A patient has HPV-negative metastatic squamous carcinoma in a level II node. PET-CT identifies no primary; examination under anaesthesia is planned. Which additional step most improves the chance of detecting a small mucosal primary?
Occult upper-aerodigestive primaries may lie in tonsillar tissue. The search should be systematic and multidisciplinary, not limited to random superficial biopsies.
A. Directed biopsies including bilateral tonsillectomy and lingual-tonsil assessment according to the specialist pathway: Occult upper-aerodigestive primaries may lie in tonsillar tissue. The search should be systematic and multidisciplinary, not limited to random superficial biopsies.
B. Open node excision before mucosal assessment: This can compromise later neck management without locating the primary.
C. Observation until the primary becomes obvious: Delay may lose a curative treatment window.
D. Empirical antibiotics for a presumed infected node: Confirmed nodal carcinoma requires oncological staging.
E. Radiotherapy without attempting primary localisation: Treatment can proceed when necessary, but localisation can inform treatment volume and counselling.
If EBV-associated non-keratinising carcinoma were found, the nasopharynx would become the priority primary site.
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