Role of tonsillectomy in the search for a squamous cell carcinoma from an unknown primary in the head and neck

Kothari, Prasad; Randhawa, Premjit S; Farrell, Roy

doi:10.1016/j.bjoms.2007.11.017

Cited by 69 publications

(72 citation statements)

References 13 publications

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“…Although panendoscopy is standard in HNSCCUP workup, there is no general consensus on the sampling modality of the palatine tonsils. Recent studies provide compelling support for unilateral [21] or even bilateral [22] tonsillectomy, which, in the experience of several groups, provided a significantly higher yield in detecting occult tumors than deep tonsillar biopsy [2,16,23,24]. The morphologic findings in our case further support this clinical approach: the few microscopic SCC foci might have been missed, had only tonsillar biopsies been obtained.…”

Section: Discussionsupporting

confidence: 67%

Small Lymphocytic Lymphoma Obscuring Microscopic Tonsillar Squamous Cell Carcinoma: an Unknown Occurrence with a Known Primary

Minca

Popat

Chadha³

et al. 2010

Head and Neck Pathol

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Head and neck squamous cell carcinoma (HNSCC) often presents with cervical lymph node metastases and at times the primary tumor cannot be identified despite extensive workup. Lymphoma is the second most common neoplasm in the head and neck region but is seldom synchronous with HNSCC and rarely involves regional mucosal sites. We report herein a rare occurrence of tonsillar involvement by small lymphocytic lymphoma (SLL) incidentally detected during the workup for a cervical lymph node SCC metastasis of a 52-year-old nonsmoker male. The microscopic human papillomaviruspositive SCC involving the tonsillar surface and crypts was obscured by SLL leading to the initial designation of 'unknown primary'. The occult HNSCC are likely explained by small tumor size, quality and quantity of sampling, thoroughness of endoscopic, radiological and pathological assessment or a combination of the above. The coexistence of another tumor such as lymphoma has not yet been reported as a confounding factor in the workup for cervical SCC metastasis. Since oropharyngeal SCC can be very small and Waldeyer's ring is a common site for lymphoma involvement, identification of such rare collision tumors requires pathologists' awareness, extensive sampling and occasionally ancillary studies for the accurate diagnosis and staging essential for the correct management.

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Section: Discussionsupporting

confidence: 67%

Small Lymphocytic Lymphoma Obscuring Microscopic Tonsillar Squamous Cell Carcinoma: an Unknown Occurrence with a Known Primary

Minca

Popat

Chadha³

et al. 2010

Head and Neck Pathol

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“…According to a recent review a contralateral PT was detected in 6% of BOT and 15% in the contralateral palatine tonsillar specimen [43] comparable to previous reports [44][45][46].…”

Section: Discussionsupporting

confidence: 64%

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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“…The tonsils have also been incriminated as the site of occult primary tumors, particularly in patients bearing head and neck tumors associated with chronic HPV infection of the upper aerodigestive mucosa. It was previously suggested that directed random biopsies and unilateral or bilateral tonsillectomy should be included in the screening for detection of the occult primary tumor (27). In the absence of a visible or palpable lesion, Waltonen et al (28) reported that tonsillectomy may result in a significantly higher likelihood of detecting an occult tonsillar tumor compared to deep tonsil biopsy.…”

Section: Diagnostic Work-upmentioning

confidence: 99%

“…In the absence of a visible or palpable lesion, Waltonen et al (28) reported that tonsillectomy may result in a significantly higher likelihood of detecting an occult tonsillar tumor compared to deep tonsil biopsy. The evidence supporting bilateral tonsillectomy is less convincing, although the detection rates of a primary tumor site in the contralateral tonsil were reported to be 10-23% (27)(28)(29).…”

Section: Diagnostic Work-upmentioning

confidence: 99%

Management of lymph node metastases from an unknown primary site to the head and neck (Review)

Zhuang

et al. 2014

Molecular and Clinical Oncology

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Abstract. Cancer of unknown primary site (CUP) is an intriguing clinical phenomenon found in ~3-9% of all head and neck cancers. It has not yet been determined whether CUP forms a distinct biological entity with specific genetic and phenotypic characteristics, or whether it is the clinical presentation of metastasis in patients with an undetected primary tumor and no visible clinical signs. The treatment of patients with cervical lymph node metastases from CUP remains controversial, due to the lack of randomized clinical trials comparing different treatment options. Consequently, treatment is currently based on non-randomized data and institutional policy. In the present review, the range and limitations of diagnostic procedures are summarized and an optimal diagnostic work-up is recommended. The initial preferred diagnostic procedures include fine-needle aspiration biopsy (FNAB) and imaging. Although neck dissection followed by postoperative radiotherapy is the the most generally accepted approach, other curative options may be used in certain patients, such as neck dissection alone, nodal excision followed by postoperative radiotherapy, or radiotherapy alone. There remains controversy regarding target radiation volumes, ranging from ipsilateral neck irradiation to prophylactic irradiation of all the potential mucosal sites and both sides of the neck. When no primary lesion is identified with imaging and endoscopy in patients without history of smoking and alcohol abuse, molecular profiling of an FNAB sample for human papillomavirus and/or Epstein-Barr virus is required.

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Role of tonsillectomy in the search for a squamous cell carcinoma from an unknown primary in the head and neck

Cited by 69 publications

References 13 publications

Small Lymphocytic Lymphoma Obscuring Microscopic Tonsillar Squamous Cell Carcinoma: an Unknown Occurrence with a Known Primary

Small Lymphocytic Lymphoma Obscuring Microscopic Tonsillar Squamous Cell Carcinoma: an Unknown Occurrence with a Known Primary

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

Management of lymph node metastases from an unknown primary site to the head and neck (Review)

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