Diagnostic approaches to carcinoma of unknown primary of the head and neck

Early Experience With Indocyanine Green (ICG) Fluorescent Guided Transoral Robotic Surgery With the Da Vinci SP

IMPORTANCE

Carcinoma of Unknown Primary (CUP) presents a clinical challenge for practitioners. The current diagnostic approach often involves extensive imaging and examinations, with variable success. We aimed to evaluate the effectiveness of Indocyanine Green (ICG) injection using the Da Vinci robot to aid in intraoperative decision making.

OBJECTIVES

To evaluate the diagnostic utility of ICG use during robotic surgery to aid in either the identification of the primary tumor or to delineate the extent of disease to guide excision.

METHODS

This study involved a retrospective review of patients treated at the Massachusetts Eye and Ear who underwent robotic surgery with the utilization of Indocyanine Green (ICG) from October 1, 2022. All patients in the study were operated on using the SP model of the Da Vinci robot. Basic demographic and pathologic data were recorded. Intraoperative data points included assessing the presence of an identifiable primary tumor using white light only and documenting the confidence level of ICG localization.

RESULTS

In total, 28 patients who underwent robotic surgery using ICG were identified for this study. The mean age of the cohort was 62 years. Twenty-six patients were male, and the primary diagnosis was HPV-related squamous cell carcinoma (SCCa) in 22 patients, HPV-negative SCC in 5 patients, atypia in 1 patient, and metastatic papillary thyroid carcinoma in 1 patient. Nine patients had either PET-localizing or visually identified primary tumors, and ICG was used to guide the surgical extent of resection. The remaining 19 patients had CUP. Within the patients with CUP, the primary was ultimately identified in 16 of the 19 (84.2%) patients. In regard to ICG localization, this resulted in a True Positive detection in 10 patients (52.6%), False Positive detection in 6 patients (31.6%), False Negative detection in 0 patients (0%), and True Negative detection in 3 patients (15.8%). Based on a confusion matrix of the aforementioned values, the calculated sensitivity, specificity, PPV, and NPV were 100%, 33.3%, 62.5%, and 100%, respectively. The discriminatory index of ICG in the detection of unknown primary disease was found to be 66.6%.

CONCLUSION

The integration of systemic ICG injection with the Da Vinci SP robot's real-time imaging capabilities offers a potential option for enhancing primary tumor identification in CUP patients that adds little to no cost, time, and morbidity to the patient. This preliminary analysis suggests that the use of ICG in robotic surgery for CUP holds promise and warrants further investigation to refine surgical techniques and enhance clinical outcomes.

Surgeon-performed intraoperative transoral ultrasound improves the detection of human papillomavirus-positive head and neck cancers of unknown primary

BACKGROUND

Squamous cell carcinomas of unknown primary (SCCUP) are often Human Papillomavirus (HPV)-positive. Due to their small size, extensive surgical workup is required to locate the primary tumors. High-frequency transoral ultrasound (US) may provide improved visualization of these small tumors. Our study aimed to explore whether surgeon-performed intraoperative transoral US for patients with HPV-positiveSCCUP could improve primary tumor detection during panendoscopy.

METHODS

This was a single-center, prospective diagnostic study including patients undergoing panendoscopy under general anesthesia with HPV-positive SCCUP. Preoperative MRIs, PET/CTs, and HPV DNA-testing of lymph node metastases were performed in all patients. Intraoperative transoral US was performed prior to panendoscopy. Frozen section biopsies were performed unblinded to US results, and transoral US-guided biopsies were attempted if initial biopsies were negative. Final histopathology was obtained with palatine- and/or lingual tonsillectomy if frozen section was negative. The main outcome was the primary tumor detection rate with intraoperative transoral US and panendoscopy.

RESULTS

Thirty patients were included: 24 (80 %) were men, and the median age was 60 years [range 35-79 years]. Twenty-nine primary tumors (97 %) were confirmed; 18 (62 %) and 10 (34 %) in the lingual- and palatine tonsils, respectively, and one (3 %) in the posterior oropharynx. Transoral US had a significantly higher sensitivity than panendoscopy to locate the primary tumor (93 % vs 76 %, p = 0.02), and significantly higher than pre-operative PET/CT (62 %, p = 0.002), CT (45 %, p < 0.001), and MRI (28 %, p < 0.001).

CONCLUSIONS

Intraoperative transoral US during panendoscopy is a promising diagnostic tool that may improve the detection of HPV-positive SCCUP.

Challenges and Considerations in Diagnosing and Managing p16+-Related Oropharyngeal Squamous Cell Carcinoma (OPSCC) with Neck Metastasis: Implications of p16 Positivity, Tobacco Exposure, and De-Escalation Strategies

BACKGROUND

The incidence of patients showing neck metastasis and no obvious primary tumor at the initial diagnostic evaluation or neck cancer of unknown primary (NCUP) is rising. It is estimated that a relevant part of these tumors arises in the tonsillar crypts or base of the tongue and are p16+-related. However, today, the detection rate of the primary tumor is suboptimal. Identifying the primary tumor and its biomolecular characterization is essential since it influences the treatment administered, possibly reducing radiation fields and providing de-escalation to primary surgical management. However, p16 IHC (immunohistochemistry) might not be sufficient to diagnose HPV-related OPSCC. The other subset of patients discussed are the HPV-positive patients who have a history of tobacco exposure and/or p53 mutations. Possible factors that could negatively influence the outcomes of these patients are investigated and discussed below. So, this paper aims to analyze the diagnostic, bio-molecular, clinico-radiological, morphological, prognostic and therapeutical aspects of p16-positive OPSCC, highlighting the possible bias that can occur during the diagnostic and prognostic process.

METHODS

A narrative review was conducted to investigate the biases in the diagnostic and therapeutic process of two groups of patients: those who are p16-positive but HPV-negative patients, and those who are p16-positive and HPV-positive with exposure to traditional risk factors and/or p53 mutations. The keywords used for the literature research included the following: NCUP, OPSCC, p16IHC, HPV testing, p16 positive HPV negative OPSCC, p16 positive HPV positive OPSCC, tonsillectomy, tobacco exposure, p53 mutations, cystic neck metastasis, extranodal extension (ENE), radiotherapy, de-escalation and neck neck dissection.

RESULTS

HPV-positive OPSCC has specific clinico-radiological features. Bilateral tonsillectomy should be considered for the identification of the primary tumor. P16 IHC alone is not sufficient for diagnosing HPV-related OPSCC; additional detection methods are required. The role of tobacco exposure and p53 mutations should be investigated especially in cases of HPV-positive tumors. Extranodal extension (ENE) must be taken into consideration in the prognostic staging of HPV-positive tumors. Surgical primary treatment involving neck dissection (ND) and bilateral tonsillectomy followed by adjuvant radiation may represent the most appropriate approach for N3 cases. Diagnosis, prognosis and therapeutical implications must be addressed considering clinical, biomolecular and morphological aspects. At least today, the numerous biases that are still present influencing the diagnostic and prognostic process do not permit considering de-escalation protocols.

CONCLUSIONS

A precise and accurate diagnosis is required in order to adequately stage and manage p16+ OPSCC, particularly with neck metastasis. The role of tobacco exposure and/or p53 mutations must be considered not only in p16+ OPSCC but especially in HPV-positive OPSCC. Until a more accurate diagnosis is possible, ENE should be considered even in p16+HPV+ OPSCC. Primary surgery with unilateral ND and bilateral tonsillectomy might be the treatment of choice given the numerous diagnostic and prognostic pitfalls. Therefore, it is inappropriate and risky to propose de-escalation protocols in routine clinical practice due to the risk of undertreatment.

Addressing positive multi-cancer early detection tests in head and neck Surgery: Experience with head and neck work up for high-risk referrals

OBJECTIVES

Blood-based multi-cancer early detection (MCED) tests are now commercially available. However, there are currently no consensus guidelines available for head and neck cancer (HNC) providers to direct work up or surveillance for patients with a positive MCED test. We seek to describe cases of patients with positive MCED tests suggesting HNC and provide insights for their evaluation.

METHODS

Retrospective chart review of patients referred to Otolaryngology with an MCED result suggesting HNC. Patients enrolled in prospective MCED clinical trials were excluded. Cancer diagnoses were confirmed via frozen-section pathology.

RESULTS

Five patients were included (mean age: 69.2 years, range 50-87; 4 male) with MCED-identified-high-risk for HNC or lymphoma. Only patient was symptomatic. After physical exam and follow-up head and neck imaging, circulating tumor HPV DNA testing, two patients were diagnosed with p16 + oropharyngeal squamous cell carcinomas and underwent appropriate therapy. A third patient had no evidence of head and neck cancer but was diagnosed with sarcoma of the thigh. The remaining two patients had no evidence of malignancy after in-depth workup.

CONCLUSIONS

In this retrospective study, 2 of 5 patients referred to Otolaryngology with a positive MCED result were diagnosed with HPV + oropharyngeal squamous cell carcinoma. We recommend that positive HNC MCED work up include thorough head and neck examination with flexible laryngoscopy and focused CT or MRI imaging. Given the potential for inaccurate MCED tissue of origin classification, PET/CT may be useful in specific situations. For a patient with no cancer identified, development of clear guidelines is warranted.

Type I Diabetes Mellitus Suppresses Experimental Skin Carcinogenesis

This study explores the previously uncharted territory of the effects of ultraviolet (UV) radiation on diabetic skin, compared to its well-documented impact on normal skin, particularly focusing on carcinogenesis and aging. Employing hairless SKH-hr2, Type 1 and 2 diabetic, and nondiabetic male mice, the research subjected these to UV radiation thrice weekly for eight months. The investigation included comprehensive assessments of photoaging and photocarcinogenesis in diabetic versus normal skin, measuring factors such as hydration, trans-epidermal water loss, elasticity, skin thickness, melanin, sebum content, stratum corneum exfoliation and body weight, alongside photo documentation. Additionally, oxidative stress and the presence of hydrophilic antioxidants (uric acid and glutathione) in the stratum corneum were evaluated. Histopathological examination post-sacrifice provided insights into the morphological changes. Findings reveal that under UV exposure, Type 1 diabetic skin showed heightened dehydration, thinning, and signs of accelerated aging. Remarkably, Type 1 diabetic mice did not develop squamous cell carcinoma or pigmented nevi, contrary to normal and Type 2 diabetic skin. This unexpected resistance to UV-induced skin cancers in Type 1 diabetic skin prompts a crucial need for further research to uncover the underlying mechanisms providing this resistance.

The Role of Trans Oral Robotic Surgery in the Carcinoma of Unknown Primary: A New Evidence in the Horizon?

The detection of the primary site in Carcinoma of Unknown Primary (CUP) is a challenging task which can significantly alter the course of management and also prognosis. Various modalities have been assessed with varying sensitivity and specificity. Imaging and cytological diagnosis have formed a key part of the diagnostic algorithm of CUP. Trans Oral Robotic Surgery offers the advantage of being both diagnostic as well as therapeutic with promising sensitivity and specificity and can form an integral part in the management of CUP. A prospective study was carried out at a tertiary care centre over a period of one year. Patients with unilateral neck swelling which was histopathologically proven squamous cell carcinoma neck metastasis were included in the study. They were evaluated with endoscopy and radiology according to the standard algorithm. When these failed to detect the primary, the patients underwent ipsilateral radical tonsillectomy and tongue base mucosal wedge biopsy via TORS. Post-operative histopathological examination was done on the resected specimens to detect the primary site. Transoral Robotic Surgery was able to localise primary in 50% of the patients enrolled in the study. Out of the primary site identified by TORS; 55.56% were located in the tonsil and 44.4% in the tongue base. TORS can offer promising detection rates of the occult primary in CUP and should form an integral part of the diagnostic algorithm.

Developments and future prospects of personalized medicine in head and neck squamous cell carcinoma diagnoses and treatments

BACKGROUND

Precision healthcare has entered a new era because of the developments in personalized medicine, especially in the diagnosis and treatment of head and neck squamous cell carcinoma (HNSCC). This paper explores the dynamic landscape of personalized medicine as applied to HNSCC, encompassing both current developments and future prospects.

RECENT FINDINGS

The integration of personalized medicine strategies into HNSCC diagnosis is driven by the utilization of genetic data and biomarkers. Epigenetic biomarkers, which reflect modifications to DNA that can influence gene expression, have emerged as valuable indicators for early detection and risk assessment. Treatment approaches within the personalized medicine framework are equally promising. Immunotherapy, gene silencing, and editing techniques, including RNA interference and CRISPR/Cas9, offer innovative means to modulate gene expression and correct genetic aberrations driving HNSCC. The integration of stem cell research with personalized medicine presents opportunities for tailored regenerative approaches. The synergy between personalized medicine and technological advancements is exemplified by artificial intelligence (AI) and machine learning (ML) applications. These tools empower clinicians to analyze vast datasets, predict patient responses, and optimize treatment strategies with unprecedented accuracy.

CONCLUSION

The developments and prospects of personalized medicine in HNSCC diagnosis and treatment offer a transformative approach to managing this complex malignancy. By harnessing genetic insights, biomarkers, immunotherapy, gene editing, stem cell therapies, and advanced technologies like AI and ML, personalized medicine holds the key to enhancing patient outcomes and ushering in a new era of precision oncology.

Early Improved Functional Outcomes in Head and Neck Cancer Patients with Primary Tumor Detection

OBJECTIVES

We characterize functional outcomes in head and neck cancer of unknown primary (CUP) based on primary site identification.

METHODS

In this retrospective study, CUP cases were categorized as known primaries (KP) if a tumor was localized after diagnostic workup or persisting unknown primaries (UP). Age, sex, HPV status, diagnostic methods, and treatments regimens were collected. Pretreatment and short-term posttreatment (3-6 months after completion of treatment) weights, PHQ-9, Eating Assessment Tool (EAT-10), and Voice Handicap Index (VHI-10) scores were compared between UP and KP.

RESULTS

Among 67 CUP patients, 35 (52.2%) had identified primaries (91.4% oropharyngeal and 8.6% nasopharyngeal). KP patients were younger (58 vs. 64, p = 0.04) and more likely to be HPV-positive (88.6% vs. 50%, p = 0.002). Overall detection rates were 16.7% for PET/CT, 34.7% for direct laryngoscopy, and 46.6% for transoral robotic oropharyngectomy. Diagnostic workup was not significantly different between groups. Patients with KP received smaller intermediate radiation dose volumes (436.5 vs. 278.9 cc, p = 0.03) and lower doses to the cricopharyngeal muscle (41.6 vs. 24.6 Gy, p = 0.03).Pretreatment weights, PHQ-9, EAT-10, and VHI-10 scores did not differ between groups. However, posttreatment, UP had greater relative weight loss (-14.1% vs. -7.6%, p = 0.032), higher EAT-10 scores (12.5 vs. 3, p = 0.004), and higher PHQ-9 scores (6 vs. 1.4, p = 0.017). Specifically, UP reported more stressful swallowing, difficulty swallowing solids and pills, and swallowing affecting public eating.

CONCLUSION

KP patients experienced less weight loss, depression, and reduced swallowing dysfunction, highlighting an early functional benefit of primary tumor identification likely driven by reduced radiation treatment volumes.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:701-707, 2024.

Factors associated with unknown primary status in head and neck squamous cell carcinoma

OBJECTIVES

Head and neck cancer of unknown primary (CUP) poses significant therapeutic challenges. We compare CUP and oropharyngeal primary (OP) cases to identify factors associated with tumor detection.

METHODS

The 2004-2019 National Cancer Database was queried to identify CUP and OP cases based on clinical and pathologic TNM staging. Clinical and demographic characteristics were compared by primary detection and HPV status with descriptive statistics. Multivariable logistic regression models to characterize OP detection were constructed. Among HPV-positive and negative patients, respectively, OP and CUP patients were matched by clinical nodal disease. Cox proportional-hazards models were constructed using matched cohorts to characterize survival.

RESULTS

81,053 CUP and OP cases were identified; 64.3 % were HPV-positive. OP detection increased over time in HPV-positive and negative disease. HPV-positive status had higher odds of OP detection (odds ratio (OR) = 1.77, p < 0.001), while females (OR = 0.95, p = 0.008), and black (OR = 0.82, p < 0.001) and Asian (OR = 0.7, p < 0.001) patients had lower odds compared to males and whites, respectively. In HPV-positive and negative disease, OP patients had higher 2 and 5-year survival rates than CUP (p < 0.001). Primary detection status conferred lower death risk in HPV-positive (hazard ratio (HR) = 0.85, p < 0.001) and negative disease (HR = 0.87, p < 0.001) when controlling for age, sex, race, comorbidities, insurance, treatment facility, and income.

CONCLUSION

In the largest cohort of CUP to date, we report a survival benefit in primary tumor detection regardless of HPV status. Groups with higher persistent CUP rates, including non-white, female, HPV-negative, and low income patients, may benefit from increased diagnostic workup to improve detection and treatment.

Stratifying risk of malignancy in cystic lateral neck lumps: a multivariant analysis of demographic, radiological and histological investigation factors and the development of a patient-centred risk-predictive tool for malignancy

BACKGROUND

Management of lateral cystic neck masses with no apparent upper aerodigestive tract primary tumour in adults is controversial. Imaging modalities and fine needle aspiration cytology often struggle to distinguish the presence of malignancy.

METHOD

This study entailed a multicentre retrospective review of all patients with isolated lateral cystic neck masses from 2012 to 2018 in three Welsh health boards, utilising demographic data and first-line investigations (ultrasound scanning and fine needle aspiration cytology) to develop an evidence-based predictive tool for risk of malignancy.

RESULTS

It was found that 29.1 per cent of cystic lesions were malignant on final histology. Age, male gender, non-benign ultrasound scan findings and fine needle aspiration cytology were significant risk factors on univariate analysis. The final multivariate analysis predicted a risk of malignancy ranging from 2.1 to 65.0 per cent depending on the covariate pattern. Smoking status was non-significant.

CONCLUSION

A rigorous, risk-stratified approach to the management of these patients should aid the clinician in minimising morbidity and optimising resources.

A Systematic Review of Diagnostic and Prognostic Biomarkers for Head and Neck Cancer of Unknown Primary: An Unmet Clinical Need

Head and neck cancer of unknown primary (HNCUP) is defined as cervical lymph node metastases without a detectable primary tumor. The management of these patients presents a challenge to clinicians since guidelines in the diagnosis and treatment of HNCUP remain controversial. An accurate diagnostic workup is fundamental for the search for the hidden primary tumor to allow the best adequate treatment strategy. The purpose of this systematic review is to present the currently available data about the diagnostic and prognostic molecular biomarkers for HNCUP. Systematic research in an electronic database was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol and identified 704 articles, of which 23 studies were selected and included in the analysis. Fourteen studies investigated HNCUP diagnostic biomarkers and focused on the human papilloma virus (HPV) and the Epstein-Barr virus (EBV) due to the strong associations with oropharyngeal cancer and nasopharyngeal cancer, respectively. HPV status was shown to possess prognostic value, correlating with longer disease-free survival and overall survival. HPV and EBV are the only available HNCUP biomarkers, and they are already used in clinical practice. A better characterization of the molecular profiling and the development of tissue-of-origin classifiers are necessary to improve the diagnosis, staging, and therapeutic management of patients with HNCUP.

Updates in the management of unknown primary of the head and neck

Squamous cell carcinoma (SCC) from an unknown primary tumor (SCCUP) accounts for 2.0%–5.0% of all head and neck cancers. SCCUP presents as enlarged cervical lymph nodes without evidence of a primary tumor upon physical examination. Primary site detection is important to target treatment and avoid treatment-related morbidity. In this review, we discuss updates in SCCUP management. Diagnostic workup should focus on localization of the primary tumor in SCCUP. Initial workup centers on neck biopsy to confirm the presence of SCC. Given the increasing incidence of HPV-related SCC in the oropharynx, HPV testing is crucial. An HPV-positive status can localize the tumor to the oropharynx, a common site for occult tumors. Imaging includes neck CT and/or MRI, and PET/CT. After imaging, panendoscopy, palatine tonsillectomy or diagnostic transoral robotic surgery can facilitate high rates of primary tumor localization. Primary tumor localization influences treatments administered. SCCUP has traditionally been treated aggressively with large treatment fields to all potential disease sites, which can induce weight loss and swallowing dysfunction. As a result, primary localization can reduce radiation fields and provide possible de-escalation to primary surgical management. Advances in intensity-modulated radiation therapy and dose management also have the potential to improve functional outcomes in SCCUP patients. Given the improved prognosis associated with HPV-positive SCCs, HPV tumor status may also inform future treatment de-intensification to reduce treatment-related toxicity.

Advancement in the Oropharyngeal Primary Unknown Cancer Diagnostic and Current Treatments Pathway: A Narrative Review

Objective: The objective of this article is to define a correct diagnostic pathway for oropharyngeal cancer of unknown primary (OPCUP) identification. Background: OPCUP represents one of the most frequent causes of neck metastases onset without the identification of the primary tumor. Therefore, there is a high percentage of late or missing diagnoses, resulting in treatment delay or in a wrong therapeutic process. The up-to-date diagnostic procedures can help us to begin therapies at the right time. Methods: This is a review of the latest articles about diagnostic pathways in the OPCUP. A selection of the references was carried out in PubMed, EMBASE, Cochrane, and CENTRAL electronic databases. Conclusion: The oropharynx represents the most common site of primary unknown head and neck cancer (HNCUP). Recent epidemiologic data reported an increasing incidence of HNCUP related to human papilloma virus positive squamous cell carcinoma. Positron emission tomography combined with computerized tomography scanning or magnetic resonance imaging allows for improving the detection of primary unknown tumors and distant and locoregional metastases. Finally, the introduction of the trans-oral robotic surgical approach has introduced a new role of surgery in the HNCUP diagnosis and treatment. Hence, the new technological improvement allows reaching in most HNCUP patients an early diagnosis, achieving targeted management and better treatment outcomes, as well as decreasing toxicity and the side effects of treatment options.

Postoperative Examination of Laryngeal Malignant Tumor Based on Narrowband Imaging Resolution Enhancement Technology

The application of endoscopic imaging in the biopsy of malignant laryngeal lesions is one of the current research hotspots in the medical field. Based on the narrowband imaging resolution enhancement technology, a model for postoperative examination of laryngeal malignant tumor was constructed in this paper. The article calculated the biopsy detection rate of malignant lesions and the correct biopsy detection rate of the two groups and made a statistical comparison. In the NBI mode group, the mucosal morphology and superficial mucosal microvascular morphology of the same lesion under two different modes of white light and NBI were compared, which solved the problem of data processing of cases. During the case comparison process, patients who needed biopsies to be sent for pathology were selected for inclusion in the study and were randomly divided into two groups. The coincidence rate of EUS combined with NBI diagnosis was significantly higher than that of ordinary white light gastroscopy (47.92%), and the difference was statistically significant (P=0.000 < 0.05). The experimental results compared the accuracy of the normal white light mode and the NBI mode to diagnose the nature of the lesions: according to the Kudo classification criteria, 23 cases of tumor lesions were to be diagnosed in the normal white light mode, with an accuracy rate of 69.70%, and the NBI mode was to be used to diagnose tumors. There were 81 cases of sexual lesions, with an accuracy rate of 93.94%. The NBI mode was more accurate in diagnosing the nature of the lesions under the Kudo classification standard (P < 0.05). In 64 cases, the accuracy rate was 63.63%. Under the NBI mode, 29 cases of tumor lesions were proposed to be diagnosed, and the accuracy rate was 87.88% to promote the application of NBI endoscopy in the biopsy of malignant laryngeal lesions.