Diagnostic strategies in cervical carcinoma of an unknown primary (CUP).

Abstract

In patients with cervical cancer of an unknown primary (CUP), no established concept exists for the necessary diagnostic procedures. In order to find the primary tumor, extensive diagnostic steps are generally recommended; however, they are often not performed consistently. In the current study, we consistently used a diagnostic algorithm and analyzed its consequences on patients' prognoses. We retrospectively studied 57 patients who were found to have a cervical metastasis of the upper- or midneck and an unknown primary tumor after routine examination of the head and neck region. Patients were analyzed for the value of applied diagnostic measures, tumor classification, survival rates and frequencies of subsequent lymph node or distant metastases after the initial treatment. Our results showed that a diagnostic algorithm (lymph node biopsy, rigid panendoscopy with systematic biopsies of suspect regions as well as blind biopsies of endoscopically inconspicuous regions, including the tongue base and nasopharynx and bilateral tonsillectomy) led to the detection of 14 occult oropharyngeal and 5 nasopharyngeal primary tumors in the patients. These tumors were primarily diagnosed as CUP. Oropharyngeal tumors either grew submucosally or were so small that only microscopic evaluation of the entire tonsil uncovered the tumor. Imaging procedures (X-ray, ultrasound, CT, MRT and FDG-PET) as well as gynecological, urological and gastroenterological consultations did not reveal the primary tumors in any of the cases. The 3-year survival rate for the patients with occult oropharyngeal primary tumors was 100% after treatment, while the patients in which our diagnostic schedule did not reveal a primary tumor showed a survival rate of 58%. The prognosis of all of the patients with cervical carcinoma metastasis was dependent on the initial nodal stage. Metachronous metastasis after completion of the initial treatment was prognostically infaust, while secondary detection of the primary tumor was worthwhile during follow-up as long as further treatment options were offered. The prognosis of patients with cervical carcinoma metastases of the upper- and midneck is much more favorable than that of patients with a CUP syndrome of other localizations. Identification of an occult pharyngeal tumor is prognostically relevant, since it opens up the possibility of specific locoregional treatment. In patients with cervical CUP, blind but systematic pharyngeal biopsies, including bilateral tonsillectomy, should be performed.