Lymph node metastases in the neck and parotid gland from an unknown primary melanoma

A lymph node metastasis in the neck or parotid region from an unknown primary melanoma is an uncommon occurrence. Out of a total of 300 patients with head and neck melanoma treated at the Netherlands Cancer Institute between 1976 and 1992, 17 (5.7%) presented in this way. The most common site for metastatic lymph nodes (18 nodes in 17 patients) was level V (n= 7), followed by the parotid region (n= 4), level II (n= 4), level III (n= 2), and level IV (n= 7). Two patients had local excision of the neck node metastasis only, while the remaining 15 patients underwent more extensive surgical treatment. The 5-year disease-specific survival rate in this group was 48%, with a median survival of 36 months, which is more or less similar to the prognosis of stage II melanoma of the head and neck with a known, surgically treated primary tumour. No relation was found between disease-free interval and sex, the number of positive lymph nodes or the duration of symptoms.     

Head and neck carcinoma of unknown primary

In adult cervicofacial pathology, carcinoma of unknown primary is defined as lymph-node metastasis the anatomic origin of which is not known at the time of initial management. It constitutes up to 5% of head and neck cancers. Presentation may suggest benign pathology, delaying and confusing oncologic treatment. Diagnostic strategy in cervical lymph node with suspicion of neoplasia requires exhaustive work-up to diagnose malignancy and, in 45% to 80% of cases, depending on the series, to identify the primary site. Histologic types comprise squamous cell carcinoma, thyroid carcinoma, adenocarcinoma, neuroendocrine carcinoma and undifferentiated carcinoma. Association is sometimes found with human papilloma virus or Epstein Barr virus, guiding treatment. The objective of the present study was to provide clinicians with the necessary diagnostic tools, based on the current state of clinical, imaging and pathologic knowledge, and to detail treatment options.     

Multiple primary malignant tumours in patients with head and neck cancer: the implications for follow-up

The pattern of second primary cancer occurrence in 518 Scottish patients with head and neck cancer was determined by a retrospective study. The overall incidence of second cancers was 9% but the true incidence increased steadily in the years following initial diagnosis to reach a maximum of 21% at 11 years. After 4 years of follow-up patients were more likely to die from a second primary cancer than from the effects of the initial tumour. The Scottish cohort differed from previously reported, overseas, study groups in having a high incidence of second primary cancers in sites outside the upper aerodigestive tract. This potential demographic difference suggests a need for local audit prior to design and implementation of screening protocols for second primary cancers.     

Neck dissection for unknown cancer of the head and neck in the era of chemoradiation

Purpose

To report outcomes for patients with cervical lymph node metastases from an unknown primary site of the head and neck treated with either non-operative therapy or neck dissection followed by adjuvant therapy.

Impact of second primary tumors on survival in head and neck cancer: an analysis of 2,063 cases

Objective/Hypothesis: To investigate the impact of second primary tumors on prognosis for patients with head and neck squamous cell carcinoma (HNSCC). Study Design: Prospectively recorded data on HNSCC patients treated at an academic tertiary referral center. Methods: An analysis of 2,063 patients treated over a 15 year period for tumors of the upper aerodigestive tract, with a minimum follow‐up of 10 years. Results: A total of 351 (17%) patients developed a second primary, mean time to diagnosis of the second tumor being more than 4 years from the date of the initial tumor. Median overall survival from the date of the first tumor among patients who later developed a second primary was 6 years versus 3 years among all other patients (P < .05). During the first 6 years after treatment of the initial tumor, cancer specific survival was better in the second primary group. After diagnosis of a second primary tumor, median survival was 12 months. A positive correlation was found between second primaries and stage I/II primary disease, low patient age, and initial tumors of the larynx and oral cavity. Conclusions: The group of patients with the highest risk of a second primary tumor was younger patients with limited initial tumors. A high proportion of patients who later developed a second primary were complete responders after treatment of the first tumor. However, prognosis was poor after the actual diagnosis of the second primary tumor.     

Measuring comorbidity in patients with head and neck cancer

BACKGROUND: Comorbidities are diseases or conditions that coexist with a disease of interest. The importance of comorbidities is that they can alter treatment decisions, change resource utilization, and confound the results of survival analysis. OBJECTIVE: The objective of this study was to determine the best comorbidity index to use in survival analysis of patients with squamous cell carcinoma of the head and neck. METHOD: Four validated indexes, with very different methodologies (i.e., the Charlson Index, the Cumulative Illness Rating Scale, the Kaplan-Feinstein Classification, the Index of Co-existent Disease), were tested using data from 379 unselected consecutive patients with complete 3-year follow-up from the Kingston Regional Cancer Center. Kaplan-Meier analysis and Cox Proportional Hazards Regression were used to stratify patients into three levels of increasing severity of comorbidity for each index. The Proportion of Variance Explained and Receiver Operating Characteristics curves were used to compare the performance of the indexes. CONCLUSION: The Kaplan-Feinstein Classification was the most successful in stratifying patients in this population.     

The role of tonsillectomy in the initial diagnostic work-up of head and neck squamous cell carcinoma of unknown primary

ObjectiveThe aim of the present study was to determine the value of tonsillectomy in the initial diagnostic work-up of head and neck squamous cell carcinoma of unknown primary (HNSCCUP).Material and methodsA single-center retrospective study (1999–2012) included 45 patients. All cases underwent physical examination, panendoscopy and contrast-enhanced neck and chest CT scan; 27 (60%) also underwent 18-FDG PET scan. Imaging was systematically performed before panendoscopy. In 34 cases (75%), histologic tonsil samples ipsilateral to the HNSCCUP were collected (28 tonsillectomies and 6 biopsies) during panendoscopy. Categoric variables were compared on Chi-square test.ResultsClinical examination and CT did not identify any primary tumor. In 13 cases (38%), invasive squamous cell carcinoma (SCC) was diagnosed on histological samples (12 tonsillectomies, 1 biopsy). For these 13 cases, lymph nodes were located in the upper or middle jugular group, and in 3 cases lymph nodes were cystic on CT scan. In 7 cases (26%), there was an abnormal tonsillar 18-FDG uptake ipsilateral to the cervical lymphadenopathy; tonsillectomy was performed, and SCC was found in 5 of these cases: i.e., 18-FDG PET showed sensitivity and specificity of respectively 55.5 and 88.8%.ConclusionTonsillectomy has a role in the initial diagnostic work-up of HNSCCUP. It is especially useful when lymph nodes are located in the upper and/or middle jugular group with a cystic aspect on CT.     

Predictive value of sentinel node biopsy in head and neck cancer

Conclusions. The negative predictive value (NPV) of sentinel lymph node biopsy (SNB) in this study was 95%. The accuracy of SNB compared to histopathologic evaluation of surgical specimen of subsequent neck dissection (ND) was 96%. Objective. To evaluate NPV of SNB in head and neck cancer. Patients and methods. This was a prospective clinical study comprising 35 patients (50 necks) with squamous cell carcinoma (SCC) of head and neck with clinically (cN0) and radiologically negative necks, without previous treatment, who underwent SNB with gamma probe and subsequent ND. The NPV, accuracy, sensitivity, and specificity of SNB were compared to histopathologic assessment of surgical specimens from NDs. Negative sentinel lymph nodes (SLNs) on histopathology were evaluated with step serial section (SSS) and immunohistochemistry (IHC). When a neck had a positive SLN, all lymph nodes of subsequent NDs were studied with SSS and IHC. Results. There were primaries of the oral cavity (n=24), lip (n=3), oropharynx (n=3), and larynx (n=5). All patients had detected SLNs. In all, 41 necks were SLN-negative on histopathologic evaluation but 2 (5%) had metastases in non-SLNs after ND. Of these 41 necks, SLNs were level Ib (26%), IIa (45%), III (21%), and IV (8%). Nine necks presented positive SLN on histopathologic evaluation, level Ib (n=3), IIa (n=5), and III (n=2), and subsequent NDs were negative on conventional histopathologic analysis, but after SSS and IHC, two presented micrometastases.     

Trismus in patients with head and neck cancer and 5-year overall survival

Abstract

Background: Trismus is a common complication of radiotherapy for head and neck cancer but its impact on survival is unknown.

Aims/Objectives: This prospective study evaluates the incidence of trismus in patients with head and neck cancer receiving radiotherapy and the impact of trismus on 5-year overall survival.

Material and methods: Two hundred forty-four patients with head and neck cancer were included. All patients received instructions on jaw exercises and were evaluated before initiation of radiotherapy and at 2, 6, and 12 months after termination of radiotherapy.

Results: One year after treatment 25% had a reduced maximum interincisal opening (MIO) of 13?mm or more as compared to the pretreatment MIO. Trismus was most prevalent in patients with oral and oropharyngeal cancer. A trend towards worse 5-year overall survival was seen among patients with trismus.

Conclusions: The trismus rate was approximately 30% at 12 months. Jaw exercises should primarily be offered to patients with oral and oropharyngeal cancer who are most likely to benefit. Further studies are required to investigate the effect of trismus on survival.

Significance: This study identifies patients likely to benefit from jaw exercises and provides basis for further research on trismus and survival.     

Gastrostomy tubes in patients with advanced head and neck cancer

OBJECTIVES: To measure the percentage of patients requiring gastrostomy tubes (G-tubes) and the timing of their placement, in addition to studying whether pretreatment variables (T stage, tumor site, N stage) and intratreatment variables (weight loss during treatment) are valid predictors for the need for G-tube placement. STUDY DESIGN: Retrospective case control study. METHODS: Retrospective review of a prospectively collected database with chart reviews was carried out on 477 patients treated on a regimen of intraarterial cisplatin and concurrent radiation. The likelihood of requiring a G-tube was calculated by studying several independent variables using chi-square analysis and the unpaired t test. RESULTS: Two hundred twenty (46%) patients had G-tubes placed, with mean time of placement being on day 20 after the initiation of treatment. Patients with T4 disease were statistically more likely to require a G-tube (50% vs. 37%, P < .05). Patients were less likely to require a G-tube when the primary site of tumor involved the larynx or paranasal sinuses (P < .05). There were no statistically significant differences between the two groups with regards to patient age, sex, N stage, and weight changes over the course of treatment. The odds of requiring a G-tube were highest for tumors involving the hypopharynx (80%), oral cavity (52%), and oropharynx (49%). CONCLUSIONS: Although clinical judgment appears to be sufficient for deciding when G-tube placement is warranted in our population, the threshold for placing a tube should be lower in those patients who had a higher likelihood of requiring a G-tube during the course of treatment, including those with advanced disease of the oral cavity, oropharynx, and hypopharynx.     

Chest computerized tomography scanning in patients presenting with head and neck cancer

Between 1 to 16% of patients with head and neck squamous cell carcinoma (HNSCC) have synchronous tumours; the majority (>50%) occurring within the lung. Previous studies have relied upon endoscopy and chest radiographs. The aim of this study was to determine the incidence of synchronous intrapulmonary tumours in this group of patients using computerized tomography (CT) scanning. Over 36 months, 111 consecutive patients were assessed at presentation by contrast enhanced CT scanning from the skull base to the diaphragm. Chest scans showed intrapulmonary lesions in 17 patients and 10 have, with time, been confirmed as neoplastic. These allowed treatment of three primary bronchial carcinomas following radical treatment of the index tumour and cancellation of radical treatment in five patients with metastases. Two patients with possible metastases at presentation underwent radical treatment to the index tumour with subsequent follow-up confirming metastatic chest disease. All 10 patients eventually died of either locoregional or metastatic disease. This is one of the first prospective reports of chest scanning in patients with head and neck cancer. An additional chest scan in this group, many of whom undergo a staging scan of the neck, requires an extra 10 min with no further contrast and in this study yielded a synchronous tumour rate of 9%.