Diagnosis and treatment of metastatic cervical cancerous nodes from an unknown primary site

Abstract

A cervical node suspected of presenting as metastatic cancer from an unknown primary tumor of the head and neck regions should not be excised immediately for diagnosis. After a careful history has been taken and repeated clinical examinations carried out, the exact nature of the node may be determined in most instances by aspiration biopsy. Radiologic studies should be completed before any biopsy specimens are removed. If no primary site can be found, even after the taking of blind biopsy specimens from such areas as the nasopharynx and the base of the tongue, only then should the excision of a node be considered for establishing the diagnosis. If metastatic squamous cancer is proved, the surgeon should then be prepared, with previous consent of the patient, to proceed with radical neck dissection. Surgical treatment in the form of a radical neck dissection (bilateral if necessary) is the treatment of choice. These patients must be closely observed for as long as they survive. If a primary site has not been found within a two or three year period, it may never be discovered. Continued observation must be made, however, although less frequent intervals are permissible. From the analysis of a series of twenty patients seen at M. D. Anderson Hospital during the period from 1952 to 1962 inclusive, but not included in the same period of time and not previously reported by Jesse and Neff [12], a primary tumor site has subsequently been found in eight patients. From an additional series of ninety-four patients admitted to M. D. Anderson Hospital from 1962 to September 1971 and presenting with cervical nodes with an unknown primary lesion, another group of eight patients has been discovered in whom the primary site of tumor was later found. In the two groups of eight each, for a total of sixteen primary sites discovered subsequently, pyriform sinus predominated with four. The base of the tongue was second, the disease having occurred there in three instances. Esophagus and retromolar trigone accounted for two each. Two lesions which arose in the pancreas were discovered at autopsy. The tonsil was found as the primary site in only one instance. Lymphosarcoma was responsible for another case, but was dormant for several years. The last case was questionable since it could have been related to a lip lesion previously treated without pathologic examination. These data are incontrovertible and should preclude any decision to carry out irradiation in a patient with cervical cancerous nodes as having a probable primary site in the nasopharynx. One might argue that the eighteen patients treated by radiotherapy as having a primary lesion in the nasopharynx, without microscopic proof, may all have been treated correctly. This statement cannot be proved or disproved without positive biopsy specimens. Since, in the sixteen patients in whom the primary site was later found, there was not one lesion which proved to be from the nasopharynx, the conclusion must be that, following a proper line of investigation, the nasopharynx no longer remains the most likely site for the primary tumor and should not be treated as such. Renewed activity in the neck of those patients with a previously excised node invariably appears in that region from which the node has been excised for diagnostic purposes. This fact has been found too frequently to be ignored, and it occurs whether the patient has been treated by radiotherapy or by operation. In conclusion, three points must be re-emphasized: 1. 1. To reiterate Dr Martin's advice repeated in several published articles, do not excise a cervical node for diagnostic purposes until all other measures fail. 2. 2. Do not treat every patient with a cervical node showing metastatic cancer as having the nasopharynx as the primary site. 3. 3. The possibility of subsequent discovery of a hidden primary tumor decreases with the passing of time.