Archives of Otol

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American Head & Neck Society
July 21-25, 2012
Metro Toronto Convention Centre
Toronto, ON, Canada

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Presentation: P103
Topic: Management of the Neck
Type: Poster
Date: Sunday - Tuesday, July 22 - 24, 2012
Session: Designated Poster viewing times
Authors: AD Dragan, MBBS, IJ Nixon, FRCS ORLHNS, TFR Pezier, MRCS, T Guerrero-Urbano, MRCP FRCR PhD, R Oakley, FRCS ORLHNS, JP Jeannon, FRCS ORLHNS, R Simo, FRCS ORLHNS
Institution(s): Head and Neck Unit, Guy’s and St Thomas’ NHS Foundation Trust, London


Diagnosis and management of patients presenting with squamous cell carcinoma (SCC) of unknown primary (CUP) has evolved over the past few decades. Modern imaging combined with targeted biopsies have significantly reduced the number of CUP. Current guidelines recommend treating all neck levels, usually through comprehensive neck dissection (CND) – which may result in significant morbidity particularly in relation to the spinal accessory nerve (SAN) - followed by panmucosal radiotherapy or chemoradiotherapy. The aim of this study is to define the pattern of metastasis in a contemporary group of CUP patients, with special emphasis on the anatomical distribution of the neck levels involved.

Materials and Methods:

Retrospective case note review of a consecutive cohort of CUP patients diagnosed in our institution between 2000-2011. All patients were evaluated with ultrasound guided fine needle aspiration cytology, computerized tomography of the neck and chest, panendoscopy and multiple site biopsies and from 2007 with Positron Emission Tomography (PET-CT). All were discussed at the multidisciplinary tumour board meeting before treatment. Demographic, staging, treatment, histopathological and outcome data were collected.


25 patients were identified, 18 (72%) were male. The median age was 60 years (range 42-87 years). 19 (76%) underwent comprehensive (CND) and 6 selective ND. 2(8%) were pN1, 18(72%) pN2 and 5(20%) pN3. The median follow up was 33 months. The 5 year overall survival, disease specific survival (DSS) and regional recurrence free survival (RRFS) were 70%, 76% and 80% respectively. Analysis of DSS and RRFS revealed that only the need for an extended neck dissection was predictive of poor outcome.

Univariate analysis of oncological outcomes
Variable     No 5yDSS p value 5yRRFS p value
cN N1 1 100%   100%  
  N2 13 88%   89%  
  N3 11 60% 0.361 69% 0.301
Neck SND 6 75%   75%  
  MRND 8 100%   100%  
  eMRND 4 50%   50%  
  RND 5 67%   75%  
  eRND 2 100% 0.064 100% 0.103
SND Yes 6 75%   75%  
  No 19 78% 0.854 83% 0.868
ExtendedND Yes 6 60%      
  No 19 100% 0.006    
pN N1 2 100%   100%  
  N2 18 78%   79%  
  N3 5 50% 0.729 75% 0.759
Extracapsular spread No 8 100%   100%  
  Yes 14 55% 0.135 64% 0.124

732 nodes were excised in total, 71 (10%) contained metastatic SCC. There were 95 nodal basins analyzed from the CNDs. 65 (68%) were clinically N0. Of these, 5 basins (8%) harbored metastatic disease on pathological examination. The occult disease rate was 0% for level I, 40% level II, 10% level III and 6% for levels IV and V. 0 patients harbored occult metastases in level I and only 1 patient (clinically staged as cN3) had a micrometastasis in level V, below the SAN (Vb), giving a rate of occult disease in level V of 6%.

Rate of occult disease


The rate of occult regional metastasis is low in patients with CUP (8%). Most patients considered free of disease in level I or V should be considered for selective ND, with the potential benefit of sparing both submandibular gland and SAN function, without compromising the oncological outcomes.

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