managment of neck nodes with occult primary

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  • Supraomohyoid neck dissection removes the lymph nodes in levels I to III and is most commonly used for patients with small oral cavity cancers and a clinically negative neck. The lateral neck dissection entails removal of level II to IV nodes and is most often used in the treatment of laryngeal, oropharyngeal, and hypopharyngeal cancers.
  • managment of neck nodes with occult primary

    1. 1. MANAGEMENT OF THE NECK NODES WITH OCCULT PRIMARY DR bHARTI DEvNANI MODERATOR:-DR RITU bHUTANI
    2. 2. DEFINITION HNCUP is defined as a biopsy proven cancerbiopsy proven cancer of the neck, which even after a complete clinical &complete clinical & radiological workupradiological workup (that includes physical examination, CT scan, esophgeoscopy, laryngoscopy, bronchoscopy & multiple survillence biopsies) reveals or yields no primaryno primary demonstrable lesion.demonstrable lesion.
    3. 3. EPIDEMOLOGY  Exact incidence is unknown.  Head-and-neck carcinoma of unknown primary (HNCUP) is the final diagnosis in 3–7%3–7% of patients with head-and-neck cancer initially presenting with metastatic squamous cell carcinoma (SCC) to the cervical lymph nodes
    4. 4. 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
    5. 5. 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
    6. 6. 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
    7. 7. 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..
    8. 8. DIAGNOSIS
    9. 9. 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
    10. 10. STAGING OF THE NECK
    11. 11. FNAC Anaplastic epithelial & Adenoca FNAC Lymphoma Thyroid Melanoma Thyroglobulin & calcitonin SCC Open biopsy should be avoidedOpen biopsy should be avoided unless the patient is prepared for definitive surgical managment
    12. 12. 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
    13. 13. 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
    14. 14. FNACFNAC SCC H & N exam ,radiological studies Primary found Primary notPrimary not foundfound
    15. 15.  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
    16. 16. SUMMARY
    17. 17. MANAGMENT
    18. 18. Category 2A
    19. 19. NECK DISSECTIONS  Radical Gold standard operation  Modified radical Preservation of non lymphatic structures  Selective Preservation of lymph node groups  Extended Removal of additional lymph node groups or non lymphatic structures
    20. 20. 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
    21. 21. BIGGEST CONCERN MAXIMISE CONTROL MINIMIZE MORBIDITY MODIFICATIONS OF RND
    22. 22.  Removes Nodal groups I-V  Preserves one or more of the nonlymphatic structures  XI (I)  IJV(II)  SCM(III) MODIFIED RADICAL NECK DISSECTION
    23. 23. M R N DDefinition Type 1 Type 2 Type 3
    24. 24. SELECTIVE NECK DISSECTION  Remove high risk lymph node groups based on tumor site.  Supraomohyoid Levels I-III  Lateral Levels II-IV  Posterolateral Levels II-V small oral cavity cancers and a clinically negative neck. laryngeal, oropharyngeal, and hypopharyngeal
    25. 25. Removal of  Additional lymph node groups  Nonlymphatic structures Extended radical neck dissection
    26. 26. 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
    27. 27. Presence of ECE suggests addition of chemotherapy.(category 1 evidence)
    28. 28. DOSES
    29. 29. TOXICITIES
    30. 30.  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.

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