Indications for oropharyngeal biopsy in head and neck squamous cell carcinoma of unknown primary: A systematic review (HNSCCUP)

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.

A Case of Oropharyngeal Carcinoma Accompanying a Presacral Malignant Epidermoid Cyst

Presacral epidermoid cysts are rare benign tumors that can undergo malignant transformation. Here, we report a case of squamous cell carcinoma (SCC) arising from a presacral epidermoid cyst that metastasized to the mesopharynx. A 66-year-old female presented with abdominal pain and fever, leading to the discovery of a 5 cm presacral epidermoid cyst. Since the tumor had invaded into the rectum and uterus, total pelvic exenteration followed by ileostomy was performed. Histopathological examination revealed poorly differentiated SCC, suggesting malignant transformation from the epithelial component of the epidermoid cyst. Four years after adjuvant radiotherapy (45Gy/18Fr), a 5 cm left cervical lymphadenopathy prompted the diagnosis of human papillomavirus (HPV)-negative mesopharyngeal carcinoma (lateral wall, T2N3b). Following neoadjuvant chemotherapy, the patient underwent tumor resection, neck dissection, and free radial forearm flap reconstruction. Histopathological analysis of the mesopharyngeal tumor and cervical lymph node revealed poorly differentiated SCC with cystic formation, resembling an epidermoid cyst, suggesting distant metastasis from the presacral malignant epidermoid cyst. Postoperative treatment included chemotherapy (FOLFOX (5-FU, leucovorin, oxaliplatin)) and radiotherapy (50Gy/25Fr). At one year and five months postoperatively, there has been no recurrence of the malignant tumor. Metastatic mesopharyngeal carcinoma originating from other organs is extremely rare. While there is no established adjuvant chemotherapy regimen for presacral malignant epidermoid cysts, we preferred FOLFOX as used in the treatment of unresectable colorectal cancer with distant metastases.

Transoral Robotic Surgery and Radiation Volume Deintensification in Unknown Primary Squamous Cell Carcinoma of the Neck: The Phase 2 FIND Nonrandomized Controlled Trial

Importance

Patients with unknown primary squamous cell carcinoma (CUP) with cervical metastases typically receive comprehensive radiotherapy (RT) of the pharynx and bilateral neck. Typically, these patients receive comprehensive RT of the pharynx and bilateral neck that may produce treatment-related toxic effects.

Objective

To determine whether localization of occult oropharyngeal cancers with transoral robotic surgery (TORS) combined with reduced pharyngeal and neck RT volumes provides acceptable disease control.

Design, Setting, and Participants

This phase 2, single-group nonrandomized controlled trial at a single institution accrued 32 prospective participants with p16-positive CUP without a primary squamous cell carcinoma on examination and imaging from 2017 to 2019, and 24-month follow-up. The data analysis was conducted from January 2021 to June 2022.

Intervention

Diagnostic- (n = 13) or therapeutic-intent (n = 9) TORS, with pharyngeal-sparing radiotherapy (PSRT) prescribed for negative margins or pT0, and unilateral neck RT (UNRT) prescribed for unilateral lymphadenopathy with lateralized primary tumor or pT0.

Main Outcomes and Measures

Out-of-radiation treatment volume failure (<15% was hypothesized to be acceptable) and reports of local and regional recurrence, overall survival, toxic effects, swallowing outcomes (per the MD Anderson Dysphagia Inventory), and videofluoroscopic swallow (per Dynamic Imaging Grade of Swallowing Toxic Effects [DIGEST]) ratings.

Results

The study sample comprised 22 patients (mean [SD] age, 59.1 [5.7] years; 3 [14%] females and 19 [86%] male) with CUP. Of these, 19 patients (86%) had tumor stage cN1; 2 (9%), cN2; and 1 (5%), cN3. Five patients (23%), 14 patients (64%), and 3 patients (13%) had 0, 1, or 2 primary tumors, respectively. Twenty patients received RT; of these, 9 patients (45%) underwent PSRT and 10 patients (50%), UNRT. In the diagnostic-intent group, 8 patients (62%) and 5 patients (38%) underwent RT and RT-concurrent chemotherapy, respectively. In the therapeutic-intent group, 6 patients (67%) and 1 patient (11%) received adjuvant RT-concurrent chemotherapy, respectively; 2 patients declined RT. Two-year out-of-radiation treatment volume failure, locoregional control, distant metastasis control, and overall survival were 0%, 100%, 95%, and 100%, respectively. Grade 3 or 4 surgical, acute, and late toxic effects occurred in 2 (9%), 5 (23%), and 1 (5%) patients, respectively. PSRT was associated with lower RT dose to superior constrictors (37 vs 53 Gy; mean difference, 16 Gy; 95% CI, 6.4, 24.9), smaller decline in swallowing scores during treatment (19.3 vs 39.7; mean difference, -20.4; 95% CI, -34.1 to -6.1), and fewer patients with worsening DIGEST grade on findings of videofluoroscopic swallow studies at 2 years (0% vs 60%; difference, 60%; 95% CI, 30% to 90%).

Conclusions and Relevance

These findings indicate that TORS for p16-positive CUP allows RT volume deintensification with excellent outcomes and support future investigation in randomized clinical trials.

Trial Registration

ClinicalTrials.gov Identifier: NCT03281499.

An Unknown Foreign laryngeal Object: an exotic complication of skull base osteoradionecrosis

BACKGROUND

Osteoradionecrosis (ORN) of the skull base is a rare complication after head and neck radiation with a broad variety of subsequent complications.

METHODS

A 68-year-old woman with a complex oncological history (right-sided sphenoid meningioma; left-sided neck metastasis of a Cancer of Unknown Primary-CUP) was admitted with a right-sided epi-/ oropharyngeal mass and severe pain exacerbations for further evaluation. CT scan revealed an advanced ORN of the skull base with subsequent abruption of the ventral part of the clivus. This dislocated part of the clivus wedged in the oropharynx for 48 h and then moved towards the larynx, resulting in dyspnea and almost complete airway obstruction.

RESULTS

Due to the dangerous airway situation, an urgent exploration and removal of the dislocated clivus was necessary. After a potential cervical spine instability was ruled out, the patient's airway was initially secured with an awake tracheotomy and the clivus was removed transorally. The tracheostomy tube was removed during the ongoing inpatient stay, and the patient was discharged with significant pain relief.

CONCLUSIONS

The present case illustrates an orphan complication of skull base ORN resulting in a major airway emergency situation.

The Role of Trans Oral Robotic Surgery in the Carcinoma of Unknown Primary: A New Evidence in the Horizon?

The detection of the primary site in Carcinoma of Unknown Primary (CUP) is a challenging task which can significantly alter the course of management and also prognosis. Various modalities have been assessed with varying sensitivity and specificity. Imaging and cytological diagnosis have formed a key part of the diagnostic algorithm of CUP. Trans Oral Robotic Surgery offers the advantage of being both diagnostic as well as therapeutic with promising sensitivity and specificity and can form an integral part in the management of CUP. A prospective study was carried out at a tertiary care centre over a period of one year. Patients with unilateral neck swelling which was histopathologically proven squamous cell carcinoma neck metastasis were included in the study. They were evaluated with endoscopy and radiology according to the standard algorithm. When these failed to detect the primary, the patients underwent ipsilateral radical tonsillectomy and tongue base mucosal wedge biopsy via TORS. Post-operative histopathological examination was done on the resected specimens to detect the primary site. Transoral Robotic Surgery was able to localise primary in 50% of the patients enrolled in the study. Out of the primary site identified by TORS; 55.56% were located in the tonsil and 44.4% in the tongue base. TORS can offer promising detection rates of the occult primary in CUP and should form an integral part of the diagnostic algorithm.

Risk of malignancy in incidental oropharyngeal lesions exhibiting fluorodeoxyglucose uptake which proceed to tissue biopsy

BACKGROUND

Utilization of positron emission tomography/computed tomography (PET/CT) with fluorodeoxyglucose is increasing in use for a variety of indications, including surveillance of cancer patients. There is a paucity of evidence pertaining to the significance of incidental PET-avid oropharyngeal lesions. This study aims to examine the clinical and radiological features of these incidental oropharyngeal lesions in patients undergoing PET for indications other than head and neck cancer.

METHODS

Retrospective cohort study of three Australian tertiary hospitals, from 2015 to 2021, on adult patients undergoing biopsy of incidental PET-avid oropharyngeal lesions. Primary outcome of interest was the incidence of malignancy. Patients with a previous history of, or undergoing investigations for, head and neck cancer were excluded.

RESULTS

Thirty-one patients were included, wherein 21 patients had tonsillar uptake, and 13 patients had base of tongue uptake. Tonsillar disease was mostly asymmetrical (n = 15/21), bilateral (n = 11/21), and had median SUVmax 9.35 (n = 12, IQR 7.4-11.15). Base of tongue was mostly asymmetrical (n = 7/13, 54%), bilateral (n = 8/13, 62%), and had median SUVmax 8.2 (n = 10, IQR 6.9-12.65). Seven patients had malignancy confirmed on tissue biopsy: five biopsies confirmed the tissue diagnosis of suspected lymphoma, and two incidental findings of unexpected malignancies: one p16 positive tonsillar squamous cell carcinoma, and one metastatic breast cancer.

CONCLUSION

In 31 patients undergoing tissue biopsy for incidental PET-avid oropharyngeal lesions, there were two unexpected malignancies. Our study results indicate that although unexpected malignancies are uncommon, a malignant diagnosis cannot be excluded from clinical features alone.

Trans oral robotic surgery for oropharyngeal cancer: A multi institutional experience

OBJECTIVES

Trans Oral Robotic Surgery (TORS) has proved to be a safe and feasible treatment for oropharyngeal squamous cell carcinoma (OPSCC). The aim of this study is to analyse oncological outcomes of OPSCC patients treated with TORS.

MATERIALS AND METHODS

This study involved 139 patients with OPSCC, treated with TORS between 2008 and 2020. Clinicopathological characteristics, treatment details and oncological outcomes were evaluated retrospectively.

RESULTS

The management strategies included TORS alone in 42.5%, TORS-RT in 25.2% and TORS-CRT in 30.9%. The ENE was noted in 28.8% of neck dissections. In 19 patients clinically classified as unknown primaries, the primary was found in 73.7%. Rates of local, regional relapses and distant metastasis were 8.6%, 7.2%, and 6.5%, respectively. The 5 year- Overall Survival and Disease Free Survival were 69.6% and 71.3%, respectively.

CONCLUSION

TORS fits well in the modern management of OPSCC. Although definitive CRT remains a milestone, TORS is proving to be a valid and safe treatment option. The choice of the therapeutic strategy requires evaluation by a multidisciplinary team.

Intrathyroidal metastasis of tonsillar squamous cell carcinoma masquerading as a primary thyroid tumor

Intrathyroidal metastasis of tonsillar squamous cell carcinoma is rare. To date, only six cases have been reported in the literature. This case was unusual and presented with thyromegaly before the diagnosis of the primary tumor. A 55-year-old male patient was suspected to have a primary thyroid tumor with nodal metastasis. The thyroid gland was diffusely enlarged, with no discernible mass. Histologically, the thyroid parenchyma revealed extensive endolymphatic tumor emboli, which were positive for p40 and p16 in a background of chronic lymphocytic thyroiditis. Positron emission tomography-computed tomography revealed hypermetabolic activity in the right tonsillar region. Tonsillar biopsy revealed human papillomavirus-positive squamous cell carcinoma. The present case is the first reported case of intrathyroidal metastasis of tonsillar squamous cell carcinoma with an initial clinical presentation of thyroid enlargement before the primary tumor of tonsillar cancer was diagnosed.

The role of transoral surgery in the diagnosis of the carcinoma of unknown origin of the head and neck

PURPOSE OF REVIEW

The aim of this article is to update readers on the most recent evidence on the role of trans oral surgery (TOS) in the diagnosis of carcinoma of the unknown primary of the head and neck.

RECENT FINDINGS

Tongue base mucosectomy has an important role in identifying the primary in patients who have had negative imaging, PET CT scans and ipsilateral tonsillectomy. In patients with bilateral nodal disease, tongue base mucosectomy should precede tonsillectomy. There are several unanswered questions that remain regarding sequencing of operations and use of intraoperative frozen section.

SUMMARY

An evidence-based approach to diagnosis is important to ensure the highest detection rates, and least morbidity, in patients with head and neck carcinoma of the unknown primary.

Transoral Robotic Surgery for Head and Neck Cancer: Advances and Residual Knowledge Gaps

Minimally invasive surgery is a growing field in surgical oncology. After acquiring its first Food and Drug Administration approval in 2009 for T1–T2 malignancies of the oral cavity, oropharynx, and larynx, transoral robotic surgery (TORS) has gained popularity thanks to its wristed instruments and magnified three-dimensional view, enhancing surgical comfort in remote-access areas. Its indications are expanding in the treatment of head and neck cancer, i.e., resection of tumors of the larynx, hypopharynx, or parapharyngeal space. However, this expansion must remain cautious and based on high-level evidence, in order to guarantee safety and oncological outcomes which are comparable to conventional approaches. This narrative review assesses the current role of TORS in head and neck cancer from an evidence-based perspective, and then identifies what knowledge gaps remain to be addressed.

Cervical squamous cell carcinoma of unknown primary: Oncological outcomes and prognostic factors

BACKGROUND/OBJECTIVES

Cervical squamous cell carcinoma of unknown primary (SCCUP) is a rare entity within head and neck cancer and both treatment regimens as well as identified potential predictors for oncological outcomes vary between published series. In this study, we evaluated oncological outcomes and identified potential prognostic factors for outcome.

PATIENTS AND METHODS

This retrospective monocentric cohort study includes 82 SCCUP patients diagnosed and treated between January 2000 and June 2021. Overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS) and locoregional recurrence-free survival (LRFS) were evaluated. The Cox proportional hazards model was used to analyze the prognostic effect of patient and tumor characteristics on oncological outcomes.

RESULTS

Five year OS, DSS, DFS and LRFS were respectively 53.9%, 72.2%, 68.9% and 67.3%. The p16 status was evaluated in 55 patients with 40% being p16 positive. On univariable analysis, p16 negative SCCUPs had significantly worse survival and recurrence rates in the presence of clinical extranodal extension (cENE) (OS: p=0.0013, DSS: p=0.0099, DFS: p=0.0164, LRFS: p=0.0099) and radiological extranodal extension (rENE) (OS: p=0.0034, DSS: p=0.0137, DFS: p=0.0167, LRFS: p=0.0100). In p16 positive SCCUP patients, rENE had a significantly negative prognostic effect on DFS (p=0.0345) and LRFS (p=0.0367). Total group multivariate analysis identified rENE as an independent negative predictor for all oncological outcomes. The "number of positive lymph nodes" was a second independent predictor for DSS (p=0.0257) and DFS (p=0.0435).

CONCLUSIONS

We report favorable oncological outcomes, comparable to previously published results. Although the presence of rENE seems associated with poor oncological outcomes, the differential effect of clinical, radiological and pathological ENE in both p16 positive and negative subgroups remain to be elucidated by further prospective research.

Patient Benefit and Quality of Life after Robot-Assisted Head and Neck Surgery

Robotic systems for head and neck surgery are at different stages of technical development and clinical application. Currently, robotic systems are predominantly used for transoral surgery of the pharynx and larynx. Robotic surgery of the neck, the thyroid, and the middle and inner ear is much less common; however, some oncological and functional outcomes have been reported. This article provides an overview of the current state of robot-assisted head and neck surgery with a special emphasis on patient benefit and postoperative quality of life (QoL). The focus is placed on the role of transoral robotic surgery (TORS) for the resection of oropharyngeal carcinomas. For this application, reported long-term outcomes show functional post-operative advantages for selected oropharyngeal cancer patients after TORS compared to open surgery and primary radiotherapy. Since TORS also plays a significant role in the context of potential therapy de-escalation for HPV-positive oropharyngeal cancer patients, ongoing trials are presented. Regarding the evaluation of the therapeutic benefit and the QoL of cancer patients, special attention has to be paid to the large degree of variability of individual patients' preferences. Influencing factors and tools for a detailed assessment of QoL parameters are therefore detailed at the beginning of this article. Notably, while some robotic systems for ear and skull base surgery are being developed in Europe, TORS systems are mainly used in North America and Asia. In Europe and Germany in particular, transoral laser microsurgery (TLM) is a well-established technology for transoral tumor resection. Future trials comparing TORS and TLM with detailed investigation of QoL parameters are therefore warranted and might contribute to identifying suitable fields for the application of the different techniques.

Transoral robotic surgery for the identification of unknown primary head and neck squamous cell carcinomas: Its effect on the wait and the weight

BACKGROUND

Neck carcinoma of unknown primary (CUP) is a frequent scenario. Transoral robotic mucosectomies (TORM) of pharynx have increased rate of primary identification, but come with cost of treatment delay.

METHODS

We reviewed patients who underwent CUP protocol from 2014 to 2020. Patients with cervical nodes carcinoma and failure to localize a primary source were classified as CUP. We determined primary identification rate and postoperative complications.

RESULTS

We included 65 patients underwent TORM. Surgical approach consisted of lingual and/or palatine tonsillectomies. The primary detection rate was 49.2%. Average weight reduction was 2.5 ± 4.3 kg. The average number of days from consultation to definitive treatment was 52.2 ± 18.3.

CONCLUSION

A systematic approach to patients with CUP showed a promising primary identification rate compared to panendoscopy alone. TORM carries a small risk of complications. The benefits of primary identification must be weighed with the morbidity and delay to definitive treatment.

Comparative ex vivo Investigations on the Cutting Quality of the CO2 Laser and the Diode Pumped Er:YAG Laser

Objectives: A sufficient histological evaluation is a key pillar in oncological treatment, especially in situations of cancer of unknown primary. CO2 laser technology is used in clinical routine of soft tissue surgery because of its cutting quality and availability. Diode pumped solid state Er(bium):YAG laser systems promise a higher cutting efficiency and minor thermal damages. The aim of this study was to compare both laser systems with respect to their suitability for cutting soft tissue. Methods: A setup was realized which enables comparable experiments with the clinical CO2 laser (AcuPulse 40ST DUO, Lumenis) and the Er:YAG laser system (DPM 40, Pantec Biosolutions AG). Fresh mucosal samples of porcine tongues were used to determine the influence of laser power and sample velocity on cutting depth and thermal damage width for both lasers. In addition, for the Er:YAG laser, the influence of the pulse repetition rate was examined additionally. For analysis, images of histological sections were taken. Results: In all experiments, the Er:YAG laser shows a significantly higher cutting depth (P < 0.0001) and less thermal damage width (P < 0.0001) than the CO2 laser. For example, at an average power of 7.7 W and a sample velocity of 5 mm/s the Er:YAG laser shows a mean cutting depth of 1.1 mm compared to the CO2 laser with 500 μm. While the Er:YAG laser shows a mean thermal damage width of 70 μm compared to 120 μm. Furthermore, the Er:YAG enables the adjustment of the cutting depth and thermal damage width by varying the irradiation parameters. A decrease of the repetition rate leads to a reduction of thermal damage. For example, a repetition rate of 100 Hz results in a thermal damage width of 46 μm compared to 87 μm at 800 Hz at an average power of 7.7 W and a cutting velocity = 5 mm/s while a homogenous cutting quality can be achieved. Conclusions: In conclusion, the results of these ex vivo experiments demonstrate significant advantages of the diode pumped Er:YAG laser system for soft tissue ablation compared to the CO2 laser, in particular regarding cutting efficiency and thermal damage width.

Human Papillomavirus and Squamous Cell Carcinoma of Unknown Primary in the Head and Neck Region: A Comprehensive Review on Clinical Implications

Squamous cell carcinoma of unknown primary (SCCUP) is a challenging diagnostic subgroup of oropharyngeal squamous cell carcinoma (OPSCC). The incidence of SCCUP is increasing in parallel with the well-documented increase in OPSCC and is likewise driven by the increase in human papillomavirus (HPV). The SCCUP patient often presents with a cystic lymph node metastasis and undergoes an aggressive diagnostic and treatment program. Detection of HPV in cytologic specimens indicates an oropharyngeal primary tumor origin and can guide the further diagnostic strategy. Advances in diagnostic modalities, e.g., transoral robotic surgery and transoral laser microsurgery, have increased the successful identification of the primary tumor site in HPV-induced SCCUP, and this harbors a potential for de-escalation treatment and increased survival. This review provides an overview of HPV-induced SCCUP, diagnostic modalities, and treatment options.

Preoperative predictors of difficult oropharyngeal exposure for transoral robotic surgery: The Pharyngoscore

BACKGROUND

Insufficient exposure may require termination of procedure in transoral robotic surgery (TORS). The aim of study was to develop a "Pharyngoscore" to quantify the risk of difficult oropharyngeal exposure (DOE) before TORS.

METHODS

Three-hundred six patients undergoing any surgical procedure at one Academic Hospital were prospectively enrolled. Oropharynx was exposed with Feyh-Kastenbauer retractor. Exposure was evaluated by direct and endoscopic visualization of the four oropharyngeal subsites. Preoperative clinical/anthropometric parameters were studied in good oropharyngeal exposure and DOE groups. Logistic regression was performed to explore association between clinical/anthropometric parameters and DOE. Statistically significant parameters at multivariate analysis were incorporated into a nomogram.

RESULTS

Sixty-five (21.2%) subjects were characterized by DOE. Variables associated with DOE at univariate analysis were male (p = 0.031), modified Mallampati Class (MMC) ≥ III (p < 0.001), smaller interincisor gap (p < 0.001), and larger neck circumference (p = 0.006). MMC, interincisor gap, and neck circumference were significant at multivariate analysis and were presented with a nomogram for creating the Pharyngoscore.

CONCLUSIONS

The Pharyngoscore is a promising tool for calculating DOE probability before TORS.

Standardized Diagnostics Including PET-CT Imaging, Bilateral Tonsillectomy and Neck Dissection Followed by Risk-Adapted Post-Operative Treatment Favoring Radio-Chemotherapy Improve Survival of Neck Squamous Cell Carcinoma of Unknown Primary Patients

BACKGROUND

About five to 10% of cancers in the head and neck region are neck squamous cell carcinoma of unknown primary (NSCCUP). Their diagnosis and treatment are challenging given the risk of missing occult tumors and potential relapse. Recently, we described human papillomavirus (HPV)-related NSCCUP-patients (NSCCUP-P) as a subgroup with superior survival. However, standardized diagnostic workup, novel diagnostic procedures, decision-making in the multidisciplinary tumor board (MDTB) and multimodal therapy including surgery and post-operative radio-chemotherapy (PORCT) may also improve survival.

METHODS

For assessing the impact of standardized diagnostic processes simultaneously established with the MDTB on outcome, we split our sample of 115 NSCCUP-P into two cohorts treated with curative intent from 1988 to 2006 (cohort 1; n = 53) and 2007 to 2018 (cohort 2; n = 62). We compared diagnostic processes and utilized treatment modalities applying Chi-square tests, and outcome by Kaplan-Meier plots and Cox regression.

RESULTS

In cohort 2, the standardized processes (regular use of [18F]-FDG-PET-CT imaging followed by examination under anesthesia, EUA, bilateral tonsillectomy and neck dissection, ND, at least of the affected site) improved detection of primaries (P = 0.026) mostly located in the oropharynx (P = 0.001). From 66.0 to 87.1% increased ND frequency (P = 0.007) increased the detection of extracapsular extension of neck nodes (ECE+) forcing risk factor-adapted treatment by increased utilization of cisplatin-based PORCT that improved 5-years progression-free and overall survival from 60.4 and 45.3 to 67.7% (P = 0.411) and 66.1% (P = 0.025).

CONCLUSIONS

Standardized diagnostic workup followed by ND and risk-factor adapted therapy improves survival of NSCCUP-P.

Diagnostic performance of 18F-FDG PET/CT for the detection of occult primary tumors in squamous cell carcinoma of unknown primary in the head and neck: a single-center retrospective study

OBJECTIVE

To investigate the diagnostic performance of 18F-FDG PET/computed tomography (CT) for the detection of occult primary tumors in patients with squamous cell carcinoma of unknown primary (SCCUP) in the head and neck.

PATIENTS

From March 2016 to January 2020, 37 patients diagnosed as SCCUP before PET/CT were retrospectively reviewed. The diagnosis of SCCUP was made when an overt primary tumor location could not be found for histologically proven squamous cell cervical lymphadenopathy after a complete diagnostic workup which includes full medical history, physical examinations, flexible rhinolaryngoscopy and CT or MRI. The PET/CT images were visually assessed by two nuclear medicine radiologists. Histopathological investigations after the PET scan served as the reference standard.

RESULTS

The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of PET/CT for SCCUP were 71.4, 43.8, 62.5, 53.9 and 59.5%, respectively. PET/CT allowed identification of previously undetected lesions in 40.5% of the SCCUP patients. A total of 24 PET/CT scans indicated a positive result. Among them, nine were categorized into false-positive because of negative results from subsequent targeted and random biopsies. There were 13 PET/CT scans with a negative result, six of which, however, were revealed to have a primary site by subsequent random biopsies.

CONCLUSION

18F-FDG PET/CT was shown to be useful in detecting a primary tumor for SCCUP, but had limitations in terms of both false-positive cases and false-negative cases. Therefore, histopathological investigations such as targeted and random biopsy should be viewed as necessary practice irrespective of PET/CT results.

Anatomical-based classification for transoral base of tongue resection

BACKGROUND

To propose a classification of transoral base of tongue (BOT) procedures able to provide uniform terminology in order to better define postoperative results.

METHODS

The classification resulted from the consensus of the different authors and is based on anatomical and surgical principles.

RESULTS

The classification comprises three types of BOT resections: type 1 is the resection of the entire lingual tonsil to the muscular plane; type 2 is performed by removing the entire lingual tonsil and part of BOT muscles; type 3 is performed by removing the entire lingual tonsil and the entire BOT muscles. Based on the extension of the dissection, we can use the suffix A (contralateral BOT), B (supraglottic larynx), C (lateral oropharynx), and/or D (oral tongue).

CONCLUSION

The proposed classification could allow us to easily compare data from different centers.

Role of Tonsillectomy in the Management of Carcinomas of Unknown Primary of the Head and Neck: A Retrospective Study Based on p16 Analysis

Purpose

To evaluate the impact of tonsillectomy on the detection of the primary tumor, based on p16 immunohistochemistry analysis, in patients with cervical unknown primary of squamous cell carcinoma (SCC-CUP).

Methods

This was a retrospective study of 63 patients, included from January 2008 to December 2017 in a single institution. All patients had an initial assessment with physical examination, CT scan of the neck and chest, whole body FDG-PET CT, and endoscopy under general anesthesia, which failed to determine the primary tumor.

Results

Forty-seven out of the 63 patients had an ipsi- or bilateral tonsillectomy which revealed 12 tonsil cancers (26%). The tonsil primary was ipsilateral to positive nodes in 10 cases, contralateral in 1 case and, in 1 case, the patient had bilateral neck involvement. The analysis of the p16 status was carried out in 41/63 patients (65%). Among the 32 patients who had a p16 analysis and tonsillectomy, the rate of primary detection was 59% (10/17) for p16-postives and 0% (0/15) for p16-negatives (p < 0.001).

Conclusion

These results suggest that an extended work-up should be systematically proposed including bilateral tonsillectomy (+/- mucosectomy of the base of tongue) in SCC-CUP p16-positive patients but not in p16-negatives.

Role of Transoral Robotic Surgery in the Work-up of the Unknown Primary

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.

Microsurgical versus endoscopic trans-sphenoidal approaches for clivus chordoma: a pooled and meta-analysis

Chordoma is a rare slow-growing neoplastic bone lesion. However, they show an invasive local growth and high recurrence rate, leading to an overall survival rate of 65% at 5 years and 35% at 10 years. We conducted a pooled and meta-analysis comparing recurrence rate, post-operative-complications, and survival in patients undergoing either microsurgical (MA) or endoscopic approaches (EA). Search of literature was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify surgical series of clivus chordomas published between January 1990 and March 2018 on Pubmed, Scopus, and Cochrane. Two different statistical analyses have been performed: a pooled analysis and a single-arm meta-analysis of overall recurrence rate and subgroup meta-analysis of complications in the subgroups open surgery and endoscopic surgery. After full-text screening, a total of 58 articles were included in the pooled analysis and 27 studies were included for the study-level meta-analysis. Pooled analysis-the extent of resection was the only association that remained significant (subtotal: HR = 2.18, p = 0.004; partial: HR = 4.40, p < 0.001). Recurrence was more prevalent among the surgical patients (45.5%) compared to endoscopic ones (23.7%). Meta-analysis-results of the cumulative meta-analysis showed an overall rate of recurrence of 25.6%. MA recurrence rate was 31.8% (99% CI 14-52.8), EA recurrence rate was 19.4% (5.4-39.2). CSF leak rate for the endoscopic group was 10.3% (99%CI 5-17.3) and 9.5% (99%CI 1.2-24.6) for the open surgery group. The partial removal versus total removal has an influence on recurrence rate (p < 0.001). MA recurrence rate was 31.8%; EA recurrence rate was 19.4%. The extent of resection is confirmed as a statistically significant factor affecting the risk for recurrence both with the pooled analysis and with the meta-analysis. Meta-analysis demonstrated that older patients tend to recur more than young patients, especially in surgical group.

Potentially malignant disorders of the oral cavity and oral dysplasia: A systematic review and meta-analysis of malignant transformation rate by subtype

IMPORTANCE

Potentially malignant disorders of the oral cavity (OPMD) are a heterogeneous group of lesions associated with a variable risk of malignant transformation (MT) to invasive cancer. Leukoplakia (LE), lichen planus (LP), oral lichenoid lesions (OLL), oral erythroplakia (OE), oral submucous fibrosis (OSF), and proliferative verrucous leukoplakia (PVL) are among the most common of these lesions. Oral dysplasia is a mucosal area characterized by cellular and architectural derangement, which may be associated with OPMDs or not.

OBJECTIVE

To define the MT rate of OPMDs and the risk of development into cancer of mild vs moderate/severe oral dysplasia. This in order to implement adequate follow-up strategies and treatment decisions.

STUDY DESIGN

We performed a systematic review and meta-analysis on studies reporting the MT rates of OPMDs and oral dysplasia. Ninety-two studies were included for the analysis. Cumulative rates were reported for OPMDs overall and as a subgroup, a comparison was made of mild vs moderate/severe dysplasia. Meta-regression on OPMD and year of publication was also performed.

MAIN OUTCOME AND MEASURES

Overall MT rates of OPMDs and odds ratio of MT of mild vs moderate/severe dysplasia.

RESULTS

Overall MT rate across all OPMD groups was 7.9% (99% confidence interval [CI] 4.9%-11.5%). MT rates of the specific OPMD subgroups were as follows: LP 1.4% (99% CI 0.9%-1.9%), LE 9.5 (5.9%-14.00%), OLL 3.8% (99% CI 1.6%-7.00%), OSF 5.2% (99% CI 2.9%-8.00%), OE 33.1% (99% CI 13.6%-56.1%), and PVL 49.5% (99% CI 26.7%-72.4%). Regarding the dysplasia grades comparison, the meta-analysis showed that moderate/severe dysplasia is meaningfully associated to a much greater risk of MT compared to mild dysplasia with an odds ratio of 2.4 (95% CI 1.5-3.8) [Correction added on 27 December 2019, after first online publication: CI updated from 99% to 95%.]. Heterogeneity was not significant. Annual MT rates were approximated based on the average follow-up as reported in the various subgroups. Lichen planus had an annual MT of 0.28%, OLL of 0.57%, leukoplakia of 1.56%, PVL of 9.3%, and OSF of 0.98%. Mild dysplasia had an annual MT of 1.7%, while severe dysplasia of 3.57%. Meta-regression showed a significant negative correlation of PVL MT rate and year of the study (P value <.001).

CONCLUSIONS AND RELEVANCE

OPMDs and oral dysplasia are relatively common conditions that general practitioners, head and neck, and oral medicine specialists, face in their everyday practice. Our analysis confirms the significant risk of MT of these lesions, although variable among the subgroups. Moderate/severe dysplasia bears a much higher risk of cancer evolution than mild dysplasia. It is important to raise public health awareness on the MT rates of these conditions, at the same time efficacious communication with the patient is of utmost importance. This, coupled with strict follow-up measures and optimal treatment strategies, would help in reducing the transformation of these oral conditions into invasive cancer.

Narrow band imaging in head and neck unknown primary carcinoma: A systematic review and meta-analysis

OBJECTIVE

To estimate the diagnostic performance of Narrow Band Imaging (NBI) in patients with cervical metastasis from head and neck squamous cell carcinoma of unknown primary (SCCUP) origin.

METHODS

PubMed, Embase, and Scopus databases were systematically scrutinized up to July 1, 2019, looking for studies that encompassed the NBI in the SCCUP diagnostic work up. The main inclusion criteria for eligible articles for the meta-analysis were non-evidence of primary tumor after physical examination and conventional cross-section imaging before NBI assessment and the availability of complete data on the diagnostic accuracy of NBI. A set of random-effects model meta-analyses was then performed following the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines.

RESULTS

Five studies, conducted between January 2003 and September 2016, comprising 169 patients imaged with NBI, were included in the meta-analysis. The pooled sensitivity and specificity of NBI in patients with head and neck SCCUP was 0.83 (99% CI, 0.54-0.95) and 0.88 (99% CI, 0.55-0.97), respectively. The positive and negative likelihood ratios were 6.38 (99% CI, 1.6-25.44) and 0.06 (99% CI, 0.005-0.86). The pooled diagnostic odds ratio (DOR) was 82.15 (99% CI, 7.06-955). The overall detection rate of NBI was 0.35 (99% CI, 0.18-0.53), which allowed localization the primary tumor in 61 out of 169 patients, otherwise not detected by the usual diagnostic work-up.

CONCLUSIONS

Current available evidence suggests that NBI has a considerable diagnostic accuracy in patients affected by head and neck SCCUP. Laryngoscope, 130:1692-1700, 2020.