Robot assisted lingual tonsillectomy for the diagnosis of unknown primary squamous cell carcinoma
Abstract Introduction and objective: The prevalence of carcinoma of unknown primary (CUP) metastatic to cervical lymph nodes has increased in the last decade because of the risen incidence of oropharyngeal squamous cell carcinoma related to human papillomavirus (HPV) (OPSCC). Transoral robotic surgery (TORS) has been included as a therapeutic and diagnostic tool in head and neck surgery and in CUP specifically. The aim of our study is to analyze the results and profitability of TORS in the diagnostic and therapeutic management of CUP in head and neck carcinomas. Method: A retrospective study has been conducted in a tertiary hospital in the North of Spain. Patients diagnosed with CUP who underwent robot assisted lingual tonsillectomy as a diagnostic procedure of the primary tumor were included. Clinicopathological variables were analyzed, such as the presence of HPV. Results: Nine patients were included in our study. The average age at diagnosis was 60 years old. The study of cervical adenopathy showed positivity to p16 in 44 % of the cases. The primary tumor was found at the base of tongue in two of those cases, both HPV DNA positive. Complication rate of TORS BOT was low, mainly I-II sequelae according to Clavien-Dindo classification. Discussion and conclusions: Robot assisted lingual tonsillectomy is a key tool in identifying the primary tumor in CUP, especially if HPV related. TORS helps an accurate staging of the oncological process and allows a less aggressive complementary treatment with fewer sequelae.
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Johnson DE, Burtness B, Leemans CR, Lui VW, Bauman JE, Grandis JR. Head and neck squamous cell carcinoma. Nat Rev Dis Primers. 2020;6(1). https://doi.org/10.1038/s41572-020-00224-3
Pavlidis N, Briasoulis E, Hainsworth J, Greco FA. Diagnostic and therapeutic management of cancer of an unknown primary. Eur J Cancer. 2003;39(14):1990-2005. https://doi.org/10.1016/s0959-8049(03)00547-1
Lee MY, Fowler N, Adelstein D, Koyfman S, Prendes B, Burkey BB. Detection and Oncologic Outcomes of Head and Neck Squamous Cell Carcinoma of Unknown Primary Origin. Anticancer Res. 2020;40(8):4207-4214. https://doi.org/10.21873/anticanres.14421
Rettig EM, D'Souza G. Epidemiology of head and neck cancer. Surg Oncol Clin N Am. 2015;24:379-96. https://doi.org/10.1016/j.soc.2015.03.001
Nauta IH, Rietbergen MM, van Bokhoven AAJD, Bloemena E, Lissenberg-Witte BI, Heideman DAM, et al. Evaluation of the eighth TNM classification on p16-positive oropharyngeal squamous cell carcinomas in the Netherlands and the importance of additional HPV DNA testing. Ann Oncol.2018;29:1273-1279. https://doi.org/10.1093/annonc/mdy060
Chaturvedi AK, Engels EA, Pfeiffer RM, Hernandez BY, Xiao W, Kim E, et al. Human papillomavirus and rising oropharyngeal cancer incidence in the United States. J Clin Oncol. 2011;29:4294-301. https://doi.org/10.1200/JCO.2011.36.4596
Ryan JF, Motz KM, Rooper LM, Mydlarz WK, Quon H, Gourin CG, et al. The Impact of a Stepwise Approach to Primary Tumor Detection in Squamous Cell Carcinoma of the Neck With Unknown Primary. Laryngoscope. 2019;129:1610-616. https://doi.org/10.1002/lary.27625
Maghami E, Ismaila N, Alvarez A, Chernock R, Duvvuri U, Geiger J, et al. Diagnosis and Management of Squamous Cell Carcinoma of Unknown Primary in the Head and Neck: ASCO Guideline. J Clin Oncol. 2020;38(22):2570-2596. https://doi.org/10.1200/JCO.20.00275
Cosway B, Drinnan M, Paleri V. Narrow band imaging for the diagnosis of head and neck squamous cell carcinoma: A systematic review. Head Neck. 2016;38 Suppl 1:E2358-67. https://doi.org/10.1002/hed.24300
van Weert S, Rijken JA, Plantone F, Bloemena E, Vergeer MR, Lissenberg-Witte BI, Leemans CR. A systematic review on Transoral robotic surgery (TORS) for carcinoma of unknown primary origin: Has tongue base mucosectomy become indispensable? Clin Otolaryngol. 2020;45(5):732-38. https://doi.org/10.1111/coa.13565.
Kalavacherla S, Sanghvi P, Lin GY, Guo T. Updates in the management of unknown primary of the head and neck. Front Oncol. 2022;12:991838. https://doi.org/10.3389/fonc.2022.991838
Kubik MW, Channir HI, Rubek N, Kim S, Ferris RL, von Buchwald C, et al. TORS Base-of-Tongue Mucosectomy in Human Papilloma Virus-Negative Carcinoma of Unknown Primary. Laryngoscope. 2021;131:78-81. https://doi.org/10.1002/lary.28617
Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205-13. https://doi.org/10.1097/01.sla.0000133083.54934.ae
de Almeida JR, Li R, Magnuson JS, Smith RV, Moore E, Lawson G, et al. Oncologic Outcomes After Transoral Robotic Surgery: A Multi-institutional Study. JAMA Otolaryngol Head Neck Surg. 2015;141:1043-1051. https://doi.org/10.1001/jamaoto.2015.1508
Ye W, Arnaud EH, Langerman A, Mannion K, Topf MC. Diagnostic approaches to carcinoma of unknown primary of the head and neck. Eur J Cancer Care (Engl). 2021;30:e13459. https://doi.org/10.1111/ecc.13459
Muraki AS, Mancuso AA, Harnsberger HR. Metastatic cervical adenopathy from tumors of unknown origin: the role of CT. Radiology. 1984;152:749-53. https://doi.org/10.1148/radiology.152.3.6463256
Mendenhall WM, Mancuso AA, Parsons JT, Stringer SP, Cassisi NJ. Diagnostic evaluation of squamous cell carcinoma metastatic to cervical lymph nodes from an unknown head and neck primary site. Head Neck. 1998;20:739-44. https://doi.org/10.1002/(sici)1097-0347(199812)20:83.0.co;2-0
Keller F, Psychogios G, Linke R, Lell M, Kuwert T, Iro H, et al. Carcinoma of unknown primary in the head and neck: comparison between positron emission tomography (PET) and PET/CT. Head Neck. 2011;33:1569-575. https://doi.org/10.1002/hed.21635
Beadle BM, William WN Jr, McLemore MS, Sturgis EM, Williams MD. p16 expression in cutaneous squamous carcinomas with neck metastases: a potential pitfall in identifying unknown primaries of the head and neck. Head Neck. 2013;35:1527-533. https://doi.org/10.1002/hed.23188
Tanzler ED, Amdur RJ, Morris CG, Werning JW, Mendenhall WM. Challenging the need for random directed biopsies of the nasopharynx, pyriform sinus, and contralateral tonsil in the workup of unknown primary squamous cell carcinoma of the head and neck. Head Neck. 2016;38:578-81. https://doi.org/10.1002/hed.23931
Pattani KM, Goodier M, Lilien D, Kupferman T, Caldito G, Nathan CO. Utility of panendoscopy for the detection of unknown primary head and neck cancer in patients with a negative PET/CT scan. Ear Nose Throat J. 2011;90:E16-E20. https://doi.org/10.1177/014556131109000818
Byrd JK, Smith KJ, de Almeida JR, Albergotti WG, Davis KS, Kim SW, et al. Transoral Robotic Surgery and the Unknown Primary: A Cost-Effectiveness Analysis. Otolaryngol Head Neck Surg.2014;150:976-82. https://doi.org/10.1177/0194599814525746
Khan N, Kass M, Miles B, Genden E. Transoral robotic assisted resection approach for identifying unknown primaries of the head and neck. Int J Radiat Oncol Biol Phys 2016; 94:P893. https://doi.org/10.1016/j.ijrobp.2015.12.092
Blanco RG, Fakhry C, Ha PK, Ryniak K, Messing B, Califano JA, Saunders JR. Transoral robotic surgery experience in 44 cases. J Laparoendosc Adv Surg Tech A. 2013;23:900-907. https://doi.org/10.1089/lap.2013.0261
Krishnan S, Connell J, Ofo E. Transoral robotic surgery base of tongue mucosectomy for head and neck cancer of unknown primary. ANZ J Surg. 2017;87(12):E281-E284. https://doi.org/10.1111/ans.13741
Pavlidis N, Briasoulis E, Hainsworth J, Greco FA. Diagnostic and therapeutic management of cancer of an unknown primary. Eur J Cancer. 2003;39(14):1990-2005. https://doi.org/10.1016/s0959-8049(03)00547-1
Lee MY, Fowler N, Adelstein D, Koyfman S, Prendes B, Burkey BB. Detection and Oncologic Outcomes of Head and Neck Squamous Cell Carcinoma of Unknown Primary Origin. Anticancer Res. 2020;40(8):4207-4214. https://doi.org/10.21873/anticanres.14421
Rettig EM, D'Souza G. Epidemiology of head and neck cancer. Surg Oncol Clin N Am. 2015;24:379-96. https://doi.org/10.1016/j.soc.2015.03.001
Nauta IH, Rietbergen MM, van Bokhoven AAJD, Bloemena E, Lissenberg-Witte BI, Heideman DAM, et al. Evaluation of the eighth TNM classification on p16-positive oropharyngeal squamous cell carcinomas in the Netherlands and the importance of additional HPV DNA testing. Ann Oncol.2018;29:1273-1279. https://doi.org/10.1093/annonc/mdy060
Chaturvedi AK, Engels EA, Pfeiffer RM, Hernandez BY, Xiao W, Kim E, et al. Human papillomavirus and rising oropharyngeal cancer incidence in the United States. J Clin Oncol. 2011;29:4294-301. https://doi.org/10.1200/JCO.2011.36.4596
Ryan JF, Motz KM, Rooper LM, Mydlarz WK, Quon H, Gourin CG, et al. The Impact of a Stepwise Approach to Primary Tumor Detection in Squamous Cell Carcinoma of the Neck With Unknown Primary. Laryngoscope. 2019;129:1610-616. https://doi.org/10.1002/lary.27625
Maghami E, Ismaila N, Alvarez A, Chernock R, Duvvuri U, Geiger J, et al. Diagnosis and Management of Squamous Cell Carcinoma of Unknown Primary in the Head and Neck: ASCO Guideline. J Clin Oncol. 2020;38(22):2570-2596. https://doi.org/10.1200/JCO.20.00275
Cosway B, Drinnan M, Paleri V. Narrow band imaging for the diagnosis of head and neck squamous cell carcinoma: A systematic review. Head Neck. 2016;38 Suppl 1:E2358-67. https://doi.org/10.1002/hed.24300
van Weert S, Rijken JA, Plantone F, Bloemena E, Vergeer MR, Lissenberg-Witte BI, Leemans CR. A systematic review on Transoral robotic surgery (TORS) for carcinoma of unknown primary origin: Has tongue base mucosectomy become indispensable? Clin Otolaryngol. 2020;45(5):732-38. https://doi.org/10.1111/coa.13565.
Kalavacherla S, Sanghvi P, Lin GY, Guo T. Updates in the management of unknown primary of the head and neck. Front Oncol. 2022;12:991838. https://doi.org/10.3389/fonc.2022.991838
Kubik MW, Channir HI, Rubek N, Kim S, Ferris RL, von Buchwald C, et al. TORS Base-of-Tongue Mucosectomy in Human Papilloma Virus-Negative Carcinoma of Unknown Primary. Laryngoscope. 2021;131:78-81. https://doi.org/10.1002/lary.28617
Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205-13. https://doi.org/10.1097/01.sla.0000133083.54934.ae
de Almeida JR, Li R, Magnuson JS, Smith RV, Moore E, Lawson G, et al. Oncologic Outcomes After Transoral Robotic Surgery: A Multi-institutional Study. JAMA Otolaryngol Head Neck Surg. 2015;141:1043-1051. https://doi.org/10.1001/jamaoto.2015.1508
Ye W, Arnaud EH, Langerman A, Mannion K, Topf MC. Diagnostic approaches to carcinoma of unknown primary of the head and neck. Eur J Cancer Care (Engl). 2021;30:e13459. https://doi.org/10.1111/ecc.13459
Muraki AS, Mancuso AA, Harnsberger HR. Metastatic cervical adenopathy from tumors of unknown origin: the role of CT. Radiology. 1984;152:749-53. https://doi.org/10.1148/radiology.152.3.6463256
Mendenhall WM, Mancuso AA, Parsons JT, Stringer SP, Cassisi NJ. Diagnostic evaluation of squamous cell carcinoma metastatic to cervical lymph nodes from an unknown head and neck primary site. Head Neck. 1998;20:739-44. https://doi.org/10.1002/(sici)1097-0347(199812)20:83.0.co;2-0
Keller F, Psychogios G, Linke R, Lell M, Kuwert T, Iro H, et al. Carcinoma of unknown primary in the head and neck: comparison between positron emission tomography (PET) and PET/CT. Head Neck. 2011;33:1569-575. https://doi.org/10.1002/hed.21635
Beadle BM, William WN Jr, McLemore MS, Sturgis EM, Williams MD. p16 expression in cutaneous squamous carcinomas with neck metastases: a potential pitfall in identifying unknown primaries of the head and neck. Head Neck. 2013;35:1527-533. https://doi.org/10.1002/hed.23188
Tanzler ED, Amdur RJ, Morris CG, Werning JW, Mendenhall WM. Challenging the need for random directed biopsies of the nasopharynx, pyriform sinus, and contralateral tonsil in the workup of unknown primary squamous cell carcinoma of the head and neck. Head Neck. 2016;38:578-81. https://doi.org/10.1002/hed.23931
Pattani KM, Goodier M, Lilien D, Kupferman T, Caldito G, Nathan CO. Utility of panendoscopy for the detection of unknown primary head and neck cancer in patients with a negative PET/CT scan. Ear Nose Throat J. 2011;90:E16-E20. https://doi.org/10.1177/014556131109000818
Byrd JK, Smith KJ, de Almeida JR, Albergotti WG, Davis KS, Kim SW, et al. Transoral Robotic Surgery and the Unknown Primary: A Cost-Effectiveness Analysis. Otolaryngol Head Neck Surg.2014;150:976-82. https://doi.org/10.1177/0194599814525746
Khan N, Kass M, Miles B, Genden E. Transoral robotic assisted resection approach for identifying unknown primaries of the head and neck. Int J Radiat Oncol Biol Phys 2016; 94:P893. https://doi.org/10.1016/j.ijrobp.2015.12.092
Blanco RG, Fakhry C, Ha PK, Ryniak K, Messing B, Califano JA, Saunders JR. Transoral robotic surgery experience in 44 cases. J Laparoendosc Adv Surg Tech A. 2013;23:900-907. https://doi.org/10.1089/lap.2013.0261
Krishnan S, Connell J, Ofo E. Transoral robotic surgery base of tongue mucosectomy for head and neck cancer of unknown primary. ANZ J Surg. 2017;87(12):E281-E284. https://doi.org/10.1111/ans.13741
Salvatierra-Vicario, B., Corriols-Noval, P., Rodríguez-Martín, M., Cobo-Díaz, R., Veiga-Alonso, A., Morales-Angulo, C., & Obeso-Agüera, S. (2024). Robot assisted lingual tonsillectomy for the diagnosis of unknown primary squamous cell carcinoma. Revista ORL, 15(4), e32055. https://doi.org/10.14201/orl.32055
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