Cervical metastasis of unknown origin: a series of 72 patients

Survival Outcome in True Carcinoma of Unknown Primary (tCUP) with p16 + Cervical Metastasis

Introduction  Age and lymph node ratio have been attributed as independent predictors for survival and recurrence in carcinoma of unknown primary (CUP). Objective  The purpose of this study was to analyze the prognostic value of p16 overexpression for CUP in the absence of true primary (TP). Methods  The study involved 43 patients who underwent therapeutic lymph node dissection (LND) from 2000 to 2015 after all the diagnostic work up for CUP. Immunohistochemistry for p16 overexpression was performed. Cox proportional hazard regression analysis was used to analyze the prognostic impact on 5-year overall survival (OS) and recurrence-free survival (RFS). Results  The male-to-female ratio was 5.1:1, with a median age of 62 years. The clinicopathological data, except for p16 overexpression, did not differ significantly in terms of 5-year OS and RFS. The Cox regression analysis proposed p16 positivity to be an independent prognosticator of regional recurrence-free survival (RRFS) (hazard ratio [HR] 6.180, p  = 0.21). The median time to recurrence and death were 10 and 25 months, respectively. Conclusion  Cervical metastasis with p16 overexpression is a significant prognostic factor of improved RFS after surgery in CUP. The prognostic significance of lymph node p16 positivity should be further studied.

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

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.

Intraosseous carcinoma of the anterior maxilla identified as the occult primary tumour of carcinoma of unknown primary

Carcinoma of unknown primary (CUP) is defined as lymph node metastasis without a detectable origin until after the initial treatment has been performed. The most common occult primary site in the head and neck, as revealed by a review of the published literature, is the oropharynx. An occult primary site in the oral region is extremely rare. We report a rare case of head and neck CUP (HNCUP) in a 69-year-old female patient, wherein the occult primary lesion was a primary intraosseous carcinoma (PIOC) invading the anterior maxilla. During the course of the initial diagnostic workup, no primary lesion could be identified; however, cervical lymph node metastasis to left levels IB and IIA were observed in the patient. A neck dissection followed by adjuvant radiotherapy was performed. However, the PIOC of the anterior maxilla was identified 6 months after neck treatment and was confirmed as the occult primary tumour of the HNCUP. This case is quite rare and required a comprehensive workup to guide optimal treatment. Careful follow-up or active biopsy should be considered if osteolytic changes are observed in the jaw.

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.

p16 immunohistochemistry for primary tumor detection in HPV-positive squamous cell carcinoma of unknown primary

PURPOSE

To examine the potential benefit of reevaluation of original slides and p16 immunohistochemistry (IHC) of tonsillectomy specimens for primary tumor identification in cases of human papillomavirus (HPV) positive squamous cell carcinoma (SCC) of the head and neck of unknown primary.

MATERIALS AND METHODS

Through a retrospective review, we identified all patients 18 or older who presented at our institution from 2003 to 2015 with histologically confirmed HPV-positive SCC in a cervical lymph node with unidentified primary tumor after initial workup. For patients for whom specimens were available, an expert head and neck pathologist re-reviewed original hematoxylin and eosin (H&E) slides to confirm absence of tumor and performed p16 IHC and deep sectioning of tissue blocks to identify potential tumor foci.

RESULTS

Among 735 patient records assessed, 80 were HPV-positive SCC with unknown primary, 28 of which did not have a primary tumor identified, and 20 with original specimens available. Upon re-review of 103 original H&E slides, invasive SCC was identified for 2 patients. Deep sectioning and p16 IHC did not identify additional primary tumors.

CONCLUSION

Re-review of original slides by an expert head and neck pathologist, but not p16 staining or deeper H&E sections, was able to identify additional tumors.

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.

Influence of postoperative radiotherapy target volumes in unilateral head and neck carcinoma of unknown primary: A multicentric study using propensity score

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.

[Cervical CUP syndrome]

The term CUP syndrome (cancer of unknown primary) refers to a multifaceted clinical picture in which the affected patients have lymph node and/or distant metastases without the location of the primary tumor being known. The criteria of CUP syndrome are fulfilled if a histologically or cytologically confirmed malignancy is present without a detectable primary tumor after completion of the primary diagnosis. Due to the usually poor prognosis and the manifold appearance, which often does not allow a standardized therapy, cervical CUP syndrome makes specific demands on clinical and imaging diagnostics. Using modern techniques such as positron emission tomography-computed tomography (PET-CT), imaging plays a key role in the detection of a possible occult primary tumor as well as in staging and prognosis assessment.

Metastatic Squamous Cell Carcinoma to the Cervical Lymph Nodes From an Unknown Primary Cancer: Management in the HPV Era

Background

Patients with metastases in the lymph nodes of the neck and no obvious primary tumor, neck cancer with unknown primary (NCUP), represent a management challenge. A majority of patients have metastatic squamous cell carcinoma (SCC), although other histologies do occur.

Methods

We comprehensively reviewed the literature, compared available guidelines, and conferred with an international team of experts.

Results

Positron emission tomography-computed tomography (PET-CT) and fine needle aspiration (FNA) under ultrasound guidance increase accuracy of diagnosis. Immunohistochemistry (IHC), determination of human papilloma virus (HPV) status, by p16 staining or by in situ hybridization (ISH), and next-generation gene sequencing can guide us regarding probable primary sites and tumor biology. Narrow Band Imaging (NBI) has been introduced for the early detection of subtle mucosal lesions. Direct laryngoscopy (DL) and tonsillectomy have long been procedures used in the search for a primary site. More recently, TransOral Robotic Surgery (TORS) or Transoral LASER Microsurgery (TLM) have been introduced for lingual tonsillectomy.

Conclusions

New technologies have been developed which can better detect, diagnose, and treat occult primary tumors. Decisions regarding therapy are based on the primary tumor site (if discovered) and N stage. Options include neck dissection with or without postoperative adjuvant therapy, primary irradiation, or combined chemotherapy with irradiation. The preferred treatment of patients whose primary remains unidentified is controversial.

Narrowband Imaging for p16+ Unknown Primary Squamous Cell Carcinoma Prior to Transoral Robotic Surgery

Our purpose was to assess the potential utility of narrowband imaging (NBI) as a tool in diagnosing and treating unknown primary oropharyngeal squamous cell carcinoma (OPSCC) in patients prior to diagnostic resection with transoral robotic surgery (TORS). Between 2016 and March 2019, 29 patients with carcinoma of unknown primary meeting inclusion criteria were identified and treated with TORS. NBI was used preoperatively in 9 of 29 patients. A suspected tumor site was delineated by NBI in 8 of 9 patients (89%). Of the patients imaged with NBI, 8 of 9 (89%) patients had a pathologically confirmed tumor following TORS, corresponding to the same 8 suspected tumor sites identified with NBI. In contrast, a primary tumor was localized following TORS in 15 of 20 (75%) patients not evaluated with NBI. Thus, we see NBI as a potentially useful tool for the diagnosis and management of p16+ carcinoma of unknown primary.Level of Evidence: IIb.

Patterns of EBV-positive cervical lymph node involvement in head and neck cancer and implications for the management of nasopharyngeal carcinoma T0 classification

OBJECTIVES

Epstein-Barr virus (EBV)-positive cervical lymph node (CLN) metastasis of unknown primary origin is classified as nasopharyngeal carcinoma (NPC) T0 by the American Joint Committee on Cancer staging manual (8th edition). We aimed to investigate the possible primary sites and patterns of EBV-positive CLN metastases and to provide implications for the management of NPC T0 classification.

MATERIALS AND METHODS

We retrospectively reviewed 269 patients with newly diagnosed EBV-positive CLN metastatic disease who underwent EBV detection via EBV-encoded RNA in situ hybridization. Fifteen patients with unknown primary tumors underwent follow-up after initial treatment.

RESULTS

In patients with EBV-positive CLNs, the most common primary sites after the nasopharynx (51.7%) were the salivary gland (24.5%), lung (7.8%), oropharynx (3.3%), nasal cavity/maxillary (3.3%), oral cavity (2.2%), orbit (1.1%), and liver (0.4%). No primary site was found in 15 patients (5.6%). For salivary gland malignancies, level II and I were the most frequently involved regions. Tumors arising from the lung or liver metastasized to the lower neck (level IV, V, and VI) rather than the upper neck. After initial treatment, 2/15 patients with EBV-positive CLNs of unknown primary exhibited primary NPC and oropharyngeal tumor, respectively. Further, even without prophylactic irradiation to the nasopharynx, only one of 13 unknown primary patients developed NPC.

CONCLUSIONS

The origins of EBV-positive CLNs may not be restricted to the nasopharynx alone, and are likely to involve the head and neck or non-head and neck regions. NPC T0 classification should be cautiously assigned to such tumors.

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.

An evaluation of the diagnostic methods in head and neck cancer of unknown primary site

BACKGROUND

Various detection methods to identify the primary in head and neck cancer of unknown primary (HN-CUP) require evaluation to improve and standardize management.

OBJECTIVES

To evaluate the use of different diagnostic methods, which aim at decreasing the incidence of HN-CUP.

MATERIAL AND METHODS

We conducted a retrospective analysis of patients with HN-CUP at the Helsinki University Hospital during 1995-2011. We evaluated clinical assessment, definitive treatment, histopathology, and follow up. We analyzed the success in identifying the primary site to show any changes in diagnostic methods over time.

RESULTS

Frequency of HN-CUP and success in identifying the primary site have remained constant despite the addition of PET-CT and determination of human papilloma virus (HPV) status in diagnostics. Among 133 patients, the diagnostic work up identified the primary site in 53% and the oropharynx predominated (69%). This left 85 patients with HN-CUP and 5-year overall and disease-free survival rates were 71 and 69%, respectively.

CONCLUSIONS

Panendoscopy including tonsillectomy should not be omitted in the work up.

SIGNIFICANCE

We demonstrate a steady frequency of HN-CUP and constant success in identifying the primary site. Detection of a primary later in the follow up did not impact the survival.

Diagnostic lymph node extirpation in CUP syndrome - useful or damaging?

OBJECTIVE

In a proportion of patients with cervical lymph node metastasis no primary can be found even with modern imaging and careful clinical examination (cancer of unknown primary syndrome = CUP syndrome). The ideal diagnostic approach is still debated on.

METHODS

The clinical data of 75 patients (median age: 61.8 years; 16 females and 59 males), which have been treated for cervical squamous cell carcinoma of unknown primary syndrome in our hospital were retrospectively analyzed.

RESULTS

In 12% of patients (n = 9) the primary demarcated in a time period of up to 5.3 years after diagnosis. In the patients who did not receive adjuvant radiotherapy (n = 13), primary became apparent in 38%. Diagnostic lymph node extirpation delayed time until therapeutic neck dissection on average for 3 weeks. In 62% of patients with previous lymph node extirpation (pN2a-N2c), a modified radical neck dissection was required compared to 41% when the surgical site was not operated on.

CONCLUSIONS

In 12% of patients' primary demarcated in the course of the disease. A diagnostic lymph node extirpation was compared to direct therapeutic neck dissection after frozen section analysis associated with a three weeks delayed therapy and higher rate of modified radical neck dissection.

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.

Cancer of unknown primary (CUP) of the head and neck: retrospective analysis of 81 patients

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.

The role of transoral robotic surgery, transoral laser microsurgery, and lingual tonsillectomy in the identification of head and neck squamous cell carcinoma of unknown primary origin: a systematic review

BACKGROUND

Squamous cell carcinoma of the head and neck can present as a cervical metastasis from an unknown primary site. Recently, transoral robotic surgery (TORS) and transoral laser microsurgery (TLM) have been incorporated in the workup of unknown primary tumors.

METHODS

We searched MEDLINE, EMBASE, Cochrane, and CINAHL from inception to June 2015 for all English-language studies that utilized TORS, TLM, or lingual tonsillectomy in the approach to an unknown primary.

RESULTS

Of 217 identified studies, eight were reviewed. TORS/TLM identified the primary tumor in 111/139 (80 %) patients overall, and 36/54 (67 %) patients with no remarkable findings following physical exam, radiologic imaging, and panendoscopy with directed biopsies. Lingual tonsillectomy identified the primary tumor in 18/25 (72 %) patients with no findings. Hemorrhage (5 %) was the most common perioperative complication.

CONCLUSION

Lingual tonsillectomy using new approaches such as TORS/TLM may improve the identification of occult primary tumors.

Transoral robotic surgery for carcinoma of unknown primary in the head and neck

Multiple diagnostic and treatment paradigms exist for the management of carcinoma of unknown primary (CUP) metastatic to cervical lymph nodes. Transoral robotic surgery (TORS) has emerged as a modality for diagnosis and treatment of CUP, optimizing identification and resection of the primary tumor, although also preventing chemotherapy in a subset of patients. This article presents the authors' treatment paradigm and reviews the literature supporting the use of TORS in the management of CUP.

Management of Squamous Cancer Metastatic to Cervical Nodes With an Unknown Primary Site

Squamous cell carcinoma of an unknown primary (SCCUP) of the head and neck is a rare disease. As a diagnosis of exclusion, the manner in which it is assigned merits consideration. Despite the development and refinement of several techniques designed to locate an occult tumor, including cross-sectional anatomic imaging, functional imaging, and transoral surgical techniques, delineating SCCUP remains an active clinical problem. Its relative rarity has prevented prospective study of the entity. Hence, investigators must rely on retrospective analyses to understand the disease and its appropriate treatment. The current understanding of SCCUP differs substantially from when it was initially described decades ago. The most common site of a small primary tumor initially thought to represent SCCUP is the tonsil or base of the tongue, and an increasing percentage are associated with human papilloma virus. Modern treatment of SCCUP by neck dissection alone, neck dissection followed by radiation with or without concurrent chemotherapy, or primary chemoradiation according to initial nodal disease burden produces extraordinarily low recurrence rates. Whether the potential mucosal primary site and/or the contralateral neck should be electively treated is controversial. Efficacy data seem to be similar; therefore, an evaluation of the toxicity of both treatment paradigms is warranted.

Evaluation and management of head and neck squamous cell carcinoma of unknown primary

The diagnostic evaluation and therapeutic management of a patient with squamous cell carcinoma of an unknown primary (SCCUP) has considerably evolved over recent decades and will likely continue to change as a result of the improving ability to identify small primary tumors and better tailor the implementation of multimodality therapy. By application of the general principles of head and neck oncology, physicians and surgeons are often able to achieve satisfactory control of the disease in patients with SCCUP.

Cervical lymphadenopathy: study of 251 patients

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.

[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.

Diagnosis and treatment of a neck node swelling suspicious for a malignancy: an algorithmic approach

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.

Head and neck manifestations of distant carcinomas

Metastatic tumors to the head and neck from distant carcinomas are rare lesions that epitomize the "zebras." They represent a diagnostic and therapeutic challenge for clinicians and health providers. These lesions usually rank low in the differential diagnosis list, but a history of cancer should prompt clinicians about the possibility of a metastatic lesion from a distant carcinoma. The presence of these lesions usually represents a poor prognosis. The surgeon's role in treating these lesions is to improve or maintain the patient's quality of life, taking into consideration the overall prognosis.

[Diagnostic algorithm in patients with cervical metastasis of malignant tumours unknown primary location]

Carcinoma of unknown primary location are heterogeneous group of metastatic tumours where primary location could not be discovered with detail anamnesis, clinical examination and diagnostic procedures. Patients with metastasis carcinoma of unknown primary location in clinical oncology are represent with about 4% of total number of patients with solid tumours. The most frequent location carcinoma of unknown primary location, discovered with autopsy, are lungs, pancreas, colon, kidney, prostate and breast. Metastasis in cervical lymph nodes carcinoma of unknown primary location are represent between 3-9% of total number of patients with head and neck carcinoma. Patients with persistent cervical lymph node should be examined through diagnostical plan "step by step" for identification carcinoma of unknown primary location.

Neck masses: evaluation and diagnostic approach

Oral and maxillofacial surgeons frequently deal with patients who present with an unknown neck mass. Formulation of a differential diagnosis is essential and requires that the surgeon bring to bear a host of skills to systematically arrive at a definitive diagnosis and ensure that the correct treatment is rendered. This article highlights some of the skills needed in the workup of neck masses and reviews some of the available techniques that aid in achieving the correct diagnosis.

Carcinoma Metastatic to Cervical Lymph Nodes From an Occult Primary Tumor: The Outcome After Combined-Modality Therapy

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.

Cervical Lymph Node Metastases from Occult Squamous Cell Carcinoma: Analysis of 82 Cases

PURPOSE

The aim of this study was to analyze the prognostic value of some clinical factors and to compare the survival of different treatment plans in patients with cervical lymph node metastases from occult squamous cell carcinoma (SCC).

METHODS

A retrospective review was conducted of patients who were diagnosed as having cervical lymph node metastases from occult SCC. Overall cumulative survival was analyzed using the standard Kaplan-Meier method. Tests of significance were based on log-rank statistics.

RESULTS

The 82 patients in the study consisted of 69 males (84.2%) and 13 females (15.8%). The average age at diagnosis was 64.7 years. Fifty patients (60.9%) underwent surgical treatment of cervical metastasis. Radiotherapy was performed in 79 patients. Thirty-two patients (40.5%) received primary fractioned external beam radiotherapy; 47 patients (59.5%) received postoperative fractioned external beam radiotherapy. Ipsilateral radiotherapy was performed on 37 patients (46.8%), bilateral neck plus mucosal irradiation was performed in 42 patients (53.2%). Ten patients (12.2%) developed a primary tumor during the follow-up. The actuarial survival rates of all patients 2, 5 and 10 years after diagnosis were 50.9, 25.3 and 18.5%, respectively. Patients with nodal stage N2b, N2c and N3 had a significantly poorer prognosis than those with nodal stage N1 and N2a (p = 0.0239). The survival in patients with metastatic nodes in the supraclavicular region (level IV) was significantly poorer than that of patients with involvement of the upper-middle jugular lymph nodes (p = 0.0003). We observed a statistically significant better survival in patients receiving bilateral neck plus mucosal irradiation (p = 0.0003).

CONCLUSIONS

Initial N-category and metastasis localization were the most important prognostic factors and nodal relapse the major cause of treatment failure, thus optimal management of cervical nodes appears crucial for the success of treatment. Patients receiving bilateral neck plus mucosal irradiation had a higher survival rate than those who received ipsilateral irradiation.

Diagnostic work-up and outcome of cervical metastases from an unknown primary

CONCLUSIONS

An intensive diagnostic work-up including (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) detects many unknown primary tumours, leads to a low emergence rate of primary tumours, and selects carcinoma of unknown primary with much more favourable results after neck dissection and postoperative radiotherapy.

OBJECTIVE

To investigate the optimal diagnostic approach and best treatment modality for rare head and neck cancer of unknown primary.

PATIENTS AND METHODS

In a retrospective study, 69 patients admitted from 1987 to 2002 with cervical lymph node metastases without apparent primary were reviewed. Test characteristics of all diagnostic procedures were calculated. Disease-free and overall survival rates were calculated. Major prognostic factors were analysed uni-variously.

RESULTS

At the primary site FDG-PET showed the best sensitivity with 69% and the highest negative predictive value with 87%. Computed tomography and magnetic resonance imaging had a better specificity with 87% and 95%, respectively. The primary tumour was detected in 23 cases (33%). Frequent primary tumour origin was the palatine tonsil (n=8, 35%), base of the tongue (n=6, 26%) and lung (n=4, 17%). All patients with unknown primary were treated by neck dissection. Adjuvant radiotherapy was performed in 26 patients (57%), concurrent radiochemotherapy was performed in 12 patients (26%). The primary emergence rate was 7%. The 5-year overall survival rate was inferior in patients with detected primary in comparison with patients with unknown primary (22% versus 52%). Significant prognostic factors in case of unknown primary were M stage, smoking, alcohol consumption and tonsillectomy. Radiotherapy but not chemotherapy with carboplatin influenced the overall survival.

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.

Head and neck metastases from occult abdominal primary site: a case report and literature review

OBJECTIVES

A very rare case of cervical lymph node metastasis from the liver is reported. The clinical findings and the diagnosis of a metastasis to the head and neck from the isolated silent abdominal cancer are discussed.

MATERIAL AND METHODS

The clinical and histopathological findings of a 56-year-old woman with a metastatic cervical lymph node of unknown origin are presented, together with a literature review of metastases from an occult abdominal primary.

RESULTS

The primary site was identified as an undifferentiated cholangiolocellular carcinoma using immunostaining for anti-cytokeratin subclasses after autopsy. Fifty-two cases of head and neck metastases from an abdominal primary cancer were found and separately summarized according to the metastatic routes.

CONCLUSIONS

When a metastatic neck cancer of unknown origin is diagnosed, it is very important to consider the possibility of a metastasis from an abdominal organ. Recognition of metastatic routes and their characteristics is helpful in the search for the occult abdominal primary site. Immunohistochemistry of the metastatic cancer may provide important information for identifying the primary site in cases of metastasis of an undifferentiated carcinoma.

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 of cystic cervical metastasis

An adult older than 40 years present with a cystic lump in the upper neck should be considered at risk of having an underlying malignancy of the head and neck-a mucosal squamous cell carcinoma or a papillary thyroid carcinoma. Although the likelihood of malignancy is small, should the diagnosis of malignancy be confirmed pathologically, this consequential diagnosis will result in devastating physical and psychologic upset to the patient and their caretakers, the treating surgeons, and possibly many other clinical groups. It is therefore recommended that all such patients be investigated by radiologic imaging-CT/MRI and fine needle aspiration cytology, followed by panendoscopy of the head and neck, which includes an ipsilateral tonsillectomy biopsy and an excision biopsy of the cystic neck lesion. Should the lesion prove to be an isolated cystic metastatic squamous cell carcinoma, a neck dissection should be performed with or without adjuvant radiotherapy. Should the lesion prove to be a metastatic papillary thyroid carcinoma, a total thyroidectomy and neck dissection should be performed. In general, patients with cystic metastasis have a better prognosis than patients who present with a noncystic neck mass.