Several factors impact on the outcome of these patients. These issues include histology, the location and number of lymph nodes in the neck, the presence or absence of extracapsular spread of disease, and the treatment decision. Preventing the development of the primary tumor appears to enhance prognosis.

Adenocarcinoma has a generally very poor prognosis. Lee et al.4 studied a group of 223 patients with metastatic adenocarcinoma to the neck from an occult primary. The supraclavicular fossa was the presenting site of involvement in 77% of these patients. Only 14% presented with nodes in the upper neck, classified in this study as above the cricoid cartilage; 84% of these patients also had metastatic disease outside the head and neck region. Treatment of these patients involved combinations of neck dissection, radiotherapy, and chemotherapy. There was a 90% mortality at 5 years. The mean survival was 17 months. Patients in this group with unilateral neck disease and with nodes confined above the cricoid cartilage had a slightly increased survival rate.

Patients with squamous cell carcinoma, in general, have a better prognosis than those with adenocarcinoma. The overall survival at 5 years for these patients is approximately 50%.38,39 Again, however, supraclavicular nodes with squamous cell carcinoma have a very poor prognosis, with approximately 15% surviving only 3 to 5 years.7 Patients with lymph nodes confined to the upper neck and those without extracapsular spread of disease have a better prognosis.

N1 nodal disease has a very favorable prognosis whether treated with surgery alone, with excisional biopsy and radiation therapy, or with neck dissection and radiation. Five-year disease specific survival rates for this group of patients ranges from 70% to 900/o.13'15'38'44 Early open nodal biopsy does not appear to compromise prognosis as long as radiation is included in subsequent treatment. Patients with N2 to N3 nodal disease do not fare as well. Five-year disease-specific survival rates reported for these patients range from 30% to 60%.37,44-46

The rate of distant metastases increases with nodal stage. In Colletier's study, the patients with multiple nodes had a rate of 23% versus 8% in those who presented with a single node in the neck.

For those patients with advanced disease, the prognosis has improved in recent years with the use ofhyperfractionated irradiation and concurrent chemotherapy. In Brizels' study, 122 patients with advanced head and neck cancer were treated with hyperfractionated RT with or without concurrent chemotherapy.53 Most of these patients had unresectable disease. The 3-year overall survival rate was 55% in the combined therapy group and 34% in the hyperfractionation radiotherapy group. The rate of local regional control of disease at 3 years was 70% in the combined treatment group versus 44% in the radiotherapy-only group. This study supports an increasing role for chemotherapy in the management of patients with advanced or unresectable disease. Other series also report encouraging results.54

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