Cervical lymph node metastasis from an unknown primary: is a tonsillectomy necessary?

Oncologic rationale for bilateral tonsillectomy in head and neck squamous cell carcinoma of unknown primary source

OBJECTIVE

To demonstrate an oncologic basis for the recommendation to perform bilateral tonsillectomy as a routine measure in the search for a primary mucosal lesion in patients presenting with cervical nodal metastasis of squamous cell carcinoma (SCC).

STUDY DESIGN

A case series of individuals selected from a 3-year period is reported.

SETTING

Academic medical center.

RESULTS

Each individual presented with metastatic squamous cell carcinoma in a cervical lymph node from an unknown primary source. In each case, the primary source was identified in a tonsillectomy specimen, either located contralateral to the node, or in both tonsils.

CONCLUSIONS

The rate of contralateral spread of metastatic cancer from occult tonsil lesions appears to approach 10%. For this reason, bilateral tonsillectomy is recommended as a routine step in the search for the occult primary in patients presenting with cervical metastasis of SCC and palatine tonsils intact.

Use of a coincidence gamma camera to detect primary tumor with 18fluoro-2-deoxy-glucose in cervical lymph node metastases from an unknown origin

This study was performed to evaluate the ability of a dual-head gamma camera with 18fluoro-2-deoxy-glucose coincidence detection emission tomography (FDG-CDET) to detect primary tumors in patients with cervical lymph node metastases of head and neck squamous cell carcinoma from an unknown origin. From 60 patients with untreated head and neck squamous cell carcinoma, we selected 4 in whom no evidence of the primary's origin was found by the conventional methods used for the evaluation of head and neck tumors. In addition to the panendoscopy, chest radiography, a computed tomography (CT) scan, and FDG-CDET were performed. Both FDG-CDET and the CT scan located cervical lymph node metastases. In addition, FDG-CDET located the primary tumor in 3 of the 4 patients, and the tumors were confirmed with histopathologic findings. In contrast, the CT scan detected the primary tumor in none of them. FDG tomography performed on a coincidence gamma camera appears to be a successful new tool in detecting occult primary tumors in head and neck carcinoma, and is useful in guiding endoscopic biopsies. It has, further, the important potential ability to detect distant metastases on whole body images.

Tonsillectomy in diagnosis of the unknown primary tumor of the head and neck

OBJECTIVES

The purpose of this study was to discuss the experience of one tumor registry with performing tonsillectomy in the diagnostic approach to unknown head and neck primary tumors. It also describes the importance of including tonsillectomy in this evaluation algorithm.

STUDY DESIGN

A retrospective chart review was done of 68 patients with either tonsillar or unknown primary squamous cell carcinoma culled from 829 patients seen from 1956 to 1996 at the head and neck tumor registry at the Naval Medical Center San Diego.

METHODS

Records from the head and neck tumor registry, radiation oncology service, and pathology department were reviewed with attention to presenting symptom, initial examination, diagnostic studies performed, and type and result of biopsies performed.

RESULTS

Thirty-four patients sought treatment for a neck lymph node metastasis of squamous cell carcinoma without an identifiable primary tumor site. Six of these (18%) had the primary site diagnosed by performing tonsillectomy ipsilateral to the presenting neck mass. Six of 14 T1 tonsillar carcinomas in this series had the primary site identified by tonsillectomy.

CONCLUSIONS

Despite a diligent search, a primary tumor site may not be found in the head and neck cancer patient. The tonsil may harbor an occult squamous cell carcinoma. The patient benefits from identification of the initial tumor site because postoperative irradiation ports may be reduced and because surveillance for recurrence may be improved. For these reasons, tonsillectomy should be performed ipsilateral to the presenting cervical metastasis if no other primary tumor site is identified.

Diagnostic evaluation of squamous cell carcinoma metastatic to cervical lymph nodes from an unknown head and neck primary site

BACKGROUND

The purpose of this study was to evaluate the efficacy of the modern diagnostic evaluation for squamous cell carcinoma metastatic to cervical lymph nodes from an unknown head and neck primary site.

METHODS

One hundred thirty patients were evaluated between June 1983 and June 1997. All underwent head and neck examinations, head and neck computed tomography (CT), and/or magnetic resonance imaging (MRI) scans, panendoscopies, and biopsies of head and neck mucosal sites. Twenty-four patients underwent 2-[fluorine-18]-2-deoxy-D-glucose (FDG) single photon emission computed tomography (SPECT); 34 patients underwent tonsillectomy.

RESULTS

The primary site was identified in 56 patients (43%); the likelihood was increased in patients with suggestive findings on physical examination and/or radiographic evaluation. Eighty-three percent of the lesions were located in the tonsillar fossa and base of tongue. Results of FDG-SPECT scans were positive in 20 patients (83%); the primary tumor was detected in 7 patients (35%). Twelve (35%) of 34 patients who underwent tonsillectomy had a primary tumor discovered in the tonsillar fossa. Multivariate analysis of successful primary site detection revealed that suggestive findings on physical examination (p= .0225) and suggestive findings on CT and/or MRI (p = .0013) were significantly related to this end point.

CONCLUSION

The primary lesion will be detected in over 40% of patients with physical examination of the head and neck and CT and/or MRI followed by panendoscopy and biopsies. Limited data pertaining to FDG-SPECT suggest that this provides additional useful information in a small subset of patients. Tonsillectomy is useful for those with suggestive findings on physical examination and/or radiographic evaluation.