Management of the unknown primary carcinoma: long-term follow-up on a negative PET scan and negative panendoscopy

Evaluation of Efficacy of Neoadjuvant Immunochemotherapy for Cervical Metastatic Squamous Cell Carcinoma of Unknown Primary

PURPOSE

This study aims to evaluate the antitumor activity of neoadjuvant immunochemotherapy in patients with cervical metastatic squamous cell carcinoma of unknown primary (CMSCCUP), providing a new idea for its treatment.

METHOD

We retrospectively examined the medical records from Sun Yat-sen University Cancer Center to identify patients with CMSCCUP from July 2020 to November 2023. CMSCCUP's diagnoses are based on the results of biopsy and imaging examination. All patients received PD-1 inhibitors combined with chemotherapy: paclitaxel (Albumin-bound) 260 mg/m2 and cisplatin 60 mg/m2 every 3 weeks for two or more cycles as their initial treatment. Clinical response after neoadjuvant immunochemotherapy was assessed using Response Evaluation Criteria in Solid Tumors (RECIST), version 1.1. Surgery, radiotherapy, or chemoradiotherapy was performed subsequently based on the imaging evaluation results. Outcomes included overall survival (OS) and disease-free survival (DFS).

RESULT

After neoadjuvant immunochemotherapy, the objective response rate (ORR) was 84.2%; complete response (CR), partial response (PR), and stable disease (SD) were 36.8%, 47.4%, and 15.8%, respectively. Of the 9 patients (42.9%) who underwent surgery after neoadjuvant immunochemotherapy, 7 (77.8%) achieved pathological complete response (pCR). No severe treatment-related adverse events occurred. The most common treatment-related adverse events were Grade 1-2 fatigue (11/14, 78.6%), decreased appetite (11/15, 73.3%), and increased aspartate transaminase (12/20, 60.0%). One (1/20, 5.0%) patient experienced Grade 3 anemia. The 2-year overall survival (OS) and 2-year disease-free survival (DFS) rates were 94.4% and 89.4%, respectively.

CONCLUSION

Neoadjuvant immunochemotherapy showed favorable efficacies, anticipated outcomes, and tolerable toxicity for patients with CMSCCUP. More clinical practice and clinical studies are still needed to confirm further.

Head and Neck Squamous Cell Carcinoma of Unknown Primary-Who Can Be Offered Surgery as the Sole Treatment Modality? A Systematic Review

OBJECTIVE

Evaluate the role of surgery as the sole treatment modality for patients with cervical head and neck squamous cell carcinoma of unknown primary (HNSCCUP).

DESIGN

Systematic review of observational cohort studies with qualitative synthesis.

SETTING

PubMed, Ovid EMBASE, and Cochrane Controlled register of Trials (CENTRAL) were screened from January 2000 up to October 2021.

PARTICIPANTS

Patients with HNSCCUP after completing diagnostic workup subsequently treated with single-modality surgery.

MAIN OUTCOME MEASURES

The primary outcome was 3-year overall survival (OS). Secondary outcomes included disease-free survival (DFS), primary emergence, regional recurrence, and distant metastasis.

RESULTS

Fourteen eligible studies were identified, including 1780 patients, of whom 294 received surgery as their sole treatment (seven studies) with 3-year OS ranging from 43.9% to 100%. 3-year DFS was reported in four studies (n = 62) ranging from 42.8% to 67.0%. 5-year OS and DFS were available in three studies (n = 31), ranging from 36.6% to 75.0%, and 43.6% to 67.0%, respectively. The rate of primary emergence ranged from 11.1% to 33.3% (seven studies, n = 157), regional relapse from 0.0% to 50.0% (five studies, n = 60) and distant metastasis from 0.0% to 3.3% (three studies, n = 45). Patients undergoing surgery as a sole treatment had predominantly p16/HPV positive N1 (TNM7) disease without ECS.

CONCLUSION

Outcomes for HNSCCUP patients undergoing surgery alone range widely in the literature but may be reasonable in a subset of patients with early-stage p16/HPV positive disease. Data is lacking for p16/HPV negative disease where the potential primary site is more varied and primary emergence appears more common.

Report of an Extremely Rare Case of BRCA-Positive Head and Neck Cancer: A New Disease on the Horizon?

Cancer of unknown primary (CUP) with metastatic squamous cell carcinoma (SCC) to the neck nodes is rare and represents <5% of all head and neck malignancies. The prognosis is poor; hence, there is a need for early comprehensive diagnostic evaluation and management. A BRCA mutation is rarely seen in patients with head and neck squamous cell carcinoma (HNSCC) with an incidence of only 5-10%. We hereby present a rare case report of CUP with metastatic neck nodes (SCC), unveiling a BRCA mutation on liquid biopsy. The patient responded very well with platinum-based cytotoxic chemotherapy followed by maintenance poly adenosine diphosphate ribose polymerase inhibitors (PARPi). This is a first-of-its-kind case in the head and neck region, especially in this part of the world, where tobacco-related head and neck cancer catches all the attention over human papillomavirus (HPV) positivity and other risk factors.

Investigating the Role of C-Reactive Protein/Albumin Ratio in the Preliminary Diagnosis of Patients With Unexplained Neck Lymphadenopathy

Purpose: Lymphadenopathies in the neck are associated with several etiological factors, such as inflammation, infection, and tumors. We diagnose some of these lymphadenopathies using serologic tests, while others are diagnosed using biopsies. The C-reactive protein/albumin ratio (CAR) has recently emerged as a crucial inflammatory marker in cardiovascular diseases and various types of cancer. Our aim in this study was to investigate the role of the CAR in the preliminary diagnosis of patients with unexplained neck lymphadenopathy. Methods: Between 2013 and 2020, 223 patients presented to our clinic with neck lymphadenopathy. Among these patients, whose cause of lymphadenopathy was not identified, 74 patients (8 children, 66 adults) who underwent neck lymphadenopathy excision were included in the study. Patients were divided into 4 groups according to pathology results: (1) patients with reactive lymphoid hyperplasia; (2) patients with granulomatous disease; (3) patients with lymphoma; and (4) patients with metastatic disease. C-reactive protein (CRP), albumin, and CAR values were compared. Results: When the CAR of the patients were compared, a significant difference was found between reactive lymphoid hyperplasia and lymphomas (P = .006). CRP values were significantly higher in lymphomas than in lymphoid hyperplasia (P = .007). When the albumin values of the patients were compared, it was found that the albumin value was significantly lower in patients with metastatic disease than in those with reactive lymphoid hyperplasia (P = .032). Patients with carcinoma metastases were more common in male patients than in other groups. Conclusion: The CAR is a parameter that can be used in the preliminary diagnosis of unexplained neck lymphadenopathy. The elevation should be evaluated in favor of malignancy. It can be used as an auxiliary parameter, particularly in the diagnosis between the preliminary diagnosis of reactive lymphoid hyperplasia and lymphoma.

Challenges and Considerations in Diagnosing and Managing p16+-Related Oropharyngeal Squamous Cell Carcinoma (OPSCC) with Neck Metastasis: Implications of p16 Positivity, Tobacco Exposure, and De-Escalation Strategies

BACKGROUND

The incidence of patients showing neck metastasis and no obvious primary tumor at the initial diagnostic evaluation or neck cancer of unknown primary (NCUP) is rising. It is estimated that a relevant part of these tumors arises in the tonsillar crypts or base of the tongue and are p16+-related. However, today, the detection rate of the primary tumor is suboptimal. Identifying the primary tumor and its biomolecular characterization is essential since it influences the treatment administered, possibly reducing radiation fields and providing de-escalation to primary surgical management. However, p16 IHC (immunohistochemistry) might not be sufficient to diagnose HPV-related OPSCC. The other subset of patients discussed are the HPV-positive patients who have a history of tobacco exposure and/or p53 mutations. Possible factors that could negatively influence the outcomes of these patients are investigated and discussed below. So, this paper aims to analyze the diagnostic, bio-molecular, clinico-radiological, morphological, prognostic and therapeutical aspects of p16-positive OPSCC, highlighting the possible bias that can occur during the diagnostic and prognostic process.

METHODS

A narrative review was conducted to investigate the biases in the diagnostic and therapeutic process of two groups of patients: those who are p16-positive but HPV-negative patients, and those who are p16-positive and HPV-positive with exposure to traditional risk factors and/or p53 mutations. The keywords used for the literature research included the following: NCUP, OPSCC, p16IHC, HPV testing, p16 positive HPV negative OPSCC, p16 positive HPV positive OPSCC, tonsillectomy, tobacco exposure, p53 mutations, cystic neck metastasis, extranodal extension (ENE), radiotherapy, de-escalation and neck neck dissection.

RESULTS

HPV-positive OPSCC has specific clinico-radiological features. Bilateral tonsillectomy should be considered for the identification of the primary tumor. P16 IHC alone is not sufficient for diagnosing HPV-related OPSCC; additional detection methods are required. The role of tobacco exposure and p53 mutations should be investigated especially in cases of HPV-positive tumors. Extranodal extension (ENE) must be taken into consideration in the prognostic staging of HPV-positive tumors. Surgical primary treatment involving neck dissection (ND) and bilateral tonsillectomy followed by adjuvant radiation may represent the most appropriate approach for N3 cases. Diagnosis, prognosis and therapeutical implications must be addressed considering clinical, biomolecular and morphological aspects. At least today, the numerous biases that are still present influencing the diagnostic and prognostic process do not permit considering de-escalation protocols.

CONCLUSIONS

A precise and accurate diagnosis is required in order to adequately stage and manage p16+ OPSCC, particularly with neck metastasis. The role of tobacco exposure and/or p53 mutations must be considered not only in p16+ OPSCC but especially in HPV-positive OPSCC. Until a more accurate diagnosis is possible, ENE should be considered even in p16+HPV+ OPSCC. Primary surgery with unilateral ND and bilateral tonsillectomy might be the treatment of choice given the numerous diagnostic and prognostic pitfalls. Therefore, it is inappropriate and risky to propose de-escalation protocols in routine clinical practice due to the risk of undertreatment.

The role of non-oropharyngeal biopsies in head and neck squamous cell carcinoma of unknown primary: A systematic review

INTRODUCTION

This systematic review aims to evaluate the role of biopsies in non-oropharyngeal subsites in patients with cervical metastasis from head and neck squamous cell carcinoma of unknown primary (HNSCCUP).

METHODS

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Articles that encompassed non-oropharyngeal biopsies in HNSCCUP as part of the diagnostic work-up were selected and analysed.

RESULTS

A comprehensive search strategy was used to search relevant literature in PubMed from inception to October 2021. Eleven articles out of 860 were included, comprising 990 patients. There are no randomised control trials comparing the outcomes of survival and or locoregional control between patients who have or have not undergone non-targeted biopsies of non-oropharyngeal sub-sites for HNSCCUP. Several retrospective studies which showed an extremely low yield from random biopsies (range of yield, 0%-9%) of non-oropharyngeal subsites. Even targeted biopsies showed a low yield (range of yield, 0.6%-16.6%) from non-oropharyngeal subsites. The primary site identified for Epstein-Barr virus (EBV) positive cervical lymph nodes with an unknown primary is mainly the nasopharynx (51.7%). Narrow band imaging (NBI) (sensitivity range, 64%-91%) helps in the detection of primaries to target biopsies in non-oropharyngeal subsites.

CONCLUSIONS

On the basis of this systematic review, it is not appropriate to offer biopsies of clinically and radiologically normal upper aerodigestive tract mucosa at non-oropharyngeal sites. Offer nasopharyngeal biopsies when the cervical node sampling reveals EBV-positive metastasis. Where available, NBI should be used to help detect and target biopsies in non-oropharyngeal subsites.

Survival Outcome in True Carcinoma of Unknown Primary (tCUP) with p16 + Cervical Metastasis

Introduction  Age and lymph node ratio have been attributed as independent predictors for survival and recurrence in carcinoma of unknown primary (CUP). Objective  The purpose of this study was to analyze the prognostic value of p16 overexpression for CUP in the absence of true primary (TP). Methods  The study involved 43 patients who underwent therapeutic lymph node dissection (LND) from 2000 to 2015 after all the diagnostic work up for CUP. Immunohistochemistry for p16 overexpression was performed. Cox proportional hazard regression analysis was used to analyze the prognostic impact on 5-year overall survival (OS) and recurrence-free survival (RFS). Results  The male-to-female ratio was 5.1:1, with a median age of 62 years. The clinicopathological data, except for p16 overexpression, did not differ significantly in terms of 5-year OS and RFS. The Cox regression analysis proposed p16 positivity to be an independent prognosticator of regional recurrence-free survival (RRFS) (hazard ratio [HR] 6.180, p  = 0.21). The median time to recurrence and death were 10 and 25 months, respectively. Conclusion  Cervical metastasis with p16 overexpression is a significant prognostic factor of improved RFS after surgery in CUP. The prognostic significance of lymph node p16 positivity should be further studied.

Contemporary Imaging and Reporting Strategies for Head and Neck Cancer: MRI, FDG PET/MRI, NI-RADS, and Carcinoma of Unknown Primary-AJR Expert Panel Narrative Review

CT, MRI, and FDG PET/CT play major roles in the diagnosis, staging, treatment planning, and surveillance of head and neck cancers. Nonetheless, an evolving understanding of head and neck cancer pathogenesis, advances in imaging techniques, changing treatment regimens, and a lack of standardized guidelines have led to areas of uncertainty in the imaging of head and neck cancer. This narrative review aims to address four issues in the contemporary imaging of head and neck cancer. The first issue relates to the standard and advanced sequences that should be included in MRI protocols for head and neck cancer imaging. The second issue relates to approaches to surveillance imaging after treatment of head and neck cancer, including the choice of imaging modality, the frequency of surveillance imaging, and the role of standardized reporting through the Neck Imaging Reporting and Data System. The third issue relates to the role of imaging in the setting of neck carcinoma of unknown primary. The fourth issue relates to the role of simultaneous PET/MRI in head and neck cancer evaluation. The authors of this review provide consensus opinions for each issue.

Radiomics analysis for differentiating of cervical lymphadenopathy between cancer of unknown primary and malignant lymphoma on unenhanced computed tomography

To investigate the usefulness of texture analysis to discriminate between cervical lymph node (LN) metastasis from cancer of unknown primary (CUP) and cervical LN involvement of malignant lymphoma (ML) on unenhanced computed tomography (CT). Cervical LN metastases in 17 patients with CUP and cervical LN involvement in 17 patients with ML were assessed by ¹⁸F-FDG PET/CT. The texture features were obtained in the total cross-sectional area (CSA) of the targeted LN, following the contour of the largest cervical LN on unenhanced CT. Values for the max standardized uptake value (SUVmax) and the mean SUV value (SUVmean), and 34 texture features were compared using a Mann-Whitney U test. The diagnostic accuracy and area under the curve (AUC) of the combination of the texture features were evaluated by support vector machine (SVM) with nested cross-validation. The SUVmax and SUVmean did not differ significantly between cervical LN metastases from CUP and cervical LN involvement from ML. However, significant differences of 9 texture features of the total CSA were observed (p = 0.001 - 0.05). The best AUC value of 0.851 for the texture feature of the total CSA were obtained from the correlation in the gray-level co-occurrence matrix features. SVM had the best AUC and diagnostic accuracy of 0.930 and 84.8%. Radiomics analysis appears to be useful for differentiating cervical LN metastasis from CUP and cervical LN involvement of ML on unenhanced CT.

Update from the 5th Edition of the World Health Organization Classification of Head and Neck Tumors: The Neck and Lymph Nodes, Metastasis, and Melanocytic Tumors

The changes made in the fifth edition of the WHO Classification of Head and Neck Tumors demonstrate the recent diagnostic, histopathological, and molecular advances in the field, and this updated information will hopefully lead to improved and standardized tumor subtyping. This review summarizes the changes related tumors and tumor-like lesions of the neck and lymph nodes (Chapter 11), metastasis to the head and neck region (Chapter 15), and melanocytic tumors (Chapter 10).

Therapeutic efficacy of selective intra-arterial chemoradiotherapy with docetaxel and nedaplatin for fixed bulky nodal disease in head and neck cancer of unknown primary

PURPOSE

Fixed bulky nodal disease in patients with head and neck cancer of unknown primary (HNCUP) remains difficult to treat. This retrospective study evaluated the therapeutic efficacy of selective intra-arterial chemoradiotherapy with docetaxel and nedaplatin for fixed bulky nodal disease in HNCUP.

METHODS

Data from seven consecutive patients with fixed bulky nodal disease in HNCUP who had undergone selective intra-arterial chemoradiotherapy were analyzed. Whole pharyngeal mucosa and all bilateral nodal areas were irradiated (total dose 50 Gy), and bulky nodal lesions were provided an additional 20 Gy. Intra-arterial chemotherapy used a combination of nedaplatin (80 mg/m²) and docetaxel (60 mg/m²). Outcome measures were local control, disease-free survival, overall survival, and adverse events. Statistical analyses were performed using the Kaplan-Meier method.

RESULTS

Median follow-up period was 24 months (range 9-64). All patients had extracapsular extension (N3b) on imaging and clinical findings. Symptoms due to bulky disease were neck discomfort (100%), tumor bleeding (43%), tracheal obstruction (14%), and carotid sinus syndrome (28%). Median value for maximum diameter of cervical disease was 84 mm (range 70-107), and 3-year local control, disease-free survival, and overall survival rates were 100, 54, and 64%, respectively. Symptoms due to bulky disease disappeared in all patients after intra-arterial chemoradiotherapy. Grade 4 leukopenia occurred in two patients (28%) as an acute adverse event. No other serious acute adverse events were observed.

CONCLUSION

Selective intra-arterial chemoradiotherapy with docetaxel and nedaplatin can potentially achieve both favorable local control and survival in in HNCUP with fixed bulky nodal disease.

Comparison of PET-CT, CT and MRI scan in initial staging and management of head and neck cancers

BACKGROUND

To evaluate the utility of positron-emission tomography (FDG PET) in initial staging and management of head and neck cancers.

METHODS

This is a retrospective study of 99 treatment naïve head and neck cancer patients treated between January 2017 and December 2020 at a tertiary teaching centre. Change in initial staging and management was noted based on PET scan compared to cross-sectional imaging (CT and MRI).

RESULTS

There were 73 (73.7%) males and 26 (26.2%) females with male-to-female ratio of 2.8:1.Overall, change in management was seen in 36/99 (36.4%) patients due to PET scan. With regards to initial staging, T, N and M stage was changed in 14/99 (14.1%), 19/99 (19.1%) and 3/99 (3%) patients, respectively. These changes were significantly higher in patients with unknown primary (63.3%, p value -0.001) and N3 (41%, p -0.045) nodal disease.

CONCLUSION

PET-CT plays an important role in appropriate initial staging and subsequent treatment planning of head and neck cancers.

ADVANCES IN KNOWLEDGE

Initial staging PETCT changes management in 36.4% cases. Accuracy of various different imaging modalities have been compared.

Cancer of the Oropharynx and the Association with Human Papillomavirus

Squamous cell carcinoma of the oropharynx (OPC) consists of human papillomavirus (HPV)-negative disease caused by tobacco and alcohol use, and HPV-positive disease caused by the sexually transmitted infection HPV. These entities have unique but overlapping risk factors, epidemiologic trends, staging systems, and survival outcomes. HPV-positive tumor status confers a significant survival benefit compared with HPV-negative disease. OPC treatment entails a combination of surgery, radiation, and chemotherapy. Ongoing trials will determine whether treatment of HPV-related disease may be safely deintensified to decrease morbidity. Emerging HPV-related biomarkers are under study as tools to inform screening, diagnosis, treatment, and surveillance for HPV-positive OPC.

Metastatic Squamous Cell Carcinoma to the Cervical Lymph Nodes From an Unknown Primary Cancer: Management in the HPV Era

Background

Patients with metastases in the lymph nodes of the neck and no obvious primary tumor, neck cancer with unknown primary (NCUP), represent a management challenge. A majority of patients have metastatic squamous cell carcinoma (SCC), although other histologies do occur.

Methods

We comprehensively reviewed the literature, compared available guidelines, and conferred with an international team of experts.

Results

Positron emission tomography-computed tomography (PET-CT) and fine needle aspiration (FNA) under ultrasound guidance increase accuracy of diagnosis. Immunohistochemistry (IHC), determination of human papilloma virus (HPV) status, by p16 staining or by in situ hybridization (ISH), and next-generation gene sequencing can guide us regarding probable primary sites and tumor biology. Narrow Band Imaging (NBI) has been introduced for the early detection of subtle mucosal lesions. Direct laryngoscopy (DL) and tonsillectomy have long been procedures used in the search for a primary site. More recently, TransOral Robotic Surgery (TORS) or Transoral LASER Microsurgery (TLM) have been introduced for lingual tonsillectomy.

Conclusions

New technologies have been developed which can better detect, diagnose, and treat occult primary tumors. Decisions regarding therapy are based on the primary tumor site (if discovered) and N stage. Options include neck dissection with or without postoperative adjuvant therapy, primary irradiation, or combined chemotherapy with irradiation. The preferred treatment of patients whose primary remains unidentified is controversial.

Diagnosis and Management of Squamous Cell Carcinoma of Unknown Primary in the Head and Neck: ASCO Guideline

PURPOSE

To provide evidence-based recommendations to practicing physicians and other health care providers on the diagnosis and management of squamous cell carcinoma of unknown primary in the head and neck (SCCUP).

METHODS

The American Society of Clinical Oncology convened an Expert Panel of medical oncology, surgery, radiation oncology, radiology, pathology, and advocacy experts to conduct a literature search, which included systematic reviews, meta-analyses, randomized controlled trials, and prospective and retrospective comparative observational studies published from 2008 through 2019. Outcomes of interest included survival, local and regional disease control, and quality of life. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations.

RESULTS

The literature search identified 100 relevant studies to inform the evidence base for this guideline. Four main clinical questions were addressed, which included subquestions on preoperative evaluations, surgical diagnostic and therapeutic procedures, appropriate pathology techniques, and adjuvant therapy.

RECOMMENDATIONS

Evidence-based recommendations were developed to address preoperative evaluation for patients with a neck mass, surgical diagnostic and therapeutic procedures, appropriate treatment options in unilateral versus bilateral SCCUP.Additional information is available at www.asco.org/head-neck-cancer-guidelines.

Predictors of survival and recurrence after primary surgery for cervical metastasis of unknown primary

PURPOSE

Cervical metastasis from unknown primary (CUP) is commonly classified as an advanced overall stage. P16 or human papillomavirus (HPV) positivity in metastatic lymph nodes (LN) might be associated with a favorable survival outcome of CUP. Therefore, we evaluated the prognostic values of p16 immuno-positivity in LN and other clinicopathological factors in patients with squamous cell carcinoma CUP (SCCUP).

METHODS

This study involved 83 patients who underwent therapeutic neck dissection and panendoscopic examination and biopsy for suspected CUP. P16 immunostaining and HPV typing in LN were performed in 56 patients. Cox proportional hazard regression analyses were used to identify factors associated with overall survival (OS) and disease-free survival (DFS).

RESULTS

Postoperatively, primary tumors (PT) were found in 32 (38.6%) patients, mainly (90.6%) in the oropharynx, and not found in 51 (61.4%) patients. The clinicopathological data (except for histological grade) and 5-year OS and DFS rates did not significantly differ between patients with and without PT identification (all P > 0.05). P16 positivity was associated with favorable OS and DFS outcomes in the patients with PT (P < 0.05) but not in those without PT (P > 0.1). Multivariate analyses showed that age (> 60 years) and LN ratio (≥ 0.1) were the independent predictors of OS and DFS outcomes (all P < 0.05). P16 positivity or other factors were not independent factors.

CONCLUSION

Age and LN ratio are significant risk factors of survival and recurrence after primary surgery for SCCUP. Prognostic significance of LN p16 positivity should be further studied.

A Review of Controversial Issues in the Management of Head and Neck Cancer: A Swiss Multidisciplinary and Multi-Institutional Patterns of Care Study-Part 2 (Radiation Oncology)

Background: The Head and Neck Cancer Working Group of Swiss Group for Clinical Cancer Research (SAKK) has investigated the level of consensus (LOC) and discrepancy in everyday practice of diagnosis and treatment in head and neck cancer.

Materials and Methods: An online survey was iteratively generated with 10 Swiss university and teaching hospitals. LOC below 50% was defined as no agreement, while higher LOC were arbitrarily categorized as low (51–74%), moderate (75–84%), and high (≥85%).

Results: Any LOC was achieved in 62% of topics (n = 60). High, moderate, and low LOC were found in 18, 20, and 23%, respectively. Regarding Head and Neck Surgery, Radiation Oncology, Medical Oncology, and biomarkers, LOC was achieved in 50, 57, 83, and 43%, respectively.

Conclusions: Consensus on clinical topics is rather low for surgeons and radiation oncologists. The questions discussed might highlight discrepancies, stimulate standardization of practice, and prioritize topics for future clinical research.

Inter-observer variability of clinical target volume delineation in definitive radiotherapy of neck lymph node metastases from unknown primary. A cooperative study of the Italian Association of Radiotherapy and Clinical Oncology (AIRO) Head and Neck Group

BACKGROUND

This study, promoted by Italian Association of Radiotherapy and Clinical Oncology (AIRO) Head and Neck Group, aimed to assess the current national practice of target volume delineation on a case of neck lymph node metastases from unknown primary evaluating inter-observer variability, in a setting of primary radiotherapy.

MATERIALS AND METHODS

A case of metastatic neck lymph node from occult primary was proposed to 17 radiation oncologists. A national reference RT center was identified and considered as benchmark. Participants were requested to delineate target volumes. A structured questionnaire was administered. A comparison between following parameters of the CTVs was performed: centroids distances, Dice similarity index (DSI), Jaccard index and mean distance to agreement (MDA). Volume expressed in cubic centimeters and CTVs cranio-caudal extension were evaluated.

RESULTS

Sixteen of 17 radiation oncologists recommended three CTVs dose levels. (CTV HD, CTV ID and CTV LD); CTV ID was not delineated by one of the participants and by the reference center. The distance between the reference centroid and the mean centroid of CTVs HD was 1.09 cm (0.36-3.99 cm); for CTV LD, a mean centroids distance of 2.45 (0.27-4.83 cm) was found, and for CTV HD, mean DSI is 0.48 and mean Jaccard index is 0.32 and MDA was 8.89 mm. CTV LD showed a mean DSI of 0.46, mean Jaccard index of 0.31 and MDA of 14.87 when compared to the reference.

CONCLUSION

Many aspects concerning treatment optimization of cervical nodes metastases from occult primary remain unclear, and we found a notable heterogeneity of global radiotherapy management reporting discordances both in target volume delineation and volume prescription.

Ultrasonography of Cervical Lymph Nodes

Ultrasonography is an excellent method for imaging evaluation of cervical lymph nodes. This article provides an image-rich review of the sonographic manifestations of diseases involving the cervical lymph nodes, with an emphasis on the expected anatomic distribution of diseases.

Reviewing indications for panendoscopy in the investigation of head and neck squamous cell carcinoma

BACKGROUND

The role of panendoscopy in the modern investigation of head and neck cancer is changing with the development of improved radiological techniques, in-office biopsy capabilities and the low rate of synchronous primary tumours. This study aimed to review the indications for panendoscopy in the investigation of newly diagnosed head and neck cancer.

METHOD

A retrospective review was conducted of 186 patients with newly diagnosed head and neck cancer, between January 2014 and December 2015, at two tertiary centres.

RESULTS

Obtaining a tissue diagnosis was the most common indication for panendoscopy (65 per cent), followed by surgical planning including transoral robotic surgery suitability assessment (22.6 per cent), and the investigation of carcinoma of an unknown primary (11.3 per cent). Two synchronous primary tumours were identified, generating a yield of 1.1 per cent.

CONCLUSION

Panendoscopy remains integral in the assessment of transoral robotic surgery suitability. Refining indications for modern panendoscopy could reduce the need for this procedure in this cohort of patients.

Unknown primary squamous cell carcinoma of the head and neck: retrospective analysis of 80 cases

OBJECTIVES

The management of patients with cervical metastasis in head and neck cancer of unknown primary (HNCUP) remains controversial. This current multicenter retrospective study investigated the treatment outcomes of patients with HNCUP.

METHODS

The study included patients who were treated curatively at 12 institutions in Japan from January 2006 to December 2015.

RESULTS

Eighty patients with HNCUP were included. The median follow-up period was 34 months. The three-year overall survival (OS), disease-specific survival (DSS), regional relapse-free survival (RRFS), local progression-free survival (LPFS), and distant metastasis-free survival (DMFS) rates were 72.5%, 80.3%, 74.0%, 89.7%, and 86.9%, respectively. Nodal status was a significant factor for OS, DSS, RRFS, and DMFS; and extracapsular extension (ECE) was significant for OS and DSS. There was a distinct difference between the survival rates of patients with N1-2a and N2b-3 disease. RT was a significant positive factor for LPFS (3-year LPFS, RT 93.0% vs. no RT 83.0%, p = .043).

CONCLUSIONS

For N2a as well as N1 disease without ECE, a single treatment modality, including ND or RT alone is acceptable. When ND alone is performed, thorough monitoring should be continued during follow-up to identify the emergence of the primary lesion.

Unilateral radiotherapy treatment for p16/human papillomavirus-positive squamous cell carcinoma of unknown primary in the head and neck

OBJECTIVES/HYPOTHESIS

The outcomes of unilateral radiotherapy treatment for patients with p16/HPV-positive squamous cell carcinomas of unknown primary (SCCUP) affecting cervical lymph nodes are under-reported. Compared to radiating large volumes of the pharyngeal axis (the more common approach), this is potentially a much less toxic treatment for a good prognosis group.

STUDY DESIGN

Retrospective cohort study.

METHODS

We identified patients with SCCUP who were treated radically at our center and did not have parotid or isolated level IV or V nodal involvement. Failure-free and overall survivals were calculated using Kaplan-Meier methods.

RESULTS

From 2004 to 2012, there were 49 radically treated patients with SCCUP. Fourteen patients had bilateral neck treatment (they had bilateral nodal disease or suspected lesions in the base of tongue, though not proven with biopsy), two had surgery alone, whereas 33 had unilateral radiotherapy (after neck dissection, excisional biopsy, or definitively with concurrent chemotherapy). Of the 33 patients, 21 tested positive to p16/HPV and had median follow-up of 57 months. In this group, no isolated contralateral neck failures or putative primaries emerged. There was 1/21 (4.3%) ipsilateral neck failure, 1/21 (4.3%) concurrent contralateral neck and distant failure, and 1/21 (4.3%) patient with distant failure. The 5-year freedom from failure was 78% (95% confidence interval [CI]: 56%-100%) and overall survival was 90% (95% CI: 79%-100%).

CONCLUSIONS

With no emergence of putative primaries and no isolated contralateral neck failures, this single-institution experience in p16/HPV-positive SCCUP patients suggests that unilateral radiotherapy may be an underutilized management strategy.

LEVELS OF EVIDENCE

4 Laryngoscope, 128:2076-2083, 2018.

Squamous Cell Carcinoma Metastatic to Cervical Lymph Nodes from an Unknown Primary Site: The Impact of Radiotherapy

Aims and background

Cervical lymph node metastases of squamous cell carcinoma from an unknown primary site constitute about 5% of the total head and neck cancer cases. The management of these patients is still a therapeutic challenge. The aim of the present study was to analyze the prognosis in a series of patients and, in particular, the impact of different radiotherapy techniques on the prognosis.

Methods and study design

Data from 60 patients with cervical lymph node metastases of squamous cell carcinoma from an unknown primary site were reviewed. Nine of 60 patients (15.0%) received excisional biopsy. Radiotherapy was delivered to the bilateral neck and pharyngeal mucosa (extensive field) in 11 patients (18.3%), to the bilateral neck in 24 patients (40.0%), and to the ipsilateral neck in 25 patients (41.7%). Fourteen patients (23.3%) also received chemotherapy.

Results

The 5-year overall survival rate of all patients was 68.5%. The overall survival of patients with N1, N2, and N3 stage was 100%, 68.0%, and 40.9%, respectively (P = 0.026). The overall survial of patients irradiated by ipsilateral neck, bilateral neck, and extensive field was 66.5%, 74.5%, and 54.6%, respectively (P = 0.5). At multivariate analysis, only N stage significantly affected overall survival (P = 0.032). The 5-year neck control rate of all patients was 65.6%. The neck control rate of patients with N1, N2, and N3 stage was 100%, 63.2%, and 34.6%, respectively (P = 0.064). The neck control rate of patients irradiated by ipsilateral neck, bilateral neck, and extensive field was 87.6%, 51.1%, and 72.7%, respectively (P = 0.279). Emergence of the occult primary was observed in 21.2% patients, and all of these occurred within the head and neck region. The primary tumor emerged in 23.3% of patients treated with ipsilateral and bilateral neck irradiation and in 12.5% of patients irradiated by extensive field (P = 0.469).

Conclusions

Patients with cervical lymph node metastases of squamous cell carcinoma from an unknown primary site have clinical features and a prognosis similar to those of other head and neck malignancies. Extensive irradiation results in a lower trend of emergence of the primary tumor than when patients are treated with ipsilateral and bilateral irradiation, but there is no significant difference in overall survival.

[Advances in the management of cervical lymphadenopathies of unknown primary: advances in diagnostic imaging and surgical modalities and new international staging system]

INTRODUCTION

Cervical lymphadenopathies of unknown primary represent 3 % of head and neck cancers. Their diagnostic work up has largely changed in recent years. This review provides an update on diagnostic developments and their potential therapeutic impact.

MATERIALS AND METHODS

This is a systematic review of the literature.

RESULTS

In recent years, changes in epidemiology-based prognostic factors such as human papilloma virus (HPV) cancers, advances in imaging and minimally invasive surgery have been integrated in the management of cervical lymphadenopathies of unknown primary. In particular, systematic use of PET scanner and increasing practice of robotic or laser surgery have contributed to increasing detection rate of primary cancers. These allow more adapted and personalized treatments. The impact of changes in the eighth TNM staging system is discussed.

CONCLUSION

The management of cervical lymphadenopathies of unknown primary cancer has changed significantly in the last 10 years. On the other hand, practice changes will have to be assessed.

Head and neck squamous cell carcinoma of unknown primary: Outcomes of a pre-defined institutional treatment policy in a region with a high prevalence of skin cancer

OBJECTIVES

To determine the rate of subsequent primary site failure in patients with head and neck squamous cell carcinoma of unknown primary (UKP HNSCC) in a region with a high prevalence of cutaneous squamous cell carcinoma, according to a pre-determined institutional policy. Secondary aims included regional and distant control, and overall survival.

MATERIAL AND METHODS

Patients presenting between April 2005 and June 2016 to the Princess Alexandra Hospital Head and Neck Multidisciplinary Meeting with UKP HNSCC from either presumed mucosal or cutaneous sites treated with curative intent were eligible. Patients with presumed mucosal origin were treated with radiation therapy (RT) with or without chemotherapy, while patients with presumed cutaneous SCC were treated with surgery and post-operative RT with or without chemotherapy.

RESULTS

A total of 63 patients met the inclusion criteria. Median follow up duration was 3.9 years (IQR 2.07-5.14). There were no subsequent primary site failures. The rate of nodal failure among presumed mucosal patients was 11.5%, and 8.1% among presumed cutaneous patients. The rate of distant metastatic failure was 11.1% among all patients. The estimated 5 year overall survival was 71.2% (95% CI 59.2-85.7%).

CONCLUSION

Treatment according to our pre-defined institutional policy for UKP HNSCC in a region with a high prevalence of cutaneous SCC appears to be safe and effective with low rates of mucosal primary emergence and nodal failure.

Hybrid imaging for detection of carcinoma of unknown primary: A preliminary comparison trial of whole-body PET/MRI versus PET/CT

PURPOSE

The aim of this study is to evaluate and compare the diagnostic potential of integrated whole-body [18F]FDG-PET/MRI to [18F]FDG-PET/CT for detection of a potential primary cancer and metastases in patients suspected for cancer of unknown primary (CUP).

METHODS

A total of 20 patients (15 male, 5 female, age 53±13 years) suspect for CUP underwent a dedicated head and neck & whole-body [18F]FDG-PET/CT (Biograph mCT 128, Siemens Healthcare) and a subsequent simultaneous [18F]FDG-PET/MRI examination (Biograph mMR, Siemens Healthcare). Two readers rated the datasets (PET/CT; PET/MRI) regarding the detection of the primary cancer and metastases, lesion conspicuity (4-point ordinal scale) and diagnostic confidence (3-point ordinal scale). PET analysis comprised the assessment of maximum standardized uptake values (SUVmax) of all PET-positive lesions using volume of interest (VOI) analysis derived from the PET/CT and PET/MR datasets. All available data considering histology and imaging including prior and clinical follow-up examinations served as reference standard. Statistical analysis included comparison of mean values using Mann-Whitney U test and correlation of SUVmax using Pearson's correlation.

RESULTS

In 14 out of 20 patients 49 malignant lesions were present. The primary cancer could be correctly identified in 11/20 patients with both PET/CT and PET/MRI. PET/CT enabled the detection of a total 38 metastases, PET/MR respectively of 37 metastases (one lung metastasis <5mm was missed). PET/CT and PET/MRI showed comparably high lesion conspicuity (2.6±0.6 each), with superior assessment of cervical lesions in PET/MRI and an indicated superior assessment of pulmonary lesions in PET/CT. Diagnostic confidence was rated comparably high in PET/CT and PET/MRI (2.7±0.5 each). The mean values of SUVmax of all PET-positive lesions (PET/MRT 7.9±4.2 vs. PET/CT 7.2±3.5) showed a strong positive correlation between the SUVs derived from both hybrid imaging systems (Pearson's correlation r=0.927).

CONCLUSIONS

Both hybrid imaging techniques provide a comparable diagnostic ability for detection of primary cancer and metastases in patients with CUP, with comparably high lesion conspicuity and diagnostic confidence, offering superior assessment of cervical lesions in PET/MRI and potentially of pulmonary lesions in PET/CT. Furthermore, due to the significantly lower dose of ionizing radiation, PET/MRI may serve as a powerful alternative to PET/CT, particularly for therapy monitoring and/or surveillance considering the long-term cumulative dose.

Positron-emission tomography/computed tomography imaging in head and neck oncology: An update

Cancers of the head and neck account for more than half a million cases worldwide annually, with a significant majority diagnosed as squamous cell carcinoma (HNSCC). Imaging studies such as contrast-enhanced computed tomography (CT), magnetic resonance imaging (MRI) and ¹⁸F-2-fluoro-2-deoxy-D-glucose positron-emission tomography/computed tomography (¹⁸F-FDG PET/CT) are widely used to determine the presence and extent of tumors and metastatic disease, both before and after treatment. Advances in PET/CT imaging have allowed it to emerge as a superior imaging modality compared to both CT and MRI, especially in detection of carcinoma of unknown primary, cervical lymph node metastasis, distant metastasis, residual/recurrent cancer and second primary tumors, often leading to alteration in management. PET/CT biomarker may further provide an overall assessment of tumor aggressiveness with prognostic implications. As new developments emerged leading to better understanding and use of PET/CT in head and neck oncology, the aim of this article is to review the roles of PET/CT in both pre- and post-treatment management of HNSCC and PET-derived parameters as prognostic indicators.

Bronchogenic cancer: It still exists

OBJECTIVES/HYPOTHESIS

Branchial cleft cysts rank among the most common differential diagnoses of cystic cervical masses. Rarely, classic cystic structures exhibit a squamous cell carcinoma differentiation that represents a bronchogenic carcinoma. The existence of bronchogenic carcinoma is controversial due to the lack of systematic immunohistologic workup. The present study aimed to identify the clinical and immunohistologic features of bronchogenic carcinoma to clearly distinguish this entity from other cystic cervical masses.

METHODS

Immunohistologic (epidermal growth factor receptor; cytokeratin 5, 6, 7, 13; and p16) and epidemiologic assessments were performed for branchial cleft cysts (n = 63), bronchogenic carcinomas (n = 5), cystic metastasized oropharyngeal carcinomas (n = 97), and carcinomas of unknown primary (n = 51). The study was conducted as a retrospective case series study with comparison.

RESULTS

The patients with bronchogenic carcinomas differed significantly in age and in the number of involved lymph nodes compared with the cystic metastasized oropharyngeal carcinoma (and carcinoma of unknown primary) patients. Regular histologic wall structures were only observed in the bronchogenic carcinomas and branchial cleft cysts. Solitary cytokeratin-7 staining was only observed in the bronchogenic carcinomas, and all of the bronchogenic carcinomas were p16 negative.

CONCLUSIONS

The existence of bronchogenic carcinoma seems to be plausible based on clinical findings. Cytokeratin-7 and p16 staining might be helpful in the diagnostic workflow.

LEVEL OF EVIDENCE

4 Laryngoscope, 126:638-642, 2016.

Carcinoma of unknown primary in the head and neck: The evaluation of the effectiveness of (18)F-FDG-PET/CT, own experience

AIM

The aim of the present study was to estimate the clinical effectiveness of (18)F-FDG-PET/CT in the detection of the primary tumor in patients with histologically proven squamous cell carcinoma cervical lymph nodes metastasis from an unknown primary.

BACKGROUND

(18)F-fluorodeoxyglucose positron emission tomography combined with CT ((18)F-FDG-PET/CT) is believed to be very helpful in localization of primary tumor in CUP Syndrome patients.

MATERIAL AND METHOD

41 patients referred to Poznan Medical University Department of Head and Neck Surgery from January 2010 to December 2013 with CUP Syndrome were included in the study. All patients presented fine-needle biopsy proven squamous cell carcinoma metastasis of the upper-, or mid neck lymph nodes. The final results were obtained from the histopathologic reports of tissue samples from anatomical regions suspected for primary tumor, additional imaging exams as well as clinical follow-up data.

RESULTS

The (18)F-FDG-PET/CT successfully detected primary tumor in 7 out of 41 patients (17%). In two more cases the primary tumor was indicated in the lung. 24 of 41 patients (58.5%) analyzed in our study remained without evidence of a primary tumor. In 4 cases (9.75%) we did not reveal any pathology within the localizations indicated by PET/CT on panendoscopy. In 4 cases we obtained histological confirmation of neoplasm on panendoscopy despite the negative results of PET/CT examinations.

CONCLUSION

We may suppose a relatively high usefulness of (18)F-FDG-PET/CT in the diagnosis process of CUP Syndrome patients. High NPV may indicate patients with no symptoms of primary tumor, which allows to avoid extensive resection or extra imaging.

Cervical lymphadenopathy: study of 251 patients

Correct diagnosis of cervical lymphadenopathy is often a great challenge. The objective of this case study is to describe the distribution of the most common causes of unclear neck swellings presented in an ENT-Department and to evaluate the clinical history, examination and laboratory findings. In a retrospective study at the Department of Otorhinolaryngology, University Medical Center Homburg/Saar, 251 patients were enrolled with clinical and ultrasound signs of cervical lymphadenopathy as well as lymph node extirpation for histopathological evaluation. 127 patients (50.6 %) had a histological malignant finding. The distribution of the most common pathological conditions was as follows: Non-specific reactive hyperplasia n = 89 (35.5 %), metastases n = 86 (34.3 %), lymphoma n = 41 (16.3 %), granulomatous lesions n = 15 (6 %), abscess formations n = 5 (2 %), necrotic lymphadenitis and Castleman's disease one case of each, lymph node with normal architecture n = 7 (2.8 %), and neck masses mimicking lymphadenopathy n = 6 cases (2.4 %). The following factors identified by multivariate logistic regression were significantly associated to malignant lymphadenopathy: increasing age, generalized lymphadenopathy and history of malignant disorder, fixed neck masses and increasing diameter in ENT examination, bulky lesion, absence of hilus, blurred outer contour, protective role of the long form and decreasing Solbiati-index values by ultrasound B-Mode gray scale examination. Level II contained more benign lymphatic lesions, while the malignancy rate in level IV and V was enhanced. Laboratory parameters significantly associated to malignancies were CRP, LDH and thrombocytopenia. Patients with persisting cervical lymphadenopathy and over 3 weeks of antibiotic treatment should be considered for early biopsy, especially if some of the risk factors, pointed out in this study, are present.

[Lymph node metastases from squamous cell carcinoma of unknown primary site. Is it time to change of paradigm?]

The diagnosis of carcinoma of unknown primary (CUP) is made after exclusion of the presence of a mucosal primary. There are two mains options for the primary treatment of CUP, either a neck node dissection followed by postoperative radiotherapy or chemo-radiotherapy, or a primary radiotherapy or chemo-radiotherapy depending on the nodal stage followed in case of residual neck disease by a selective neck dissection. There is no data to suggest the superiority of one over the other. For radiotherapy, unilateral neck or bilateral neck, including the upper aerodigestive tract mucosa are possible options. There is no definite data to demonstrate the superiority of one over the other, but owing the reduced toxicity of unilateral irradiation, and the possibility of salvage treatment in case of emergence of a mucosal primary and/or a contralateral neck node development, the former may be the preferred option. Advances in radiotherapy such as intensity modulated radiation therapy have the potential to spare organs at risk and reduce late toxicity rates. A selective irradiation approach customized on "major" criteria, such as nodal stage and level, HPV and EBV status and accessory criteria, such as histological variants, is under investigation.

Head and neck squamous cell carcinoma of unknown primary: neck dissection and radiotherapy or definitive radiotherapy

BACKGROUND

Management of head and neck carcinoma from unknown primary (HNCUP) remains controversial, with neck dissection and radiotherapy (RT) or definitive RT both commonly used. The purpose of this study was to characterize HNCUP and retrospectively compare outcomes for patients treated with neck dissection + RT versus definitive RT.

METHODS

From 1994 to 2009, 41 patients with HNCUP underwent either neck dissection + RT (n = 22) or definitive RT ± concurrent chemotherapy (n = 19) at our institution. Treatment outcomes were compared using Kaplan-Meier methods and log-rank test.

RESULTS

There were no differences between patients treated with neck dissection + RT and definitive RT in overall survival (OS), progression-free survival (PFS), locoregional relapse-free survival (LRFS), freedom from locoregional failure (FFLRG), or freedom from distant failure (FFDF). Among 17 patients who underwent neck dissection + RT for whom human papillomavirus (HPV) status could be determined, HPV(+) patients trended toward improved OS (p = .06) and PFS (p = .15).

CONCLUSION

Neck dissection and postoperative RT resulted in similar outcomes as definitive RT. The prognostic implications of HPV(+) nodes in HNCUP are similar to those in oropharyngeal primary cancers.

CUP-syndrome diagnostic procedure scheme

Patients with CUP-Syndrome represent a small percentage of patients treated by ENT doctor. Often, in spite of the implementation detailed diagnostics, detection of the primary tumor fails. Very important element is to follow the correct sequence of tests and taking into account conditions outside ENT. I our article, we would like to propose a diagnostic scheme including interview with patient, laryngological and imaging tests and multi-disciplinary consulting. We hope that this scheme will facilitate the treatment of patients with CUP-Syndrome and increase the efficiency of detection of primary tumor.

[Usefulness of (18)F-fluorodeoxyglucose-positron emission tomography-computerized tomography in the identification of the primary tumor in patients with cancer of unknown origin]

BACKGROUND AND OBJECTIVE

We determined the utility of the (18)F-fluorodeoxyglucose ((18)F-FDG) positron emission tomography (PET)-computerized tomography (CT) in the localization of the primary tumor in patients with tumor of unknown origin (TUO).

PATIENTS AND METHOD

(18)F-FDG PET-CT scans, performed between November 2006 and November 2010, in search for the primary tumor in patients with TUO, were retrospectively evaluated. Patients underwent a standard PET-CT, 50-60minutes after intravenous injection of 296-370MBq (18)F-FDG. PET-CT studies were assessed as pathological, with/without identification of the primary tumour and no pathological. Final diagnosis was established by histological confirmation and/or clinical/radiologic follow-up longer than 6 months.

RESULTS

We studied 74 patients (59 males, 15 females), with ages ranging from 41-89 years. In 38 (51%) patients the PET-CT assessed the correct origin of the primary tumour. In 8 cases, a histological confirmation in the primary lesion was obtained. In 4 patients the PET-CT showed a false positive result.

CONCLUSION

PET-CT scanning identified 51% of the primary sites in our sample of patients.

Contemporary management of lymph node metastases from an unknown primary to the neck: I. A review of diagnostic approaches

In an era of advanced diagnostics, metastasis to cervical lymph nodes from an occult primary tumor is a rare clinical entity and accounts for approximately 3% of head and neck malignancies. Histologically, two thirds of cases are squamous cell carcinomas (SCCs), with other tissue types less common in the neck. With modern imaging and tissue examinations, a primary tumor initially undetected on physical examination is revealed in >50% of patients and the site of the index primary can be predicted with a high level of probability. In the present review, the range and limitations of diagnostic procedures are summarized and the optimal diagnostic workup is proposed. Initial preferred diagnostic procedures are a fine-needle aspiration biopsy (FNAB) and imaging. This allows directed surgical biopsy (such as tonsillectomy), based on the preliminary findings, and prevents misinterpretation of postsurgical images. When no primary lesion is suggested after imaging and panendoscopy, and for patients without a history of smoking and alcohol abuse, molecular profiling of an FNAB sample for human papillomavirus (HPV) and/or Epstein-Barr virus (EBV) is important.

Liver Function Tests

Objective. Report the prevalence and risk factors of liver metastasis in head and neck squamous cell carcinoma (HNSCC) while evaluating the utility of liver function tests (LFTs) in detection of such metastases.

Study Design. Case series with chart review.

Setting. Tertiary referral center.

Subjects and Methods. Of 745 patients with newly diagnosed HNSCC (oral cavity, oropharynx, hypopharynx, larynx) treated at University of North Carolina hospitals from 1989 to 2005, 655 had sufficient data for analysis.

Results. Prevalence of liver metastasis was 3% (20/655) with 7 patients demonstrating early metastasis and 12 with late metastasis. Oropharyngeal and hypopharyngeal lesions constituted 65% of identified liver metastasis but only 39% of the study population. Patients with oropharyngeal lesions were most likely to develop liver metastasis ( P = .047). Abnormal LFTs were seen in 26% of all patients. Overall sensitivity and specificity were 45% and 75%. Seventy-five percent of patients with liver metastasis had stage IV disease at diagnosis and were more likely to have abnormal LFTs than other stages ( P = .048). In these patients, 2.2% (8/365) had liver metastases and abnormal LFTs, whereas 1.9% (7/365) had liver metastases and normal LFTs. Sensitivity for alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, and lactate dehydrogenase 0%, 10%, 20%, and 30%, respectively. Specificities ranged from 88.0% to 94.3%. Positive predictive values were poor, with the highest being 10.5%.

Conclusions. Liver metastases are rare in HNSCC and often delayed in presentation. This study clearly reveals that LFTs do not reliably identify patients with liver metastasis and do not provide physicians with an adequate screening modality in this population.

Efficacy and toxicity of chemoradiotherapy using intensity-modulated radiotherapy for unknown primary of head and neck

PURPOSE

No single standard treatment paradigm is available for head-and-neck squamous cell carcinoma of an unknown primary (HNCUP). Bilateral neck radiotherapy with mucosal axis irradiation is widely used, with or without chemotherapy and/or surgical resection. Intensity-modulated radiotherapy (IMRT) is a highly conformal method for delivering radiation that is becoming the standard of care and might reduce the long-term treatment-related sequelae. We report the Dana-Farber Cancer Institute experience with IMRT-based treatment for HNCUP.

PATIENTS AND MATERIALS

A retrospective study of all patients treated at the Dana-Farber Cancer Institute for HNCUP with IMRT between August 2004 and January 2009. The primary endpoint was overall survival; the secondary endpoints were locoregional and distant control, and acute and chronic toxicity.

RESULTS

A total of 24 patients with HNCUP were included. Of these patients, 22 had Stage N2 disease or greater. All patients underwent neck computed tomography, positron emission tomography-computed tomography, and examination under anesthesia with directed biopsies. Of the 24 patients, 22 received concurrent chemotherapy, and 7 (29%) also underwent induction chemotherapy. The median involved nodal dose was 70 Gy, and the median mucosal dose was 60 Gy. With a median follow-up of 2.1 years, the 2-year actuarial overall survival and locoregional control rate was 92% and 100%, respectively. Only 25% of the patients had Grade 2 xerostomia, although 11 patients (46%) required esophageal dilation for stricture.

CONCLUSION

In a single-institution series, IMRT-based chemoradiotherapy for HNCUP was associated with superb overall survival and locoregional control. The xerostomia rates were promising, but the aggressive therapy was associated with significant rates of esophageal stenosis.