title: Transoral Robotic Surgery-Assisted Endoscopy With Primary Site Detection and Treatment in Occult Mucosal Primaries.
abstract: Management of cervical lymph node metastasis without a known primary tumor is a diagnostic and treatment challenge for head and neck oncologists. Identification of the occult mucosal primary tumor minimizes the morbidity of treatment.
  
  
  
  To analyze the role of transoral robotic surgery (TORS) in facilitating the identification of a primary tumor site for patients presenting with squamous cell carcinoma of unknown primary (CUP). In addition, we assessed treatment deintensification by determining the number of patients who did not undergo definitive radiation therapy and chemotherapy.
  
  
  
  In this retrospective case series from January 2011 to September 2015, 60 consecutive patients with squamous cell CUP who underwent TORS-assisted endoscopy and ipsilateral neck dissection were included from an academic medical center and studied to study the rate success rate of TORS identifying occult mucosal malignancy.
  
  
  
  Success rate of identifying occult mucosal malignancy; usage of radiation therapy and chemotherapy.
  
  
  
  Overall, 60 patients (mean [SD] age, 55.5 [8.9] years) were identified; 48 of the 60 patients (80.0%) had a mucosal primary identified during their TORS-assisted endoscopic procedure. The mean (SD) size of the identified mucosal primary lesions was 1.3 (0.1) cm. All mucosal primaries, when found, originated in the oropharynx including the base of tongue in 28 patients (58%), palatine tonsil in 18 patients (38%), and glossotonsillar sulcus in 2 patients (4%). Among patients in this study, 40 (67%) did not receive chemotherapy, and 15 (25%) did not receive radiation therapy.
  
  
  
  Advances in transoral surgical techniques have helped identify occult oropharyngeal malignancies that traditionally have been treated with comprehensive radiation to the entire pharyngeal axis. We demonstrate the efficacy of a TORS-assisted approach to identify and surgically treat the primary tumor in patients presenting with CUP. In addition, patients managed with the TORS-assisted endoscopic approach benefit from surgical and pathological triage, which in turn results in deintensification of treatment by eliminating the need for chemotherapy in the majority of patients, as well as avoiding radiation therapy in select patients.
authors.affiliation: Department of Otorhinolaryngology-Head & Neck Surgery, University of Maryland School of Medicine, Baltimore.
authors.forename: Kyle M
authors.initials: KM
authors.lastname: Hatten
authors.affiliation: Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania School of Medicine, Philadelphia.
authors.forename: Bert W
authors.initials: BW
authors.lastname: O'Malley
authors.affiliation: Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania School of Medicine, Philadelphia.
authors.forename: Andres M
authors.initials: AM
authors.lastname: Bur
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Emory University Hospital Midtown, Atlanta, Georgia.
authors.forename: Mihir R
authors.initials: MR
authors.lastname: Patel
authors.affiliation: Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania School of Medicine, Philadelphia.
authors.forename: Christopher H
authors.initials: CH
authors.lastname: Rassekh
authors.affiliation: Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania School of Medicine, Philadelphia.
authors.forename: Jason G
authors.initials: JG
authors.lastname: Newman
authors.affiliation: Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania School of Medicine, Philadelphia.
authors.forename: Steven B
authors.initials: SB
authors.lastname: Cannady
authors.affiliation: Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania School of Medicine, Philadelphia.
authors.forename: Ara A
authors.initials: AA
authors.lastname: Chalian
authors.affiliation: Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania School of Medicine, Philadelphia.
authors.forename: Benjamin L
authors.initials: BL
authors.lastname: Hodnett
authors.affiliation: Department of Radiation Oncology, University of Pennsylvania School of Medicine, Philadelphia.
authors.forename: Alexander
authors.initials: A
authors.lastname: Lin
authors.affiliation: Department of Radiation Oncology, University of Pennsylvania School of Medicine, Philadelphia.
authors.forename: John N
authors.initials: JN
authors.lastname: Lukens
authors.affiliation: Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia.
authors.forename: Roger B
authors.initials: RB
authors.lastname: Cohen
authors.affiliation: Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia.
authors.forename: Joshua M
authors.initials: JM
authors.lastname: Bauml
authors.affiliation: Department of Pathology and Laboratory Medicine, University of Pennsylvania School of Medicine, Philadelphia.
authors.forename: Kathleen T
authors.initials: KT
authors.lastname: Montone
authors.affiliation: Department of Pathology and Laboratory Medicine, University of Pennsylvania School of Medicine, Philadelphia.
authors.forename: Virginia A
authors.initials: VA
authors.lastname: Livolsi
authors.affiliation: Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania School of Medicine, Philadelphia.
authors.forename: Gregory S
authors.initials: GS
authors.lastname: Weinstein
mesh_terms: D000328:Adult; D000368:Aged; D002294:Carcinoma, Squamous Cell / Q000000981:diagnostic imaging / Q000556:secondary* / Q000601:surgery; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D057605:Natural Orifice Endoscopic Surgery; D037981:Neck Dissection; D009382:Neoplasms, Unknown Primary / Q000000981:diagnostic imaging* / Q000601:surgery*; D009959:Oropharyngeal Neoplasms / Q000000981:diagnostic imaging / Q000556:secondary* / Q000601:surgery; D012189:Retrospective Studies; D065287:Robotic Surgical Procedures