Algorithm for neck secondaries of unknown origin

1. Diagnostic approaches In CUP
Neck(Carcinoma of Unknown
Primary)
DR.E.KAUSHIK KUMAR
DEPARTMENT OF GENERAL SURGERY
STANLEY MEDICAL COLLEGE

2. • குறள் 71:
அன்பிற்கும் உண்டைோ அடைக்குந்தோழ்
ஆர்வலர்
புன்கண ீர் பூசல் தரும். :
அன்பிற்கும் கூைப் பிறர் அறியோமல்
தன்டை மூடி டவக்கும் கதவு உண்டைோ?
இல்டல. தம்மோல் அன்பு
சசய்யப்பட்ைவரின் துன்பத்டதக்
கோணும்டபோது வடியும் கண்ண ீடே அன்பு
உள்ளத்டதக் கோட்டிவிடும்.

3. AIM
• Clarifying the histology of the nodal
metastases
• Detecting the primary.

4. History
• Family and Personal history, including history of previous
malignancy both in the head and neck, and elsewhere
• History of previous radiation
• History of a previous facial or cervical skin lesion that has
disappeared
• History of any upper aero-digestive tract related
symptoms (sore throat, otalgia, hoarseness, dysphagia,
hearing loss or epistaxis)
• Previous operations (breast, abdomen, chest, etc.).

5. Clinical Evaluation
• Scrupulous physical and fiber-optic evaluation of the
head and neck district including palpation of the oral
cavity, oropharynx, and base of the tongue, and search
for scars in the head and neck indicating previous
surgery.
• Examination of the neck, which includes site, size,
mobility, and relationship of the node(s) to the adjacent
structures.
• Complete physical examination for abnormalities
elsewhere: breast, axilla, groins, testicles, abdomen.

6. Investigations
• FNAC
• Imaging
• Endoscopy
• Molecular assays
• Examination under General Anaesthesia

7. FNAC
• Recommended if the above evaluation does not
detect any primary.
• Repetitive non-diagnostic FNACs- an indication for an
open biopsy, intra-operative histologic examination
and possible neck dissection
• Performed by experienced specialists
• Allow detection of the primary in more than 50% of
patients

8. IMAGING
• Head and Neck- CT, MRI
• CECT Thorax
– Trachea
– Oesophagus
– Lungs
• CECT Abdomen
– Liver
– Ovary
– Testes
– Prostate

9. PET-CT
• Overall staging accuracy -69-78%
• Positive predictive value -56-83%
• Negative predictive value-75-86%
• Sensitivity-63-100%
• Specificity -90– 94%
• With negative routine clinical examination, CT, and
MRI, PET scan allows detection of primary tumours
in 5-43% of patients.
• Higher rates of primary tumour detection-non-head
and-neck CUP or histologies other than SCC

10. • The resolution of the PET scan limited to 5 mm
• Tumours of the supraglottic region and Waldeyer’ s
tonsillar ring-most difficult to be diagnosed with
FDG-PET
– low tumour volume in small, superficial lesions
– the presence of normal lymphoid tissues
– accumulation of FDG secreted by salivary glands to saliva
pools in the valleculae and pyriform sinuses
– Improved detection may probably be achieved with a 12-h
pre-study fast,

11. • Ideally, biopsies should be performed after PET scan
– Sampling of the areas suspected in PET
– Avoids false positive PET-scans at biopsy site.
• Exclusion of other metastases
• Post-radiotherapy neck evaluation
• Subsequent monitoring

12. Endoscopy
• Tracheo-broncoscopy
• Oesophago-Gastroscopy
• Colonscopy

13. MOLECULAR ASSAYS
• Recently proposed to differentiate the potential primary site.
• Detection of the Epstein-Barr virus (EBV) with the use of in situ
hybridization in metastatic lymph nodes may suggest
nasopharyngeal tumour
• Human Papilloma virus (HPV) detected by polymerase chain
reaction may indicate oropharyngeal cancer
• Microsatellite mutation analysis of metastatic nodal tissue and
samples of normal pharyngeal mucosa
• In CUP the primary acquires a metastatic phenotype soon after
transformation and remains small, either by inborn errors leading
to involution of the primary, or due to extremely slow growth rate
• Inhibiting the growth of the primary by metastases

14. Examination under general
anaesthesia
• When the primary is not dectected, an evaluation
under general anaesthesia is mandatory.
• Biopsies are taken from all sites suspicious at the
clinical and imaging evaluation, and blindly from
the sites of possible origin of the primary
– base of tongue
– tonsil or tonsillar fossa
– pyriform sinus
– nasopharynx.

15. • Another option is open biopsy
• Increased risk of distant metastases following
this procedure has been suggested
• Detection rate
– CT scan -15-20%
– Panendoscopy with biopsies -up to 65%
• The most common sites of primary (82%)
– Tonsil
– Base of tongue

17. THANK YOU