Transoral robotic surgery for management of cervical unknown primary squamous cell carcinoma: Updates on efficacy, surgical technique and margin status

Geltzeiler, Mathew; Doerfler, Sean; Turner, Meghan; Albergotti, William Greer; Kubik, Mark; Kim, Seungwon; Duvvuri, Umamaheswar

doi:10.1016/j.oraloncology.2016.12.033

Cited by 64 publications

(84 citation statements)

References 22 publications

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“…11,40,41 Blind biopsies from the nasopharynx, palatine tonsil, tongue base, and piriform sinus were commonly performed in the past, but is not currently standard practice in patients with radiological and clinical normal findings. [45][46][47][48][49][50] Unfortunately, the corresponding studies report on the identification rate of these techniques in the overall population of SCCUP and does not specify its efficacy in the subset of HPV-related SCCUP. 43 Bilateral tonsillectomy is controversial but identifies a primary tumor site in 15%-25% without major morbidity.…”

Section: Diagnostic Approachmentioning

confidence: 99%

“…42 Examination with microlaryngoscopy under general anesthesia with biopsy/excision of suspicious areas increases the primary tumor detection rate from 25% to 94%. [45][46][47][48][49][50] In one study of 64 patients with SCCUP (48 HPV-related SCCUP) undergoing lingual mucosectomy and tonsillectomy, the primary lesion is reported more frequently in the base of the tongue than in the palatine tonsil (86% vs 14%). 44 Transoral laser microsurgery or transoral robotic surgery has recently emerged as effective modalities in the identification and treatment of SCCUP.…”

Section: Diagnostic Approachmentioning

confidence: 99%

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Comprehensive management of HPV‐related squamous cell carcinoma of the head and neck of unknown primary

2019

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Background Human papillomavirus (HPV)‐related squamous cell carcinoma of unknown primary (SCCUP) is currently rising in incidence but lacks a validated management approach. Aims This paper reviews the clinical presentation, diagnosis, and treatment of HPV‐related SCCUP. Materials and Methods The Medline/Pubmed database was searched by using the following keywords “CUP”, “cancer of unknown primary”, “HPV”, “human papilloma virus”, and “head and neck”. The references of the publications of interest were also screened for relevant papers. Results The clinical assessment of HPV‐related SCCUP includes a complete clinical examination, an endoscopic evaluation with white‐light and narrow band imaging, and radiologic assessment using morphologic and metabolic imaging. If the diagnosis remains unconfirmed, endoscopic examination under anesthesia with tonsillectomy ± base of tongue mucosectomy is performed. The therapeutic rationale aims to eradicate the involved lymph nodes and potential primary tumor with a sequence of chemoradiotherapy and neck dissection. Discussion As a general approach, p16‐negative SCCUP are truly HPV negative, whereas p16‐positive specimens require confirmation with HPV in situ hybridization or polymerase chain reaction to confirm HPV infection. If a cervical metastasis is considered HPV positive, the primary lesion is likely in the oropharynx, and further diagnostic interventions such as tonsillectomy seems to be mandatory. Whether the optimal treatment is neck dissection followed by adjuvant radiotherapy or concomitant chemoradiotherapy (CRT) (in case of extranodal extension or advanced lymph node stages) or definitive CRT followed by neck dissection (in case of positive 18F‐FDG‐PET/CT) remains a matter of debate. Solid scientific evidence supporting treatment de‐escalation in HPV‐related SCCUP is lacking, and the results of ongoing trials are at the brink of reporting. Conclusion Currently, the treatment of patients with HPV‐related SCCUP should not differ from the standard treatment of other SCCUP patients and is similarly based on the staging of the disease and general condition of the patient.

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Section: Diagnostic Approachmentioning

confidence: 99%

Section: Diagnostic Approachmentioning

confidence: 99%

Comprehensive management of HPV‐related squamous cell carcinoma of the head and neck of unknown primary

2019

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“…The procedure is performed according to Mehta et al [35] with minor modifications to include a slightly deeper ipsilateral (muscle) resection margin, following recent published data from Geltzeiler et al [38]. Monopolar settings are usually at 20-25 W. The initial (vertical) incision is made in the midline of the tongue base with monopolar cautery from the level of the circumvallate papillae down to the level of the vallecula (Fig.…”

Section: Surgical Proceduresmentioning

confidence: 99%

“…With TORS base of tongue mucosectomy providing additional primary tumour detection rates of 50%-90% after all other diagnostic modalities have failed [27,28,34,38], increased survival rates may be achieved [2], and radiation fields can be limited to the affected oropharynx only, thus minimising the morbidity of radiotherapy treatment to patients. In addition, if the tumour is well lateralised in the tongue base, some tumour boards or head and neck cancer multidisciplinary teams may advocate omitting contralateral neck irradiation.…”

Section: Controversies: Why Perform Tors Lingual Tonsillectomy For Thmentioning

confidence: 99%

“…Finally, the additional patient morbidity from pain, short-term swallowing dysfunction, additional bleeding risk, and small risk of pharyngeal stenosis need to be considered. Thankfully, published studies from several international centres have shown that the morbidity from robotic base of tongue mucosectomy is low [27,28,34,38].…”

Section: Controversies: Why Perform Tors Lingual Tonsillectomy For Thmentioning

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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Association of Intraoperative Frozen Section Controls With Improved Margin Assessment During Transoral Robotic Surgery for Human Papillomavirus–Positive Oropharyngeal Squamous Cell Carcinoma

Afework

Goldstein

et al. 2022

JAMA Otolaryngol Head Neck Surg

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ImportanceIntraoperative margin assessment is an important technique for ensuring complete tumor resection in malignant cancers. However, in patients undergoing transoral robotic surgery (TORS) for oropharyngeal carcinomas, tissue artifact may provide pathologic uncertainty.ObjectiveTo assess the benefit of providing frozen section control samples (“positive tumor biopsies”) for use during intraoperative margin assessment for patients undergoing TORS for human papillomavirus (HPV)-16–positive oropharyngeal squamous cell carcinoma (OPSCC).Design, Setting, and ParticipantsIn this cohort study, patients receiving curative-intent TORS for biopsy-proven HPV-16–positive OPSCC performed by a single attending surgeon (A.H.M.) at Ronald Reagan UCLA Medical Center from 2017 to 2021 were included in a retrospective data analysis. Exclusion criteria included HPV-negative status, participation in clinical trials, and tumors of unknown primary origin.Main Outcomes and MeasuresSurvival outcomes investigated included overall and disease-free survival. Adverse pathologic outcomes measured included occurrence of nondiagnostic margins and margin reversal from frozen to fixed pathology.ResultsOf the 170 patients included (mean [SD] age, 61.8 [9.9] years; 140 [82%] male), 50% of patients (n = 85) received a frozen section control. Use of a frozen section control was associated with statistically significantly improved sensitivity of intraoperative margin assessment, from 82.8% to 88.9% (difference, 6.1%; 95% CI, 3.9%-8.3%). Eleven percent (n = 18) of all tumors evaluated exhibited at least 1 nondiagnostic intraoperative margin, and 11% (n = 18) experienced margin reversal from frozen to fixed pathology. In patients with nondiagnostic margins, use of frozen section controls was associated with statistically significantly reduced time spent in the operating room (Cohen d, 1.14; 95% CI, 0.12-2.14).Conclusions and RelevanceIn this cohort study, frozen intraoperative margins assessed during TORS resections of HPV-16–positive OPSCC were diagnostically challenging. Adverse pathologic outcomes, such as margin status reversal from positive on frozen pathology to negative on formal analysis, were common. Providing intraoperative frozen section control biopsies may offer clarity in cases with nondiagnostic margins, reducing the need for additional sampling and time spent in the operating room.

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Transoral robotic surgery for management of cervical unknown primary squamous cell carcinoma: Updates on efficacy, surgical technique and margin status

Cited by 64 publications

References 22 publications

Comprehensive management of HPV‐related squamous cell carcinoma of the head and neck of unknown primary

Comprehensive management of HPV‐related squamous cell carcinoma of the head and neck of unknown primary

Transoral Robotic Surgery and the Unknown Primary

Association of Intraoperative Frozen Section Controls With Improved Margin Assessment During Transoral Robotic Surgery for Human Papillomavirus–Positive Oropharyngeal Squamous Cell Carcinoma

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