A Standardized Algorithm's Impact on Primary Detection in Head and Neck Carcinoma of Unknown Primary

Objective(s): National guidelines for HPV-associated head and neck squamous cell carcinoma of unknown primary (HNSCCUP) were adapted into a standardized institutional diagnostic algorithm. This study evaluated the impact of algorithm implementation on primary site detection, treatment selection, and oncologic outcomes. Study Design: Retrospective implementation study. Setting: Single tertiary-care cancer center. Methods: We reviewed patients with clinically occult, PET/CT nonlocalizing HPV-associated HNSCCUP treated before (2014-2021) and after (2022-2023) implementation of the algorithm. Results: Among 139 patients, those treated after algorithm implementation (n = 33) were more likely to undergo robotic ipsilateral lingual ± palatine tonsillectomy rather than bilateral palatine tonsillectomy, resulting in higher mucosal detection rates (88% vs 59%, P =.003). Postimplementation patients were more likely to receive primary surgical rather than nonsurgical treatment (54% vs 20%, P <.001) and unilateral radiotherapy without elective contralateral nodal irradiation (78% vs 43.5%, P =.002). Algorithm implementation was associated with a fourfold increase in the odds of primary site detection (OR 4.1, 95% CI 1.3-13.0, P =.018); however, detection rates also increased in HNSCCUPs not managed with robotic surgery, from 57% to 87% (P =.04). After implementation, 21.2% of patients received surgery alone compared with 5.7% prior, while postoperative chemoradiation was used in 9.1% versus 3.8%, respectively. No locoregional failures have occurred since implementation. Conclusion: Implementation of a standardized diagnostic algorithm for HPV-associated HNSCCUP significantly improved primary site detection and altered treatment without compromising disease control. Improvements in detection were not fully explained by the use of robotic surgery. Potential functional benefits warrant further study. Level of Evidence: 4.