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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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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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Troise S, Arena A, Barone S, Raccampo L, Salzano G, Abbate V, Bonavolontà P, Romano A, Sembronio S, Robiony M, Califano L, Dell'Aversana Orabona G. Transoral robotic surgery in maxillofacial surgery: Systematic review of literature on current situation and future perspectives. Curr Probl Surg 2024; 61:101504. [PMID: 39098337 DOI: 10.1016/j.cpsurg.2024.101504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 05/14/2024] [Accepted: 05/15/2024] [Indexed: 08/06/2024]
Affiliation(s)
- Stefania Troise
- Department of Neurosciences, Maxillofacial Surgery Unit, Reproductive and Odontostomatological Sciences, University Federico II of Naples, Naples, Italy.
| | - Antonio Arena
- Department of Neurosciences, Maxillofacial Surgery Unit, Reproductive and Odontostomatological Sciences, University Federico II of Naples, Naples, Italy
| | - Simona Barone
- Department of Neurosciences, Maxillofacial Surgery Unit, Reproductive and Odontostomatological Sciences, University Federico II of Naples, Naples, Italy
| | - Luca Raccampo
- Department of Medicine, Maxillofacial Surgery Department, Academic Hospital of Udine, University of Udine, Udine, Italy
| | - Giovanni Salzano
- Department of Neurosciences, Maxillofacial Surgery Unit, Reproductive and Odontostomatological Sciences, University Federico II of Naples, Naples, Italy
| | - Vincenzo Abbate
- Department of Neurosciences, Maxillofacial Surgery Unit, Reproductive and Odontostomatological Sciences, University Federico II of Naples, Naples, Italy
| | - Paola Bonavolontà
- Department of Neurosciences, Maxillofacial Surgery Unit, Reproductive and Odontostomatological Sciences, University Federico II of Naples, Naples, Italy
| | - Antonio Romano
- Department of Neurosciences, Maxillofacial Surgery Unit, Reproductive and Odontostomatological Sciences, University Federico II of Naples, Naples, Italy
| | - Salvatore Sembronio
- Department of Medicine, Maxillofacial Surgery Department, Academic Hospital of Udine, University of Udine, Udine, Italy
| | - Massimo Robiony
- Department of Medicine, Maxillofacial Surgery Department, Academic Hospital of Udine, University of Udine, Udine, Italy
| | - Luigi Califano
- Department of Neurosciences, Maxillofacial Surgery Unit, Reproductive and Odontostomatological Sciences, University Federico II of Naples, Naples, Italy
| | - Giovanni Dell'Aversana Orabona
- Department of Neurosciences, Maxillofacial Surgery Unit, Reproductive and Odontostomatological Sciences, University Federico II of Naples, Naples, Italy
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de Almeida JR, Martino R, Hosni A, Goldstein DP, Bratman SV, Chepeha DB, Waldron JN, Weinreb I, Perez-Ordonez B, Yu E, Metser U, Hansen AR, Xu W, Su SJ, Kim J. Transoral Robotic Surgery and Radiation Volume Deintensification in Unknown Primary Squamous Cell Carcinoma of the Neck: The Phase 2 FIND Nonrandomized Controlled Trial. JAMA Otolaryngol Head Neck Surg 2024; 150:463-471. [PMID: 38602692 PMCID: PMC11009865 DOI: 10.1001/jamaoto.2024.0423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 02/17/2024] [Indexed: 04/12/2024]
Abstract
Importance Patients with unknown primary squamous cell carcinoma (CUP) with cervical metastases typically receive comprehensive radiotherapy (RT) of the pharynx and bilateral neck. Typically, these patients receive comprehensive RT of the pharynx and bilateral neck that may produce treatment-related toxic effects. Objective To determine whether localization of occult oropharyngeal cancers with transoral robotic surgery (TORS) combined with reduced pharyngeal and neck RT volumes provides acceptable disease control. Design, Setting, and Participants This phase 2, single-group nonrandomized controlled trial at a single institution accrued 32 prospective participants with p16-positive CUP without a primary squamous cell carcinoma on examination and imaging from 2017 to 2019, and 24-month follow-up. The data analysis was conducted from January 2021 to June 2022. Intervention Diagnostic- (n = 13) or therapeutic-intent (n = 9) TORS, with pharyngeal-sparing radiotherapy (PSRT) prescribed for negative margins or pT0, and unilateral neck RT (UNRT) prescribed for unilateral lymphadenopathy with lateralized primary tumor or pT0. Main Outcomes and Measures Out-of-radiation treatment volume failure (<15% was hypothesized to be acceptable) and reports of local and regional recurrence, overall survival, toxic effects, swallowing outcomes (per the MD Anderson Dysphagia Inventory), and videofluoroscopic swallow (per Dynamic Imaging Grade of Swallowing Toxic Effects [DIGEST]) ratings. Results The study sample comprised 22 patients (mean [SD] age, 59.1 [5.7] years; 3 [14%] females and 19 [86%] male) with CUP. Of these, 19 patients (86%) had tumor stage cN1; 2 (9%), cN2; and 1 (5%), cN3. Five patients (23%), 14 patients (64%), and 3 patients (13%) had 0, 1, or 2 primary tumors, respectively. Twenty patients received RT; of these, 9 patients (45%) underwent PSRT and 10 patients (50%), UNRT. In the diagnostic-intent group, 8 patients (62%) and 5 patients (38%) underwent RT and RT-concurrent chemotherapy, respectively. In the therapeutic-intent group, 6 patients (67%) and 1 patient (11%) received adjuvant RT-concurrent chemotherapy, respectively; 2 patients declined RT. Two-year out-of-radiation treatment volume failure, locoregional control, distant metastasis control, and overall survival were 0%, 100%, 95%, and 100%, respectively. Grade 3 or 4 surgical, acute, and late toxic effects occurred in 2 (9%), 5 (23%), and 1 (5%) patients, respectively. PSRT was associated with lower RT dose to superior constrictors (37 vs 53 Gy; mean difference, 16 Gy; 95% CI, 6.4, 24.9), smaller decline in swallowing scores during treatment (19.3 vs 39.7; mean difference, -20.4; 95% CI, -34.1 to -6.1), and fewer patients with worsening DIGEST grade on findings of videofluoroscopic swallow studies at 2 years (0% vs 60%; difference, 60%; 95% CI, 30% to 90%). Conclusions and Relevance These findings indicate that TORS for p16-positive CUP allows RT volume deintensification with excellent outcomes and support future investigation in randomized clinical trials. Trial Registration ClinicalTrials.gov Identifier: NCT03281499.
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Affiliation(s)
- John R. de Almeida
- Department of Otolaryngology–Head and Neck Surgery, Princess Margaret Cancer Center/University Health Network, University of Toronto, Toronto, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Canada
| | - Rosemary Martino
- Department of Otolaryngology–Head and Neck Surgery, Princess Margaret Cancer Center/University Health Network, University of Toronto, Toronto, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada
- Department of Speech-Language Pathology, University of Toronto, Toronto, Canada
- The Swallowing Lab, University of Toronto, Toronto, Canada
- Krembil Research Institute, University Health Network, Toronto, Canada
| | - Ali Hosni
- Department of Radiation Oncology, Princess Margaret Cancer Center/University Health Network, University of Toronto, Toronto, Canada
| | - David P. Goldstein
- Department of Otolaryngology–Head and Neck Surgery, Princess Margaret Cancer Center/University Health Network, University of Toronto, Toronto, Canada
| | - Scott V. Bratman
- Department of Radiation Oncology, Princess Margaret Cancer Center/University Health Network, University of Toronto, Toronto, Canada
| | - Douglas B. Chepeha
- Department of Otolaryngology–Head and Neck Surgery, Princess Margaret Cancer Center/University Health Network, University of Toronto, Toronto, Canada
| | - John N. Waldron
- Department of Radiation Oncology, Princess Margaret Cancer Center/University Health Network, University of Toronto, Toronto, Canada
| | - Ilan Weinreb
- Department of Pathology, University Health Network, Toronto, Canada
| | | | - Eugene Yu
- Department of Medical Imaging, University Health Network, Toronto, Canada
| | - Ur Metser
- Department of Medical Imaging, University Health Network, Toronto, Canada
| | - Aaron R. Hansen
- Department of Medical Oncology, Princess Margaret Cancer Center, Toronto, Canada
| | - Wei Xu
- Department of Biostatistics, Princess Margaret Cancer Center, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Susie Jie Su
- Department of Biostatistics, Princess Margaret Cancer Center, Toronto, Canada
| | - John Kim
- Department of Radiation Oncology, Princess Margaret Cancer Center/University Health Network, University of Toronto, Toronto, Canada
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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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Chettuvatti K, Panda NK, Bakshi JB, Verma RK, Nayak GR, Goel N, Das A, Bhattacharya A, Mittal A, Rohilla M. The Role of Trans Oral Robotic Surgery in the Carcinoma of Unknown Primary: A New Evidence in the Horizon? Indian J Otolaryngol Head Neck Surg 2024; 76:1941-1948. [PMID: 38566719 PMCID: PMC10982237 DOI: 10.1007/s12070-023-04460-3] [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: 09/07/2023] [Accepted: 12/21/2023] [Indexed: 04/04/2024] Open
Abstract
The detection of the primary site in Carcinoma of Unknown Primary (CUP) is a challenging task which can significantly alter the course of management and also prognosis. Various modalities have been assessed with varying sensitivity and specificity. Imaging and cytological diagnosis have formed a key part of the diagnostic algorithm of CUP. Trans Oral Robotic Surgery offers the advantage of being both diagnostic as well as therapeutic with promising sensitivity and specificity and can form an integral part in the management of CUP. A prospective study was carried out at a tertiary care centre over a period of one year. Patients with unilateral neck swelling which was histopathologically proven squamous cell carcinoma neck metastasis were included in the study. They were evaluated with endoscopy and radiology according to the standard algorithm. When these failed to detect the primary, the patients underwent ipsilateral radical tonsillectomy and tongue base mucosal wedge biopsy via TORS. Post-operative histopathological examination was done on the resected specimens to detect the primary site. Transoral Robotic Surgery was able to localise primary in 50% of the patients enrolled in the study. Out of the primary site identified by TORS; 55.56% were located in the tonsil and 44.4% in the tongue base. TORS can offer promising detection rates of the occult primary in CUP and should form an integral part of the diagnostic algorithm.
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Affiliation(s)
- Karthika Chettuvatti
- Department of Otorhinolaryngology and Head-Neck Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Naresh Kumar Panda
- Department of Otorhinolaryngology and Head-Neck Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jaimanti B Bakshi
- Department of Otorhinolaryngology and Head-Neck Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Roshan K Verma
- Department of Otorhinolaryngology and Head-Neck Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Gyan Ranjan Nayak
- Department of Otorhinolaryngology and Head-Neck Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Nitika Goel
- Department of Anaesthesia, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashim Das
- Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anish Bhattacharya
- Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anupam Mittal
- Department of Translational and Regenerative Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Manish Rohilla
- Department of Cytology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Fancello G, Jiang S, Licci G, Gallo O. Comments on the article titled "Factors associated with unknown primary status in head and neck squamous cell carcinoma": Is the N status the overlooked elephant in the room? Oral Oncol 2024; 151:106727. [PMID: 38387260 DOI: 10.1016/j.oraloncology.2024.106727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 02/18/2024] [Indexed: 02/24/2024]
Affiliation(s)
- Giuseppe Fancello
- Department of Otorhinolaryngology, Careggi University Hospital, Largo Brambilla 3, 50134 Florence, Italy
| | - Serena Jiang
- Department of Otorhinolaryngology, Careggi University Hospital, Largo Brambilla 3, 50134 Florence, Italy
| | - Giuseppe Licci
- Department of Otorhinolaryngology, Careggi University Hospital, Largo Brambilla 3, 50134 Florence, Italy
| | - Oreste Gallo
- Department of Otorhinolaryngology, Careggi University Hospital, Largo Brambilla 3, 50134 Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Viale Morgagni 48, 50134 Florence, Italy.
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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.
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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.
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De Virgilio A, Pellini R, Cammaroto G, Sgarzani R, De Vito A, Gessaroli M, Costantino A, Petruzzi G, Festa BM, Campo F, Moretti C, Pichi B, Mercante G, Spriano G, Vicini C, Meccariello G. Trans oral robotic surgery for oropharyngeal cancer: A multi institutional experience. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:106945. [PMID: 37331862 DOI: 10.1016/j.ejso.2023.05.020] [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: 01/11/2023] [Revised: 05/23/2023] [Accepted: 05/30/2023] [Indexed: 06/20/2023]
Abstract
OBJECTIVES Trans Oral Robotic Surgery (TORS) has proved to be a safe and feasible treatment for oropharyngeal squamous cell carcinoma (OPSCC). The aim of this study is to analyse oncological outcomes of OPSCC patients treated with TORS. MATERIALS AND METHODS This study involved 139 patients with OPSCC, treated with TORS between 2008 and 2020. Clinicopathological characteristics, treatment details and oncological outcomes were evaluated retrospectively. RESULTS The management strategies included TORS alone in 42.5%, TORS-RT in 25.2% and TORS-CRT in 30.9%. The ENE was noted in 28.8% of neck dissections. In 19 patients clinically classified as unknown primaries, the primary was found in 73.7%. Rates of local, regional relapses and distant metastasis were 8.6%, 7.2%, and 6.5%, respectively. The 5 year- Overall Survival and Disease Free Survival were 69.6% and 71.3%, respectively. CONCLUSION TORS fits well in the modern management of OPSCC. Although definitive CRT remains a milestone, TORS is proving to be a valid and safe treatment option. The choice of the therapeutic strategy requires evaluation by a multidisciplinary team.
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Affiliation(s)
- Armando De Virgilio
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20090, Pieve Emanuele, MI, Italy; Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, MI, Italy
| | - Raul Pellini
- Department of Otolaryngology-Head and Neck Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy.
| | - Giovanni Cammaroto
- Otolaryngology and Head-Neck Surgery Unit, Department of Surgery, Morgagni Pierantoni Hospital, Azienda USL della Romagna, Forlì, Italy
| | - Rossella Sgarzani
- Plastic Surgery, DIMES Department, University of Bologna, Bologna, Italy
| | - Andrea De Vito
- Otolaryngology and Head-Neck Surgery Unit, Department of Surgery, Morgagni Pierantoni Hospital, Azienda USL della Romagna, Forlì, Italy
| | - Manlio Gessaroli
- Maxillo-Facial Unit, Department of Surgery, Maurizio Bufalini Hospital, Azienda USL della Romagna, Cesena, Italy
| | - Andrea Costantino
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20090, Pieve Emanuele, MI, Italy; Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, MI, Italy
| | - Gerardo Petruzzi
- Department of Otolaryngology-Head and Neck Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Bianca Maria Festa
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20090, Pieve Emanuele, MI, Italy; Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, MI, Italy
| | - Flaminia Campo
- Department of Otolaryngology-Head and Neck Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Claudio Moretti
- Department of Otolaryngology-Head and Neck Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy; University of Ferrara, Ferrara, Italy
| | - Barbara Pichi
- Department of Otolaryngology-Head and Neck Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Giuseppe Mercante
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20090, Pieve Emanuele, MI, Italy; Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, MI, Italy
| | - Giuseppe Spriano
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20090, Pieve Emanuele, MI, Italy; Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, MI, Italy
| | - Claudio Vicini
- Otolaryngology and Head-Neck Surgery Unit, Department of Surgery, Morgagni Pierantoni Hospital, Azienda USL della Romagna, Forlì, Italy; University of Ferrara, Ferrara, Italy
| | - Giuseppe Meccariello
- Otolaryngology and Head-Neck Surgery Unit, Department of Surgery, Morgagni Pierantoni Hospital, Azienda USL della Romagna, Forlì, Italy
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Meulemans J, Voortmans J, Nuyts S, Daisne JF, Clement P, Laenen A, Delaere P, Van Lierde C, Poorten VV. Cervical squamous cell carcinoma of unknown primary: Oncological outcomes and prognostic factors. Front Oncol 2022; 12:1024414. [DOI: 10.3389/fonc.2022.1024414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 10/26/2022] [Indexed: 11/15/2022] Open
Abstract
Background/ObjectivesCervical squamous cell carcinoma of unknown primary (SCCUP) is a rare entity within head and neck cancer and both treatment regimens as well as identified potential predictors for oncological outcomes vary between published series. In this study, we evaluated oncological outcomes and identified potential prognostic factors for outcome.Patients and methodsThis retrospective monocentric cohort study includes 82 SCCUP patients diagnosed and treated between January 2000 and June 2021. Overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS) and locoregional recurrence-free survival (LRFS) were evaluated. The Cox proportional hazards model was used to analyze the prognostic effect of patient and tumor characteristics on oncological outcomes.ResultsFive year OS, DSS, DFS and LRFS were respectively 53.9%, 72.2%, 68.9% and 67.3%. The p16 status was evaluated in 55 patients with 40% being p16 positive. On univariable analysis, p16 negative SCCUPs had significantly worse survival and recurrence rates in the presence of clinical extranodal extension (cENE) (OS: p=0.0013, DSS: p=0.0099, DFS: p=0.0164, LRFS: p=0.0099) and radiological extranodal extension (rENE) (OS: p=0.0034, DSS: p=0.0137, DFS: p=0.0167, LRFS: p=0.0100). In p16 positive SCCUP patients, rENE had a significantly negative prognostic effect on DFS (p=0.0345) and LRFS (p=0.0367). Total group multivariate analysis identified rENE as an independent negative predictor for all oncological outcomes. The “number of positive lymph nodes” was a second independent predictor for DSS (p=0.0257) and DFS (p=0.0435).ConclusionsWe report favorable oncological outcomes, comparable to previously published results. Although the presence of rENE seems associated with poor oncological outcomes, the differential effect of clinical, radiological and pathological ENE in both p16 positive and negative subgroups remain to be elucidated by further prospective research.
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Poupore NS, Chen T, Nguyen SA, Nathan CAO, Newman JG. Transoral Robotic Surgery for Oropharyngeal Squamous Cell Carcinoma of the Tonsil versus Base of Tongue: A Systematic Review and Meta-Analysis. Cancers (Basel) 2022; 14:cancers14153837. [PMID: 35954500 PMCID: PMC9367622 DOI: 10.3390/cancers14153837] [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: 07/25/2022] [Revised: 08/01/2022] [Accepted: 08/04/2022] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Transoral Robotic Surgery (TORS) has become widely adopted for the surgical removal of oropharyngeal squamous cell carcinoma (OPSCC). However, it is currently unknown if TORS has equal efficacy and outcomes in patients with tonsillar or base of tongue (BOT) OPSCC. Therefore, we performed a systematic review, including articles describing the surgical management of OPSCC with TORS that compared margin status, complications, and recurrence between tonsil and BOT. BOT OPSCC had a higher rate of positive margins compared to tonsillar OPSCC. However, no differences were seen in the recurrence or postoperative hemorrhage rates of BOT and tonsillar OPSCC. While a higher rate of positive margins was seen in BOT OPSCC when compared to tonsillar OPSCC, this did not translate to a higher recurrence rate in the BOT group. Future research on which subset of patients with BOT is more likely to have positive margins is warranted to improve the utility of TORS further. Abstract Transoral Robotic Surgery (TORS) has become widely adopted for the surgical removal of oropharyngeal squamous cell carcinoma (OPSCC), with the most common locations being in the tonsil and base of tongue (BOT). However, it is currently unknown if TORS has equal efficacy and outcomes in patients with tonsillar or BOT OPSCC. Therefore, the aim of this study was to compare the margin status and recurrence rates of tonsillar and BOT OPSCC after TORS. Per PRISMA guidelines, PubMed, Scopus, and CINAHL were systematically searched from inception to 2/28/2022. Articles including the surgical management of OPSCC with TORS that compared margin status, complications, and recurrence between tonsil and BOT were included. Meta-analyses of proportions and odds ratios were performed. A total of 28 studies were included, comprising 1769 patients with tonsillar OPSCC and 1139 patients with BOT OPSCC. HPV positivity was seen in 92.3% of tumors. BOT OPSCC had a higher rate of positive margins compared to tonsillar OPSCC (28.1% [95%CI 15.1–43.3] vs. 7.5% [95%CI 3.3–13.3]). No differences were seen in recurrence between BOT and tonsillar OPSCC (OR 1.1 [95%CI 0.8–1.5], p = 0.480). In addition, no differences in postoperative hemorrhage were seen between tonsillar and BOT OPSCC (10.7% [95%CI 6.1–16.5] vs. 8.8% [95% CI 1.5–21.3]). While a higher rate of positive margins was seen in BOT OPSCC when compared to tonsil OPSCC, this did not translate to a higher recurrence rate in the BOT group. Future research on which subset of patients with BOT is more likely to have positive margins is warranted to improve the utility of TORS further.
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Affiliation(s)
- Nicolas S. Poupore
- Department of Otolaryngology—Head and Neck Surgery, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Tiffany Chen
- Department of Otolaryngology—Head and Neck Surgery, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Shaun A. Nguyen
- Department of Otolaryngology—Head and Neck Surgery, Medical University of South Carolina, Charleston, SC 29425, USA
- Correspondence:
| | - Cherie-Ann O. Nathan
- Department of Otolaryngology—Head and Neck Surgery, Louisiana State University Health Sciences Center, Shreveport, LA 71103, USA
| | - Jason G. Newman
- Department of Otolaryngology—Head and Neck Surgery, Medical University of South Carolina, Charleston, SC 29425, USA
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12
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Advancement in the Oropharyngeal Primary Unknown Cancer Diagnostic and Current Treatments Pathway: A Narrative Review. SURGERIES 2022. [DOI: 10.3390/surgeries3030022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: The objective of this article is to define a correct diagnostic pathway for oropharyngeal cancer of unknown primary (OPCUP) identification. Background: OPCUP represents one of the most frequent causes of neck metastases onset without the identification of the primary tumor. Therefore, there is a high percentage of late or missing diagnoses, resulting in treatment delay or in a wrong therapeutic process. The up-to-date diagnostic procedures can help us to begin therapies at the right time. Methods: This is a review of the latest articles about diagnostic pathways in the OPCUP. A selection of the references was carried out in PubMed, EMBASE, Cochrane, and CENTRAL electronic databases. Conclusion: The oropharynx represents the most common site of primary unknown head and neck cancer (HNCUP). Recent epidemiologic data reported an increasing incidence of HNCUP related to human papilloma virus positive squamous cell carcinoma. Positron emission tomography combined with computerized tomography scanning or magnetic resonance imaging allows for improving the detection of primary unknown tumors and distant and locoregional metastases. Finally, the introduction of the trans-oral robotic surgical approach has introduced a new role of surgery in the HNCUP diagnosis and treatment. Hence, the new technological improvement allows reaching in most HNCUP patients an early diagnosis, achieving targeted management and better treatment outcomes, as well as decreasing toxicity and the side effects of treatment options.
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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.
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Affiliation(s)
- Timon Hussain
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Essen, Universität Duisburg-Essen
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Alzahrani F, Sahovaler A, Mundi N, Rammal A, Fnais N, MacNeil SD, Mendez A, Yoo J, Fung K, Laxague F, Warner A, Palma DA, Nichols A. Transoral robotic surgery for the identification of unknown primary head and neck squamous cell carcinomas: Its effect on the wait and the weight. Head Neck 2022; 44:1206-1212. [PMID: 35224796 DOI: 10.1002/hed.27023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 02/13/2022] [Accepted: 02/17/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Neck carcinoma of unknown primary (CUP) is a frequent scenario. Transoral robotic mucosectomies (TORM) of pharynx have increased rate of primary identification, but come with cost of treatment delay. METHODS We reviewed patients who underwent CUP protocol from 2014 to 2020. Patients with cervical nodes carcinoma and failure to localize a primary source were classified as CUP. We determined primary identification rate and postoperative complications. RESULTS We included 65 patients underwent TORM. Surgical approach consisted of lingual and/or palatine tonsillectomies. The primary detection rate was 49.2%. Average weight reduction was 2.5 ± 4.3 kg. The average number of days from consultation to definitive treatment was 52.2 ± 18.3. CONCLUSION A systematic approach to patients with CUP showed a promising primary identification rate compared to panendoscopy alone. TORM carries a small risk of complications. The benefits of primary identification must be weighed with the morbidity and delay to definitive treatment.
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Affiliation(s)
- Faisal Alzahrani
- Department Otolaryngology-Head and Neck Surgery, Western University, London, Ontario, Canada.,Department Otolaryngology-Head and Neck Surgery, King Saud University, Riyadh, Saudi Arabia
| | - Axel Sahovaler
- Department Otolaryngology-Head and Neck Surgery, Western University, London, Ontario, Canada
| | - Neil Mundi
- Department of Otolaryngology, Southern Illinois University, Springfield, Illinois, USA
| | - Almoaidbellah Rammal
- Department Otolaryngology-Head and Neck Surgery, King AbdulAziz University, Jeddah, Saudi Arabia
| | - Naif Fnais
- Department Otolaryngology-Head and Neck Surgery, Western University, London, Ontario, Canada.,Department Otolaryngology-Head and Neck Surgery, King Saud University, Riyadh, Saudi Arabia
| | - S Danielle MacNeil
- Department Otolaryngology-Head and Neck Surgery, Western University, London, Ontario, Canada
| | - Adrian Mendez
- Department Otolaryngology-Head and Neck Surgery, Western University, London, Ontario, Canada
| | - John Yoo
- Department Otolaryngology-Head and Neck Surgery, Western University, London, Ontario, Canada
| | - Kevin Fung
- Department Otolaryngology-Head and Neck Surgery, Western University, London, Ontario, Canada
| | - Francisco Laxague
- Department Otolaryngology-Head and Neck Surgery, Western University, London, Ontario, Canada
| | - Andrew Warner
- Department of Radiation Oncology, Western University, London, Ontario, Canada
| | - David A Palma
- Department of Radiation Oncology, Western University, London, Ontario, Canada
| | - Anthony Nichols
- Department Otolaryngology-Head and Neck Surgery, Western University, London, Ontario, Canada
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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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Transoral robotic surgery for oropharyngeal cancer in the era of chemoradiation therapy. Auris Nasus Larynx 2022; 49:535-546. [DOI: 10.1016/j.anl.2022.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 12/26/2021] [Accepted: 01/18/2022] [Indexed: 12/26/2022]
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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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Johnson DE, Burtness B, Leemans CR, Lui VWY, Bauman JE, Grandis JR. Head and neck squamous cell carcinoma. Nat Rev Dis Primers 2020; 6:92. [PMID: 33243986 PMCID: PMC7944998 DOI: 10.1038/s41572-020-00224-3] [Citation(s) in RCA: 1689] [Impact Index Per Article: 422.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/01/2020] [Indexed: 02/07/2023]
Abstract
Most head and neck cancers are derived from the mucosal epithelium in the oral cavity, pharynx and larynx and are known collectively as head and neck squamous cell carcinoma (HNSCC). Oral cavity and larynx cancers are generally associated with tobacco consumption, alcohol abuse or both, whereas pharynx cancers are increasingly attributed to infection with human papillomavirus (HPV), primarily HPV-16. Thus, HNSCC can be separated into HPV-negative and HPV-positive HNSCC. Despite evidence of histological progression from cellular atypia through various degrees of dysplasia, ultimately leading to invasive HNSCC, most patients are diagnosed with late-stage HNSCC without a clinically evident antecedent pre-malignant lesion. Traditional staging of HNSCC using the tumour-node-metastasis system has been supplemented by the 2017 AJCC/UICC staging system, which incorporates additional information relevant to HPV-positive disease. Treatment is generally multimodal, consisting of surgery followed by chemoradiotherapy (CRT) for oral cavity cancers and primary CRT for pharynx and larynx cancers. The EGFR monoclonal antibody cetuximab is generally used in combination with radiation in HPV-negative HNSCC where comorbidities prevent the use of cytotoxic chemotherapy. The FDA approved the immune checkpoint inhibitors pembrolizumab and nivolumab for treatment of recurrent or metastatic HNSCC and pembrolizumab as primary treatment for unresectable disease. Elucidation of the molecular genetic landscape of HNSCC over the past decade has revealed new opportunities for therapeutic intervention. Ongoing efforts aim to integrate our understanding of HNSCC biology and immunobiology to identify predictive biomarkers that will enable delivery of the most effective, least-toxic therapies.
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Affiliation(s)
- Daniel E. Johnson
- Department of Otolaryngology-Head and Neck Surgery, University of California at San Francisco, San Francisco, CA, USA
| | - Barbara Burtness
- Department of Medicine, Yale University School of Medicine and Yale Cancer Center, New Haven, CT, USA
| | - C. René Leemans
- Department of Otolaryngology-Head and Neck Surgery, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Vivian Wai Yan Lui
- School of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR
| | - Julie E. Bauman
- Department of Medicine-Hematology/Oncology, University of Arizona, Tucson, AZ, USA
| | - Jennifer R. Grandis
- Department of Otolaryngology-Head and Neck Surgery, University of California at San Francisco, San Francisco, CA, USA,
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Potential therapeutic implications of the new tumor, node, metastasis staging system for human papillomavirus-mediated oropharyngeal cancer. Curr Opin Otolaryngol Head Neck Surg 2020; 28:100-106. [PMID: 32022732 DOI: 10.1097/moo.0000000000000607] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The 8th edition tumor, node, metastasis (TNM) classification (TNM-8) introduced a new classification for human papillomavirus (HPV)-mediated oropharyngeal carcinoma (HPV+ OPC). This review summarizes its potential therapeutic implications focusing on literature published since 2018. RECENT FINDINGS The following are active research areas involved in clinical care and therapy relevant to TNM-8: tumor HPV testing and its clinical implications; stage I disease: treatment selection and lessons learned from recent deintensification trials; emerging strategies addressing stage II and III disease. SUMMARY The TNM-8 classification depicts prognosis of HPV+ OPC much more reliably compared with TNM-7. Among the advantages in outcome comparison and stratification for clinical trial entry and conduct, it also enables more satisfactory individual patient consultation to adequately estimate prognosis, and facilitates clinical and translational research. However, clinicians must remain mindful that the TNM classification is not a guideline for treatment but, instead, provides a framework for clinical research and treatment decision-making. The TNM-8 has potential to improve risk-tailored treatment algorithms for HPV+ OPC including selection of treatment modality (primary trans-oral surgery vs. radiotherapy, addition of chemotherapy) and adjusting the intensity of approaches. To realize these goals fully, it is apparent that the TNM-8 needs to evolve further.
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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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BAYRAM A, ESKİİZMİR G, CİNGİ C, HANNA E. Robotic Surgery in Otolaryngology-Head and Neck Surgery: Yesterday, Today and Tomorrow. ENT UPDATES 2020. [DOI: 10.32448/entupdates.780604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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22
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Transoral robotic surgery (TORS) for head and neck squamous cell carcinoma: healing by secondary intention, local flap or free flap. EUROPEAN JOURNAL OF PLASTIC SURGERY 2019. [DOI: 10.1007/s00238-019-01586-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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