Transoral laser microsurgery: a new approach for unknown primaries of the head and neck

Objectives/hypothesis: To evaluate the efficacy of transoral laser microsurgery (TLM) used at examination under anesthesia (EUA) for detection and management of an unidentified primary site and to determine survival with both TLM EUA and traditional rigid pharyngolaryngoscopy EUA, with directed biopsies.

Study design: Comparative retrospective review of patients who underwent two different procedures, TLM EUA and traditional EUA, to identify a primary site.

Methods: Thirty patients presenting with occult primary met the study criteria. Eighteen underwent TLM EUA and 12 underwent traditional EUA. We collected data on the treatment approach, detection rate of the primary site, neck dissection, postoperative radiotherapy, and disease-free survival (DFS).

Results: The primary site detection rate with TLM EUA was 94% (17 of 18) and with traditional EUA was 25% (3 of 12). Overall, the occult primary was identified in 20 of 30 patients. The majority of patients (95%) had a primary in the oropharynx (19 of 20). Sixteen occult primaries in the TLM EUA group were immediately resected with TLM. At median follow-up of 30 months, there was no recurrence in the TLM EUA group. There was a 41.6% (5 of 12) recurrence rate in traditional EUA group. The Kaplan-Meier 5-year DFS was 100% for the TLM EUA group and 44% for the traditional EUA group (log rank value = 0.0006).

Conclusions: TLM management of occult primary malignancies allowed high detection rates of primary tumor and was associated with a high level of DFS. Application of TLM during EUA both detects and treats the primary and may decrease the number of patients requiring wide-field irradiation.