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Hardman JC, Constable J, Dobbs S, Hogan C, Hulse K, Khosla S, Milinis K, Tudor-Green B, Williamson A, Paleri V. Survival outcomes in head and neck squamous cell carcinoma of unknown primary: A national cohort study. Clin Otolaryngol 2024. [PMID: 38766691 DOI: 10.1111/coa.14167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 03/14/2024] [Accepted: 04/07/2024] [Indexed: 05/22/2024]
Abstract
INTRODUCTION To investigate factors influencing survival in head and neck squamous cell carcinoma of unknown primary (HNSCCUP). METHODS A retrospective observational cohort study was conducted, over 5 years from January 2015, in UK Head and Neck centres, of consecutive adults undergoing 18F-Fluorodeoxyglucose-PET-CT within 3 months of diagnosis with metastatic cervical squamous cell carcinoma. Patients treated as HNSCCUP underwent survival analysis, stratified by neck dissection and/or radiotherapy to the ipsilateral neck, and by HPV status. RESULTS Data were received from 57 centres for 965 patients, of whom 482 started treatment for HNSCCUP (65.7% HPV-positive, n = 282/429). Five-year overall survival (OS) for HPV-positive patients was 85.0% (95% CI 78.4-92.3) and 43.5% (95% CI 32.9-57.5) for HPV-negative. HPV-negative status was associated with worse OS, disease-free (DFS), and disease-specific (DSS) survival (all p < .0001 on log-rank test) but not local control (LC) (p = .16). Unilateral HPV-positive disease treated with surgery alone was associated with significantly worse DFS (p < .0001) and LC (p < .0001) compared to radiotherapy alone or combined modalities (5-year DFS: 24.9%, 82.3% and 94.3%; 5-year LC: 41.8%, 98.8% and 98.6%). OS was not significantly different (p = .16). Unilateral HPV-negative disease treated with surgery alone was associated with significantly worse LC (p = .017) (5-year LC: estimate unavailable, 93.3% and 96.6%, respectively). Small numbers with bilateral disease precluded meaningful sub-group analysis. CONCLUSIONS HPV status is associated with variable management and outcomes in HNSCCUP. Unilateral neck disease is treated variably and associated with poorer outcomes when managed with surgery alone. The impact of diagnostic oropharyngeal surgery on primary site emergence, survival and functional outcomes is unestablished.
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Affiliation(s)
- John C Hardman
- Head and Neck Unit, The Royal Marsden Hospital, London, UK
| | - James Constable
- Department of Otolaryngology, Head and Neck Surgery, Gloucestershire Royal Hospital, Gloucester, UK
| | - Sian Dobbs
- Manchester Royal Infirmary, Manchester Foundation Trust, Manchester, UK
| | - Christopher Hogan
- Department of Otolaryngology, Head and Neck Surgery, Basildon University Hospital, Basildon, UK
| | - Kate Hulse
- Department of Otolaryngology, Head and Neck Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Shivun Khosla
- Department of Otolaryngology, Head and Neck Surgery, Royal Surrey County Hospital, Guildford, UK
| | - Kristijonas Milinis
- Liverpool Head and Neck Centre, Liverpool University Foundation Trust, Liverpool, UK
| | - Ben Tudor-Green
- Department of Otorhinolaryngology-Head & Neck Surgery, Derriford Hospital, Plymouth, UK
| | - Andrew Williamson
- Department of Otolaryngology, Head and Neck Surgery, Monklands University Hospital, Glasgow, UK
| | - Vinidh Paleri
- Head and Neck Unit, The Royal Marsden Hospital, London, UK
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Prediction of extranodal extension in oropharyngeal cancer patients and carcinoma of unknown primary: value of metabolic tumor imaging with hybrid PET compared with MRI and CT. Eur Arch Otorhinolaryngol 2023; 280:1973-1981. [PMID: 36471046 DOI: 10.1007/s00405-022-07765-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 11/23/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The aim of this study was to investigate the value of metabolic tumor imaging using hybrid PET for the preoperative detection of extranodal extension (ENE) in lymph node metastases of oropharyngeal squamous cell carcinoma (OPSCC). METHODS We performed a retrospective analysis of a consecutive cohort of patients with OPSCC treated with primary surgery with or without adjuvant (chemo-) radiotherapy at the Kantonsspital Sankt-Gallen and the University Hospital Zurich, Switzerland, from 2010 until 2019. Hybrid PET was compared to conventional cross-sectional imaging with MRI and CT. Histopathological presence of ENE of neck dissection specimen served as gold standard. RESULTS A total number of 234 patients were included in the study, 95 (40.6%) of which had pathological ENE (pENE). CT has a good specificity with 93.7%; meanwhile, MRI was the most sensitive diagnostic method (72.0%). The nodal metabolic tumor parameters (SUVmax, TLG, MTV) were significantly higher in patients with positive ENE (p < 0.001 for all three parameters) than in patients with negative ENE (p < 0.001, for all three parameters). CONCLUSIONS CT achieved the best specificity, while MRI had the best sensitivity to detect ENE. Nodal metabolic tumor parameters differed significantly between ENE-positive/negative and p16-positive/negative patients. Hence, quantitative data obtained by metabolic imaging might predict presence of ENE and, therefore, could be helpful in customizing therapy management.
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Pouyiourou M, Regnery S, Bochtler T, Herfarth K, Krämer A. [Cancer of unknown primary (CUP)-single-site, oligometastatic, and in the head and neck region]. RADIOLOGIE (HEIDELBERG, GERMANY) 2023; 63:358-365. [PMID: 36944857 DOI: 10.1007/s00117-023-01133-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 02/20/2023] [Indexed: 03/23/2023]
Abstract
INTRODUCTION About 20% of all cancer of unknown primary (CUP) cases can be classified into favorable subgroups, which are defined by either obvious analogies to certain cancers with a known primary or amenability to local ablative treatment. In the updated European Society for Medical Oncology (ESMO) guidelines for diagnosis and treatment of CUP, the definition of favorable subgroups has been revised according to the latest scientific findings. In particular, the definition and treatment of oligometastatic CUP have undergone considerable changes in recent years. Thus, we delineate the current diagnostic and therapeutic standards for the two favorable CUP subtypes single-site/oligometastatic and head/neck CUP. METHODS The classification, diagnostic workup, and treatment of single-site and oligometastatic CUP are summarized based on the current ESMO and American Society of Clinical Oncology (ASCO) guidelines together with a literature review. CONCLUSIONS Single-site and oligometastatic CUP is defined by the presence of a maximum of five metastases that are amenable to local ablative treatment. Median overall survival is favorable and exceeds 4 years after local ablation of all detectable metastases. Lymph node metastases in the head and neck region represent a frequent scenario of single-site CUP. They usually originate from human papillomavirus (HPV)-associated squamous cell carcinoma in the oropharynx. Diagnostic workup comprises computed tomography (CT), magnetic resonance imaging (MRI) if necessary, and fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT), followed by panendoscopy and biopsies of suspicious mucosal sites. Neck dissection, potentially followed by adjuvant radiotherapy, and definitive radiotherapy represent equally effective oncological treatment options with respect to a favorable prognosis.
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Affiliation(s)
- Maria Pouyiourou
- Klinische Kooperationseinheit Molekulare Hämatologie/Onkologie, Deutsches Krebsforschungszentrum (DKFZ) und Medizinische Klinik V, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 280, 69120, Heidelberg, Deutschland.
- Medizinische Klinik V, Universitätsklinikum Heidelberg, Heidelberg, Deutschland.
| | - Sebastian Regnery
- Abteilung für Radioonkologie und Strahlentherapie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland.
| | - Tilmann Bochtler
- Klinische Kooperationseinheit Molekulare Hämatologie/Onkologie, Deutsches Krebsforschungszentrum (DKFZ) und Medizinische Klinik V, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 280, 69120, Heidelberg, Deutschland
- Medizinische Klinik V, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
- Medizinische Onkologie, Nationales Centrum für Tumorerkrankungen (NCT) Heidelberg, Heidelberg, Deutschland
| | - Klaus Herfarth
- Abteilung für Radioonkologie und Strahlentherapie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland
| | - Alwin Krämer
- Klinische Kooperationseinheit Molekulare Hämatologie/Onkologie, Deutsches Krebsforschungszentrum (DKFZ) und Medizinische Klinik V, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 280, 69120, Heidelberg, Deutschland
- Medizinische Klinik V, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
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Meulemans J, Voortmans J, Nuyts S, Daisne JF, Clement P, Laenen A, Delaere P, Van Lierde C, Poorten VV. Cervical squamous cell carcinoma of unknown primary: Oncological outcomes and prognostic factors. Front Oncol 2022; 12:1024414. [DOI: 10.3389/fonc.2022.1024414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 10/26/2022] [Indexed: 11/15/2022] Open
Abstract
Background/ObjectivesCervical squamous cell carcinoma of unknown primary (SCCUP) is a rare entity within head and neck cancer and both treatment regimens as well as identified potential predictors for oncological outcomes vary between published series. In this study, we evaluated oncological outcomes and identified potential prognostic factors for outcome.Patients and methodsThis retrospective monocentric cohort study includes 82 SCCUP patients diagnosed and treated between January 2000 and June 2021. Overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS) and locoregional recurrence-free survival (LRFS) were evaluated. The Cox proportional hazards model was used to analyze the prognostic effect of patient and tumor characteristics on oncological outcomes.ResultsFive year OS, DSS, DFS and LRFS were respectively 53.9%, 72.2%, 68.9% and 67.3%. The p16 status was evaluated in 55 patients with 40% being p16 positive. On univariable analysis, p16 negative SCCUPs had significantly worse survival and recurrence rates in the presence of clinical extranodal extension (cENE) (OS: p=0.0013, DSS: p=0.0099, DFS: p=0.0164, LRFS: p=0.0099) and radiological extranodal extension (rENE) (OS: p=0.0034, DSS: p=0.0137, DFS: p=0.0167, LRFS: p=0.0100). In p16 positive SCCUP patients, rENE had a significantly negative prognostic effect on DFS (p=0.0345) and LRFS (p=0.0367). Total group multivariate analysis identified rENE as an independent negative predictor for all oncological outcomes. The “number of positive lymph nodes” was a second independent predictor for DSS (p=0.0257) and DFS (p=0.0435).ConclusionsWe report favorable oncological outcomes, comparable to previously published results. Although the presence of rENE seems associated with poor oncological outcomes, the differential effect of clinical, radiological and pathological ENE in both p16 positive and negative subgroups remain to be elucidated by further prospective research.
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Factors Influencing the Outcome of Head and Neck Cancer of Unknown Primary (HNCUP). J Clin Med 2022; 11:jcm11102689. [PMID: 35628814 PMCID: PMC9143827 DOI: 10.3390/jcm11102689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 05/03/2022] [Accepted: 05/06/2022] [Indexed: 11/17/2022] Open
Abstract
Background: This study on patients with head and neck cancer of unknown primary (HNCUP) assesses the impact of surgical and non-surgical treatment modalities and the tumour biology on the oncological outcome. Methods: A total of 80 patients with HNCUP (UICC I−IV) were treated with simultaneous neck dissection followed by adjuvant therapy, between 1 January 2007 and 31 March 2020. As the primary objective, the influence of treatment modalities on the overall survival (OS), the disease-specific survival (DSS) and the progression-free survival (PFS) were analysed in terms of cox regression and recursive partitioning. The tumour biology served as secondary objectives. Results: The 5-year OS for the entire cohort was 67.7%, (95% CI: 54.2−81.2%), the 5-year DSS was 82.3% (72.1−92.5%) and the 5-year PFS was 72.8% (61.8−83.8%). Cox regression revealed that patients undergoing adjuvant radiotherapy only had a four times higher risk to die compared to patients receiving chemoradiation therapy (HR = 4.45 (1.40; 14.17), p = 0.012). The development of distant metastases had a significantly negative impact on OS (HR = 8.24 (3.21−21.15), p < 0.001) and DSS (HR = 23.79 (6.32−89.56), p < 0.001). Recursive portioning underlined the negative influence of distant metastases on OS (3.2-fold increase in death probability) and DSS (4.3-fold increase in death probability), while an UICC stage of IVb increased the risk for further progression of the disease by a factor of 2. Conclusions: The presence of distant metastases as well as adjuvant treatment with radiation without concomitant chemotherapy, were among others, significant predictors for the overall survival of HNCUP patients, with distant metastases being the most significant predictor.
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Balk M, Rupp R, Mantsopoulos K, Allner M, Grundtner P, Mueller SK, Traxdorf M, Eckstein M, Speer S, Semrau S, Fietkau R, Iro H, Hecht M, Gostian AO. Relevance of the time interval between surgery and adjuvant radio (chemo) therapy in HPV-negative and advanced head and neck carcinoma of unknown primary (CUP). BMC Cancer 2021; 21:1236. [PMID: 34794411 PMCID: PMC8600706 DOI: 10.1186/s12885-021-08885-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 10/12/2021] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION In contrast to head and neck squamous cell carcinoma (HNSCC), the effect of treatment duration in HNSCC-CUP has not been thoroughly investigated. Thus, this study aimed to assess the impact of the time interval between surgery and adjuvant therapy on the oncologic outcome, in particular the 5-year overall survival rate (OS), in advanced stage, HPV-negative CUPs at a tertiary referral hospital. 5-year disease specific survival rate (DSS) and progression free survival rate (PFS) are defined as secondary objectives. MATERIAL AND METHODS Between January 1st, 2007, and March 31st, 2020 a total of 131 patients with CUP were treated. Out of these, 59 patients with a confirmed negative p16 analysis were referred to a so-called CUP-panendoscopy with simultaneous unilateral neck dissection followed by adjuvant therapy. The cut-off between tumor removal and delivery of adjuvant therapy was set at the median, i.e. patients receiving adjuvant therapy below or above the median time interval. RESULTS Depending on the median time interval of 55 days (d) (95% CI 51.42-84.52), 30 patients received adjuvant therapy within 55 d (mean 41.69 d, SD = 9.03) after surgery in contrast to 29 patients at least after 55 d (mean 73.21 d, SD = 19.16). All patients involved in the study were diagnosed in advanced tumor stages UICC III (n = 4; 6.8%), IVA (n = 27; 45.8%) and IVB (n = 28; 47.5%). Every patient was treated with curative neck dissection. Adjuvant chemo (immune) radiation was performed in 55 patients (93.2%), 4 patients (6.8%) underwent adjuvant radiation only. The mean follow-up time was 43.6 months (SD = 36.7 months). The 5-year OS rate for all patients involved was 71% (95% CI 0.55-0.86). For those patients receiving adjuvant therapy within 55 d (77, 95% CI 0.48-1.06) the OS rate was higher, yet not significantly different from those with delayed treatment (64, 95% CI 0.42-0.80; X2(1) = 1.16, p = 0.281). Regarding all patients, the 5-year DSS rate was 86% (95% CI 0.75-0.96). Patients submitted to adjuvant treatment in less than 55 d the DSS rate was 95% (95% CI 0.89-1.01) compared to patients submitted to adjuvant treatment equal or later than 55 d (76% (95% CI 0.57-0.95; X2(1) = 2.32, p = 0.128). The 5-year PFS rate of the entire cohort was 72% (95% CI 0.59-0.85). In the group < 55 d the PFS rate was 78% (95% CI 0.63-0.94) and thus not significantly different from 65% (95% CI 0.45-0.85) of the group ≥55 d; (X2(1) = 0.29, p = 0.589). CONCLUSIONS The results presented suggest that the oncologic outcome of patients with advanced, HPV-negative CUP of the head and neck was not significantly affected by a prolonged period between surgery and adjuvant therapy. Nevertheless, oncologic outcome tends to be superior for early adjuvant therapy.
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Affiliation(s)
- Matthias Balk
- Department of Otolaryngology, Head & Neck Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, 91054, Erlangen, Germany.
| | - Robin Rupp
- Department of Otolaryngology, Head & Neck Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, 91054, Erlangen, Germany
| | - Konstantin Mantsopoulos
- Department of Otolaryngology, Head & Neck Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, 91054, Erlangen, Germany
| | - Moritz Allner
- Department of Otolaryngology, Head & Neck Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, 91054, Erlangen, Germany
| | - Philipp Grundtner
- Department of Otolaryngology, Head & Neck Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, 91054, Erlangen, Germany
| | - S K Mueller
- Department of Otolaryngology, Head & Neck Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, 91054, Erlangen, Germany
| | - Maximilian Traxdorf
- Department of Otolaryngology, Head & Neck Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, 91054, Erlangen, Germany
| | - Markus Eckstein
- Department of Pathology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Stefan Speer
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Sabine Semrau
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Heinrich Iro
- Department of Otolaryngology, Head & Neck Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, 91054, Erlangen, Germany
| | - Markus Hecht
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Antoniu-Oreste Gostian
- Department of Otolaryngology, Head & Neck Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, 91054, Erlangen, Germany
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Heianna J, Makino W, Hirakawa H, Agena S, Tomita H, Ariga T, Ishikawa K, Takehara S, Maemoto H, Murayama S. Therapeutic efficacy of selective intra-arterial chemoradiotherapy with docetaxel and nedaplatin for fixed bulky nodal disease in head and neck cancer of unknown primary. Eur Arch Otorhinolaryngol 2021; 279:3105-3113. [PMID: 34628548 DOI: 10.1007/s00405-021-07121-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 10/01/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Fixed bulky nodal disease in patients with head and neck cancer of unknown primary (HNCUP) remains difficult to treat. This retrospective study evaluated the therapeutic efficacy of selective intra-arterial chemoradiotherapy with docetaxel and nedaplatin for fixed bulky nodal disease in HNCUP. METHODS Data from seven consecutive patients with fixed bulky nodal disease in HNCUP who had undergone selective intra-arterial chemoradiotherapy were analyzed. Whole pharyngeal mucosa and all bilateral nodal areas were irradiated (total dose 50 Gy), and bulky nodal lesions were provided an additional 20 Gy. Intra-arterial chemotherapy used a combination of nedaplatin (80 mg/m2) and docetaxel (60 mg/m2). Outcome measures were local control, disease-free survival, overall survival, and adverse events. Statistical analyses were performed using the Kaplan-Meier method. RESULTS Median follow-up period was 24 months (range 9-64). All patients had extracapsular extension (N3b) on imaging and clinical findings. Symptoms due to bulky disease were neck discomfort (100%), tumor bleeding (43%), tracheal obstruction (14%), and carotid sinus syndrome (28%). Median value for maximum diameter of cervical disease was 84 mm (range 70-107), and 3-year local control, disease-free survival, and overall survival rates were 100, 54, and 64%, respectively. Symptoms due to bulky disease disappeared in all patients after intra-arterial chemoradiotherapy. Grade 4 leukopenia occurred in two patients (28%) as an acute adverse event. No other serious acute adverse events were observed. CONCLUSION Selective intra-arterial chemoradiotherapy with docetaxel and nedaplatin can potentially achieve both favorable local control and survival in in HNCUP with fixed bulky nodal disease.
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Affiliation(s)
- Joichi Heianna
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, 207, Uehara, Nishihara, Okinawa, 903-0215, Japan.
| | - Wataru Makino
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, 207, Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Hitoshi Hirakawa
- Department of Otorhinolaryngology, Head and Neck Surgery, Graduate School of Medical Science, University of the Ryukyus, 207, Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Shinya Agena
- Department of Otorhinolaryngology, Head and Neck Surgery, Graduate School of Medical Science, University of the Ryukyus, 207, Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Hayato Tomita
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, 207, Uehara, Nishihara, Okinawa, 903-0215, Japan.,Department of Radiology, St Marianna University School of Medicine, 2-6-1, Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| | - Takuro Ariga
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, 207, Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Kazuki Ishikawa
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, 207, Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Shota Takehara
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, 207, Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Hitoshi Maemoto
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, 207, Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Sadayuki Murayama
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, 207, Uehara, Nishihara, Okinawa, 903-0215, Japan
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Impact of Neck Dissection in Head and Neck Squamous Cell Carcinomas of Unknown Primary. Cancers (Basel) 2021; 13:cancers13102416. [PMID: 34067697 PMCID: PMC8156697 DOI: 10.3390/cancers13102416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 05/06/2021] [Indexed: 11/17/2022] Open
Abstract
Simple Summary A retrospective multicentric study of 322 patients with head and neck cancers of unknown primary (HNCUP) was performed testing the impact of neck dissection (ND) extent on nodal relapse, progression-free survival and survival. After 5 years, the incidence of nodal relapse was 13.4%, and progression-free survival (PFS) was 59.1%. In multivariate analysis after adjusting for nodal stage, the risk of nodal relapse or progression was reduced with lymphadenectomy, selective ND or radical/modified ND but survival rates were similar. Patients undergoing lymphadenectomy or ND had significantly better PFS and a lower nodal relapse incidence in the N1 + N2a group, but the improvement was not significant for the N2b or N2 + N3c patients. Severe toxicity rates exceeded 40% with radical ND. In HNCUP, ND improves PFS regardless of nodal stage but fails to improve survival. The magnitude of the benefit of ND did not appear to depend on ND extent and decreased with a more advanced nodal stage. Abstract Purpose: Management of head and neck cancers of unknown primary (HNCUP) combines neck dissection (ND) and radiotherapy, with or without chemotherapy. The prognostic value of ND has hardly been studied in HNCUP. Methods: A retrospective multicentric study assessed the impact of ND extent (adenectomy, selective ND, radical/radical-modified ND) on nodal relapse, progression-free survival (PFS) or survival, taking into account nodal stage. Results: 53 patients (16.5%) had no ND, 33 (10.2%) had lymphadenectomy, 116 (36.0%) underwent selective ND and 120 underwent radical/radical-modified ND (37.3%), 15 of which received radical ND (4.7%). With a 34-month median follow-up, the 3-year incidence of nodal relapse was 12.5% and progression-free survival (PFS) 69.1%. In multivariate analysis after adjusting for nodal stage, the risk of nodal relapse or progression was reduced with lymphadenectomy, selective or radical/modified ND, but survival rates were similar. Patients undergoing lymphadenectomy or ND had a better PFS and lowered nodal relapse incidence in the N1 + N2a group, but the improvement was not significant for the N2b or N2 + N3c patients. Severe toxicity rates exceeded 40% with radical ND. Conclusion: In HNCUP, ND improves PFS, regardless of nodal stage. The magnitude of the benefit of ND does not appear to depend on ND extent and decreases with a more advanced nodal stage.
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Moy J, Li R. Approach to the Patient with Unknown Primary Squamous Cell Carcinoma of the Head and Neck. Curr Treat Options Oncol 2020; 21:93. [DOI: 10.1007/s11864-020-00791-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2020] [Indexed: 12/18/2022]
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Axelsson L, Holmberg E, Nyman J, Högmo A, Sjödin H, Gebre-Medhin M, von Beckerath M, Ekberg T, Farnebo L, Talani C, Spak LN, Notstam I, Hammerlid E. Swedish National Multicenter Study on Head and Neck Cancer of Unknown Primary: Prognostic Factors and Impact of Treatment on Survival. Int Arch Otorhinolaryngol 2020; 25:e433-e442. [PMID: 34377181 PMCID: PMC8321641 DOI: 10.1055/s-0040-1712106] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 03/25/2020] [Indexed: 12/05/2022] Open
Abstract
Introduction
Head and neck cancer of unknown primary (HNCUP) is a rare condition whose prognostic factors that are significant for survival vary between studies. No randomized treatment study has been performed thus far, and the optimal treatment is not established.
Objective
The present study aimed to explore various prognostic factors and compare the two main treatments for HNCUP: neck dissection and (chemo) radiation vs primary (chemo) radiation.
Methods
A national multicenter study was performed with data from the Swedish Head and Neck Cancer Register (SweHNCR) and from the patients' medical records from 2008 to 2012.
Results
Two-hundred and sixty HNCUP patients were included. The tumors were HPV-positive in 80%. The overall 5-year survival rate of patients treated with curative intent was 71%. Age (
p
< 0.001), performance status (
p
= 0.036), and N stage (
p
= 0.046) were significant factors for overall survival according to the multivariable analysis. Treatment with neck dissection and (chemo) radiation (122 patients) gave an overall 5-year survival of 73%, and treatment with primary (chemo) radiation (87 patients) gave an overall 5-year survival of 71%, with no significant difference in overall or disease-free survival between the 2 groups.
Conclusions
Age, performance status, and N stage were significant prognostic factors. Treatment with neck dissection and (chemo) radiation and primary (chemo) radiation gave similar survival outcomes. A randomized treatment study that includes quality of life is needed to establish the optimal treatment.
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Affiliation(s)
- Lars Axelsson
- Department of Otorhinolaryngology, University of Gothenburg Sahlgrenska Academy, Goteborg, Sweden.,Department of Otorhinolaryngology - Head and Neck Surgery, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Erik Holmberg
- Regional Cancer Center in Western Sweden, Gothenburg, Sweden.,Department of Oncology, University of Gothenburg Sahlgrenska Academy, Gothenburg, Sweden
| | - Jan Nyman
- Department of Oncology, University of Gothenburg Sahlgrenska Academy, Gothenburg, Sweden
| | - Anders Högmo
- Department of Otorhinolaryngology - Head and Neck Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Helena Sjödin
- Department of Oncology, Karolinska University Hospital, Stockholm, Sweden
| | | | - Mathias von Beckerath
- Department of Otorhinolaryngology - Head and Neck Surgery, Örebro University Hospital, Örebro, Sweden
| | - Tomas Ekberg
- Department of Otorhinolaryngology - Head and Neck Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Lisa Farnebo
- Department of Otorhinolaryngology - Head and Neck Surgery, Linköping University Hospital, Linkoping, Sweden
| | - Charbel Talani
- Department of Oncology, Linköping University Hospital, Linkoping, Sweden
| | - Lena Norberg Spak
- Department of Otorhinolaryngology - Head and Neck Surgery, Norrlands University Hospital, Umea, Sweden
| | - Isak Notstam
- Department of Otorhinolaryngology, County Hospital Sundsvall-Harnosand, Sundsvall, Sweden
| | - Eva Hammerlid
- Department of Otorhinolaryngology, University of Gothenburg Sahlgrenska Academy, Goteborg, Sweden.,Department of Otorhinolaryngology - Head and Neck Surgery, Sahlgrenska University Hospital, Goteborg, Sweden
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11
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Ota I, Kitahara T. Cancer of unknown primary in the head and neck: Diagnosis and treatment. Auris Nasus Larynx 2020; 48:23-31. [PMID: 32888761 DOI: 10.1016/j.anl.2020.08.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 08/04/2020] [Accepted: 08/12/2020] [Indexed: 10/23/2022]
Abstract
Cancer of unknown primary in the head and neck is defined by the presence of cancer in one or more lymph nodes within the head and neck region, not confined to the supraclavicular region, without an identifiable primary tumor. These primary sites are increasingly being identified with the help of advanced diagnostic techniques such as endoscopy, PET/CT, the HPV test, the EBV test, evaluation of biomarkers, and pathological examination. However, the remainder of these patients fall into the category of metastatic cervical cancer of unknown primary (MCCUP). MCCUP accounts for approximately 3-5% of all head and neck squamous cell carcinomas (HNSCCs). Moreover, optimal therapy for patients with MCCUP is still controversial. The treatment options range from neck dissection alone to irradiation of the bilateral neck, with or without irradiation of plausible primary sites as well. In future, precision medicine should improve the diagnosis and methods of therapy for MCCUP patients.
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Affiliation(s)
- Ichiro Ota
- Department of Otolaryngology-Head and Neck Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan.
| | - Tadashi Kitahara
- Department of Otolaryngology-Head and Neck Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan
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12
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Abstract
Fluorine-18 (18F)-fluorodeoxyglucose (FDG) positron emission tomography fused with computed tomography (PET/CT) is a valuable tool in surgical planning for head and neck squamous cell carcinoma (HNSCC). If performed prior to biopsy or other surgical intervention, FDG-PET/CT has high sensitivity for the detection of the primary site in patients with cervical lymph node metastases from unknown primary origin and can be used to direct the surgical workup. FDG-PET/CT is superior to CT alone for detection of nodal metastases outside the expected pattern or distant metastases or second primary cancers and can greatly affect determination of appropriate management including surgical eligibility. Prior to the advent of PET/CT, many patients undergoing (chemo)radiation-based therapy had planned post-treatment neck dissection; FDG-PET/CT now has a proven role in the evaluation of recurrent or persistent disease amenable to salvage surgery and enables safe avoidance of planned postradiation neck dissection with a high negative predictive value. Specifically for this important application, two standardized reporting metrics may be used in the head and neck anatomic region: the "Hopkins criteria" and the "Neck Imaging Reporting and Data System"; both systems produce a formalized evaluation and recommendation based on PET/CT findings. The role of PET/CT as a replacement for elective neck dissection or examination under anesthesia remains controversial but deserves further study. FDG-PET/CT has a wide-ranging impact on the surgical management of patients with HNSCC and should be used routinely in patients with unknown primary nodal disease and those presenting with advanced-stage cancers at initial staging and to assess treatment response.
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Affiliation(s)
- Madeleine P Strohl
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, CA
| | - Patrick K Ha
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, CA
| | - Robert R Flavell
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA
| | - Sue S Yom
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA.
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13
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Martinez-Monedero R, Danielian A, Angajala V, Dinalo JE, Kezirian EJ. Methodological Quality of Systematic Reviews and Meta-analyses Published in High-Impact Otolaryngology Journals. Otolaryngol Head Neck Surg 2020; 163:892-905. [PMID: 32450783 DOI: 10.1177/0194599820924621] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To assess the methodological quality of intervention-focused systematic reviews (SRs) and meta-analyses (MAs) published in high-impact otolaryngology journals. DATA SOURCES Ovid Medline, Embase, and Cochrane Library. REVIEW METHODS A comprehensive search was performed for SR and MA citations from 2012 to 2017 in the 10 highest impact factor otolaryngology journals. Abstracts were screened to identify published manuscripts in which the authors indicated clearly that they were performing an SR or MA. Applying a modified typology of reviews, 4 reviewers characterized the review type as SR, MA, or another review type. A simplified version of the AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews 2) tool was used to assess the reporting and methodological quality of the SRs and MAs that were focused on interventions. RESULTS Search and abstract screening generated 499 manuscripts that identified themselves as performing an SR or MA. A substantial number (85/499, 17%) were review types other than SRs or MAs, including 34 (7%) that were literature reviews. In total, 236 SRs and MAs focused on interventions. Over 50% of these SRs and MAs had weaknesses in at least 3 of the 16 items in the AMSTAR 2, and over 40% had weaknesses in at least 2 of the 7 critical domains. Ninety-nine percent of SRs and MAs provided critically low confidence in the results of the reviews. CONCLUSION Intervention-focused SRs and MAs published in high-impact otolaryngology journals have important methodological limitations that diminish confidence in the results of these reviews.
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Affiliation(s)
- Rodrigo Martinez-Monedero
- USC Caruso Department of Otolaryngology-Head & Neck Surgery, Keck School of Medicine of USC, California, USA
| | - Arman Danielian
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Varun Angajala
- Keck School of Medicine of USC, Los Angeles, California, USA
| | - Jennifer E Dinalo
- Health Sciences Libraries, Keck School of Medicine of USC, Los Angeles, California, USA
| | - Eric J Kezirian
- USC Caruso Department of Otolaryngology-Head & Neck Surgery, Keck School of Medicine of USC, California, USA
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14
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Maghami E, Ismaila N, Alvarez A, Chernock R, Duvvuri U, Geiger J, Gross N, Haughey B, Paul D, Rodriguez C, Sher D, Stambuk HE, Waldron J, Witek M, Caudell J. Diagnosis and Management of Squamous Cell Carcinoma of Unknown Primary in the Head and Neck: ASCO Guideline. J Clin Oncol 2020; 38:2570-2596. [PMID: 32324430 DOI: 10.1200/jco.20.00275] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
PURPOSE To provide evidence-based recommendations to practicing physicians and other health care providers on the diagnosis and management of squamous cell carcinoma of unknown primary in the head and neck (SCCUP). METHODS The American Society of Clinical Oncology convened an Expert Panel of medical oncology, surgery, radiation oncology, radiology, pathology, and advocacy experts to conduct a literature search, which included systematic reviews, meta-analyses, randomized controlled trials, and prospective and retrospective comparative observational studies published from 2008 through 2019. Outcomes of interest included survival, local and regional disease control, and quality of life. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations. RESULTS The literature search identified 100 relevant studies to inform the evidence base for this guideline. Four main clinical questions were addressed, which included subquestions on preoperative evaluations, surgical diagnostic and therapeutic procedures, appropriate pathology techniques, and adjuvant therapy. RECOMMENDATIONS Evidence-based recommendations were developed to address preoperative evaluation for patients with a neck mass, surgical diagnostic and therapeutic procedures, appropriate treatment options in unilateral versus bilateral SCCUP.Additional information is available at www.asco.org/head-neck-cancer-guidelines.
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Affiliation(s)
| | | | | | | | | | | | | | - Bruce Haughey
- Advent Health Medical Group, Otolaryngology, Head and Neck Surgery, Celebration, FL, and University of South Florida, Tampa, FL
| | - Doru Paul
- Weill Cornell Medical College, New York, NY
| | | | - David Sher
- University of Texas Southwestern, Dallas, TX
| | | | - John Waldron
- Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Matt Witek
- University of Wisconsin School of Medicine and Public Health, Madison, WI
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15
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Xu C, Yuan J, Du W, Wu J, Fang Q, Zhang X, Li H. Significance of the Neutrophil-to-Lymphocyte Ratio in p16-Negative Squamous Cell Carcinoma of Unknown Primary in Head and Neck. Front Oncol 2020; 10:39. [PMID: 32083001 PMCID: PMC7001523 DOI: 10.3389/fonc.2020.00039] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 01/09/2020] [Indexed: 12/22/2022] Open
Abstract
Objective: The neutrophil-to-lymphocyte ratio (NLR) has been reported to be associated with survival in solid malignancies. The main goal was to evaluate the prognostic significance of the NLR in patients with p16-negative squamous cell carcinoma of unknown primary (SCCUP) in head and neck. Methods: The association between the NLR and clinical pathologic variables was evaluated by the chi-square test. The primary endpoint of interest was disease-specific survival (DSS). Univariate and Coxmodel analyses were used to evaluate prognostic factors. Results: A total of 153 patients were included in the analysis. Cancer cachexia was noted in 10 patients. The mean NLR value was 3.9 (range: 1.4–8.3). A high NLR was significantly associated with cancer cachexia development. The 5-year DSS rate was 58%. In patients with NLRs varying from 1.4 to 3.7, the 5-year DSS rate was 71%; in patients with NLRs varying from 3.7 to 6.0, the 5-year DSS rate was 57%; in patients with NLRs varying from 6.0 to 8.3, the 5-year DSS rate was 39%, and the difference was significant (p = 0.001). Further Cox model analysis confirmed the independence of the NLR in predicting survival. Conclusions: In patients with p16-negative SCCUP, an NLR ≥ 6.0 is significantly associated with worse prognosis.
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Affiliation(s)
- Chunmiao Xu
- Department of Radiology, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Junhui Yuan
- Department of Radiology, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Wei Du
- Department of Head Neck and Thyroid, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Junfu Wu
- Department of Head Neck and Thyroid, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Qigen Fang
- Department of Head Neck and Thyroid, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Xu Zhang
- Department of Head Neck and Thyroid, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Hailiang Li
- Department of Radiology, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
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16
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Pflumio C, Troussier I, Sun XS, Salleron J, Petit C, Caubet M, Beddok A, Calugaru V, Servagi-Vernat S, Castelli J, Miroir J, Krengli M, Giraud P, Romano E, Khalifa J, Doré M, Blanchard N, Coutte A, Dupin C, Sumodhee S, Pointreau Y, Patel S, Rehailia-Blanchard A, Catteau L, Bensadoun RJ, Tao Y, Roth V, Geoffrois L, Faivre JC, Thariat J. Unilateral or bilateral irradiation in cervical lymph node metastases of unknown primary? A retrospective cohort study. Eur J Cancer 2019; 111:69-81. [PMID: 30826659 DOI: 10.1016/j.ejca.2019.01.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 01/02/2019] [Accepted: 01/06/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Patients with cervical lymphadenopathy of unknown primary carcinoma (CUP) usually undergo neck dissection and irradiation. There is an ongoing controversy regarding the extent of nodal and mucosal volumes to be irradiated. We assessed outcomes after bilateral or unilateral nodal irradiation. METHODS This retrospective multicentre study included patients with CUP and squamous cellular carcinoma who underwent radiotherapy (RT) between 2000 and 2015. RESULTS Of 350 patients, 74.5% had unilateral disease and 25.5% had bilateral disease. Of 297 patients with available data on disease and irradiation sides, 61 (20.5%) patients had unilateral disease and unilateral irradiation, 155 (52.2%), unilateral disease and bilateral irradiation and 81 (27.3%), bilateral disease and bilateral irradiation. Thirty-four (9.7%) and 217 (62.0%) patients received neoadjuvant and/or concomitant chemotherapy, respectively. Median follow-up was 37 months. Three-year local, regional, locoregional failure rates and CUP-specific survival were 5.6%, 11.7%, 15.0% and 84.7%, respectively. In patients with unilateral disease, the 3-year cumulative incidence of regional/local relapse was 7.7%/4.3% after bilateral irradiation versus 16.9%/11.1% after unilateral irradiation (hazard ratio = 0.56/0.61, p = 0.17/0.32). The cumulative incidence of CUP-specific deaths was 9.2% after bilateral irradiation and 15.5% after unilateral irradiation (p = 0.92). In multivariate analysis, mucosal irradiation was associated with better local control, whereas no neck dissection, ≥N2b and interruption of RT for more than 4 days were associated with poorer regional control. Toxicity was higher after bilateral irradiation (p < 0.05). No positron-emission tomography-computed tomography, largest node diameter, ≥N2b, neoadjuvant chemotherapy and interruption of RT were associated with poorer cause-specific survival. CONCLUSION Bilateral nodal irradiation yielded non-significant better nodal and mucosal control rates but was associated with higher rates of severe toxicity.
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Affiliation(s)
- Carole Pflumio
- Department of Medical Oncology, Institut de Cancérologie de Lorraine, Vandoeuvre-lès-Nancy, France
| | - Idriss Troussier
- Department of Radiation Therapy, CHU Pitié Salpêtrière, Assistance Publique, Hôpitaux de Paris, Paris, France
| | - Xu Shan Sun
- Department of Radiation Therapy, Hôpital de Montbéliard, Montbéliard, France
| | - Julia Salleron
- Department of Biostatistics and Data Management, Institut de Cancérologie de Lorraine, Vandoeuvre-Lès-Nancy, France
| | - Claire Petit
- Department of Radiation Therapy, Institut Gustave Roussy, Villejuif, France
| | - Matthieu Caubet
- Department of Radiation Therapy, CHU de Besançon, Besançon, France
| | - Arnaud Beddok
- Department of Radiation Therapy, Institut Curie, Paris, France
| | | | | | - Joël Castelli
- Department of Radiation Therapy, Institut Eugène Marquis, Rennes, France
| | - Jessica Miroir
- Department of Radiation Therapy, Institut Jean Perrin, Clermont-Ferrand, France
| | - Marco Krengli
- Department of Radiation Therapy, University of Piemonte Orientale, Pavia, Italy
| | - Paul Giraud
- Department of Radiation Therapy, Hôpital Tenon, Assistance Publique, Hôpitaux de Paris, Paris, France
| | - Edouard Romano
- Department of Radiation Therapy, Hôpital Tenon, Assistance Publique, Hôpitaux de Paris, Paris, France
| | - Jonathan Khalifa
- Department of Radiation Therapy, Institut Universitaire du Cancer, Toulouse, France
| | - Mélanie Doré
- Department of Radiation Therapy, Institut de Cancérologie de l'Ouest, Nantes, France
| | - Nicolas Blanchard
- Department of Radiation Therapy, Clinique les Dentellières, Valenciennes, France
| | | | - Charles Dupin
- Department of Radiation Therapy, Centre Antoine Lacassagne, Nice, France
| | - Shakeel Sumodhee
- Department of Radiation Therapy, Centre Antoine Lacassagne, Nice, France
| | - Yoann Pointreau
- Department of Radiation Therapy, Clinique Victor Hugo, Le Mans, France
| | - Samir Patel
- Department of Radiation Therapy, Mayo Clinic, Arizona, USA
| | | | - Ludivine Catteau
- Department of Radiation Therapy, CHU de Poitiers, Poitiers, France
| | | | - Yungan Tao
- Department of Radiation Therapy, Institut Gustave Roussy, Villejuif, France
| | | | - Lionnel Geoffrois
- Department of Medical Oncology, Institut de Cancérologie de Lorraine, Vandoeuvre-lès-Nancy, France
| | - Jean-Christophe Faivre
- Academic Department of Radiation Therapy, Lorraine Institute of Cancerology, Vandoeuvre-lès-Nancy, France
| | - Juliette Thariat
- Department of Radiation Therapy, Centre Francois Baclesse, Advanced Resource Center for Hadrontherapy in Europe, Caen, France, Unicaen-Normandie Universite.
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17
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Abe M, Watanabe K, Shinozaki-Ushiku A, Ushiku T, Abe T, Fujihara Y, Amano Y, Zong L, Wang CP, Kubo E, Inaki R, Kinoshita N, Yamashita S, Takai D, Ushijima T, Nagase T, Hoshi K. Identification of a metastatic lung adenocarcinoma of the palate mucosa through genetic and histopathological analysis: a rare case report and literature review. BMC Cancer 2019; 19:52. [PMID: 30634950 PMCID: PMC6329170 DOI: 10.1186/s12885-019-5277-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 01/04/2019] [Indexed: 02/08/2023] Open
Abstract
Background Cancers of unknown primary origin (CUPs) are reported to be the 3-4th most common causes of cancer death. Recent years have seen advances in mutational analysis and genomics profiling. These advances could improve accuracy of diagnosis of CUPs and might improve the prognosis of patients with CUPs. Case presentation A 76-year old male with an adenocarcinoma of unknown primary origin in the lung presented with another tumor of the palate mucosa. The tumor cells in the pleural effusion were all negative for immunohistochemical markers (TTF-1 and Napsin A) and lung-specific oncogenic driver alterations (EGFR mutation and ALK translocation). The tumor of the palate mucosa was likewise identified as an adenocarcinoma, and the cells showed cytological similarities with the tumor cells in the pleural effusion; TTF-1, Napsin A, EGFR mutation and ALK translocation were all negative. This result suggested that origins of the tumors of the palate mucosa and in the lung were the same, even though the origin had not yet been determined. Next, we addressed whether the tumor of the palate mucosa was a primary tumor or not. Secretory carcinoma (SC), which is a common type of minor salivary gland tumor (MSGT), was suspected; however, mammaglobin was negative and ETV6-NTRK3 (EN) fusion was not observed. Other MSGTs were excluded based on histological and immunohistochemical findings. Furthermore, an additional examination demonstrated an oncogenic KRAS mutation at codon 12 (p.G12D) in both palate tumor and in pleural effusion. KRAS mutation is known to exist in one-third of lung adenocarcinomas (LUADs), but quite rare in MSGTs. The possibility of metastasis from other organs was considered unlikely from the results of endoscopic and imaging studies. This result indicated that the primary site of the CUP was indeed the lung, and that the tumor of the palate mucosa was a metastasis of the LUAD. Conclusions A tumor of the palate mucosa that showed diagnostic difficulties was determined to be a metastatic LUAD by genomic alterations and histopathological findings. Electronic supplementary material The online version of this article (10.1186/s12885-019-5277-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Masanobu Abe
- Department of Oral & Maxillofacial Surgery, University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan. .,Division for Health Service Promotion, University of Tokyo, Tokyo, Japan.
| | - Kousuke Watanabe
- Department of Respiratory Medicine, University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Aya Shinozaki-Ushiku
- Department of Pathology, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
| | - Tetsuo Ushiku
- Department of Pathology, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
| | - Takahiro Abe
- Department of Oral & Maxillofacial Surgery, University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Yuko Fujihara
- Department of Oral & Maxillofacial Surgery, University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Yosuke Amano
- Department of Respiratory Medicine, University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Liang Zong
- Graduate School of Medicine, the University of Tokyo, Tokyo, Japan.,Department of Gastrointestinal Surgery, Peking University Cancer Hospital & Institute, Beijing, China
| | - Cheng-Ping Wang
- Department of Otolaryngology, National Taiwan University Hospital, Taipei, Taiwan
| | - Emi Kubo
- Division of Epigenomics, National Cancer Center Research Institute, Tokyo, Japan
| | - Ryoko Inaki
- Department of Oral & Maxillofacial Surgery, University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Naoya Kinoshita
- Department of Oral & Maxillofacial Surgery, University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Satoshi Yamashita
- Division of Epigenomics, National Cancer Center Research Institute, Tokyo, Japan
| | - Daiya Takai
- Department of Clinical Laboratory, University of Tokyo Hospital, Tokyo, Japan
| | - Toshikazu Ushijima
- Division of Epigenomics, National Cancer Center Research Institute, Tokyo, Japan
| | - Takahide Nagase
- Department of Respiratory Medicine, University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kazuto Hoshi
- Department of Oral & Maxillofacial Surgery, University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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18
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Cheraghlou S, Torabi SJ, Husain ZA, Otremba MD, Osborn HA, Mehra S, Yarbrough WG, Burtness BA, Judson BL. HPV status in unknown primary head and neck cancer: Prognosis and treatment outcomes. Laryngoscope 2018; 129:684-691. [DOI: 10.1002/lary.27475] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Shayan Cheraghlou
- Division of Otolaryngology, Department of Surgery; New Haven Connecticut U.S.A
| | - Sina J. Torabi
- Division of Otolaryngology, Department of Surgery; New Haven Connecticut U.S.A
| | - Zain A. Husain
- Department of Therapeutic Radiology; New Haven Connecticut U.S.A
- Yale Cancer Center; New Haven Connecticut U.S.A
| | - Michael D. Otremba
- Division of Otolaryngology, Department of Surgery; New Haven Connecticut U.S.A
| | - Heather A. Osborn
- Division of Otolaryngology, Department of Surgery; New Haven Connecticut U.S.A
- Department of Medicine; Yale School of Medicine; New Haven Connecticut U.S.A
| | - Saral Mehra
- Division of Otolaryngology, Department of Surgery; New Haven Connecticut U.S.A
- Yale Cancer Center; New Haven Connecticut U.S.A
| | - Wendell G. Yarbrough
- Division of Otolaryngology, Department of Surgery; New Haven Connecticut U.S.A
- Department of Pathology; New Haven Connecticut U.S.A
- Yale Cancer Center; New Haven Connecticut U.S.A
| | - Barbara A. Burtness
- Department of Medicine; Yale School of Medicine; New Haven Connecticut U.S.A
- Yale Cancer Center; New Haven Connecticut U.S.A
| | - Benjamin L. Judson
- Division of Otolaryngology, Department of Surgery; New Haven Connecticut U.S.A
- Yale Cancer Center; New Haven Connecticut U.S.A
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19
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Troussier I, Klausner G, Blais E, Giraud P, Lahmi L, Pflumio C, Faivre JC, Geoffrois L, Babin E, Morinière S, Maingon P, Thariat J. [Advances in the management of cervical lymphadenopathies of unknown primary with intensity modulated radiotherapy: Doses and target volumes]. Cancer Radiother 2018; 22:438-446. [PMID: 29731331 DOI: 10.1016/j.canrad.2017.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 10/24/2017] [Indexed: 11/16/2022]
Abstract
The definition of nodal and/or mucosal target volumes for radiation therapy for lymphadenopathies of unknown primary is controversial. Target volumes may include all nodal areas bilaterraly and be pan-mucosal or unilateral, selective, including the sole oropharyngeal mucosa. This review presents current recommendations in light of changes in the TNM classification, Human papillomavirus status and therapeutic advances. We conducted a systematic review of the literature with the following keywords: lymphadenopathy; head and neck; unknown primary and radiation therapy. There are no direct comparative studies between unilateral or bilateral nodal irradiation or pan-mucosal and selective mucosal irradiation. Contralateral lymph node failure rates range from 0 to 6% after unilateral nodal irradiation and 0 and 31% after bilateral irradiation. Occurrence of a mucosal primary varies between 0 and 19.2%. Initial clinical presentation and Human papillomavirus status are critical to define mucosal target volumes. Intensity-modulated radiotherapy is recommended (rather than three-dimensional irradiation) to avoid toxicities. Systemic treatments have similar indications as for identified primary head and neck cancers. Failures do not appear superior in case of unilateral nodal irradiation but comparative studies are warranted due to major biases hampering direct comparisons. Human papillomavirus status should be incorporated into the therapeutic strategy and practice-changing TNM staging changes will need to be evaluated.
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Affiliation(s)
- I Troussier
- Radio-oncologie, hôpitaux universitaires de Genève, Avenue de la Roseraie 53 CH-1205 Genève
| | - G Klausner
- Radiothérapie, groupe hospitalier Pitié-Salpétrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - E Blais
- Radiothérapie, groupe hospitalier Pitié-Salpétrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - P Giraud
- Radiothérapie, groupe hospitalier Pitié-Salpétrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - L Lahmi
- Radiothérapie, groupe hospitalier Pitié-Salpétrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - C Pflumio
- Oncologie médicale, centre Alexis-Vautrin, 6, avenue de Bourgogne, 54511 Vandoeuvre-lès-Nancy cedex, France
| | - J-C Faivre
- Radiothérapie, centre Alexis-Vautrin, 6, avenue de Bourgogne, 54511 Vandoeuvre-lès-Nancy cedex, France
| | - L Geoffrois
- Oncologie médicale, centre Alexis-Vautrin, 6, avenue de Bourgogne, 54511 Vandoeuvre-lès-Nancy cedex, France
| | - E Babin
- Carcinologie cervicofaciale, CHRU de Caen, avenue de la Côte-de-Nacre, 14033 Caen, France
| | - S Morinière
- Carcinologie cervicofaciale, CHRU de Tours, 2, boulevard Tonnellé, 37000 Tours, France
| | - P Maingon
- Radiothérapie, groupe hospitalier Pitié-Salpétrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - J Thariat
- Département de radiothérapie/Archade, centre François-Baclesse, 3, avenue General-Harris, 14000 Caen, France; Université Unicaen, 14000 Caen, France.
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Troussier I, Klausner G, Morinière S, Blais E, Jean-Christophe Faivre, Champion A, Geoffrois L, Pflumio C, Babin E, Maingon P, Thariat J. [Advances in the management of cervical lymphadenopathies of unknown primary: advances in diagnostic imaging and surgical modalities and new international staging system]. Bull Cancer 2017; 105:181-192. [PMID: 29275831 DOI: 10.1016/j.bulcan.2017.11.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 11/10/2017] [Accepted: 11/15/2017] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Cervical lymphadenopathies of unknown primary represent 3 % of head and neck cancers. Their diagnostic work up has largely changed in recent years. This review provides an update on diagnostic developments and their potential therapeutic impact. MATERIALS AND METHODS This is a systematic review of the literature. RESULTS In recent years, changes in epidemiology-based prognostic factors such as human papilloma virus (HPV) cancers, advances in imaging and minimally invasive surgery have been integrated in the management of cervical lymphadenopathies of unknown primary. In particular, systematic use of PET scanner and increasing practice of robotic or laser surgery have contributed to increasing detection rate of primary cancers. These allow more adapted and personalized treatments. The impact of changes in the eighth TNM staging system is discussed. CONCLUSION The management of cervical lymphadenopathies of unknown primary cancer has changed significantly in the last 10 years. On the other hand, practice changes will have to be assessed.
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Affiliation(s)
- Idriss Troussier
- CHRU Pitié-Salpêtrière, radiothérapie, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - Guillaume Klausner
- Institut Gustave-Roussy, radiothérapie, 114, rue Edouard-Vaillant, 94800 Villejuif, France
| | - Sylvain Morinière
- CHRU de Tours, carcinologie cervicofaciale, 2, boulevard Tonnellé, 37000 Tours, France
| | - Eivind Blais
- Centre Bergonié, radiothérapie, 229, cours de l'Argonne, 33000 Bordeaux, France
| | - Jean-Christophe Faivre
- Institut de cancérologie de Lorraine, oncologie médicale, 6, avenue de Bourgogne, 54519 Vandœuvre-lès-Nancy, France
| | - Ambroise Champion
- Hôpitaux universitaires Genève, radiothérapie, rue Gabrielle-Perret-Gentil, 4, 1205 Genève, Suisse
| | - Lionnel Geoffrois
- CHRU de Tours, carcinologie cervicofaciale, 2, boulevard Tonnellé, 37000 Tours, France
| | - Carole Pflumio
- CHRU de Tours, carcinologie cervicofaciale, 2, boulevard Tonnellé, 37000 Tours, France
| | - Emmanuel Babin
- CHRU de Caen, carcinologie cervicofaciale, avenue de la Côte-de-Nacre, 14033 Caen, France
| | - Philippe Maingon
- CHRU Pitié-Salpêtrière, radiothérapie, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - Juliette Thariat
- ARCHADE centre François-Baclesse, radiothérapie, 3, avenue du Général-Harris, 14000 Caen, France.
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Huo M, Panizza B, Bernard A, Porceddu SV. Head and neck squamous cell carcinoma of unknown primary: Outcomes of a pre-defined institutional treatment policy in a region with a high prevalence of skin cancer. Oral Oncol 2017; 77:43-48. [PMID: 29362125 DOI: 10.1016/j.oraloncology.2017.12.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 11/09/2017] [Accepted: 12/15/2017] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To determine the rate of subsequent primary site failure in patients with head and neck squamous cell carcinoma of unknown primary (UKP HNSCC) in a region with a high prevalence of cutaneous squamous cell carcinoma, according to a pre-determined institutional policy. Secondary aims included regional and distant control, and overall survival. MATERIAL AND METHODS Patients presenting between April 2005 and June 2016 to the Princess Alexandra Hospital Head and Neck Multidisciplinary Meeting with UKP HNSCC from either presumed mucosal or cutaneous sites treated with curative intent were eligible. Patients with presumed mucosal origin were treated with radiation therapy (RT) with or without chemotherapy, while patients with presumed cutaneous SCC were treated with surgery and post-operative RT with or without chemotherapy. RESULTS A total of 63 patients met the inclusion criteria. Median follow up duration was 3.9 years (IQR 2.07-5.14). There were no subsequent primary site failures. The rate of nodal failure among presumed mucosal patients was 11.5%, and 8.1% among presumed cutaneous patients. The rate of distant metastatic failure was 11.1% among all patients. The estimated 5 year overall survival was 71.2% (95% CI 59.2-85.7%). CONCLUSION Treatment according to our pre-defined institutional policy for UKP HNSCC in a region with a high prevalence of cutaneous SCC appears to be safe and effective with low rates of mucosal primary emergence and nodal failure.
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Affiliation(s)
- Michael Huo
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia; The University of Queensland, Queensland, Australia.
| | - Benedict Panizza
- The University of Queensland, Queensland, Australia; Department of Otolaryngology, Head and Neck Surgery, Princess Alexandra Hospital, Queensland, Australia
| | - Anne Bernard
- QFAB Bioinformatics, Institute for Molecular Bioscience, University of Queensland, Brisbane, Australia
| | - Sandro V Porceddu
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia; The University of Queensland, Queensland, Australia
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Kuta V, Williams B, Rigby M, Hart R, Trites J, MacKay C, Taylor SM. Management of head and neck primary unknown squamous cell carcinoma using combined positron emission tomography-computed tomography and transoral laser microsurgery. Laryngoscope 2017; 128:2307-2311. [PMID: 29214640 DOI: 10.1002/lary.27034] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 10/29/2017] [Accepted: 11/06/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVES/HYPOTHESIS The unknown primary of the neck is commonly encountered by the head and neck surgeon. Despite the exhaustive diagnostic tools employed in traditional detection protocols, many unknown primaries are not found, and the patient is subjected to wide-field radiation and chemotherapy during treatment. Localizing the primary tumor has demonstrated therapeutic benefits, improved quality of life, and overall survival. The authors' objective was to determine the efficacy of a new management protocol for unknown primaries of the head and neck. STUDY DESIGN Prospective cohort study. METHODS Our technique involved a preoperative positron emission tomography-computed tomography (PET-CT) followed by a planned transoral laser microsurgery (TLM) approach. Efficacy was assessed based on survival statistics, disease control, detection rates, the proportion of patients not receiving adjuvant therapy, and the proportion of PET-CT scans helpful for detection of the primary cancer. RESULTS The occult primary was located in 25 of the 27 patients (93%), with the majority found in the palatine tonsil (52%). Both overall survival and disease-specific survival was 80% at 36 months. Local control was achieved in 100% of patients. After surgery, 37.0% (n = 10) received adjuvant radiation alone and 33.3% (n = 9) of patients went on to receive adjuvant chemoradiation. On imaging, 72% (n = 18) of PET-CT scans correctly localized the primary tumor. CONCLUSIONS Occult head and neck primaries present a diagnostic challenge that is not adequately overcome using traditional detection protocols. The current study presents our unique protocol at Dalhousie University, which demonstrates the efficacy of the PET-CT TLM protocol from both a detection and therapeutic perspective. LEVEL OF EVIDENCE 4. Laryngoscope, 128:2307-2311, 2018.
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Affiliation(s)
- Victoria Kuta
- Faculty of Medicine, Victoria General Hospital, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Blair Williams
- Division of Otolaryngology, Victoria General Hospital, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Matthew Rigby
- Division of Otolaryngology, Victoria General Hospital, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Robert Hart
- Division of Otolaryngology, Victoria General Hospital, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jonathan Trites
- Division of Otolaryngology, Victoria General Hospital, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Colin MacKay
- Division of Otolaryngology, Victoria General Hospital, Dalhousie University, Halifax, Nova Scotia, Canada
| | - S Mark Taylor
- Division of Otolaryngology, Victoria General Hospital, Dalhousie University, Halifax, Nova Scotia, Canada
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Zhou MJ, van Zante A, Lazar AA, Groppo ER, Garsa AA, Ryan WR, El-Sayed IH, Eisele DW, Yom SS. Squamous cell carcinoma of unknown primary of the head and neck: Favorable prognostic factors comparable to those in oropharyngeal cancer. Head Neck 2017; 40:904-916. [PMID: 29210145 DOI: 10.1002/hed.25028] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 10/25/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Treatment for squamous cell carcinoma (SCC) of unknown primary consists of radiotherapy (RT) +/- chemotherapy or neck dissection +/- adjuvant RT/chemoradiotherapy (CRT). We compared these strategies and identified prognostic factors. METHODS From 1993 to 2015, 75 patients with SCC of unknown primary had RT-based or surgery-based treatment. Primary endpoints were overall survival (OS) and disease-free survival (DFS). Event-time distributions were estimated using the Kaplan-Meier method. RESULTS Five-year OS and DFS for RT-based and surgery-based treatments were similar (OS 73% vs 68%, respectively; DFS 65% vs 64%, respectively). Among 38 patients with p16 data, 76% were p16 positive and showed improved 5-year DFS (90% vs 33%; P = .001) and OS (96% vs 33%; P < .001). Smoking history ≤10 pack-years conferred better 5-year DFS (88% vs 49%; P < .001) and OS (91% vs 59%; P < .001). CONCLUSION RT-based and surgery-based treatments produced similar outcomes. Patients with p16-positive disease with ≤10 pack-years of smoking history and limited nodal stage constitute a "low-risk" group in SCC of unknown primary similar to that in oropharyngeal cancer.
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Affiliation(s)
- Margaret J Zhou
- Department of Radiation Oncology, University of California, San Francisco, California
| | - Annemieke van Zante
- Department of Pathology, University of California, San Francisco, California
| | - Ann A Lazar
- Department of Preventive and Restorative Dental Sciences, University of California, San Francisco, California.,Department of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Eli R Groppo
- Sacramento Ear, Nose and Throat, Sacramento, California
| | - Adam A Garsa
- Department of Radiation Oncology, University of California, San Francisco, California
| | - William R Ryan
- Department of Otolaryngology - Head and Neck Surgery, University of California, San Francisco, San Francisco, California
| | - Ivan H El-Sayed
- Department of Otolaryngology - Head and Neck Surgery, University of California, San Francisco, San Francisco, California
| | - David W Eisele
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Sue S Yom
- Department of Radiation Oncology, University of California, San Francisco, California
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Eskander A, Ghanem T, Agrawal A. AHNS Series: Do you know your guidelines? Guideline recommendations for head and neck cancer of unknown primary site. Head Neck 2017; 40:614-621. [PMID: 29159978 DOI: 10.1002/hed.25026] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 10/16/2017] [Indexed: 11/07/2022] Open
Abstract
This article reviews the clinical practice guidelines for head and neck oncology focusing on the management of head and neck cancers of unknown primary (CUP). The primary purpose of this series is to raise awareness of the current guidelines in head and neck oncology by reviewing the recommendations and the evidence supporting such recommendations, particularly those published by the National Comprehensive Cancer Network (NCCN). We review the importance of a thorough history and physical examination, the impact of the American Joint Committee on Cancer (AJCC) eighth edition changes and the importance of immunohistochemistry, the timing and type of imaging, the role of panendoscopy and tonsillectomy (palatine and lingual), and the role of surgery, radiation, and chemotherapy in the primary management of these tumors.
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Affiliation(s)
- Antoine Eskander
- Department of Otolaryngology - Head and Neck Surgery, Division of Head and Neck Oncology, University of Toronto, Sunnybrook Health Sciences Centre and the Odette Cancer Centre, Toronto, Ontario, Canada
| | - Tamer Ghanem
- Department of Otolaryngology - Head and Neck Surgery, Henry Ford Health System, Detroit, Michigan
| | - Amit Agrawal
- Department of Otolaryngology - Head and Neck Surgery, Division of Head and Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, Ohio
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Axelsson L, Nyman J, Haugen-Cange H, Bove M, Johansson L, De Lara S, Kovács A, Hammerlid E. Prognostic factors for head and neck cancer of unknown primary including the impact of human papilloma virus infection. J Otolaryngol Head Neck Surg 2017; 46:45. [PMID: 28601094 PMCID: PMC5466757 DOI: 10.1186/s40463-017-0223-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 05/26/2017] [Indexed: 01/03/2023] Open
Abstract
Background Head and neck cancer of unknown primary (HNCUP) is rare and prospective studies are lacking. The impact of different prognostic factors such as age and N stage is not completely known, the optimal treatment is not yet established, and the reported survival rates vary. In the last decade, human papilloma virus (HPV) has been identified as a common cause of and important prognostic factor in oropharyngeal cancer, and there is now growing interest in the importance of HPV for HNCUP. The aim of the present study on curatively treated HNCUP was to investigate the prognostic importance of different factors, including HPV status, treatment, and overall survival. Methods A search for HNCUP was performed in the Swedish Cancer Registry, Western health district, between the years 1992–2009. The medical records were reviewed, and only patients with squamous cell carcinoma or undifferentiated carcinoma treated with curative intent were included. The tumor specimens were retrospectively analyzed for HPV with p16 immunostaining. Results Sixty-eight patients were included. The mean age was 59 years. The majority were males, and had N2 tumors. Sixty-nine percent of the tumors were HPV positive using p16 staining. Patients who were older than 70 years, patients with N3-stage tumors, and patients with tumors that were p16 negative had a significantly worse prognosis. The overall 5-year survival rate for patients with p16-positive tumors was 88% vs 61% for p16-negative tumors. Treatment with neck dissection and postoperative radiation or (chemo) radiation had 81 and 88% 5-year survival rates, respectively. The overall and disease-free 5-year survival rates for all patients in the study were 82 and 74%. Conclusions Curatively treated HNCUP had good survival. HPV infection was common. Independent prognostic factors for survival were age over 70 years, HPV status and N3 stage. We recommend that HPV analysis should be performed routinely for HNCUP. Treatment with neck dissection and postoperative radiation or (chemo) radiation showed similar survival rates.
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Affiliation(s)
- Lars Axelsson
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Gothenburg, Sahlgrenska University Hospital, Göteborg, Sweden.
| | - Jan Nyman
- Department of Oncology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Hedda Haugen-Cange
- Department of Oncology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Mogens Bove
- Department of Otorhinolaryngology, Norra Älvsborgs Hospital, Trollhättan, Sweden
| | - Leif Johansson
- Department of Otorhinolaryngology, Central Hospital Skövde, Skövde, Sweden
| | - Shahin De Lara
- Department of Clinical Pathology and Genetics, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Anikó Kovács
- Department of Clinical Pathology and Genetics, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Eva Hammerlid
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Gothenburg, Sahlgrenska University Hospital, Göteborg, Sweden
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Takes RP, Kaanders JHAM, van Herpen CML, Merkx MAW, Slootweg PJ, Melchers WJG. Human papillomavirus detection in fine needle aspiration cytology of lymph node metastasis of head and neck squamous cell cancer. J Clin Virol 2016; 85:22-26. [PMID: 27816020 DOI: 10.1016/j.jcv.2016.10.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 10/12/2016] [Accepted: 10/14/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Currently, testing on HPV in oropharyngeal squamous cell carcinoma (OPSCC) is performed on histological material. However, in a certain percentage of the cases who present with lymph node metastases no primary tumor can be identified and only fine needle aspiration cytology (FNAC) is available for analysis. OBJECTIVES Purpose of this study was to assess HPV status on FNAC and to validate it using histological material of the same patients. STUDY DESIGN Patients with cervical metastasis from OPSCC or cancer of an unknown primary tumor (CUP), diagnosed between 2007 and 2012 were included. In 6 of the 47 patients, no primary tumor could be identified. HPV detection and genotyping was performed in both FNAC slides scrapings and formalin fixed paraffin embedded (FFPE) histological material from the same patients, using the HPV SPF10-LiPA25 assay. HPV PCR analysis on FFPE material was considered the reference standard for HPV status of each case. RESULTS Compared with HPV negative cases (n=22), significantly more HPV positive cases (n=25) presented initially with cervical metastasis (27% vs 56% respectively; p=0·047). The HPV PCR assay on FNAC material showed a high sensitivity (96%; 95% CI 86.6-97.4) and specificity (100%; 95% CI 85.1-96.7) using the reference standard of HPV PCR analysis on FFPE material of the same patients. CONCLUSION In this study, testing on HPV in FNAC of cervical lymph node metastases of SCC is validated. It provides a valuable alternative for testing of HPV on histological material from patients with oropharyngeal squamous cell carcinoma or cancer of an unknown primary tumor.
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Affiliation(s)
- Robert P Takes
- Department of Otolaryngology and Head and Neck Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Johannes H A M Kaanders
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Carla M L van Herpen
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Matthias A W Merkx
- Department of Oral and Maxillofacial Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Pieter J Slootweg
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Willem J G Melchers
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands.
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Squamous cell carcinoma of unknown primary tumor metastatic to neck nodes: role of elective irradiation. Eur Arch Otorhinolaryngol 2016; 273:4561-4569. [PMID: 27363402 DOI: 10.1007/s00405-016-4172-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 06/24/2016] [Indexed: 01/09/2023]
Abstract
In patients with squamous cell carcinoma (SCC) metastases to neck lymph nodes and unknown primary tumor, the role of elective irradiation of uninvolved neck and potential mucosal primary sites is yet to be determined. The aim of this study was to review the experience treating SCC of unknown primary metastatic to neck nodes with surgery and postoperative radiotherapy (PORT) in Slovenia between 1995 and 2010 and to determine the importance of the extent of irradiated volume. For this purpose, the nationwide Cancer Registry of Slovenia database was used for identifying patients. 126 patients were identified. Involved-field PORT and extended-field PORT was used in 50 and 76 patients, respectively. At 5 years, locoregional control was 86 %, disease-specific survival 77 %, and overall survival 57 %. In multivariate analysis, the extent of irradiated volume has not been predictive for any outcome under study. Grade ≥3 acute and late radiotherapy-induced toxicities were more frequent in the extended-field PORT group. In conclusion, although not superior, involved-field PORT seems to be a preferred treatment option in SCC of unknown primary metastatic to neck nodes due to significantly reduced toxicity and better prospects for successful salvage.
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Dixon PR, Au M, Hosni A, Perez-Ordonez B, Weinreb I, Xu W, Song Y, Huang SH, O'Sullivan B, Goldstein DP, de Almeida JR. Impact of p16 expression, nodal status, and smoking on oncologic outcomes of patients with head and neck unknown primary squamous cell carcinoma. Head Neck 2016; 38:1347-53. [DOI: 10.1002/hed.24441] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 12/19/2015] [Accepted: 02/02/2016] [Indexed: 01/12/2023] Open
Affiliation(s)
- Peter R. Dixon
- Department of Otolaryngology - Head and Neck Surgery; Princess Margaret Cancer Center, University Health Network, University of Toronto; Toronto Canada
| | - Michael Au
- Department of Otolaryngology - Head and Neck Surgery; Princess Margaret Cancer Center, University Health Network, University of Toronto; Toronto Canada
| | | | - Bayardo Perez-Ordonez
- Department of Pathology; Princess Margaret Cancer Center, University Health Network, University of Toronto; Toronto Canada
| | - Ilan Weinreb
- Department of Pathology; Princess Margaret Cancer Center, University Health Network, University of Toronto; Toronto Canada
| | - Wei Xu
- Department of Biostatistics; Princess Margaret Cancer Center, University Health Network, University of Toronto; Toronto Canada
| | - Yuyao Song
- Department of Biostatistics; Princess Margaret Cancer Center, University Health Network, University of Toronto; Toronto Canada
| | - Shao Hui Huang
- Department of Radiation Oncology; Princess Margaret Cancer Centre, University Health Network, University of Toronto; Toronto Canada
| | - Brian O'Sullivan
- Department of Radiation Oncology; Princess Margaret Cancer Centre, University Health Network, University of Toronto; Toronto Canada
| | - David P. Goldstein
- Department of Otolaryngology - Head and Neck Surgery; Princess Margaret Cancer Center, University Health Network, University of Toronto; Toronto Canada
| | - John R. de Almeida
- Department of Otolaryngology - Head and Neck Surgery; Princess Margaret Cancer Center, University Health Network, University of Toronto; Toronto Canada
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Smith KA, Dort JC, Hall SF, Rudmik L. Cost-effectiveness of positron emission tomography-CT in the evaluation of cancer of unknown primary of the head and neck. Head Neck 2014; 37:1781-7. [DOI: 10.1002/hed.23830] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Revised: 05/22/2014] [Accepted: 06/29/2014] [Indexed: 11/08/2022] Open
Affiliation(s)
- Kristine A. Smith
- Division of Otolaryngology - Head and Neck Surgery, Department of Surgery; University of Calgary; Calgary Alberta
| | - Joseph C. Dort
- Division of Otolaryngology - Head and Neck Surgery, Department of Surgery; University of Calgary; Calgary Alberta
| | - Stephen F. Hall
- Department of Otolaryngology - Head and Neck Surgery; Division of Cancer Care and Epidemiology, Queens Cancer Research Institute, Queens University; Ontario Canada
| | - Luke Rudmik
- Division of Otolaryngology - Head and Neck Surgery, Department of Surgery; University of Calgary; Calgary Alberta
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Kaemmerer D, Posorski N, von Eggeling F, Ernst G, Hörsch D, Baum RP, Prasad V, Langer R, Esposito I, Klöppel G, Sehner S, Knösel T, Hommann M. The search for the primary tumor in metastasized gastroenteropancreatic neuroendocrine neoplasm. Clin Exp Metastasis 2014; 31:817-27. [PMID: 25098566 DOI: 10.1007/s10585-014-9672-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Accepted: 07/28/2014] [Indexed: 12/16/2022]
Abstract
Gastroenteropancreatic neuroendocrine tumors (NETs) often present as liver metastasis from a carcinoma of unknown primary. We recently showed that primary NETs from the pancreas, small intestine and stomach as well as their respective liver metastases differ from each other by the expression profile of the three genes CD302, PPWD1 and ABHB14B. The gene and protein expression of CD302, PPWD1, and ABHB14B was studied in abdominal NET metastases to identify the site of the respective primary tumors. Cryopreserved tissue from NET metastases collected in different institutions (group A: 29, group B: 50, group C: 132 specimens) were examined by comparative genomic hybridization (Agilent 105 K), gene expression analysis (Agilent 44 K) (groups A and B) and immunohistochemistry (group C). The data were blindly evaluated, i.e. without knowing the site of the primary. Gene expression analysis correctly revealed the primary in the ileum in 94 % of the cases of group A and in 58 % of group B. A pancreatic primary was predicted in 83 % (group A) and 20 % (group B), respectively. The combined sensitivity of group A and B was 75 % for ileal NETs and 38 % for pancreatic NETs. Immunohistochemical analysis of group C revealed an overall sensitivity of 80 %. Gene and protein expression analysis of CD302 and PPWD1 in NET metastases correctly identifies the primary in the pancreas or the ileum in 80 % of the cases, provided that the tissue is well preserved. Immunohistochemical profiling revealed CD302 as the best marker for ileal and PPWD1 for pancreatic detection.
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Affiliation(s)
- D Kaemmerer
- Department of General and Visceral Surgery, Zentralklinik Bad Berka, Robert-Koch-Allee 9, 99437, Bad Berka, Germany,
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Durmus K, Patwa HS, Gokozan HN, Kucur C, Teknos TN, Agrawal A, Old MO, Ozer E. Functional and quality-of-life outcomes of transoral robotic surgery for carcinoma of unknown primary. Laryngoscope 2014; 124:2089-95. [PMID: 24706455 DOI: 10.1002/lary.24705] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2013] [Revised: 03/26/2014] [Accepted: 04/02/2014] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS To determine speech, eating, aesthetics, social disruption, and overall quality-of-life outcomes over a year period in patients who underwent transoral robotic surgery as part of carcinoma of unknown primary diagnosis and treatment. STUDY DESIGN Observational prospective study. METHODS Twenty-two patients who underwent transoral robotic surgery for the management of carcinoma of unknown primary were included. Patients prospectively completed the Head and Neck Cancer Inventory during a preoperative visit, and at 3-week, 3-month, 6-month, and 12-month postoperative visits. Patients' demographic, pathological, and follow-up information were also collected. RESULTS The mean follow-up time was 19.8 months. There were overall declines in all quality of life scores during treatment period, which was followed by a continuous recovery. The scores immediately after transoral robotic surgery (3 weeks) were significantly higher than the scores after conclusion of adjuvant therapy (3 months) in multiple domains (P < .05) and the 6-month scores in speech (P = .02) and eating (P = .008) domains. All scores, except for eating (P = .01) returned to pretreatment levels at 1 year. Patients with detected primaries displayed similar quality-of-life scores compared to patients with occult primaries. Human papillomavirus status and type of adjuvant treatment had no significant impact on quality of life. CONCLUSIONS Transoral robotic surgery is a promising, minimally invasive procedure for the surgical management of carcinoma of unknown primary. Patients maintain high functional and quality-of-life status at 1 year after surgery.
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Affiliation(s)
- Kasim Durmus
- Department of Otolaryngology-Head and Neck Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
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[Lymph node metastases from squamous cell carcinoma of unknown primary site. Is it time to change of paradigm?]. Bull Cancer 2014; 101:455-60. [PMID: 24886896 DOI: 10.1684/bdc.2014.1965] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The diagnosis of carcinoma of unknown primary (CUP) is made after exclusion of the presence of a mucosal primary. There are two mains options for the primary treatment of CUP, either a neck node dissection followed by postoperative radiotherapy or chemo-radiotherapy, or a primary radiotherapy or chemo-radiotherapy depending on the nodal stage followed in case of residual neck disease by a selective neck dissection. There is no data to suggest the superiority of one over the other. For radiotherapy, unilateral neck or bilateral neck, including the upper aerodigestive tract mucosa are possible options. There is no definite data to demonstrate the superiority of one over the other, but owing the reduced toxicity of unilateral irradiation, and the possibility of salvage treatment in case of emergence of a mucosal primary and/or a contralateral neck node development, the former may be the preferred option. Advances in radiotherapy such as intensity modulated radiation therapy have the potential to spare organs at risk and reduce late toxicity rates. A selective irradiation approach customized on "major" criteria, such as nodal stage and level, HPV and EBV status and accessory criteria, such as histological variants, is under investigation.
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Weiss D, Koopmann M, Stenner M, Savvas E, Rudack C. Clinicopathological characteristics of carcinoma from unknown primary in cervical lymph nodes. Eur Arch Otorhinolaryngol 2014; 272:431-7. [PMID: 24633307 DOI: 10.1007/s00405-014-2980-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 02/21/2014] [Indexed: 01/07/2023]
Abstract
Carcinoma in cervical lymph nodes of unknown origin represents a rare clinical entity where optimal diagnostic and therapeutic management is still a widely debated issue. Molecular classification of these metastases is thus of utmost importance. We analyzed the expression of eight basic molecular markers in 26 metastases from unknown primaries, 31 metastases from overt primaries and their associated primaries. Medical records of the respective patients were reviewed for main clinicopathological parameters. The expression rates showed no significant differences between the two tumor entities, neither in absolute terms nor in comparison among the parameters. Surprisingly, patients with metastases from unknown primary demonstrated improved progression-free survival (p = 0.046) despite advanced age (p = 0.029), advanced nodal stage (p = 0.006) and higher incidence of extracapsular spread (p = 0.045) compared to patients with metastases from overt primaries. Presence of extracapsular spread was associated with increased expression of epidermal growth factor receptor in metastases from overt primaries (p = 0.035) and reduced expression of matrix metalloproteinase-2 in metastases from unknown primary (p = 0.031). We thus conclude that cervical metastases from unknown and overt primaries show similarities in their molecular profile, but fundamental differences in clinical parameter.
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Affiliation(s)
- Daniel Weiss
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Münster, Kardinal-von-Galen-Ring 10, 48149, Münster, Germany,
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Janssen S, Glanzmann C, Huber G, Studer G. Individualized IMRT treatment approach for cervical lymph node metastases of unknown primary. Strahlenther Onkol 2014; 190:386-93. [DOI: 10.1007/s00066-013-0508-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 11/08/2013] [Indexed: 01/08/2023]
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Abstract
BACKGROUND The term cancer of unknown primary (CUP) encompasses a group of entities which differ to a great extent regarding etiology, prognosis and therapeutic management. OBJECTIVES The aim of the study was an elaboration of the role of radiotherapy in CUP syndrome. MATERIAL AND METHODS Systematic literature search and specification of the available treatment options. RESULTS Radiotherapy is an integral part of interdisciplinary management approaches for patients with CUP in both curative and palliative situations. Radio-oncological techniques, such as intensity-modulated radiotherapy and stereotactic body radiotherapy increase the therapeutic window. Modern diagnostic modalities from radiology and nuclear medicine are the cornerstone of radiotherapeutic interventions, especially in terms of target volume definition and pretherapeutic staging. In the interdisciplinary setting radiation oncology offers the possibility of curative and often organ preserving approaches in patients with axillary and cervical CUP. In addition, improvement and preservation of quality of life can be achieved in patients with metastatic disease. CONCLUSION Radiation oncology is a crucial component of the interdisciplinary management of patients with CUP. Therapeutic decisions in patients with CUP should be made in an interdisciplinary setting.
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Durmus K, Rangarajan SV, Old MO, Agrawal A, Teknos TN, Ozer E. Transoral robotic approach to carcinoma of unknown primary. Head Neck 2013; 36:848-52. [PMID: 23720223 DOI: 10.1002/hed.23385] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Revised: 02/05/2013] [Accepted: 05/15/2013] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The management of carcinoma of unknown primary (CUP) is one of the challenging conditions in head and neck oncologic surgery. Despite various diagnostic tools, the primary tumor site in more than half of cases remains unidentified. The purpose of this study was to assess the feasibility and efficiency of utilizing transoral robotic surgery (TORS) for the diagnosis and treatment of CUP in the head and neck. METHODS In this prospective, single-institutional, clinical TORS trial, 22 of 181 patients were treated for CUP between 2008 and 2012. RESULTS Among all those 22 patients, primary tumor site identification and complete tumor removal was achieved in 17 patients (77.3%) with TORS. Tonsil (59.1%) and base of tongue (18.1%) were identified as the most common tumor locations. CONCLUSION Together with panendoscopy, directed biopsies, and positron emission tomography (PET)/CT, TORS is a valuable option in the identification and treatment of primary tumor sites.
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Affiliation(s)
- Kasim Durmus
- Department of Otolaryngology - Head and Neck Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Comprehensive Cancer Center, Wexner Medical Center at The Ohio State University, Columbus, Ohio
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