1. Management of metastatic squamous neck cancer with unknown primary depends on nodal stage, presence of extracapsular spread, and risk of primary sites. Excision biopsy and neck dissection followed by postoperative radiotherapy is often recommended. 2. Intensity modulated radiotherapy has improved outcomes over conventional radiotherapy by better targeting tumor tissue and reducing dose to surrounding organs. 3. The addition of chemotherapy to surgery or radiotherapy can provide even better survival results.

1. DR ROOHIA

2. How metastatic squamous neck cancer
with occult primary is treated
THERAPEUTIC OPTIONS
 Include excision biopsy of involved lymph nodes,
 Neck dissection,
 Radiotherapy,
 Chemoradiotherapy or
 Radiotherapy with Salvage neck dissection

4.  HOW TO MANAGE A NECK SECONDARY???
 N STAGING
 NODAL REGIONS AND DRAINAGE
 DIFFERENT TYPES OF NECK DISSECTION

5. “N” classification – AJCC (1997)
 Consistent for all mucosal sites except the
nasopharynx
 Thyroid and nasopharynx have different
staging based on tumor behavior and
prognosis

7. The prevalence of occult neck metastases by
site is as follows:
60 %
Pyriform sinus -
Oral tongue -
Tongue base -
30%
 Floor of mouth
 Buccal mucosa
 Retromolar trigone
 Tonsil
 Aryepiglottic fold
 True vocal cord - 15%
 False vocal cord - 15%
 Alveolus - 15%
 Epiglottis - 15%
 Hard palate - 15%

8. CLASSIFICATION OF NDs
 RND originally described by Crile and
later popularized by martin
 now has been modified in various ways
 given rise to several types of cervical
lymph node dissections that are currently used
for the surgical treatment of the neck.

9.  These modifications were classified according to a
random system of terminology depending on the
author at the time.
 In 1991 the Academy’s Committee for Head and Neck
Surgery and Oncology published an
official report standardizing the classifications
for these modified neck dissection

10. The committee classified four
major types of neck dissections:
 1) Radical neck dissection
 2) Modified radical neck dissection
 3) Selective neck dissection including
posterolateral
lateral
anterior
supraomohyoid
 4) Extended radical neck dissection.

11. radical neck dissection
removing all of the lymphatic tissue in
regions I - V including removal of
 SAN
 SCM
 IJV

12. Modified radical neck dissection
defined as excision of all lymph nodes
(levels 1 to 5)
with preservation of one or more
non lymphatic structures,
SAN, IJV, SCM.

13. Medina subclassifies the MRND
 types I-III
 type I MRND preserves the SAN
 type II MRND preserves the SAN and IJV
 type III MRND preserves the SAN, IJV, and
SCM.

14.  The type III MRND is also referred to as the
"functional neck dissection"
as popularized by Bocca

15.  Selective neck dissection
defined as any type of cervical lymphadenectomy
where there is preservation of one or more
lymph
node groups removed by the radical neck
dissection

16. There are four common subtypes
 1. supraomohyoid neck dissection.
 This removes lymph tissue contained in
regions I - III.
The posterior limit of the dissection
is marked by the cutaneous branches of the cervical
plexus and the posterior border of the SCM.
The inferior limit is the superior belly of the omohyoid
muscle where it crosses the IJV

17. 2. posterolateral neck dissection
removal of the
 levels II - IV
 level V and additional
 suboccipital lymph nodes
 post - auricular lymph nodes
This procedure is used most often to remove nodal
disease from cutaneous melanoma of the posterior
scalp and neck.
Originally described by Rochlin in 1962( the SAN, SCM,
and IJV were preserved )

18.  3. The lateral neck dissection
 Removes lymph tissue in levels II - IV.

19.  4. Anterior neck dissection
 last subtype of selective neck dissection
 removal of lymph nodes surrounding the visceral
structures of the anterior aspect of
the neck previously defined as level VI
(perithyroid: pretracheal : precricoid: paratrachel )

20. The last major subtype is the
 extended neck dissection
 defined literally as removal of one or more
additional lymph node groups and/or
non - lymphatic structures not encompassed
by radical neck dissection, such as
parapharyngeal,
superior mediastinal and
paratracheal..

21. Management of occult primary:
 Treatment of metastatic squamous neck cancer
with occult primary depends on :
 how many lymph nodes contain cancer
 whether or not an original (primary) tumor is
found
 the patient’s age
 overall condition

22.  Presentation: lymphadenopathy in mid- to upper
neck levels
 90% primary site detected
 10% remains as unknown primary

23.  mid- to upper jugular nodes
associated with 5 possible mucosal sites:
which may harbour the primary
lesion
(1) nasopharynx,
(2) tonsillar region
(3) base of tongue,
(4) pyriform sinus,
(5) supraglottic larynx

24. jatin shah correlated
the primary site metastasis to particular lymph node
levels:
(1) oral cavity: levels I to III,
 (2) oropharynx: levels II to IV
 (3) hypopharynx: levels II to IV and
 (4) larynx: levels II to IV

25.  Level II and upper level V lymphadenopathy
(particularly bulky):
primary nasopharyngeal carcinoma
suggestive evidence :
1. serology titre ( EBV virus titre)
2. histopathology - lymphoepithelioma or poorly
differentiated cancer
3. Chinese ethnicity
4. Retropharyngeal node involvement

26. Controvorsies in management :
 1. types of dissection to be performed
 2. fields of radiation ( whether ipsilateral neck only
or whole neck )
 3. role of chemotherapy as a sequence to RT and neck
dissection
optimal mx : yet to be decided

27.  Mx based on the nodal stage and the high-risk mucosal
sites.
 Patients who clinically present with a mid- to high neck
node that is felt to be ≤ 3 cm in diameter
a fine-needle aspiration biopsy to establish
the diagnosis of cancer
if search for primary is negative
undergo neck dissection

28. If the
pathologic diagnosis show a clear, uncomplicated
N1 node,
may be considered only for monitoring
as the risk of regional neck recurrence is
10 % with
Primary surgery or radiation therapy

29.  The risk of subsequently developing a
primary site manifestation 6 to 50 %
in the world’s literature
a Ref study :
M.D. Anderson Hospital Cancer Center,
20 % of
the patients who were managed initially with surgery
alone for the cervical lymphadenopathy subsequently
developed a primary lesion

30.  However, if the pathology evaluation reveals stages
N2a, N2b or N2c or extracapsular extension
undergo ND + postoperative radiotherapy
 Also, if the
patient had undergone an incisional or excisional
biopsy of the node prior to ND , postoperative RT is
also recommended

31.  In MRND if the specimen has
less than 2 involved nodes without extracapsular
spread
no need for post – RT
( mucosal site damages can be avoided )

32. neck dissection with RT
vs
RT without neck dissection
 Ref study : ( a canadian study )
Statistically no difference in 8 year survival rates (
64.8 % and 67.6% )
conclusion:
definitive RT to neck and potential mucosal sites is good
in achieving good local control rates whether preceded
by
neck dissection or not

33. Coster et al study
N1 disease with no
extracapsular extension
surgery alone
N2 OR higher or
with extra capsular
involvment
surgery + post RT

34. According to Stell & Maran authors:
 Excision biopsy
followed by definitive
MRND
in all cases ….
 exception :
where nodes are
smaller
( less than 2 cm
+
no extracapsular
spread

35. Recent consensus :
 For N2 and N3 : dual modality therapy
ND followed by RT
OR
RT followed by interval neck dissection

37. Post Radiotherapy :
 The nodal areas would be treated with conventional
fractionation
54Gy
subsequent boost to high-risk nodal
regions to a total dosage of 63 Gy
54 - 63 Gy ( over 6 to 6.5 weeks)

38.  The possible primary mucosal sites would be similarly
irradiated to a total dosage of
54 Gy.
Neck : 66 – 74 Gy to gross disease,
44- 64 Gy for subclinical disease
Mucosa: 50 – 66 Gy

39. The dosage is dependent on the lymph node size:
(1) ≤ 1 cm: 65 grays
(2) ≥ 1 cm to 2 cm: 70 Gy
(3) > 2 cm to 3 cm: 75 Gy

40. Radiotherapy principles .1. High posterior triangle node - treat as primary
nasopharyngeal carcinoma.
 2. Jugulodigastric or midjugular node - treat as
primary nasopharyngeal carcinoma, omit larynx
shield.
 3.Upper or midjugular node – fields include the
ipsilateral tonsillar fossa, posterior tongue,
pyriform fossa, and ipsilateral neck nodes

41.  4. Multiple or bilateral nodes: treat as primary
nasopharyngeal carcinoma, but omit larynx
shield.
 5. Supraclavicular node only: palliative
irradiation.
 6. Radical radiation doses – as for stage T1 primary
cancer, with additional boost to the metastatic
node

42. Side effects can appear around 2 weeks after the first
radiation treatment or much later and can include:
 Mouth sores (feels like little cuts or ulcers in your mouth).
 Dry mouth (also called “xerostomia”
 Pain or difficulty with swallowing.
 Changes in taste or smell.
 Changes in the sound of your voice.
 Jaw stiffness and jaw bone decay.
 Changes in your skin.
 Feeling tired.

43. Best Options in recurrence …
 Limited volume radiation therapy and a fractionated
boost with brachytherapy
( found very effective in recurrent nasopx tumors)
 Brachytherapy alone
 Concurrent chemotherapy ( chemo + RT )

44. In jatin shah ‘s institute For recurrence after radiation :
IMRT was used and studies done……
showed more survival rate
IMRT : ( intensity modulated radiotherapy)
advanced form of 3D conformal treatment planning
which involves the use of the most sophisticated
computer-generated treatment planning and clinical
linear accelerators available

45. indicated in the treatment of lesions with
complex
anatomy that are adjacent to vital structures
such as
the spinal cord or brain stem.
IMRT
 improves the therapeutic ratio
 optimizing the dose to the tumor target
 decreases the dose given to the target

46. IMRT vs conventional RT: bhide et al study
 Improved radiation coverage of mucosa including
nasopharynx
 Significant reduction of dose to the parotid gland
contralateral to the involved neck…….thereby
reducing risk of xerostomia

47. Treatment options
Chemotherapy
3- 6 courses either pre or post RT
 BMC REGIME
Bleomycin 10 units i.m days 1, 8, 15
Methotrexate: 40 mg i.m days 1 and 15
Cisplatin: 50 mg iv on day 4
repeat every 21 days
 C F : Cisplatin - Fluorouracil
Cisplatin : 100 mg iv day 1
Flourouracil : by continuous iv infusion for 96 hours
repeat
every 3 weeks

48. Summary…….
 • All patients with suspected UPC should be
thoroughly examined and investigated with
panendoscopy, CT or MRI of head and neck, and
(FDG) CT-PET.
 Modified neck dissection is recommended for all
patients with UPC with cervical lymphadenopathy
 Postoperative selective or panmucosal
radiotherapy is indicated for most patients with
advanced operable neck disease

49.  • The only tumour marker of clinical value is Epstein-
Barr virus serology. Positive EBV serology should be
followed on by multiple biopsies of the nasopharynx in
the search for an occult primary.

50.  Use of IMRT improves survival rates and decreases
complications
 Use of chemotherapy regimes with RT or surgery
have even better outcome results