Transoral laser microsurgery for the unknown primary: Role for lingual tonsillectomy

Nagel, Thomas H.; Hinni, Michael L.; Hayden, Richard E.; Lott, David G.

doi:10.1002/hed.23372

Cited by 64 publications

(69 citation statements)

References 34 publications

(95 reference statements)

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“…The additional diagnostic yield of TOLM and TORS for head and neck CUP has prompted some authors to recommend upfront lingual tonsillectomy at the time of panendoscopy + biopsy, instead of following negative targeted biopsies of the oropharynx [8,29,30]. This has been shown to be a more cost-effective approach from reductions in delays to diagnosis, and the additional expense of a second operation.…”

Section: Diagnostic Transoral Surgerymentioning

confidence: 99%

“…TOLM alone has enhanced occult tumour detection rates following lingual tonsillectomy of 61%-68% [8,30] versus 51%-100% for TORS lingual tonsillectomy [28,[31][32][33][34][35][36]. Compared to TOLM lingual tonsillectomy, TORS has the added advantage of superior three-dimensional (3D) high-definition visualisation, wider range of instrument motion with seven degrees of freedom plus the ability to manoeuvre around corners with the help of angled scopes, significant reduction in hand tremors, decreased fatigue, and improved hand-eye coordination [35,37].…”

Section: Tolm Versus Tors Lingual Tonsillectomymentioning

confidence: 99%

“…lymphoid tissue of the nasopharynx, tonsil, and base of tongue [5], particularly in the oropharyngeal region, and especially amongst patients who are high-risk human papilloma virus (HPV) positive [6][7][8]. Even with advanced diagnostic workup the primary tumour location remains unknown in over 40% of cases [9][10][11].…”

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confidence: 99%

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Transoral Robotic Surgery and the Unknown Primary

Ofo

Spiers

Kim

et al. 2018

ORL

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Carcinoma of unknown primary (CUP) comprises approximately 1%–5% of all head and neck malignancies. Primary site detection rates for metastatic cervical squamous cell carcinoma (SCC) remain variable, with current diagnostic imaging unable to identify all tumours. Prevailing evidence suggests that most head and neck CUP are located in the oropharynx. Diagnostic surgical efforts have been directed at sampling the entire oropharynx. Present techniques that make this possible include transoral robotic surgery (TORS). TORS Lingual tonsillectomy or tongue base mucosectomy performed in the setting of head and neck CUP increases the detection rate of occult tumour. The indication, surgical technique, evidence base, and controversies of performing TORS in the context of the unknown primary are presented.

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Section: Diagnostic Transoral Surgerymentioning

confidence: 99%

Section: Tolm Versus Tors Lingual Tonsillectomymentioning

confidence: 99%

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Transoral Robotic Surgery and the Unknown Primary

Ofo

Spiers

Kim

et al. 2018

ORL

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“…Transoral laser microsurgery may also be an option for detecting primary tumours in SCCUP patients with comparable detection rates, and can be recommended in Institutes where robotic surgery is unavailable [9,16]. Studies using a TORS approach have found high detection rates (77-90%), but they used different definitions of a true 'SCCUP' syndrome; however, they still managed to identify the majority of primary tumours in the oropharyngeal palatine and lingual tonsils.…”

Section: Discussionmentioning

confidence: 96%

Transoral robotic surgery for the management of head and neck squamous cell carcinoma of unknown primary

Channir¹,

Rubek²,

Nielsen³

et al. 2015

Acta Oto-Laryngologica

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“…Recent case series have reported high rates of detection ranging from 86 to 94% including TLM [38,39] and 72 to 90% including TORS [37,38,40] in the diagnostic work-up of patients with suspected CUP. According to Durmus et al [41] the PT was identified in 77% of patients (17 of 22) with 80% HPV-positive LNM residing in the palatine tonsil in 59% (13 of 22), and the BOT in 18% (4 of 22).…”

Section: Discussionmentioning

confidence: 99%

Impact of the 8th edition of the UICC TNM classification on staging and survival in patients with neck metastases of unknown primary tumor

Nussbaumer-Vorburger¹,

Förbs²,

Jochum³

et al. 2017

Otorhinolaryngol Head Neck Sur

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Objectives: The aims of this study were to assess the predictive value of HPV-positivity in cervical lymph node metastases for the detection of a primary tumor (PT), to investigate the influence of HPV-positivity in cervical lymph node metastases on tumor control and survival and to analyse the impact of the 8 th edition of the UICC TNM classification on staging and survival.Methods: Neck dissection specimen of 47 consecutively included patients were analysed by PCR-based HPV DNA-testing and p16-immunostaining and survival analysis by Kaplan-Meier and Cox proportional hazard regression models were performed. Results:After standard work-up algorithm in patients with suspected CUP 27/47 patients (57%) remained a CUP whereas in 20/47 (43%) a PT was detected (tonsils, lung, parotid gland, skin). 14/20 (70%) with detected PT and 9/27 (30%) with CUP had HPV-positive cervical lymph node metastases (LNM). Sensitivity, specificity, positive predictive value and negative predictive value of HPV-positivity in LNM for diagnosis of a PT in the oropharynx achieved 65%, 95%, 94% and 69%, respectively. In the subgroup of patients with CUP the 5-year overall/disease specific survival (OS/DSS) of patients with HPV-positive compared to HPVnegative LNM was higher (5y-OS 73% vs. 41%, p=0.01, 5y-DSS 73% vs. 53%, p=0.02). The use of the new UICC TNM classification leads to down staging of 65% of patients with detected PT and 33% with CUP. Furthermore, advanced N-category becomes an important negative prognosticator for OS (N≥2: HR 3.05, 95% CI 1.21-7.67, p=0.01). Conclusion:HPV-positivity in LNM directs the detection of PT in the oropharynx in patients with CUP. One third of LNM in patients with CUP were HPVpositive associated with improved OS and DSS. When applying the 8 th edition advanced N-category and UICC stages are negative prognosticators for survival supporting the role for integration of biomarkes in staging systems.

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Transoral laser microsurgery for the unknown primary: Role for lingual tonsillectomy

Abstract: A surgical algorithm for the unknown primary that includes TLM-assisted techniques, including a lingual tonsillectomy, offers the greatest likelihood of successfully detecting the location of occult primary tumors.

Cited by 64 publications

References 34 publications

Transoral Robotic Surgery and the Unknown Primary

Transoral Robotic Surgery and the Unknown Primary

Transoral robotic surgery for the management of head and neck squamous cell carcinoma of unknown primary

Impact of the 8th edition of the UICC TNM classification on staging and survival in patients with neck metastases of unknown primary tumor

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