This document discusses the management of neck metastasis. Some key points: 1. Neck metastasis, also called neck nodes, refers to cancer spreading from a primary site to lymph nodes in the neck. The presence, level, size and number of metastatic nodes are important prognostic factors. 2. Cancer cells can spread passively through lymph vessels from a primary tumor to regional lymph nodes. They then proliferate, remain dormant, or enter blood vessels to metastasize further. 3. Assessment of neck nodes involves medical history, physical exam, imaging like ultrasound, CT, MRI, and biopsy of suspicious nodes. Nodes are grouped by anatomical levels that correlate with primary drainage patterns. 4. Treatment depends

1. MANAGEMENT OF NECK
METASTASIS
Dr DISHA SHARMA
JR ENT-HNS
IGMC ,SHIMLA

2. Introduction
When cancer cell spreads to lymph nodes in the neck or
around clavicle,it is called “neck metastasis”.
Most important prognostic factor in head & neck cancers
Presence or absence ,level and size of metastasis .
Most common squamous cell carcinoma of head & neck
Non squamous cell carcinoma of head & neck include
Malignant melanoma, cancer of salivary gland origin,
Cancer of thyroid and lymphomas…

3. Behaviour of disease within cervical
lymph nodes.
• Spread of disease from primary tumour to regional lymph
nodes by passive transport within lymph.
• Progresses from superior to inferior
• Some situations lymph node group bypassed in normal
lymphogram
• Tumour cells proliferate,die, remain dormant or enter
blood circulation through blood vessels in nodes

4. Cancer invasion & metastasis
• Invasion is active translocation of neoplastic cells across
tissue boundaries & through host cellular & extracellular
matrix barrier.
• Active process
• Result of combination of
1. Angiogenesis+co-ordinated alteration between matrix
proteolysis & cellular adhesion
2. Endothelial cell proliferation stimulated by
• PGE2
• TGF-B
• FGF
• VEGF

5. High Degree of vascularization provide better access to
circulation for metastatic spread.
3.Degradation of extracellular material- by MMP
(metalloproteinase)produced by tumour cell- lead to
proteolysis- disruption of extracellular matrix-local tumour
invasion- penetration of blood vessels and lymphatics-
Leading to tumour dissemination and metastasis.

6. ASSESMENT OF NECK
NODES

7. LYMPH NODE
LEVELS/REGIONS

8. Subgroups
• Ia Submental
• Ib Submandibular
• IIa Upper jugular (Anterior to XI)
• IIb Upper jugular (Posterior to XI)
• III Middle jugular
• IVa Lower jugular (Clavicular)
• IVb Lower jugular (Sternal)
• Va Posterior triangle (XI)
• Vb Posterior triangle (Transverse
cervical)
• VI Central compartment

11. PATTERN OF NODAL
DRAINAGE

12. Oral cavity drainage
• Extend from level I to IV
• Median lower Lip,floor of mouth,ventral tongueIa
• Upper lip, lateral lower lip, buccal mucosa- Ib
• Post portion of oral cavity -II
• OROPHARYNGEAL LYMPHATIC
DRAINAGE
Soft palate,palatine,lingual tonsils,post pharyngeal wall.
Level II.level III primarily

13. Tongue lymphatic drainage
• Ventral tongue follows drainage pattern of floor of mouth
• To level IA anteromedially IB laterally.
• Dorsal oral tongue- level I medially level II laterally.
• Tongue base –level II and level III.
• Level IV –involved in advanced disease or via alternative
drainage pattern.
• Midline lesion- bilateral drainage pattern.

14. Laryngeal drainage
Upper and lower system;division at true vocal cord level.
Supraglottis  level II,level III
Lower system level III,level IV
Vocal cords : watershed area
few lymphatics;
uncommon metastasis
Subglottis : level III. Level IV

15. Nasopharynx lymphatic Drainage
• Highest rate of nodal metastasis
• Lateral retropharyngeal nodes.levelI nodes.
• In advanced disease- level III. Level IV
• Posteriorly to level V

16. lymphatic drainage to paratracheal lymph
nodes
• Cervical oesophagus, thyroid,and parathyroid glands
• Some subglottic location shows paratracheal drainage.
level VI and level VII

17. Lymphatic metastasis of cutaneous
malignancy melanoma of head &neck
• Parotid & cervical lymph nodes most often involved.
• Frontal & parietal region scalp- parotid node
• Posterior scalp-suboccipital &retroauricular node
Further directed to level II & internal jugular nodes.
Post scalp –post accesory pathway –level II/V
Lower facial(cheek,nose,lip)-IA,IB
Anterior ear/preauricular region-upper jugular node.
Helix/lateral aspect of auricular- retroauricular,suboccipital
Neck skin-nodes adjacent to neck level
Skin in midline anterior neck- pretracheal level VI

18. ECHELON GROUPS
• Oral Cavity :level I,II, III
• Larynx and pharynx :level II,III,IV
• Thyroid :level VI,VII,IV
• Parotid gland :preauricular,periparotid and
intraparotid lymph nodes
• Submandibular and
Sublingual gland :level I,II,III

19. CLINICALASSESMENT

20. History taking
Lump in neck
Sorethroat
Hoarseness
Dysphagia
Earache

21. Clinical examination
• Neck Exposed to the level of clavicles and manubrium
• Palpate the neck while standing behind the patient
• Following characteristics are noted- anatomic
location,size,shape,consistency,mobility and tenderness
• False positive rate between 20-30%
• False negative 30-40%
• Examination of oral cavity, hypopharynx, larynx,
• Digital palpation of the tonsillar fossa and base of tongue.
• Nasolaryngoscopy- for assesment of nasal cavity,
nasopharynx

22. Staging of the neck
• “N” classification – AJCC
• Consistent for all mucosal sites except the nasopharynx
• Thyroid and nasopharynx have different staging based on
tumor behaviour and prognosis
 Developed by Memorial Sloan-Kettering Cancer Center
 Ease and uniformity in describing regional nodal
involvement in cancer of the head and neck

24. • Nasopharyngeal Carcinoma
• N1 Unilateral < 6cm above supraclavicular
fossa,including retropharyngeal LN
• N2 Bilateral < 6 cm
• N3a > 6 cm
• N3b Extension to supraclavicular fossa
• Thyroid
• N1 Regional node metastasis
• N1a metastasis to level VI Ipsilateral
• N1b unilateral/ Bilateral/ contralateral cervical or
superior mediastinal LN

25. INVESTIGATIONS

26. Ultrasonography
oGrey scale and doppler usg- high frequency 13MHz probe
oNormal nodes- echogenic
oPathological nodes – decreased echogenicity
oPower doppler differentiate-Benign and malignant nodes
SIZE >1.5cm (jugulodigastric)
> 1 cm for other nodes
> 6-8mm retropharyngeal node
oShape: ovalbenign
roundmalignant
• L/S RATIO: long to short axis ratio
>2 in benign,<2 in malignant

27. • Vascularity(doppler usg):hilar in benign
:peripherial in malignant.
• Borders :sharp in malignancy due to
intranodal tumour infilteration
Necrosis
Extracapsular spread
Senstivity- 75% to 92%
Specificity- 63% to 91%
Some studies say that measurement criteria for
sonography considered > 6 to 7mm dia for level I & level II
> 5mm level III & IV is abnormal.

30. CT-computed tomography
• base of skull to clavicle
Accurate than clinical examination
Sensitivity-84%,accuracy-83%
Important in asessing retropharyngeal nodes and for
restaging
Suspicious characteristics:
• Enlarged node(>1 cm) except jugulodiagastric >1.5 in
length, necrotic centre,thin rim of inflammation:rim
enhancement

31. • Length to transverse ratio >2- benign
<2- malignant
• Most reliable indicator is ‘ central necrosis’ low attenuation
tumour deposit infilterate from cortex to medulla of nodes
• Nodal metastases from papillary thyroid tumours may be
Homogeneous, show intense enhancement after contrast,
puctate calcification.
Extracapsular spread-imaging features are blurring of
nodal margins and soft tissue infilteration of adjacent fat
or muscles.

32. Indications
1. Primary tumour assessment
2. High chances of occult disease
3. Staging prior to nonsurgical treatment
4. Restaging
5. To know the presence of deep fixation or contralateral
spread ,so as to decide management of the disease
Note: if < 180 degree of vessel circumference involved –
direct vascular invasion unlikely
If > 270 degree of encasement present- arterial invasion
possible

34. Magnetic resonance imaging
Reactive nodes- homogeneous low signal on T1W
high signal on T2W
Malignant nodes –mixed nodes so heterogeneous signal
on both T1 andT2
Central low signal with peripheral enhancement

35. • SPIO- superparamagnetic iron oxide- lymphoangiographic
agent in MRI
• Iron oxide injected I/V taken up by reticuloendothelial
system
• Signal drop not seen in metastatic nodes

36. Positron emission tomography
• Measures biochemical pysiological process with
3D images of functional process of body.
• Picks up metabolic signals of actively growing cancer
cell in the body.
• Used to stage primary squamous cell carcinoma
• Nodal involvement,distant metastasis, recurrent tumour.
• Tracer element use fluorine-18 fluorodeoxyglucose.

37. • PET detect primary that goes unnoticed by other
modalities in 25% cases
• PET detect systemic metastatic disease in additional 27%
of cases missed by other modalities
• FDG-PET low specificity and 40% false positive rate in
tonsil
• PET performed prior to tests such as to avoid false
positives.

39. Single –photon emission computed
tomography (SPECT)
• Thallium -201 SPECT useful for detection of occult head
and neck cancer and for assessing recurrences.
• SPECT images, obtained 60min after administration of
150MBq201thallium –chloride.
• 95% versus 88% for CT/MRI in confirming malignancy.

40. Fine needle aspirate cytology
Useful in palpable node in unknown primary
Nature of histology may help in search of primary
Accuracy is 90%

41. Pathology
• Histology reporting
following neck dissection
 prepare specimen on board
 Report number of nodes
 Report nodes levels
 Is there any extracapsular spread?

42. Sentinel lymph node
• Initial lymph node metastasis is most likely to occur at first
node in lymphatic drainage pathway.
• Accurate identification & evaluation of sentinel lymph
node for presence of micrometastasis crucial component
for evaluate & treatment of cutaneous malignant
melanoma.
• Tumour thickness >1mm with ulceration & increase
mitosis more risk of metastasis.
• if metastatic node evaluated the patients stage increases
to stage III- neck dissection required

43. Sentinal node mapping
• Three techniques
1. Radioisotope scan imaging
2. Injection of blue dye
3. Use of handheld isotope tracer probe for localization
technitium 99m labeled sulfur colloid – 0.05mci
injected in 4 quadrants around primary lesion
Visual images 3min and 15 min and 1hour.
1st lymph node identified is considered sentinal lymph
node

44. Open biopsy
• Course of lymphatic spread is altered and previous scar
tissue may pose difficulty in future surgery
• Only indicated when repeated FNAC is inconclusive or
suggest lymphoma or anaplastic carcinoma

45. Risk for regional metastasis
• 1-for tumors of larynx ,pharynx risk increases with
progression from center of upper aerodigestive tract to
periphery.
• 2<15% T1
15%-30% T2
30-50% T3
75% for T4 head and neck sq cell ca.
• 3-endophytic tumour have high risk than exophytic.
• 4-poorly differentiated > well differentiated
• 5-Tm 4mm thickness > thinner lesion
• 6-Risk low in salivary and cutaneous malignancies

46. Molecular diagnosis
• Polymerase chain reaction-LOH (loss of heterozygosity)
• Of specific markers in biopsy specimen of tissue prior to
development of invasive malignancy.
• Overexpression of telomerase & mutant P53
• Detection of microsatellite & methylated DNA- marker
• For inactivated tumour suppressor gene assayed in
blood.
• Overexpressed proteins in blood- such as cytokines &
angiogenesis factor predicting behaviour & reoccurance.

47. TREATMENT

48. • Adverse effect on survival
• Only 50% with neck metastasis survive 5 Years
• Untreated neck:predictable pattern of spreadfirst
echelon groupconcept of selective neck dissection.

49. No neck
Elective surgery
Elective radiotherapy
Elective neck investigations-CT/MRI
Wait and watch policy

50. Indication for elective neck surgery
More than 20-25%chance of occult disease
Vigilant follow up is not possible
Limited neck dissection has low morbidity and mortality
Clinical evaluation of neck is difficult
Surgery being done on neck for reconstruction
Imaging suggests possibility of occult nodal metastasis
If neck is being entered to remove primary its better to
perform resection

51. If metastasis is not identified on examination or imaging,
treatment of cervical lymph nodes becomes elective
decision based on risk of metastasic disease.
If there is >15% risk of metastasis disease to regional
lymph nodes then nodes should be electively treated with
elective neck dissection or elective radiation.

52. Radiotherapy for neck nodes
- External beam radiation approx 40-50 gy to N0 neck will
control metastasis in upto 90-95% cases
-If primary tumour is being treated by radiotherapy then
elective treatment Given to first echelon group of nodes or
whole of neck
- Bilateral radiotherapy when midline extension occurs

53. Treatment – N1
• Most patientsmetastatic disease
-All five levels can be involved
-Minimum operation recommended is MODIFIED
RADICAL NECK DISSECTION
• ROLE OF RADIOTHERAPY
• -Less efficient than surgery
• -Less preferred option unless primary is also being
treated with RT alone(nasopharyngeal carcinoma)

54. Treatment –N2
• N2a and N2b
 Advanced disease
 Radical Surgery advocated for treatment
 Post operative radiotherapy
 N2c
 5% of head and neck cancer
 Common primary site:base of tongue and supraglottis
 Prognosissize,number,of nodes,extracapsular spread

55. Radical surgery if primary site is operable
Post operative radiotherapy: MUST

56. INTERVAL CONTRALATERAL
LYMPHADENOPATHY
• Node appear on contralateral side after neck dissection
on one side
• Can be salvaged surgically
• Modified radical or radical neck dissection- 30% of 5 year
survival

57. Treatment N3
• Uncommon
• 5%N3 nodes
• Nodes fixed to skin or underlying structure
• Most:incurable,surgery in certain instances
• Decision depends on stage of disease,presence or absence
of fixation and structure to which node is fixed
• Radiological imaging :mandatory for assesment.

58. • Fixation to mandible,SCM,midline muscles ,prevertebral fascia
:treatable
• Extended radical neck dissection may be helpful
• Fixation to brachial plexus or skull base: contraindication to
surgery
• Arterial invasion,if present,careful assessment
.

59. •Contraindication of neck dissection
• Unresectable/uncontrolled primary
• Unfit for surgery ;risk of anaesthesia
• Inoperable neck disease
• Distant metastasis

60. RECURRENCE AND SALVAGE
SURGERY
Bad prognosis
Careful evaluation and staging with radiological imaging.
Surgery:wide resection followed by Post operative RT
If post op RT already received ,further radiotherapy may
be given in form of LOCAL BRACYTHERAPY.

61. Lymphomas of neck
• 75% of lymphomas that occur in head &neck are nodal
• Hodgkin lymphomas – young adult, painless
lymphadenopathy, rubbery ,wax or wanes in size in
cervical (60-70%)/supraclavicular region( 75-90%), ‘B’
• symptoms
• Non hodgkin’s lymphoma 70% of primary head &neck
cases- small lymphocytic lymphomas involves
tonsil,adenoid,tongue base,nasopharynx.
• Common presentation : dysphagia,neck mass ,airway
obstruction .

62. Management
• Open biopsy-gold standard
• Chemotherapy- ABVD (doxorubicn,bleomycin,vinblastin,
dacarbazine ) followed by 20Gy involved field RT
BEACOPP- ( bleomycin,,etoposide,doxorubicin,
cyclophosphamide.,,vincristin,procarbazine and prednisone
For advance stages)

63. Clinical applications
• Possible future therapeutic strategies
Virus directed enzyme prodrug therapy- adenovirus
mediated p53 gene transfer in patients with advanced
recurrent head & neck squamous cell carcinoma reduces
tumour growth.
Tissue inhibitors of matrix metalloprotienases (TIMP)
prevent degradation of matrix.
Antiangiogenesis agents. – bevacizumab, Erlotinib
(EGFR) epidermal growth factor inhibitor.

64. NECK DISSECTION

65. CLASSIFICATION
The radical neck dissection is classified according to the
Academy’s committee for head & neck surgery & oncology
into four major type:
Radical Neck Dissection (RND)
Modified Radical Neck Dissection (MRND)
Selective Neck Dissection
Supraomohyoid
Posterolateral
Lateral
Anterior
Extended Radical Neck Dissection

66. MEDINA classification(1989)
• Comprehensive neck dissection
-Radical neck dissection
-Modified radical neck dissection
-type I(XI preserved)
-type II(XI,IJV preserved)
-type III(XI,IJV,SCM )
• Selective neck dissection

67. Radical neck dissection
• All lymph nodes from level I to V including spinal
accessory nerve,IJV,SCM along with submandibular gland
and tail of parotid
• Indication :extensive cervical involvement or matted
lymph nodes with gross extracapsular spread and
invasion into SAN,IJV,SCM.

68. Modified radical neck dissection
• Definition: excision of same node bearing regions as RND
with preservation of one or more nonlymphatic
structures(SAN,IJV,SCM)
• 3 types
• ADVANTAGES:
-Shoulder syndrome incidence reduced
-Improve cosmetic outcome
-Reduce likelihood of bilateral IJV resection

69. Modified Radical Neck Dissection Type I
Indications
• – Clinically obvious
lymph node metastases
• – SAN not involved by
tumor
MRND-I modification
Avoiding dissection of fatty
tissue (circumferential)
Dissection prevent post op
Deficient in shoulder
function

70. Modified Radical Neck DisectionType II
Indications
• -it preserves SCM and
SAN & sacrifies IJV
- Differentiated thyroid
cancer

71. MRND Type III
Neck dissection of choice
for N0 neck
Preserving SCM,SAN,IJV
Metastatic lymph nodes
from differentiated
carcinoma thyroid gland
Skin tumour
:melanoma,merkels
carcinoma, squamous cell
carcinoma

73. (a)Supraomohyoid ( b)Extended Supraomohyoid

74. Primary carcinoma of lateral border of the oral tongue have
small risk of having skip metastasis to level IV of ipsilateral
neck.
In addition to standard supraomohyoid neck dissection
extended operation being undertaken to include level IV

75. Central compartment node dissection
for metastasis from primary differentiated carcinoma of
thyroid gland.
invasion of the capsule of thyroid gland
extension beyond capsule of thyroid gland
If both sides involved then bilateral tracheoesophageal
groove lymph nodes are dissected
Minimal enlargement of central compartment lymph nodes
observed during thyroidectomy and finding of lateral part of
neck are negative, a central compartment node dissection
is adequate.

77. EXTENDED RADICAL NECK
DISSECTION
Removal of one or more additional lymph node groups or
nonlymphatic structures,or both, not encompassed by the
RADICAL NECK DISSECTION such as
parapharyngeal,superior mediastinal,and paratracheal.

78. Super Selective Neck Dissection
• Limited to 1 or 2 contigous neck levels.
• Most common applied- supraglottic cancers.
• Tumour has high propensity to metastatise to level IIA
& III.
• Role in treatment of residual disease followed by
chemoradiation that is confined to single level.

79. INCISIONS

82. Modified Schobinger Incision

84. Apron Incision

85. Half Apron Incision

87. H INCISION

88. Hetters incision

89. Utility incision

90. LATERAL UTILITY

91. VISOR INCISION

92. EXTENDED THYROID INCISION

93. STEPS OF RND
• 4 MAJOR AND MINOR POINTS OF CONSTERATION
• MAJOR:
-Lower end of internal jugular vein(IJV)
-Junction of clavicle with trapezius border
-Upper end of IJV
-Submandibular triangle

94. • Minor -lymph nodes
-retrophayngeal lymph nodes
-chaissaignac triangle
*Chaissaignac triangle is angle made by longus
colli,scalene anterior,base by subclavian artery and
apex by tubercle of C6 vertebrae(chaissaigac tubercle
*Content:-thoracic duct, vertebral vein and
thyrocervical trunk.

95. • Marginal
Mandibular
and cervical
branch of facial
nerve.

96. Lower end of Internal Jugular Vein
• Main vein draining the primary tumour being removed
divided first.
• Reduce no of systemic metastasis due to release of small
tumour emboli released by manipulation of tumour
• Injury to IJV: risk of AIR EMBOLISM
• SUTURE may slip:put finger on hole ,tilt the patient down
and stitch the hole with non absorbable suture

98. • Houseman‘ s
Suture
• Transfixion
Stitch at the
Lower end.

99. Thoracic duct
• Passes medial to jugular vein,then posterior to it
• Finally curve around to enter the junction of IJV and
subclavian vein.
• Ideally- to be tied off
• Any chyle leak :repair there and then.
• VALSALVA manouver

100. Supraclavicular dissection
• Omohyoid muscle retracted upwards.
• Should not bleed if cut through tendon
• Fat lateral to IJV removed ,prevertebral fascia identified.
• Phrenic nerve is identified (runs over scaleneus anterior .
• Not to breech the prevertebral fascia.
• Chaissagnaic triangle :dissection of scalene node

101. Dissection of posterior triangle
• Imp: accessory nerve (in roof)
• Chance of injury high early in course of dissection
• Identification :
A)Erb`s point: 1 cm above point where greater auricular
nerve winds around the SCM
B)Leaves post border of SCM at upper third and lower two
third.

102. Division of upper end of Internal Jugular
Vein
• Identified by palpating he transverse process of C2
vertebrae
• Retract the posterior belly of digastric upwards.
• Vagus and hypoglossal nerve should be identified and
preserved
• Venous tributaries to venae nervi hypoglossi should be
ligated

103. • Hypoglossal tunnel
• Occipital artery crosses posterior part of IJV ligated
• PRESSURE -4cm of water- bleeding controlled by
packingligation.

104. Dissection of submandibular triangle
• Fourth corner of consternation.
• Anterior belly and posterior belly of digastric visualized
• Mylohyoid muscle is retracted forward to identify the
submandibular duct,lingual nerve is pulled down in a
curve
• Submandibular duct is identified and ligated. And
submandibular gland is removed

106. Closure
Wound is irrigated with normal saline and bleeding point ,if
any,secured.
• Large drain put
• Drain should never cross the carotid sheath
• Final check for any chyle leak,any bleeding
• Wound is closed in two layers with absorbable suture and
skin closed with non-absorbable.
• Any three point junction should be away from carotid
artery.

107. Complications of neck dissection
1)Anaesthetic complication-
• Post operative atelectasis
• Urinary retention/pneumonia
• Deep vein thrombosis

108. Local complications
Haemorrhage
Wound infection
Carotid artery rupture
Chylous fistula
Pneumothorax
Nerve injuries
Cerebral oedema

109. Haemorrhage
Injury to IJV-pressure with finger
-ligation of vein
Injury to carotid arterial system- more tumour invading the
artery,attempts to dissect cancer off a vessel

110. Wound infection
• Contamination of surgical field
• Postoperative hematoma that later get infected..
• Flap necrosis
• Wound breakdown

111. Carotid artery rupture
• Necrosis in arterial wall due to infection
• Common in preoperative radiotherapy (post op salivary
fistula with loss of skin)-surgical debridement with
systemic antibiotics
• Removal of adventitiaincreased risk
• Rupture of artery:ligation; mortality 38% and morbidity
hemiplegia rate 50%

112. Chylous fistula
• <100 ml leak/dayconservative management
Pressure dressing and parental feeding.
• 300ml leak/dayreexploration identifying and repairing
the source of leak.
• Loss of proteins and electroytes
• Lateral thoracotomy- suture between the oesophagus and
descending aorta in posterior and inferior mediastinum

113. Pneumothorax
• Injury to apical pleura
• Air leak at time of surgery
• To be repaired.

114. Nerve injury
• Accessory nerve
• Branches of cervical plexuses-lesser occipital,greater
auricular,transverse cutaneous,supraclavicular nerve
• Descendens hypoglossi

115. Cerebral odema
• Complication of B/L neck dissection
U/L:three fold increase
B/L: 5 fold increase

116. Laryngeal oedema
• If planning on doing B/L Neck Dissection- laryngeal
oedema –elective tracheostomy.

117. NECK METASTASIS FROM
UNKNOWN PRIMARY

118. Unknown or occult primary carcinoma
• Pesentation of metastatic neck lymph adenopathy without
the development of a primary lesion within a subsequent
five year period.
Failure to identify occult primary-
Spontaneous regression of primary tumour
Autoimmune destruction
Accelerated tumour progression

119. • Metastatic carcinoma with no evidence of primary site
after history,physical examination and radiological
imaging.
• Secondary of neck<10% of all unknown primary
• Most likely head and neck primary site: tonsil(45%),base
of tongue(40%) and piriform fossa (10%).

120. Diagnostic steps
• History
• Physical examination:
• complete head and neck examination
ipsilateral otalgia with normal otoscopy
• direct attention to tongue base, tonsil, supraglottis and
hypopharynx.
• Unilateral serous otitis media
• Nasopharyngeal examination

121. Diagnostic work up of patient with
unknown primary
• History
• Physical examination(including skin and scalp)
• Careful examination of neck and supraclavicular lymph
nodes
• Examination of oral cavity,pharynx and larynx

122. Radiological Investigations
• Chest X-ray
• Ultrasonography
• CT scan and MRI of head and neck cancer
• FDF- PET scan of whole body if lower neck node.
• Radionuclide scanning

123. Direct laryngoscopy and directed biopsies
Nasopharynx,tonsils,base of tongue,pyriform fossa and
any suspicious or abnormal mucosal areass
FNAC –fine needle aspiration cytology(accuracy-90%)
Open biopsy or core needle biopsy

124. FNAC
• Adenocarcinoma
upper neck- imaging for salivary gland
• primary found- treat primary and neck
• no primary found- treat neck
Lower neck- rule out thyroid gland malignancy
+ve - thyroidectomy and neck dissection
-ve - metastatic workup

125. Possible histology
• MOST:sq cell ca or poorly differentiated carcinoma
• Adenocarcinoma in neck:rule out salivary gland,thyroid or
parathyroid primary tumours
• Other possibilities:lymphoma,tuberculoma
• Rarely: sarcoma

126. Role of PET IN unknown primary
• Recommended for detecting primary disease and staging
• Define suspicious regions and lymph nodes to biopsy in
head and neck region as well identify metastasis
• FDG-PET is 88.3% sensitive
• 74.9% specific
• 78.8% accurate in detecting unknown primary

127. Role of ipsilateral tonsillectomy
• Ipsilateral tonsillectomy suggested for patients with
submandibular ,subdigastric and mid-jugular nodes as
this may be site of primary disease in 25%-35% of
patients.

128. Pan-endoscopy
• If sq cell carcinoma on FNACpanendoscopy
• Direct visualization of
nasopharynx,oropharynx,hypopharynx,larynx,trachea,
bronchial airway and esophagus.
• Directed biopsy
• - all suspicious mucosal lesions
• -areas of concern on CT or MRI
• - nasopharynx, tonsil, base of tongue,
pyriform fossa,retromolar trigone

129. • Sites of primary tumours are tonsillar fossae and base of
tongue in 82% of cases

130. Treatment of squamous cell ca of unknown
primary head and neck cancer
• Multidisplinary team approach: surgery,radiation and
chemotherapy
• Treatment modality :
• limited neck disease without extracapsular
extentionNeck Dissection or ipsilateral neck radiation
• Nodal disease with extracapsular spread:post op
radiation.

131. Pan mucosal irradiation
• Radiotherapy to the neck and naso-oro-hypopharynx
except when there is a strong suspicion that nasopharynx
is a primary site in which case the hypopharynx may be
spared
• Nasopharynx may be omitted when disease is limited to
lower nodes
• Treatment of both sides of neck

132. MANAGEMENT OF PATIENT
WITH METASTATIC NECK NODE
FROM AN UNKNOWN PRIMARY

133. Complete head and
neck examination
Imaging CT/PET
FNAC
Non
diagno
stic
Repeat
Non
diagnosti
c
Open
biopsy
Benign
Inflamm
atory
Obs
erve
treat
Adenocarci
noma
Upper
neck
Imagiong for
salivary primary
Primary
found’
Excision
Primary not
found
MND
Lower neck
Tgb stain
Positive
Thyroidecto
my
Negative
Metastatic
workup
Systemic
treatment
Melanoma
Search for
primary
None found
mnd
Lymphoma
Core or open
biopsy
Diagnosis
confirmed
Appropriate
treatment and
workup
Squamous
cell
carcinomaUnd
ifferentiated
carcinoma
Multiple
endoscopies
nad directed
biopsy
No primary
found
N1 neck
Mnd
Rt
N2-n3 neck
Mnd/rnd
RT

134. EVALUATION AND
MANAGEMENT OF NECK
OF PATIENT WHO HAD
CHEMORADIATION

135. Completion of CTRT
Clinical assessment at 6 weeks
CT/MRI PET/CT+-CT with contrast at
10-12 weeks
Neck dissection
PET +ve or CT +ve
High SUV or large
volume abnormality
PET –ve /CT –ve
Low volume
abnormality
PET +VE/CT –ve
Low SUV
PET –ve/
CT-ve
Neck
dissection
Observe or
Neck
dissection
Selective
neck
dissection
Excisional
biopsy and
Neck
dissection
Observe