Mistry et al39
2020
UK
RS
28
Negative Ex, imaging inc PETCT.
67.8% (19/28)
47% (9/19) (3 in BOT and tonsil)
37% (7/19)
16% (3/19) synchronous BOT and tonsil. 5% CL LT (3 in BOT and tonsil) 82.6% 100% in OP primary
10.3% (n=3) bleed - Cx
TORS TBM promising technique proffers high yield. Well tolerated with min morbidity
Ryan et al15 2019 USA RS 110 PETCT, PE and Biopsy, tonsillectomy then TORS TBM (not all negative) 66% with TORS, 44% before 57% (8/14) 36% (17/47) 17% (2/12 BL TE) in palatine tonsils 73% (80/110) Stepwise approach primary identification inc. tonsillectomy and TORS TBM
Hatten et al40
2017
USA
RS
60
MRI/CT negative. PETCT. PE and Biopsy, IL tonsillectomy, then IL TBM. If HPV positive CL not resected.
80% (48/60)
58% (28/48)
38% (18/48)
92% (55/60) enrolled at least one marker
13% (8/60): 5% post-op bleed (6% of these RTT)
TOR assisted endoscopy useful technique to identify and de-intensification Tx. Imp identification primary
Geltzeiler et al al41
2017
USA
RS
64
Negative Ex, flexible nasolaryngoscopy, CT &/or PETCT. DL, TORS LT UL/BL +/- PT UL or BL 80% (51/64) 74% (37/50) ID TORS alone 22% (14/64) DL alone
86.5% (32/37)
13.5% (5/37)
12% CL BOT (3/25 underwent BL BOT)
96% (n=48)
6% (3/50) 4% - RTT bleeding 2% peri-op feeding tube Further h 16% gastrostomy feeding 6/12
Operative laryngoscopy and TORS efficacious localising primary. Standardised surgical technique increases diagnostic yield and decreasing negative margin rate
TLM
Authors Year Origin Study Design N CT/MRI/PETCT Primary Yield BOT Tonsil Synchronous HPV Complications Recommendations
Herruer et al42
2020
Canada
PS
61
PETCT and intraoperative identification. TLM IL PT, IL TBM, CL tonsil, CL TBM
90.1% (55/61) combined PETCT and TLM.
91.9% (57/61)
27.9% (17 complications in 15 patients) overall - not all TLM TLM: 12 Delayed recovery swallow - 5 DC NGT, 1 OP bleed (Cx), 3 Neck haematoma 1 chyle leak.
PETCT localised tumour less half cases. Addition of TLM improved identification (90%). Intra-op frozen section margin assessment shown potential with specificity 92% compared to final histology. As a result adjuvant therapy avoided almost 1/3 pts
Kuta et al43 2017 Canada PS 27 Ex negative. PETCT (not all negative). TLM Biopsy. IL PT and TBM 92.6% (25/27) 48% (12/25) 52% (13/25) 92.6% (25/27) Study demonstrated the efficacy of PETCT TLM protocol detection and therapeutic perspective
Graboyes et al44
2015
USA
CS
65
Negative ex, CT/MRI &/or PETCT. Rigid pharyngoscopy and directed Biopsy. If negative IL PT, IL TBM and CL 1cm (Maj TLM small min TOR after microscopy)
89% (58/65)
41.5% (27/65)
52.3% (34/65)
5% (3/58) synchronous IL palatine and lingual tonsil n=2, BL palatine tonsil 1)
100% (65/65) inclusion criteria
16.9% (11) surgery related): 9.2% (n=6) post-op haemorrhage - surgery or embolisation 7.7% (n=5) shoulder weakness n=9: CRT complications
11/65 from Karni et al (n=30). Transoral approach highly effective Dx and Tx P16 positive HNSCCUP and laid foundation for for de-escalation
Nagel et al16
2014
USA
RS
52
Traditional approach inc. PT vs TLM approach IL tonsil, IL TBM then CL
Overall 75% (39/52). TLM protocol 86.1% (31/36) Traditional 50% (8/16)
65% (n=26)
27.5% (n=11)
2.3% (n=1 both palatine tonsils)
Lingual 92% Palatine 100%
2.8% haemorrhage requiring RTT (n=1). ?Temporary swallow dysfunction
Surgical algorithm UK primary inc TLM-assisted techniques, including TBM, offers greatest likelihood detecting CUP
Karni et al17
2013
USA
RS cohort
30 (18 TLM)
TLM vs traditional (+/- PT) TLM: IL tonsil, IL TBM
94.4% TLM (17/18), 25% (3/12) traditional
60% (12/20)
35% (7/20)
1/20 in NP and HP (21 complete tumours)
TLM MX occult primary high detection rates and high levels DFS. Detects and treats