Unknown/Occult Primary Cancers (CUP) of Head & Neck: Panendoscopy, biopsies and tonsillectomy

  • Prior imaging to direct biopsies to suspicious areas increases diagnostic yield
  • Nasopharynx
    • Normal nasopharyngoscopy findings: no need to biopsy
    • Biopsy nasopharynx under local (LA) or general anaesthesia (GA) if
      • Suspicious nasopharyngoscopy findings
      • Suspicious CT or MRI
      • EBV +ve node
      • Nasopharyngoscopy not available / mirror exam only
      • Level V nodes & otitis media with effusion (OME)
  • Panendoscopy
    • Oesophagoscopy, laryngoscopy, pharyngoscopy
    • Palpate tonsils and base of tongue
    • Re-examine looking for bleeding after initial palpation of tonsil and base of tongue and retraction of tonsillar pillars
  • Tissue biopsies
    • Biopsy clinically or radiologically suspicious areas
    • Some advocate transoral lingual tonsillectomy: robotic / non-robotic with Lindholm scope, telescope, and extension on long Bovie tip
    • Note
      • May be impossible to distinguish normal lingual / pharyngeal tonsil tissue from HPV related basaloid SCC
      • Primary may be hidden in tonsillar crypts
    • If imaging not readily available / unhelpful
      • Bilateral tonsillectomy (10 – 23% contralateral tonsil primary)
      • Multiple biopsies of base of tongue or lingual tonsillectomy with CO2 laser / electrocautery / TORS

Index: Clinical Practice Guidelines for CUP

Resource Appropriate CUP Guideline Scenarios