Abstract
BackgroundTransoral 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.MethodsA structured search of the literature was performed with the search terms ‘TORS’ and ‘Carcinoma of Unknown Primary’.ResultsTwo 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.ConclusionsTransoral 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.
Highlights
Carcinoma of unknown primary (CUP) metastatic to cervical lymph nodes represents 1%-5% of all cases of head and neck malignancies, and consists mainly of squamous cell carcinoma (SCC) (50%-70%).[1,2] Once identified, the majority of initially occult oropharyngeal cancers turn out to be high-risk human papillomavirus related.As a result of the increase in HPV-related oropharyngeal squamous cell carcinoma (OPSCC), the incidence of carcinoma of unknown primary (CUP) is increasing.[3,4] The reported HPV prevalence for CUP in head and neck ranges between 22%-91% worldwide. p16 protein expression is considered to be a good surrogate marker of HPV-status ( 15% of p16 positive tumours is HPV DNA negative) which is currently the most important independent prognostic factor in OPSCC.[5]
The present study aims to determine the true benefit of Transoral robotic surgery (TORS) in detecting unknown primary tumours by conducting a systemic review of the literature
This review shows a superior detection rate for occult tumours by TORS: 72% vs. 41% compared to conventional endoscopy under general anaesthesia (EUA) with biopsies, respectively.[29,30,31]
Summary
Carcinoma of unknown primary (CUP) metastatic to cervical lymph nodes represents 1%-5% of all cases of head and neck malignancies, and consists mainly of squamous cell carcinoma (SCC) (50%-70%).[1,2] Once identified, the majority of initially occult oropharyngeal cancers turn out to be high-risk human papillomavirus (hrHPV) related.As a result of the increase in HPV-related oropharyngeal squamous cell carcinoma (OPSCC), the incidence of CUP is increasing.[3,4] The reported HPV prevalence for CUP in head and neck ranges between 22%-91% worldwide. p16 protein expression is considered to be a good surrogate marker of HPV-status ( 15% of p16 positive tumours is HPV DNA negative) which is currently the most important independent prognostic factor in OPSCC.[5]. Carcinoma of unknown primary (CUP) metastatic to cervical lymph nodes represents 1%-5% of all cases of head and neck malignancies, and consists mainly of squamous cell carcinoma (SCC) (50%-70%).[1,2] Once identified, the majority of initially occult oropharyngeal cancers turn out to be high-risk human papillomavirus (hrHPV) related. As a result of the increase in HPV-related oropharyngeal squamous cell carcinoma (OPSCC), the incidence of CUP is increasing.[3,4] The reported HPV prevalence for CUP in head and neck ranges between 22%-91% worldwide.
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