Management of the Unknown Primary in the Era of HPV and Robotics

Abstract

Objectives:

A subset of patients with squamous cell carcinoma of the head and neck present with a cervical metastasis from an unknown primary site. Currently, many of these patients have human papillomavirus (HPV) positive tumors, making the oropharynx the most likely primary site. Objectives: 1) Develop a minimally invasive approach to identify and definitively treat patients initially diagnosed with carcinoma of unknown primary (CUP) using transoral robotic surgery (TORS). Additionally, we anticipate that this aggressive approach will yield the primary lesion in a higher subset of patients.

Methods:

A retrospective chart review study was conducted to evaluate a novel minimally-invasive management approach using TORS to assess the primary site.

Results:

We identified 12 patients with CUP of the head and neck that had undergone this approach from December 2011 to April 2012. Ten patients were classified as HPV positive using p16 staining as surrogate marker. The primary site was identified in 10 of 12 patients (83%), the majority of which was found to be the base of tongue.

Conclusions:

We have developed a minimally invasive surgical approach using TORS for the diagnosis and subsequent management of the patient with CUP. Using this algorithm, we are able to move from frozen section directly to an en bloc definitive resection in many patients. Our results show a significant rate of primary tumor identification using a robotic-assisted approach and support the rationale for further investigation of this technique.