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.