NECK UNKNOWN PRIMARY NECK ANTOMY

1. Level system of lymph nodes of
neck , management of
UNKNOWN PRIMARIES OF NECK
TOPIC PRESENTATION
28-5- 2015
DR MUHAMMED MUNEER M
MS GENERAL SURGERY
SGMC & RF
TRIVANDRUM KERALA

2. Anatomy of Neck

3. • Neck
– Anterior cervical region
of neck
– Sternocleidomastoid
region
– Lateral cervical region
of neck
– Posterior cervical
region

4. ANTERIOR
TRIANGLE
Suprahyoid region
-submental
triangle
-submandibular
triangle
(Digastric)

5. POSTERIOR
TRIANGLE
-Occipital triangle
-Subclavian
triangle
(Omoclavicular
triangle)
Triangles of lateral region of neck

8. • SUBMENTAL LYMPH NODES
drain superficial tissues below chin
central part of lower lip
adjoining gums
ant part of floor of mouth
tip of tongue
Efferents pass to submandibular nodes.

10. • SUBMANDIBULAR LYMPH NODES
• Drain
- centre of forehead
- nose with frontal,ethmoid,maxillary
sinus
- inner canthus of eyes
- upper lip and ant part of cheek with
underlying
gum and teeth.
-ant 2/3 of tongue excluding tip and
floor of mouth

13. • MUSCULAR TRIANGLE
Ant: median line of neck from
hyoid bone to sternum
Post sup: sup belly of OH
Post inf : ant border of SCM
CONTENTS
sternohyoid,
sternothyroid,thyrohyoid
thyroid & parathyroid

14. • Sternocleidomastoid
muscle
-Superior part of
external jugular vein
- Greater auricular
nerve
- Transverse cervical
nerve
- Lesser occipital nerve

15. POSTERIOR TRIANGLE

17. CONTENTS
CERVICAL PLEXUS
-Lesser occipital N
-Great auricular N
-Ant cutaneous N of neck
-Supraclavicular N
UPPER PART OF BRACHIAL PLEXUS
-Dorsal scapular N
Transverse cervical vessels
Occipital artery
OCCIPITAL TRIANGLE

18. • Bounded by post border of SCM
• Middle 3rd
of clavicle and
• inf belly of omohyoid.
• Covered by skin ,superficial facia
and investing layer
• Floor: prevertebral fascia &
inf part of scalenus
SUBCLAVIAN TRIANGLE

19. CONTENTS
-Trunks of brachial plexus
-N to serratus anterior
-N to subclavius
-Suprascapular N
-Subclavian vessels(3rd
part)
-suprascapular artery&vein
-transverse cervical artery
SUPRACLAVICULAR NODES

20. Groups of Lymph nodes in the neck
Superficial and deep arranged
Horizontally/Vertically
Superficial
1. Submental, Submandibular
2. Parotid
3. Pre auricular/post auricular
4. Occipital
LYMPH NODES OF NECK

21. Central
Lateral
Central :-
 Prelaryngeal
 Pretracheal
 Paratrachial
 Retropharyngeal nodes
Lateral
 Ant.Superior and Ant.Inferior
 Post.superior and Post. Inferior
Central :-
 Prelaryngeal (Delphian)
 Pretracheal
 Paratrachial
 Retropharyngeal nodes
Lateral
 Ant.Superior and Ant.Inferior
 Post.superior and Post. Inferior
Central
Lateral
Deep

22. Lymph Node Levels/Nodal
Regions

23. • Developed by Memorial Sloan-Kettering
Cancer Center
• Ease and uniformity in describing regional
nodal involvement in cancer of the head
and neck
Lymph node levels/Nodal
regions

25. • Level I: Submental and submandibular
triangles

26. • Levels II, III, IV: nodes associated with IJV
within the adipose tissue. (lie underneath
the sternocleido mastoid)
Lymph node levels/Nodal
regions

27. • Level II: Upper jugular chain,
Lymphnodes located around upper 3rd
of
IJV
jugulodigastric and upper posterior
cervical nodes.
Boundaries - hyoid bone (clinical landmark)
carotid bifurcation (surgical landmark)
Anteriorly- lateral border of sternohyoid
Posteriorly- posterior border of sternocleidomastoid
Lymph node levels/Nodal
regions

28. • Level III: Middle jugular nodes
• Boundaries
• above: inf border of hyoid bone
• below: inf border of cricoid cartilage
• Jugulo-omohyoid node-
• Level IV: Lower jugular nodes
• Boundaries- cricoid cartilage above
• clavicle below
Lymph node levels/Nodal
regions

29. • Level V: Posterior triangle of neck
Boundaries - Posterior border of
SCM, Anterior border of trapezius
Clavicle below
Lymph node levels/Nodal
regions

30. • Level VI: Anterior compartment
structures (hyoid bone - sup
• suprasternal notch – inf
, medial border of carotid sheath on either
side
• Level VII: superior mediastinal lymph
nodes
(superior-suprasternal notch
inferior-aortic arch)
Lymph node levels/Nodal
regions

31. Lymph Node Subzones
XIXI
XI
VII Superior mediastinal lymph nodes

32. Subzones of Levels I-V

34. • Suggested by Suen and Goepfert (1997)
• Biologic significance for lymphatic
drainage depending on site of tumor
– Level I subzones
• Lower lip, ventral tongue ,ant mandibular alveolar
ridge – Ia
• oral cavity, ant nasal cavity, soft tissue structures
of mid face
• submandibular gland – Ib
Rationale for subzones

35.  Level II subzones
IIA – ant to spinal accessory N
IIB – post to spinal accessory N
• Oral cavity ,nasal cavity, Oropharynx,
nasopharynx hypopharynx , larynx and
parotid
 Level III
jugulo omohyoid node
oral cavity, nasopharynx, oropharynx,
hypopharynx and larynx
Rationale for Subzones

36. – Level IV subzones
hypopharynx, cervical oesophagus & larynx
Virchows node is located in level IV
– Level V subzones
Va- spinal accessory nodes
Oropharynx, nasopharynx,– Va
Vb- nodes following transverse cervical vessels &
supraclavicular node
Thyroid- Vb
Va & Vb- horizontal plane marking the inf border of
cricoid cartilage
Rationale for Subzones

37. Staging of the Neck

38. • “N” classification – AJCC
• Consistent for all mucosal sites except the
nasopharynx
• Thyroid and nasopharynx have different
staging based on tumor behavior and
prognosis
• Based on extent of disease prior to first
treatment
Staging of the neck

40. AJCC Nodal Staging

41. • NX: Regional lymph nodes cannot be
assessed
• N0: No regional lymph node metastasis
• N1: Metastasis in a single ipsilateral
lymph node, < 3cm.
• N2a: Metastasis in a single ipsilateral
lymph node 3 to 6 cm
Staging of the neck

42. • N2b: Metastasis in multiple ipsilateral
lymph nodes < 6 cm
• N2c: Metastasis in bilateral or
contralateral nodes < 6cm
• N3: Metastasis in a lymph node more
than 6 cm in greatest dimension
Staging of the Neck

43. Unknown primary
• A lymph node in the neck with malignant
pathology without any obvious primary
mucosal origin.
• Head and neck unknown primaries are
generally squamous cell carcinomas
• Incidence: 2-3% of head and neck
cancers are unknown primaries .

44. Clinical Presentation
• Patients generally present with a painless,
solitary neck mass, most often discovered
by the patient.
• Masses are usually at least 2-3 cm
• Patients have usually gone through at
least one course of antibiotics
• Benign masses are also often solitary and
painless

45. Differential diagnosis
• Benign
– Developmental (i.e., thyroglossal duct cyst,
branchial cleft cysts or inclusion cysts)
– Inflammatory (i.e., lymphadenitis, benign
reactive hyperplasia, infected sebaceous cyst)
– Benign Neoplasms (i.e., lipoma, fibroma,
hemangioma, neurofibroma, parathyroid
adenoma or goiter)

46. Differential diagnosis
• Malignant
– Metastatic carcinoma, sarcoma or melanoma
– Lymphoma, Leukemia
– Carotid body tumor
– Primary major salivary gland tumor
– Thyroid cancer
– Parathyroid cancer
– Histiocytosis
– Carcinoid

47. Relationship of Node Location to
Likely Disease
• Nodes at certain levels more likely certain
primaries
• Upper neck nodes are the most likely to
be head and neck cancer
– Subdigastric node may be virtually any head
and neck primary, or a non-Hodgkin’s
lymphoma
– Submandibular node suggests oral cavity, lip,
nasal vestibule or salivary gland primary
– Submental nodes are uncommon

49. Relationship of Node Location to
Likely Disease
• Mid Neck
– Likely primaries include larynx, hypopharynx, and
less commonly esophagus, disease below
clavicles or lymphoma
•Lower Neck and Supraclavicular Nodes
– Most often metastatic from chest or abdomen,
possible esophagus or lymphoma. A primary
head and neck node is uncommon at this level
Parotid lymph nodes are more likely skin cancer
than from a primary parotid tumor
Benign neck masses are most common except in
supraclavicular lymph nodes

50. Percentage of patients presenting
with neck nodes who go on to
develop squamous cell carcinoma
Erkal HS, Mendenhall WM et al. Squamous cell carcinomas metastatic to cervical lymph nodes from an unknown head-and-neck mucosal site
treated with radiation therapy alone or in combination with neck dissection. Int J Radiat Oncol Biol Phys 2001a;50:55-63

51. Diagnosis
Physical exam
• Soft, rubbery nodules suggest lymphoma
and leukemia
• Hard, fixed masses suggest carcinoma
• Indirect examination of oral cavity and
oropharynx with mirror and/or fiberoptic
endoscopy
• Panendoscopy – laryngoscopy, bronchoscopy, and esophagoscopy

52. Diagnosis
Biopsy
• Fine needle biopsy of LN
• Incisional or excisional biopsy before
definitive treatment have increased rates
of neck recurrence, distant metastasis and
wound necrosis compared to patients
without a biopsy.

53. Diagnosis
Imaging
• CT followed by an MRI if inconclusive
• If there is still no imaging data for a primary, a
PET may be ordered
– In a meta-analysis of 16 studies looking at the role of
PET in 302 patients with cervical node metastases
where a primary has yet to be discovered through the
work up, 25% of primaries are identified through PET.
Previously unrecognized regional or distant
metastases were identified in 27% of patients
• Rusthoven, KE, Koshy, M, Paulino, AC, The role of fluorodeoxyglucose PET
in cervical lymph node metastases from an unknown primary tumor. Cancer
2004; 101:2461

55. Diagnosis
Laryngoscopy
• Direct laryngoscopy with biopsies of
nasopharynx, tonsils, base of tongue,
pyriform sinuses as well as any suspicious
areas seen on imaging.

56. Diagnosis
Screening Tonsillectomy
• If a primary site has not been discovered by this
point, an ipsilateral screening tonsillectomy may
be performed
– This is of greatest benefit in patients with
subdigastric, submandibular or midjugulocarotid
lymph nodes
– primary can be found in 10 to 25% of cases - Small
tumors may originate in the deep crypts and not be detected
by superficial biopsy

57. Treatment
• Treat as aggressive disease
• Treat based on staging
• N1- neck dissection (MRND) OR radiation( if positive
margins,capsular invasion,)
• N2, N3- combined neck dissection AND radiation
• N2a & 2b –mobile->RND followed by RT, fixed nodes  RT
followed by RND.
• N2 c-B/L RND followed by RT.
• N3- resectable->RND followed by RT+ CHEMO.
• unresectable-RT followed by RND when it is resectable.
• Treat as locally advanced head and neck cancer

58. Treatment
• N1 with a history of excisional or incisional
biopsy- neck dissection and radiation
• N2a with no persistent tumor after
radiation may forego neck dissection
• Incisional or excisional biopsy before
definitive treatment have increased rates
of neck recurrence, distant metastasis and
wound necrosis compared to patients
without a biopsy.

59. Radiation- Dosing
• Dose to mucosa- 50 to 70 Gy
• Dose to the neck- 59 to 70 Gy
• Neck 55Gy at 180 cGy fractions with
addition 500 to 1000cGy in 3-5 fractions to
any suspected site. Spinal cord to max
45Gy
• Lateral-opposed fields

60. IMRT
• Part of the purpose of using IMRT is to
decrease dose to the parotid, in order to
decrease the grade of xerostomia and
improve dose homogeneity
• Bhide, S et al. Intensity modulated radiotherapy improves target coverage and parotid
gland sparing when delivering total mucosal irradiation in patients with squamous cell
carcinoma of head and neck of unknown primary site. 2007; 32(3):188-95
• Can also keep dose off of the larynx

61. IMRT
• 21 patients underwent IMRT for unknown primary either
as initial treatment or post-op. Median dose was 66Gy.
During treatment 57% patients developed grade 1
xerostomia and 43% developed grade 2 xerostomia. The
researchers concluded IMRT shows acceptable toxicity
and encouraging efficacy. Patients had marked
improvement of xerostomia by 6 months. Three patients
developed esophageal strictures, and were effectively
treated with dilation. Techniques to limit esophageal
dose may help further minimize this complication.
Klem ML et al, Intensity-modulated radiation therapy for head and neck cancer of unknown
primary. 2006 ASCO Annual Meeting

62. Radiation
• Ipsilateral neck vs. bilateral neck, Bilateral favored
• Some studies show increase risk of neck disease or emergence of
primary with ipsilateral treatment compared to bilateral without
overall survival being affected
• Alternate studies show extensive radiation of
mucosa and bilateral neck improve survival
compared to ipsilateral neck radiation
– Study of 352 patients with squamous cell or
undifferentiated cancer of the cervical lymph nodes
with no evident primary, the patients who received
ipsilateral neck radiation compared to those receiving
bilateral had a 1.9 relative risk of recurrence in the
head and neck and lower 5 year disease free survival
• Grau, C Johansen, LV, Jakobsen, J et al. Cervical lymph node metastases from
unknown primary tumours. Results from a national survey by the Danish Society for
Head and Neck Oncology. Radiother Oncol 2000;55:121.

63. Radiation by levels
– Radiation fields need to include neck and potential
primary sites (decreased subsequent incidence of
primary tumor)
• Level I: no mucosal radiation recommended due
to potential extensive morbidity
• Levels II and V: radiation field should include
naso- and oropharynx
• Level III: radiation field should include naso,
oropharynx. It is generally not recommended to
include hypopharynx and larynx as well, since
these are of low probability as primary site, and
have an increased probability of complications.

64. Radiation by Node location
• Upper nodes
– Naso-, oro- and hypopharynx and supraglottic
larynx. Oral cavity not included
• Junctional or lateral retropharyngeal node
– Naso- and oropharynx
• Submandibular- solitary node
– Neck only because of the major morbidity of
irradiating the entire oral cavity
• Midjugular
– Oro-, hypopharynx and supraglottic larynx
• Supraclavicular
– Large portal to include apex of axilla

65. Complications of Radiation Therapy
• Most common complication is xerostomia (dry
mouth due to decreased saliva production)
• Also, fatigue
• Mucositis
• Altered taste sensations
• Red and irritated skin
• Occasional nausea
• Esophageal stricture

66. Chemotherapy
• Platinum-based chemotherapy in combination
with radiation recommended for N3 patients by
European Society of Medical Oncology (ESMO)
• Consider concurrent chemo/RT with
supraclavicular LN or undifferentiated tumors,
though no strong data to support
• Chemo/ RT is an option for palliation,
unresectable local disease, distant metastatic
spread

67. Treatment outcomes

68. Recurrence
• Comparing subsequent mucosal primary
lesions in patients with unknown primaries
to head and neck cancer with a known
primary site shows the incidence of a
subsequent mucosal recurrence was
similar for both groups.

69. Percentage of unknown primaries
compared to known sites to
develop mucosal recurrence
Erkal HS, Mendenhall WM et al. Squamous cell carcinomas metastatic to cervical lymph nodes from an unknown head-and-neck
mucosal site treated with radiation therapy alone or in combination with neck dissection. Int J Radiat Oncol Biol Phys 2001a;50:55-63

70. Prognosis
• The best indicator of prognosis is N stage
at presentation
• Also, the presence of extracapsular
extension is associated with a poorer
prognosis
• Prognosis is similar between patients with
a known vs. an unknown primary with the
same nodal stage.

71. Survival by N stage
Erkal HS, Mendenhall WM et al. Squamous cell carcinomas metastatic to cervical lymph nodes from an unknown head-and-neck
mucosal site treated with radiation therapy alone or in combination with neck dissection. Int J Radiat Oncol Biol Phys 2001a;50:55-63

72. Cervical Lymph Nodes --
Treatment
• Typical approach
– Neck dissection
– Followed by radiation therapy
• Controversy exists
– Either treatment modality alone
– Extent of radiation
• Bilateral neck and total mucosal has high morbidity
• Localized radiation to ipsilateral neck alone
• Retrospective studies suggest more aggressive approach
improves local control and survival
• Prognosis depends on extent on lymph node
involvement
– Long term local control 50-75% of patients
– Five-year survival 40-60%

73. Treatment
• Historically combination chemotherapy
used
– 5fu, cisplatin, adriamycin or mitomycin
– Response rates 0-40%
– Median survival 3-8 months
• Recent combinations included taxanes
– Carboplatin, paclitaxel and oral etoposide
– Hainsworth et al reported
• Response rate of 47%
• Median survival of 13 months
– Other trials not as impressive results

74. Newer agents
• Gemcitabine and Docetaxel combination
– Cisplatin refractory disease
– Response rate 28%
– Median survival 8 months
• Molecular agents
– Herceptin for Her-2-neu positive disease
– VEGF inhibitors
– EGFR inhibitors
– Proteosome inhibitors

75. THANK YOU