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Thomas R, Kelemen N, Molena E, Lester S. Indications for oropharyngeal biopsy in head and neck squamous cell carcinoma of unknown primary: A systematic review (HNSCCUP). Clin Otolaryngol 2024; 49:552-566. [PMID: 38773941 DOI: 10.1111/coa.14168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 04/07/2024] [Accepted: 04/13/2024] [Indexed: 05/24/2024]
Abstract
INTRODUCTION Patients presenting with head and neck squamous cell carcinoma of unknown primary (HNSCCUP) remain challenging clinical scenarios as large variation exists in practices used to locate the primary. OBJECTIVE The objective of this systematic review is to review of the literature and offer recommendations for oropharyngeal biopsies in HNSCCUP. METHOD Pubmed, Medline and Embase were searched to identify studies from inception to October 2021. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. RESULTS A total of 483 articles were included and screened, 41 studies met the inclusion criteria, including over 3400 patients from the original articles (122 of these patients were reported on in two sequential articles by a single author - table 1) and 4 large metaanalyses including 1852 patients. The primary site identification rate following random biopsies or deep tissue biopsies is less than 5% in most studies. The mean detection rate following ipsilateral tonsillectomy is 34%; two pooled analyses indicate that the mean detection rate following tongue base mucosectomy is 64%, with this figure rising when the tonsils are negative. CONCLUSIONS High level evidence is lacking, with heterogeneity in the reported studies. Published meta-analyses are based on retrospective data. There is little evidence supporting the practice of random/non-directed oropharyngeal biopsies. Available evidence supports palatine tonsillectomy and tongue base mucosectomy compared to deep tissue biopsies.
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Affiliation(s)
- Rachael Thomas
- Department of Plastic Surgery, St John's Hospital, Edinburgh, Scotland
| | - Noemi Kelemen
- Department of Plastic Surgery, Hull University Teaching Hospitals NHS Trust, UK
| | - Emma Molena
- Department of Plastic Surgery, Hull University Teaching Hospitals NHS Trust, UK
| | - Shane Lester
- Department of Ear Nose and Throat Surgery, James Cook University Hospital, Middlesborough, UK
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2
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Gupta KK, Khan H, Mughal Z, De M, Sharma N, Garas G. Primary Tumour Detection in Carcinoma of Unknown Primary with Transoral Robotic Surgery (TORS) Tongue Base Mucosectomy: A Meta-analysis. Ann Surg Oncol 2024; 31:6065-6076. [PMID: 38980583 DOI: 10.1245/s10434-024-15758-z] [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: 04/01/2024] [Accepted: 06/24/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND Head and neck carcinoma of unknown primary (CUP) represents a challenging diagnostic process when standard work-up fails to identify the primary tumour site. The aim of this systematic review and meta-analysis was to evaluate the diagnostic utility and complication profile of transoral robotic surgery (TORS) tongue base mucosectomy (TBM) in the management of CUP. PATIENTS AND METHODS An electronic database search was performed in the EMBASE, MEDLINE, PubMed and Cochrane databases. A meta-analysis of proportions was performed to obtain an estimate of the overall proportion for the detection and complication rates. RESULTS Nine studies representing 235 patients with CUP who had TORS TBM were included in the final analysis. The overall pooled tumour detection rate was 66.2% [95% confidence interval (CI) 56.1-75.8]. The incidence of tumour detection in human papilloma virus (HPV)-positive cases (81.5%, 95% CI 60.8-96.4) was significantly higher than HPV-negative cases (2.3%, 95% CI 0.00-45.7). Weighted overall complication rate was 11.4% (95% CI 7.2-16.2). The majority were grade I or II (80%) according to the Clavien-Dindo classification. CONCLUSIONS This meta-analysis suggests TORS to be safe and effective in localising the primary tumour site in patients with CUP. While the current data supports the use of TORS in patients who are HPV positive, larger numbers of HPV-negative cases are required to determine the true diagnostic effect with TORS before any valid conclusions can be inferred in this particular subgroup. Further research should focus on high quality prospective trials with stringent methodological work-up to minimise heterogeneity and allow for more accurate statistical analysis.
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Affiliation(s)
- Keshav Kumar Gupta
- Head & Neck Surgical Oncology Unit, Department of Otorhinolaryngology and Head and Neck Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK.
| | - Hamad Khan
- Head & Neck Surgical Oncology Unit, Department of Otorhinolaryngology and Head and Neck Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Zahir Mughal
- Department of Otorhinolaryngology and Head and Neck Surgery, Walsall Manor Hospital, Walsall, UK
| | - Mriganka De
- Head & Neck Surgical Oncology Unit, Department of Otorhinolaryngology and Head and Neck Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Neil Sharma
- Head & Neck Surgical Oncology Unit, Department of Otorhinolaryngology and Head and Neck Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - George Garas
- Head & Neck Surgical Oncology Unit, Department of Otorhinolaryngology and Head and Neck Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
- Department of Surgery and Cancer, Imperial College London, St. Mary's Hospital, London, UK
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Awad L, Reed B, Bollen E, Langridge BJ, Jasionowska S, Butler PEM, Ponniah A. The emerging role of robotics in plastic and reconstructive surgery: a systematic review and meta-analysis. J Robot Surg 2024; 18:254. [PMID: 38878229 PMCID: PMC11180031 DOI: 10.1007/s11701-024-01987-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 05/19/2024] [Indexed: 06/19/2024]
Abstract
The role of robotics has grown exponentially. There is an active interest amongst practitioners in the transferability of the potential benefits into plastic and reconstructive surgery; however, many plastic surgeons report lack of widespread implementation, training, or clinical exposure. We report the current evidence base, and surgical opportunities, alongside key barriers, and limitations to overcome, to develop the use of robotics within the field. This systematic review of PubMed, Medline, and Embase has been conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PROSPERO (ID: CRD42024524237). Preclinical, educational, and clinical articles were included, within the scope of plastic and reconstructive surgery. 2, 181, articles were screened; 176 articles met the inclusion criteria across lymph node dissection, flap and microsurgery, vaginoplasty, craniofacial reconstruction, abdominal wall reconstruction and transoral robotic surgery (TOR). A number of benefits have been reported including technical advantages such as better visualisation, improved precision and accuracy, and tremor reduction. Patient benefits include lower rate of complications and quicker recovery; however, there is a longer operative duration in some categories. Cost presents a significant barrier to implementation. Robotic surgery presents an exciting opportunity to improve patient outcomes and surgical ease of use, with feasibility for many subspecialities demonstrated in this review. However, further higher quality comparative research with careful case selection, which is adequately powered, as well as the inclusion of cost-analysis, is necessary to fully understand the true benefit for patient care, and justification for resource utilisation.
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Affiliation(s)
- Laura Awad
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK.
- Department of Plastic Surgery, Royal Free Hospital, London, UK.
- Department of Surgery and Interventional Sciences, University College London, Royal Free Hospital, London, UK.
| | - Benedict Reed
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
- Department of Plastic Surgery, Royal Free Hospital, London, UK
| | - Edward Bollen
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
| | - Benjamin J Langridge
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
- Department of Plastic Surgery, Royal Free Hospital, London, UK
- Department of Surgery and Interventional Sciences, University College London, Royal Free Hospital, London, UK
| | - Sara Jasionowska
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
- Department of Plastic Surgery, Royal Free Hospital, London, UK
| | - Peter E M Butler
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
- Department of Plastic Surgery, Royal Free Hospital, London, UK
- Department of Surgery and Interventional Sciences, University College London, Royal Free Hospital, London, UK
| | - Allan Ponniah
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
- Department of Plastic Surgery, Royal Free Hospital, London, UK
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Mettias B, Nijim H, Laugharne D, Mortimore S. Transoral robotic tongue base mucosectomy for head and neck cancer of unknown primary: six-year outcome experience. J Laryngol Otol 2024; 138:548-553. [PMID: 38099446 DOI: 10.1017/s0022215123002098] [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] [Indexed: 02/27/2024]
Abstract
BACKGROUND AND OBJECTIVE Head and neck carcinoma of unknown primary is a diagnostic dilemma. The clinical and imaging workup remains ineffective in two-thirds of patients. Transoral robotic surgery has shown an advantage in the primary detection over the previous standard panendoscopy. METHODS This is an observational cohort study that took place at a large healthcare centre with robotic surgery experience in head and neck over six-years. All included carcinoma of unknown primary patients followed the standard recommendation for primary identification. Final diagnostic step of robotic tongue base mucosectomy with or without tonsillectomy was introduced. The cancer detection rate in tongue base only, the functional outcome and the effect on the cancer pathway were evaluated. RESULTS Carcinoma of unknown primary was reported in 44 per cent of patients. All identified specimens were human papillomavirus positive. There was no significant effect on functional outcome of swallowing and the national 62-day cancer pathway. Robotic surgery allowed optimum treatment of carcinoma of unknown primary in early nodal disease. CONCLUSION Robotic surgery is a useful paradigm in the management of carcinoma of unknown primary. It is safe with minimal morbidity and good functional outcome after the surgery.
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Affiliation(s)
- Bassem Mettias
- Department of Otolaryngology & Head and Neck Surgery Mid and South Essex NHS Foundation trust, Basildon, SS16 5NL, UK
| | - Hazem Nijim
- Department of Otolaryngology & Head and Neck Surgery Mid and South Essex NHS Foundation trust, Basildon, SS16 5NL, UK
| | - David Laugharne
- Royal Derby Hospital, University Hospitals of Derby and Burton NHS Trust, Uttoxeter Rd, Derby, DE22 3NE, UK
| | - Sean Mortimore
- Department of Otolaryngology & Head and Neck Surgery Mid and South Essex NHS Foundation trust, Basildon, SS16 5NL, UK
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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.
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Mella MH, Chabrillac E, Dupret-Bories A, Mirallie M, Vergez S. Transoral Robotic Surgery for Head and Neck Cancer: Advances and Residual Knowledge Gaps. J Clin Med 2023; 12:jcm12062303. [PMID: 36983308 PMCID: PMC10056198 DOI: 10.3390/jcm12062303] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 03/11/2023] [Accepted: 03/14/2023] [Indexed: 03/17/2023] Open
Abstract
Minimally invasive surgery is a growing field in surgical oncology. After acquiring its first Food and Drug Administration approval in 2009 for T1–T2 malignancies of the oral cavity, oropharynx, and larynx, transoral robotic surgery (TORS) has gained popularity thanks to its wristed instruments and magnified three-dimensional view, enhancing surgical comfort in remote-access areas. Its indications are expanding in the treatment of head and neck cancer, i.e., resection of tumors of the larynx, hypopharynx, or parapharyngeal space. However, this expansion must remain cautious and based on high-level evidence, in order to guarantee safety and oncological outcomes which are comparable to conventional approaches. This narrative review assesses the current role of TORS in head and neck cancer from an evidence-based perspective, and then identifies what knowledge gaps remain to be addressed.
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Affiliation(s)
- Mariam H. Mella
- Department of Otolaryngology, Head and Neck Surgery, Toulouse University Hospital—Larrey Hospital, 24 Chemin de Pouvourville, CEDEX 9, 31059 Toulouse, France
| | - Emilien Chabrillac
- Department of Surgery, University Cancer Institute of Toulouse—Oncopole, 31100 Toulouse, France
| | - Agnès Dupret-Bories
- Department of Otolaryngology, Head and Neck Surgery, Toulouse University Hospital—Larrey Hospital, 24 Chemin de Pouvourville, CEDEX 9, 31059 Toulouse, France
- Department of Surgery, University Cancer Institute of Toulouse—Oncopole, 31100 Toulouse, France
| | - Mathilde Mirallie
- Department of Otolaryngology, Head and Neck Surgery, Toulouse University Hospital—Larrey Hospital, 24 Chemin de Pouvourville, CEDEX 9, 31059 Toulouse, France
- Department of Surgery, University Cancer Institute of Toulouse—Oncopole, 31100 Toulouse, France
| | - Sébastien Vergez
- Department of Otolaryngology, Head and Neck Surgery, Toulouse University Hospital—Larrey Hospital, 24 Chemin de Pouvourville, CEDEX 9, 31059 Toulouse, France
- Department of Surgery, University Cancer Institute of Toulouse—Oncopole, 31100 Toulouse, France
- Correspondence: ; Tel.: +33-5-67-77-17-32
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Siddiq S, Stephen S, Lin D, Fox H, Robinson M, Paleri V. Robotic lateral oropharyngectomy following diagnostic tonsillectomy is oncologically safe in patients with human papillomavirus-related squamous cell cancer: Long-term results. Head Neck 2022; 44:2753-2759. [PMID: 36056651 DOI: 10.1002/hed.27186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/19/2022] [Accepted: 08/23/2022] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION To report the long-term oncological and functional outcomes of en bloc TORS lateral oropharyngectomy to address the close/involved margin following diagnostic tonsillectomy in HPV-related SCC of unknown primary. MATERIAL AND METHODS A single tertiary center observational cohort over a 4-year period. Primary outcome measures were disease-specific survival (DSS), overall survival (OS), and PSS NOD (Performance Status Scale-Normalcy of Diet) scores. RESULTS TORS specimens did not evidence residual carcinoma in 93% of patients. Of 14 patients, 50% received surgery alone (median follow-up 57 months; range 46-96), the remainder surgery and adjuvant therapy (median follow-up of 58 months; range 51-69) with 100% DSS, OS and no deterioration of PSS NOD scores. CONCLUSIONS Long-term oncological outcomes confirm TORS lateral oropharyngectomy alone is an oncologically safe treatment. Due consideration of this approach is warranted to mitigate against the morbidity of adjuvant radiotherapy treatment in this group of patients.
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Affiliation(s)
- Somiah Siddiq
- Head and Neck Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Sarah Stephen
- Otolaryngology - Head and Neck Surgery, Newcastle upon Tyne Hospitals, Newcastle upon Tyne, UK
| | - Daniel Lin
- Otolaryngology - Head and Neck Surgery, Newcastle upon Tyne Hospitals, Newcastle upon Tyne, UK
| | - Hannah Fox
- Otolaryngology - Head and Neck Surgery, Newcastle upon Tyne Hospitals, Newcastle upon Tyne, UK
| | - Max Robinson
- Centre for Oral Health Research, Newcastle University, Newcastle upon Tyne, UK
| | - Vinidh Paleri
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
- The Institute of Cancer Research, London, UK
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Kalavacherla S, Sanghvi P, Lin GY, Guo T. Updates in the management of unknown primary of the head and neck. Front Oncol 2022; 12:991838. [PMID: 36185196 PMCID: PMC9521035 DOI: 10.3389/fonc.2022.991838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 08/30/2022] [Indexed: 11/25/2022] Open
Abstract
Squamous cell carcinoma (SCC) from an unknown primary tumor (SCCUP) accounts for 2.0%–5.0% of all head and neck cancers. SCCUP presents as enlarged cervical lymph nodes without evidence of a primary tumor upon physical examination. Primary site detection is important to target treatment and avoid treatment-related morbidity. In this review, we discuss updates in SCCUP management. Diagnostic workup should focus on localization of the primary tumor in SCCUP. Initial workup centers on neck biopsy to confirm the presence of SCC. Given the increasing incidence of HPV-related SCC in the oropharynx, HPV testing is crucial. An HPV-positive status can localize the tumor to the oropharynx, a common site for occult tumors. Imaging includes neck CT and/or MRI, and PET/CT. After imaging, panendoscopy, palatine tonsillectomy or diagnostic transoral robotic surgery can facilitate high rates of primary tumor localization. Primary tumor localization influences treatments administered. SCCUP has traditionally been treated aggressively with large treatment fields to all potential disease sites, which can induce weight loss and swallowing dysfunction. As a result, primary localization can reduce radiation fields and provide possible de-escalation to primary surgical management. Advances in intensity-modulated radiation therapy and dose management also have the potential to improve functional outcomes in SCCUP patients. Given the improved prognosis associated with HPV-positive SCCs, HPV tumor status may also inform future treatment de-intensification to reduce treatment-related toxicity.
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Affiliation(s)
- Sandhya Kalavacherla
- School of Medicine, University of California, San Diego, La Jolla, CA, United States
| | - Parag Sanghvi
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, San Diego, CA, United States
| | - Grace Y. Lin
- Department of Pathology, University of California, San Diego, San Diego, CA, United States
| | - Theresa Guo
- Department of Otolaryngology – Head & Neck Surgery, University of California, San Diego, San Diego, CA, United States
- *Correspondence: Theresa Guo,
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Tofanelli M, Rigo S, Polesel J, Zanconati F, Bonazza D, Vito Marcuzzo A, Gardenal N, Boscolo-Rizzo P, Tirelli G. Accuracy of fine-needle aspiration and frozen section for the detection of squamous metastasis in cystic masses of the lateral neck. Br J Oral Maxillofac Surg 2022; 60:1261-1265. [DOI: 10.1016/j.bjoms.2022.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 06/07/2022] [Accepted: 07/22/2022] [Indexed: 10/16/2022]
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10
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Reducing the unknowns: A systematic review & meta-analysis of the effectiveness of trans-oral surgical techniques in identifying head and neck primary cancer in carcinoma unknown primary. Oral Oncol 2022; 126:105748. [PMID: 35144209 DOI: 10.1016/j.oraloncology.2022.105748] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 01/17/2022] [Accepted: 01/24/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The use of transoral robotic surgery (TORS), transoral laser microsurgery (TLM) and more recently reported transoral endoscopic electrocautery (TOEC) in identifying the primary cancer in head and neck Carcinoma Unknown Primary (CUP) patients have gained popularity. This review aims to assess the effectiveness of TORS, TLM and TOEC. MATERIALS & METHODS A systematic review and meta-analysis was carried out. EMBASE, MEDLINE and CINAHL databases were searched from inception to September 2020. All primary studies were considered for inclusion. Primary outcome measure was detection rates of primary cancer of the different techniques. Secondary outcome measures were complications and length of hospital stay. RESULTS 289 studies were identified of which 30 met the inclusion criteria. The primary cancer was identified in 567 /777 patients (pooled results was 64% (95% CI 54-73). The primary identification rates were 45% and 32% in lingual (n = 273) and palatine tonsillectomy (n = 118) respectively. The primary cancer identification rates by surgical techniques are: TORS was 60% (95% CI 49-70), TLM was 80% (95% CI 0.58, 1.01), TOEC was 41% (95% CI 0.05, 0.76). 529/777 (68%) tumours were Human Papilloma Virus (HPV) related. The pooled data of studies that reported on detection rates relating to HPV status were 178/216 (82%) for HPV +ve and 7/59 (12%) for HPV -ve tumours. Coefficient of variation results suggest heterogenous data for TORS and TLM. The commonest complication was haemorrhage (5.3%). The length of reported hospital stay ranged from 1.4 to 7 days. CONCLUSIONS This is the largest systematic review in the subject. The quality of studies and heterogeneity of data limit conclusive findings. Lingual tonsillectomy is an effective procedure in CUP work up. Further larger, multicentre, prospective studies of PET CT negative CUP patients is needed to draw conclusive results.
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Channir HI, Lomholt AF, Gerds TA, Charabi BW, Kiss K, von Buchwald C. Human papillomavirus testing in metastatic squamous cell carcinoma of the neck with unknown primary using PCR on fine-needle aspiration smears: a prospective clinical study. Eur Arch Otorhinolaryngol 2021; 279:3115-3121. [PMID: 34689237 DOI: 10.1007/s00405-021-07133-5] [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: 07/08/2021] [Accepted: 10/07/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE Squamous cell carcinoma metastasis of the head and neck with unknown primary tumor (CUP) comprises a diagnostic challenge. Human papillomavirus (HPV) testing on cytologic specimens is gaining increasing focus as this may facilitate an early diagnosis of HPV-induced oropharyngeal carcinoma. This study aimed to prospectively assess PCR-based HPV-DNA testing on FNA smears in a clinical setting. METHODS Patients referred to a tertiary Head and Neck Cancer Center with suspected CUP were included from November 2016 to November 2018. Scraped cell material from FNA smears was analyzed for HPV-DNA with PCR using general primers (GP5 + /GP6 +) and correlated with the origin and histology of the primary tumor (oropharynx vs. outside oropharynx or benign tumor). The turn-around time reflecting the workflow for HPV-DNA testing by PCR was also calculated. RESULTS A total of 93 patients were enrolled in the study. The sensitivity and specificity were 86.7% [95% CI 75.4-94.1%] and 92.0% [95% CI 74.0-99.0%], and the positive and negative predictive values were 96.3% [95% CI 87.3-99.0%] and 74.2% [95% CI 59.9-84.7%], respectively. The turn-around time for HPV testing was a mean four calendar days. CONCLUSION HPV-DNA testing on FNA smears can be performed within a reasonable timeframe and can guide for the detection of an HPV-positive oropharyngeal primary tumor in the clinical setting for patients presenting with CUP of the head and neck.
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Affiliation(s)
- Hani Ibrahim Channir
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 8, 2100, Copenhagen, Denmark.
| | - Anne Fog Lomholt
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 8, 2100, Copenhagen, Denmark
| | - Thomas Alexander Gerds
- Department of Biostatistics Copenhagen, University of Copenhagen, Oester Farimagsgade 5, 1014, Copenhagen, Denmark
| | - Birgitte Wittenborg Charabi
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 8, 2100, Copenhagen, Denmark
| | - Katalin Kiss
- Department of Pathology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Christian von Buchwald
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 8, 2100, Copenhagen, Denmark
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12
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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.
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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.
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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
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14
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Transoral robotic surgery in Ireland: the beginning. Ir J Med Sci 2021; 191:361-365. [PMID: 33559869 DOI: 10.1007/s11845-021-02539-w] [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: 12/05/2020] [Accepted: 02/01/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Transoral robotic surgery (TORS) has shown promising results in the treatment of myriad head and neck pathologies but is now most commonly used in the investigation and management of oropharyngeal squamous cell carcinoma. AIMS The aim of this study was to report our cases of the newly introduced TORS, particularly its role in identifying primary of unknown origin and the potential implications for patients. A literature review and our early experience should begin to debunk some of the criticisms of TORS including setup times and cost. METHODS Prospective data was collected from all patients undergoing transoral robotic surgery including demographics, indication, histology results in primary of unknown origin and complications. RESULTS We have performed 36 TORS procedures in total ranging from intermediate to major complex. Our complication rate is low, and this has improved with the passage of time. Haemorrhage rates remain at 5.6% (n = 2), and the average length of stay is 1 day. Successful identification of a primary tumour in cancer of unknown primary was 80% (n = 8). CONCLUSIONS We anticipate the integration of TORS into routine practice in the investigation and management of a number of ENT pathologies following robust clinical trials.
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Podeur P, Mancini J, Delgrande J, Santini L, Salas S, Wong S, Giovanni A, Dessi P, Michel J, Radulesco T, Fakhry N. Role of Tonsillectomy in the Management of Carcinomas of Unknown Primary of the Head and Neck: A Retrospective Study Based on p16 Analysis. Front Oncol 2020; 10:594168. [PMID: 33194759 PMCID: PMC7609868 DOI: 10.3389/fonc.2020.594168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 09/22/2020] [Indexed: 01/13/2023] Open
Abstract
Purpose To evaluate the impact of tonsillectomy on the detection of the primary tumor, based on p16 immunohistochemistry analysis, in patients with cervical unknown primary of squamous cell carcinoma (SCC-CUP). Methods This was a retrospective study of 63 patients, included from January 2008 to December 2017 in a single institution. All patients had an initial assessment with physical examination, CT scan of the neck and chest, whole body FDG-PET CT, and endoscopy under general anesthesia, which failed to determine the primary tumor. Results Forty-seven out of the 63 patients had an ipsi- or bilateral tonsillectomy which revealed 12 tonsil cancers (26%). The tonsil primary was ipsilateral to positive nodes in 10 cases, contralateral in 1 case and, in 1 case, the patient had bilateral neck involvement. The analysis of the p16 status was carried out in 41/63 patients (65%). Among the 32 patients who had a p16 analysis and tonsillectomy, the rate of primary detection was 59% (10/17) for p16-postives and 0% (0/15) for p16-negatives (p < 0.001). Conclusion These results suggest that an extended work-up should be systematically proposed including bilateral tonsillectomy (+/- mucosectomy of the base of tongue) in SCC-CUP p16-positive patients but not in p16-negatives.
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Affiliation(s)
- Pauline Podeur
- Department of Otorhinolaryngology, Head and Neck Surgery, Centre Hospitalier Universitaire la Conception, Assistance Publique-Hôpitaux de Marseille, Aix Marseille Univ, Marseille, France
| | - Julien Mancini
- Aix-Marseille Univ, INSERM, IRD, APHM, UMR1252, SESSTIM, Department of Public Health (BIOSTIC), Hôpital de la Timone, Marseille, France
| | - Jean Delgrande
- Medical Oncology Department, Centre Hospitalier (CHU) La Timone, Marseille, France
| | - Laure Santini
- Department of Otorhinolaryngology, Head and Neck Surgery, Centre Hospitalier Universitaire la Conception, Assistance Publique-Hôpitaux de Marseille, Aix Marseille Univ, Marseille, France
| | - Sébastien Salas
- Medical Oncology Department, Centre Hospitalier (CHU) La Timone, Marseille, France
| | - Stéphanie Wong
- Radiation Oncology Department, Hôpital Timone Adultes, Marseille, France
| | - Antoine Giovanni
- Department of Otorhinolaryngology, Head and Neck Surgery, Centre Hospitalier Universitaire la Conception, Assistance Publique-Hôpitaux de Marseille, Aix Marseille Univ, Marseille, France
| | - Patrick Dessi
- Department of Otorhinolaryngology, Head and Neck Surgery, Centre Hospitalier Universitaire la Conception, Assistance Publique-Hôpitaux de Marseille, Aix Marseille Univ, Marseille, France
| | - Justin Michel
- Department of Otorhinolaryngology, Head and Neck Surgery, Centre Hospitalier Universitaire la Conception, Assistance Publique-Hôpitaux de Marseille, Aix Marseille Univ, Marseille, France
| | - Thomas Radulesco
- Department of Otorhinolaryngology, Head and Neck Surgery, Centre Hospitalier Universitaire la Conception, Assistance Publique-Hôpitaux de Marseille, Aix Marseille Univ, Marseille, France
| | - Nicolas Fakhry
- Department of Otorhinolaryngology, Head and Neck Surgery, Centre Hospitalier Universitaire la Conception, Assistance Publique-Hôpitaux de Marseille, Aix Marseille Univ, Marseille, France
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de Almeida JR. Role of Transoral Robotic Surgery in the Work-up of the Unknown Primary. Otolaryngol Clin North Am 2020; 53:965-980. [PMID: 32951898 DOI: 10.1016/j.otc.2020.07.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Unknown primary squamous cell carcinoma metastatic to cervical lymph nodes is a relatively rare tumor presentation, although the incidence may be increasing along with the rising incidence of human papilloma virus-mediated oropharyngeal cancers. Traditional diagnostic methods with palatine tonsillectomy and panendoscopy may identify the minority of primary tumors. The addition of a transoral lingual tonsillectomy may improve the diagnostic yield of identifying a primary tumor. Incorporation of transoral robotic surgery may be used for diagnostic purposes to identify a primary site and also for therapeutic purposes, whereby a primary tumor may be completely resected and combined with a neck dissection.
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Affiliation(s)
- John R de Almeida
- Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Centre/University Health Network, University of Toronto, Toronto General Hospital, 200 Elizabeth Street, 8NU-883, Toronto, Ontario, Canada; Department of Surgical Oncology, Princess Margaret Cancer Centre/University Health Network, University of Toronto, Toronto General Hospital, 200 Elizabeth Street, 8NU-883, Toronto, Ontario, Canada.
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17
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Is the Da Vinci Xi system a real improvement for oncologic transoral robotic surgery? A systematic review of the literature. J Robot Surg 2020; 15:1-12. [PMID: 32749569 DOI: 10.1007/s11701-020-01132-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/26/2020] [Indexed: 12/26/2022]
Abstract
In this paper, we reviewed the current literature about TORS procedures performed with Xi system and we discussed the pros and cons of this robotic system comparing it to the previous Si model. A systematic literature review was conducted using the PubMed, Scopus, Web of Science and Cochrane databases for adequate published studies about TORS procedure performed with da Vinci Si and Xi models. Five papers on the TORS-Xi procedures met our inclusion and exclusion criteria. These papers showed results based on 74 subjects (mean age 60.51 ± 4.55 years old). The most common TORS procedure was performed to address the oropharynx (65 procedures). One case (1.35%) of a tongue base tumor was converted into a transmandibular approach. One subject (1.35%) had a positive margin, while two subjects (2.7%) had close/uncertain margins at final histology. Nine papers on the TORS-Si procedures met our inclusion and exclusion criteria. These papers showed results based on 128 subjects (mean age 59.79 ± 5.93 years old). The most common TORS procedure was performed to address the oropharynx (90 procedures). Three procedures (2.34%) were aborted due to inadequate exposure of the tumor. None of the subject had positive margins, while three subjects (2.34%) had close/uncertain margins at final histology. Despite its improved vision, easier docking and narrower robotic arms, the da Vinci Xi system has structural peculiarities that limit its applications for certain TORS procedures.
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