A 60-year-old male with a 2 cm firm neck node at level II, no identifiable primary on examination, is found on PET-CT to have no primary. Biopsy shows squamous cell carcinoma, p16 positive. The most appropriate next step is:
- A Neck dissection alone
- B Panendoscopy and random biopsies of the oropharynx with ipsilateral tonsillectomy ✓
- C Empirical chemoradiation to whole pharyngeal axis
- D Wait and observe for 6 months
Correct answer: B. Panendoscopy and random biopsies of the oropharynx with ipsilateral tonsillectomy
Explanation
P16-positive squamous cell carcinoma of an unknown primary in a level II node strongly suggests an HPV-related oropharyngeal primary. The recommended work-up includes panendoscopy under anaesthesia with directed biopsies and ipsilateral (or bilateral) tonsillectomy, as the primary is found in the tonsil in 20–30% of cases on tonsillectomy. PET-CT has already excluded distant disease. Empirical chemoradiation before primary identification forgoes potential definitive surgical management.
Reference: Dhingra Diseases of Ear, Nose and Throat, 7th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.