unknown primary

1. MANAGEMENT OF THE
NECK NODES WITH
OCCULT PRIMARY
DR REKHA ARYA
MODERATOR:-DR ANURITA

2. DEFINITION
Carcinomas with an unknown primary siteCarcinomas with an unknown primary site
(CUP) are tumors that present with lymph(CUP) are tumors that present with lymph
node or distant metastases when appropriatenode or distant metastases when appropriate
investigations fail toinvestigations fail to
localize a primary sitelocalize a primary site..

3. FNAC
Sqamous cell
carcinoma,
Adenocarcinoma,
Undifferenciated
Poorly
differenciated
Anaplastic
carcinoma
FNAC
Lymphoma
SCC
suspecting
that primary
is in head and
neck

4. EPIDEMOLOGY AND ETIOLOGY
 Exact incidence is unknown.

5. POINTS TO CONSIDER WHEN
LOOKING FOR A PRIMARY
1) Location of lymph nodes
2) Lymphatic drainage of the region
3) Possible location of the primary tumor (hidden
sites)
4) Histology of nodes
5) Past history (relevant)

6. 1) LYMPHATICS
 Profuse capillary lymphatic network present in
Nasopharynx & Pyriform sinus
 Paranasal sinuses, middle ear and true vocal
cords have sparse capillary lymphatics

7. 2) RISK GROUPS BASED ON LOCATION AND SIZE 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

8. 3) HISTOLOGICAL
DIFFERENTIATION

9. Proposed explanations for inability to detect the
occult primary
 The primary tumor may have involuted spontaneously
and is no longer detectable, despite the presence of
metastatic disease.
 The malignant phenotype of the primary tumor favors
metastatic biologic behavior over local tumor growth.

10.  In evaluating metastatic SCC to cervical lymph
nodes, the occult primary is eventually detected
in about half of the cohort.
ROUTES OF SPREAD

12. Diagnostic work up

13. 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

15. 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

17. 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

18. CHARACTERISTICS OF FDG-PET
IMAGING

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

20. MANAGMENT

21. IF ONLY CN1+
 Selective or modified radical neck dissection
ADVANTAGE
1) Directs pathology
2) Post-op RT dose is lower
DISADVANTAGE
1) Surgical morbidity
If no additional lymphadenopathy or extracapsular
extension (ECE) - observe
If >2 LN or ECE: post-op RT or chemo-RT

22. IF > CN2+
 Early N2 disease (N2A, early N2B): RT
 Advanced N2-N3: chemo-RT
PET/CT 8 weeks after RT or chemo-RT
 Risk of residual disease <5% : observe
 Risk of residual disease >5%
1. Nodes >15 mm,
2. Focal lucency,
3. Enhancement or calcification in lymph node,
4. ECE or nodal rupture : neck dissection

23. NECESSITY FOR ADJUVANT NECK DISSECTION IN SETTING
OF CONCURRENT CHEMORADIATION FOR ADVANCED HEAD-
AND-NECK CANCER.
BRIZEL DM1, PROSNITZ RG, HUNTER S, FISHER SR, CLOUGH
RL, DOWNEY MA, SCHER RL.
 A total of 154 patients received concurrent chemoradiation. Of
these, 108 presented with nodal disease: N1, n = 30; and N2-N3, n
= 78. MND was performed in 65 (60%) of 108 patients. The
median follow-up was 4 years. The 4-year disease-free survival
rate was 75% for N2-N3 patients who had a cCR and underwent
MND vs. 53% for patients who had a cCR but did not undergo
MND (p = 0.08). The 4-year overall survival rate was 77% vs. 50%
for these two groups of patients (p = 0.04).
Int J Radiat Oncol Biol Phys. 2004 Apr 1;58(5):1418-23.

24. STUDIES OF POSTRADIOTHERAPY
NECK DISSECTION
 Narayan et al. (1999):
 Clayman et al. (2001):
 Brizel (IJROBP 2004):
 Liauw et al. (2006):
 Yao et al. (2007):
 Van der Putten et al. (2009):

25. 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

26. Post surgery management depends upon:-
1)Stage
2) Level of LN
3)Presence of extracapsular extension

27.  Typically irradiate nasopharynx, oropharynx,
and both sides of neck
 Hypopharynx and larynx were irradiated historically;
eliminated more recently because they are rarely the primary
site and including these sites greatly increases morbidity of
treatment
 Consider hypopharyngeal and laryngeal irradiation for
adenopathy centered in level III/IV
 Oral cavity is not irradiated unless submandibular
lymphadenopathy is present
 If submandibular lymphadenopathy: perform neck dissection
and observe, or irradiate oral cavity and oropharynx but not
nasopharynx

28. CONVENTIONAL RADIOTHERAPY
PLANNING
 Simulation and field design
Patient set-up:
supine, hyperextend head, may need bolus, shoulders pulled down with
straps, immobilization with thermoplastic mask or bite block.
Volumes:
Nasopharynx,oropharynx,bilateral retropharyngeal nodes and levels
IB-IV, ipsilateral ± contralateral supraclavicular nodes
Include oral cavity only if submandibular adenopathy present,and may
eliminate nasopharynx in that case

29. CONVENTIONAL BORDERS
Upper Neck Fields
Parallel -opposed lateral fields at 1.8–2 Gy/fraction
Superior = covers nasopharynx and level Ib and V to base of
tongue
Posterior = behind spinous processes to C2 , cord shielded after
40–44 Gy, with posterior electron field matching to the
required target dose
Anterior = 2 cm margin on nasopharynx and the base of tongue;
shield skin and subcutaneous tissue of submentum as much as
possible
Inferior = thyroid notch

30. Lower Neck Fields
Superiorly - the field should match the upper fields
with an isocentric or half-beam block technique,

Inferior border - including the clavicular heads.
Laterally, the field should cover the medial or entire
supraclavicular region, depending on the extent of
nodal involvement.
 A laryngeal block may be placed to spare the larynx
and hypopharynx .

34.  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
ECE spread.
 Patients with extra capsular 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.

36. DOSES

37. COMPLICATIONS
Surgical
Operative mortality 2–3%
Morbidity = infection, hematoma/seroma,
lymphedema, wound dehiscence, chyle fistula,
pharyngocutaneous fistula, cranial nerve VII, X, XI, XII
injury, carotid exposure, or rupture
Incidence of complications is greater with RT doses >60
Gy Radiation therapy
Acute and chronic mucositis, xerostomia
Skin reaction
Subcutaneous fibrosis

39. `

41. THANK YOU