Atypical Metastasis to the Head and Neck Region: An Analysis of 11 Patients

When neck lymph nodes metastases do not origin from a head and neck unknown primary

PURPOSE OF REVIEW

The evidence for a standardized approach to the management of cervical metastasis from a distant primary tumour is limited. The objective of this review is to provide an overview of the current status of research in this field and to present the latest diagnostic and therapeutic approaches.

RECENT FINDINGS

Although infraclavicular tumours are typically observed to metastasise to levels IV and V of the neck, all levels may potentially be affected. In conjunction with imaging and immunohistochemical analyses, next-generation sequencing and artificial intelligence-based tools are emerging as potential methods for identifying the primary tumour. Cervical metastasis can be classified as N3 or M1 in accordance with the histology and site of the primary tumour. A neck dissection + adjuvant chemoradiotherapy may prove beneficial in selected patients with breast, nonsmall cell lung, renal cell, oesophageal and testicular cancers, resulting in improved survival rates.

SUMMARY

The diagnosis and subsequent treatment of such cases requires the input of a multidisciplinary team, as the condition is often complex and requires a multifaceted approach. Isolated supraclavicular metastases should prompt the clinician to investigate a distant primary. In select patients with some types of primary tumours, surgical treatment of the neck may improve the prognosis. It is, therefore, essential to control the primary tumour in order to optimize the success of the overall treatment plan.

Modern management of distant metastases from head and neck squamous cell carcinoma

PURPOSE OF REVIEW

The rate of distant metastases in patients with head and neck squamous cell carcinoma (HNSCC) ranges between 4 and 26%. Their appearance marks a critical stage in disease progression, significantly reducing survival rates. Treatment options require a multidisciplinary approach and differ based on the number and extension of distant metastases. The aim of this narrative review is to provide a comprehensive and updated overview of the current state of the art in management of such a clinical scenario.

RECENT FINDINGS

Accurate detection and staging of distant metastases are essential to determine prognosis and guide therapeutic strategies. Oligometastatic condition refers to patients with only a few distant metastases (up to 5). Surgery or stereotactic body radiotherapy are the best curative treatment options for oligometastatic. However, the majority of HNSCC has a polymetastatic disease, not amenable to curative approach. Therefore, systemic therapies, including chemotherapy (CHT) or target molecular therapy and/or best supportive care, are usually reserved to these patients. Rarely, head and neck region, in particular supraclavicular cervical lymph nodes, may be a site of distant metastases from non-head and neck cancer, particularly from the genitourinary and gastrointestinal tracts.

SUMMARY

The occurrence of distant metastases in HNSCC represents a pivotal point in the disease progression, lowering survival rates. Pattern of distant metastases has been related to survival outcomes. Patients with distant metastases from an HNSCC always require a multidisciplinary approach and an accurate selection is necessary to individualize the best treatment strategy.

Metastatic disease in head & neck oncology

The head and neck district represents one of the most frequent sites of cancer, and the percentage of metastases is very high in both loco-regional and distant areas. Prognosis refers to several factors: a) stage of disease; b) loco-regional relapses; c) distant metastasis. At diagnosis, distant metastases of head and neck cancers are present in about 10% of cases with an additional 20-30% developing metastases during the course of their disease. Diagnosis of distant metastases is associated with unfavorable prognosis, with a median survival of about 10 months. The aim of the present review is to provide an update on distant metastasis in head and neck oncology. Recent achievements in molecular profiling, interaction between neoplastic tissue and the tumor microenvironment, oligometastatic disease concepts, and the role of immunotherapy have all deeply changed the therapeutic approach and disease control. Firstly, we approach topics such as natural history, epidemiology of distant metastases and relevant pathological and radiological aspects. Focus is then placed on the most relevant clinical aspects; particular attention is reserved to tumours with distant metastasis and positive for EBV and HPV, and the oligometastatic concept. A substantial part of the review is dedicated to different therapeutic approaches. We highlight the role of immunotherapy and the potential effects of innovative technologies. Lastly, we present ethical and clinical perspectives related to frailty in oncological patients and emerging difficulties in sustainable socio-economical governance.