Management of Secondaries neck with

occult primaryDR ROOHIA

How metastatic squamous neck cancer with occult primary is treatedTHERAPEUTIC OPTIONS

Include excision biopsy of involved lymph nodes,

Neck dissection,Radiotherapy, Chemoradiotherapy or Radiotherapy with Salvage neck dissection

HOW TO MANAGE A NECK SECONDARY???

N STAGING NODAL REGIONS AND DRAINAGE DIFFERENT TYPES OF NECK

DISSECTION

“N” classification – AJCC (1997)

Consistent for all mucosal sites except the nasopharynx Thyroid and nasopharynx have different staging based on tumor behavior and prognosis

The prevalence of occult neck metastases by site is as follows: 60 %

Pyriform sinus - Oral tongue - Tongue base -

30%

Floor of mouth Buccal mucosa Retromolar trigone Tonsil Aryepiglottic fold

True vocal cord - 15%False vocal cord - 15%Alveolus - 15%Epiglottis - 15%Hard palate - 15%

CLASSIFICATION OF NDs RND originally described by Crile and later popularized by martin now has been modified in various ways

given rise to several types of cervical lymph node dissections that are currently

used for the surgical treatment of the neck.

These modifications were classified according to a random system of terminology depending on the author at the time.

In 1991 the Academy’s Committee for Head and Neck Surgery and Oncology published an

official report standardizing the classifications

for these modified neck dissection

The committee classified four major types of neck dissections:

1) Radical neck dissection 2) Modified radical neck dissection3) Selective neck dissection including

posterolateral lateral anterior supraomohyoid

4) Extended radical neck dissection.

radical neck dissection removing all of the lymphatic tissue in regions I - V including removal of SANSCM IJV

Modified radical neck dissection defined as excision of all lymph nodes (levels 1 to 5) with preservation of one or more non lymphatic structures, SAN, IJV, SCM.

Medina subclassifies the MRND

types I-III

type I MRND preserves the SAN type II MRND preserves the SAN and IJVtype III MRND preserves the SAN, IJV, and

SCM.

The type III MRND is also referred to as the "functional neck dissection"

as popularized by Bocca

Selective neck dissection defined as any type of cervical

lymphadenectomy where there is preservation of one or more lymph

node groups removed by the radical neck dissection

There are four common subtypes1. supraomohyoid neck dissection. This removes lymph tissue contained in regions I - III.

The posterior limit of the dissection is marked by the cutaneous branches of the

cervical plexus and the posterior border of the SCM.

The inferior limit is the superior belly of the omohyoid muscle where it crosses the IJV

2. posterolateral neck dissection removal of the levels II - IV level V and additional suboccipital lymph nodes post - auricular lymph nodes

This procedure is used most often to remove nodal disease from cutaneous melanoma of the posterior scalp and neck.

Originally described by Rochlin in 1962( the SAN, SCM, and IJV were preserved )

3. The lateral neck dissection Removes lymph tissue in levels II - IV.

4. Anterior neck dissection last subtype of selective neck dissection

removal of lymph nodes surrounding the visceral structures of the anterior aspect of

the neck previously defined as level VI

(perithyroid: pretracheal : precricoid: paratrachel )

The last major subtype is theextended neck dissection defined literally as removal of one or

more additional lymph node groups and/or non - lymphatic structures not

encompassed by radical neck dissection, such as parapharyngeal, superior mediastinal and paratracheal..

Management of occult primary:Treatment of metastatic squamous neck

cancer with occult primary depends on :

how many lymph nodes contain cancer whether or not an original (primary)

tumor is found the patient’s age overall condition

Presentation: lymphadenopathy in mid- to upper neck levels

90% primary site detected10% remains as unknown primary

mid- to upper jugular nodes associated with 5 possible mucosal sites: which may harbour the

primary lesion (1) nasopharynx, (2) tonsillar region (3) base of tongue, (4) pyriform sinus, (5) supraglottic larynx

jatin shah correlatedthe primary site metastasis to particular

lymph node levels:

(1) oral cavity: levels I to III, (2) oropharynx: levels II to IV (3) hypopharynx: levels II to IV and (4) larynx: levels II to IV

Level II and upper level V lymphadenopathy (particularly bulky): primary nasopharyngeal carcinoma

suggestive evidence : 1. serology titre ( EBV virus titre) 2. histopathology - lymphoepithelioma or

poorly differentiated cancer 3. Chinese ethnicity 4. Retropharyngeal node involvement

Controvorsies in management :1. types of dissection to be performed2. fields of radiation ( whether ipsilateral

neck only or whole neck )3. role of chemotherapy as a sequence to RT

and neck dissection optimal mx : yet to be decided

Mx based on the nodal stage and the high-risk mucosal sites.

Patients who clinically present with a mid- to high neck node that is felt to be ≤ 3 cm in diameter

a fine-needle aspiration biopsy to establish the diagnosis of cancer

if search for primary is negative

undergo neck dissection

If the pathologic diagnosis show a clear,

uncomplicated N1 node,

may be considered only for monitoring as the risk of regional neck recurrence is 10 % with Primary surgery or radiation therapy

The risk of subsequently developing a primary site manifestation 6 to 50 % in the world’s literature a Ref study : M.D. Anderson Hospital Cancer Center, 20 % of the patients who were managed initially with surgery alone for the cervical lymphadenopathy

subsequently developed a primary lesion

However, if the pathology evaluation reveals stages N2a, N2b or N2c or extracapsular extension

undergo ND + postoperative radiotherapy

Also, if the patient had undergone an incisional or excisional biopsy of the node prior to ND , postoperative RT is also recommended

In MRND if the specimen has less than 2 involved nodes without

extracapsular spread

no need for post – RT ( mucosal site damages can be avoided )

neck dissection with RTvsRT without neck dissection

Ref study : ( a canadian study ) Statistically no difference in 8 year survival

rates ( 64.8 % and 67.6% )

conclusion: definitive RT to neck and potential mucosal

sites is good in achieving good local control rates whether preceded by

neck dissection or not

Coster et al study

N1 disease with no extracapsular extension

surgery alone

N2 OR higher or with extra capsular

involvment

surgery + post RT

According to Stell & Maran authors:Excision biopsy

followed by definitive MRND

in all cases ….

exception :

where nodes are smaller

( less than 2 cm

+ no extracapsular spread

Recent consensus :For N2 and N3 : dual modality therapy

ND followed by RT OR RT followed by interval neck dissection

Post Radiotherapy :The nodal areas would be treated with

conventional fractionation 54Gy subsequent boost to high-risk nodal regions to a total dosage of 63 Gy

54 - 63 Gy ( over 6 to 6.5 weeks)

The possible primary mucosal sites would be similarly irradiated to a total dosage of

54 Gy.

Neck : 66 – 74 Gy to gross disease, 44- 64 Gy for subclinical disease Mucosa: 50 – 66 Gy

The dosage is dependent on the lymph node size:

(1) ≤ 1 cm: 65 grays (2) ≥ 1 cm to 2 cm: 70 Gy (3) > 2 cm to 3 cm: 75 Gy

Radiotherapy principles.1. High posterior triangle node - treat as

primary nasopharyngeal carcinoma.

2. Jugulodigastric or midjugular node - treat as primary nasopharyngeal carcinoma, omit larynx shield.

3.Upper or midjugular node – fields include the ipsilateral tonsillar fossa, posterior tongue, pyriform fossa, and ipsilateral neck nodes

4. Multiple or bilateral nodes: treat as primary nasopharyngeal carcinoma, but omit larynx shield.

5. Supraclavicular node only: palliative irradiation.

6. Radical radiation doses – as for stage T1 primary cancer, with additional boost to the metastatic node

Side effects can appear around 2 weeks after the first radiation treatment or much later and can include:

Mouth sores (feels like little cuts or ulcers in your mouth).

Dry mouth (also called “xerostomia” Pain or difficulty with swallowing.Changes in taste or smell.Changes in the sound of your voice.Jaw stiffness and jaw bone decay.Changes in your skin.Feeling tired.

Best Options in recurrence …Limited volume radiation therapy and a

fractionated boost with brachytherapy ( found very effective in recurrent nasopx

tumors)

Brachytherapy alone

Concurrent chemotherapy ( chemo + RT )

In jatin shah ‘s instituteFor recurrence after radiation : IMRT was used and studies

done…… showed more survival rate

IMRT : ( intensity modulated radiotherapy) advanced form of 3D conformal treatment

planning which involves the use of the most sophisticated computer-generated treatment planning and clinical linear accelerators available

indicated in the treatment of lesions with complex

anatomy that are adjacent to vital structures such as

the spinal cord or brain stem.

IMRT improves the therapeutic ratio optimizing the dose to the tumor target decreases the dose given to the target

IMRT vs conventional RT: bhide et al studyImproved radiation coverage of mucosa

including nasopharynx

Significant reduction of dose to the parotid gland contralateral to the involved neck…….thereby reducing risk of xerostomia

Treatment optionsChemotherapy 3- 6 courses either pre or post RT

BMC REGIME Bleomycin 10 units i.m days 1, 8, 15 Methotrexate: 40 mg i.m days 1 and 15 Cisplatin: 50 mg iv on day 4 repeat every 21 days

C F : Cisplatin - Fluorouracil Cisplatin : 100 mg iv day 1 Flourouracil : by continuous iv infusion for 96

hours repeat every 3 weeks

Summary…….• All patients with suspected UPC should

be thoroughly examined and investigated with panendoscopy, CT or MRI of head and neck, and (FDG) CT-PET.

Modified neck dissection is recommended for all patients with UPC with cervical lymphadenopathy

Postoperative selective or panmucosal radiotherapy is indicated for most patients with advanced operable neck disease

• The only tumour marker of clinical value is Epstein-Barr virus serology. Positive EBV serology should be followed on by multiple biopsies of the nasopharynx in the search for an occult primary.

Use of IMRT improves survival rates and decreases complications

Use of chemotherapy regimes with RT or surgery have even better outcome results

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