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

Abstract

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.

Accuracy of Diagnostic Methods for Detection of Head and Neck Primary Origin in Metastatic Neck Mass

“…1). A quick, inexpensive, procedure with high spatial resolution is the contrast-enhanced CT-scan from the skull base to clavicles, complemented or substituted by a gadolinium contrast-enhanced MRI with superior soft tissue resolution [43]. In case of a cervical lymph node metastasis, the chance for CT, MRI or both to detect the primary site ranges from 9 to 23% [7,[47][48][49].…”

“…The prognosis for patients with CUP highly depends on the histology and involved region ranges from poor (adenocarcinoma metastatic to bone, brain and/or viscera) to favorable (e.g., squamous cell carcinoma metastatic to neck lymph nodes). The median survival of the poor prognostic group ranges from 7 to 11 months, whereas the survival of the favorable subset is similar to head and neck carcinomas with known primaries (e.g., HNSCC) [2,[41][42][43]. Here, we provide a comprehensive review of current diagnostic and therapeutic strategies, discuss open questions and challenges in the management of HNCUP patients like (stage dependent) universus multimodality treatment, RT treatment volumes and the need of concomitant chemotherapy and also propose a treatment algorithm.…”

Current Approaches to Primary Unknown Neck Metastases

“…İnce iğne aspirasyon biyopsi (İİAB) her zaman tanısal olmayabilir, bu durumda 2-3 kez tekrarlanması önerilmektedir. Metastatik lezyonlar için sensitivitesi %83-97, spesifitesi %91-100' dür (12). Kistik metastazlarda yanlış negatiflik oranı %42'dir (12).…”

“…Metastatik lezyonlar için sensitivitesi %83-97, spesifitesi %91-100' dür (12). Kistik metastazlarda yanlış negatiflik oranı %42'dir (12). Tekrarlanan İİAB'lerine rağmen tanı konulamadı ise tru-cut veya açık biyopsi denenebilir.…”

Epidemiological and molecular features of cutaneous squamous cell carcinoma with perineural spread

“…Unknown primaries in the head and neck of SCC histology presenting with cervical lymph node malignancy occur in less than 3% of head and neck cancer patients, and if the primary is identified approximately 90% are mucosal and located in the oropharynx. 193 The patients in this report represent an entirely different disease entity, with an apparent biological predilection for perineural invasion not lymphatic spread.…”