Approach to the Patient with Unknown Primary Squamous Cell Carcinoma of the Head and Neck
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Head and Neck Cancer (CP Rodriguez, Section Editor)
Approach to the Patient with Unknown Primary Squamous Cell Carcinoma of the Head and Neck Jennifer Moy Ryan Li* Address * Department of Otolaryngology - Head and Neck Surgery, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road PV01, Portland, OR, 97239-3098, USA Email: [email protected]
* Springer Science+Business Media, LLC, part of Springer Nature 2020
This article is part of the Topical Collection on Head and Neck Cancer Keywords HPV I Oropharyngeal cancer I Unknown primary I Head and neck cancer
Opinion statement Head and neck cancer of unknown primary (HNCUP) is increasingly encountered in both community otolaryngology practice and the academic head and neck cancer program. A stepwise diagnostic evaluation will identify many primary sites. However, true HNCUP remains common in high-volume practices after appropriate examination, imaging, and biopsies. The prognosis for the majority of the patients is good, owing to the common association with high-risk HPV, and putative oropharyngeal primary origin. With high oncologic control rates, judicious treatment selection is essential to optimize functional outcomes.
Introduction Head and neck cancer of unknown primary (HNCUP) encompasses 2–5% of all head and neck cancers, with a rising incidence in concert with the rise in HPV-related oropharyngeal cancers [1–3]. However, the incidence is likely lower with advances in imaging and diagnostic procedures to identify the primary site, with 50–80% of cases identified in the
palatine tonsils and base of the tongue [4]. Metastatic cervical nodal disease can primarily originate from other sites as well, and the clinician should consider cutaneous, thyroid, nasopharyngeal, hematologic, thoracic, and even abdominal-pelvic sites. Only squamous cell carcinoma will be discussed in this chapter. The natural history of HNCUP may be
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variable, with potential reasons including small primary tumor volume and slow growth rate, or even involution [5, 6]. However, a rational approach to identify the primary site is important to help guide efficient treatment and minimize treatment-related morbidity. The National Comprehensive Cancer Network (NCCN) published clinical practice guidelines for the management of HNCUP in 2018. In early
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2020, the American Society of Clinical Oncology (ASCO) likewise published evidence-based recommendations for diagnosis and management of HNCUP [7]. This chapter will review a systematic approach to the diagnosis and treatment of HNCUP with a focus on the most recently published literature while providing an overview of outcomes from current treatment strategies to date.
Diagnostic approaches Evaluation of the upper aerodigestive tract HNCUP typically presents with a painless enlarging neck mass with minimal additional symptoms. It most commonly affects males in the fifth and sixth decades with little to no prior tobacco or alcohol exposure. Initial assessment should include a t
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