Initial Direct Laryngoscopy Versus TORS Alone for Unknown Primary HPV+ Oropharyngeal Squamous Cell Carcinoma

Abstract

Objective: This study aims to determine whether initial direct laryngoscopy with biopsy (DLBx) before transoral robotic surgery (TORS) has differences in perioperative outcomes, tumor identification, and oncologic outcomes for unknown primary oropharyngeal human papillomavirus (HPV+) squamous cell carcinoma (OPSCC). Study design: A retrospective cohort. Setting: A single-institution, tertiary referral center. Methods: All patients with HPV+ squamous cell carcinoma and unknown primary (cTx) undergoing TORS from 2014 to 2024 were collected. Patients receiving DLBx + TORS versus TORS alone were compared. Results: A total of 57 patients had no evidence of primary disease on exam, flexible laryngoscopy, and PET/CT imaging, of which 20 (35%) underwent TORS + neck dissection without previous DLBx. Primary tumor was identified on 38% of DLBx and 74% of combined primary and secondary TORS. Only 19% of all cTx patients remained true unknown primary on final pathology (pT0). Demographics and perioperative courses were similar between the two groups. TORS was able to detect primary tumor in the majority of tongue base disease (83%). There were no differences in overall primary tumor size (median 0.8 vs. 1.0 cm), nodal burden, tumor, node, metastasis classification, adjuvant treatment, or 5-year disease-free survival. Conclusion: Initial DLBx for unknown primary HPV+ OPSCC has similar perioperative and oncologic outcomes to performing initial TORS alone and may unnecessarily delay definitive surgery and add healthcare costs. Level of evidence: IV.