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

Francisco Civantos ,June Corry,K Thomas Robbins,Dana M Hartl,Carlos Suárez,Jan B Vermorken,Remco De Bree,Robert P Takes,Alfio Ferlito,Alessandra Rinaldo,Juan P Rodrigo,Vinidh Paleri,Ashok R Shaha,Jatin P Shah,Ng Wai Tong,Cesare Piazza,Johannes A Langendijk,Luiz Paulo Kowalski ,Michael L Hinni ,Álvaro Sanábria ,Primož Strojan ,Antti Mäkitie ,Andrés Coca‐Pelaz ,Kerry D Olsen ,William M Mendenhall ,Juan C Hernandez–Prera

doi:10.3389/fonc.2020.593164

Abstract

BackgroundPatients 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.MethodsWe comprehensively reviewed the literature, compared available guidelines, and conferred with an international team of experts.ResultsPositron 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.ConclusionsNew 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.

Highlights

The patient with proven or suspected metastatic cancer in the cervical nodes and no evident primary cancer represents a unique challenge
When the robot is not available, we have found it helpful to work twohanded with the FK retractor, and an assistant holding a 30-degree telescope to provide the angle needed to visualize the lingual tonsil well, and this can be complementary to the microscope
Modern management of metastatic neck cancer with an unknown primary site requires proper recognition of the typical clinical presentation, and avoidance of diagnostic pitfalls that can lead to inappropriate interventions

Summary

Introduction

The patient with proven or suspected metastatic cancer in the cervical nodes and no evident primary cancer represents a unique challenge. The majority of these patients will have an occult squamous cell carcinoma of the upper aerodigestive tract, infrequently other histological types and primary sites do occur. Identification of the primary site allows us to direct appropriate treatment strategies This topic was well-reviewed by Strojan et al [1, 2] in a two-part series in 2013. 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), other histologies do occur

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Conclusion