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

Abstract

Purpose: To evaluate the impact of tonsillectomy on the detection of the primary tumor, based on p16 immunohistochemistry analysis, in patients with cervical unknown primary of squamous cell carcinoma (SCC-CUP). Methods: This was a retrospective study of 63 patients, included from January 2008 to December 2017 in a single institution. All patients had an initial assessment with physical examination, CT scan of the neck and chest, whole body FDG-PET CT, and endoscopy under general anesthesia, which failed to determine the primary tumor. Results: Forty-seven out of the 63 patients had an ipsi-or bilateral tonsillectomy which revealed 12 tonsil cancers (26%). The tonsil primary was ipsilateral to positive nodes in 10 cases, contralateral in 1 case and, in 1 case, the patient had bilateral neck involvement. The analysis of the p16 status was carried out in 41/63 patients (65%). Among the 32 patients who had a p16 analysis and tonsillectomy, the rate of primary detection was 59% (10/17) for p16-postives and 0% (0/15) for p16-negatives (p < 0.001). Conclusion: These results suggest that an extended work-up should be systematically proposed including bilateral tonsillectomy (+/-mucosectomy of the base of tongue) in SCC-CUP p16-positive patients but not in p16-negatives.

Standardized Diagnostics Including PET-CT Imaging, Bilateral Tonsillectomy and Neck Dissection Followed by Risk-Adapted Post-Operative Treatment Favoring Radio-Chemotherapy Improve Survival of Neck Squamous Cell Carcinoma of Unknown Primary Patients

“…The high rate of subclinical (occult) primary lesions detected by PET-CT and EUA confirms recent results from a meta-analysis demonstrating the highly increased probability to detect small lesions given combined utilization of these modern approaches (26). Mostly, the primary tumors identified in our cohort were located in the base of tongue or palatine tonsils, in line with recent data (27,28). At time of NSCCUP diagnosis and more than 6 months thereafter a total of six (five within 60 months) occult HNSCC tumors were detected in our cohort 1 but only two in cohort 2 (compare Table 1 and Figure 2F).…”

“…cisplatin-based PORCT already introduced in 2004. However, the treatment in cohort 2 is in line with recommendations according to guidelines and clinical evidence (7,8,(25)(26)(27)(28)(30)(31)(32)(33). Some analyses suffer from impossibility to obtain pathologic data not included in the available reports, and molecular data including p16 status is missing especially in cohort 1.…”

Transoral Robotic Surgery for Head and Neck Cancer: Advances and Residual Knowledge Gaps

“…With respect to the HPV status, the likelihood of finding the primary tumor in a base-of-tongue mucosectomy in HPV-negative carcinomas of unknown primary seems much lower than in their HPV-positive counterparts (13% versus approximately 50%), and most studies to date included mainly HPV-positive patients [ 6 , 56 , 57 ]. Therefore, in HPV-negative carcinomas of occult primary, the risk/benefit balance of base-of-tongue mucosectomy seems currently unfavorable.…”

Indications for Oropharyngeal Biopsy in Head and Neck Squamous Cell Carcinoma of Unknown Primary - A Systematic Review (HNSCCUP)

“…The search identified 16 studies including over 2700 patients 5,[10][11][12][13][14][18][19][20][21][22][23][24][25][26][27] . 11 studies documented detection rate with tonsillectomy 5,10-14,18,19-22 (table 2 & 3), 9 studies quoted the rates of synchronous tonsillar SCC 5,11,12,14,19,[23][24][25][26] (not necessarily HNSCCUP 23,24 ) (table 4) and 3 examined the role of HPV status in cancer detection following tonsillectomy 19,24,27 (table 5).…”

“…Five studies investigated the efficacy of random tonsil biopsies versus tonsillectomy 5,10,11,18,19 (Table 2). The rate of positive findings on tonsil biopsy ranged from 0 19 -16.7% 18 in these studies, whereas positive findings on tonsillectomy ranged from 25.5 19 -44.3% 14 (table 2-5).…”