title: The use of ultrasound in the search for the primary site of unknown primary head and neck squamous cell cancers.
abstract: BACKGROUND
  Although human papillomavirus detection in cervical lymph nodes of head and neck squamous cell cancers (HNSCC) of unknown primary site (UP) is indicative of a primary tumor of the oropharynx (OP), localization can remain elusive. Therefore, we investigated ultrasonography (US) for the identification of the primary tumor.
  
  
  METHODS
  Eligible cases had HNSCC of UP after evaluation by a head and neck surgical oncologist. Controls were healthy volunteers. Transcervical and intraoral ultrasonography was performed by a standard protocol using convex (3.75-6.0 MHz and 5-7.5 MHz) transducers. US findings were compared with operative examination (exam under anesthesia, direct laryngoscopy) and biopsies. The primary outcome of interest was the presence or absence of a lesion on US.
  
  
  RESULTS
  10 cases and 20 controls were enrolled. PET/CT scans were negative/nonspecific (9), or suspicious (1) for a primary lesion. On US, predominantly hypoechoic (9 of 10) lesions were visualized consistent with base of tongue (n=7) or tonsil (n=3) primary tumors. On operative examination, 5 of 10 were appreciated. Two additional primaries were confirmed with biopsies "directed" by preoperative US. This represents an overall diagnostic rate of 70%, which is 20% higher than our detection rate for 2008-2010. The three cases in which a suspicious lesion was visualized on US, yet remained UP despite further interventions, could represent false positives, misclassification or operator variability. No lesions were suspected among the controls.
  
  
  CONCLUSIONS
  Ultrasound has promise for detection of UPs of the OP and therefore warrants further investigation.
authors.affiliation: Department of Otolaryngology - Head and Neck Surgery, Division of Head and Neck Surgery, Johns Hopkins Medicine, Baltimore, MD, United States; Milton J. Dance Jr. Head and Neck Center, Johns Hopkins Head and Neck Surgery, Baltimore, MD, United States; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States. Electronic address: cfakhry@jhmi.edu.
authors.forename: Carole
authors.initials: C
authors.lastname: Fakhry
authors.affiliation: Department of Otolaryngology - Head and Neck Surgery, Division of Head and Neck Surgery, Johns Hopkins Medicine, Baltimore, MD, United States.
authors.forename: Nishant
authors.initials: N
authors.lastname: Agrawal
authors.affiliation: Department of Otolaryngology - Head and Neck Surgery, Division of Head and Neck Surgery, Johns Hopkins Medicine, Baltimore, MD, United States; Milton J. Dance Jr. Head and Neck Center, Johns Hopkins Head and Neck Surgery, Baltimore, MD, United States.
authors.forename: Joseph
authors.initials: J
authors.lastname: Califano
authors.affiliation: Milton J. Dance Jr. Head and Neck Center, Johns Hopkins Head and Neck Surgery, Baltimore, MD, United States.
authors.forename: Barbara
authors.initials: B
authors.lastname: Messing
authors.affiliation: Department of Otolaryngology - Head and Neck Surgery, Division of Head and Neck Surgery, Johns Hopkins Medicine, Baltimore, MD, United States.
authors.forename: Jia
authors.initials: J
authors.lastname: Liu
authors.affiliation: Department of Otolaryngology - Head and Neck Surgery, Division of Head and Neck Surgery, Johns Hopkins Medicine, Baltimore, MD, United States; Milton J. Dance Jr. Head and Neck Center, Johns Hopkins Head and Neck Surgery, Baltimore, MD, United States.
authors.forename: John
authors.initials: J
authors.lastname: Saunders
authors.affiliation: Department of Otolaryngology - Head and Neck Surgery, Division of Head and Neck Surgery, Johns Hopkins Medicine, Baltimore, MD, United States; Milton J. Dance Jr. Head and Neck Center, Johns Hopkins Head and Neck Surgery, Baltimore, MD, United States.
authors.forename: Patrick
authors.initials: P
authors.lastname: Ha
authors.affiliation: Department of Radiology, Johns Hopkins Medicine, Baltimore, MD, United States.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Coquia
authors.affiliation: Department of Radiology, Johns Hopkins Medicine, Baltimore, MD, United States.
authors.forename: Ulrike
authors.initials: U
authors.lastname: Hamper
authors.affiliation: Department of Internal Medicine, Ohio State University Comprehensive Cancer Center, Columbus, OH, United States.
authors.forename: Maura
authors.initials: M
authors.lastname: Gillison
authors.affiliation: Department of Otolaryngology - Head and Neck Surgery, Division of Head and Neck Surgery, Johns Hopkins Medicine, Baltimore, MD, United States; Milton J. Dance Jr. Head and Neck Center, Johns Hopkins Head and Neck Surgery, Baltimore, MD, United States.
authors.forename: Ray
authors.initials: R
authors.lastname: Blanco
mesh_terms: D000328:Adult; D000368:Aged; D002294:Carcinoma, Squamous Cell / Q000000981:diagnostic imaging* / Q000556:secondary; D016022:Case-Control Studies; D005260:Female; D006258:Head and Neck Neoplasms / Q000000981:diagnostic imaging* / Q000556:secondary; D006801:Humans; D008297:Male; D008875:Middle Aged; D009382:Neoplasms, Unknown Primary / Q000000981:diagnostic imaging*; D014463:Ultrasonography
keywords: Head and neck cancer; Human papillomavirus (HPV); Oropharynx neoplasm; Ultrasonography; Unknown primary