TORS Base‐of‐Tongue Mucosectomy in Human Papilloma Virus‐Negative Carcinoma of Unknown Primary

Abstract

Objective To analyze the role of transoral robotic base‐of‐tongue mucosectomy in a cohort of patients with human papilloma virus negative unknown primary carcinoma. Study Design Retrospective database analysis. Methods A retrospective database review from 2012 to 2018 was performed at two large tertiary centers to study patients with human papilloma virus (HPV)‐negative unknown primary carcinoma who underwent transoral robotic base‐of‐tongue mucosectomy. P16 testing was used as a surrogate for HPV status. Patients were included that had squamous cell carcinoma metastatic to the lateral neck based on fine needle aspiration or open biopsy. Preoperatively, all patients were classified as having an unknown primary based on normal clinical and flexible endoscopic exam, normal operative endoscopy, nonlocalizing imaging, and tonsillectomy. All patients underwent robotic base‐of‐tongue mucosectomy. The primary outcome measure was the incidence of pathologic identification of a mucosal primary. Results Twenty‐three patients with p16‐negative unknown primary carcinoma were identified and studied. All patients underwent transoral robotic base‐of‐tongue mucosectomy. Median age was 60 years at the time of diagnosis, and 18 of 23 (78.2%) were male. Pathologic analysis of the base‐of‐tongue specimens showed a primary tumor in only three of 23 (13.0%) of patients. Conclusion Despite prior evidence suggesting a high rate of primary site identification in HPV‐related disease, robotic base‐of‐tongue mucosectomy may not be indicated for HPV‐negative unknown primary carcinoma based on a low likelihood of finding the primary. Level of Evidence 4 Laryngoscope, 131:78–81, 2021

Role of Tonsillectomy in the Management of Carcinomas of Unknown Primary of the Head and Neck: A Retrospective Study Based on p16 Analysis

“…The primary tumor was identified in only 3 out of 23 cases (13%). In these three cases, the tumor was found in the ipsilateral base-of-tongue specimen in contrast with their previous series showing a tumor identification rate of 80% in the HPV-positive patients (4,14).…”

“…On the other hand, tonsillectomy and/or mucosectomy of the base of the tongue for p16-negative patients is much more debatable since, in our series, no primary was found in p16negative patients who underwent tonsillectomy. This observation was already made by Kubic et al (14), who analyzed the rate of primary detection in 23 p16-negative patients using TORS base of tongue mucosectomy. The primary tumor was identified in only 3 out of 23 cases (13%).…”

Carcinoma of Unknown Primary and the 8th Edition TNM Classification for Head and Neck Cancer

“…Recent studies have tried to reduce patient side effects by reducing treatment intensity 35–38 . Ultimately, the search for the primary remains the patients' best chance of being assessed and referred to an appropriate therapy with multiple studies emerging in this field over recent years 39–42 . Karni et al have shown that transoral laser microsurgery reveals the primary oropharyngeal carcinoma in 94% of patients (37% palatine tonsil, 63% tongue‐base) 43 …”

“…[35][36][37][38] Ultimately, the search for the primary remains the patients' best chance of being assessed and referred to an appropriate therapy with multiple studies emerging in this field over recent years. [39][40][41][42] Karni et al have shown that transoral laser microsurgery reveals the primary oropharyngeal carcinoma in 94% of patients (37% palatine tonsil, 63% tongue-base). 43 This study's limitations are clearly associated with its retrospective approach.…”

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

“…The procedure is, as also proven in previous diagnostic steps, highly effective in identifying the primary tumor site in the group of patients with HPV+ lymph node metastasis, as 55–96% of the identified tumors are HPV+ [ 87 , 88 ]. This is contrasted by an identification rate of only 13% in HPV− cases [ 89 ]. The procedure consequently entails improved tumor detection in HPV+ cases with the potential for radical surgical treatment when the tumor site is identified.…”