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Fritz C, Ng JJ, Harris J, Romeo DJ, Prasad A, Moreira A, Rajasekaran K. Clinical practice guidelines for management of head and neck squamous cell carcinoma of unknown primary: an AGREE II appraisal. Eur Arch Otorhinolaryngol 2023; 280:4195-4204. [PMID: 37103581 DOI: 10.1007/s00405-023-07997-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 04/24/2023] [Indexed: 04/28/2023]
Abstract
IMPORTANCE Squamous cell carcinoma without a known primary is an uncommon form of head and neck cancer that requires multidisciplinary collaboration for effective management. OBJECTIVE To evaluate the quality of clinical practice guidelines (CPG) using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. DESIGN A systematic literature search was performed to identify CPGs pertaining to the diagnosis and treatment of head and neck squamous cell carcinoma of unknown primary (HNSCCUP). Data were abstracted from guidelines meeting inclusion criteria and appraised by four independent reviewers in the six domains of quality defined by the AGREE II. SETTING Online database. PARTICIPANTS None. EXPOSURE None. MAIN OUTCOME(S) AND MEASURE(S) Quality domain scores and intraclass correlation coefficients (ICC) were calculated across domains to qualify inter-rater reliability. RESULTS Seven guidelines met inclusion criteria. Two guidelines achieved a score of > 60% in five or more AGREE II quality domains to gain designation as 'high'-quality content. One "average-quality" guideline authored by the ENT UK Head and Neck Society Council achieved a score of > 60% in three quality domains. The remaining four CPGs demonstrated low-quality content, with deficits most pronounced in domains 3 and 5, suggesting a lack of rigorously developed and clinically applicable information. CONCLUSIONS AND RELEVANCE As the diagnosis and treatment of head and neck cancer continues to evolve, identification of high-quality guidelines will become increasingly important. The authors recommend consulting HNSCCUP guidelines from the National Institute for Health and Care Excellence (NICE) or the American Society of Clinical Oncology (ASCO). TRIAL REGISTRATION None.
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Affiliation(s)
- Christian Fritz
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, 800 Walnut Street, 18th Floor, Philadelphia, PA, 19107, USA
| | - Jinggang J Ng
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jacob Harris
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Dominic J Romeo
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Aman Prasad
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Alvaro Moreira
- Department of Pediatrics, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, 800 Walnut Street, 18th Floor, Philadelphia, PA, 19107, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
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2
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Chan SP, McLarty J, Knecht E, Lee SC. Transoral Laser Resection of the Tongue Base in the Workup of Unknown Primary Head and Neck Squamous Cell Carcinoma. Cureus 2023; 15:e41103. [PMID: 37519526 PMCID: PMC10382210 DOI: 10.7759/cureus.41103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2023] [Indexed: 08/01/2023] Open
Abstract
Objective Failure to localize the primary tumor site in head and neck carcinoma of unknown origin after imaging and endoscopic evaluation leads to increased treatment-related morbidity. The use of transoral laser microsurgery to improve the detection of unknown primary carcinoma site identification is described in this article. Methods A retrospective cohort of 71 consecutive cases of cervical carcinoma of an unknown primary source from 2006 until 2012 from a single academic institution was analyzed. Of these, 10 patients were excluded based on our exclusion criteria. All patients underwent endoscopy with biopsies performed by fellowship-trained head and neck cancer surgeons. Results The primary detection rate was 76% for patients who underwent laser tongue base resection versus 34% for traditional operative examination. There were no complications or prolonged recovery times in either group. Operative time was increased by the addition of the transoral base of tongue resection by 30 minutes. Conclusions Laser tongue base excision offers improved sensitivity in primary site detection without a significant increase in morbidity and only a modest increase in operative time.
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Affiliation(s)
- Sarah P Chan
- Otolaryngology - Head and Neck Surgery, Loma Linda University School of Medicine, Loma Linda, USA
| | - Justin McLarty
- Otolaryngology - Head and Neck Surgery, Kaiser Permanente, Riverside, USA
| | | | - Steve C Lee
- Otolaryngology - Head and Neck Surgery, Loma Linda University School of Medicine, Loma Linda, USA
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3
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Baskin RM, Boyce BJ, Amdur R, Mendenhall WM, Hitchcock K, Silver N, Dziegielewski PT. Transoral robotic surgery for oropharyngeal cancer: patient selection and special considerations. Cancer Manag Res 2018; 10:839-846. [PMID: 29719420 PMCID: PMC5916264 DOI: 10.2147/cmar.s118891] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
The increasing incidence of oropharyngeal squamous cell carcinoma (OPSCC) emphasizes the importance of optimizing treatment for the disease. Historical protocol has utilized definitive radiation and invasive open procedures; these techniques expose the patient to significant risks and morbidity. Transoral robotic surgery (TORS) has emerged as a therapeutic modality with promise. Here, the literature regarding proper patient selection and other considerations for this procedure was reviewed. Multiple patient and tumor-related factors were found to be relevant for successful use of this treatment strategy. Outcomes regarding early and advanced-stage OPSCC were analyzed. Finally, the literature regarding use of TORS in three distinct patient populations, individuals with primary OPSCC, carcinoma of unknown primary and those with recurrent OPSCC, was examined.
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Affiliation(s)
- R Michael Baskin
- Department of Otolaryngology, University of Florida, Gainesville, FL, USA
| | - Brian J Boyce
- Department of Otolaryngology, University of Florida, Gainesville, FL, USA.,University of Florida Health Cancer Center, Gainesville, FL, USA
| | - Robert Amdur
- University of Florida Health Cancer Center, Gainesville, FL, USA.,Department of Radiation Oncology, University of Florida, Gainesville, FL, USA
| | - William M Mendenhall
- University of Florida Health Cancer Center, Gainesville, FL, USA.,Department of Radiation Oncology, University of Florida, Gainesville, FL, USA
| | - Kathryn Hitchcock
- University of Florida Health Cancer Center, Gainesville, FL, USA.,Department of Radiation Oncology, University of Florida, Gainesville, FL, USA
| | - Natalie Silver
- Department of Otolaryngology, University of Florida, Gainesville, FL, USA.,University of Florida Health Cancer Center, Gainesville, FL, USA
| | - Peter T Dziegielewski
- Department of Otolaryngology, University of Florida, Gainesville, FL, USA.,University of Florida Health Cancer Center, Gainesville, FL, USA
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Winter SC, Ofo E, Meikle D, Silva P, Fraser L, O'Hara J, Kim D, Robinson M, Paleri V. Trans-oral robotic assisted tongue base mucosectomy for investigation of cancer of unknown primary in the head and neck region. The UK experience. Clin Otolaryngol 2017; 42:1247-1251. [PMID: 28258624 DOI: 10.1111/coa.12860] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The diagnosis of cancer of unknown primary (CUP) in head and neck occurs when the treating clinicians have utilised all available diagnostic tests and failed to identify the origin of the disease. There is no agreed consensus on which diagnostic investigations to use, or the order in which to use them in, although broad recommendations exist. Small tumours arising in the tongue base can be below the limits of resolution of conventional diagnostic techniques. Given the difficulty in targeting the tongue base, current practice involves blind random biopsies, which leads to a variable detection rate. Robotically assisted surgical removal of the tongue base, tongue base mucosectomy (TBM) has been shown to improve diagnostic yield. This study reports the diagnostic hit rate for tongue base primaries using this technique. DESIGN Retrospective case review. SETTING UK Head and Neck Centres. PARTICIPANTS Patients presenting as an unknown primary, investigated with clinical examination, PET-CT and palatine tonsillectomy. MAIN OUTCOME MEASURES The detection of a primary site of head and neck cancer in the otherwise unknown primary tumour. RESULTS The primary tumour site was identified in the tongue base in 53% (n=17) of patients. In 15 patients the tumour was in the ipsliateral tongue base (88%) while in two cases (12%) the tumour was located in contra lateral tongue base. CONCLUSIONS Trans-oral robotic assisted TBM raises the possibility of identifying over 50% of tumours that would otherwise be classified as CUP. Identifying these in the contralateral tongue base has implications for treatment planning and outcome.
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Affiliation(s)
- S C Winter
- Oxford University NHS Trusts, Oxford, UK
| | - E Ofo
- St George's University Hospitals NHS Foundation Trust, London, UK
| | - D Meikle
- Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - P Silva
- Oxford University NHS Trusts, Oxford, UK
| | - L Fraser
- Oxford University NHS Trusts, Oxford, UK
| | - J O'Hara
- Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - D Kim
- St George's University Hospitals NHS Foundation Trust, London, UK
| | - M Robinson
- Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - V Paleri
- Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
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Abstract
OPINION STATEMENT Given the potential for long-term toxicities from concurrent chemoradiation, there is great interest in surgery as a primary treatment modality for head and neck cancers, particularly in the younger HPV-positive oropharyngeal cancer patient. Transoral robotic surgery (TORS) has proven to be an effective technique to safely treat oropharyngeal and select supraglottic tumors surgically. Sound, traditional surgical principles are employed using improved endoscopic visualization and precise instrumentation to perform oncologic surgery without the morbidity of transmandibular or transcervical approaches. Although level 1 evidence prospective clinical trials are currently underway for TORS, the literature supports its safety and efficacy based on numerous studies. Currently, prospective randomized trials are underway to provide better evidence for or against TORS in oropharyngeal cancer. Patient selection based on comorbidities, anatomy, and available pathological data is critical in choosing patients for TORS.
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Patel SA, Parvathaneni A, Parvathaneni U, Houlton JJ, Karni RJ, Liao JJ, Futran ND, Méndez E. Post-operative therapy following transoral robotic surgery for unknown primary cancers of the head and neck. Oral Oncol 2017; 72:150-156. [PMID: 28797451 DOI: 10.1016/j.oraloncology.2017.07.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 07/08/2017] [Accepted: 07/17/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Our primary objective is to describe the post- operative management in patients with an unknown primary squamous cell carcinoma of the head and neck (HNSCC) treated with trans-oral robotic surgery (TORS). MATERIALS & METHODS We conducted a retrospective multi-institutional case series including all patients diagnosed with an unknown primary HNSCC who underwent TORS to identify the primary site from January 1, 2010 to June 30, 2016. We excluded those with recurrent disease, ≤6months of follow up from TORS, previous history of radiation therapy (RT) to the head and neck, or evidence of primary tumor site based on previous biopsies. Our main outcome measure was receipt of post-operative therapy. RESULTS The tumor was identified in 26/35 (74.3%) subjects. Post-TORS, 2 subjects did not receive adjuvant therapy due to favorable pathology. Volume reduction of RT mucosal site coverage was achieved in 12/26 (46.1%) subjects who had lateralizing tumors, ie. those confined to the palatine tonsil or glossotonsillar sulcus. In addition, for 8/26 (30.1%), the contralateral neck RT was also avoided. In 9 subjects, no primary was identified (pT0); four of these received RT to the involved ipsilateral neck nodal basin only without pharyngeal mucosal irradiation. CONCLUSION Surgical management of an unknown primary with TORS can lead to deintensification of adjuvant therapy including avoidance of chemotherapy and reduction in RT doses and volume. There was no increase in short term treatment failures. Treatment after TORS can vary significantly, thus we advocate adherence to NCCN guideline therapy post-TORS to avoid treatment-associated variability.
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Affiliation(s)
- Sapna A Patel
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA, United States; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States; Surgery Service, Department of Veterans Affairs Medical Center, Seattle, WA, United States
| | - Aarthi Parvathaneni
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States
| | - Upendra Parvathaneni
- Department of Radiation-Oncology, University of Washington, Seattle, WA, United States
| | - Jeffrey J Houlton
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA, United States; Surgery Service, Department of Veterans Affairs Medical Center, Seattle, WA, United States
| | - Ron J Karni
- Department of Otorhinolaryngology-Head & Neck Surgery, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Jay J Liao
- Department of Radiation-Oncology, University of Washington, Seattle, WA, United States
| | - Neal D Futran
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA, United States
| | - Eduardo Méndez
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA, United States; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States.
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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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Truong Lam M, O'Sullivan B, Gullane P, Huang SH. Challenges in establishing the diagnosis of human papillomavirus-related oropharyngeal carcinoma. Laryngoscope 2016; 126:2270-5. [PMID: 27074870 DOI: 10.1002/lary.25985] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 02/18/2016] [Accepted: 02/25/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS To describe initial presentations and idiosyncrasies in establishing the diagnosis for human papillomavirus-related (HPV(+) ) compared to HPV-unrelated (HPV(-) ) oropharyngeal carcinoma (OPC). STUDY DESIGN A single institution retrospective series derived from an institutional prospectively compiled database supplemented by chart review. METHODS We reviewed consecutive OPC patients referred to an academic tertiary cancer center from 2009 to 2011. HPV status was evaluated by p16 staining. Signs/symptoms and procedures to establish diagnosis were recorded independently by two abstractors blinded to the HPV status during data retrieval. Initial presentations (signs/symptoms), interval, and the procedures to establish the diagnosis were compared between HPV(+) and HPV(-) OPC. RESULTS The most common initial presentation was an asymptomatic nodal mass for HPV(+) patients (n = 208; 69% vs. 29%, P < .001) in contrast to dysphagia/odynophagia for HPV(-) (n = 96; 34% vs. 63%, P < .001). Protracted interval (>12 months) from onset of signs/symptoms to diagnosis was observed in 18 (9%) HPV(+) versus three (3%) HPV(-) patients (P = .058). More HPV(+) patients required repeated (≥2) biopsy procedures (56% vs. 10%, P < .001). Misattribution to other disease occurred in eight (4%) HPV(+) patients (seven were mistaken as having a "branchial cleft cyst" when there were cystic lymph nodes and one as having a "lymphoma") compared to none in HPV(-) . CONCLUSIONS About two-thirds of HPV(+) patients present with an asymptomatic neck mass and often require multiple biopsy procedures to establish the diagnosis. Idiosyncrasies in appreciating the diagnostic setting (cystic lymph node, misattribution to other entities, or submucosal location of the tumor) or patient-related factors could delay the diagnosis of HPV(+) OPC. LEVEL OF EVIDENCE 4 Laryngoscope, 126:2270-2275, 2016.
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Affiliation(s)
- Michelle Truong Lam
- Department of Radiation Therapy, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Brian O'Sullivan
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada.,Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Patrick Gullane
- Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Shao Hui Huang
- Department of Radiation Therapy, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada. .,Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada.
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