Cummings Michael A, Ma Sung Jun, Van Der Sloot Paul, Milano Michael T, Singh Deepinder P, Singh Anurag K
Department of Radiation Oncology, University of Rochester, Rochester, NY, USA.
Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA.
Ann Transl Med. 2021 Feb;9(4):284. doi: 10.21037/atm-20-4631.
Squamous cell carcinoma of unknown primary of the head and neck region is a known entity described mainly by retrospective reports. We searched a hospital-based registry to better describe the changing incidence, and to assess diagnostic and treatment strategies.
The National Comprehensive Cancer Database was queried for head and neck cancers from oropharynx, tonsil, tongue, larynx, hypopharynx primary sites with a designation of clinical T0, representing an unknown primary. Kaplan Meier, Cox multivariate models, and propensity matched cohorts were used to assess significant factors for overall survival.
There were 964 cases that met the criteria, and 468 cases with known treatments, staging, and survival data. The incidence increased over time, with the highest rates supported in the last 5 years. In patients who underwent HPV testing, 72% were positive. Patients with AJCC 7 clinical N2c or N3 disease had significantly worse outcomes despite the majority receiving neck dissection, radiation, and chemotherapy. Local surgery, compared to incisional or excisional biopsy, had the highest diagnostic yield of finding a primary tumor. In multivariate models, no combination of surgical approach, radiation, or systemic therapy was significantly associated with improved survival. This remained true in 1:1 propensity matched cohorts for age, comorbidities, and clinical nodal burden. In a subset of cN1 patients, combined chemoradiation therapy after excisional biopsy or local surgery was associated with (not statistically significant) improved survival compared to radiation alone (P=0.054).
The incidence of unknown primary head and neck carcinoma is increasing, and current cases have a high proportion of HPV positivity. HPV positivity predicts strongly for a tonsil primary. Local surgery was associated with the highest diagnostic yield. Clinical nodal burden strongly predicts for overall outcome, and type of treatment facility is an important driver of survival. A subset of cN1 patients may benefit from the addition of chemotherapy to radiation.
头颈部原发灶不明的鳞状细胞癌是一种已知的疾病实体，主要通过回顾性报告进行描述。我们检索了一个基于医院的登记处，以更好地描述发病率的变化，并评估诊断和治疗策略。
查询国家综合癌症数据库中来自口咽、扁桃体、舌、喉、下咽等头颈部癌症的原发部位，指定临床T0表示原发灶不明。采用Kaplan Meier法、Cox多变量模型和倾向匹配队列来评估总生存的显著因素。
有964例符合标准，468例有已知的治疗、分期和生存数据。发病率随时间增加，过去5年支持率最高。在接受HPV检测的患者中，72%呈阳性。AJCC 7期临床N2c或N3疾病的患者预后明显较差，尽管大多数患者接受了颈部清扫、放疗和化疗。与切取活检或切除活检相比，局部手术发现原发肿瘤的诊断率最高。在多变量模型中，手术方式、放疗或全身治疗的任何组合均与生存率提高无显著相关性。在年龄、合并症和临床淋巴结负担的1:1倾向匹配队列中也是如此。在cN1患者亚组中，切除活检或局部手术后联合放化疗与单纯放疗相比（无统计学意义）生存率有所提高（P=0.054）。
头颈部原发灶不明的癌发病率正在增加，目前病例中HPV阳性比例较高。HPV阳性强烈提示扁桃体原发。局部手术的诊断率最高。临床淋巴结负担强烈预测总体预后，治疗机构类型是生存的重要驱动因素。cN1患者亚组可能从放疗联合化疗中获益。
