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A tonsillectomy and tongue base mucosectomy is becoming increasingly accepted as the optimal surgical intervention to aid in identifying the primary source of a p16+ / HPV-related squamous cell carcinoma (SCC) of unknown origin, given that this disease almost exclusively arises in the oro-pharynx. Transoral robotic surgery (TORS) is considered the ideal method of performing a resection of the tongue base mucosa, owing to its ability to provide superior visualisation and manipulation of this region compared to conventional techniques. This study sought to assess the impact of TORS on tumour detection and overall survival for patients with HPV+ SCC of unknown primary (HNCUP) by interrogating the US National Cancer Database from 2004 to 2017. In total, 3716 patients with HPV+ HNCUP were identified, of whom 481 (12.9%) received TORS. The proportion of cases treated with TORS increased from 6.9% in 2010 to 18.1% in 2017. A lower proportion of patients who underwent TORS received radiotherapy and/or chemotherapy compared to those treated with non-robotic surgery. The primary tumour was identified in 95.9% of patients who received TORS compared to 53.9% who did not. The five-year overall survival was also significantly higher for patients treated with TORS versus no robotic surgery (95.4% vs. 84.0%). The most commonly identified primary sites were the tonsils (59.8%) and base of tongue (23.7%). Whilst the methodology of this study is susceptible to selection bias and unmeasured confounders, the large number of patients included does provide fairly robust data in support of the observation that the use of TORS in the workup of HPV+ HNCUP is associated with higher rates of tumour identification and improved overall survival.

Transoral robotic surgery in HPV+ oropharyngeal cancer of unknown primary.
Roman KM, Nguyen C, Torabi SJ, et al.
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Christopher Burgess

Musgrove Park Hospital, Taunton, UK.

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