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Comment & Response
October 2017

Transoral Robotic Surgery-Assisted Endoscopy—Reply

Author Affiliations
  • 1School of Medicine, Department of Otorhinolaryngology–Head & Neck Surgery, University of Maryland, Baltimore
  • 2Department of Otorhinolaryngology–Head & Neck Surgery, University of Pennsylvania School of Medicine, Philadelphia
  • 3Department of Radiation Oncology, University of Pennsylvania School of Medicine, Philadelphia
JAMA Otolaryngol Head Neck Surg. 2017;143(10):1059. doi:10.1001/jamaoto.2017.1188

In Reply We appreciate Drs Garden and Morrison’s interest in our recently published article reviewing the surgical experience of transoral robotic surgery-assisted endoscopy (TORS-AE) for carcinoma of unknown primary (CUP).

We agree with their recommendations to reduce the utilization of chemotherapy for CUP. Currently, many community and academic centers offer concurrent chemoradiation therapy for CUP. In our opinion, this treatment evolution has mirrored the increasing use of chemoradiation for oropharyngeal cancer. Reports now find over 90% of CUPs are human papillomavirus (HPV)-associated squamous cell carcinomas.1 Coupled with the fact that over 90% of HPV-associated cancers are found in the oropharynx justifies HPV-associated CUP being reclassified as an oropharyngeal cancer in the eighth edition of the American Joint Committee on Cancer’s Cancer Staging Manual. With this knowledge, TORS-AE was designed to identify and resect these occult oropharyngeal cancers that can be as small as millimeters in size and otherwise not identifiable. Therefore, by identifying the primary in 80% of cases with TORS-AE, the radiation field size, with or without chemotherapy, is smaller, the dose or radiation is lower, and chemotherapy is avoided in a considerable percentage of cases.