This document discusses the management of neck nodes with an occult primary tumor. It defines this condition as biopsy-proven cancer of the neck that cannot be linked to a primary lesion after a full clinical and radiological workup. It notes the estimated incidence is 3-7% of head and neck cancers initially presenting with cervical lymph node metastases. Risk of lymph node metastases depends on factors like density of lymphatics in the potential primary site and histologic characteristics of the lesion. Diagnostic workup involves imaging, biopsies of suspicious areas, and examination under anesthesia. Treatment involves neck dissection, with options like radical, modified radical or selective dissection depending on the extent of disease. Post-surgery management considers disease

1. MANAGEMENT OF THE
NECK NODES WITH
OCCULT PRIMARY
DR bHARTI DEvNANI
MODERATOR:-DR RITU bHUTANI

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. 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. 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. 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. 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. 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. DIAGNOSIS

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

11. STAGING OF THE NECK

12. 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

13. 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

14. 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

15. FNACFNAC
SCC
H & N exam ,radiological studies
Primary
found Primary notPrimary not
foundfound

16.  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

17. SUMMARY

19. MANAGMENT

20. Category 2A

21. 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

22. 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

23. BIGGEST CONCERN
MAXIMISE CONTROL
MINIMIZE MORBIDITY
MODIFICATIONS OF RND

24.  Removes
Nodal groups I-V
 Preserves one or more of
the nonlymphatic
structures
 XI (I)
 IJV(II)
 SCM(III)
MODIFIED RADICAL NECK
DISSECTION

25. M R N DDefinition
Type 1 Type 2 Type 3

26. 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

27. Removal of
 Additional lymph node groups
 Nonlymphatic structures
Extended radical neck
dissection

28. 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

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

32. DOSES

36. TOXICITIES

38.  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.