managment of neck nodes with occult primary
TRANSCRIPT
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.