Treatment of Untreated Metastatic Squamous Neck Cancer With Occult Primary

Surgical biopsy or excision to establish a histological diagnosis, but only after an aerodigestive tract primary has been carefully ruled out by the following procedures:

Surgical biopsy or excision to establish a histological diagnosis, but only after an aerodigestive tract primary has been carefully ruled out by the following procedures:

Direct nasopharyngoscopy, laryngoscopy, bronchoscopy, and esophagoscopy, with biopsy of any suspicious area.

Surgical biopsy or excision to establish a histological diagnosis, but only after an aerodigestive tract primary has been carefully ruled out by the following procedures: › Direct nasopharyngoscopy, laryngoscopy, bronchoscopy, and esophagoscopy, with biopsy of any suspicious area.

If no suspicious lesions are found, random biopsies of the nasopharynx, base of tongue, tonsil, and pyriform sinus on the side of the lesion should be performed.

Surgical biopsy or excision to establish a histological diagnosis, but only after an aerodigestive tract primary has been carefully ruled out by the following procedures: › Direct nasopharyngoscopy, laryngoscopy, bronchoscopy, and esophagoscopy, with biopsy of any suspicious area.

If the tonsil is not present, biopsy of the tonsillar fossa should be performed.

Surgical biopsy or excision to establish a histological diagnosis, but only after an aerodigestive tract primary has been carefully ruled out by the following procedures: › Direct nasopharyngoscopy, laryngoscopy, bronchoscopy, and esophagoscopy, with biopsy of any suspicious area.

Sinus x-rays are probably indicated; if an abnormality is found, it should be biopsied as well.

Selected other studies if indicated. Magnetic resonance imaging offers an advantage over computed tomography scans to detect head and neck tumors and to distinguish lymph nodes from blood vessels. It should be considered in the initial evaluation of the patient with metastatic squamous cell cancer in cervical lymph nodes.[1] Positron emission tomography may help determine the primary site.[2]Patients should undergo a full course of radiation therapy or adequate neck dissection, when possible. In cases of fixed massive homolateral adenopathy or bilateral nodes, radiation therapy should be administered first. The radiation fields should also include the nasopharynx, base of tongue, and pyriform sinuses. If radiation therapy is the primary mode of treatment and the neck mass persists upon completion of radiation therapy, cervical lymph node dissection should be performed. Patients with metastatic carcinoma in the supraclavicular region are best managed with a full course of radiation therapy, followed by surgical dissection if palpable tumor persists. Careful continued follow-up of these patients is of utmost importance. Depending on the likely site of origin and histology, chemotherapy appropriate to the most treatable site may be indicated. Accumulating evidence has demonstrated a high incidence (>30%–40%) of hypothyroidism in patients who receive external-beam radiation therapy to the entire thyroid gland or the pituitary gland. Thyroid function testing of patients should be considered before therapy and as part of posttreatment follow-up.[3,4]

Radical neck dissection.

Radiation therapy.[5,6] Intensity-modulated radiation therapy may have less short- and long-term toxicity than conventional radiation therapy in terms of xerostomia, acute dysphagia, and skin fibrosis.[7,8]

Combined surgery and radiation therapy.[9]

Chemotherapy followed by radiation therapy (under clinical evaluation).[10]

Simultaneous chemotherapy and hyperfractionated radiation therapy (under clinical evaluation).[11]

Clinical trials for advanced tumors should be considered.