The role of transoral robotic surgery, transoral laser microsurgery, and lingual tonsillectomy in the identification of head and neck squamous cell carcinoma of unknown primary origin: a systematic review

Intraoperative Pathology Consultation in Patients With p16-Positive Unknown Primary Squamous Cell Carcinoma

Importance

Current guidelines recommend intraoperative frozen section(s) during diagnostic surgery for squamous cell carcinoma for unknown primary tumors (SCCUP).

Objective

To determine the utility of intraoperative pathology consultation during transoral robotic surgery (TORS) in localizing primary tumors and influencing need for adjuvant therapy.

Design, Setting, and Participants

A retrospective case series including 47 adult patients with human papillomavirus (HPV)-associated SCCUP who underwent TORS/oropharyngectomy between January 2016 and February 2023 was carried out at a single tertiary care hospital. The analysis took place on May 13, 2024.

Exposures

Nodal stage, tonsillectomy history, extranodal extension (ENE).

Main Outcomes and Measures

Intraoperative pathology consultation and final pathology results were compared with surgical outcomes, including margin revision, need for second procedure and/or radiation with or without chemotherapy.

Results

This study included 47 adult patients. Mean (range) age was 61 (41-79) years; patients were mostly men (37 [79%]). Overall, primary tumors were identified in 37 patients (79%), including all cases with positive nodes involving more than 1 neck level. Patients whose primary tumor was not found tended to have tobacco use history (8/10 vs 13/37 [35%]; difference, 45%; 95% CI, 16%-74%) and absence of ENE (8/10 vs 15/37 [41%]; difference, 39%; 95% CI, 10%-68%). Primary tumor was identified intraoperatively in 18 of 37 patients (49%). SCCs identified intraoperatively were significantly larger than SCCs found on permanent sections only: mean (SE), 1.2 (0.13) cm vs 0.5 (0.1) cm (difference, 0.7 cm; 95% CI, 0.53-1.94). The sensitivity, specificity, positive predictive value, and negative predictive value of intraoperative consultation was 49% (95% CI, 33%-64%), 100% (95% CI, 100%-100%), 100%, and 34% (95% CI, 19%-53%), respectively. Margins were revised in 11 of 18 patients (61%) whose primary tumor was identified intraoperatively (during original procedure) and in 3 of 19 patients (16%) whose primary tumor was identified on permanent pathologic findings only (during a second procedure) (11/18 [61%] vs 3/19 [16%]; difference, 45%; 95% CI, 17%-73%). However, there was no significant difference in the use of adjuvant radiotherapy with or without chemotherapy or need for a second procedure based on intraoperative primary tumor localization.

Conclusion and Relevance

In this case series study, the sensitivity and negative predictive value of intraoperative pathology consultation among 47 patients was less than 50%. Given the lack of influence on the need for radiotherapy with or without chemotherapy or second procedure, the practical utility of routine intraoperative frozen section requires further scrutiny.

A Scoping Review of Pain Management After Transoral Robotic Surgery

OBJECTIVE

Pain following transoral robotic surgery (TORS) is a driver of adverse outcomes and can lead to readmission and treatment delays. A scoping review was conducted to characterize TORS-related pain and identify key management strategies utilized in the literature.

DATA SOURCES

OVID Medline, CINAHL, Cochrane, Pubmed, and Embase databases were queried.

REVIEW METHODS

Two team members independently screened titles and abstracts and completed full-text reviews. Studies examining TORS for OPSCC with quantitative pain data were included. The study followed the PRISMA guidelines.

RESULTS

A total of 1467 studies were imported for screening and 25 studies were ultimately included. The average study sample size was 89 participants. 68% were conducted in a single-center academic setting. Pain was assessed on varying timelines up to 3 years using 13 different metrics. Pain peaks days-weeks postoperatively and returns to baseline thereafter. Postoperative pain is a significant cause of morbidity and limited data exist about optimal management.

CONCLUSION

Prospective studies are needed to characterize and address TORS-related pain.

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

Importance

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

Objective

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

Design, Setting, and Participants

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

Intervention

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Trial Registration

ClinicalTrials.gov Identifier: NCT03281499.

Transoral robotic tongue base mucosectomy for head and neck cancer of unknown primary: six-year outcome experience

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.

Prognostic Factors of Mandibular Osteoradionecrosis Including Accurate Colocalization of Avulsions and Dosimetric Dental Mapping Software, a Case-control Study

PURPOSE

Osteoradionecrosis (ORN) of the mandible remains a significant complication in the intensity modulated radiation therapy (IMRT) era. Dental dose cannot be predicted from heterogeneous IMRT dose distributions; mandibular dose metrics cannot guide dentist avulsion decisions in high-risk ORN situations. Using a mapping tool to report dental root dose, avulsions, and ORN sites, we re-examined ORN risk factors in a case-control study.

METHODS AND MATERIALS

From 2008 to 2019, 897 consecutive patients with oral cavity/oropharynx or unknown primary cancer undergoing IMRT were analyzed to identify ORN cases. These were matched (1 ORN/2 controls) retrospectively for tumor location, surgery, and tobacco consumption in a monocentric case-control study. Univariate and multivariate analyses integrated ORN factors and accurate dental dose data (grouped into 4 mandibular sectors). Generalizability was investigated in a simulated population database.

RESULTS

A total of 171 patients were included. The median follow-up was 5.2 and 4.5 years in the ORN and control groups, respectively. The median time to ORN was 12 months. In univariate analysis, post-IMRT avulsions at the ORN site (hazard ratio [HR] = 3.6; 95% confidence interval [CI] = 1.5-8.9; P = .005), tumor laterality (HR, 4.4; 95% CI, = 1.4-14, P = .01), mean mandibular dose (HR, 1.1; 95% CI, = 1.01-1.1; P = .018) and mean dose to the ORN site (HR, 1.1; 95% CI, = 1.1-1.2; P < .001) correlated with higher ORN risk. In multivariate analysis, mean dose to the ORN site (HR, 1.1; 95% CI, = 1.1-1.2; P < .001) and post-IMRT avulsions at the ORN site (HR, 4.6; 95% CI, = 1.5-14.7; P = .009) were associated with ORN. For each increase in gray in dental dose, the ORN risk increased by 12%. Simulations confirmed study observations.

CONCLUSIONS

Dental dose and avulsions are associated with ORN, with a 12% increase in risk with each additional gray. Accurate dose information can help dentists in their decisions after IMRT.

Predictors for Success and Failure in Transoral Robotic Surgery-A Retrospective Study in the North of the Netherlands

Transoral Robotic Surgery (TORS) is utilized for treating various malignancies, such as early-stage oropharyngeal cancer and lymph node metastasis of an unknown primary tumor (CUP), and also benign conditions, like obstructive sleep apnea (OSA) and chronic lingual tonsillitis. However, the success and failure of TORS have not been analyzed to date. In this retrospective observational multicenter cohort study, we evaluated patients treated with TORS using the da Vinci surgical system. Success criteria were defined as identification of the primary tumor for CUP, >2 mm resection margin for malignant conditions, and improvement on respiratory polygraphy and tonsillitis complaints for benign conditions. A total of 220 interventions in 211 patients were included. We identified predictors of success, such as low comorbidity status ACE-27, positive P16 status, and lower age for CUP, and female gender and OSA severity for benign conditions. For other malignancies, no predictors for success were found. Predictors of failure based on postoperative complications included high comorbidity scores (ASA) and anticoagulant use, and for postoperative pain, younger age and female gender were identified. This study provides valuable insights into the outcomes and predictors of success and failure in TORS procedures across various conditions and may also help in patient selection and counseling.

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

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

Head and neck squamous cell carcinoma with heterotopic ossification, lymphovascular invasion, and nodal and pulmonary metastases in a 23-year-old Morgan gelding

Primary squamous cell carcinoma of the head and neck occurs in the skin or squamous epithelial lining tissues of the oral cavity, pharynx, larynx, and sinonasal tract. Although it is a common tumor in horses, distant metastatic spread to the lung is rare. This report describes a case of metastatic pulmonary squamous cell carcinoma in a 23-year-old Morgan gelding. The clinical signs displayed by this gelding in some ways mimicked the typical presentation of equine multinodular pulmonary fibrosis or thoracic lymphoma. The postmortem diagnosis in this case was head and neck squamous cell carcinoma, but a primary site of origin could not be ascertained. Cancer-associated heterotopic ossification (HO) was also identified in this case; this is an exceedingly rare finding with equine pulmonary neoplasia. Key clinical message: Careful physical examination should be undertaken in all horses presenting with clinical signs of intrathoracic disease. Clinical and radiographic abnormalities in this case of pulmonary metastatic disease resembled some of those associated with interstitial pneumonia. Rarely encountered in domestic animal species, there has been only 1 previous report of HO in a case of oronasal carcinoma in a horse.

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

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

Establishing and integrating a transoral robotic surgery programme into routine oncological management of head and neck cancer - a UK perspective

BACKGROUND

The introduction of transoral robotic surgery into routine management of patients is complex. It involves organisational, logistical and clinical challenges. This study presents our experience of implementing such a programme and provides a blueprint for other centres willing to establish similar services.

METHODS

Implementation of the robotic surgery programme focused on several key domains: training, logistics, governance, multidisciplinary team awareness, pre-operative imaging, anaesthesia, post-operative care, finance, patient selection and consent. Programme outcomes were evaluated by assessing operative outcomes of the first 117 procedures performed.

RESULTS

The success of the transoral robotic surgery programme has been possible because of the scrupulous planning phase before the first procedure, and the time invested on team awareness and training.

CONCLUSION

Implementation of a new transoral robotic surgery service has led to: the development of a dedicated transoral robotic surgery patient care protocol, the performance of progressively more complex procedures, the inclusion of transoral robotic surgery training and the establishment of several research projects.

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

Background/Objectives

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

Patients and methods

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

Results

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

Conclusions

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

Existe espaço para a microcirurgia na cirurgia robótica?

Robotic surgery opened a new era of minimally-invasive procedures, through its improved precision, elimination of tremors, greater degrees of freedom, and other facilitating aspects. The field of robotic microsurgery showed great growth in recent years in particular, since robotics offers a potentially-ideal configuration to perform the sensitive manipulations required in microsurgery. We conducted a systematic review to assess the benefits of robotic surgery and its contributions to microsurgery, comparing it with other surgical techniques used in patients of all age groups. We assessed 25 articles found in the PubMed and Cochrane databases using the terms ' robotic surgery ' AND microsurgery , with a filter for studies published in the last five years, and studies conducted in humans and published in English or Portuguese. We concluded that there is plenty of room for robotic surgery in microsurgery, such as in male infertility procedures, neurological microsurgery, ocular and otological surgeries, and transoral, hepatobiliary, microvascular, plastic and reconstructive surgeries.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Transoral Robotic Surgery

Transoral robotic surgery (TORS) became a valuable new head and neck surgery approach from the past decade since its approval. TORS was initially conceived for oropharyngeal squamous cell carcinoma (OPSCC); now, the indications are gradually extrapolated into other subsites. There have been numerous studies comparing the outcomes following surgical and non-surgical treatment, especially for oropharyngeal cancers. TORS for laryngeal cancers is in its infancy, and only a few reports are describing it. Many report suggestive of better functional outcomes following TORS, but level 1 evidence is still lacking. With the further development of novel, flexible, miniaturized robots, it is highly likely to expand TORS indications further. This article provides an overview of TORS in head and neck cancers.

An overview of the current clinical status of optical imaging in head and neck cancer with a focus on Narrow Band imaging and fluorescence optical imaging

Early and accurate identification of head and neck squamous cell carcinoma (HNSCC) is important to improve treatment outcomes and prognosis. New optical imaging techniques may assist in both the diagnostic process as well as in the operative setting by real-time visualization and delineation of tumor. Narrow Band Imaging (NBI) is an endoscopic technique that uses blue and green light to enhance mucosal and submucosal blood vessels, leading to better detection of (pre)malignant lesions showing aberrant blood vessel patterns. Fluorescence optical imaging makes use of near-infrared fluorescent agents to visualize and delineate HNSCC, resulting in fewer positive surgical margins. Targeted fluorescent agents, such as fluorophores conjugated to antibodies, show the most promising results. The aim of this review is: (1) to provide the clinical head and neck surgeon an overview of the current clinical status of various optical imaging techniques in head and neck cancer; (2) to provide an in-depth review of NBI and fluorescence optical imaging, as these techniques have the highest potential for clinical implementation; and (3) to describe future improvements and developments within the field of these two techniques.

[Role of Robotic Surgery in ENT]

Since the beginning of the 21^st century, surgical robots have been used in the ENT-environment. They primarily support surgeons in minimal invasive transoral operations, especially in multidisciplinary treatment concepts of head and neck tumors, but also in snoring surgery the robot provides a complement to the established transoral laser surgery. In the meantime there is a large number of data that deals with the importance of oncological results, function maintenance, economics and future perspectives.Operation areas of the current robot devices are still limited in the ENT-environment. As the number of cases are small, efforts are being made to connect centres on a national and international level. Thus, uniform training standards, targeted knowledge and data exchange as well as further development of systems would be managed better. The creation of small and agile ENT-specific equipment could expand the possibilities as a next step for the future and finally lead to a wide scale of ENT-surgical applications.

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

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

Robotic and Endoscopic Approaches to Head and Neck Surgery

Technological developments have disrupted the practice of medicine throughout history. Endoscopic and robotic techniques in head and neck surgery have emerged over the past half-century and have been incrementally adapted to expanding indications within otolaryngology. Robotic and endoscopic surgery have an established role in treatment of oropharyngeal and laryngeal cancers, reducing surgical morbidity and improving survival relative to traditional open approaches. Surgical treatment of human papillomavirus-mediated oropharyngeal cancer via transoral robotic surgery offers equivalent oncologic and functional outcomes relative to radiotherapy. Newer iterations of single-port robotic systems continue to expand the scope of robotics in head and neck surgery.

Diagnostic approaches to carcinoma of unknown primary of the head and neck

Squamous cell carcinoma in cervical lymph nodes arising from an undetected primary tumour, termed carcinoma of unknown primary (SCCUP), is a well-recognized clinical presentation within head and neck oncology. SCCUP is a common presentation for patients with human papillomavirus-mediated oropharyngeal cancer (HPV + OPSCC), as patients with HPV + OPSCC often present with smaller primary tumours and early nodal metastasis. Meticulous work-up of the SCCUP patient is central to the management of these patients as identification of the primary site improves overall survival and allows for definitive oncologic resection or more focused radiation when indicated. This review summarizes the comprehensive diagnostic approach to the SCCUP patient, including history and physical examination, methods of biopsy of the cervical lymph node, imaging modalities and intraoperative methods to localize the unknown primary. Novel techniques such as transcervical ultrasound of the oropharynx, narrow band imaging and diagnostic transoral robotic surgery are also discussed.

Narrow-Band Imaging in oncologic otorhinolaryngology: State of the art

OBJECTIVES

To describe the diagnostic performance of Narrow Band Imaging (NBI) combined with White Light Imaging (WLI) in the diagnosis of mucosal lesions at each location of the upper aerodigestive tract, for detection of primary tumor in case of carcinoma of unknown primary, for determination of intraoperative resection margins, and to describe its main diagnostic pitfalls.

MATERIAL AND METHODS

A PubMed search was carried out according to the PRISMA method.

RESULTS

Four hundred and seventy-seven articles published between 2007 and 2020 were identified, 133 of which met the study inclusion criteria and were assessed.

CONCLUSION

The current literature seems to support the use of NBI in diagnosis and/or follow-up of (pre-)malignant head & neck tumors, and in the determination of intraoperative resection margins.

Head and neck squamous cell carcinoma

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.

Metastatic Squamous Cell Carcinoma to the Cervical Lymph Nodes From an Unknown Primary Cancer: Management in the HPV Era

Background

Patients with metastases in the lymph nodes of the neck and no obvious primary tumor, neck cancer with unknown primary (NCUP), represent a management challenge. A majority of patients have metastatic squamous cell carcinoma (SCC), although other histologies do occur.

Methods

We comprehensively reviewed the literature, compared available guidelines, and conferred with an international team of experts.

Results

Positron emission tomography-computed tomography (PET-CT) and fine needle aspiration (FNA) under ultrasound guidance increase accuracy of diagnosis. Immunohistochemistry (IHC), determination of human papilloma virus (HPV) status, by p16 staining or by in situ hybridization (ISH), and next-generation gene sequencing can guide us regarding probable primary sites and tumor biology. Narrow Band Imaging (NBI) has been introduced for the early detection of subtle mucosal lesions. Direct laryngoscopy (DL) and tonsillectomy have long been procedures used in the search for a primary site. More recently, TransOral Robotic Surgery (TORS) or Transoral LASER Microsurgery (TLM) have been introduced for lingual tonsillectomy.

Conclusions

New technologies have been developed which can better detect, diagnose, and treat occult primary tumors. Decisions regarding therapy are based on the primary tumor site (if discovered) and N stage. Options include neck dissection with or without postoperative adjuvant therapy, primary irradiation, or combined chemotherapy with irradiation. The preferred treatment of patients whose primary remains unidentified is controversial.

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

Unknown primary squamous cell carcinoma metastatic to cervical lymph nodes is a relatively rare tumor presentation, although the incidence may be increasing along with the rising incidence of human papilloma virus-mediated oropharyngeal cancers. Traditional diagnostic methods with palatine tonsillectomy and panendoscopy may identify the minority of primary tumors. The addition of a transoral lingual tonsillectomy may improve the diagnostic yield of identifying a primary tumor. Incorporation of transoral robotic surgery may be used for diagnostic purposes to identify a primary site and also for therapeutic purposes, whereby a primary tumor may be completely resected and combined with a neck dissection.

Current Indications for Transoral Robotic Surgery in Oropharyngeal Cancer

The incidence of oropharyngeal squamous cell carcinoma (OPSCC) is increasing dramatically and is conclusively linked to increasing rates of human papillomavirus (HPV) infection. HPV-related oropharyngeal cancers have been shown to occur in a unique demographic group and show favorable oncologic outcomes compared with HPV-negative OPSCC. There has been a paradigm shift in the treatment of early-stage OPSCC, with most patients now undergoing primary surgery in the United States. Transoral robotic surgery is associated with excellent oncologic and functional outcomes in the treatment of OPSCC and is increasingly being used for a broader range of oropharyngeal indications.

PET/CT in Surgical Planning for Head and Neck Cancer

Fluorine-18 (¹⁸F)-fluorodeoxyglucose (FDG) positron emission tomography fused with computed tomography (PET/CT) is a valuable tool in surgical planning for head and neck squamous cell carcinoma (HNSCC). If performed prior to biopsy or other surgical intervention, FDG-PET/CT has high sensitivity for the detection of the primary site in patients with cervical lymph node metastases from unknown primary origin and can be used to direct the surgical workup. FDG-PET/CT is superior to CT alone for detection of nodal metastases outside the expected pattern or distant metastases or second primary cancers and can greatly affect determination of appropriate management including surgical eligibility. Prior to the advent of PET/CT, many patients undergoing (chemo)radiation-based therapy had planned post-treatment neck dissection; FDG-PET/CT now has a proven role in the evaluation of recurrent or persistent disease amenable to salvage surgery and enables safe avoidance of planned postradiation neck dissection with a high negative predictive value. Specifically for this important application, two standardized reporting metrics may be used in the head and neck anatomic region: the "Hopkins criteria" and the "Neck Imaging Reporting and Data System"; both systems produce a formalized evaluation and recommendation based on PET/CT findings. The role of PET/CT as a replacement for elective neck dissection or examination under anesthesia remains controversial but deserves further study. FDG-PET/CT has a wide-ranging impact on the surgical management of patients with HNSCC and should be used routinely in patients with unknown primary nodal disease and those presenting with advanced-stage cancers at initial staging and to assess treatment response.

Outcomes of microvascular bone flaps versus osteocutaneous flaps in head and neck reconstruction

BACKGROUND

Surgical resection of head and neck (H&N) neoplasms requiring osseous reconstruction have underdefined complication profiles. This study aimed to characterize postoperative outcomes of patients with H&N neoplasia undergoing osteocutaneous flap (OCF) or bare bone flap (BBF) reconstructions.

MATERIALS AND METHODS

Retrospective analysis of the National Surgical Quality Improvement Program (NSQIP) 2005-2017 databases. Queried for diagnosis and procedural codes extracted patients with H&N neoplasms undergoing BBF or OCF reconstruction. Postoperative complications were evaluated. Multivariable regression generated adjusted odds ratios.

RESULTS

A cohort of 746 patients were identified. Of reconstructions, 24.9% (n = 186/746) were BBFs while 75.1% (n = 560/746) were OCFs. 58.1% of the BBF cohort and 59.9% of the OCF cohort experienced an all-cause complication (p = .654). Sub-stratified, 24.2% of BBF and 17.5% of OCF patients experienced a wound complication (p = .045). Regression analysis demonstrated no difference in risk for medical complications between cohorts. However, patients receiving OCFs had a decreased likelihood of developing a wound complication (OR 0.652; 95%CI 0.430-0.989; p = .044) compared to patients receiving BBFs.

CONCLUSION

The incidence of complications following osseous reconstruction of the H&N is considerable. Although several complication outcomes do not seem to differ between BBF or OCF reconstructions, OCFs is associated with a decreased likelihood of wound complications.

A systematic review on Transoral robotic surgery (TORS) for carcinoma of unknown primary origin: Has tongue base mucosectomy become indispensable?

Background

Transoral robotic surgery (TORS) is increasingly used in head and neck surgery and in carcinoma of unknown primary (CUP) origin specifically. Due to the rising incidence of human papillomavirus (HPV)‐related oropharyngeal squamous cell carcinoma (OPSCC), there is a rationale for finding ways to de‐escalate treatment strategies. This review aims to test the hypothesis that TORS is a meaningful adjunct in the diagnostic (and therapeutic) pathway in CUP in head and neck.

Methods

A structured search of the literature was performed with the search terms ‘TORS’ and ‘Carcinoma of Unknown Primary’.

Results

Two hundred and seventy four cases of CUP in which TORS was used were identified for further analysis. Workup for CUP was comparable in all series with regard to physical examination, fine and/or gross needle examination of cervical nodes, fibre optic endoscopy, imaging and robot assisted mucosectomy of the base of tongue (BOT). Identification rate of the primary tumour was 72% on average (range 17%‐ 90%), and 55%‐ 96% were HPV positive. Clear margins were achieved in 60% (range 0%‐85%) of resected occult tumours. Complication rate of TORS BOT mucosectomy was low with mainly grade I‐III sequelae according to Clavien–Dindo.

Conclusions

Transoral robotic surgery seems to be a useful and safe adjunct in the diagnostic and therapeutic pathway in case of CUP in an era of increasing incidence of HPV‐positive OPSCC.

Carcinoma of unknown primary detected by whole-body diffusion-weighted imaging: A case report and review of the literature

Carcinoma of unknown primary accounts for 2%-5% of all head and neck tumors. Identification of the primary site is challenging. We present a case report of a 43-year-old man with metastatic cervical lymphadenopathy for 3 year, and the primary tumor was unknown after routine examinations, including positron emission tomography/computed tomography. Whole-body diffusion-weighted imaging was performed to detect small lesions in the nasopharynx, and a biopsy confirmed the lesions as squamous cell carcinoma. Therefore, the primary tumor site was found in a patient with carcinoma of unknown primary, suggesting that whole-body diffusion-weighted imaging can be very helpful in detecting small occult cancer.

Diagnosis and Management of Squamous Cell Carcinoma of Unknown Primary in the Head and Neck: ASCO Guideline

PURPOSE

To provide evidence-based recommendations to practicing physicians and other health care providers on the diagnosis and management of squamous cell carcinoma of unknown primary in the head and neck (SCCUP).

METHODS

The American Society of Clinical Oncology convened an Expert Panel of medical oncology, surgery, radiation oncology, radiology, pathology, and advocacy experts to conduct a literature search, which included systematic reviews, meta-analyses, randomized controlled trials, and prospective and retrospective comparative observational studies published from 2008 through 2019. Outcomes of interest included survival, local and regional disease control, and quality of life. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations.

RESULTS

The literature search identified 100 relevant studies to inform the evidence base for this guideline. Four main clinical questions were addressed, which included subquestions on preoperative evaluations, surgical diagnostic and therapeutic procedures, appropriate pathology techniques, and adjuvant therapy.

RECOMMENDATIONS

Evidence-based recommendations were developed to address preoperative evaluation for patients with a neck mass, surgical diagnostic and therapeutic procedures, appropriate treatment options in unilateral versus bilateral SCCUP.Additional information is available at www.asco.org/head-neck-cancer-guidelines.

Transoral robotic surgery in the management of head and neck squamous cell cancer with unknown primary

Background: Transoral robotic surgery (TORS) assisted base of the tongue (BOT) resection has been suggested as part of the work-up for head and neck squamous cell cancer with unknown primary (HNSCC-CUP). Success rates vary with regard to identification of primary BOT lesions, and cases with likely such lesions appear to be included in previous reports.Objectives: To analyse the possible benefits of a superficial TORS-assisted BOT resection in thoroughly investigated HNSCC-CUP.Material and methods: Retrospectively, 13 patients subjected to superficial TORS-assisted BOT resections due to HNSCC-CUP, where previous thorough work-ups including PET-scans had been performed and primary lesions had still not been identified, were reviewed.Results: Nodal status, according to the TNM-8 classification, was N1, N2, N2a, N2b, N2c, and N3, respectively, for 7, 1, 1, 4, 0, and 0 patients. In 38% of the cases, T1 BOT cancers were identified using superficial TORS-assisted BOT resections and treatments adjusted.Conclusion: Addition of a superficial TORS-assisted BOT resection to the work-up of HNSCC-CUP frequently identifies primary lesions and alters the treatment for this group of patients even after thorough work-up.

A Review on Cancer of Unknown Primary Origin: The Role of Molecular Biomarkers in the Identification of Unknown Primary Origin

The primary site cannot be found after clinical and pathological evaluation, which are called cancers of unknown primary origin (CUP). CUPs may resemble a specific primary tumor site which shares common clinicopathological characteristics and prognosis. However, it may be present as a distinct disease entity with undifferentiated pathological features. More than 4% of patients are diagnosed as CUP. These patients were diagnosed as malignant tumors by cytology or pathology. And they were usually treated with empirical chemotherapy and associated with a poor prognosis. How to accurately diagnose and treat a cancer of unknown primary origin is a major clinical concern. To address this question, a complex assessment is carried out which includes a complete medical history of the patient, physical examination, complete blood count, urinalysis, serum chemistries, histologic evaluation, chest radiograph, computed tomography, magnetic resonance imaging, and immunohistochemistry (IHC) studies. Molecular diagnostic information reflects that CUP's molecular characteristics are similar to primary tumors with the development of genomics and the expansion of gene sequencing technology. Gene expression profiling is the most commonly used molecular diagnostic method for CUP. In this chapter, we summarize the current diagnostic methods and challenges of CUP, and the clinical value of the molecular-level tumor diagnostic technique.

Supervised Autonomous Electrosurgery via Biocompatible Near-Infrared Tissue Tracking Techniques

Autonomous robotic surgery systems aim to improve patient outcomes by leveraging the repeatability and consistency of automation and also reducing human induced errors. However, intraoperative autonomous soft tissue tracking and robot control still remains a challenge due to the lack of structure, and high deformability of such tissues. In this paper, we take advantage of biocompatible Near-Infrared (NIR) marking methods and develop a supervised autonomous 3D path planning, filtering, and control strategy for our Smart Tissue Autonomous Robot (STAR) to enable precise and consistent incisions on complex 3D soft tissues. Our experimental results on cadaver porcine tongue samples indicate that the proposed strategy reduces surface incision error and depth incision error by 40.03% and 51.5%, respectively, compared to a teleoperation strategy via da Vinci. Furthermore, compared to an autonomous path planning method with linear interpolation between the NIR markers, the proposed strategy reduces the incision depth error by 48.58% by taking advantage of 3D tissue surface information.

Advances in Diagnosis and Multidisciplinary Management of Oropharyngeal Squamous Cell Carcinoma: State of the Art

During the past decade and a half, the most common cause of oropharyngeal squamous cell carcinoma (OPSCC) has shifted from tobacco and alcohol to the human papillomavirus (HPV). HPV-driven p16-positive OPSCC and tobacco-related OPSCC differ in their underlying molecular and genetic profiles, socioeconomic demographics, and response to treatment. HPV-related OPSCC tends to occur in younger patients and has a significantly better response to treatment and excellent prognosis. The stark contrast in prognosis-with around 90% overall 5-year survival for HPV-related p16-positive OPSCC and 40% for non-HPV-related p16-negative OPSCC-has prompted major changes in the eighth edition of the staging manual of the AJCC (American Joint Committee on Cancer). The past 10-15 years have also witnessed major advances in surgery, radiation therapy (RT), and systemic therapy. Minimally invasive surgery has come of age, with transoral robotic procedures and laser microsurgery. Intensity-modulated RT (IMRT) and more recently proton-beam RT have markedly improved the conformity of RT, with an ability to precisely target the cancer and cancer-bearing regions while sparing normal structures and significantly reducing long-term treatment-related morbidity. Progress in systemic therapy has come in the form of immunotherapy and targeted agents such as cetuximab. Owing to the better prognosis of HPV-driven OPSCC as well as the morbidity associated with treatment, de-escalation of therapy via multiple strategies is being explored. The article reviews the advances in diagnosis and multidisciplinary management of OPSCC in the HPV era.^©RSNA, 2019.

The impact of the patient's condition, diagnostic procedures and treatment on the survival of carcinoma of unknown primary site patients

Introduction

Carcinoma of unknown primary site (CUP) refers to 1–5% of all head and neck neoplasms. Very often, the primary site remains difficult to determine. Squamous cell carcinoma is the most frequent histopathological type diagnosed in the head and neck region. According to statistics, a primary site is usually located in the oropharynx.

Study objective

The study presents diagnostic difficulties and the methods of diagnosing and the therapy of CUP and primary sites in patients treated in the region of Lower Silesia and Silesia. The aim of the study was to show a retrospective analysis of 233 CUP patients to assess how clinical features, diagnosis and treatment affect the survival of patients.

Material and methods

The diagnostics of patients included panendoscopy with specimen collection (nasoendoscopy, laryngoscopy, esophagoscopy, brochoscopy), computed tomography examination of the neck, chest, abdomen and pelvis minor, as well as positron emission tomography examination. Tonsilletomy was performed in 37 patients. Neck dissection was carried out in 109 subjects and 165 patients were treated bt radiotherapy, and 135 by chemotherapy.

Conclusions

Tonsillectomy is required in CUP patients with the negative results of biopsy and imaging tests. It gives a possibility of detecting the primary site and improves the results of treatment and survival of CUP patients.Combination therapy, including surgical treatment and chemoradiotherapy, gives the best therapeutic results in CUP patients. The general condition of patient and younger age have an impact on prognosis and survival.

The emerging role of trans-oral robotic surgery for the detection of the primary tumour site in patients with head-neck unknown primary cancers: A meta-analysis

The identification of the site in head neck unknown primary (HNUP) tumour is of utmost importance to help select best treatment while decreasing treatment-related morbidity and mortality. The primary purpose of this study is to demonstrate that TORS may be a valuable tool in detecting primary tumour. Studies were systematically searched in the PubMed, EMBASE, the Cochrane Library and CENTRAL electronic databases. A total of 12 selected studies (349 patients) were analyzed. The primary tumour detection and positive surgical margins rates were 70.8% and 19.4%, respectively. The rate of HPV-related tumour was 71.3%. The primary tumour was mainly in base of tongue (64%). In conclusion, TORS seems to be an effective surgical approach both in terms of detection of primary tumour site and in terms of therapeutic perspective for HNUP. In particular, a subset of HPV-related tumours might benefits all advantages from this surgical modality.

Transoral tongue base mucosectomy for the identification of the primary site in the work-up of cancers of unknown origin: Systematic review and meta-analysis

BACKGROUND

The use of transoral robotic surgery (TORS) and laser microsurgery (TLM) in the diagnosis and identification of the site of the unknown primary has become increasingly common. This systematic review and meta-analysis aims to assess the use and efficacy of TORS and TLM for this indication.

METHOD

Systematic review and meta-analysis of studies employing TORS or TLM in diagnosis of the unknown primary tumor site in patients with cervical nodal metastases of squamous cell origin. MEDLINE, EMBASE and CINHAL were searched from inception to July 2018 for all studies that used TORS and or TLM in identifying the unknown primary.

RESULTS

251 studies were identified, of which 21 were eligible for inclusion. The primary tumour was identified by TORS/TLM in 78% of patients (433 out of 556). Tongue base mucosectomy (TBM) identified the primary in 222 of 427 cases (53%). In patients with negative physical examination, diagnostic imaging and PETCT, TBM identified the primary in 64% (95% CI 50, 79) cases. In patients who had negative CT/MRI imaging, negative PETCT and negative EUA and tonsillectomy, TBM identified a tongue base primary in 78% (95% CI 41, 92) cases. Haemorrhage, the commonest complication, was reported in 4.9% cases. Mean length of stay varied between 1.4 and 6.3 days.

CONCLUSION

Tongue base mucosectomy, performed by TORS or TLM, is highly efficacious in identifying the unknown primary in the head and neck region.

Human papillomavirus and p16 immunostaining, prevalence and prognosis of squamous carcinoma of unknown primary in the head and neck region

The prevalence of human papillomavirus (HPV) in squamous cell carcinoma of unknown primary in the head and neck (SCCUPHN), and prognosis by HPV status of SCCUPHN patients has been difficult to estimate because of the rarity of this subtype. In MEDLINE, Epub Ahead of Print, In-Process & Other Non-Indexed Citations, EMBASE, Cochrane library and Web of Science searches, observational studies and clinical trials that reported survival rates of patients with SCCUPHN by HPV status were identified. Meta-analysis estimated the prevalence and prognosis (overall survival, OS; progression-free survival, PFS) of SCCUPHN by HPV status, and compared them to studies of oropharyngeal squamous cell carcinoma (OPSCC) from the same institutions and across continents. In 17 SCCUPHN studies (n = 1,149) and 17 institution-matched OPSCC studies (n = 6,522), the pooled HPV prevalence of SCCUPHN was 49%, which was only 10% (95%CI: 1-19%) lower than OPSCC prevalence in the underlying population. Estimated 5-year OS for HPV-negative SCCUPHN was 44% (95%CI: 36-51%) vs. HPV-positive SCCUPHN of 91% (95%CI: 86-96%); hazard ratio (HR) for OS was 3.25 (95%CI: 2.45-4.31) and PFS was 4.49 (95%CI: 2.88-7.02). HRs by HPV status for OPSCC were similar to that in SCCUPHN. While North American SCCUPHNs had higher HPV prevalence than European SCCUPHNs (OR = 2.68 (95%CI: 1.3-5.6)), HR of OS for HPV-negative vs. HPV-positive patients were similar in both continents (HRs of 3.78-4.09). Prevalence of HPV among SCCUPHN patients were lower than in OPSCC. The survival benefit conferred by being HPV-positive was similar in SCCUPHN as in OPSCCs, independent of continent.

The Impact of a Stepwise Approach to Primary Tumor Detection in Squamous Cell Carcinoma of the Neck With Unknown Primary

OBJECTIVES/HYPOTHESIS

To examine the cumulative effect of diagnostic steps for primary tumor identification in patients with head and neck squamous cell carcinoma of unknown primary (HNSCCUP), including lingual tonsillectomy, and the impact of primary tumor identification on subsequent treatment.

STUDY DESIGN

Retrospective analysis.

METHODS

We reviewed the records of 110 patients diagnosed with HNSCCUP between 2003 and 2015. Results of diagnostic imaging (fluorodeoxyglucose-positron emission tomography/computed tomography [FDG-PET/CT]), tumor detection with direct laryngoscopy with biopsies, palatine tonsillectomy, and transoral robotic surgery (TORS) lingual tonsillectomy were recorded. Associations between demographic and treatment variables with overall survival (OS) and progression-free survival (PFS) were modeled with Cox proportional hazards models.

RESULTS

FDG-PET/CT was suspicious for a primary site in 23/77 (30%) patients. Direct laryngoscopy identified a primary tumor in 34/110 patients (31%). Forty-seven patients underwent palatine tonsillectomy, which identified 17 primaries (36%), yielding a cumulative primary tumor identification of 51/110 (46%). Fourteen patients underwent TORS lingual tonsillectomy, which identified eight primaries (57%), resulting in a cumulative identification of 59/110 (53%). The detection rate increased from 28/63 (44%) to 31/47 (66%) after the addition of TORS lingual tonsillectomy to our institutional approach. Detection rates varied by HPV status. Primary tumor identification altered subsequent radiation planning, as patients with an identified primary tumor received radiation to a smaller volume of tissue than did those without an identified primary tumor. However, there was no significant association between primary tumor identification and OS or PFS.

CONCLUSIONS

A stepwise approach to primary tumor identification identifies a primary tumor in a majority of patients.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:1610-1616, 2019.

Combination of panendoscopy and positron emission tomography/computed tomography increases detection of unknown primary head and neck carcinoma

OBJECTIVES/HYPOTHESIS

With positron emission tomography/computed tomography (PET/CT) now commonplace as a diagnostic tool, new questions have arisen regarding the utility and cost-effectiveness of panendoscopy. In this retrospective review of a large cohort of head and neck squamous cell carcinoma of unknown primary (HNSCC-UP), we describe the enduring utility of panendoscopy in the detection of the primary site of mucosal disease even when PET/CT is negative.

STUDY DESIGN

Retrospective cohort study.

METHODS

A retrospective analysis of patients presenting to the senior author (y.d.) from July 1 1997 to July 1 2017 with fine-needle aspiration-proven metastatic squamous cell carcinoma to the neck. All patients underwent formal panendoscopy (direct laryngoscopy, bronchoscopy, and rigid esophagoscopy). Presence of squamous cell carcinoma on final pathology was examined.

RESULTS

A total of 190 patients had HNSCC-UP, with 87 positive and 103 negative on PET/CT. Of the PET/CT-negative patients, 71 patients retained the HNSCC-UP designation after panendoscopy. Eighteen patients (56% of cases) were found to have primary tonsillar squamous cell carcinoma. Eight of 32 primary sites were found in the base of tongue (25%), with HPV positivity in two of these patients. The sensitivity and negative predictive value of PET/CT in detecting the primary site in unknown primary head and neck squamous cell carcinoma in the total study population were 73.1% and 68.9%, respectively.

CONCLUSIONS

Surgical panendoscopy has an important role in the workup of patients with unknown primary head and neck squamous cell carcinoma. There is a high rate of cancer diagnosis, even in PET/CT negative patients.

LEVEL OF EVIDENCE

4 Laryngoscope, 2573-2575, 2018.