsy), two had surgery alone, whereas 33 had unilateral radiotherapy (after neck dissection, excisional biopsy, or definitively with concurrent chemotherapy). Of the 33 patients, 21 tested positive to p16/HPV and had median follow-up of 57 months. In this group, no isolated contralateral neck failures or putative primaries emerged. There was 1/21 (4.3%) ipsilateral neck failure, 1/21 (4.3%) concurrent contralateral neck and distant failure, and 1/21 (4.3%) patient with distant failure. The 5-year freedom from failure was 78% (95% confidence interval [CI]: 56%-100%) and overall survival was 90% (95% CI: 79%-100%). CONCLUSIONS With no emergence of putative primaries and no isolated contralateral neck failures, this single-institution experience in p16/HPV-positive SCCUP patients suggests that unilateral radiotherapy may be an underutilized management strategy. LEVELS OF EVIDENCE 4 Laryngoscope, 128:2076-2083, 2018.
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Affiliation(s)
- Albert Tiong
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Danny Rischin
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,University of Melbourne, Parkville, Victoria, Australia
| | - Richard J Young
- Molecular Therapeutics and Biomarkers Laboratory, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Alan Herschtal
- Department of Biostatistics and Clinical Trials, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Ben Solomon
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,University of Melbourne, Parkville, Victoria, Australia
| | - Ieta D'Costa
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Tsien Fua
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Chen Liu
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Andrew Coleman
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Stephen Kleid
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Benjamin J Dixon
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Surgery, University of Melbourne, St. Vincent's Hospital, Fitzroy, Victoria, Australia
| | - June Corry
- University of Melbourne, Parkville, Victoria, Australia.,GenesisCare Radiation Oncology Centre, St Vincent's Hospital, Fitzroy, Victoria, Australia
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Troussier I, Klausner G, Morinière S, Blais E, Jean-Christophe Faivre, Champion A, Geoffrois L, Pflumio C, Babin E, Maingon P, Thariat J. [Advances in the management of cervical lymphadenopathies of unknown primary: advances in diagnostic imaging and surgical modalities and new international staging system]. Bull Cancer 2017; 105:181-192. [PMID: 29275831 DOI: 10.1016/j.bulcan.2017.11.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 11/10/2017] [Accepted: 11/15/2017] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Cervical lymphadenopathies of unknown primary represent 3 % of head and neck cancers. Their diagnostic work up has largely changed in recent years. This review provides an update on diagnostic developments and their potential therapeutic impact. MATERIALS AND METHODS This is a systematic review of the literature. RESULTS In recent years, changes in epidemiology-based prognostic factors such as human papilloma virus (HPV) cancers, advances in imaging and minimally invasive surgery have been integrated in the management of cervical lymphadenopathies of unknown primary. In particular, systematic use of PET scanner and increasing practice of robotic or laser surgery have contributed to increasing detection rate of primary cancers. These allow more adapted and personalized treatments. The impact of changes in the eighth TNM staging system is discussed. CONCLUSION The management of cervical lymphadenopathies of unknown primary cancer has changed significantly in the last 10 years. On the other hand, practice changes will have to be assessed.
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Affiliation(s)
- Idriss Troussier
- CHRU Pitié-Salpêtrière, radiothérapie, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - Guillaume Klausner
- Institut Gustave-Roussy, radiothérapie, 114, rue Edouard-Vaillant, 94800 Villejuif, France
| | - Sylvain Morinière
- CHRU de Tours, carcinologie cervicofaciale, 2, boulevard Tonnellé, 37000 Tours, France
| | - Eivind Blais
- Centre Bergonié, radiothérapie, 229, cours de l'Argonne, 33000 Bordeaux, France
| | - Jean-Christophe Faivre
- Institut de cancérologie de Lorraine, oncologie médicale, 6, avenue de Bourgogne, 54519 Vandœuvre-lès-Nancy, France
| | - Ambroise Champion
- Hôpitaux universitaires Genève, radiothérapie, rue Gabrielle-Perret-Gentil, 4, 1205 Genève, Suisse
| | - Lionnel Geoffrois
- CHRU de Tours, carcinologie cervicofaciale, 2, boulevard Tonnellé, 37000 Tours, France
| | - Carole Pflumio
- CHRU de Tours, carcinologie cervicofaciale, 2, boulevard Tonnellé, 37000 Tours, France
| | - Emmanuel Babin
- CHRU de Caen, carcinologie cervicofaciale, avenue de la Côte-de-Nacre, 14033 Caen, France
| | - Philippe Maingon
- CHRU Pitié-Salpêtrière, radiothérapie, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - Juliette Thariat
- ARCHADE centre François-Baclesse, radiothérapie, 3, avenue du Général-Harris, 14000 Caen, France.
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Kuta V, Williams B, Rigby M, Hart R, Trites J, MacKay C, Taylor SM. Management of head and neck primary unknown squamous cell carcinoma using combined positron emission tomography-computed tomography and transoral laser microsurgery. Laryngoscope 2017; 128:2307-2311. [PMID: 29214640 DOI: 10.1002/lary.27034] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 10/29/2017] [Accepted: 11/06/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVES/HYPOTHESIS The unknown primary of the neck is commonly encountered by the head and neck surgeon. Despite the exhaustive diagnostic tools employed in traditional detection protocols, many unknown primaries are not found, and the patient is subjected to wide-field radiation and chemotherapy during treatment. Localizing the primary tumor has demonstrated therapeutic benefits, improved quality of life, and overall survival. The authors' objective was to determine the efficacy of a new management protocol for unknown primaries of the head and neck. STUDY DESIGN Prospective cohort study. METHODS Our technique involved a preoperative positron emission tomography-computed tomography (PET-CT) followed by a planned transoral laser microsurgery (TLM) approach. Efficacy was assessed based on survival statistics, disease control, detection rates, the proportion of patients not receiving adjuvant therapy, and the proportion of PET-CT scans helpful for detection of the primary cancer. RESULTS The occult primary was located in 25 of the 27 patients (93%), with the majority found in the palatine tonsil (52%). Both overall survival and disease-specific survival was 80% at 36 months. Local control was achieved in 100% of patients. After surgery, 37.0% (n = 10) received adjuvant radiation alone and 33.3% (n = 9) of patients went on to receive adjuvant chemoradiation. On imaging, 72% (n = 18) of PET-CT scans correctly localized the primary tumor. CONCLUSIONS Occult head and neck primaries present a diagnostic challenge that is not adequately overcome using traditional detection protocols. The current study presents our unique protocol at Dalhousie University, which demonstrates the efficacy of the PET-CT TLM protocol from both a detection and therapeutic perspective. LEVEL OF EVIDENCE 4. Laryngoscope, 128:2307-2311, 2018.
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Affiliation(s)
- Victoria Kuta
- Faculty of Medicine, Victoria General Hospital, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Blair Williams
- Division of Otolaryngology, Victoria General Hospital, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Matthew Rigby
- Division of Otolaryngology, Victoria General Hospital, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Robert Hart
- Division of Otolaryngology, Victoria General Hospital, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jonathan Trites
- Division of Otolaryngology, Victoria General Hospital, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Colin MacKay
- Division of Otolaryngology, Victoria General Hospital, Dalhousie University, Halifax, Nova Scotia, Canada
| | - S Mark Taylor
- Division of Otolaryngology, Victoria General Hospital, Dalhousie University, Halifax, Nova Scotia, Canada
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Investigation and management of the unknown primary with metastatic neck disease: United Kingdom National Multidisciplinary Guidelines. The Journal of Laryngology & Otology 2017; 130:S170-S175. [PMID: 27841129 PMCID: PMC4873921 DOI: 10.1017/s0022215116000591] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. It discusses the evidence base pertaining to the management of metastatic neck disease in the setting of an unknown primary and provides recommendations on the work up and management for this group of patients receiving cancer care.
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Arosio AD, Pignataro L, Gaini RM, Garavello W. Neck lymph node metastases from unknown primary. Cancer Treat Rev 2016; 53:1-9. [PMID: 28027480 DOI: 10.1016/j.ctrv.2016.11.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 11/23/2016] [Accepted: 11/29/2016] [Indexed: 11/18/2022]
Abstract
Metastatic cervical carcinoma from unknown primary is a metastatic disease in the lymph nodes of the neck without any evidence of a primary tumour after appropriate investigation. The condition is rare and definite evidence is lacking for both diagnosis and treatment. In this review of the literature, we tried to draw some clinical indications based on the few available studies. We ultimately came to the following conclusions: (1) a thorough and accurate diagnostic work-up should be systematically offered. It includes accurate inspection with fibroscopy, CT or MRI, fine needle aspiration, panendoscopy and positron emission tomography, (2) Patients with low-volume neck disease, N1 and N2a stage and without extracapsular extension on histopathological examination should receive single modality treatment. Radiotherapy and surgery may be similarly effective but, if possible, surgery (excisional biopsy, neck dissection and tonsillectomy) should be favoured because it consents a more precise staging, (3) patients with more advanced conditions require combined treatment in the form of either resection followed by adjuvant radiation (±chemotherapy) or primary chemoradiation (±post-therapy neck dissection).
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Affiliation(s)
- Alberto Daniele Arosio
- Department of Otorhinolaryngology, School of Medicine and Surgery, University of Milano-Bicocca, San Gerardo Hospital, Monza, Italy
| | - Lorenzo Pignataro
- Department of Otorhinolaryngology, Department of Clinical Sciences and Community Health, University of Milan, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Renato Maria Gaini
- Department of Otorhinolaryngology, School of Medicine and Surgery, University of Milano-Bicocca, San Gerardo Hospital, Monza, Italy
| | - Werner Garavello
- Department of Otorhinolaryngology, School of Medicine and Surgery, University of Milano-Bicocca, San Gerardo Hospital, Monza, Italy.
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Bekeny JR, Ozer E. Transoral robotic surgery frontiers. World J Otorhinolaryngol Head Neck Surg 2016; 2:130-135. [PMID: 29204557 PMCID: PMC5698526 DOI: 10.1016/j.wjorl.2016.05.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 05/12/2016] [Indexed: 10/30/2022] Open
Abstract
Transoral robotic surgery is a exciting field that continues to develop and push the boundaries of current procedural ability and challenges historical treatment paradigms. With the first use of a surgical robot in 1985, to the first clinical use of the robot transorally in 2005, there was some lag in adoption of robotic techniques in the head and neck region. However, since 2005 transoral robotic surgery has rapidly gained momentum amongst head and neck surgeons. With FDA approval of the da Vinci robot in 2009, transoral robotic surgery is currently offered as a treatment modality for malignant and nonmalignant disease of the head and neck region. This new technology is being used to reconsider historical treatment paradigms for malignancies of the upper aerodigestive tract due to the fact that minimally invasive surgical access to the oropharynx and larynx has been improved. Along with this enhanced access have come innovative procedures and uses of the technology for multiple facets of head and neck disease. Technology continues to improve and innovation in surgical robotics is expected to continue as more companies attempt to capture this market. This article aims to provide a view at the landscape of transoral robotic surgery and explore the future frontiers.
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Affiliation(s)
- James R Bekeny
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Medical Center, The James Cancer Hospital and Solove Research Institute, Columbus, OH 43210, USA
| | - Enver Ozer
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Medical Center, The James Cancer Hospital and Solove Research Institute, Columbus, OH 43210, USA
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Squamous cell carcinoma of unknown primary tumor metastatic to neck nodes: role of elective irradiation. Eur Arch Otorhinolaryngol 2016; 273:4561-4569. [PMID: 27363402 DOI: 10.1007/s00405-016-4172-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 06/24/2016] [Indexed: 01/09/2023]
Abstract
In patients with squamous cell carcinoma (SCC) metastases to neck lymph nodes and unknown primary tumor, the role of elective irradiation of uninvolved neck and potential mucosal primary sites is yet to be determined. The aim of this study was to review the experience treating SCC of unknown primary metastatic to neck nodes with surgery and postoperative radiotherapy (PORT) in Slovenia between 1995 and 2010 and to determine the importance of the extent of irradiated volume. For this purpose, the nationwide Cancer Registry of Slovenia database was used for identifying patients. 126 patients were identified. Involved-field PORT and extended-field PORT was used in 50 and 76 patients, respectively. At 5 years, locoregional control was 86 %, disease-specific survival 77 %, and overall survival 57 %. In multivariate analysis, the extent of irradiated volume has not been predictive for any outcome under study. Grade ≥3 acute and late radiotherapy-induced toxicities were more frequent in the extended-field PORT group. In conclusion, although not superior, involved-field PORT seems to be a preferred treatment option in SCC of unknown primary metastatic to neck nodes due to significantly reduced toxicity and better prospects for successful salvage.
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Fu TS, Foreman A, Goldstein DP, de Almeida JR. The role of transoral robotic surgery, transoral laser microsurgery, and lingual tonsillectomy in the identification of head and neck squamous cell carcinoma of unknown primary origin: a systematic review. J Otolaryngol Head Neck Surg 2016; 45:28. [PMID: 27142355 PMCID: PMC4855481 DOI: 10.1186/s40463-016-0142-6] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 04/25/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Squamous cell carcinoma of the head and neck can present as a cervical metastasis from an unknown primary site. Recently, transoral robotic surgery (TORS) and transoral laser microsurgery (TLM) have been incorporated in the workup of unknown primary tumors. METHODS We searched MEDLINE, EMBASE, Cochrane, and CINAHL from inception to June 2015 for all English-language studies that utilized TORS, TLM, or lingual tonsillectomy in the approach to an unknown primary. RESULTS Of 217 identified studies, eight were reviewed. TORS/TLM identified the primary tumor in 111/139 (80 %) patients overall, and 36/54 (67 %) patients with no remarkable findings following physical exam, radiologic imaging, and panendoscopy with directed biopsies. Lingual tonsillectomy identified the primary tumor in 18/25 (72 %) patients with no findings. Hemorrhage (5 %) was the most common perioperative complication. CONCLUSION Lingual tonsillectomy using new approaches such as TORS/TLM may improve the identification of occult primary tumors.
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Affiliation(s)
- Terence S Fu
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Andrew Foreman
- Department of Otolaryngology - Head and Neck Surgery, University of Toronto, Toronto, ON, Canada
| | - David P Goldstein
- Department of Otolaryngology - Head and Neck Surgery, University of Toronto, Toronto, ON, Canada
| | - John R de Almeida
- Department of Otolaryngology - Head and Neck Surgery, University of Toronto, Toronto, ON, Canada.
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Hussain T, Savariar EN, Diaz-Perez JA, Messer K, Pu M, Tsien RY, Nguyen QT. Surgical molecular navigation with ratiometric activatable cell penetrating peptide for intraoperative identification and resection of small salivary gland cancers. Head Neck 2016; 38:715-23. [PMID: 25521629 PMCID: PMC4472578 DOI: 10.1002/hed.23946] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2014] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND We evaluated the use of intraoperative fluorescence guidance by enzymatically cleavable ratiometric activatable cell-penetrating peptide (RACPPPLGC(Me)AG) containing Cy5 as a fluorescent donor and Cy7 as a fluorescent acceptor for salivary gland cancer surgery in a mouse model. METHODS Surgical resection of small parotid gland cancers in mice was performed with fluorescence guidance or white light (WL) imaging alone. Tumor identification accuracy, operating time, and tumor-free survival were compared. RESULTS RACPP guidance aided tumor detection (positive histology in 90% [27/30] vs 48% [15/31] for WL; p < .001). An approximate 25% ratiometric signal increase as the threshold to distinguish between tumor and adjacent tissue, yielded >90% detection sensitivity and specificity. Operating time was reduced by 54% (p < .001), and tumor-free survival was increased with RACPP guidance (p = .025). CONCLUSION RACPP provides real-time intraoperative guidance leading to improved survival. Ratiometric signal thresholds can be set according to desired detection accuracy levels for future RACPP applications.
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Affiliation(s)
- Timon Hussain
- Division of Head and Neck Surgery, University of California San Diego
| | | | | | - Karen Messer
- Division of Biostatistics, Moores Cancer Center, University of California San Diego
| | - Minya Pu
- Division of Biostatistics, Moores Cancer Center, University of California San Diego
| | - Roger Y. Tsien
- Department of Pharmacology, University of California San Diego
- Howard Hughes Medical Institute, University of California San Diego
| | - Quyen T. Nguyen
- Division of Head and Neck Surgery, University of California San Diego
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Son EL, Underbrink MP, Qiu S, Resto VA. The surgical plane for lingual tonsillectomy: an anatomic study. J Otolaryngol Head Neck Surg 2016; 45:22. [PMID: 27044530 PMCID: PMC4820931 DOI: 10.1186/s40463-016-0137-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 03/30/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The presence of a plane between the lingual tonsils and the underlying soft tissue has not been confirmed. The objective of this study is to ascertain the presence and the characteristics about this plane for surgical use. METHODS Five cadaver heads were obtained for dissection of the lingual tonsils. Six permanent sections of previous tongue base biopsies were reviewed. Robot assisted lingual tonsillectomy was performed using the dissection technique from the cadaver dissection. RESULTS In each of the 5 cadavers, an avascular plane was revealed deep to the lingual tonsils. Microscopic review of the tongue base biopsies revealed a clear demarcation between the lingual tonsils and the underlying minor salivary glands and muscle tissue. This area was relatively avascular. Using the technique described above, a lingual tonsillectomy using TORS was performed with similar findings from the cadaver dissections. CONCLUSIONS A surgical plane for lingual tonsillectomy exists and may prove to have a role with lingual tonsillectomy with TORS.
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Affiliation(s)
- Eugene L Son
- Department of Otolaryngology - Head and Neck Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA.
| | - Michael P Underbrink
- Department of Otolaryngology - Head and Neck Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA
| | - Suimin Qiu
- Department of Pathology, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA
| | - Vicente A Resto
- Department of Otolaryngology - Head and Neck Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA
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Son EL, Underbrink MP, Qiu S, Resto VA. The surgical plane for lingual tonsillectomy: an anatomic study. J Otolaryngol Head Neck Surg 2016. [PMID: 27044530 DOI: 10.11186/s40463-016-0137-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
BACKGROUND The presence of a plane between the lingual tonsils and the underlying soft tissue has not been confirmed. The objective of this study is to ascertain the presence and the characteristics about this plane for surgical use. METHODS Five cadaver heads were obtained for dissection of the lingual tonsils. Six permanent sections of previous tongue base biopsies were reviewed. Robot assisted lingual tonsillectomy was performed using the dissection technique from the cadaver dissection. RESULTS In each of the 5 cadavers, an avascular plane was revealed deep to the lingual tonsils. Microscopic review of the tongue base biopsies revealed a clear demarcation between the lingual tonsils and the underlying minor salivary glands and muscle tissue. This area was relatively avascular. Using the technique described above, a lingual tonsillectomy using TORS was performed with similar findings from the cadaver dissections. CONCLUSIONS A surgical plane for lingual tonsillectomy exists and may prove to have a role with lingual tonsillectomy with TORS.
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Affiliation(s)
- Eugene L Son
- Department of Otolaryngology - Head and Neck Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA.
| | - Michael P Underbrink
- Department of Otolaryngology - Head and Neck Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA
| | - Suimin Qiu
- Department of Pathology, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA
| | - Vicente A Resto
- Department of Otolaryngology - Head and Neck Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA
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Dixon PR, Au M, Hosni A, Perez-Ordonez B, Weinreb I, Xu W, Song Y, Huang SH, O'Sullivan B, Goldstein DP, de Almeida JR. Impact of p16 expression, nodal status, and smoking on oncologic outcomes of patients with head and neck unknown primary squamous cell carcinoma. Head Neck 2016; 38:1347-53. [DOI: 10.1002/hed.24441] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 12/19/2015] [Accepted: 02/02/2016] [Indexed: 01/12/2023] Open
Affiliation(s)
- Peter R. Dixon
- Department of Otolaryngology - Head and Neck Surgery; Princess Margaret Cancer Center, University Health Network, University of Toronto; Toronto Canada
| | - Michael Au
- Department of Otolaryngology - Head and Neck Surgery; Princess Margaret Cancer Center, University Health Network, University of Toronto; Toronto Canada
| | | | - Bayardo Perez-Ordonez
- Department of Pathology; Princess Margaret Cancer Center, University Health Network, University of Toronto; Toronto Canada
| | - Ilan Weinreb
- Department of Pathology; Princess Margaret Cancer Center, University Health Network, University of Toronto; Toronto Canada
| | - Wei Xu
- Department of Biostatistics; Princess Margaret Cancer Center, University Health Network, University of Toronto; Toronto Canada
| | - Yuyao Song
- Department of Biostatistics; Princess Margaret Cancer Center, University Health Network, University of Toronto; Toronto Canada
| | - Shao Hui Huang
- Department of Radiation Oncology; Princess Margaret Cancer Centre, University Health Network, University of Toronto; Toronto Canada
| | - Brian O'Sullivan
- Department of Radiation Oncology; Princess Margaret Cancer Centre, University Health Network, University of Toronto; Toronto Canada
| | - David P. Goldstein
- Department of Otolaryngology - Head and Neck Surgery; Princess Margaret Cancer Center, University Health Network, University of Toronto; Toronto Canada
| | - John R. de Almeida
- Department of Otolaryngology - Head and Neck Surgery; Princess Margaret Cancer Center, University Health Network, University of Toronto; Toronto Canada
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Mani N, George MM, Nash L, Anwar B, Homer JJ. Role of 18-Fludeoxyglucose positron emission tomography-computed tomography and subsequent panendoscopy in head and neck squamous cell carcinoma of unknown primary. Laryngoscope 2015; 126:1354-8. [PMID: 26671043 DOI: 10.1002/lary.25783] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2015] [Indexed: 11/06/2022]
Abstract
OBJECTIVES/HYPOTHESIS Head and neck squamous cell carcinomas of unknown primary (HNSCCUP) accounts for up to 10% of presenting head and neck squamous cell carcinomas. Identification of the primary site allows for directed therapy. Where initial investigations have failed to locate the primary site, 18-fludeoxyglucose positron emission tomography-computed tomography (PET/CT) has emerged as a useful tool with improved sensitivity over positron emission tomography alone. Following PET/CT scan, the role of subsequent panendoscopy ± biopsy has not been fully assessed. We aim to evaluate and quantify the role of PET/CT and subsequent panendoscopy in HNSCCUP. STUDY DESIGN Retrospective cohort study. METHODS Patients with HNSCCUP presenting between January 2005 and December 2010 at a regional oncology referral center were studied. All patients who presented with a metastatic neck node and unknown primary who had undergone PET/CT prior to panendoscopy were included. The accuracy of PET/CT was calculated and compared with panendoscopy and histopathological findings. RESULTS Fifty-two patients were included. Twenty-seven PET/CT scans suggested a primary site. Calculated diagnostic parameters were 83% sensitivity, 87% specificity, positive predictive value 89%, and negative predictive value 80%. Three false-positive PET/CT scans were noted after panendoscopy and normal histology. Importantly, three confirmed tongue base tumors were found on panendoscopy, which were undetected on PET/CT. CONCLUSIONS PET/CT is a valuable resource for locating tumors in HNSCCUP. It helps direct biopsy and aids in the detection of local and distant metastases along with synchronous primary tumors. Importantly, due to both false-positive and false-negative PET/CT rates, panendoscopy and biopsy remains an essential adjunct investigation irrespective of PET/CT results. LEVEL OF EVIDENCE 4 Laryngoscope, 126:1354-1358, 2016.
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Affiliation(s)
- Navin Mani
- Head and Neck Oncology Department, The Christie NHS Trust, Manchester, United Kingdom
| | - Manish M George
- Head and Neck Oncology Department, The Christie NHS Trust, Manchester, United Kingdom
| | - Laura Nash
- Head and Neck Oncology Department, The Christie NHS Trust, Manchester, United Kingdom
| | - Bilal Anwar
- Head and Neck Oncology Department, The Christie NHS Trust, Manchester, United Kingdom
| | - Jarrod J Homer
- Head and Neck Oncology Department, The Christie NHS Trust, Manchester, United Kingdom
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Galloway TJ, Ridge JA. Management of Squamous Cancer Metastatic to Cervical Nodes With an Unknown Primary Site. J Clin Oncol 2015; 33:3328-37. [PMID: 26351351 DOI: 10.1200/jco.2015.61.0063] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Squamous cell carcinoma of an unknown primary (SCCUP) of the head and neck is a rare disease. As a diagnosis of exclusion, the manner in which it is assigned merits consideration. Despite the development and refinement of several techniques designed to locate an occult tumor, including cross-sectional anatomic imaging, functional imaging, and transoral surgical techniques, delineating SCCUP remains an active clinical problem. Its relative rarity has prevented prospective study of the entity. Hence, investigators must rely on retrospective analyses to understand the disease and its appropriate treatment. The current understanding of SCCUP differs substantially from when it was initially described decades ago. The most common site of a small primary tumor initially thought to represent SCCUP is the tonsil or base of the tongue, and an increasing percentage are associated with human papilloma virus. Modern treatment of SCCUP by neck dissection alone, neck dissection followed by radiation with or without concurrent chemotherapy, or primary chemoradiation according to initial nodal disease burden produces extraordinarily low recurrence rates. Whether the potential mucosal primary site and/or the contralateral neck should be electively treated is controversial. Efficacy data seem to be similar; therefore, an evaluation of the toxicity of both treatment paradigms is warranted.
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Affiliation(s)
| | - John A Ridge
- All authors: Fox Chase Cancer Center, Philadelphia, PA.
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Channir HI, Rubek N, Nielsen HU, Kiss K, Charabi BW, Lajer CB, von Buchwald C. Transoral robotic surgery for the management of head and neck squamous cell carcinoma of unknown primary. Acta Otolaryngol 2015; 135:1051-7. [PMID: 26073750 DOI: 10.3109/00016489.2015.1052983] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
CONCLUSION The addition of transoral robotic surgery (TORS) in the diagnostic management of patients classified with head and neck squamous cell carcinoma of unknown primary (SCCUP) is promising and appears to improve detection rates of the primary tumour. The approach presented in this first Scandinavian study could potentially minimize the radiation field to the pharyngeal axis in patients with identified primary tumours. OBJECTIVES The aim of the study was to investigate whether bilateral lingual tonsillectomy performed with TORS is feasible, and whether it could improve the detection rates of primary tumours in patients diagnosed and classified as having SCCUP. METHODS The study was retrospective and included 13 patients with SCCUP who were referred to TORS between October 2013 and January 2015. All 13 patients had previously undergone a full investigation programme following the national guidelines including whole-body PET/CT, examination in general anaesthesia, including random biopsies of the base of the tongue and bilateral palatine tonsillectomy without identification of the primary tumour. RESULTS The primary tumour was identified by TORS in seven of the 13 patients (54%) at the lingual tonsils. Human papillomavirus DNA and p16 were positive in all identified primary tumour specimens and in the corresponding lymph node metastases.
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Martin JM, Galloway TJ. Evaluation and management of head and neck squamous cell carcinoma of unknown primary. Surg Oncol Clin N Am 2015; 24:579-91. [PMID: 25979401 DOI: 10.1016/j.soc.2015.03.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The diagnostic evaluation and therapeutic management of a patient with squamous cell carcinoma of an unknown primary (SCCUP) has considerably evolved over recent decades and will likely continue to change as a result of the improving ability to identify small primary tumors and better tailor the implementation of multimodality therapy. By application of the general principles of head and neck oncology, physicians and surgeons are often able to achieve satisfactory control of the disease in patients with SCCUP.
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Affiliation(s)
- Jeffrey M Martin
- Department of Radiation Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111, USA
| | - Thomas J Galloway
- Department of Radiation Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111, USA.
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45
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Deschler DG, Richmon JD, Khariwala SS, Ferris RL, Wang MB. The "new" head and neck cancer patient-young, nonsmoker, nondrinker, and HPV positive: evaluation. Otolaryngol Head Neck Surg 2014; 151:375-80. [PMID: 24925311 PMCID: PMC4894657 DOI: 10.1177/0194599814538605] [Citation(s) in RCA: 117] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Accepted: 05/15/2014] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The near epidemic rise of the incidence of human papillomavirus (HPV)-related oropharyngeal squamous cell carcinomas (OPSCC) presents the practitioner with a "new" head and neck cancer patient, vastly different from those with the traditional risk factors who formed the basis of most practitioners' training experience. Accordingly, a thorough and disease-specific evaluation process is necessitated. This article will review the evaluation of the HPV-related cancer patient, including a review of the HPV-positive oropharyngeal cancer epidemic from the surgeon's perspective, evaluation of the primary lesion, evaluation of the neck mass, and role of imaging, to provide a framework for addressing the challenging questions patients may ask. DATA SOURCES Available peer-reviewed literature and practice guidelines. REVIEW METHODS Assessment of selected specific topics by authors solicited from the Head and Neck Surgery and Oncology Committee of the American Academy of Otolaryngology-Head and Neck Surgery Foundation and the American Head and Neck Society. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE The dramatic rise in OPSSC related to HPV is characterized by a "new" cancer patient who is younger and lacks traditional risk factors. Today's caregiver must be prepared to appropriately evaluate, counsel, and treat these patients with HPV-positive disease with the expectation that traditional treatment algorithms will evolve to maintain or improve current excellent cure rates while lessening treatment related side effects.
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Affiliation(s)
- Daniel G Deschler
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeremy D Richmon
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Samir S Khariwala
- Department of Otolaryngology-Head and Neck Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Robert L Ferris
- Department of Otolaryngology-Head and Neck Surgery, Pittsburgh University Medical Center, Pittsburgh, Pennsylvania, USA
| | - Marilene B Wang
- Department of Otolaryngology-Head and Neck Surgery, University of California, Los Angeles, Los Angeles, California, USA
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The "new" head and neck cancer patient-young, nonsmoker, nondrinker, and HPV positive: evaluation. OTOLARYNGOLOGY--HEAD AND NECK SURGERY : OFFICIAL JOURNAL OF AMERICAN ACADEMY OF OTOLARYNGOLOGY-HEAD AND NECK SURGERY 2014. [PMID: 24925311 DOI: 10.1177/0194599814538605.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The near epidemic rise of the incidence of human papillomavirus (HPV)-related oropharyngeal squamous cell carcinomas (OPSCC) presents the practitioner with a "new" head and neck cancer patient, vastly different from those with the traditional risk factors who formed the basis of most practitioners' training experience. Accordingly, a thorough and disease-specific evaluation process is necessitated. This article will review the evaluation of the HPV-related cancer patient, including a review of the HPV-positive oropharyngeal cancer epidemic from the surgeon's perspective, evaluation of the primary lesion, evaluation of the neck mass, and role of imaging, to provide a framework for addressing the challenging questions patients may ask. DATA SOURCES Available peer-reviewed literature and practice guidelines. REVIEW METHODS Assessment of selected specific topics by authors solicited from the Head and Neck Surgery and Oncology Committee of the American Academy of Otolaryngology-Head and Neck Surgery Foundation and the American Head and Neck Society. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE The dramatic rise in OPSSC related to HPV is characterized by a "new" cancer patient who is younger and lacks traditional risk factors. Today's caregiver must be prepared to appropriately evaluate, counsel, and treat these patients with HPV-positive disease with the expectation that traditional treatment algorithms will evolve to maintain or improve current excellent cure rates while lessening treatment related side effects.
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47
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Byrd JK, Smith KJ, de Almeida JR, Albergotti WG, Davis KS, Kim SW, Johnson JT, Ferris RL, Duvvuri U. Transoral Robotic Surgery and the Unknown Primary: A Cost-Effectiveness Analysis. Otolaryngol Head Neck Surg 2014; 150:976-82. [PMID: 24618502 PMCID: PMC4167971 DOI: 10.1177/0194599814525746] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 02/06/2014] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the cost-effectiveness of transoral robotic surgery (TORS) for the diagnosis and treatment of cervical unknown primary squamous cell carcinoma (CUP). STUDY DESIGN Case series with chart review. SETTING Tertiary academic hospital. SUBJECTS AND METHODS A retrospective chart review was performed on patients with new occult primary squamous cell carcinoma of the head and neck with nondiagnostic imaging and/or endoscopy who were treated with TORS at a tertiary hospital between 2009 and 2012. Direct costs were obtained from the hospital's billing system, and national data were used for inpatient hospital costs and physician fees. The proportion of tumors found in 3 strategies was used as effectiveness to calculate the incremental cost-effectiveness ratio. RESULTS In total, 206 head and neck robotic cases were performed at our institution between December 2009 and December 2012. Three surgeons performed TORS on 22 patients for occult primary squamous cell carcinoma. The primary tumor was located in 19 of 22 patients (86.4%). The incremental cost-effectiveness ratio for sequential and simultaneous examination under anesthesia with tonsillectomy (EUA) and TORS base of tongue resection was $8619 and $5774 per additional primary identified, respectively. CONCLUSION Sequential EUA followed by TORS is associated with an incremental cost-effectiveness ratio of $8619 compared with traditional EUA alone. Bilateral base of tongue resection should be considered in the workup of these patients, particularly if the palatine tonsils have already been removed.
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Affiliation(s)
- J Kenneth Byrd
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kenneth J Smith
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - John R de Almeida
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - W Greer Albergotti
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kara S Davis
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Seungwon W Kim
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jonas T Johnson
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Robert L Ferris
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Umamaheswar Duvvuri
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA VA Pittsburgh Health System, Pittsburgh, Pennsylvania, USA
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48
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Zhang GZ, Liu ZL, Gong JS, Cheng ZQ, Ke C. Cystic metastatic nasopharyngeal carcinoma presenting as branchial cleft cyst: report of two cases and review of the literature. J Oral Maxillofac Surg 2014; 72:2366-74. [PMID: 25172673 DOI: 10.1016/j.joms.2014.05.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 05/10/2014] [Accepted: 05/17/2014] [Indexed: 12/14/2022]
Abstract
PURPOSE To describe the differential diagnosis between solitary cystic metastatic carcinoma from branchial cleft cyst and provide references for clinicians to treat cystic metastases from primary sites of the head and neck region. MATERIALS AND METHODS Two cases of cystic metastatic nasopharyngeal carcinoma (NPC) are presented and a review of the relevant English literature on cystic metastasis from head and neck cancer was performed. RESULTS Two adult patients with a lateral cystic neck mass were initially clinically diagnosed as branchial cleft cysts. Based on the postoperative histopathologic examination and nasopharyngeal blind biopsy, they were finally diagnosed as cystic metastases from occult nasopharyngeal carcinoma. After a review of the literature, diagnostic strategies, histopathologic features, and therapeutic options for cervical cystic metastases were discussed. CONCLUSION Cervical cystic metastasis of NPC in adults may mimic branchial cleft cyst in clinical, radiological, and even histological features. Surgeons should bear in mind that when lateral neck cysts with characteristics of suspected malignancy are confronted, nasopharynx examination, including blind or random biopsy, is highly recommended before surgery. Metastatic disease should always be considered as a potential differential diagnosis in adult patients with a cystic neck lesion. Correct diagnosis is important so that appropriate surgical and radiotherapeutic treatment can be delivered.
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Affiliation(s)
- Guo Zhi Zhang
- Professor and Chairman, Department of Oral and Maxillofacial Surgery, Second Clinical Medical College of Jinan University, Shenzhen, Guangdong, China.
| | - Zi Long Liu
- Resident, Department of Oral and Maxillofacial Surgery, Second Clinical Medical College of Jinan University, Shenzhen, Guangdong, China
| | - Jing Shan Gong
- Professor and Chairman, Department of Radiology, Second Clinical Medical College of Jinan University, Shenzhen, Guangdong, China
| | - Zhi Qiang Cheng
- Professor and Chairman, Department of Pathology, Second Clinical Medical College of Jinan University, Shenzhen, Guangdong, China
| | - ChaoYang Ke
- Professor and Chairman, Department of Otorhinolaryngology, Second Clinical Medical College of Jinan University, Shenzhen, Guangdong, China
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