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

Indications for oropharyngeal biopsy in head and neck squamous cell carcinoma of unknown primary: A systematic review (HNSCCUP)

INTRODUCTION

Patients presenting with head and neck squamous cell carcinoma of unknown primary (HNSCCUP) remain challenging clinical scenarios as large variation exists in practices used to locate the primary.

OBJECTIVE

The objective of this systematic review is to review of the literature and offer recommendations for oropharyngeal biopsies in HNSCCUP.

METHOD

Pubmed, Medline and Embase were searched to identify studies from inception to October 2021. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed.

RESULTS

A total of 483 articles were included and screened, 41 studies met the inclusion criteria, including over 3400 patients from the original articles (122 of these patients were reported on in two sequential articles by a single author - table 1) and 4 large metaanalyses including 1852 patients. The primary site identification rate following random biopsies or deep tissue biopsies is less than 5% in most studies. The mean detection rate following ipsilateral tonsillectomy is 34%; two pooled analyses indicate that the mean detection rate following tongue base mucosectomy is 64%, with this figure rising when the tonsils are negative.

CONCLUSIONS

High level evidence is lacking, with heterogeneity in the reported studies. Published meta-analyses are based on retrospective data. There is little evidence supporting the practice of random/non-directed oropharyngeal biopsies. Available evidence supports palatine tonsillectomy and tongue base mucosectomy compared to deep tissue biopsies.

[Cervical CUP Syndrome: Diagnosis and Therapy]

In CUP syndrome (CUP = cancer of unknown primary) there are 1 or more metastases of a primary tumor that cannot be localized despite extensive diagnostics. CUP syndrome accounts for 5% of all human malignancies, making it one of the 10 most common forms of cancer. In addition to inflammatory lymph node enlargement and benign changes such as cervical cysts, lymph node metastases are among the most common cervical masses. Cervical CUP syndrome is a histologically confirmed cervical lymph node metastasis with an unknown primary tumor. In addition to anamnesis, clinical examination and histological confirmation, diagnostics include radiological imaging using PET-CT and panendoscopy with histological primary tumor search. Treatment options include surgical therapy with neck dissection and chemoradiotherapy.

Carcinoma of Unknown Primary (CUP) versus CUP Turned to Primary Carcinoma of the Head and Neck—An Analysis of Diagnostic Methods and the Impact of Primary Tumor on Clinical Outcome

Background. The purpose of this study was to analyze the value of different diagnostic methods in detecting the primary site and the impact of primary tumors on the clinical outcome of carcinoma of unknown primary (CUP). Methods. In this multicenter, retrospective study, 124 patients with true CUP (n = 94) and CUP turned to primary carcinoma (n = 30) were included. Patients with evidence of primary site during the clinical examination were excluded a priori. The diagnostic procedure was comprised of imaging and invasive methods (fine-needle-aspiration, tonsillectomy and panendoscopy). All patients were treated with curative intent. Results. Despite extensive diagnostic workup, the primary site remained unknown in 75.8%. Invasive diagnostic methods showed higher primary detection rates than imaging modalities (15.1% vs. 7.8%). Tonsillectomy and panendoscopy revealed the primary tumor in 14.9% and 15.2% of patients, whereas the detection rates of CT, MRI and FDG-PET-CT were 10.1%, 4.8% and 6.5%, respectively. The occurrence of primary tumors led to a significantly deteriorating 5-year overall survival (p = 0.002) and emerged as survival prognosticator (HR = 2.764, p = 0.003). Conclusion. Clinical examination in combination with tonsillectomy and panendoscopy was superior to imaging alone in detecting the primary tumor. When the CUP of patients turned to a primary tumor, clinical outcome was significantly worse than in CUP patients.

Cancer of the Oropharynx and the Association with Human Papillomavirus

Squamous cell carcinoma of the oropharynx (OPC) consists of human papillomavirus (HPV)-negative disease caused by tobacco and alcohol use, and HPV-positive disease caused by the sexually transmitted infection HPV. These entities have unique but overlapping risk factors, epidemiologic trends, staging systems, and survival outcomes. HPV-positive tumor status confers a significant survival benefit compared with HPV-negative disease. OPC treatment entails a combination of surgery, radiation, and chemotherapy. Ongoing trials will determine whether treatment of HPV-related disease may be safely deintensified to decrease morbidity. Emerging HPV-related biomarkers are under study as tools to inform screening, diagnosis, treatment, and surveillance for HPV-positive OPC.

Diagnostic approaches to carcinoma of unknown primary of the head and neck

Squamous cell carcinoma in cervical lymph nodes arising from an undetected primary tumour, termed carcinoma of unknown primary (SCCUP), is a well-recognized clinical presentation within head and neck oncology. SCCUP is a common presentation for patients with human papillomavirus-mediated oropharyngeal cancer (HPV + OPSCC), as patients with HPV + OPSCC often present with smaller primary tumours and early nodal metastasis. Meticulous work-up of the SCCUP patient is central to the management of these patients as identification of the primary site improves overall survival and allows for definitive oncologic resection or more focused radiation when indicated. This review summarizes the comprehensive diagnostic approach to the SCCUP patient, including history and physical examination, methods of biopsy of the cervical lymph node, imaging modalities and intraoperative methods to localize the unknown primary. Novel techniques such as transcervical ultrasound of the oropharynx, narrow band imaging and diagnostic transoral robotic surgery are also discussed.

Diagnostic performance of 18F-FDG PET/CT for the detection of occult primary tumors in squamous cell carcinoma of unknown primary in the head and neck: a single-center retrospective study

OBJECTIVE

To investigate the diagnostic performance of 18F-FDG PET/computed tomography (CT) for the detection of occult primary tumors in patients with squamous cell carcinoma of unknown primary (SCCUP) in the head and neck.

PATIENTS

From March 2016 to January 2020, 37 patients diagnosed as SCCUP before PET/CT were retrospectively reviewed. The diagnosis of SCCUP was made when an overt primary tumor location could not be found for histologically proven squamous cell cervical lymphadenopathy after a complete diagnostic workup which includes full medical history, physical examinations, flexible rhinolaryngoscopy and CT or MRI. The PET/CT images were visually assessed by two nuclear medicine radiologists. Histopathological investigations after the PET scan served as the reference standard.

RESULTS

The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of PET/CT for SCCUP were 71.4, 43.8, 62.5, 53.9 and 59.5%, respectively. PET/CT allowed identification of previously undetected lesions in 40.5% of the SCCUP patients. A total of 24 PET/CT scans indicated a positive result. Among them, nine were categorized into false-positive because of negative results from subsequent targeted and random biopsies. There were 13 PET/CT scans with a negative result, six of which, however, were revealed to have a primary site by subsequent random biopsies.

CONCLUSION

18F-FDG PET/CT was shown to be useful in detecting a primary tumor for SCCUP, but had limitations in terms of both false-positive cases and false-negative cases. Therefore, histopathological investigations such as targeted and random biopsy should be viewed as necessary practice irrespective of PET/CT results.

Radiotherapeutic management of cervical lymph node metastases from an unknown primary site - experiences from a large cohort treated with modern radiation techniques

Purpose

To analyze management and outcomes following (chemo)radiation therapy in patients with cervical lymph node metastases from an unknown primary site (CCUP) in a large single-center cohort.

Methods

Between 2008 and 2019, 58 patients with CCUP were treated with (chemo)radiation therapy at the University of Freiburg Medical Center and were included in this analysis. Overall survival (OS), locoregional progression-free survival (PFS) and distant metastasis-free survival (DMFS) were calculated using the Kaplan-Meier method. The use of diagnostic procedures and their impact on oncological outcomes was analyzed by Cox regression, and treatment-related toxicities were quantified.

Results

Median follow-up was 29.9 months (range 4.6–121.9). Twenty-one patients (36.2%) received definitive RT, 35 (60.3%) underwent adjuvant RT, and 2 (3.4%) were treated for oligometastatic disease. Concurrent chemotherapy was prescribed in 40 patients (69.0%). 89.6% of patients completed the prescribed RT, and 65.0% completed the prescribed simultaneous chemotherapy. Locoregional recurrence was observed in 7 patients (12.1%) and distant metastases in 13 cases (22.4%). OS was 81,1, 64.9% and 56,6% after 1, 3 and 5 years, respectively.

Univariate analysis of age, gender, extracapsular spread, tumor grading, neck dissection, diagnostic utilization of ¹⁸F-fluorodeoxyglucose positron-emission tomography and concomitant chemotherapy showed no effect on OS (p > 0.05 for all), while smoking was significantly associated with decreased survival (p < 0.05). There was a trend towards impaired OS for patients with advanced nodal status (pN3) (p = 0.07). Three patients (5.2%) experienced grade 3 radiation dermatitis, and 12 (22.4%) developed grade 3 and 1 (1.7%) grade 4 mucositis.

Conclusions

RT of the panpharynx and cervical lymph nodes with concurrent chemotherapy in case of risk factors demonstrated good locoregional control, but the metachronous occurrence of distant metastases limited survival and must be further addressed.

The impact of the patient's condition, diagnostic procedures and treatment on the survival of carcinoma of unknown primary site patients

Introduction

Carcinoma of unknown primary site (CUP) refers to 1–5% of all head and neck neoplasms. Very often, the primary site remains difficult to determine. Squamous cell carcinoma is the most frequent histopathological type diagnosed in the head and neck region. According to statistics, a primary site is usually located in the oropharynx.

Study objective

The study presents diagnostic difficulties and the methods of diagnosing and the therapy of CUP and primary sites in patients treated in the region of Lower Silesia and Silesia. The aim of the study was to show a retrospective analysis of 233 CUP patients to assess how clinical features, diagnosis and treatment affect the survival of patients.

Material and methods

The diagnostics of patients included panendoscopy with specimen collection (nasoendoscopy, laryngoscopy, esophagoscopy, brochoscopy), computed tomography examination of the neck, chest, abdomen and pelvis minor, as well as positron emission tomography examination. Tonsilletomy was performed in 37 patients. Neck dissection was carried out in 109 subjects and 165 patients were treated bt radiotherapy, and 135 by chemotherapy.

Conclusions

Tonsillectomy is required in CUP patients with the negative results of biopsy and imaging tests. It gives a possibility of detecting the primary site and improves the results of treatment and survival of CUP patients.Combination therapy, including surgical treatment and chemoradiotherapy, gives the best therapeutic results in CUP patients. The general condition of patient and younger age have an impact on prognosis and survival.

Head and neck carcinoma of unknown primary

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.

The Impact of a Stepwise Approach to Primary Tumor Detection in Squamous Cell Carcinoma of the Neck With Unknown Primary

OBJECTIVES/HYPOTHESIS

To examine the cumulative effect of diagnostic steps for primary tumor identification in patients with head and neck squamous cell carcinoma of unknown primary (HNSCCUP), including lingual tonsillectomy, and the impact of primary tumor identification on subsequent treatment.

STUDY DESIGN

Retrospective analysis.

METHODS

We reviewed the records of 110 patients diagnosed with HNSCCUP between 2003 and 2015. Results of diagnostic imaging (fluorodeoxyglucose-positron emission tomography/computed tomography [FDG-PET/CT]), tumor detection with direct laryngoscopy with biopsies, palatine tonsillectomy, and transoral robotic surgery (TORS) lingual tonsillectomy were recorded. Associations between demographic and treatment variables with overall survival (OS) and progression-free survival (PFS) were modeled with Cox proportional hazards models.

RESULTS

FDG-PET/CT was suspicious for a primary site in 23/77 (30%) patients. Direct laryngoscopy identified a primary tumor in 34/110 patients (31%). Forty-seven patients underwent palatine tonsillectomy, which identified 17 primaries (36%), yielding a cumulative primary tumor identification of 51/110 (46%). Fourteen patients underwent TORS lingual tonsillectomy, which identified eight primaries (57%), resulting in a cumulative identification of 59/110 (53%). The detection rate increased from 28/63 (44%) to 31/47 (66%) after the addition of TORS lingual tonsillectomy to our institutional approach. Detection rates varied by HPV status. Primary tumor identification altered subsequent radiation planning, as patients with an identified primary tumor received radiation to a smaller volume of tissue than did those without an identified primary tumor. However, there was no significant association between primary tumor identification and OS or PFS.

CONCLUSIONS

A stepwise approach to primary tumor identification identifies a primary tumor in a majority of patients.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:1610-1616, 2019.

Cancer of Unknown Primary: Opportunities and Challenges

Cancer of unknown primary (CUP) is defined as histologically proven metastatic tumors whose primary site cannot be identified during pretreatment evaluation. Among all malignancies, 3%–5% remained as CUP even after the extensive radiological and pathological workup. Immunohistochemistry and molecular gene expression tumor profiling are being utilized to predict the tissue of origin. Unfortunately, the survival of these patients remains poor (6–9 months) except in 20% of patients who belong to a favorable subset (12–36 months). There is a need to understand the basic biology and to identify the molecular pathways which can be targeted with small molecules. This article reviews our current approach as well as treatment evolution occurred in the past three decades.

Synchronous HPV-Related Cancer of Bilateral Tonsils Detected Using Transoral Endoscopic Examination with Narrow-Band Imaging

Background

The incidence of human papillomavirus- (HPV-) related oropharyngeal squamous cell carcinoma (OPSCC) has been rapidly increasing worldwide. HPV is reported in approximately 50% cases of OPSCC in Japan. However, there are few reports of synchronous bilateral HPV-positive tonsillar carcinoma, and, in almost all those cases, carcinoma was detected using positron emission tomography/computed tomography and/or bilateral tonsillectomy.

Methods and Results

We report the case of a 63-year-old male with bilateral tonsillar carcinoma detected using transoral endoscopic examination with narrow-band imaging (NBI). A biopsy of the bilateral tonsils revealed squamous cell carcinoma, which was demonstrated to be HPV-related using in situ hybridization and p16 immunohistochemistry. The patient was diagnosed as synchronous bilateral tonsillar carcinoma: T1 (2) N2b M0. He was treated with induction chemotherapy, bilateral radical tonsillectomy with neck dissection, and radiotherapy.

Conclusion

To our knowledge, this is the first report of a synchronous bilateral tonsillar carcinoma detected using transoral NBI in the outpatient setting. Early diagnosis without the inspection under general anesthesia is beneficial for the patients with lymph node metastasis from unknown primary lesion.

AHNS Series: Do you know your guidelines? Guideline recommendations for head and neck cancer of unknown primary site

This article reviews the clinical practice guidelines for head and neck oncology focusing on the management of head and neck cancers of unknown primary (CUP). The primary purpose of this series is to raise awareness of the current guidelines in head and neck oncology by reviewing the recommendations and the evidence supporting such recommendations, particularly those published by the National Comprehensive Cancer Network (NCCN). We review the importance of a thorough history and physical examination, the impact of the American Joint Committee on Cancer (AJCC) eighth edition changes and the importance of immunohistochemistry, the timing and type of imaging, the role of panendoscopy and tonsillectomy (palatine and lingual), and the role of surgery, radiation, and chemotherapy in the primary management of these tumors.

Computed Tomography Versus Magnetic Resonance in Head and Neck Cancer: When to Use What and Image Optimization Strategies

This article provides a practical overview of head and neck cancers, outlining an approach to evaluating these lesions and optimizing imaging strategies. Recognition of key anatomic landmarks as suggested by American Joint Committee on Cancer (AJCC) tumor, node, metastasis (TNM) criteria is emphasized. Further, the recently updated eighth edition of the AJCC staging manual has introduced some modifications that influence the TNM staging. These modifications are discussed throughout the article to provide an updated review on head and neck cancer.

Impact of 3T multiparametric MRI and FDG-PET-CT in the evaluation of occult primary cancer with cervical node metastasis

Background

This study aimed to determine the ability of multimodal evaluation with multiparametric 3T-MRI (MPMRI) and positron emission tomography - computed tomography (PET/CT) to detect cancer of unknown primary origin (CUP) with neck lymph node (LN) metastasis.

Methods

The study group comprised 38 retrospectively analysed consecutive patients with LN metastasis in the head and neck (HN) region without known primary tumours (PTs). Statistical values of 3T-MRI and of FDG-PET/CT scans were evaluated.

Results

Of the 38 CUPs, conventional native T1-, T2-weighted and STIR sequences detected 6 PTs. Native sequences plus diffusion-weighted imaging (DWI) found 14-, and with fat suppression contrast-enhanced T1-weighted measurement as well as with the complex MPMRI found 15 primaries and with PET/CT 17 CUPs could be evaluated, respectively. The detection rates were 15.8, 36.8, 39.5, 39.5 and 44.7 % for conventional native MRI, native plus DWI, native with contrast-enhanced MRI (CE-MRI), for MPMRI, and for PET/CT, respectively. The overall detection rate proved by histology was 47.4 %. PET/CT provided the highest sensitivity (Sv: 94.4 %) but a lower specificity (Sp: 65.0 %), using MPMRI (Sv: 88.2 %) the specificity increased to 71.4 %. DWIincreased specificity of the native sequences (Sp: 76.2 %). Conventional native sequences plus DWI as well as 3T-MPMRI and PET/CT were same accurate (Acc: 79.0 %) and had similar likelihood ratio (LR: 3.42, 3.03 and 2.62) in detecting unknown PT sites.

Conclusions

The accuracy of FDG-PET/CT and MPMRI in case of CUP in finding the primary cancer in the neck regions is identical. While using PET/CT whole body information can be obtained in one examination. MPMRI shows the local soft tissue status more accurately. In cases of CUP PET/CT should be the first method of choice if it is available. MPMRI can clarify the exact primary tumor stage, and it can be advantageous in clarifying the prognostic factors, which is necessary in case of advanced tumor stage and when surgery is under consideration. In case low N stage is likely after the clinical examination and wait and see policy can be considered, MPMRI is recommended, and in this case the significance the of radiation free MPMRI is increasing.

Electronic supplementary material

The online version of this article (doi:10.1186/s40644-016-0097-x) contains supplementary material, which is available to authorized users.

Diagnostic Imaging Efficacy In Metastases From Unknown Primary Site--Own Material

Cancer of Unknown Primary Origin (CUPO) is defined by the presence of metastatic lesions, diagnosed by means of cytological or pathological evaluation, for which no primary site can be detected during a thorough examination. The clinical investigation, directed at locating the site of the neoplastic lesion, is determined by the results of laboratory tests, imaging procedures, and pathological examinations. It is also essential to conduct a complete medical history and thorough physical examination. The detection of the primary site allowed to introduce specific therapy, which can offer clinical benefits, considering a favorable prognosis. The aim of the study was to assess the range of diagnostic procedures performed in patients with CUPO and efficacy in identifying the primary lesion.

MATERIAL AND METHODS

Retrospective analysis comprised a group of 29 patients with CUPO, operated between January, 2002 and December, 2011, at the Department of Surgical Oncology, Medical University in Łódź. The study group comprised 16 male and 13 female patients; median age at presentation was 58.3 years (ranging between 30-79 years).

RESULTS

Detailed diagnostic management depending on the location of metastatic lesions and their histological type was performed in 20 of the 29 study patients (69%). Considering the remaining 9 (31%) patients detailed diagnostics was not performed, due to the patients' poor general condition. In 55% (11/20) of patients subject to detailed diagnostics, the primary neoplastic lesion was determined.

CONCLUSIONS

Considering the study group, most patients with cancer of unknown primary origin were characterized by a favorable prognosis, which justified thorough diagnostics, in order to establish the primary neoplastic lesion. The introduction of diagnostic examinations enabled to identify the primary site of the tumor in more than 50% of patients. With the development of imaging methods one can expect improvement of unsatisfactory results, considering the detection of primary neoplastic foci.

A model and nomogram to predict tumor site origin for squamous cell cancer confined to cervical lymph nodes

BACKGROUND

The current study was conducted to develop a multifactorial statistical model to predict the specific head and neck (H&N) tumor site origin in cases of squamous cell carcinoma confined to the cervical lymph nodes ("unknown primaries").

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was analyzed for patients with an H&N tumor site who were diagnosed between 2004 and 2011. The SEER patients were identified according to their H&N primary tumor site and clinically positive cervical lymph node levels at the time of presentation. The SEER patient data set was randomly divided into 2 data sets for the purposes of internal split-sample validation. The effects of cervical lymph node levels, age, race, and sex on H&N primary tumor site were examined using univariate and multivariate analyses. Multivariate logistic regression models and an associated set of nomograms were developed based on relevant factors to provide probabilities of tumor site origin.

RESULTS

Analysis of the SEER database identified 20,011 patients with H&N disease with both site-level and lymph node-level data. Sex, race, age, and lymph node levels were associated with primary H&N tumor site (nasopharynx, hypopharynx, oropharynx, and larynx) in the multivariate models. Internal validation techniques affirmed the accuracy of these models on separate data.

CONCLUSIONS

The incorporation of epidemiologic and lymph node data into a predictive model has the potential to provide valuable guidance to clinicians in the treatment of patients with squamous cell carcinoma confined to the cervical lymph nodes.

[Target volumes in cervical lympadenopathies of unknown primary: toward a selective customized approach? On behalf of REFCOR]

The treatment of carcinomas of unknown primary revealed by cervical lymphadenopathy is based on neck dissection and nodal and pan-mucosal irradiation to control the neck and avoid the emergence of a metachronous primary. The aim of this review was to assess diagnostic and therapeutic approaches and criteria that may be used for a customized selective approach to avoid severe toxicities of pan-mucosal irradiation. A literature search was performed with the following keywords: cervical lymphadenopathy, unknown primary, upper aerodigestive tract, cancer, radiotherapy, squamous cell carcinoma, variants. The diagnostic workup includes a head and neck scanner or MRI, ((18)F)-FDG PET CT, a panendoscopy and tonsillectomy. Squamous cell carcinoma represents over two thirds of cases. The number of metastatic cervical nodes, nodal level, and histological variant (associated with HPV/EBV status) may determine the primary site origin and might be weighted for the determination of radiation target volumes on a multidisciplinary basis. A selective customized approach is relevant to decrease radiation toxicity only if neck and mucosal control is not impaired. Although no recommendation can yet be made in the absence of sufficient level of evidence, the relevance of systematic pan-mucosal irradiation appears questionable in a number of clinical situations. Accordingly, a customized selective redefinition of target volumes may be discussed and be prospectively evaluated in relation to the therapeutic index obtained.

A new paradigm for the diagnosis and management of unknown primary tumors of the head and neck: a role for transoral robotic surgery

OBJECTIVES/HYPOTHESIS

In 2% to 3% of patients with cancer metastatic to cervical lymph nodes, a primary tumor will not be found despite exhaustive diagnostic efforts. The treatment for these patients includes cervical lymphadenectomy followed by radiation to areas with increased risk of harboring a mucosal primary. Wide-field radiation therapy increases the incidence of xerostomia and dysphagia. Localizing a primary tumor has thus both therapeutic and quality-of-life implications, allowing possible complete surgical excision, concentrated radiation therapy, and potential deintensification of adjuvant therapy. With improved visualization and freedom of motion, transoral robotic surgery (TORS) is an innovative surgical modality that allows resection of oropharyngeal subsites with minimal morbidity.

STUDY DESIGN

Retrospective chart review.

METHODS

Ten patients with unknown primary tumors of the head and neck were identified. All patients underwent a cervical biopsy, positron-emission tomography/computed tomography, formal endoscopy, and bilateral tonsillectomy. When the initial endoscopy and biopsies did not localize a primary tumor, all patients underwent transoral robotic base of tongue resection.

RESULTS

Evaluation of the patients' oropharyngeal mucosa using the robot did not reveal an obvious lesion and no palpable tumors were appreciated in the resected specimens. In 9/10 (90%) patients, pathologic examination revealed invasive squamous cell carcinoma (SCCA) with a mean diameter of 0.9 cm.

CONCLUSIONS

Unknown primary SCCA presents a diagnostic challenge to the head and neck surgeon. We present a small series of tumors that would have been treated as unknown primaries under traditional diagnostic and therapeutic algorithms. TORS base of tongue resection identified primary tumors in 90% patients with minimal morbidity.

Utility of panendoscopy for the detection of unknown primary head and neck cancer in patients with a negative PET/CT scan

We conducted a retrospective review of the records of 23 patients who had been diagnosed with regionally metastatic head and neck squamous cell carcinoma from an unknown primary tumor. Our goal was to assess the utility of panendoscopy in locating the primary tumor in those patients whose positron-emission tomography/computed tomography (PET/CT) findings were negative. Overall, we found that PET/CT had correctly identified the unknown primary in 12 of the 23 patients (52%); panendoscopy confirmed this finding in all 12. Of the remaining 11 patients, however, panendoscopy located the primary tumor in only 1 (9%). In this era of cost containment and ongoing advances in imaging and transnasal esophagoscopy, it is important to revisit the workup of an unknown primary in patients with a negative PET/CT scan. There are various advantages and disadvantages to performing panendoscopy with biopsy in patients with an unknown primary and a negative PET/CT scan, but our results and the findings of others indicate that it will detect the primary in only about 10% of these cases. We recommend careful selection of patients who are to undergo panendoscopy for the routine workup of an unknown primary.

Contemporary management of lymph node metastases from an unknown primary to the neck: I. A review of diagnostic approaches

In an era of advanced diagnostics, metastasis to cervical lymph nodes from an occult primary tumor is a rare clinical entity and accounts for approximately 3% of head and neck malignancies. Histologically, two thirds of cases are squamous cell carcinomas (SCCs), with other tissue types less common in the neck. With modern imaging and tissue examinations, a primary tumor initially undetected on physical examination is revealed in >50% of patients and the site of the index primary can be predicted with a high level of probability. In the present review, the range and limitations of diagnostic procedures are summarized and the optimal diagnostic workup is proposed. Initial preferred diagnostic procedures are a fine-needle aspiration biopsy (FNAB) and imaging. This allows directed surgical biopsy (such as tonsillectomy), based on the preliminary findings, and prevents misinterpretation of postsurgical images. When no primary lesion is suggested after imaging and panendoscopy, and for patients without a history of smoking and alcohol abuse, molecular profiling of an FNAB sample for human papillomavirus (HPV) and/or Epstein-Barr virus (EBV) is important.

Diagnosis of Bilateral Tonsil Cancers via Staging PET/CT: Case Report and Review

Diagnostic workup of metastatic head and neck squamous cell carcinoma of unknown primary site has traditionally included CT and/or MRI imaging and endoscopic biopsies. Routine bilateral tonsillectomy is highly controversial and the role of PET/CT is evolving, both for identification of potential primary sites and the detection of distant metastases. We report a case of cervical nodal metastasis of squamous cell carcinoma from an unknown primary site, in which dual-modality PET/CT led to the unexpected diagnosis of synchronous bilateral tonsillar cancers. In addition, PET/CT correctly distinguished pulmonary sarcoidosis from metastatic disease in this patient.

Unknown primary cancer of the head and neck: a multidisciplinary approach

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.

Outcomes of patients with tonsillar carcinoma treated with post-tonsillectomy radiation therapy

BACKGROUND

Our aim was to evaluate the therapeutic outcomes of patients with squamous cell carcinoma of the tonsil that underwent tonsillectomies followed by radiotherapy.

METHODS

A search of the database maintained within the Department of Radiation Oncology at The University of Texas M. D. Anderson Cancer Center identified 120 patients with carcinoma of the tonsil who were irradiated between 1979 and 2004 following total gross removal of their disease by tonsillectomy.

RESULTS

Thirty-six patients had stage III disease and 64 patients had stage IV disease. Only 12 patients received systemic chemotherapy. With median follow-up of 51 months, the 5-year local-regional control rate, recurrence-free survival rate, and overall survival rates were 97%, 92%, and 86%, respectively.

CONCLUSION

Patients who undergo tonsillectomies resulting in total gross removal of their primary disease followed by radiation have excellent outcomes. Our common practice is to deliver 66 Gy to the tonsillar bed. This practice has resulted in extremely high local control rates.

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

OBJECTIVES/HYPOTHESIS

To discuss our experience with the diagnostic evaluation in patients with squamous cell carcinomas (SCCAs) of the head and neck metastatic to the cervical lymph nodes from an unknown primary site.

METHODS

Between June 1983 and December 2008, 236 patients were evaluated with lymph node biopsy, computed tomography (CT), and/or magnetic resonance imaging (MRI) of the head and neck, and panendoscopy with directed biopsies. Additional studies included fluorodeoxyglucose-single photon emission computed tomography (FDG-SPECT) in 26 patients and FDG-positron emission tomography (FDG-PET) or FDG-PET/CT in 21 patients. Seventy-nine patients underwent an ipsilateral (72) or bilateral (seven) tonsillectomy.

RESULTS

An occult primary site was detected in 126 patients (53.4%); six patients had two synchronous primary cancers. The most common primary sites were in the tonsillar fossa (59 patients; 44.7%) and the base of tongue (58 patients; 43.9%). The primary site was found in 21 (29.2%) of the 72 patients with no suspicious findings on physical exam and/or radiographic evaluation compared with 105 (64.0%) of 164 remaining patients. Tonsillectomy revealed the primary cancer in 35 (44.3%) of 79 patients. FDG-SPECT and FDG-PET or FDG-PET/CT was the sole method of primary site detection in only one patient (2.1%) of 47 patients.

CONCLUSIONS

Diagnostic evaluation should include a thorough physical examination, CT and/or MRI of the head and neck, and panendoscopy with directed biopsies. Unilateral or bilateral tonsillectomy should be performed on patients with adequate lymphoid tonsillar tissue. FDG-PET or FDG-PET/CT should be considered for those with indeterminate findings on physical examination and/or head and neck CT and/or MRI if those sites are located outside of the oropharynx.

Current status of biomarkers in head and neck cancer

As our understanding of HNSCC increases so has biomarker development. HPV16 integration is a significant marker of favorable prognosis and response to therapy for HNSCC. EGFR-amplification and overexpression is a poor-prognostic indicator. For premalignant lesions, LOH of 3p&9p21 loci confers an elevated risk of malignant transformation. As molecular targets are identified, these will be candidates for biomarkers for detection, diagnosis, prognosis, and therapy. Validation of these biomarkers requires demonstration of independence of significance beyond known biomarkers.

Clinical implications of human papillomavirus in head and neck cancers

Human papillomavirus (HPV) is now recognized to play a role in the pathogenesis of a subset of head and neck squamous cell carcinomas (HNSCCs), particularly those that arise from the lingual and palatine tonsils within the oropharynx. High-risk HPV16 is identified in the overwhelming majority of HPV-positive tumors, which have molecular-genetic alterations indicative of viral oncogene function. Measures of HPV exposure, including sexual behaviors, seropositivity to HPV16, and oral, high-risk HPV infection, are associated with increased risk for oropharyngeal cancer. HPV infection may be altering the demographics of HNSCC patients, as these patients tend to be younger, nonsmokers, and nondrinkers. There is sufficient evidence to conclude that a diagnosis of HPV-positive HNSCC has significant prognostic implications; these patients have at least half the risk of death from HNSCC when compared with the HPV-negative patient. The HPV etiology of these tumors may have future clinical implications for the diagnosis, therapy, screening, and prevention of HNSCC.

Benefit of postoperative chemoradiotherapy for patients with unknown primary squamous cell carcinoma of the head and neck

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.

Value of panendoscopy in metastases of unknown origin

Introduction Neck metastases of unknown origin are metastatic solid tumors with primary undetactable by physical examination, chest x-ray, rutine blood and urine studies and histologic evaluation. Material and methods This study included 77 patients of both sexes, average age 57 years, undergoing a diagnostic procedure at ENT clinic, Clinical Center Novi Sad, in the period from 1992 to 2001. Results The primary tumor was detected in 51% of all cases by panendoscopy and bilateral tonsillectomy. In 14 of 26 patients (54%), in whom the site of the primary tumor was not detected, after telecobalt therapy and radical neck dissection, no relapses occurred. Pathohistological examination revealed planocellular carcinoma in 50 (65%) cases, transitional cell carcinoma in 9 (11.7%) cases and lymphoma in 7 (9.1%) cases. Conclusion Cervical metastases with unknown primary tumor are the first sign of head and neck malignant disease. Panendoscopy with bilateral tonsillectomy and multiple mucosal biopsies are necessary procedures in detecting the primary tumor site. .

Diagnostic strategies for unknown primary cancer

Unknown primary cancer (UPC) is defined by the presence of metastatic disease for which a primary site is undetectable on presentation. Computed tomography scan of the body was performed routinely in search of the primary cancer and invasive procedures were pursued in selective cases. Magnetic resonance imaging of the breast enables identification of an occult breast primary tumor in < or = 75% of women who present with adenocarcinoma in the axillary lymph nodes and can influence surgical management. Positron emission tomography scan also can be used in the diagnosis of UPCs, but its value is controversial. Cytokeratins 7 and 20 and thyroid transcription factor are some of the histochemical markers used in most patients who present with metastatic adenocarcinoma. Some of the newly discovered immunohistochemical markers further assist in narrowing the differential diagnosis. The role of molecular profiling to make the diagnosis, establish the prognosis, and assess the response to treatment in UPCs is evolving. The authors discuss the role of histochemical markers in the diagnosis of UPC and the most recent data regarding the use of imaging and invasive diagnostic modalities and gene expression profiles.

Cervical lymph node metastases of squamous cell carcinoma from an unknown primary

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.

Management of cervical metastasis

Cervical metastasis from head and neck cancer is a common occurrence. Despite improvements in diagnostic modalities and treatment options, survival in this group of patients has not changed appreciably over the past few decades. Cervical metastasis portends a poor prognosis and also presents a diagnostic and treatment dilemma for the head and neck oncologist. This article reviews the current state of the art in the diagnosis and treatment of this difficult group of patients and the literature on the topic.

Diagnosis and management of carcinoma of unknown primary in the head and neck

Carcinoma of unknown primary is defined as the histological diagnosis of metastasis without the detection of a primary tumor. In the literature, the incidence of CUP in all patients with a malignant disease is said to be between 3% and 15%. The most frequent histopathological results of CUP metastases are adenocarcinoma, followed by undifferentiated carcinoma and squamous cell carcinoma. In this retrospective investigation the clinical records of 167 patients were studied. All patients had been admitted and treated for cervical CUP at the Department of Otorhinolaryngology of the Grosshadern Clinic from 1979 to 1998. Cervical swelling was the first noted symptom in all cases, followed by pain and dysphagia. The study group comprised 134 men and 33 women with an average age of 55 years at admission. Squamous cell carcinoma (n=123) was the predominant histopathological finding of the cervical lymph nodes. During the 10-year follow-up, a primary tumor was detected in 36 (21.5%) of the 167 initially diagnosed CUP patients. In over 90% of these cases the tumor was localized in the head and neck region. The most frequent origin of the tumor was the tonsilla palatina (n=7). Neck dissection and additional postoperative radiotherapy was performed in 118 (70.7%) of the 167 CUP patients. Primary radiotherapy was the treatment of choice in 28 patients; eight patients received combined radio-chemotherapy as the primary treatment and seven patients were treated with chemotherapy alone. Six patients had no treatment. Comparison of different treatment protocols revealed a significant difference in patient survival: in comparison with primary radiotherapy alone or neck dissection and postoperative radiotherapy, the survival rate improved significantly in patients that received a bilateral tonsillectomy in addition to neck dissection and postoperative radiotherapy. The treatment of choice in patients with cervical CUP should be a surgical procedure including (radical) neck dissection and diagnostic bilateral tonsillectomy followed by postoperative radiation of the cervical lymph drainage. Bilateral tonsillectomy is especially important and is correlated with a significant improvement of the survival rate in CUP patients. Additional postoperative radiation of the entire pharyngeal and laryngeal mucosa should also be considered in order to treat a possible small primary tumor in this region.

Management and outcome of cervical lymph node metastases of unknown primary sites: a retrospective study

Analysis of the case records of 114 patients with cervical lymph node metastases from unknown primary sites showed that management should be adapted according to the site of nodal disease and the histopathology. Poorly differentiated carcinoma was best treated with radiotherapy, squamous cell carcinoma with radiotherapy and excision, and non-papillary adenocarcinoma by radical thyroidectomy and neck dissection. The 5-year survival for each regimen alone, was 15/40 (38%), 7/13 (54%) and 5/8 (63%), respectively. For metastatic masses in the supraclavicular region, chemotherapy was the preferred treatment. The overall survival for the 107 patients who completed the follow up was 36%.

[A study of cervical metastases from unknown primary tumor]

Cervical metastases of cancer of an unknown primary tumour (CMUPT) are infrequent but they represent botha diagnostic and therapeutic challenge for ENT physicians. We present a retrospective study over 22 patients with CMUPT diagnosed in our hospital during 13 years (3.4% of the patients with head and neck cancer). The sensitivity of the fine-needle aspiration technique was 94.7%. 54% were N2a, 36% N3 and 9% N2b. 73% were squamous cell carcinoma and 27% were undifferentiated carcinoma. We established our protocol on diagnosis and management: panendoscopy with biopsies of nasopharynx, vallecula and pyriform sinus and ipsilateral tonsillectomy. The primary source was identified in 23% of the series. All squamous cell carcinoma were treated with radical neck surgery plus radiotherapy and the undifferentiated carcinoma with chemotherapy and radiotherapy. The overall survival was 64% at 3 years. The N-stage affected the survival rate.

Do metastatic tumours from an unknown primary reflect angiogenic incompetence of the tumour at the primary site?--a hypothesis

Metastases from unknown primary tumours (MUP) are not an uncommon clinical problem. A hypothesis that discusses the plausible role of neoangiogenesis, as a central theme in the development of MUPs, is presented. Invasive cancers, which cannot or do not switch to the angiogenic phenotype, remain subclinical. In situations where a non-angiogenic tumour attempts to grow beyond the volume that can be supported by the vasculature, marked apoptosis and cell turnover result. Tumours with a high cell turnover are biologically advanced. Thus, such subclinical tumours acquire a metastatic phenotype. In the viscera, metastases may remain dormant for varying periods until subclones with an angiogenic phenotype arise due to tumour evolution or they burn out. Visceral MUPs, due to their longer evolution, are biologically advanced and have dismal prognosis. Contrary to this, tumour cells reaching lymph nodes (LN) grow without acquiring any phenotypic or genotypic change, as angiogenesis is redundant for growth within the metastatic LNs.

Squamous cell carcinoma metastatic to the neck from an unknown head and neck primary site

Squamous cell carcinoma metastatic to the neck from an unknown head and neck primary site is relatively uncommon and presents a challenging diagnostic and therapeutic dilemma. Diagnostic evaluation includes fine-needle aspiration of the neck mass, chest roentgenography, computed tomography, and/or magnetic resonance imaging of the head and neck, followed by panendoscopy and biopsies. The primary tumor will be detected in approximately 40% of patients; approximately 80% of cancers are located in the base of the tongue or tonsillar fossa. Management options include treatment of the neck alone or both sides of the neck and the potential head and neck primary sites. The latter approach is associated with better long-term control above the clavicles. The 5-year survival rate is approximately 50% after treatment and is influenced by the extent of neck disease. In this article, we review the pertinent literature.

Cervical lymph node metastases from occult squamous cell carcinoma: cut down a tree to get an apple?

PURPOSE

To review the value of extended diagnostic work-up procedures and to compare the results of comprehensive or volume-restricted radiotherapy in patients presenting with cervical lymph node metastases from clinically undetectable squamous cell carcinoma.

METHODS AND MATERIALS

A systematic review was undertaken of published papers up to May 2000.

RESULTS

Positron emission tomography (PET) has an overall staging accuracy of 69%, with a positive predictive value of 56% and negative predictive value of 86%. With negative routine clinical examination and computerized tomography (CT) or magnetic resonance imaging (MRI), PET detected primary tumors in 5-25% of patients, whereas ipsilateral tonsillectomy discovered carcinoma in about 25% of patients. Laser-induced fluorescence imaging with panendoscopy and directed biopsies showed some encouraging preliminary results and warrants further study. All together, the reported mucosal carcinoma emergence rates were 2-13% (median, 9.5%) after comprehensive radiotherapy and 5-44% (median, 8%) after unilateral neck irradiation. The corresponding nodal relapse rates were 8-45% (median, 19%) and 31-63% (median, 51.5%), and 5-year survival rates were 34-63% (median, 50%) and 22-41% (median, 36.5%), respectively. Retrospective single-institution comparisons between comprehensive and unilateral neck radiotherapy did not show apparent differences in outcome. Prognostic determinants for survival are the N stage, number of nodes, extracapsular extension, and histologic grade. No data were found to support the benefit of chemotherapy in this disease.

CONCLUSION

Physical examination, CT or MRI, and panendoscopy with biopsies remain the standard work-up for these patients. Routine use of PET or laser-induced fluorescence imaging cannot be firmly advocated based on presently available data. Although combination of nodal dissection with comprehensive radiotherapy yielded most favorable results, its impact on the quality of life should be recognized, and the confounding effects of patient selection for various treatment modalities on therapeutic outcome cannot be ruled out. A randomized trial comparing the therapeutic value of comprehensive vs. volume-limited radiotherapy is being considered.

Outcome of ipsilateral treatment for patients with metastases to neck nodes of unknown origin

It is not uncommon for head and neck cancer patients to present with neck node metastases. Standard treatment for patients in whom no primary tumor is found include surgery and radiotherapy but there is still controversy about the type and extent of treatment. A retrospective review was carried out on 51 consecutive patients with cervical lymph node metastases of unknown origin, treated between 1980 and 1994 at Radiumhemmet, Karolinska Hospital. All patients received radiotherapy to the ipsilateral neck and the corresponding mucosa and surgery was performed in 55% of cases. The 5-year overall survival rate was 41%. A primary tumor was later found in 6 cases (12%). Two cases of cancer were detected after 5 years and classified as 'second primaries'. Results from this small retrospective material have to be interpreted with caution but indicate that limited, ipsilateral radiotherapy to mucosa and lymph nodes combined with surgery, when possible, may be justified.