MANAGEMENT OF THE NECK NODES WITH OCCULT PRIMARY

dr bharti devnaniModerator:-dr ritu bhutani

DEFINITION

HNCUP is defined as a biopsy proven cancer biopsy proven cancer of

the neck, which even after a complete complete

clinical & radiological workup clinical & radiological workup (that includes

physical examination, CT scan,

esophgeoscopy, laryngoscopy, bronchoscopy

& multiple survillence biopsies) reveals or

yields no primary demonstrable lesion.no primary demonstrable lesion.

EPIDEMOLOGY

Exact incidence is unknown.

Head-and-neck carcinoma of unknown primary (HNCUP) is the final diagnosis in 3–3–7% 7% of patients with head-and-neck cancer initially presenting with metastatic squamous cell carcinoma (SCC) to the cervical lymph nodes

RISK OF LYMPH NODE METASTASES DEPENDS UPON:-

1) Density of capillary lymphatics

2) Location of the primary tumor

3) Histologic differentiation,

4) Size of the lesion

5) Recurrent v/s untreated lesions

DENSITY OF CAPILLARY LYMPHATICS

Profuse capillary lymphatic network present in

Nasopharynx & Pyriform sinus

Paranasal sinuses, middle ear and true vocal

cords have sparse capillary lymphatics

RISK GROUPS BASED ON LOCATION OF PRIMARY TUMOR

Group

Estimated Risk of Subclinical Neck Disease % Stage Site

Low risk <20 T1 FOM, RMT, gingiva, hard palate, buccal mucosa

Intermediate risk

20-30 T1 Oral tongue, soft palate, pharyngeal wall, supraglottic larynx, tonsil

    T2 FOM, oral tongue, RMT, gingiva, hard palate, BM

High risk >30 T1-4 Nasopharynx, Pyriform sinus, BOT

    T2-4 Soft palate, pharyngeal wall, supraglottic larynx, tonsil

    T3-4 FOM, oral tongue, RMT, gingiva, hard palate, BM

HISTOLOGICAL DIFFERENTIATION The majority of patients have either

squamous cell or poorly differentiated carcinoma.

Adenocarcinoma

High chances of primary lesion below the clavicles

If nodes are located in the upper neck Salivary glandSalivary gland ThyroidThyroid Parathyroid primary tumorParathyroid primary tumor. .

DIAGNOSIS

DIAGNOSTIC WORKUP History

Physical examination

Careful examination of the neck and supraclavicular regions with attention to skin

Examination of oral cavity, pharynx, and larynx

Mirror & fiberoptic examination to visualise nasopharynx,oropharynx,hypopharynx,larynx

STAGING OF THE NECK

FNAC

Anaplastic epithelial &

Adenoca

FNACLymphoma

Thyroid Melanoma

Thyroglobulin &

calcitonin

SCC

Open biopsy should be avoided Open biopsy should be avoided unless the patient is prepared for definitive surgical managment

Radiological Studies

Chest imaging

CT with contrast or MRI with Gd (skull base through thoracic

inlet)

PET CT scan (If other tests do not reveal a primary)

Laboratory studies

Complete blood cell count

Blood chemistry profile

HPV testing (Suggestive of occult primary in BOT or Tonsil,

helps in customize radiation targets)

EBV testing

EVIDENCE ON ROLE OF PET CT In a meta-analysis of 16 studies looking at

the role of PET in 302 patients with cervical node metastases where a primary has yet to be discovered through the work up, 25% 25% of primaries are identified through PET. Previously unrecognized regional or distant metastases were identified in 27% of patients

Rusthoven, KE, Koshy, M, Paulino, AC, The role of fluorodeoxyglucose PET in cervical lymph node metastases from an unknown primary tumor. Cancer 2004; 101:2461

FNACFNAC

SCC

H & N exam ,radiological studies

Primary found Primary Primary

not foundnot found

Examination under anasthesia Direct laryngoscopy

Biopsy to be taken from(Nasopharynx, tonsils, BOT, Pyriform sinuses & any suspicious mucosal areas)

In a study of 87 patients with unknown primaries, 26% were discovered to have a tonsillar primary after tonsillectomy

Lapeyre, M, Malissard, L, Peiffert, D et al. Cervical lymph node metastasis from an unknown primary: Is a tonsillectomy necessary? Int J Radiat Oncol Biol Phys; 39: 291

SUMMARY

MANAGMENT

Category 2A

NECK DISSECTIONS

RadicalGold standard operation

Modified radicalPreservation of non lymphatic structures

SelectivePreservation of lymph node groups

ExtendedRemoval of additional lymph node groups

or non lymphatic structures

Standard radical neck dissection

Involves removal of :-

Lymph nodes in levels I to V sternocleidomastoid muscle, Omohyoid muscle, Internal and external jugular

veins, Spinal accessory nerve, Submandibular gland. Tail of parotid

BIGGEST CONCERN

MAXIMISE CONTROL

MINIMIZE MORBIDITY

MODIFICATIONS OF RND

RemovesNodal groups I-V

Preserves one or more of

the nonlymphatic structures

XI (I) IJV(II) SCM(III)

MODIFIED RADICAL NECK DISSECTION

M R N DDefinition

Type 1 Type 2 Type 3

SELECTIVE NECK DISSECTION

Remove high risk lymph node groups based on tumor site.

SupraomohyoidLevels I-III

LateralLevels II-IV

PosterolateralLevels II-V

small oral cavity cancers and a clinically negative neck.

laryngeal, oropharyngeal, and hypopharyngeal

Removal of

Additional lymph node groups

Nonlymphatic structures

Extended radical neck dissection

Post surgery management depends upon:-

1)Stage N1/N2-N3

2) Level of LN I/II-III-upper V/IV/lower level V

3)Presence of extracapsular extension If present chemotherapy to be added

Presence of ECE suggests addition of chemotherapy.(category 1 evidence)

DOSES

TOXICITIES

IMRT for HNCUP has survival rates comparable to those with conventional radiotherapy.

By using IMRT the degree of toxicity can be reduced compared with conventional methods.

High OS, DFS, and nodal control can be

achieved for patients with T0N1 or T0N2a disease without extracapsular spread.

Patients with extracapsular spread or bulky T0N2b–c or T0N3 disease have a worse prognosis and may benefit from the addition of more cytotoxic chemotherapy,molecular targeted therapy, and/or accelerated radiation regimens.