Secondaries in the Neck lymph nodes
They are divided into 3 types
1.Secondaries in the Neck with Known Primary
2.Secondaries in the Neck with Clinically Unidentified Primary
3.Secondaries in the Neck with an Occult Primary
• Here secondaries are present and primary has been
identified clinically in the oral cavity, pharynx, larynx,
thyroid or other areas.
• Investigations: Biopsy from the primary and
FNAC from the secondaries
• Primary is treated by -Curative Radiotherapy or
• Secondaries, when mobile are treated by radical lymph
node block dissection in the neck
2.Secondariesin the Neckwith Clinically
• Hard neck lymph nodes are secondaries, but primary
has not been identified clinically.
• Investigations: FNAC from the secondaries
Then search for the primary is done by various
investigations. They are
b) Surveillance biopsy
c) FNAC of thyroid and suspected areas
d) CT scan.
b. Surveillance biopsy : Blind biopsies are taken from
Fossa of Rosenmuller
Lateral wall of pharynx
Base of tongue
Subglottic region (larynx)
c. FNAC of thyroid and suspected areas
d. CT scan
(Note: Surveillance biopsy is done to reveal unknown primary in
15% of cases of secondaries in neck. If this surveillance biopsy is
negative, then ipsilateral tonsillectomy may be needed.)
Primary is treated by Curative radiotherapy.
Secondaries in the neck is treated by Radical Neck Dissection.
3.Secondaries in the Neck with an
• Occult = hidding from view
• Secondaries in the neck lymph nodes are confirmed by
FNAC, but primary has not been revealed clinically and
by any available investigations.
• Occult primary : When all the investigations do not show any
evidence of primary.
• Reasons for primary lesion being occult
Too small a primary to detect;
Possibility of immunological spontaneous regression of primary and
Inability of the present diagnostic tools to detect the primary.
• Histologically secondaries in neck with occult primary may be
of squamous cell carcinoma or of nonsquamous cell
carcinoma, i.e., adenocarcinoma/poorly differentiated
• In upper and midcervical region 80% are due to squamous cell
• In lower cervical and supraclavicular region 40% can be
• Common sites of primary here (for adenocarcinoma) are
thyroid, breast, gastrointestinal tract, salivary glands, lungs,
prostate and kidney.
• 70% of occult nodes occur in jugulodigastric group.
• Differential diagnosis for secondary with occult primary is
lymphoma and primary branchogenic carcinoma.
Investigations for seconday tumour
FNAC is the tool to confirm the occult secondary.
Open biopsy (if FNAC is inconclusive)-incision/excision
Open biopsy helps in high suspects of lymphomas or poorly
differentiated carcinomas .
It facilitates tissue study, immunohistochemistry, and special
Many studies prove that risk of seedling, survival and
prognosis will not alter by open biopsy.
But at present it is proposed only when FNAC fails or special
methods are mandatory to type the disease.
After open biopsy, frozen section confirmation and immediate
neck dissection has to be done.
Immunoperoxidase staining is the most commonly
used on FNAC specimen or formalin fixed paraffin tissue using
monoclonal or polyclonal antibodies.
Immunoperoxidase mainly used in
Electron microscopy is superior to
immunohistochemistry as ultrastructure details can be
assessed. But it is costly.
Chromosomal analysis for tumour specific genes is
used in B, T and germ cell lymphomas.
Investigation for occult primary
• CECT is the investigation of choice to look for primary
• FNAC of node/open biopsy to confirm
• Other methods are – MRI , triple endoscopy, surveillance
biopsy, FNAC of thyroid, ipsilateral tonsillectomy if surveillance
biopsy and other methods are negaive
Initially the SECONDARIES in the neck are treated by Radical
Neck Dissection, then regular follow-up is done (at 3 monthly
intervals) until the primary reveals.
Once PRIMARY is revealed it is confirmed by biopsy and
treated accordingly, either by Curative Radiotherapy or by
Wide Excision depending on location of revealed primary.
This type is usually less aggressive and has got better
Nodal staging in secondaries
• Nx – nodes cannot be assessed
• No – no nodal metastasis
• N1 – single node same side <3 cm
• N2a – single node same side 3-6cm
• N2b – multiple nodes same side <6cm
• N2c – bilateral /contralateral nodes < 6cm
• N3 – node > 6 cm
Investigations for secondaries in neck
FNAC of secondary:
open incision biopsy is not advised here. It destroys the fascial
barriers and causes the spread of tumours faster and earlier
into next level nodes or other soft tissues. Eventual neck
dissection technically becomes difficult. Recurrence rate in
neck will be higher after open biopsy.
If FNAC of node and all investigations for primary become
negative, then open biopsy of node following confirmation
with frozen section and immediate neck dissection is
undertaken. In such situation if neck dissection is delayed
after open biopsy confirmation, chances of cure will be
Biopsy from primary : Incision biopsy is the choice here.
Blind biopsies from suspected areas.
Panendoscopy with examination under anaesthesia.
CT scan is to see the base of skull, paranasal sinuses,
nasopharynx, extension of primary tumour/secondary
deposites; CT scan of chest and abdomen.
Chest X-ray to visualise primary or secondaries in case
melanomas or mediastinal nodes.
MRI scan or PET scan in conjunction with CT scan or MRI. MRI
identifies soft tissue extension/changes; guided primary
biopsy is possible; extension into bone is identified.
CT chest and abdomen in case of infraclavicular primaries or
to assess nodes.