AHNS Series: Do you know your guidelines? Guideline recommendations for head and neck cancer of unknown primary site

Abstract

This article reviews the clinical practice guidelines for head and neck oncology focusing on the management of head and neck cancers of unknown primary (CUP). The primary purpose of this series is to raise awareness of the current guidelines in head and neck oncology by reviewing the recommendations and the evidence supporting such recommendations, particularly those published by the National Comprehensive Cancer Network (NCCN). We review the importance of a thorough history and physical examination, the impact of the American Joint Committee on Cancer (AJCC) eighth edition changes and the importance of immunohistochemistry, the timing and type of imaging, the role of panendoscopy and tonsillectomy (palatine and lingual), and the role of surgery, radiation, and chemotherapy in the primary management of these tumors.

Ultraviolet light‐related DNA damage mutation signature distinguishes cutaneous from mucosal or other origin for head and neck squamous cell carcinoma of unknown primary site

“…Current guidelines recommend a comprehensive workup for HNSCCUP including a thorough history and physical examination, fine‐needle aspiration biopsy with p16 and EBV testing, CT and/or MRI, PET/CT, and panendoscopy with directed biopsies based on the neck levels involved . In p16‐positive cases, the addition of high‐risk HPV testing may help differentiate between cutaneous vs mucosal primary, as 21%‐31% of cutaneous SCC of the head and neck overexpress p16 but are negative for high‐risk HPV, which would be more indicative of oropharyngeal cancer origin .…”

“…Endoscopic ultrasound-guided biopsy revealed identical pathology to the left neck nodal mass examination, fine-needle aspiration biopsy with p16 and EBV testing, CT and/or MRI, PET/CT, and panendoscopy with directed biopsies based on the neck levels involved. 3 In p16-positive cases, the addition of high-risk HPV testing may help differentiate between cutaneous vs mucosal primary, as 21%-31% of cutaneous SCC of the head and neck overexpress p16 but are negative for high-risk HPV, which would be more indicative of oropharyngeal cancer origin. 4,5 However, 21%-25% of SCCs of the lung are p16 positive and up to 22% may be HPV positive using a variety of detection methods.…”

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

“…Interestingly, p53 was associated with poor prognosis in one study, whereas another study failed to confirm the observation. 13 The eradication of involved lymph nodes and potential primary tumor in the oropharyngeal mucosa with limited comorbidities is the backdrop for a successful treatment approach. 16,18,22 Tobacco use (pack-year ≤10 or >10) and lymph node involvement (N1-N2b or N2c-N3) were not found to have an impact on the prognosis in HPV/p16-positive SCCUP.…”

“…9 The interest toward HPV-related SCCUP has been growing consequent to the refinements in diagnostic procedures and better understanding of the natural history of the disease. 13 In order to better understand the peculiarities of HPV-related SCCUP, in regard to its clinical presentation, diagnosis, and treatment, we will provide a comprehensive review of the data published during the last years on this specific disease. Nevertheless, level I evidence in the management of HPV-related SCCUP is still lacking.…”

Role of palatine tonsillectomy in the diagnostic workup of head and neck squamous cell carcinoma of unknown primary origin: A systematic review and meta‐analysis

“…The diagnostic workup of a patient with a neck mass starts in the outpatient clinic, with a careful evaluation of medical history, alcohol and tobacco consumption, sexual habits, and any previous treatment for skin lesions of the head and neck . The physical examination with fiber‐optic nasopharyngoscopy should be combined with the palpation of oral cavity, tonsils, and tongue base …”