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Pala M, Novakova P, Pechacova Z, Vesela L, Vrana A, Sukova J, Holeckova P, Drbohlavova T, Podlesak T, Petruzelka L. Long-term results of radio(chemo)therapy in metastatic carcinoma to cervical lymph nodes from an unknown primary. Adult Comorbidity Evaluation 27 score as a predictor of survival. Strahlenther Onkol 2023; 199:149-159. [PMID: 35943554 DOI: 10.1007/s00066-022-01983-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 07/10/2022] [Indexed: 01/28/2023]
Abstract
PURPOSE To evaluate the effectiveness and toxicity of curative (chemo)radiotherapy in patients with metastatic carcinoma to cervical lymph nodes from an unknown primary. METHODS Retrospective study of 90 consecutive patients, treated with curative radiotherapy from 2003 to 2018 (median age 59 years; current/former smokers 76%) was conducted. The distribution of nodal staging was as follows: N1: 12%, N2a: 21%, N2b: 43%, N2c: 10%, N3: 13%. In 62% of patients, neck dissection was performed before radiotherapy. Concomitant chemotherapy was given to 64% of patients. RESULTS The median follow-up of surviving patients was 86 months. The median total radiotherapy dose achieved was 70 Gy. The 5‑ and 10-year locoregional control were 84% in both cases, while 5‑ and 10-year distant control were 90% and 89%, respectively. A primary tumor in the head and neck area was detected in only 2 patients. No patient had an initial failure in the pharyngeal axis or contralateral cervical nodes. The 5‑ and 10-year overall survival were 55% and 42%, respectively. Severe early toxicity occurred in 71%; severe late toxicity in 33% of patients. Multivariate analysis demonstrated N‑status (hazard ratio [HR] 2.424; 95% confidence interval [CI] 1.121-5.241; p = 0.024) and comorbidity scores assessed by ACE-27 (Adult Comorbidity Evaluation; HR 3.058; 95% CI 1.489-6.281; p = 0.002) as two independent prognostic factors for overall survival. CONCLUSION The results of our work study demonstrate the high effectiveness of curative (chemo)radiotherapy on the pharyngeal axis and bilateral cervical nodes with long-term locoregional and distant control in 3/4 of the treated patients. N‑status and comorbidity scores were shown as strong prognostic factors influencing overall survival.
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Affiliation(s)
- Miloslav Pala
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic.
| | - Pavla Novakova
- Radiophysics Department, Bulovka University Hospital, Prague, Czech Republic
| | - Zdena Pechacova
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic
| | - Lucie Vesela
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic
| | - Antonin Vrana
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic
| | - Jarmila Sukova
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic
| | - Petra Holeckova
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic
| | - Tereza Drbohlavova
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic
| | - Tomas Podlesak
- Department of Otorhinolaryngology, Bulovka University Hospital, Prague, Czech Republic
| | - Lubos Petruzelka
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic
- Department of Oncology of the 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
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2
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Brenet E, Philouze P, Schiffler C, Pommier P, Crozes C, Benzerdjeb N, Monchet E, Boulagnon-Rombi C, Ton Van J, Podeur F, Servagi-Vernat S, Liem X, Merol JC, Ceruse P, Serre AA, Chabaud S, Julieron M, Deneuve S. Influence of postoperative radiotherapy target volumes in unilateral head and neck carcinoma of unknown primary: A multicentric study using propensity score. Radiother Oncol 2021; 160:1-8. [PMID: 33845043 DOI: 10.1016/j.radonc.2021.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 03/22/2021] [Accepted: 04/01/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To compare the impact of two radiation modalities on loco-regional control, survival and tumour emergence, after node dissection for an unilateral head and neck carcinoma of unknown primary (HNCUP). MATERIALS AND METHODS This is a multicentric retrospective study of 138 patients with unilateral HNCUP treated between 2002 and 2017. The absence of primary tumour was assessed by a systematic panendoscopy and positron emission tomography. Neck dissection was initially performed for all patients. Radiation Therapy was delivered on ipsilateral lymph node areas in 62 cases (44%: UL-RT group) and on bilateral lymph node areas and the entire pharyngeal mucosa in 77 cases (56%: COMP-RT group). Impact of radiation modalities on locoregional control and overall survival was assessed using propensity score matching method in order to balance baseline characteristics between the two groups. RESULTS The population included 80.4% men, 80.4% smokers, 32.6% P16 positive tumours and 71.0% extracapsular extension. After a median follow-up of 5 years, the locoregional control rate was 80.3% in the UL-RT group and 75.3% in the COMP-RT group (p = 0.688). The corresponding rate of contralateral lymph node recurrence was 0% versus 2.6% (p = 0.503) and the rate of tumour emergence was 11.5% versus 9.1% (p = 0.778). No significant difference was observed between the UL-RT and the COMP-RT groups for overall survival (p = 0.9516), specific survival (p = 0.4837) or tumour emergence (p = 0.9034). CONCLUSION UL-RT seems to provide similar outcomes as COMP-RT in unilateral HNCUP post-operative management.
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Affiliation(s)
- Esteban Brenet
- Head and Neck Surgery Department, Centre Hospitalo Universitaire Reims, France
| | - Pierre Philouze
- Head and Neck Surgery Department, Centre Hospitalo Universitaire Lyon Sud, France
| | | | - Pascal Pommier
- Radiotherapy Department, Centre Léon Bérard, Lyon, France
| | - Carole Crozes
- Pathological Anatomy Department, Centre Léon Bérard, Lyon, France
| | - Nazim Benzerdjeb
- Pathological Anatomy Department, Centre Hospitalo Universitaire Lyon Sud, France
| | - Elodie Monchet
- Head and Neck Surgery Department, Centre Oscar Lambret, Lille, France
| | | | - Jean Ton Van
- Head and Neck Department, Centre Oscar Lambret, Lille, France
| | - Fabien Podeur
- Oncologic Surgery Department, Centre Léon Bérard, Lyon, France
| | | | - Xavier Liem
- Radiotherapy Department, Centre Oscar Lambret, Lille, France
| | - Jean-Claude Merol
- Head and Neck Department, Centre hospilato Universitaire Reims, France
| | - Philippe Ceruse
- Head and Neck Surgery Department, Centre Hospitalo Universitaire Lyon Sud, France
| | | | - Sylvie Chabaud
- Biostatistics Department, Centre Léon Bérard, Lyon, France
| | - Morbize Julieron
- Head and Neck Surgery Department, Centre Oscar Lambret, Lille, France
| | - Sophie Deneuve
- Oncologic Surgery Department, Centre Léon Bérard, Lyon, France.
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3
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Berzenji D, Monserez DA, Verduijn GM, Dronkers EA, Jansen PP, Keereweer S, Sewnaik A, Baatenburg de Jong RJ, Hardillo JA. Treatment of head and neck carcinoma of unknown primary: Cracking a nut with a sledgehammer? Laryngoscope Investig Otolaryngol 2021; 6:211-218. [PMID: 33869753 PMCID: PMC8035952 DOI: 10.1002/lio2.539] [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: 11/05/2020] [Revised: 01/24/2021] [Accepted: 01/29/2021] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES To compare the impact on survival and late radiation toxicity of patients with squamous cell carcinoma of unknown primary who were treated with ipsilateral neck dissection and ipsilateral postoperative radiotherapy (PORT) and patients treated with ipsilateral neck dissection and PORT to both sides of the neck plus the pharyngeal axis. METHODS Retrospective cohort study performed at the Erasmus University Medical Center in which 78 patients with squamous cell carcinoma of unknown primary were identified. Thirty-nine patients received PORT to both sides of the neck plus the pharyngeal axis (BILAX) and another 39 patients were irradiated on the ipsilateral neck (IPSI) only. The endpoints of the present study were 3-year overall survival (OS), 3-year disease-free survival (DFS), and overall late radiation toxicity. RESULTS The 3-year OS rate of the entire group of 78 patients was 74.2% and the 3-year DFS rate was 72.7%. The 3-year OS rates for the IPSI and the BILAX groups were 74.4% and 74.1%, respectively (P = .654). The most common late radiation toxicity experienced was xerostomia (64.8%), which was significantly more often seen in the BILAX group than in the IPSI group (83.8% and 44.1%, respectively, P = .001). Overall late radiation toxicity was significantly higher in the BILAX group (P = .003). CONCLUSION There was no significant difference in OS and DFS rates between the IPSI and the BILAX group. Late radiation toxicity was significantly higher in the BILAX group. LEVEL OF EVIDENCE Level 2b: Individual retrospective cohort study.
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Affiliation(s)
- Diako Berzenji
- Department of Otorhinolaryngology and Head and Neck SurgeryErasmus University Medical CenterRotterdamThe Netherlands
| | - Dominiek A. Monserez
- Department of Otorhinolaryngology and Head and Neck SurgeryErasmus University Medical CenterRotterdamThe Netherlands
| | - Gerda M. Verduijn
- Department of Radiation OncologyErasmus University Medical CenterRotterdamThe Netherlands
| | - Emilie A.C. Dronkers
- Department of Otorhinolaryngology and Head and Neck SurgeryErasmus University Medical CenterRotterdamThe Netherlands
| | - Peter P. Jansen
- Department of Radiation OncologyErasmus University Medical CenterRotterdamThe Netherlands
| | - Stijn Keereweer
- Department of Otorhinolaryngology and Head and Neck SurgeryErasmus University Medical CenterRotterdamThe Netherlands
| | - Aniel Sewnaik
- Department of Otorhinolaryngology and Head and Neck SurgeryErasmus University Medical CenterRotterdamThe Netherlands
| | - Robert J. Baatenburg de Jong
- Department of Otorhinolaryngology and Head and Neck SurgeryErasmus University Medical CenterRotterdamThe Netherlands
| | - Jose A. Hardillo
- Department of Otorhinolaryngology and Head and Neck SurgeryErasmus University Medical CenterRotterdamThe Netherlands
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4
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Cummings MA, Ma SJ, Van Der Sloot P, Milano MT, Singh DP, Singh AK. Squamous cell carcinoma of the head and neck with unknown primary: trends and outcomes from a hospital-based registry. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:284. [PMID: 33708911 PMCID: PMC7944267 DOI: 10.21037/atm-20-4631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Squamous cell carcinoma of unknown primary of the head and neck region is a known entity described mainly by retrospective reports. We searched a hospital-based registry to better describe the changing incidence, and to assess diagnostic and treatment strategies. Methods The National Comprehensive Cancer Database was queried for head and neck cancers from oropharynx, tonsil, tongue, larynx, hypopharynx primary sites with a designation of clinical T0, representing an unknown primary. Kaplan Meier, Cox multivariate models, and propensity matched cohorts were used to assess significant factors for overall survival. Results There were 964 cases that met the criteria, and 468 cases with known treatments, staging, and survival data. The incidence increased over time, with the highest rates supported in the last 5 years. In patients who underwent HPV testing, 72% were positive. Patients with AJCC 7th clinical N2c or N3 disease had significantly worse outcomes despite the majority receiving neck dissection, radiation, and chemotherapy. Local surgery, compared to incisional or excisional biopsy, had the highest diagnostic yield of finding a primary tumor. In multivariate models, no combination of surgical approach, radiation, or systemic therapy was significantly associated with improved survival. This remained true in 1:1 propensity matched cohorts for age, comorbidities, and clinical nodal burden. In a subset of cN1 patients, combined chemoradiation therapy after excisional biopsy or local surgery was associated with (not statistically significant) improved survival compared to radiation alone (P=0.054). Conclusions The incidence of unknown primary head and neck carcinoma is increasing, and current cases have a high proportion of HPV positivity. HPV positivity predicts strongly for a tonsil primary. Local surgery was associated with the highest diagnostic yield. Clinical nodal burden strongly predicts for overall outcome, and type of treatment facility is an important driver of survival. A subset of cN1 patients may benefit from the addition of chemotherapy to radiation.
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Affiliation(s)
- Michael A Cummings
- Department of Radiation Oncology, University of Rochester, Rochester, NY, USA
| | - Sung Jun Ma
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Paul Van Der Sloot
- Department of Ear Nose and Throat Surgery, University of Rochester, Rochester, NY, USA
| | - Michael T Milano
- Department of Radiation Oncology, University of Rochester, Rochester, NY, USA
| | - Deepinder P Singh
- Department of Radiation Oncology, University of Rochester, Rochester, NY, USA
| | - Anurag K Singh
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
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5
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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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6
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Dhouib F, Bertaut A, Maingon P, Siala W, Daoud J, Aubignac L, Lestrade L, Crehange G, Vulquin N. Patterns of Failure in Patients With Head and Neck Squamous Cell Carcinomas of Unknown Primary Treated With Chemoradiotherapy. Technol Cancer Res Treat 2020; 19:1533033820905826. [PMID: 32484037 PMCID: PMC7268107 DOI: 10.1177/1533033820905826] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: To evaluate the patterns of failure in patients treated for head and neck carcinoma of unknown primary and to discuss treatment practices concerning radiotherapy target volumes definition and dose prescription. Methods: Eleven patients presenting a locoregional recurrence after head and neck carcinoma of unknown primary treatment with curative-intent radiochemotherapy performed between 2007 and 2017 in the departments of radiation oncology of 2 French cancer institutes. Images of the computed tomography scan or the magnetic resonance imaging performed at the time of the recurrence were fused with those of the simulation computed tomography scan to delimit a volume corresponding to the recurrence and to define the area of relapse compared to the volumes treated. Results: Irradiation was unilateral in 6 cases and bilateral in 5 cases. The median time to onset of recurrence was 7.24 months (extreme 3-67.7 months). Six patients had only a neck node recurrence, 3 had a neck node and subsequent primary recurrence, and 1 had only a median subsequent primary recurrence. Only 1 patient had synchronous distance progression to local recurrence. All neck node recurrences were solitary and ipsilateral. The subsequent primary recurrences were in the oropharynx in 3 cases and in the contralateral oral cavity in one case. All neck node recurrences were into the irradiated volume. The subsequent primary recurrences were either within or in border of the irradiated volumes. The median of the mean dose, received by neck node recurrences, was 69.9 Gy and that of the mean dose, minimum dose, maximum dose, and dose received by 95% of the volume of recurrence was 66.7 Gy. For the primary relapses, the median of the mean dose was 52.1 Gy and that of the mean dose, minimum dose, maximum dose, and dose received by 95% of the volume of recurrence was 39.9 Gy. Conclusions: All local nodal recurrences occurred at sites that received high radiotherapy doses and doses received by sites of eventual failure did not vary significantly from sites that remain in control.
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Affiliation(s)
- Fatma Dhouib
- Department of Oncology Radiotherapy, Centre Georges-François-Leclerc, Dijon, France.,Department of Oncology Radiotherapy, Habib Bourguiba Central University Hospital, Sfax, Tunisia
| | - Aurélie Bertaut
- Department of Oncology Radiotherapy, Centre Georges-François-Leclerc, Dijon, France
| | - Philippe Maingon
- Department of Oncology Radiotherapy, Central University Hospital La Pitié Salpêtrière, Paris, France
| | - Wicem Siala
- Department of Oncology Radiotherapy, Habib Bourguiba Central University Hospital, Sfax, Tunisia
| | - Jamel Daoud
- Department of Oncology Radiotherapy, Habib Bourguiba Central University Hospital, Sfax, Tunisia
| | - Léone Aubignac
- Department of Oncology Radiotherapy, Centre Georges-François-Leclerc, Dijon, France
| | - Laetitia Lestrade
- Department of Oncology Radiotherapy, Central University Hospital, Besançon, France
| | - Gilles Crehange
- Department of Oncology Radiotherapy, Centre Georges-François-Leclerc, Dijon, France
| | - Noemie Vulquin
- Department of Oncology Radiotherapy, Centre Georges-François-Leclerc, Dijon, France
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7
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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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8
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Albadri ST, Salomão D. Metastatic prostate adenocarcinoma to cervical lymph nodes: an unusual diagnosis on fine-needle aspiration biopsy. J Am Soc Cytopathol 2020; 10:231-238. [PMID: 32950433 DOI: 10.1016/j.jasc.2020.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/10/2020] [Accepted: 08/17/2020] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Metastatic prostatic adenocarcinoma (PAC) has mostly involved the pelvic lymph nodes; metastases to the cervical lymph nodes are exceedingly rare. MATERIALS AND METHODS A retrospective review of cytopathology files (January 1990 to March 2019) identified 13 cases of metastatic PAC to cervical lymph nodes diagnosed using fine-needle aspiration biopsy (FNAB). The clinical and demographic information were collected from the electronic medical records, and the slides were reviewed. RESULTS A total of 13 male patients with a mean age at FNAB 69 years (range, 61-86 years); 12 patients had a known history of PAC. In the patient without a history of PAC, the FNAB finding had been misinterpreted as papillary thyroid carcinoma. The interval between the original diagnosis and cervical lymph node metastasis was 98.5 months (range, 1-288 months). Most involved the left side (85%). Most smears had a clean background with few lymphocytes (46%) and numerous cellular clusters in flat sheets and acini (62%) and were composed of polygonal cells (46%) with round-oval shaped nuclei and indistinct cell borders (92%). The cytoplasm was granular (61%) or scanty (46%). The nuclei were uniform, size ≥2 times that of a neutrophil (69%). Prominent nucleoli and anisonucleosis were seen in 54% of cases; cellular pleomorphism was infrequent (30%). Immunostains confirmed the prostate origin in 7 tissue cores. CONCLUSIONS Metastatic PAC to the cervical lymph nodes occurs infrequently. If the history is unknown, cases can be misdiagnosed as metastases from cervical neoplasms. The findings indicating metastatic PAC to the cervical lymph nodes on FNAB include involvement of left-sided cervical lymph nodes in elderly male patients and cellular smears composed of uniform polygonal cells, arranged in flat sheets and acini, with granular cytoplasm, indistinct cell borders, and round-oval nuclei with prominent nucleoli.
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Affiliation(s)
- Sam T Albadri
- Division of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota
| | - Diva Salomão
- Division of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota.
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9
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Broglie MA, Dulguerov P, Henke G, Siano M, Putora PM, Simon C, Zwahlen D, Huber GF, Ballerini G, Beffa L, Giger R, Rothschild S, Negri SV, Elicin O. A Review of Controversial Issues in the Management of Head and Neck Cancer: A Swiss Multidisciplinary and Multi-Institutional Patterns of Care Study-Part 4 (Biomarkers). Front Oncol 2019; 9:1128. [PMID: 31709188 PMCID: PMC6822019 DOI: 10.3389/fonc.2019.01128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 10/09/2019] [Indexed: 11/13/2022] Open
Abstract
Background: The Head and Neck Cancer Working Group of Swiss Group for Clinical Cancer Research (SAKK) has investigated the level of consensus (LOC) and discrepancy in everyday practice of diagnosis and treatment in head and neck cancer. Materials and Methods: An online survey was iteratively generated with 10 Swiss university and teaching hospitals. LOC below 50% was defined as no agreement, while higher LOC were arbitrarily categorized as low (51-74%), moderate (75-84%), and high (≥85%). Results: Any LOC was achieved in 62% of topics (n = 60). High, moderate, and low LOC were found in 18, 20, and 23%, respectively. Regarding Head and Neck Surgery, Radiation Oncology, Medical Oncology, and biomarkers, LOC was achieved in 50, 57, 83, and 43%, respectively. Conclusions: Consensus on clinical topics is rather low for surgeons and radiation oncologists. The questions discussed might highlight discrepancies, stimulate standardization of practice, and prioritize topics for future clinical research.
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Affiliation(s)
- Martina A Broglie
- Department of Otorhinolaryngology, Head and Neck Surgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland.,Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Pavel Dulguerov
- Department of Otorhinolaryngology, Head and Neck Surgery, Geneva University Hospital, Geneva, Switzerland
| | - Guido Henke
- Department of Radiation Oncology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Marco Siano
- Department of Medical Oncology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland.,Department of Medical Oncology, Hôpital Riviera-Chablais, Vevey, Switzerland
| | - Paul Martin Putora
- Department of Radiation Oncology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland.,Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christian Simon
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital of Lausanne, Lausanne, Switzerland
| | - Daniel Zwahlen
- Department of Radiation Oncology, Cantonal Hospital Graubünden, Chur, Switzerland.,Department of Radiation Oncology, Cantonal Hospital of Winterthur, Winterthur, Switzerland
| | - Gerhard F Huber
- Department of Otorhinolaryngology, Head and Neck Surgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland.,Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Giorgio Ballerini
- Department of Radiation Oncology, Clinica Luganese SA, Lugano, Switzerland
| | - Lorenza Beffa
- Department of Radiation Oncology, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Roland Giger
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Sacha Rothschild
- Department of Medical Oncology, University Hospital of Basel, Basel, Switzerland
| | - Sandro V Negri
- Department of Otorhinolaryngology, Lindenhofspital, Bern, Switzerland
| | - Olgun Elicin
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Abstract
In adult cervicofacial pathology, carcinoma of unknown primary is defined as lymph-node metastasis the anatomic origin of which is not known at the time of initial management. It constitutes up to 5% of head and neck cancers. Presentation may suggest benign pathology, delaying and confusing oncologic treatment. Diagnostic strategy in cervical lymph node with suspicion of neoplasia requires exhaustive work-up to diagnose malignancy and, in 45% to 80% of cases, depending on the series, to identify the primary site. Histologic types comprise squamous cell carcinoma, thyroid carcinoma, adenocarcinoma, neuroendocrine carcinoma and undifferentiated carcinoma. Association is sometimes found with human papilloma virus or Epstein Barr virus, guiding treatment. The objective of the present study was to provide clinicians with the necessary diagnostic tools, based on the current state of clinical, imaging and pathologic knowledge, and to detail treatment options.
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11
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Chan JW, Yeh I, El‐Sayed IH, Algazi AP, Glastonbury CM, Ha PK, Yom SS, Zante A. Ultraviolet light‐related DNA damage mutation signature distinguishes cutaneous from mucosal or other origin for head and neck squamous cell carcinoma of unknown primary site. Head Neck 2019; 41:E82-E85. [DOI: 10.1002/hed.25613] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 12/12/2018] [Indexed: 01/01/2023] Open
Affiliation(s)
- Jason W. Chan
- Department of Radiation OncologyUniversity of California San Francisco San Francisco California
| | - Iwei Yeh
- Departments of Dermatology and PathologyUniversity of California San Francisco San Francisco California
| | - Ivan H. El‐Sayed
- Department of Otolaryngology – Head and Neck SurgeryUniversity of California San Francisco San Francisco California
| | - Alain P. Algazi
- Department of Medicine – Hematology/OncologyUniversity of California San Francisco San Francisco California
| | - Christine M. Glastonbury
- Department of Radiology and Biomedical ImagingUniversity of California San Francisco San Francisco California
| | - Patrick K. Ha
- Department of Otolaryngology – Head and Neck SurgeryUniversity of California San Francisco San Francisco California
| | - Sue S. Yom
- Department of Radiation OncologyUniversity of California San Francisco San Francisco California
| | - Annemieke Zante
- Department of Anatomic PathologyUniversity of California San Francisco San Francisco California
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12
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Cabrera Rodríguez J, Cacicedo J, Giralt J, García Miragall E, Lloret M, Arias F, González Ruiz MA, Contreras J. GEORCC recommendations on target volumes in radiotherapy for Head Neck Cancer of Unkown Primary. Crit Rev Oncol Hematol 2018; 130:51-59. [PMID: 30196912 DOI: 10.1016/j.critrevonc.2018.07.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 04/16/2018] [Accepted: 07/17/2018] [Indexed: 12/22/2022] Open
Abstract
Head Neck Cancer of Unknown Primary (HNCUP) is a rare condition, representing approximately 5-10% of all head neck cancers. Radiotherapy, adjuvant or radical, is usually employed in the treatment of those patients. To date, no specific guidelines for the optimal definition of the target volume to be irradiated have been published. In recent years, there have been advances in the knowledge of the molecular biology of HNCUP, its diagnostic imaging and the implementation of sophisticated radiotherapy techniques with enhanced precision in target localization and treatment delivery. These progresses have provided valuable information about the natural history of HNCUP that will allow for establishment of the best treatment for each patient, including standardized, consistent and reproducible target volumes definitions. Several recommendations regarding how to choose volumes when contouring HNCUP in clinical practice are reported, in order to achieve a high rate of loco-regional control while avoiding unnecessary toxicity.
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Affiliation(s)
- Joaquín Cabrera Rodríguez
- Radiation Oncology Department, Hospital Universitario Infanta Cristina, Avenida de Elvas, s/n, 06080 Badajoz, Spain.
| | - Jon Cacicedo
- Radiation Oncology Department, Hospital Universitario de Cruces, Plaza de Cruces, s/n, 48903 Baracaldo, Spain
| | - Jordi Giralt
- Radiation Oncololgy Deparment, Hospital General Vall D'Hebron, Passeig de la Vall d'Hebron, 119-129, 08035 Barcelona, Spain
| | - Enrique García Miragall
- Radiation Oncology Department, Hospital General Universitario Valencia- ERESA, Avenida Blasco Ibáñez, 17, 46010 Valencia, Spain
| | - Marta Lloret
- Radiation Oncology Department, Hospital Universitario Doctor Negrín, c/ Barranco de la ballena, s/n, 35010, Las Palmas de Gran Ganaria, Spain
| | - Fernando Arias
- Radiation Oncology Department, Complejo Hospitalario de Navarra, C/ Irunlarrea, 4, 31008 Pamplona, Spain
| | - María Angeles González Ruiz
- Radiation Oncology Department, Hospital Universitario Infanta Cristina, Avenida de Elvas, s/n, 06080 Badajoz, Spain
| | - Jorge Contreras
- Radiation Oncology Department, Complejo Hospitalario Carlos Haya, Avenida de Carlos Haya, s/n, 29010 Málaga, Spain
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Müller von der Grün J, Bon D, Rödel C, Balermpas P. Patterns of care analysis for head & neck cancer of unknown primary site: a survey inside the German society of radiation oncology (DEGRO). Strahlenther Onkol 2018; 194:750-758. [DOI: 10.1007/s00066-018-1308-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 04/23/2018] [Indexed: 11/30/2022]
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Lu X, Hu C, Ji Q, Shen C, Feng Y. Squamous Cell Carcinoma Metastatic to Cervical Lymph Nodes from an Unknown Primary Site: The Impact of Radiotherapy. TUMORI JOURNAL 2018; 95:185-90. [DOI: 10.1177/030089160909500209] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims and background Cervical lymph node metastases of squamous cell carcinoma from an unknown primary site constitute about 5% of the total head and neck cancer cases. The management of these patients is still a therapeutic challenge. The aim of the present study was to analyze the prognosis in a series of patients and, in particular, the impact of different radiotherapy techniques on the prognosis. Methods and study design Data from 60 patients with cervical lymph node metastases of squamous cell carcinoma from an unknown primary site were reviewed. Nine of 60 patients (15.0%) received excisional biopsy. Radiotherapy was delivered to the bilateral neck and pharyngeal mucosa (extensive field) in 11 patients (18.3%), to the bilateral neck in 24 patients (40.0%), and to the ipsilateral neck in 25 patients (41.7%). Fourteen patients (23.3%) also received chemotherapy. Results The 5-year overall survival rate of all patients was 68.5%. The overall survival of patients with N1, N2, and N3 stage was 100%, 68.0%, and 40.9%, respectively (P = 0.026). The overall survial of patients irradiated by ipsilateral neck, bilateral neck, and extensive field was 66.5%, 74.5%, and 54.6%, respectively (P = 0.5). At multivariate analysis, only N stage significantly affected overall survival (P = 0.032). The 5-year neck control rate of all patients was 65.6%. The neck control rate of patients with N1, N2, and N3 stage was 100%, 63.2%, and 34.6%, respectively (P = 0.064). The neck control rate of patients irradiated by ipsilateral neck, bilateral neck, and extensive field was 87.6%, 51.1%, and 72.7%, respectively (P = 0.279). Emergence of the occult primary was observed in 21.2% patients, and all of these occurred within the head and neck region. The primary tumor emerged in 23.3% of patients treated with ipsilateral and bilateral neck irradiation and in 12.5% of patients irradiated by extensive field (P = 0.469). Conclusions Patients with cervical lymph node metastases of squamous cell carcinoma from an unknown primary site have clinical features and a prognosis similar to those of other head and neck malignancies. Extensive irradiation results in a lower trend of emergence of the primary tumor than when patients are treated with ipsilateral and bilateral irradiation, but there is no significant difference in overall survival.
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Affiliation(s)
- Xueguan Lu
- Department of Radiation Oncology, Second Affiliated Hospital of Soochow University, Suzhou
- Department of Radiation Oncology, Cancer Hospital of Fudan University, Shanghai, China
| | - Chaosu Hu
- Department of Radiation Oncology, Cancer Hospital of Fudan University, Shanghai, China
| | - Qinghai Ji
- Department of Head & Neck Surgery, Cancer Hospital of Fudan University, Shanghai, China
| | - Chunying Shen
- Department of Radiation Oncology, Cancer Hospital of Fudan University, Shanghai, China
| | - Yan Feng
- Department of Radiation Oncology, Cancer Hospital of Fudan University, Shanghai, China
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Hu KS, Mourad WF, Gamez ME, Lin W, Jacobson AS, Persky MS, Urken ML, Culliney BE, Li Z, Tran TN, Schantz SP, Chadha J, Harrison LB. Five-year outcomes of an oropharynx-directed treatment approach for unknown primary of the head and neck. Oral Oncol 2017. [PMID: 28622886 DOI: 10.1016/j.oraloncology.2017.05.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE Squamous cell carcinoma of unknown primary (SCCHNUP) is commonly treated with comprehensive radiation to the laryngopharynx and bilateral necks. In 1998, we established a departmental policy to treat SCCHNUP with radiation directed to the oropharynx and bilateral neck. METHODS From 1998-2011, 60 patients were treated - N1: 18%, N2: 75% and N3: 7%. 82% underwent neck dissection. 55% received IMRT and 62% underwent concurrent chemoradiotherapy. RESULTS At median follow-up of 54months, 5 patients failed regionally and 4 emerged with a primary (tongue base, hypopharynx and thoracic esophagus). Five-year rates of regional control, primary emergence, distant metastasis, disease-free survival and overall survival were 90%, 10%, 20%, 72% and 79%, respectively. The 5year rate of primary emergence in a non-oropharynx site was 3%. CONCLUSION This is the first demonstration that an oropharynx-directed approach yields low rates of primary emergence in SCCHNUP with excellent oncologic outcomes.
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Affiliation(s)
- Kenneth Shung Hu
- Dept of Radiation Oncology, New York University Langone Medical Center, New York, NY, United States.
| | - Waleed Fouad Mourad
- Dept of Radiation Oncology, Georgia Regents University, Augusta, GA, United States
| | - Mauricio E Gamez
- Dept of Radiation Oncology, Mayo Clinic Arizona, Phoenix, AZ, United States.
| | - Wilson Lin
- Dept of Radiation Oncology, Mount Sinai at Beth Israel Medical Center, New York, NY, United States
| | - Adam Saul Jacobson
- Dept of Otolaryngology, New York University Langone Medical Center, New York, NY, United States
| | - Mark Stephen Persky
- Dept of Otolaryngology, New York University Langone Medical Center, New York, NY, United States
| | - Mark L Urken
- Dept of Otolaryngology, Mount Sinai at Beth Israel, New York, NY, United States
| | - Bruce E Culliney
- Dept of Medicine, Mount Sinai at Beth Israel, New York, NY, United States
| | - Zujun Li
- Dept of Medicine, New York University Langone Medical Center, New York, NY, United States
| | - Theresa Nguyen Tran
- Dept of Otolaryngology, New York University Langone Medical Center, New York, NY, United States
| | | | - Juskaran Chadha
- Dept of Medicine, Mount Sinai at Roosevelt Hospital, New York, NY, United States
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Al Kadah B, Papaspyrou G, Linxweiler M, Schick B, Rübe C, Büchler BS, Niewald M. Cancer of unknown primary (CUP) of the head and neck: retrospective analysis of 81 patients. Eur Arch Otorhinolaryngol 2017; 274:2557-2566. [PMID: 28314959 DOI: 10.1007/s00405-017-4525-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 03/01/2017] [Indexed: 11/28/2022]
Abstract
The treatment of patients with cervical lymph node metastases without detectable primary tumor remains an important challenge, until today, no standard therapy is available. The present study investigated the multimodal treatment of patients with head and neck CUP syndrome (HNCUP) and their follow-up retrospectively. 81 patients with cervical lymph node metastases without a primary tumor were treated at the Departments of Otorhinolaryngology as well as Radiotherapy and Radiation Oncology at the University of Saarland in Homburg, Germany in the period between 1991 and 2013. All patients received routine work-up consisting of CUP panendoscopy and imaging. Neck dissection was then performed in 77% of the patients. The most common histology was squamous cell carcinoma (80%). Ten percent of the patients had distant metastases. All patients underwent primary or adjuvant radiation therapy, or simultaneous radiochemotherapy. After a median follow-up of 3.5 years, the 5-year survival rate was 30%. There was a local recurrence that was known in 20/63 patients (31%) and distant metastases were documented in 19/61 M0 patients (31%). Higher grade late toxicity (grade 3-4) was observed in 12% of patients. Neck dissection and radiation therapy remains an integral part of HNCUP therapy, while the use of chemotherapy could be considered in selected cases. Prospective multicenter randomized trials would be necessary to identify the best target volume and to clarify the role of chemotherapy.
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Affiliation(s)
- Basel Al Kadah
- Department of Otorhinolaryngology, Saarland University Medical Center, Kirrberger Straße 100, 66421, Homburg/saar, Germany.
| | - Giorgos Papaspyrou
- Department of Otorhinolaryngology, Saarland University Medical Center, Kirrberger Straße 100, 66421, Homburg/saar, Germany
| | - Maximilian Linxweiler
- Department of Otorhinolaryngology, Saarland University Medical Center, Kirrberger Straße 100, 66421, Homburg/saar, Germany
| | - Bernhard Schick
- Department of Otorhinolaryngology, Saarland University Medical Center, Kirrberger Straße 100, 66421, Homburg/saar, Germany
| | - Christian Rübe
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Center, Homburg/saar, Germany
| | - Benjamin Simeon Büchler
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Center, Homburg/saar, Germany
| | - Marcus Niewald
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Center, Homburg/saar, Germany
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Al Kadah B, Popov HH, Schick B, Knöbber D. Cervical lymphadenopathy: study of 251 patients. Eur Arch Otorhinolaryngol 2014; 272:745-52. [PMID: 25294051 DOI: 10.1007/s00405-014-3315-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 09/26/2014] [Indexed: 02/05/2023]
Abstract
Correct diagnosis of cervical lymphadenopathy is often a great challenge. The objective of this case study is to describe the distribution of the most common causes of unclear neck swellings presented in an ENT-Department and to evaluate the clinical history, examination and laboratory findings. In a retrospective study at the Department of Otorhinolaryngology, University Medical Center Homburg/Saar, 251 patients were enrolled with clinical and ultrasound signs of cervical lymphadenopathy as well as lymph node extirpation for histopathological evaluation. 127 patients (50.6 %) had a histological malignant finding. The distribution of the most common pathological conditions was as follows: Non-specific reactive hyperplasia n = 89 (35.5 %), metastases n = 86 (34.3 %), lymphoma n = 41 (16.3 %), granulomatous lesions n = 15 (6 %), abscess formations n = 5 (2 %), necrotic lymphadenitis and Castleman's disease one case of each, lymph node with normal architecture n = 7 (2.8 %), and neck masses mimicking lymphadenopathy n = 6 cases (2.4 %). The following factors identified by multivariate logistic regression were significantly associated to malignant lymphadenopathy: increasing age, generalized lymphadenopathy and history of malignant disorder, fixed neck masses and increasing diameter in ENT examination, bulky lesion, absence of hilus, blurred outer contour, protective role of the long form and decreasing Solbiati-index values by ultrasound B-Mode gray scale examination. Level II contained more benign lymphatic lesions, while the malignancy rate in level IV and V was enhanced. Laboratory parameters significantly associated to malignancies were CRP, LDH and thrombocytopenia. Patients with persisting cervical lymphadenopathy and over 3 weeks of antibiotic treatment should be considered for early biopsy, especially if some of the risk factors, pointed out in this study, are present.
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Affiliation(s)
- Basel Al Kadah
- Department of Otorhinolaryngology, University Medical Center, Kirrberger Street, 66421, Homburg/Saar, Germany,
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19
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Zhuang SM, Wu XF, Li JJ, Zhang GH. Management of lymph node metastases from an unknown primary site to the head and neck (Review). Mol Clin Oncol 2014; 2:917-922. [PMID: 25279174 DOI: 10.3892/mco.2014.361] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Accepted: 02/12/2014] [Indexed: 12/14/2022] Open
Abstract
Cancer of unknown primary site (CUP) is an intriguing clinical phenomenon found in ~3-9% of all head and neck cancers. It has not yet been determined whether CUP forms a distinct biological entity with specific genetic and phenotypic characteristics, or whether it is the clinical presentation of metastasis in patients with an undetected primary tumor and no visible clinical signs. The treatment of patients with cervical lymph node metastases from CUP remains controversial, due to the lack of randomized clinical trials comparing different treatment options. Consequently, treatment is currently based on non-randomized data and institutional policy. In the present review, the range and limitations of diagnostic procedures are summarized and an optimal diagnostic work-up is recommended. The initial preferred diagnostic procedures include fine-needle aspiration biopsy (FNAB) and imaging. Although neck dissection followed by postoperative radiotherapy is the the most generally accepted approach, other curative options may be used in certain patients, such as neck dissection alone, nodal excision followed by postoperative radiotherapy, or radiotherapy alone. There remains controversy regarding target radiation volumes, ranging from ipsilateral neck irradiation to prophylactic irradiation of all the potential mucosal sites and both sides of the neck. When no primary lesion is identified with imaging and endoscopy in patients without history of smoking and alcohol abuse, molecular profiling of an FNAB sample for human papillomavirus and/or Epstein-Barr virus is required.
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Affiliation(s)
- Shi Min Zhuang
- Department of Otorhinolaryngology-Head and Neck Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510630, P.R. China
| | - Xi-Fu Wu
- Department of Otorhinolaryngology-Head and Neck Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510630, P.R. China
| | - Jing-Jia Li
- Department of Otorhinolaryngology-Head and Neck Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510630, P.R. China
| | - Ge-Hua Zhang
- Department of Otorhinolaryngology-Head and Neck Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510630, P.R. China
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Nagel TH, Hinni ML, Hayden RE, Lott DG. Transoral laser microsurgery for the unknown primary: Role for lingual tonsillectomy. Head Neck 2014; 36:942-6. [DOI: 10.1002/hed.23372] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Revised: 02/06/2013] [Accepted: 04/11/2013] [Indexed: 01/08/2023] Open
Affiliation(s)
- Thomas H. Nagel
- Department of Otolaryngology - Head and Neck Surgery; Mayo Clinic Arizona; Phoenix Arizona
| | - Michael L. Hinni
- Department of Otolaryngology - Head and Neck Surgery; Mayo Clinic Arizona; Phoenix Arizona
| | - Richard E. Hayden
- Department of Otolaryngology - Head and Neck Surgery; Mayo Clinic Arizona; Phoenix Arizona
| | - David G. Lott
- Department of Otolaryngology - Head and Neck Surgery; Mayo Clinic Arizona; Phoenix Arizona
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Shum JW, Dierks EJ. Evaluation and Staging of the Neck in Patients with Malignant Disease. Oral Maxillofac Surg Clin North Am 2014; 26:209-21. [DOI: 10.1016/j.coms.2014.01.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Straetmans J, Vent J, Lacko M, Speel EJ, Huebbers C, Semrau R, Hoebers F, Mujagic Z, Klussmann JP, Preuss SF, Kremer B. Management of neck metastases of unknown primary origin united in two European centers. Eur Arch Otorhinolaryngol 2014; 272:195-205. [DOI: 10.1007/s00405-014-2934-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Accepted: 02/04/2014] [Indexed: 10/25/2022]
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Beadle BM, William WN, McLemore MS, Sturgis EM, Williams MD. p16 expression in cutaneous squamous carcinomas with neck metastases: a potential pitfall in identifying unknown primaries of the head and neck. Head Neck 2012; 35:1527-33. [PMID: 23108906 DOI: 10.1002/hed.23188] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2012] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Human papillomavirus (HPV) positivity (+) has been used to identify oropharyngeal squamous carcinomas (SCCs) presenting as unknown primaries in the neck. p16 overexpression correlates with HPV+ in the oropharynx; however, the use of p16 alone as a surrogate marker of oropharyngeal HPV+ tumors has not been validated. METHODS We immunohistochemically analyzed p16 expression in surgically resected aggressive cutaneous head and neck SCC primaries and their nodal metastases from 24 patients to determine the potential overlap of p16 expression outside of the oropharynx. RESULTS Five of 24 primary tumors (20.8%) and 3 lymph node metastases (12.5%) in levels II, III, and V, and the periparotid region diffusely expressed p16. HPV (high-risk types by in situ hybridization) was negative. CONCLUSIONS p16 expression is relatively common in lymph node-positive cutaneous head and neck SCCs; thus, p16 expression as an independent biomarker and mechanism to determine the oropharyngeal source of an unknown primary is not advised.
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Affiliation(s)
- Beth M Beadle
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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24
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Balaker AE, Abemayor E, Elashoff D, St. John MA. Cancer of unknown primary: Does treatment modality make a difference? Laryngoscope 2012; 122:1279-82. [DOI: 10.1002/lary.22424] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Revised: 08/09/2011] [Accepted: 08/11/2011] [Indexed: 11/09/2022]
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Abstract
In patients presenting with a neck adenopathy from a clinically unknown primary, efforts should be made to localize the primary tumour, as this allows a more focused therapy. Imaging is helpful in identifying suspicious mucosal sites that should be further investigated endoscopically, including biopsy. In case no primary tumour is detected in the head and neck, a positron emission tomography (PET) study can be considered to search for an infraclavicular primary tumour. This article reviews the diagnostic value of computed tomography (CT), magnetic resonance imaging, PET and PET/CT in this clinical context.
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Affiliation(s)
- Robert Hermans
- Department of Radiology, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium.
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Head and neck squamous cell carcinoma from an unknown primary site. Am J Otolaryngol 2011; 32:286-90. [PMID: 20719404 DOI: 10.1016/j.amjoto.2010.05.004] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Accepted: 05/10/2010] [Indexed: 11/22/2022]
Abstract
BACKGROUND The purpose of this study is to present our experience treating patients with squamous cell carcinoma (SCC) from an unknown head and neck primary site and to determine whether a policy change eliminating the larynx and hypopharynx from the radiotherapy (RT) portals has impacted outcome. METHODS One hundred seventy-nine patients received definitive RT with or without a neck dissection for SCC from an unknown head and neck primary site. RT was delivered to the ipsilateral neck alone or both sides of the neck and, usually, the potential mucosal primary sites. The median mucosal dose was 5670 cGy. The median neck dose was 6500 cGy. One hundred nine patients (61%) received a planned neck dissection. RESULTS Mucosal control at 5 years was 92%. The mucosal control rate in patients with RT limited to the nasopharynx and oropharynx was 100%. The 5-year neck-control rates were as follows: N(1), 94%; N(2a), 98%; N(2b), 86%; N(2c), 86%; N(3), 57%; and overall, 81%. The 5-year cause-specific survival rates were as follows: N(1), 94%; N(2a), 88%; N(2b), 82%; N(2c), 71%; N(3), 48%; and overall, 73%. The 5-year overall survival rates were as follows: N(1), 50%; N(2a), 70%; N(2b), 59%; N(2c), 45%; N(3), 34%; and overall, 52%. Eleven patients (7%) developed severe complications. CONCLUSION RT alone or combined with neck dissection results in a high probability of cure with a low risk of severe complications. Eliminating the larynx and hypopharynx from the RT portals did not compromise outcome and likely reduces treatment toxicity.
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Abstract
The management of patients with cervical lymph node metastases from an unknown primary cancer (CUP) remains a matter of controversy. Although new advanced diagnostic tools, such as positron emission tomography, have recently been introduced in oncology, the frequency of this tumour entity in clinical practice means it is still relevant. Recently introduced molecular profiling platforms may provide biological classification for the primary tissue of origin as well as insights into the pathophysiology of this clinical entity, including the characterisation of the Epstein-Barr virus and human papilloma virus genomas in the metastatic cervical nodes. Due to the lack of randomised trials, a standard therapy has not been identified yet. Although neck dissection followed by post-operative radiotherapy is the most generally accepted approach, there are other curative options that can be used in some patients: neck dissection alone, nodal excision followed by post-operative radiotherapy or radiotherapy alone. A major controversy remains in the target radiation volumes that range from ipsilateral neck irradiation to prophylactic irradiation of all potential mucosal sites and both sides of the neck. Finally, the administration of concurrent chemotherapy is currently being advised for patients with adverse prognostic factors.
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Outcomes of patients with head-and-neck cancer of unknown primary origin treated with intensity-modulated radiotherapy. Int J Radiat Oncol Biol Phys 2011; 81:e83-91. [PMID: 21377283 DOI: 10.1016/j.ijrobp.2011.01.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2010] [Revised: 01/16/2011] [Accepted: 02/22/2011] [Indexed: 11/24/2022]
Abstract
PURPOSE To analyze survival, failure patterns, and toxicity in patients with head-and-neck carcinoma of unknown primary origin (HNCUP) treated with intensity-modulated radiotherapy (IMRT). METHODS AND MATERIALS Records from 27 patients with HNCUP treated during the period 2002-2008 with IMRT were reviewed retrospectively. Nodal staging ranged from N1 to N3. The mean preoperative dose to gross or suspected disease, Waldeyer's ring, and uninvolved bilateral cervical nodes was 59.4, 53.5, and 51.0 Gy, respectively. Sixteen patients underwent neck dissection after radiation and 4 patients before radiation. Eight patients with advanced nodal disease (N2b-c, N3) or extracapsular extension received chemotherapy. RESULTS With a median follow-up of 41.9 months (range, 25.3-93.9 months) for non deceased patients, the 5-year actuarial overall survival, disease-free survival, and nodal control rates were 70.9%, 85.2%, and 88.5%, respectively. Actuarial disease-free survival rates for N1, N2, and N3 disease were 100%, 94.1%, and 50.0%, respectively, at 5 years. When stratified by non advanced (N1, N2a nodal disease without extracapsular spread) vs. advanced nodal disease (N2b, N2c, N3), the 5-year actuarial disease-free survival rate for the non advanced nodal disease group was 100%, whereas for the advanced nodal disease group it was significantly lower at 66.7% (p = 0.017). Three nodal recurrences were observed: in 1 patient with bulky N2b disease and 2 in patients with N3 disease. No nodal failures occurred in patients with N1 or N2a disease who received only radiation and surgery. CONCLUSION Definitive IMRT to 50-56 Gy followed by neck dissection results in excellent nodal control and overall and disease-free survival, with acceptable toxicity for patients with T0N1 or non bulky T0N2a disease without extracapsular spread. Patients with extracapsular spread, advanced N2 disease, or N3 disease may benefit from concurrent chemotherapy, targeted therapeutic agents, or accelerated radiation regimens in addition to surgery.
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Efficacy and toxicity of chemoradiotherapy using intensity-modulated radiotherapy for unknown primary of head and neck. Int J Radiat Oncol Biol Phys 2010; 80:1405-11. [PMID: 21177045 DOI: 10.1016/j.ijrobp.2010.04.029] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2010] [Revised: 04/05/2010] [Accepted: 04/06/2010] [Indexed: 10/18/2022]
Abstract
PURPOSE No single standard treatment paradigm is available for head-and-neck squamous cell carcinoma of an unknown primary (HNCUP). Bilateral neck radiotherapy with mucosal axis irradiation is widely used, with or without chemotherapy and/or surgical resection. Intensity-modulated radiotherapy (IMRT) is a highly conformal method for delivering radiation that is becoming the standard of care and might reduce the long-term treatment-related sequelae. We report the Dana-Farber Cancer Institute experience with IMRT-based treatment for HNCUP. PATIENTS AND MATERIALS A retrospective study of all patients treated at the Dana-Farber Cancer Institute for HNCUP with IMRT between August 2004 and January 2009. The primary endpoint was overall survival; the secondary endpoints were locoregional and distant control, and acute and chronic toxicity. RESULTS A total of 24 patients with HNCUP were included. Of these patients, 22 had Stage N2 disease or greater. All patients underwent neck computed tomography, positron emission tomography-computed tomography, and examination under anesthesia with directed biopsies. Of the 24 patients, 22 received concurrent chemotherapy, and 7 (29%) also underwent induction chemotherapy. The median involved nodal dose was 70 Gy, and the median mucosal dose was 60 Gy. With a median follow-up of 2.1 years, the 2-year actuarial overall survival and locoregional control rate was 92% and 100%, respectively. Only 25% of the patients had Grade 2 xerostomia, although 11 patients (46%) required esophageal dilation for stricture. CONCLUSION In a single-institution series, IMRT-based chemoradiotherapy for HNCUP was associated with superb overall survival and locoregional control. The xerostomia rates were promising, but the aggressive therapy was associated with significant rates of esophageal stenosis.
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Shukla P, Gupta D, Bisht SS, Pant MC, Bhatt ML, Srivastava K, Negi MPS. Metastatic squamous cell carcinoma neck with occult primary: A retrospective analysis. Indian J Med Paediatr Oncol 2010; 30:124-30. [PMID: 20838553 PMCID: PMC2930299 DOI: 10.4103/0971-5851.65334] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Introduction: Metastatic carcinoma in the lymph nodes of the neck from an unknown primary is relatively rare, accounting for about 3% of all head and neck cancers. Management of secondary neck of undetermined primary is controversial. Materials and Methods: The case records of all the patients treated in the Department of Radiotherapy, Chatrapati Shahuji Maharaj Medical University, from Oct 1999 to Sep 2004, were studied and the patients with secondary neck without a known primary tumor were analyzed in detail to elucidate the outcome of various treatment modalities in various stages of the disease. One hundred and forty patients were found to be eligible for this analysis. Initial treatment could be divided into two categories: concurrent chemoradiation (n=76) and radiotherapy alone (n=64). Results: The patients who had received radiotherapy alone (53.1%) had lesser complete response as compared to those who had received chemoradiotherapy (68.4%). The overall survival duration in patients of the radiotherapy treatment group ranged from 5 to 60 months, with an average (±SD) of 31.06 ± 21.01 months, while in the chemoradiotherapy treatment group it ranged from 6 to 60 months, with an average (±SD) of 39.42 ± 21.33 months. Both hematological and nonhematological toxicities, although higher in the chemoradiotherapy group, showed statistically insignificant differences. Conclusion: To the best of our knowledge, this is the only study evaluating the role of concurrent chemoradiation in cases of secondary neck with primary unknown. The improved response rates along with an increased survival (both disease free and overall) show the superiority of chemoradiotherapy in the management of such cases.
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Affiliation(s)
- Pragya Shukla
- Department of Radiation Oncology, TATA Memorial Cancer Hospital, Mumbai, India
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Diagnosis and treatment of a neck node swelling suspicious for a malignancy: an algorithmic approach. Int J Surg Oncol 2010; 2010:581540. [PMID: 22312490 PMCID: PMC3265261 DOI: 10.1155/2010/581540] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Accepted: 03/27/2010] [Indexed: 12/03/2022] Open
Abstract
Aim. To present an up-to-date algorithm incorporating recent advances regarding its diagnosis and treatment. Method. A Medline/Pubmed search was performed to identify relevant studies published in English from 1990 until 2008. Only clinical studies were identified and were used as basis for the diagnostic algorithm. Results. The eligible literature provided only observational evidence. The vast majority of neck nodes from occult primaries (>90%) represent SCC with a high incidence among middle aged man. Smoking and alcohol abuse are important risk factors. Asiatic and North African patients with neck node metastases are at risk of harbouring an occult nasopharyngeal carcinoma. The remainder are adenocarcinoma, undifferentiated carcinoma, melanoma, thyroid carcinoma and Merkel cell carcinoma. Fine needle aspiration cytology (FNAC) reaches sensitivity and specificity percentages of 81% and 100%, respectively and plays an important role as the second diagnostic step after routine ENT mirror and/or endoscopic examination. FDG-PET/CT has proven to be helpful in identifying occult primary carcinomas of the head and neck, especially when applied as a guiding tool prior to panendoscopy, and may induce treatment related clinical decisions in up to 60% of cases. Conclusion. Although reports on the diagnostic process offer mainly descriptive studies, current information seems sufficient to formulate a diagnostic algorithm to contribute to a more systematic diagnostic approach preventing unnecessary steps.
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Impact of target volumes and radiation technique on loco-regional control and survival for patients with unilateral cervical lymph node metastases from an unknown primary. Radiother Oncol 2009; 93:483-7. [DOI: 10.1016/j.radonc.2009.08.027] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2008] [Revised: 07/29/2009] [Accepted: 08/11/2009] [Indexed: 11/20/2022]
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Pavlidis N, Pentheroudakis G, Plataniotis G. Cervical lymph node metastases of squamous cell carcinoma from an unknown primary site: a favourable prognosis subset of patients with CUP. Clin Transl Oncol 2009; 11:340-8. [DOI: 10.1007/s12094-009-0367-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Unknown primary head and neck cancer treated with intensity-modulated radiation therapy: To what extent the volume should be irradiated. Oral Oncol 2009; 45:474-9. [DOI: 10.1016/j.oraloncology.2008.06.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2008] [Revised: 06/17/2008] [Accepted: 06/16/2008] [Indexed: 11/18/2022]
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Abstract
Head and neck cancers account for less than 5% of all cancers and for less than 3% of all cancer deaths in the United States. The populations at risk for head and neck cancers are those who have a long-standing history of smoking and alcohol use. More recently, the incidence of oropharyngeal cancer in younger populations has been increasing and is associated with exposure to the human papillomavirus. This subset of patients appears to have a better overall prognosis and to respond better to treatment. This review is limited to head and neck cancers of squamous cell histology, which constitute more than 90% of head and neck cancers. Because treatment of head and neck cancers is complex and involves multiple modalities, a multidisciplinary approach is needed. This review focuses on the goal of organ preservation and postoperative treatment of high-risk patients with the concurrent use of chemotherapy and radiation therapy. This review also highlights recent advances in treatment using molecularly targeted therapies, specifically the role of inhibitors of the epidermal growth factor receptor in locally advanced and recurrent/metastatic squamous cell cancer of the head and neck. Studies in the English language were identified by searching the MEDLINE, EMBASE database (1980-2007) using the search terms head and neck, squamous cell, carcinoma, chemotherapy, radiation, human papillomavirus, epidermal growth factor receptor, and targeted therapy.
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Affiliation(s)
- Shanthi Marur
- Bunting-Blaustein CRB1 G92, 1650 Orleans St, Baltimore, MD 21231-1000, USA. smarur1 @jhmi.edu
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Intensity-modulated radiotherapy for cervical lymph node metastases from unknown primary cancer. Int J Radiat Oncol Biol Phys 2008; 71:1158-66. [PMID: 18258383 DOI: 10.1016/j.ijrobp.2007.11.059] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2007] [Revised: 11/15/2007] [Accepted: 11/16/2007] [Indexed: 11/24/2022]
Abstract
PURPOSE To compare the effectiveness of intensity-modulated radiotherapy (IMRT) and conventional (two-dimensional) radiotherapy in the treatment of cervical lymph node metastases from unknown primary cancer (UPC). METHODS AND MATERIALS Between February 2003 and September 2006, 23 patients with UPC of squamous cell carcinoma were treated with IMRT. Extended putative mucosal and bilateral nodal sites were irradiated to a median dose of 66 Gy. In 19 patients, IMRT was performed after lymph node dissection, and in 4 patients primary radiotherapy was given. The conventional radiotherapy group (historical control group) comprised 18 patients treated to a median dose of 66 Gy between August 1994 and October 2003. RESULTS Twenty patients completed treatment. As compared with conventional radiotherapy, the incidence of Grade 3 acute dysphagia was significantly lower in the IMRT group (4.5% vs. 50%, p = 0.003). By 6 months, Grade 3 xerostomia was detected in 11.8% patients in the IMRT group vs. 53.4% in the historical control group (p = 0.03). No Grade 3 dysphagia or skin fibrosis was observed after IMRT but these were noted after conventional radiotherapy (26.7%, p = 0.01) and 26.7%, p = 0.03) respectively). With median follow-up of living patients of 17 months, there was no emergence of primary cancer. One patient had persistent nodal disease and another had nodal relapse at 5 months. Distant metastases were detected in 4 patients. The 2-year overall survival and distant disease-free probability after IMRT did not differ significantly from those for conventional radiotherapy (74.8% vs. 61.1% and 76.3% vs. 68.4%, respectively). CONCLUSIONS Use of IMRT for UPC resulted in lower toxicity than conventional radiotherapy, and was similar in efficacy.
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Beldì D, Jereczek-Fossa BA, D'Onofrio A, Gambaro G, Fiore MR, Pia F, Chiesa F, Orecchia R, Krengli M. Role of radiotherapy in the treatment of cervical lymph node metastases from an unknown primary site: retrospective analysis of 113 patients. Int J Radiat Oncol Biol Phys 2007; 69:1051-8. [PMID: 17716824 DOI: 10.1016/j.ijrobp.2007.04.039] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2007] [Revised: 04/20/2007] [Accepted: 04/21/2007] [Indexed: 12/01/2022]
Abstract
PURPOSE The management of patients with cervical lymph-node metastases from unknown primary site (UPS) remains a matter of discussion. This study aimed to analyze the results and prognostic factors in a series of patients treated with radiotherapy. METHODS AND MATERIALS Data from 113 patients who presented with cervical lymph nodes metastases from UPS treated from 1980 to 2004 were reviewed. Eighty-seven patients (77.0%) were squamous cell carcinoma (SCC). Ninety-one patients were treated with curative and 22 with palliative intent. Fifty-nine of 113 patients (52.2%) received surgery followed by radiotherapy and 54 of 113 (47.8%) received radiotherapy alone. Radiotherapy was delivered to the neck and pharyngeal mucosa in 67 patients and to the ipsilateral or bilateral neck in 45 patients. Twenty-one patients (18.5%) also received chemotherapy. RESULTS The 5-year overall survival rates were 40.7% for the entire group and 46.6% for the SCC subgroup. The occurrence of the occult primary was observed in 23 of 113 patients (20.3%), 19 (82.6%) within the head and neck region. At multivariate analysis, treatment with curative intent and extensive irradiation of bilateral neck and pharyngeal mucosa were favorable prognostic factors for the whole series, and treatment with curative intent, extensive irradiation of bilateral neck and pharyngeal mucosa, and absence of extracapsular spread were favorable prognostic factors for the SCC subgroup. CONCLUSIONS Patients with cervical lymph node metastases from UPS have a similar prognosis to those affected by other head and neck malignancies. Curative treatment strategies including neck dissection and extensive irradiation by three-dimensional conformal radiation therapy resulted in significantly better outcomes.
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Affiliation(s)
- Debora Beldì
- Radiotherapy Department, Hospital Maggiore della Carità, Novara, Italy
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Boscolo-Rizzo P, Gava A, Da Mosto MC. Carcinoma Metastatic to Cervical Lymph Nodes From an Occult Primary Tumor: The Outcome After Combined-Modality Therapy. Ann Surg Oncol 2007; 14:1575-82. [PMID: 17508250 DOI: 10.1245/s10434-006-9329-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2006] [Revised: 11/30/2006] [Accepted: 12/07/2006] [Indexed: 11/18/2022]
Abstract
BACKGROUND The aim of this retrospective analysis was to analyze the results of treatment of patients with cervical node metastases from carcinoma of occult primary with a policy including neck dissection and postoperative comprehensive radiotherapy. METHODS Ninety patients were treated with curative intent from 1990 to 2002. RESULTS The actuarial rate of neck disease control was 68.8% at 5 years (95% confidence interval [CI], 58.9%-78.7%). On multivariate analysis, the rate of neck disease control was significantly related to lymph nodal metastatic level (P = .006). The actuarial rate of developing head and neck primary tumors at 5 years was 8.9% (95% CI, 2.6%-15.2%). The 5-year actuarial rate of distant metastases was 19.1% (95% CI, 9.4%-28.9%). In multivariate analysis, a statistically significant difference in the rate of distant metastasis was obtained when patients were stratified according to the level of nodal involvement (P = .01) and the presence of extracapsular extension (P = .013). At the time of analysis, 50 of the 90 patients were alive. A total of 32 (35.6%) had died from causes related to their primary disease. Actuarial disease-specific survival at 2 and 5 years was 73.6% (95% CI, 64.3%-82.9%) and 62.8% (95% CI, 51.9%-73.7%), respectively. In multivariate analysis, a statistically significant difference in disease-specific survival was obtained when patients were stratified according to the level of nodal involvement and the presence of extracapsular extension. CONCLUSIONS Our study seems to support the use of combined-modality therapy in patients with neck metastases from carcinoma of occult primary. However, in the absence of randomized trials, comprehensive irradiation cannot be routinely advised.
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Affiliation(s)
- Paolo Boscolo-Rizzo
- ENT Department and Regional Center for Head and Neck Cancer, University of Padua, School of Medicine, Treviso Regional Hospital, Treviso, Italy.
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Chang DT, Sandow PR, Morris CG, Hollander R, Scarborough L, Amdur RJ, Mendenhall WM. Do pre-irradiation dental extractions reduce the risk of osteoradionecrosis of the mandible? Head Neck 2007; 29:528-36. [PMID: 17230555 DOI: 10.1002/hed.20538] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND This study was done to determine if pre-radiotherapy (pre-RT) dental extractions reduce the risk of osteoradionecrosis (ORN). METHODS Between 1987 and 2004, 413 patients with oropharyngeal carcinomas were treated with definitive RT at the University of Florida. Dentate patients underwent pretreatment dental evaluation. Teeth in the RT field were usually extracted if thought to have poor long-term prognosis from dental disease. The endpoint was > or = grade 2 ORN using a modified staging system. Patients were excluded for local recurrence, additional RT above the clavicles, or head and neck surgery besides neck dissection. RESULTS ORN rates were as follows: edentulous, <1%; teeth in-field with pre-RT extractions, 15%; and teeth in-field without pre-RT extractions, 9%. Patients with poor in-field teeth and pre-RT extractions had a higher 5-year incidence of ORN than those who did not have pre-RT extractions (16% vs 6%, p = .48). Likewise, for those with in-field teeth in good condition and pre-RT extractions, the 5-year ORN incidence was higher than for those who did not undergo extractions (15% vs 2%, p = .42). Multivariate analysis revealed increased ORN risk with doses of >70 Gy, once-daily fractionation, or brachytherapy. CONCLUSION Pre-RT extractions do not appear to reduce the risk of ORN.
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Affiliation(s)
- Daniel T Chang
- Department of Radiation Oncology, College of Medicine, University of Florida, Gainesville, Florida, USA
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Abstract
"Suddenly a solitary horseman appeared on the horizon, then another, then another...in a few moments a whole crowd of horsemen swooped down upon him."-Leacock The illusion of solitary metastases is counterintuitive but has generated a sizable literature on the subject. The reality is that there are more metastatic deaths each year than the total number of true long-term survivors of solitary metastases combining all organ sites in the literature of the past century up to the present time. The largest number of solitary metastases survivors had metastases primarily in the lung and/or liver. With innovations in molecular imaging and advances in molecular oncology, the stage is set to detect truly solitary metastases early. Then, aggressive treatment by surgical excision, stereotactic body radiosurgery, targeted chemotherapy, or immunotherapy could eradicate the lesion. A comprehensive review of solitary metastases in a large variety of anatomic sites is presented. A broader staging system is recommended to encompass a solitary metastasis (M1) and oligometastases (M2) as distinct from multiple metastases (M3).
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Affiliation(s)
- Philip Rubin
- Department of Radiation Oncology, James P. Wilmot Cancer Center at the University of Rochester School of Medicine and Dentistry, Rochester, NY 14642, USA.
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Shehadeh NJ, Ensley JF, Kucuk O, Black C, Yoo GH, Jacobs J, Lin HS, Heilbrun LK, Smith D, Kim H. Benefit of postoperative chemoradiotherapy for patients with unknown primary squamous cell carcinoma of the head and neck. Head Neck 2006; 28:1090-8. [PMID: 16933316 DOI: 10.1002/hed.20470] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Postopertative adjuvant chemoradiotherapy recently became an established modality for patients with selected high-risk locally advanced head and neck cancers. The optimal treatment of unknown primary squamous cell cancer of the head and neck (SCCHN) continues to be controversial, since major randomized studies excluded those patients. METHODS We conducted a retrospective review of patients treated during 1995 to 2002 for unknown primary SCCHN. All patients were treated with a neck dissection followed by concurrent high-dose cisplatin (100 mg/m(2)) and bilateral neck radiotherapy. RESULTS Thirty-seven patients were identified with nodal disease distribution of N1 (5%), N2a (22%), N2b (41%), N2c (8%), N3 (22%), and Nx (3%). Modified neck dissection was done on the majority (30/37 = 81%) of patients. With a median follow-up of 42 months among the survivors, very few patients had regional recurrence (5%) or distant failure (11%), and 89% of patients were alive. The actuarial 5-year overall survival rate could not be estimated because there were no deaths beyond 20 months after surgery. Substantial yet acceptable acute and late morbidities were demonstrated in this cohort of patients. CONCLUSIONS Postoperative chemoradiotherapy is of potential benefit to patients with unknown primary SCCHN by improving survival and reducing failures. This treatment warrants further prospective evaluation.
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Affiliation(s)
- Nasfat J Shehadeh
- Division of Hematology/Oncology and Transplantation (HOT), Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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Barker CA, Morris CG, Mendenhall WM. Larynx-Sparing Radiotherapy for Squamous Cell Carcinoma From an Unknown Head and Neck Primary Site. Am J Clin Oncol 2005; 28:445-8. [PMID: 16199981 DOI: 10.1097/01.coc.0000162963.69302.12] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The objective of this study was to evaluate the efficacy of larynx-sparing radiotherapy (RT) alone or in combination with a neck dissection for patients with squamous cell carcinomas metastatic to cervical lymph nodes from an unknown head and neck primary site. Seventeen patients were treated with curative intent between 1997 and 2002; 16 of 17 patients had follow up for at least 2 years. No patient developed a squamous cell carcinoma in a head and neck mucosal site after treatment. One patient (6%) had persistent nodal disease and 1 patient (6%) had recurrent nodal disease 1 year after completing RT. No patients experienced distant metastases. The 5-year cause-specific and overall survival rates were 88% and 82%, respectively. Based on our limited experience, larynx-sparing RT appears to result in a high likelihood of local-regional control and survival and likely reduces both acute and late toxicity.
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Affiliation(s)
- Christopher A Barker
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida, USA
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Jereczek-Fossa BA, Jassem J, Orecchia R. Cervical lymph node metastases of squamous cell carcinoma from an unknown primary. Cancer Treat Rev 2004; 30:153-64. [PMID: 15023433 DOI: 10.1016/j.ctrv.2003.10.001] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Cervical lymph node metastases of squamous cell carcinoma from occult primary constitute about 2-5% of all patients with carcinoma of unknown primary site (CUP). Metastases in the upper and middle neck are generally attributed to head and neck cancers, whereas the lower neck (supraclavicular area) involvement is often associated with primary malignancies below the clavicles. The diagnostic procedures include physical examination with thorough evaluation of the head and neck mucosa using fiber-optic endoscopy, biopsies from all suspicious sites or blindly from the sites of possible origin of the primary, computer tomography and/or magnetic resonance. A systematic tonsillectomy in the absence of suspicious lesions is often recommended since up to 25% of primary tumors can be detected in this site. The thoracic primary (tracheal, bronchial, lung, esophagus) has to be excluded, especially in the case of lower neck involvement. Positron emission tomography (PET) with fluoro-2-deoxy-D-glucose allows detection of primary tumor in about 25% of cases, but this procedure is still considered investigational. Therapeutic approaches include surgery (lymph node excision or neck dissection), with or without postoperative radiotherapy, radiotherapy alone and radiotherapy followed by surgery. In early stages (N1), neck dissection and radiotherapy seem to have similar efficacy, whereas more advanced cases (N2, N3) necessitate combined approaches. The extent of radiotherapy (irradiation of bilateral neck and mucosa versus ipsilateral neck radiotherapy) remains debatable. A potential benefit from extensive radiotherapy should be weighted against its acute and late morbidity and difficulties in re-irradiation in the case of subsequent primary emergence. The role of other methods, such as chemotherapy and hyperthermia, remains to be determined.
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Affiliation(s)
- Barbara A Jereczek-Fossa
- Department of Radiation Oncology, European Institute of Oncology, via Ripamonti 435, Milan 20141, Italy.
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Abstract
Depending on patient and tumor characteristics, reported 5-year actuarial survival rates of patients with cervical nodal metastasis from an unknown primary carcinoma range from 18% to 63%. Prognostic factors for survival include N-stage, number of nodes, grading, extracapsular extension, and performance status. Retrospective studies suggest that neck relapse is more common than are distant metastases or emergence of mucosal primary tumors. The treatment options include neck dissection alone, radiation alone to the neck with or without the putative mucosal origin, and combination unilateral neck dissection plus limited or comprehensive radiotherapy. Combination of nodal dissection with comprehensive bilateral radiotherapy yielded most favorable results in local-regional disease control. However, its impact on the quality of life should be recognized. Also, the confounding effects of patient selection for various treatment modalities on therapeutic outcome cannot be quantified. Retrospective single-institution comparisons between comprehensive and unilateral neck radiotherapy did not show apparent differences in outcome. A randomized trial to compare the therapeutic value of comprehensive versus volume-limited radiotherapy is being planned. No data were found to support the benefit of chemotherapy for the treatment of this disease.
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Affiliation(s)
- Carsten Nieder
- Department of Radiation Oncology, Klinikum rechts der Isar, TU Munich, Ismaninger Str. 22, 81675 Munich, Germany.
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