To the Editor Hatten et al1 hypothesize 2 potential roles of transoral robotic surgery-assisted endoscopy (TORS-AE) for deintensification in the treatment of patients presenting with metastatic carcinoma of the neck from an unknown primary site (CUP).
The first role is to eliminate chemotherapy in most cases, and even radiation in some cases. However, it is the neck dissection, not the TORS-AE, that impacts the treatment decisions. Historically, neck dissection (with or without adjuvant radiation) was the principal approach for patients with CUP. Other than mimicking the transition in the past 2 decades to chemoradiation as the approach for oropharyngeal cancer, it is difficult to pinpoint a specific discovery in the treatment of CUP that led many to forsake neck dissection. Three decades ago, Wang and colleagues2 reported on an approach of neck dissection with or without adjuvant treatment. Over one-third of the 157 cases reported in the study were treated with neck dissection alone, with a 5-year survival of 86% (in an era that predated the human papillomavirus [HPV] epidemic). In addition, although National Comprehensive Cancer Network guidelines do include chemoradiation as an option, the evidence for the addition of chemotherapy to radiation in the treatment of CUP is sparse.
Garden AS, Morrison WH. Transoral Robotic Surgery-Assisted Endoscopy. JAMA Otolaryngol Head Neck Surg. 2017;143(10):1058–1059. doi:10.1001/jamaoto.2017.1185
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