title: Management of human papillomavirus-related unknown primaries of the head and neck with a transoral surgical approach.
abstract: BACKGROUND
  Amidst a rising incidence of p16-positive (p16+) oropharyngeal cancer, a significant number of cases present as regionally metastatic disease with an "unknown" primary. Preliminary data support transoral surgery as an effective method of primary detection/treatment.
  
  
  METHODS
  An observational cohort study of 65 p16+ unknown primary patients treated with transoral surgery and neck dissection (2001-2012) was performed. Adjuvant therapy and recurrence data were collected. Kaplan-Meier estimates were computed for disease-specific survival (DSS) and overall survival (OS).
  
  
  RESULTS
  The primary detection rate was 89% (58 of 65). Five-year DSS and OS were 98% and 97% for the detected group and 100% for the undetected, respectively. Seventeen patients were treated with surgery alone. Of the 47 patients receiving adjuvant therapy, radiation to the pharynx was spared in 36.
  
  
  CONCLUSIONS
  The transoral approach was highly effective for the diagnosis and treatment of the p16+ unknown primary and laid the foundation for deescalated radiation by elimination of the pharyngeal field.
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Washington University in St. Louis, St. Louis, Missouri.
authors.forename: Evan M
authors.initials: EM
authors.lastname: Graboyes
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Washington University in St. Louis, St. Louis, Missouri.
authors.forename: Parul
authors.initials: P
authors.lastname: Sinha
authors.affiliation: Department of Radiation Oncology, Washington University in St. Louis, St. Louis, Missouri.
authors.forename: Wade L
authors.initials: WL
authors.lastname: Thorstad
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Washington University in St. Louis, St. Louis, Missouri.
authors.forename: Jason T
authors.initials: JT
authors.lastname: Rich
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Washington University in St. Louis, St. Louis, Missouri.
authors.forename: Bruce H
authors.initials: BH
authors.lastname: Haughey
mesh_terms: D000328:Adult; D000368:Aged; D059248:Chemoradiotherapy / Q000379:methods*; D015331:Cohort Studies; D003131:Combined Modality Therapy; D016208:Databases, Factual; D018572:Disease-Free Survival; D005260:Female; D005500:Follow-Up Studies; D006258:Head and Neck Neoplasms / Q000401:mortality / Q000556:secondary / Q000628:therapy* / Q000821:virology*; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008866:Microsurgery / Q000379:methods; D008875:Middle Aged; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods*; D009382:Neoplasms, Unknown Primary / Q000401:mortality / Q000473:pathology* / Q000601:surgery; D009959:Oropharyngeal Neoplasms / Q000401:mortality / Q000473:pathology / Q000628:therapy / Q000821:virology; D027383:Papillomaviridae / Q000302:isolation & purification; D030361:Papillomavirus Infections / Q000175:diagnosis / Q000628:therapy; D018570:Risk Assessment; D016019:Survival Analysis; D014062:Tongue Neoplasms / Q000401:mortality / Q000473:pathology / Q000628:therapy / Q000821:virology; D016896:Treatment Outcome; D014412:Tumor Virus Infections / Q000175:diagnosis / Q000401:mortality / Q000628:therapy
keywords: human papillomavirus (HPV); p16; transoral laser microsurgery (TLM); transoral robotic surgery (TORS); unknown primary