Controversies. Nancy L. Snyderman, MD, Editor . Cervical metastatic squamous carcinoma of unknown or occult primary source

Whether to accept the report of the referring physician is often a stumbling block for many otolaryngologist-head and neck surgeons, especially when management of the case is changing hands. Thus, it is no surprise that all the consultants would repeat the examination of the upper aerodigestive tract under anesthesia. Drs. Robbins and Fried objected to the term "blind" biopsies and preferred "random-guided" and "directed" biopsies is that order. Yet, all 3 specialists agree that multiple biopsies of Waldeyer's ring should be obtained. They emphasize that palpation is an integral part of the endoscopy and may guide the surgeon in deciding where to biopsy. The surgeons agree that the base of tongue has the highest yield in cases like this one. Dr. Robbins stands alone in his use of ipsilateral tonsillectomy as a screening biopsy technique. Dr. Robbins believes imaging studies have a role prior to the initial panendoscopy and prefers an MRI of the head and neck. Drs. Gluckman and Fried use imaging studies if the primary tumor is in a clinically difficult area to evaluate. Faced with a normal repeat endoscopy and no other cervical adenopathy, Drs. Fried and Robbins would treat Waldeyer's ring and both sides of the neck with radiotherapy; Dr. Fried suggests 60 to 65 Gy over 6 weeks and Dr. Robbins suggests 65 to 70 Gy over 6 to 7 weeks to Waldeyer's ring and the upper neck but would treat the remaining nodal areas of the neck with 50 Gy over 5 weeks.(ABSTRACT TRUNCATED AT 250 WORDS)