1
|
Thomas R, Kellerman 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. [PMID: 38773941 DOI: 10.1111/coa.14168] [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: 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.
Collapse
Affiliation(s)
- Rachael Thomas
- Department of Plastic Surgery, St John's Hospital, Edinburgh, Scotland
| | - Noemi Kellerman
- 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
| |
Collapse
|
2
|
Roman KM, Nguyen C, Torabi SJ, Berger MH, Kuan EC, Tjoa T, Haidar YM. Transoral robotic surgery in HPV+ oropharyngeal cancer of unknown primary. Am J Otolaryngol 2024; 45:104060. [PMID: 37832331 DOI: 10.1016/j.amjoto.2023.104060] [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: 04/30/2023] [Accepted: 09/17/2023] [Indexed: 10/15/2023]
Abstract
PURPOSE This study was designed to assess trends in and outcomes associated with TORS-treated HNCUP using a large national database. MATERIALS AND METHODS HPV+ oropharyngeal HNCUPs were isolated from the 2004-2017 National Cancer Database. Overall survival (OS) was assessed, with patients stratified by 1) use of TORS and 2) whether the occult tumor was ultimately located. Demographic and oncologic predictors of survival were evaluated on regression. RESULTS The cohort contained 284,734 cases, of which 8336 were HNCUPs. HNCUPs represented 2.49 % of all HNSCC in 2010 versus 3.13 % in 2017. 3897 (46.7 %) of these unknown primaries were ultimately identified. The proportion of cases treated with TORS increased from 6.9 % in 2010 to 18.1 % in 2017 (p < 0.001). Kaplan-Meier analysis of 2991 HPV+ oropharyngeal HNCUPs demonstrated higher 5-year overall survival (OS) for patients treated with robotic surgery versus no robotic surgery (95.4 % ± 1.7 % standard error [SE] versus 84.0 % ± 0.9 % SE; p < 0.001). Patients with primary tumors identified during treatment had improved OS compared to those whose tumors were not located (5-year OS was 90.5 % ± 0.9 % SE and 77.3 % ± 1.5 % SE, respectively; p < 0.001). For patients in which the primary tumor was found, those who received robotic surgery survived longer than those who did not (96.5 % ± 1.4 % SE versus 89.1 % ± 1.0 % SE 5-year OS; p < 0.001). The relationship between TORS and OS remained significant on Cox regression controlling for confounders. CONCLUSIONS Use of TORS in the workup for HPV+ HNCUP is associated with higher rates of tumor identification and improved OS.
Collapse
Affiliation(s)
- Kelsey M Roman
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Cecilia Nguyen
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Sina J Torabi
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Michael H Berger
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Tjoson Tjoa
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Yarah M Haidar
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA.
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
The role of transoral surgery in the diagnosis of the carcinoma of unknown origin of the head and neck. Curr Opin Otolaryngol Head Neck Surg 2023; 31:129-133. [PMID: 36912225 DOI: 10.1097/moo.0000000000000880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
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.
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Shu Q, Deng M, Hu M, Liu M, Chen X, Chen Y, Cai L. The additional role of [68Ga]Ga-FAPI-04 PET/CT in patients with unknown primary lesion with a negative or equivocal [18F]FDG. Eur J Nucl Med Mol Imaging 2023; 50:1442-1452. [PMID: 36609606 DOI: 10.1007/s00259-022-06095-y] [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: 09/09/2022] [Accepted: 12/22/2022] [Indexed: 01/08/2023]
Abstract
PURPOSE [18F]FDG PET/CT to detect unknown primary lesions is essential for clinical management but still has limitations. [68Ga]Ga-FAPI is a tumor-stromal imaging agent that provides a promising alternative to [18F]FDG for the assessment of malignancies. We aimed to investigate whether [68Ga]Ga-FAPI PET/CT has an additional role in identifying unknown primary lesions with negative or equivocal [18F] FDG PET/CT results. METHODS This single-center prospective clinical study was conducted between March 2020 and March 2022 at Southwest Medical University Hospital. Patients underwent [18F]FDG PET/CT for the identification of unknown primary lesions. They underwent repeat [68Ga]Ga-FAPI PET/CT when [18F]FDG PET/CT results were negative or equivocal. Histopathological examination, surgery, or clinical follow-up (at least 3 months) for FAPI-positive lesions. The diagnostic efficacy of [68Ga]Ga-FAPI in identifying unknown primary lesions was evaluated. RESULTS A total of 44 participants (median age, 57 ± 12 [SD]; 22 [50%] men) were evaluated. Thirteen of the 44 patients had equivocal [18F]FDG PET/CT findings, while the diagnosis was clear on [68Ga]Ga-FAPI PET/CT. [68Ga]Ga-FAPI PET/CT also revealed primary lesions in additional 17 patients with negative [18F]FDG PET/CT findings. In fourteen of 44 patients, no primary lesion was detected by either tracer. On this basis, we analyzed 94 lymph node metastatic lesions. The mean SUVmax of lymph node metastases on [68Ga] Ga-FAPI PET/CT and [18F]FDG PET/CT were 9.2 ± 5.1, 7.9 ± 4.8 (p = 0.03) and the mean TBR were 9.1 ± 5.2, 4.9 ± 3.1 (p < 0.01), respectively. CONCLUSION [68Ga]Ga-FAPI PET/CT showed great potential for identifying unknown primary lesions and has the potential to improve the detection rate of unknown primary lesions with negative or equivocal for [18F]FDG findings. TRIAL REGISTRATION ClinicalTrial.gov. Identifier: ChiCTR2100044131.
Collapse
Affiliation(s)
- Qiaoqiao Shu
- Department of Nuclear Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, Sichuan, People's Republic of China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, Luzhou, 646000, Sichuan, People's Republic of China
- Institute of Nuclear Medicine, Southwest Medical University, No. 25, Taiping St., Jiangyang District, Luzhou, 646000, Sichuan, People's Republic of China
| | - Maoxue Deng
- Department of Nuclear Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, Sichuan, People's Republic of China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, Luzhou, 646000, Sichuan, People's Republic of China
- Institute of Nuclear Medicine, Southwest Medical University, No. 25, Taiping St., Jiangyang District, Luzhou, 646000, Sichuan, People's Republic of China
| | - Mei Hu
- School of Pharmacy, Southwest Medical University, Luzhou, 646000, Sichuan, People's Republic of China
| | - Mengna Liu
- Department of Nuclear Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, Sichuan, People's Republic of China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, Luzhou, 646000, Sichuan, People's Republic of China
- Institute of Nuclear Medicine, Southwest Medical University, No. 25, Taiping St., Jiangyang District, Luzhou, 646000, Sichuan, People's Republic of China
| | - Xi Chen
- Department of Nuclear Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, Sichuan, People's Republic of China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, Luzhou, 646000, Sichuan, People's Republic of China
- Institute of Nuclear Medicine, Southwest Medical University, No. 25, Taiping St., Jiangyang District, Luzhou, 646000, Sichuan, People's Republic of China
| | - Yue Chen
- Department of Nuclear Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, Sichuan, People's Republic of China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, Luzhou, 646000, Sichuan, People's Republic of China
- Institute of Nuclear Medicine, Southwest Medical University, No. 25, Taiping St., Jiangyang District, Luzhou, 646000, Sichuan, People's Republic of China
| | - Liang Cai
- Department of Nuclear Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, Sichuan, People's Republic of China.
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, Luzhou, 646000, Sichuan, People's Republic of China.
- Institute of Nuclear Medicine, Southwest Medical University, No. 25, Taiping St., Jiangyang District, Luzhou, 646000, Sichuan, People's Republic of China.
| |
Collapse
|
7
|
Hussain T. Patient Benefit and Quality of Life after Robot-Assisted Head and Neck Surgery. Laryngorhinootologie 2022; 101:S160-S185. [PMID: 35605618 DOI: 10.1055/a-1647-8650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
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.
Collapse
Affiliation(s)
- Timon Hussain
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Essen, Universität Duisburg-Essen
| |
Collapse
|
8
|
Stepan K, Craig E, Skillington SA, Deutsch BC, Chen S, Wamkpah NS, Bollig CA, Kallogjeri D, Thorstad WL, Puram SV, Pipkorn P, Jackson RS. Development of second primary malignancies after transoral surgery in human papilloma virus-positive oropharyngeal squamous cell carcinoma. Head Neck 2022; 44:1069-1078. [PMID: 35175648 PMCID: PMC9112335 DOI: 10.1002/hed.27002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 12/08/2021] [Accepted: 02/01/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Little data exists regarding the incidence of oropharyngeal and upper aerodigestive tract (UADT) second primary malignancies (SPM) among human papilloma virus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC). Here we evaluate SPM rates among patients with HPV-related OPSCC. METHODS A retrospective cohort study of 412 patients with HPV-related OPSCC who underwent transoral resection +/- adjuvant therapy at a single center between 1996 and 2018. RESULTS Twenty patients (4.9%) developed SPM of the UADT, nine (2.2%) occurring in the oropharynx. Median time to diagnosis was 59.5 months (0-173 months). Risk of SPM was lower for patients receiving adjuvant radiation (aHR: 0.25, 95%CI: 0.08-0.78). There was no difference in overall or disease-free survival between those with and without SPM. CONCLUSION The rate of SPM among patients with HPV-positive OPSCC is lower than reported rates among HPV-negative OPSCC. To date, this is the largest study evaluating SPM in patients with surgically treated HPV-positive OPSCC.
Collapse
Affiliation(s)
- Katelyn Stepan
- Department of Otolaryngology - Head and Neck Surgery, Northwestern Medicine, Chicago, Illinois, USA
| | - Ethan Craig
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Scott Andrew Skillington
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Brian C Deutsch
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Stephanie Chen
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Nneoma S Wamkpah
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Craig A Bollig
- Department of Otolaryngology - Head and Neck Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Dorina Kallogjeri
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Wade L Thorstad
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Sidharth V Puram
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Patrik Pipkorn
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ryan S Jackson
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| |
Collapse
|
9
|
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: 7] [Impact Index Per Article: 3.5] [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.
Collapse
|
10
|
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.
Collapse
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
| |
Collapse
|
11
|
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.
Collapse
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
| |
Collapse
|
12
|
Human Papillomavirus and Squamous Cell Carcinoma of Unknown Primary in the Head and Neck Region: A Comprehensive Review on Clinical Implications. Viruses 2021; 13:v13071297. [PMID: 34372502 PMCID: PMC8310239 DOI: 10.3390/v13071297] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 06/28/2021] [Accepted: 06/29/2021] [Indexed: 01/02/2023] Open
Abstract
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.
Collapse
|
13
|
Ye W, Arnaud EH, Langerman A, Mannion K, Topf MC. Diagnostic approaches to carcinoma of unknown primary of the head and neck. Eur J Cancer Care (Engl) 2021; 30:e13459. [PMID: 33932056 DOI: 10.1111/ecc.13459] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/12/2021] [Accepted: 04/19/2021] [Indexed: 11/27/2022]
Abstract
Squamous cell carcinoma in cervical lymph nodes arising from an undetected primary tumour, termed carcinoma of unknown primary (SCCUP), is a well-recognized clinical presentation within head and neck oncology. SCCUP is a common presentation for patients with human papillomavirus-mediated oropharyngeal cancer (HPV + OPSCC), as patients with HPV + OPSCC often present with smaller primary tumours and early nodal metastasis. Meticulous work-up of the SCCUP patient is central to the management of these patients as identification of the primary site improves overall survival and allows for definitive oncologic resection or more focused radiation when indicated. This review summarizes the comprehensive diagnostic approach to the SCCUP patient, including history and physical examination, methods of biopsy of the cervical lymph node, imaging modalities and intraoperative methods to localize the unknown primary. Novel techniques such as transcervical ultrasound of the oropharynx, narrow band imaging and diagnostic transoral robotic surgery are also discussed.
Collapse
Affiliation(s)
- Wenda Ye
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ethan H Arnaud
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Alexander Langerman
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kyle Mannion
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michael C Topf
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
14
|
Berzenji D, Monserez DA, Verduijn GM, Dronkers EA, Jansen PP, Keereweer S, Sewnaik A, Baatenburg de Jong RJ, Hardillo JA. Treatment of head and neck carcinoma of unknown primary: Cracking a nut with a sledgehammer? Laryngoscope Investig Otolaryngol 2021; 6:211-218. [PMID: 33869753 PMCID: PMC8035952 DOI: 10.1002/lio2.539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/24/2021] [Accepted: 01/29/2021] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES To compare the impact on survival and late radiation toxicity of patients with squamous cell carcinoma of unknown primary who were treated with ipsilateral neck dissection and ipsilateral postoperative radiotherapy (PORT) and patients treated with ipsilateral neck dissection and PORT to both sides of the neck plus the pharyngeal axis. METHODS Retrospective cohort study performed at the Erasmus University Medical Center in which 78 patients with squamous cell carcinoma of unknown primary were identified. Thirty-nine patients received PORT to both sides of the neck plus the pharyngeal axis (BILAX) and another 39 patients were irradiated on the ipsilateral neck (IPSI) only. The endpoints of the present study were 3-year overall survival (OS), 3-year disease-free survival (DFS), and overall late radiation toxicity. RESULTS The 3-year OS rate of the entire group of 78 patients was 74.2% and the 3-year DFS rate was 72.7%. The 3-year OS rates for the IPSI and the BILAX groups were 74.4% and 74.1%, respectively (P = .654). The most common late radiation toxicity experienced was xerostomia (64.8%), which was significantly more often seen in the BILAX group than in the IPSI group (83.8% and 44.1%, respectively, P = .001). Overall late radiation toxicity was significantly higher in the BILAX group (P = .003). CONCLUSION There was no significant difference in OS and DFS rates between the IPSI and the BILAX group. Late radiation toxicity was significantly higher in the BILAX group. LEVEL OF EVIDENCE Level 2b: Individual retrospective cohort study.
Collapse
Affiliation(s)
- Diako Berzenji
- Department of Otorhinolaryngology and Head and Neck SurgeryErasmus University Medical CenterRotterdamThe Netherlands
| | - Dominiek A. Monserez
- Department of Otorhinolaryngology and Head and Neck SurgeryErasmus University Medical CenterRotterdamThe Netherlands
| | - Gerda M. Verduijn
- Department of Radiation OncologyErasmus University Medical CenterRotterdamThe Netherlands
| | - Emilie A.C. Dronkers
- Department of Otorhinolaryngology and Head and Neck SurgeryErasmus University Medical CenterRotterdamThe Netherlands
| | - Peter P. Jansen
- Department of Radiation OncologyErasmus University Medical CenterRotterdamThe Netherlands
| | - Stijn Keereweer
- Department of Otorhinolaryngology and Head and Neck SurgeryErasmus University Medical CenterRotterdamThe Netherlands
| | - Aniel Sewnaik
- Department of Otorhinolaryngology and Head and Neck SurgeryErasmus University Medical CenterRotterdamThe Netherlands
| | - Robert J. Baatenburg de Jong
- Department of Otorhinolaryngology and Head and Neck SurgeryErasmus University Medical CenterRotterdamThe Netherlands
| | - Jose A. Hardillo
- Department of Otorhinolaryngology and Head and Neck SurgeryErasmus University Medical CenterRotterdamThe Netherlands
| |
Collapse
|
15
|
Boeker R, Stromberger C, Heiland M, Beck-Broichsitter B, Hofmann VM, Neumann K, Ochsenreither S, Olze H, Dommerich S, Piwonski I, Coordes A. Carcinoma of Unknown Primary and the 8th Edition TNM Classification for Head and Neck Cancer. Laryngoscope 2021; 131:E2534-E2542. [PMID: 33734438 DOI: 10.1002/lary.29499] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 02/06/2021] [Accepted: 02/20/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVE In the 8th Edition TNM Classification for Head and Neck Cancer, the classification for carcinoma of unknown primary (CUP) changed in addition to oropharyngeal carcinomas. The current classification considers extranodal extension (ENE), determination of p16 (surrogate marker for human papillomavirus), and detection of Epstein-Barr virus (EBV). The aim of this study was to investigate the influence of the new classification on the prognosis of p16-positive and p16-negative CUP and the impact of EBV proof. METHODS Clinical and pathological data from patients with CUP of the head and neck between 2009 and 2018 were evaluated. The 7th (UICC7) and 8th (UICC8) edition of the Union for International Cancer Control staging system were applied and compared. RESULTS There were 97 patients treated, 26.8% women and 73.2% men. The average age at initial diagnosis was 64.6 years. Of which, 58.8% had a documented history of smoking, 37.1% were positive for p16, 4.1% were positive for EBV, and 66% had ENE. Most of the patients were at stage III/IVa (78.4% according to UICC7). According to UICC8, p16+ patients were mainly at stage I (86.1%), and p16- at stage IVb (56.1%). P16 status (P = .002), ENE (P = .001), nodal category (TNM7, P < .001), UICC stage (TNM7, P < .001) and UICC stage (TNM8, P < .001) had a significant impact on survival in the univariate analysis. The 8th TNM classification resulted in a downstaging of p16-positive CUP syndromes and an upstaging of p16-negative syndromes. CONCLUSION The 8th TNM classification shows the lower UICC stage in p16-positive CUP syndromes. The prognostic significance for survival has improved from the 7th to the 8th TNM classification. LEVEL OF EVIDENCE USING THE 2011 OCEBM: Level 3. Laryngoscope, 131:E2534-E2542, 2021.
Collapse
Affiliation(s)
- Robert Boeker
- Department of Otorhinolaryngology, Head and Neck Surgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Carmen Stromberger
- Department of Radiooncology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow Klinikum, Berlin, Germany
| | - Max Heiland
- Department of Oral and Maxillofacial Surgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow Klinikum and Campus Benjamin Franklin, Berlin, Germany
| | - Benedicta Beck-Broichsitter
- Department of Oral and Maxillofacial Surgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow Klinikum and Campus Benjamin Franklin, Berlin, Germany
| | - Veit M Hofmann
- Department of Otorhinolaryngology, Head and Neck Surgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Benjamin Franklin, Berlin, Germany
| | - Konrad Neumann
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute for Biometrics and Clinical Epidemiology, Campus Charité Mitte, Berlin, Germany
| | - Sebastian Ochsenreither
- Department of Hematology and Oncology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Benjamin Franklin, Berlin, Germany.,Charité Comprehensive Cancer Center, Berlin, Germany
| | - Heidi Olze
- Department of Otorhinolaryngology, Head and Neck Surgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Steffen Dommerich
- Department of Otorhinolaryngology, Head and Neck Surgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Iris Piwonski
- Department of Pathology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Annekatrin Coordes
- Department of Otorhinolaryngology, Head and Neck Surgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow Klinikum and Campus Charité Mitte, Berlin, Germany
| |
Collapse
|
16
|
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: 17] [Impact Index Per Article: 4.3] [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.
Collapse
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
| |
Collapse
|
17
|
Moy J, Li R. Approach to the Patient with Unknown Primary Squamous Cell Carcinoma of the Head and Neck. Curr Treat Options Oncol 2020; 21:93. [DOI: 10.1007/s11864-020-00791-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2020] [Indexed: 12/18/2022]
|
18
|
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.
Collapse
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.
| |
Collapse
|
19
|
van Weert S, Rijken JA, Plantone F, Bloemena E, Vergeer MR, Lissenberg-Witte BI, Leemans CR. A systematic review on Transoral robotic surgery (TORS) for carcinoma of unknown primary origin: Has tongue base mucosectomy become indispensable? Clin Otolaryngol 2020; 45:732-738. [PMID: 32369264 PMCID: PMC7496155 DOI: 10.1111/coa.13565] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 03/10/2020] [Accepted: 04/26/2020] [Indexed: 12/22/2022]
Abstract
Background Transoral robotic surgery (TORS) is increasingly used in head and neck surgery and in carcinoma of unknown primary (CUP) origin specifically. Due to the rising incidence of human papillomavirus (HPV)‐related oropharyngeal squamous cell carcinoma (OPSCC), there is a rationale for finding ways to de‐escalate treatment strategies. This review aims to test the hypothesis that TORS is a meaningful adjunct in the diagnostic (and therapeutic) pathway in CUP in head and neck. Methods A structured search of the literature was performed with the search terms ‘TORS’ and ‘Carcinoma of Unknown Primary’. Results Two hundred and seventy four cases of CUP in which TORS was used were identified for further analysis. Workup for CUP was comparable in all series with regard to physical examination, fine and/or gross needle examination of cervical nodes, fibre optic endoscopy, imaging and robot assisted mucosectomy of the base of tongue (BOT). Identification rate of the primary tumour was 72% on average (range 17%‐ 90%), and 55%‐ 96% were HPV positive. Clear margins were achieved in 60% (range 0%‐85%) of resected occult tumours. Complication rate of TORS BOT mucosectomy was low with mainly grade I‐III sequelae according to Clavien–Dindo. Conclusions Transoral robotic surgery seems to be a useful and safe adjunct in the diagnostic and therapeutic pathway in case of CUP in an era of increasing incidence of HPV‐positive OPSCC.
Collapse
Affiliation(s)
- Stijn van Weert
- Department of Otolaryngology/Head and Neck Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Johannes A Rijken
- Department of Otolaryngology/Head and Neck Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - Elisabeth Bloemena
- Department of Pathology and Department of Oral and Maxillofacial Surgery/Pathology, Amsterdam UMC and Academic Centre for Dentistry Amsterdam (ACTA), Cancer Center Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Marije R Vergeer
- Department of Radiation Oncology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Birgit I Lissenberg-Witte
- Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - C René Leemans
- Department of Otolaryngology/Head and Neck Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
20
|
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.
Collapse
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
| | | |
Collapse
|
21
|
Nilsson JS, Wahlberg P, Greiff L. Transoral robotic surgery in the management of head and neck squamous cell cancer with unknown primary. Acta Otolaryngol 2020; 140:85-88. [PMID: 31738643 DOI: 10.1080/00016489.2019.1688863] [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: 10/25/2022]
Abstract
Background: Transoral robotic surgery (TORS) assisted base of the tongue (BOT) resection has been suggested as part of the work-up for head and neck squamous cell cancer with unknown primary (HNSCC-CUP). Success rates vary with regard to identification of primary BOT lesions, and cases with likely such lesions appear to be included in previous reports.Objectives: To analyse the possible benefits of a superficial TORS-assisted BOT resection in thoroughly investigated HNSCC-CUP.Material and methods: Retrospectively, 13 patients subjected to superficial TORS-assisted BOT resections due to HNSCC-CUP, where previous thorough work-ups including PET-scans had been performed and primary lesions had still not been identified, were reviewed.Results: Nodal status, according to the TNM-8 classification, was N1, N2, N2a, N2b, N2c, and N3, respectively, for 7, 1, 1, 4, 0, and 0 patients. In 38% of the cases, T1 BOT cancers were identified using superficial TORS-assisted BOT resections and treatments adjusted.Conclusion: Addition of a superficial TORS-assisted BOT resection to the work-up of HNSCC-CUP frequently identifies primary lesions and alters the treatment for this group of patients even after thorough work-up.
Collapse
Affiliation(s)
- Johan S. Nilsson
- Department of ORL, Head and Neck Surgery, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Peter Wahlberg
- Department of ORL, Head and Neck Surgery, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Lennart Greiff
- Department of ORL, Head and Neck Surgery, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| |
Collapse
|
22
|
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.
Collapse
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
| |
Collapse
|
23
|
Rassy E, Nicolai P, Pavlidis N. Comprehensive management of HPV‐related squamous cell carcinoma of the head and neck of unknown primary. Head Neck 2019; 41:3700-3711. [DOI: 10.1002/hed.25858] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 04/09/2019] [Accepted: 06/12/2019] [Indexed: 01/19/2023] Open
Affiliation(s)
- Elie Rassy
- Department of Medical OncologyInstitut Gustave Roussy Villejuif France
- Department of Medical OncologyHotel Dieu de France University Hospital, Faculty of Medicine, Saint Joseph University Beirut Lebanon
| | - Piero Nicolai
- Department of OtorhinolaryngologyHead and Neck Surgery, University of Brescia Brescia Italy
| | | |
Collapse
|
24
|
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.
Collapse
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
| |
Collapse
|
25
|
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]
|
26
|
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: 42] [Impact Index Per Article: 8.4] [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.
Collapse
|
27
|
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]
|
28
|
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
| | | |
Collapse
|
29
|
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]
|
30
|
Ryan JF, Motz KM, Rooper LM, Mydlarz WK, Quon H, Gourin CG, Tan M, Eisele DW, Fakhry C. The Impact of a Stepwise Approach to Primary Tumor Detection in Squamous Cell Carcinoma of the Neck With Unknown Primary. Laryngoscope 2018; 129:1610-1616. [PMID: 30565698 DOI: 10.1002/lary.27625] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 09/20/2018] [Accepted: 09/26/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVES/HYPOTHESIS To examine the cumulative effect of diagnostic steps for primary tumor identification in patients with head and neck squamous cell carcinoma of unknown primary (HNSCCUP), including lingual tonsillectomy, and the impact of primary tumor identification on subsequent treatment. STUDY DESIGN Retrospective analysis. METHODS We reviewed the records of 110 patients diagnosed with HNSCCUP between 2003 and 2015. Results of diagnostic imaging (fluorodeoxyglucose-positron emission tomography/computed tomography [FDG-PET/CT]), tumor detection with direct laryngoscopy with biopsies, palatine tonsillectomy, and transoral robotic surgery (TORS) lingual tonsillectomy were recorded. Associations between demographic and treatment variables with overall survival (OS) and progression-free survival (PFS) were modeled with Cox proportional hazards models. RESULTS FDG-PET/CT was suspicious for a primary site in 23/77 (30%) patients. Direct laryngoscopy identified a primary tumor in 34/110 patients (31%). Forty-seven patients underwent palatine tonsillectomy, which identified 17 primaries (36%), yielding a cumulative primary tumor identification of 51/110 (46%). Fourteen patients underwent TORS lingual tonsillectomy, which identified eight primaries (57%), resulting in a cumulative identification of 59/110 (53%). The detection rate increased from 28/63 (44%) to 31/47 (66%) after the addition of TORS lingual tonsillectomy to our institutional approach. Detection rates varied by HPV status. Primary tumor identification altered subsequent radiation planning, as patients with an identified primary tumor received radiation to a smaller volume of tissue than did those without an identified primary tumor. However, there was no significant association between primary tumor identification and OS or PFS. CONCLUSIONS A stepwise approach to primary tumor identification identifies a primary tumor in a majority of patients. LEVEL OF EVIDENCE 4 Laryngoscope, 129:1610-1616, 2019.
Collapse
Affiliation(s)
- John F Ryan
- Department of Otolaryngology-Head and Neck Surgery, Baltimore, Maryland, U.S.A
| | - Kevin M Motz
- Department of Otolaryngology-Head and Neck Surgery, Baltimore, Maryland, U.S.A
| | | | - Wojciech K Mydlarz
- Department of Otolaryngology-Head and Neck Surgery, Baltimore, Maryland, U.S.A
| | - Harry Quon
- Department of Otolaryngology-Head and Neck Surgery, Baltimore, Maryland, U.S.A.,Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Christine G Gourin
- Department of Otolaryngology-Head and Neck Surgery, Baltimore, Maryland, U.S.A
| | - Marietta Tan
- Department of Otolaryngology-Head and Neck Surgery, Baltimore, Maryland, U.S.A
| | - David W Eisele
- Department of Otolaryngology-Head and Neck Surgery, Baltimore, Maryland, U.S.A
| | - Carole Fakhry
- Department of Otolaryngology-Head and Neck Surgery, Baltimore, Maryland, U.S.A.,Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, U.S.A
| |
Collapse
|
31
|
Zhang S, Xiao HD, Cai Z, Covinsky M, Saluja K, Patino MO, Liu X, Zhu H. P16-positive cystic squamous cell carcinoma in midline neck: metastasis from oropharynx or primary carcinoma arising from thyroglossal duct cyst? Hum Pathol 2018; 81:291-297. [DOI: 10.1016/j.humpath.2018.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 01/23/2018] [Accepted: 03/02/2018] [Indexed: 01/21/2023]
|
32
|
Sokoya M, Chowdhury F, Kadakia S, Ducic Y. Combination of panendoscopy and positron emission tomography/computed tomography increases detection of unknown primary head and neck carcinoma. Laryngoscope 2018; 128:2573-2575. [PMID: 30194842 DOI: 10.1002/lary.27268] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVES/HYPOTHESIS With positron emission tomography/computed tomography (PET/CT) now commonplace as a diagnostic tool, new questions have arisen regarding the utility and cost-effectiveness of panendoscopy. In this retrospective review of a large cohort of head and neck squamous cell carcinoma of unknown primary (HNSCC-UP), we describe the enduring utility of panendoscopy in the detection of the primary site of mucosal disease even when PET/CT is negative. STUDY DESIGN Retrospective cohort study. METHODS A retrospective analysis of patients presenting to the senior author (y.d.) from July 1 1997 to July 1 2017 with fine-needle aspiration-proven metastatic squamous cell carcinoma to the neck. All patients underwent formal panendoscopy (direct laryngoscopy, bronchoscopy, and rigid esophagoscopy). Presence of squamous cell carcinoma on final pathology was examined. RESULTS A total of 190 patients had HNSCC-UP, with 87 positive and 103 negative on PET/CT. Of the PET/CT-negative patients, 71 patients retained the HNSCC-UP designation after panendoscopy. Eighteen patients (56% of cases) were found to have primary tonsillar squamous cell carcinoma. Eight of 32 primary sites were found in the base of tongue (25%), with HPV positivity in two of these patients. The sensitivity and negative predictive value of PET/CT in detecting the primary site in unknown primary head and neck squamous cell carcinoma in the total study population were 73.1% and 68.9%, respectively. CONCLUSIONS Surgical panendoscopy has an important role in the workup of patients with unknown primary head and neck squamous cell carcinoma. There is a high rate of cancer diagnosis, even in PET/CT negative patients. LEVEL OF EVIDENCE 4 Laryngoscope, 2573-2575, 2018.
Collapse
Affiliation(s)
- Mofiyinfolu Sokoya
- Department of Otolaryngology , University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Farshad Chowdhury
- Department of Otolaryngology , University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Sameep Kadakia
- Department of Facial Plastic and Reconstructive Surgery , Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas, U.S.A
| | - Yadranko Ducic
- Department of Facial Plastic and Reconstructive Surgery , Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas, U.S.A
| |
Collapse
|
33
|
Lewis JS, Beadle B, Bishop JA, Chernock RD, Colasacco C, Lacchetti C, Moncur JT, Rocco JW, Schwartz MR, Seethala RR, Thomas NE, Westra WH, Faquin WC. Human Papillomavirus Testing in Head and Neck Carcinomas: Guideline From the College of American Pathologists. Arch Pathol Lab Med 2018; 142:559-597. [PMID: 29251996 DOI: 10.5858/arpa.2017-0286-cp] [Citation(s) in RCA: 329] [Impact Index Per Article: 54.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context Human papillomavirus (HPV) is a major cause of oropharyngeal squamous cell carcinomas, and HPV (and/or surrogate marker p16) status has emerged as a prognostic marker that significantly impacts clinical management. There is no current consensus on when to test oropharyngeal squamous cell carcinomas for HPV/p16 or on which tests to choose. Objective To develop evidence-based recommendations for the testing, application, interpretation, and reporting of HPV and surrogate marker tests in head and neck carcinomas. Design The College of American Pathologists convened a panel of experts in head and neck and molecular pathology, as well as surgical, medical, and radiation oncology, to develop recommendations. A systematic review of the literature was conducted to address 6 key questions. Final recommendations were derived from strength of evidence, open comment period feedback, and expert panel consensus. Results The major recommendations include (1) testing newly diagnosed oropharyngeal squamous cell carcinoma patients for high-risk HPV, either from the primary tumor or from cervical nodal metastases, using p16 immunohistochemistry with a 70% nuclear and cytoplasmic staining cutoff, and (2) not routinely testing nonsquamous oropharyngeal carcinomas or nonoropharyngeal carcinomas for HPV. Pathologists are to report tumors as HPV positive or p16 positive. Guidelines are provided for testing cytologic samples and handling of locoregional and distant recurrence specimens. Conclusions Based on the systematic review and on expert panel consensus, high-risk HPV testing is recommended for all new oropharyngeal squamous cell carcinoma patients, but not routinely recommended for other head and neck carcinomas.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - William C Faquin
- From the Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee (Dr Lewis); the Department of Radiation Oncology, Stanford University Medical Center, Palo Alto, California (Dr Beadle); the Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland (Drs Bishop and Westra); the Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, Missouri (Dr Chernock); Surveys, the College of American Pathologists, Northfield, Illinois (Mss Colasacco and Thomas); Policy and Advocacy, American Society of Clinical Oncology, Alexandria, Virginia (Ms Lacchetti); the Department of Pathology, Walter Reed National Military Medical Center, Bethesda, Maryland (Dr Moncur); the Department of Otolaryngology-Head and Neck Surgery, Ohio State University Wexler Medical Center, Columbus (Dr Rocco); the Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas (Dr Schwartz); the Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (Dr Seethala); and the Department of Pathology, Massachusetts General Hospital, Boston (Dr Faquin)
| |
Collapse
|
34
|
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%.
Collapse
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
| |
Collapse
|
35
|
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.
Collapse
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
| |
Collapse
|
36
|
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.
Collapse
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.
| |
Collapse
|
37
|
Hu KS, Mourad WF, Gamez ME, Lin W, Jacobson AS, Persky MS, Urken ML, Culliney BE, Li Z, Tran TN, Schantz SP, Chadha J, Harrison LB. Five-year outcomes of an oropharynx-directed treatment approach for unknown primary of the head and neck. Oral Oncol 2017. [PMID: 28622886 DOI: 10.1016/j.oraloncology.2017.05.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE Squamous cell carcinoma of unknown primary (SCCHNUP) is commonly treated with comprehensive radiation to the laryngopharynx and bilateral necks. In 1998, we established a departmental policy to treat SCCHNUP with radiation directed to the oropharynx and bilateral neck. METHODS From 1998-2011, 60 patients were treated - N1: 18%, N2: 75% and N3: 7%. 82% underwent neck dissection. 55% received IMRT and 62% underwent concurrent chemoradiotherapy. RESULTS At median follow-up of 54months, 5 patients failed regionally and 4 emerged with a primary (tongue base, hypopharynx and thoracic esophagus). Five-year rates of regional control, primary emergence, distant metastasis, disease-free survival and overall survival were 90%, 10%, 20%, 72% and 79%, respectively. The 5year rate of primary emergence in a non-oropharynx site was 3%. CONCLUSION This is the first demonstration that an oropharynx-directed approach yields low rates of primary emergence in SCCHNUP with excellent oncologic outcomes.
Collapse
Affiliation(s)
- Kenneth Shung Hu
- Dept of Radiation Oncology, New York University Langone Medical Center, New York, NY, United States.
| | - Waleed Fouad Mourad
- Dept of Radiation Oncology, Georgia Regents University, Augusta, GA, United States
| | - Mauricio E Gamez
- Dept of Radiation Oncology, Mayo Clinic Arizona, Phoenix, AZ, United States.
| | - Wilson Lin
- Dept of Radiation Oncology, Mount Sinai at Beth Israel Medical Center, New York, NY, United States
| | - Adam Saul Jacobson
- Dept of Otolaryngology, New York University Langone Medical Center, New York, NY, United States
| | - Mark Stephen Persky
- Dept of Otolaryngology, New York University Langone Medical Center, New York, NY, United States
| | - Mark L Urken
- Dept of Otolaryngology, Mount Sinai at Beth Israel, New York, NY, United States
| | - Bruce E Culliney
- Dept of Medicine, Mount Sinai at Beth Israel, New York, NY, United States
| | - Zujun Li
- Dept of Medicine, New York University Langone Medical Center, New York, NY, United States
| | - Theresa Nguyen Tran
- Dept of Otolaryngology, New York University Langone Medical Center, New York, NY, United States
| | | | - Juskaran Chadha
- Dept of Medicine, Mount Sinai at Roosevelt Hospital, New York, NY, United States
| | | |
Collapse
|
38
|
de Ridder M, Klop M, Hamming-Vrieze O, de Boer J, Jasperse B, Smit L, Vogel W, van den Brekel M, Al-Mamgani A. Unknown primary head and neck squamous cell carcinoma in the era of fluorodeoxyglucose-positron emission tomography/CT and intensity-modulated radiotherapy. Head Neck 2017; 39:1382-1391. [PMID: 28370570 DOI: 10.1002/hed.24762] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The diagnosis and treatment of head and neck carcinoma of unknown primary (CUP) have changed with the introduction of fluorodeoxyglucose-positron emission tomography (FDG-PET)/CT and intensity-modulated radiotherapy (IMRT), with potential implications for outcome. METHODS We conducted a retrospective analysis of 80 patients with head and neck CUP who were PET-staged and treated with curative intention using IMRT between 2006 and 2016 in the Netherlands Cancer Institute. Patient, tumor, and treatment demographics were recorded and oncologic outcomes were analyzed. RESULTS Local control was 100% in mucosal irradiated patients. Regional control was 90%. Ten patients developed distant metastases, which were associated with N3, extracapsular extension (ECE) and lower neck positive lymph nodes. Overall survival (OS) at 5 years was 62% and disease-specific survival was 78%. ECE, N3 neck, multiple levels of positive lymph nodes, and positive lymph nodes in the lower neck were associated with worse prognosis. CONCLUSION Locoregional outcome of head and neck CUP managed with modern techniques is good. Future research needs to focus on reducing toxicity and patients prone for distant metastasis.
Collapse
Affiliation(s)
- Mischa de Ridder
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Martin Klop
- Department of Head and Neck Surgery, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Olga Hamming-Vrieze
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - JanPaul de Boer
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Bas Jasperse
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Laura Smit
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Wouter Vogel
- Department of Nuclear Medicine, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Michiel van den Brekel
- Department of Head and Neck Surgery, Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Oral and Maxillofacial Surgery, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Abrahim Al-Mamgani
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| |
Collapse
|
39
|
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.
Collapse
|
40
|
Geltzeiler M, Doerfler S, Turner M, Albergotti WG, Kubik M, Kim S, Ferris R, Duvvuri U. Transoral robotic surgery for management of cervical unknown primary squamous cell carcinoma: Updates on efficacy, surgical technique and margin status. Oral Oncol 2017; 66:9-13. [PMID: 28249654 DOI: 10.1016/j.oraloncology.2016.12.033] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 12/27/2016] [Accepted: 12/29/2016] [Indexed: 10/20/2022]
Abstract
IMPORTANCE Management of cervical unknown primary squamous cell carcinoma (CUP) has evolved with the introduction of transoral robotic surgery (TORS). OBJECTIVES 1. To describe the efficacy of TORS lingual and palatine tonsillectomy in identifying the primary site of malignancy. 2. To explore how the extent of surgery affects diagnostic yield. 3. To report margin status of TORS resections. DESIGN, SETTING AND PARTICIPANTS A retrospective, single-center cohort study utilizing a prospectively collected database of CUP patients in a high-volume tertiary referral center. Patient underwent operative laryngoscopy plus TORS as clinically indicated. MAIN OUTCOMES AND MEASURES Primary end point was successful identification of the primary. The extent of surgery and margin status were also examined. RESULTS From 2010-2016, 64 patients with CUP were treated. The primary tumor was found in 51 patients (80%). Fourteen patients (22%) were identified with operative laryngoscopy alone. Fifty patients underwent TORS lingual tonsillectomy ± palatine tonsillectomy with 37 primary tumors identified (74%). The primary was located in the lingual tonsil in 32 patients (86%) and palatine tonsil in 5 patients (10%, p<0.001). Negative margins were achieved in 19 patients (51%). The deep margin was the most commonly positive margin (47%, p=0.049). CONCLUSION AND RELEVANCE Operative laryngoscopy with TORS is efficacious, localizing the primary in 80% of patients. If a margin was positive, it was most commonly the deep margin. This study provides valuable information that can help standardize surgical technique, further increasing the diagnostic yield and decreasing the negative margin rate of TORS for CUP.
Collapse
Affiliation(s)
- Mathew Geltzeiler
- UPMC Department of Otolaryngology/Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Sean Doerfler
- UPMC Department of Otolaryngology/Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Meghan Turner
- UPMC Department of Otolaryngology/Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - William Greer Albergotti
- UPMC Department of Otolaryngology/Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mark Kubik
- UPMC Department of Otolaryngology/Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Seungwon Kim
- UPMC Department of Otolaryngology/Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Robert Ferris
- UPMC Department of Otolaryngology/Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Umamaheswar Duvvuri
- UPMC Department of Otolaryngology/Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| |
Collapse
|
41
|
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).
Collapse
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.
| |
Collapse
|
42
|
Abstract
CONCLUSION The management of Head and Neck Cancer of Unknown Primary (HNCUP) patients varies both between centres within and also between the Nordic countries. This study contributes to a continuing discussion of how to improve the accuracy of diagnosis and quality of treatment of HNCUP patients. OBJECTIVES The initiative for this study was based on the lack of common guidelines for diagnostic procedures and for treatment of HNCUP patients in the Nordic countries constituting a region having a rather homogeneous population. METHOD A structured questionnaire was sent to all university hospitals in the five Nordic countries. RESULTS Four of the five Nordic countries use either national guidelines or specific protocols when handling HNCUP. The main diagnostic tools are PET-CT, fine needle aspiration, endoscopic evaluation with biopsies, and most often bilateral tonsillectomy. At 21 of 22 university hospitals the treatment decision is made at a multidisciplinary conference. Three of seven Swedish centres use only radiotherapy or chemoradiotherapy to treat N+ HNCUP patients. Robotic surgery for biopsy of the tongue base is beginning to become an alternative to targeted biopsies in Sweden and Finland. Narrow Band Imaging is used only in Finland.
Collapse
|
43
|
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.
Collapse
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
| |
Collapse
|
44
|
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.
Collapse
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.
| |
Collapse
|
45
|
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.
Collapse
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
| |
Collapse
|
46
|
Kang SY, Dziegielewski PT, Old MO, Ozer E. Transoral robotic surgery for carcinoma of unknown primary in the head and neck. J Surg Oncol 2015; 112:697-701. [PMID: 26437845 DOI: 10.1002/jso.24027] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 08/17/2015] [Indexed: 11/09/2022]
Abstract
Multiple diagnostic and treatment paradigms exist for the management of carcinoma of unknown primary (CUP) metastatic to cervical lymph nodes. Transoral robotic surgery (TORS) has emerged as a modality for diagnosis and treatment of CUP, optimizing identification and resection of the primary tumor, although also preventing chemotherapy in a subset of patients. This article presents the authors' treatment paradigm and reviews the literature supporting the use of TORS in the management of CUP.
Collapse
Affiliation(s)
- Stephen Y Kang
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio.,Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio
| | - Peter T Dziegielewski
- Department of Otolaryngology-Head and Neck Surgery, University of Florida, Gainesville, Florida
| | - Matthew O Old
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio.,Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio
| | - Enver Ozer
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio.,Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio
| |
Collapse
|
47
|
Clark J, Jeffery CC, Zhang H, Cooper T, O'Connell DA, Harris J, Seikaly H, Biron VL. Correlation of PET-CT nodal SUVmax with p16 positivity in oropharyngeal squamous cell carcinoma. J Otolaryngol Head Neck Surg 2015; 44:37. [PMID: 26374294 PMCID: PMC4570692 DOI: 10.1186/s40463-015-0091-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 09/02/2015] [Indexed: 11/10/2022] Open
Abstract
Background The incidence of human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) has been rising in recent years. Given the clinical impact of HPV/p16 positivity in OPSCC, identifying surrogate markers of this disease early in the diagnostic work-up of these patients could improve patient care. Methods Demographic, pathologic, staging and PET-CT data from patients diagnosed with OPSCC from 2009–2014 were obtained from a prospectively collected provincial cancer registry. Tumor HPV/p16 status was correlated to the maximum standard uptake value (SUVmax) of the primary tumor and cervical nodes. Comparisons of means and multinomial regression models were used to determine associations between p16 status and SUVmax. A diagnostic odds ratio was calculated using a cut off value for predicting HPV/p16 positivity based on nodal SUVmax. Results PET-CT and HPV/p16 data was obtained for 65 patients treated surgically for OPSCC. Significantly higher nodal SUVmax was associated with HPV/p16 positive nodes (SUVmax 10.8 vs 7.9). No significant differences were seen between HPV/p16 positive vs negative primary tumor SUVmax (10.3 vs 13.7). In combination with other clinical parameters, higher nodal SUVmax was highly correlated with HPV/p16 positivity. Conclusion Elevated nodal SUVmax is a significant predictor of HPV/p16 positive disease.
Collapse
Affiliation(s)
- Jessica Clark
- Faculty of Medicine and Dentistry, Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Alberta, Edmonton, Alberta, Canada.
| | - Caroline C Jeffery
- Faculty of Medicine and Dentistry, Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Alberta, Edmonton, Alberta, Canada.
| | - Han Zhang
- Faculty of Medicine and Dentistry, Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Alberta, Edmonton, Alberta, Canada.
| | - Tim Cooper
- Faculty of Medicine and Dentistry, Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Alberta, Edmonton, Alberta, Canada.
| | - Daniel A O'Connell
- Faculty of Medicine and Dentistry, Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Alberta, Edmonton, Alberta, Canada. dan.o'
| | - Jeffrey Harris
- Faculty of Medicine and Dentistry, Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Alberta, Edmonton, Alberta, Canada.
| | - Hadi Seikaly
- Faculty of Medicine and Dentistry, Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Alberta, Edmonton, Alberta, Canada.
| | - Vincent L Biron
- Faculty of Medicine and Dentistry, Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Alberta, Edmonton, Alberta, Canada. .,University of Alberta, Otolaryngology-Head and Neck Surgery, 1E4, Walter Mackenzie Centre, University of Alberta Hospital, 8440-112St, Edmonton, Alberta, T6G 2B7, Canada.
| |
Collapse
|
48
|
Helman SN, Schwedhelm T, Kadakia S, Wang Y, Schiff BA, Smith RV. Transoral Robotic Surgery in Oropharyngeal Carcinoma. Arch Pathol Lab Med 2015; 139:1389-97. [DOI: 10.5858/arpa.2014-0573-ra] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context
The incidence of oropharyngeal squamous cell carcinoma has increased during the past decade and is related primarily to the human papillomavirus. This change in etiology, from tobacco and alcohol to human papillomavirus, has resulted in improved survival for the disease. In the United States, open resection had largely been replaced by concurrent chemotherapy and/or radiotherapy by the early 2000s. The advent of transoral surgery has led to an increase in surgery as the primary treatment for both early- and advanced-stage oropharyngeal squamous cell carcinoma because it has potential advantages over open surgery and nonsurgical modalities.
Objective
To provide an overview of transoral robotic surgery for oropharyngeal squamous cell carcinoma and contrast it with other surgical and nonsurgical modalities.
Data Sources
Articles from 2000 to 2014 were accessioned on PubMed and reviewed for utility by the primary authors.
Conclusions
Transoral surgery has become more commonly used as a minimally invasive approach to treat oropharyngeal tumors. Other strategies, including radiation, chemotherapy with radiation, and open surgery, are still important treatment approaches. The treatment options for an individual patient rely on multiple factors, including the tumor location and size, features of the tumor, and patient comorbidities. The continued study of these techniques is important to match the patient with the most appropriate treatment.
Collapse
Affiliation(s)
| | | | | | | | | | - Richard V. Smith
- From the Department of Otolaryngology/Head and Neck Surgery, New York Eye and Ear Infirmary–Mount Sinai Health System, New York, New York (Drs Helman and Kadakia); Albert Einstein College of Medicine, Bronx, New York (Mr Schwedhelm); and the Departments of Pathology (Dr Wang) and Otorhinolaryngology–Head and Neck Surgery (Drs Schiff and Smith), Montefiore Medical Center, Albert Einstein College o
| |
Collapse
|
49
|
Tanzler ED, Amdur RJ, Morris CG, Werning JW, Mendenhall WM. Challenging the need for random directed biopsies of the nasopharynx, pyriform sinus, and contralateral tonsil in the workup of unknown primary squamous cell carcinoma of the head and neck. Head Neck 2015; 38:578-81. [PMID: 25488125 DOI: 10.1002/hed.23931] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Revised: 10/08/2014] [Accepted: 12/04/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Many guidelines recommend random directed biopsies of the nasopharynx, contralateral tonsil, and hypopharynx to evaluate an unknown primary squamous cell carcinoma of the head and neck. There are no published data documenting the need for these recommendations. The purpose of our study was to report the rate of positive blind biopsies in this setting. METHODS We recorded the rate of positive random directed biopsies performed as part of the workup for 156 patients treated with radiotherapy between 1985 and 2014 for an unknown primary squamous cell carcinoma presenting with the main location of adenopathy in nodal stations 2, 3, 4, or 5. RESULTS Rate of positive result by subsite: nasopharynx and pyriform sinus = 0%; tonsillectomy: ipsilateral = 39%, bilateral = 6%; and base of tongue = 18%. CONCLUSION With modern imaging, random directed biopsies of the nasopharynx and hypopharynx are unnecessary in the workup of unknown primary squamous cell carcinoma of the head and neck.
Collapse
Affiliation(s)
- Emily D Tanzler
- Department of Radiation Oncology, University of Florida, Gainesville, Florida
| | - Robert J Amdur
- Department of Radiation Oncology, University of Florida, Gainesville, Florida
| | | | - John W Werning
- Department of Otolaryngology, University of Florida, Gainesville, Florida
| | | |
Collapse
|
50
|
Lukianova-Hleb EY, Lapotko DO. Rapid detection and destruction of squamous cell carcinoma of the head and neck by nano-quadrapeutics. Head Neck 2015; 37:1547-55. [DOI: 10.1002/hed.24018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Revised: 10/12/2014] [Accepted: 02/06/2015] [Indexed: 01/28/2023] Open
Affiliation(s)
| | - Dmitri O. Lapotko
- Department of BioSciences at Rice; Rice University; Houston Texas
- Department of Physics and Astronomy; Rice University; Houston Texas
| |
Collapse
|