Guidelines Summary

United Kingdom

Guidelines from the United Kingdom on the workup and management of patients with metastatic neck cancer with an unknown primary site include the following recommendations^[45]:

All patients presenting with confirmed cervical lymph node metastatic squamous cell carcinoma and no apparent primary site should undergo: (1) PET-CT whole-body scanning, (2) panendoscopy and directed biopsies, and (3) bilateral tonsillectomy
Tongue base mucosectomy can be offered if facilities and expertise exist
Concomitant chemotherapy with radiation should be considered in patients with an unknown primary
Concomitant chemotherapy with radiation should be offered to suitable patients in the postoperative setting, where indicated
Neoadjuvant chemotherapy can be used in gross “unresectable” disease
Patients should be followed up to a minimum of 5 years, with a prolonged follow-up for selected patients
PET-CT scanning at 3-4 months after treatment is a useful follow-up strategy for patients treated by chemoradiation therapy

French Society of Otorhinolaryngology and Head and Neck Surgery

Guidelines from the French Society of Otorhinolaryngology and Head and Neck Surgery include the following recommendations with regard to clinical and imaging assessment of cystic neck lymphadenopathy with unknown primary site^[46]:

In adults with a lateral cervical mass with cystic aspect, clinical examination should include “inspection of head and neck teguments, otoscopy, head and neck mucosal examination with pharyngolaryngeal flexible endoscopy, and palpation of the tongue base and tonsils, thyroid and salivary glands and lateral and central cervical lymph-node areas”
With regard to ultrasonographic assessment of cystic neck lymphadenopathy without clear etiology, first-line cervical and thyroid ultrasonographic scanning should be performed, a high-frequency probe coupled to B-mode and Doppler should be employed, and ultrasonographically guided fine-needle aspiration of the lymph node and any suspicious thyroid nodule should be carried out
Evaluation of adults with cystic cervical neck lymphadenopathy with unknown primary site should be performed using contrast-enhanced head and neck and chest CT scanning
Primary detection using 18F-FDG PET/CT scanning should be performed in metastatic cystic lymphadenopathy of unknown primary site, “notably revealing oropharyngeal carcinoma”; the examination preferably should be carried out prior to pharyngeal biopsy

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Media Gallery

Computed tomography (CT) scan of neck with contrast. The arrows indicate metastatic lymphadenopathy. Image courtesy of Head and Neck Cancer-Multidisciplinary Approach, Davidson, BJ.
Computed tomography (CT)/positron emission tomography (PET) fusion; areas of uptake on the PET scan are mapped to the CT scan, and this image depicts the primary lesion in the left floor of mouth with metastatic disease to level II.
Histologic appearance of metastatic squamous cell carcinoma. Image courtesy of Atlas of Head and Neck Pathology, Wenig, BM.

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Author

Philip E Zapanta, MD, FACS Associate Professor of Surgery, Otolaryngology Residency Program Director and Medical Education Fellowship Co-Director, George Washington University School of Medicine and Health Sciences; Staff Surgeon, Division of Otolaryngology-Head and Neck Surgery, GW Medical Faculty Associates

Philip E Zapanta, MD, FACS is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, Christian Medical and Dental Associations, Medical Society of the District of Columbia

Disclosure: Nothing to disclose.

Coauthor(s)

Guy J Petruzzelli, MD, PhD, MBA, FACS Physician-in-Chief and Vice President of Oncology Programs, Curtis and Elizabeth Anderson Cancer Institute at Memorial University Medical Center; Professor of Surgery-Head, Neck, and Endocrine Surgery, Mercer University School of Medicine-Savannah Campus

Guy J Petruzzelli, MD, PhD, MBA, FACS is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Association for the Advancement of Science, American Association of Clinical Anatomists, American College of Surgeons, American Head and Neck Society, American Medical Association, American Society of Clinical Oncology, Chicago Medical Society, Georgia Society of Otolaryngology-Head and Neck Surgery, International Academy of Oral Oncology, International Head and Neck Scientific Group, North American Skull Base Society, Society of Surgical Oncology, Society of University Otolaryngologists-Head and Neck Surgeons, SWOG

Disclosure: Nothing to disclose.

Jeremy B White, MD Plastic Surgeon, ARC Plastic Surgery, Hollywood, FL

Jeremy B White, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Nader Sadeghi, MD, FRCSC Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, McGill University Faculty of Medicine; Chief Otolaryngologist, MUHC; Director, McGill Head and Neck Cancer Program, Royal Victoria Hospital, Canada

Nader Sadeghi, MD, FRCSC is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society, American Thyroid Association, Royal College of Physicians and Surgeons of Canada

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Merck.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan; Ryte; Neosoma; MI10<br/>Received income in an amount equal to or greater than $250 from: Neosoma; Cyberionix (CYBX)<br/>Received ownership interest from Cerescan for consulting for: Neosoma, MI10.

Additional Contributors

Benoit J Gosselin, MD, FRCSC Associate Professor of Surgery, Dartmouth Medical School; Director, Comprehensive Head and Neck Oncology Program, Norris Cotton Cancer Center; Staff Otolaryngologist, Division of Otolaryngology-Head and Neck Surgery, Dartmouth-Hitchcock Medical Center

Benoit J Gosselin, MD, FRCSC is a member of the following medical societies: American Head and Neck Society, American Academy of Facial Plastic and Reconstructive Surgery, North American Skull Base Society, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, American Rhinologic Society, Canadian Medical Association, Canadian Society of Otolaryngology-Head & Neck Surgery, College of Physicians and Surgeons of Ontario, New Hampshire Medical Society, Ontario Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

Ahmed Mohyeldin, PhD George Washington University School of Medicine and Health Sciences

Disclosure: Nothing to disclose.

Sections Neck Cancer With Unknown Primary Site
Overview
Workup
Treatment
Guidelines
Media Gallery
Tables
References

Symptom	Possible Source
Otalgia/aural fullness	Pharynx, larynx, nasopharynx, or ear
Dysphagia/odynophagia	Pharynx, esophagus, or oral cavity
Hoarseness	Larynx
Trismus, dysarthria	Oral cavity or oropharynx
Nasal congestion, epistaxis	Sinonasal tract
Aspiration	Oropharynx or larynx

Neck Cancer With Unknown Primary Site Guidelines

Guidelines Summary

United Kingdom

French Society of Otorhinolaryngology and Head and Neck Surgery

References

Tables

Contributor Information and Disclosures

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