Robert P Zitsch III and Russell B Smith


Cancer in the head and neck region commonly manifests in an otherwise asymptomatic patient as metastatic disease to the cervical lymph nodes. In most cases, a complete history and physical examination are sufficient to ascertain the primary site of origin of the metastatic disease. The primary lesion is found to be in the head and neck region at least 70% of the time.1'2 Occasionally, however, the primary lesion responsible for the cervical metastasis is found to have originated at a site remote from the head and neck, and therefore, metastatic neck disease often represents a distant metastasis from this primary site.

Among those patients with head and neck cancer presenting with cervical lymph node metastases, a primary lesion may sometimes fail to be identified despite a thorough diagnostic evaluation. This is reported to occur in approximately 5% of all patients presenting with cervical lymph node metastases, and the term occult primary or unknown primary has been commonly used to describe this clinical situation.1 The diagnosis of metastatic cancer to the neck from an occult primary requires histologic or cytologic evidence of malignancy in a cervical lymph node as well as the failure to identify the primary site of origin after a systematic, comprehensive search. Thyroid cancers and lymphomas are excluded from this definition. Traditionally, this search has implied a complete history, a thorough physical examination of the upper aerodigestive tract, and multiple endoscopic examinations (direct laryngoscopy, esophagoscopy, bronchoscopy, nasopharyngoscopy) under anesthesia, usually with random or directed biopsies.

There are several controversial issues regarding both the assessment and the treatment of patients with cervical metastases from an unknown primary site. In the realm of assessment, controversy arises over which of the diagnostic studies should be routinely done in order to find the primary site. Imaging studies such as computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), and 2-[fluorine-18]-2-deoxy-D-glucose single photon emission computed tomography (FDG-SPECT) for surveillance of potential primary sites are central to any assessment controversy.3 In addition, the role of serologic Epstein-Barr viral (EBV) tests or EBV genomic DNA assays in patients with cervical lymph node metastases from an occult primary is also uncertain.4 Furthermore, the routine use of random aerodigestive tract biopsies and routine ipsilateral tonsillectomy in the diagnostic workup has been recommended by some and rejected by others.3,5

New technology that has been found to be useful in the assessment of head and neck cancer patients has not always generated controversy. Rigid and flexible endoscopes, generally regarded as indispensable for conducting a thorough examina tion of the pharynx and larynx today, have been an obvious improvement over the traditional indirect examination methods, particularly for the nasopharynx.

As with most head and neck cancer patients in general, both radiotherapy and surgery have important roles for patients having metastatic cervical disease with an occult primary. Some disagreement exists about whether single-modality treatment, particularly surgery, should be used for earlier-stage disease. The routine practice of irradiating potential primary mucosal sites has also been challenged. Finally, a role for chemotherapy in this group of patients has been suggested.

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