Abstract
BackgroundAbout five to 10% of cancers in the head and neck region are neck squamous cell carcinoma of unknown primary (NSCCUP). Their diagnosis and treatment are challenging given the risk of missing occult tumors and potential relapse. Recently, we described human papillomavirus (HPV)-related NSCCUP-patients (NSCCUP-P) as a subgroup with superior survival. However, standardized diagnostic workup, novel diagnostic procedures, decision-making in the multidisciplinary tumor board (MDTB) and multimodal therapy including surgery and post-operative radio-chemotherapy (PORCT) may also improve survival.MethodsFor assessing the impact of standardized diagnostic processes simultaneously established with the MDTB on outcome, we split our sample of 115 NSCCUP-P into two cohorts treated with curative intent from 1988 to 2006 (cohort 1; n = 53) and 2007 to 2018 (cohort 2; n = 62). We compared diagnostic processes and utilized treatment modalities applying Chi-square tests, and outcome by Kaplan–Meier plots and Cox regression.ResultsIn cohort 2, the standardized processes (regular use of [18F]-FDG-PET-CT imaging followed by examination under anesthesia, EUA, bilateral tonsillectomy and neck dissection, ND, at least of the affected site) improved detection of primaries (P = 0.026) mostly located in the oropharynx (P = 0.001). From 66.0 to 87.1% increased ND frequency (P = 0.007) increased the detection of extracapsular extension of neck nodes (ECE+) forcing risk factor-adapted treatment by increased utilization of cisplatin-based PORCT that improved 5-years progression-free and overall survival from 60.4 and 45.3 to 67.7% (P = 0.411) and 66.1% (P = 0.025).ConclusionsStandardized diagnostic workup followed by ND and risk-factor adapted therapy improves survival of NSCCUP-P.
Highlights
The earliest description of cervical lymph node metastasis as the primal symptom of cancer by Hayes Martin dates back to 1944 [1]
Since 2007 clinical work-up was standardized and included, as recommended [7, 8], clinical examination, ultrasound sonography, contrast-enhanced computed tomography (CT), positronemission tomography (PET)-CT/PET-magnet-resonance imaging (MRI) followed by examination under anesthesia (EUA) accompanied by taking multiple biopsies from the epipharynx, base of the tongue or lingual tonsillectomy plus bilateral tonsillectomy
We identified the standardized diagnostic workup and decision-making for surgery followed by risk-factor adapted adjuvant therapy applied to neck squamous cell carcinoma of unknown primary (NSCCUP)-P since 2007 as a significant Pi for improved tumorspecific survival (TSS)
Summary
The earliest description of cervical lymph node metastasis as the primal symptom of cancer by Hayes Martin dates back to 1944 [1]. Today a subgroup of about 5% of head and neck cancer cases [2] and 3–5% of all human cancer cases [3] are diagnosed based on a lump in the neck [4] without obvious signs for a primary tumor and are designated neck squamous cell carcinoma of unknown primary (NSCCUP). To the best of our knowledge, literature showing facilitated diagnostic processes, decision-making for particular treatment leading to improved survival of NSCCUP-patients (NSCCUP-P) based on full implementation of these guidelines [7, 8] does not exist. About five to 10% of cancers in the head and neck region are neck squamous cell carcinoma of unknown primary (NSCCUP). Their diagnosis and treatment are challenging given the risk of missing occult tumors and potential relapse. Standardized diagnostic workup, novel diagnostic procedures, decision-making in the multidisciplinary tumor board (MDTB) and multimodal therapy including surgery and post-operative radio-chemotherapy (PORCT) may improve survival
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