D Dequanter, R Lamartine, A Rodriguez, R Javadian
Head and Neck Department CHU Saint Pierre Rue Haute, BelgiumFulltext PDF
Introduction: Treatment of Carcinoma of Unknown Primary (CUP) that represent 3-7 % of all head and neck cancer is controversial and dependant on stage. Radiotherapy or chemoradiotherapy as primary modality of treatment followed by neck dissection for the patient’s persistent disease is employed. However, a combined modality approach, with surgery followed by postoperative (chemo) radiotherapy depending on the pathology findings is also widely recommended. The aim of the paperin CUP patients who underwent neck dissection is to compare the preoperative clinical staging and postoperative histological staging and determine the extent of neck dissection without compromising the oncological outcome
Methods: A cohort of patients with clinically T0N+ of the neck managed surgically was reviewed. Demographical and tumour factors were recorded for all the patients. Preoperative clinical staging, details of adjuvant therapy and histological features were recorded. Outcomes data on recurrence and details of mode of death were extracted from hospital records
Results: A total of 23 patients were identified of whom 3 (13 %) were female. The median age was 66 years (range 37- 83 years). The clinical N stage was cN1 in 8 patients, cN2 in 9 patients and cN3 in 6 patients. 8 patients were postoperatively treated by surgery and radiotherapy, and 15 patients had post-operative chemoradiotherapy. Radiotherapy fields included all levels of the ipsilateral neck and mucosal surfaces. The median time for surgery to completion of radiotherapy was 89 days (range 46-113 days).All the patients had comprehensive neck dissection (including levels I-V). Following histopathological analysis of surgical specimens, the pN stage was N1 in 5 cases, N2 in 12 and N3 for the remaining 6 patients. 9/23 (39 %) patients had evidence of extracapsular extension on histological analysis. The mean follow-up was 49 months (range 2- 72 months). There were 10 deaths. No patient developed evidence of local recurrence within the upper aerodigestive tract during follow-up. Three patients developed regional recurrence, two of which were ipsilateral, all of them ultimately died of disease. Three patients developed metastatic disease. Four patients died from primary lung cancer. The 5 year overall survival, and regional recurrence free survival were 56,5 and 86 % respectively. From a total of 666 excised nodes, 211 (32 %) were found to contain metastatic SCC. Nodes from multiples levels were found to be involved in 16 cases (70 %). In the remaining 7 cases (30 %), involvement was limited to a single level. Of the 23 patients who had all levels of the neck treated surgically, level I was clinically involved in three cases (13 %) , level II in 16 (69,5 %), level III in 9 (39 %), level IV in 6 (26 %) and level V in one case (4 %). Postoperative histopathological assessment identified disease in level in three cases (13 %), level II in 20 cases(87 %), level III in 11 (49 %), level IV in 7 (30 %) and level V in 6 cases (26 %). Comparison of clinical versus pathological staging in the patients with comprehensive neck dissection revealed that 22 % of nodal basins preoperatively considered free of disease were late shown to harbor microscopic pathological evidence of occult metastasis. Conclusions: Our results suggest that in patients with carcinoma of unknown primary, the probability of occult disease may be high enough to consider level V when performing neck dissection.
Unknown Primary; Head and Neck Cancer; Pathological Staging; Neck Dissection
D Dequanter, R Lamartine, A Rodriguez, R Javadian. Comparison of Clinical Versus Pathological Staging in Patients with Carcinoma of Unknown Primary Treated by Comprehensive Neck Dissection. Ann Clin Otolaryngol. 2018; 3(1): 1029.