A case of oral cancer with delayed occipital lymph node metastasis: Case report

Consideration of unexpected metastasis in patients who have undergone neck dissection with advanced tumors must be anticipated with careful follow-up

A study of neck secondaries in pharyngeal and laryngeal malignancies.

Lymphatic metastasis is the most important mechanism in the spread of head and neck malignancies. The rate of metastasis probably reflects the aggressiveness of the primary tumour and is an important prognosticator. Not only the presence, but also the number of nodal metastases, the level in the neck, the size of the nodes and the presence of extracapsular spread are important prognostic factors. Majority of the cervical metastases were due to squamous cell carcinoma of the head and neck. • Certain primary sites had a predilection for certain group of nodes. • Thus in this study, the incidence of cervical nodal metastasis is highest for: i. Nasopharyngeal tumours (100%) followed by ii. Hypopharyngeal tumours (87%) iii. Oropharyngeal tumours (83%) and iv. Laryngeal tumours (57%) • Lesions of nasopharynx metastasise to levels II and V. • Lesions of oropharynx metastasise to levels II, III and I. • Lesions of hypopharynx metastasise to II, III and IV and a small proportion to level VI. • Lesions of larynx metastasise to levels II and III and a small proportion to levels IV and VI. • Most of the patients presented with positive nodes belonged to N2 stage followed by patients in N1 stage. • Jugulodigastric nodes (level II) are involved more often than other groups or other levels of nodes. • In most of the cases, increasing size of the primary had increasing number of nodes as well as an increasing ‘N’ stage

Clinicopathological evaluation of cervical nodal metastasis in pharyngeal and laryngeal tumours

AIMS AND OBJECTIVES • To determine the incidence of cervical node metastasis by the site of primary. • To describe the distribution of neck node secondaries by the site of primary. • To correlate individually the size of tumour with the incidence of cervical node metastasis and the time of initial presentation. • To determine the different types of malignancy. DESIGN OF STUDY PRIMARY PURPOSE: Clinicopathological evaluation PERIOD OF STUDY : From November 2010 to November 2011. SELECTION OF STUDY SUBJECTS: Ages Eligible for Study : 18 Years to 80 Years Genders Eligible for Study : Both Total no of patients included in the study : 61 Inclusion Criteria: All patients presenting with swelling in the neck with palpable nodes more than 1 cm in size, firm to hard in consistency and spherical rather than ovoid. All patients with palpable nodes in the site of drainage of the primary. Exclusion Criteria: Inability to fully evaluate or confirm diagnosis by histology. DATA COLLECTION: Through clinical examination followed by biopsy and FNAC reports. METHODOLOGY A detailed history was obtained including information as to whether the patient had ENT, respiratory, gastrointestinal or urinary symptoms. A complete physical examination was then carried out including a postnasal examination and an indirect laryngoscopy for characteristics of primary in terms of site, extent, size, macroscopic appearance, degree of local infiltration, presence of synchronous lesion and the T Stage. The palpable nodes were considered significant if they were more than 1 cm in size, firm to hard in consistency, spherical rather than ovoid and those in the site of drainage of the primary. The important features noted regarding the nodes during palpation include the location, level of the node, size, consistency, number of nodes and the group to which they belong, as well as signs of extracapsular spread such as invasion of the overlying skin, fixation to deeper tissues or paralysis of cranial nerves or sympathetics. The presence of contralateral nodes and the N-stage was also determined. The clinical impression of the first observer was confirmed by atleast one other observer. A fine needle aspiration cytology of the nodes was then done. Biopsy from the primary site was done in all cases to know the nature and degree of differentiation of the primary. RESULTS Out of the 61 patients selected for the study, males predominate over females with a male to female ratio of 5.8:1. The age incidence is identical to that seen in the West with the maximum incidence in the sixth decade. CONCLUSION Majority of the cervical metastases were due to Squamous cell carcinoma of the head and neck. Certain primary sites have a predilection for certain groups of nodes. Incidence of cervical node metastasis was highest for Nasopharyngeal tumours (100%), followed by Hypopharynx (83%), Oropharynx (82%) and Larynx (71%). In most of the cancers in the study, it is observed that increasing size of the primary had increasing number of nodes as well as an increasing nodal stage

A study of malignant cervical lymphadenopathy with unknown primary

BACKGROUND: Head and Neck cancers account for 3% of all newly discovered cancers metastatic carcinoma within cervical lymphnodes with an unknown primary tumour site accounts for 3-5% of all head and neck cancers, this highlights the need for proper systematic screening and management of secondaries neck with unknown primaries. Objectives. The most common histopathological type common in our population and the age and sex incidence of the malignant cervical lymphadenopathy with an unknown primary, the staging of the disease, interpretation of possible site of primary based on nodal involvement and various investigations to identify the primary site and ideal treatment modality for the patients studied and reported METHODOLOGY: Patients with malignant cervical lymhadenopathy are diagnosed in department of General Surgery at Government Royapettah hospital.43 of them are to be selected, detailed history is elicited from the patient thorough clinical examination of the patient is done and disease staged according to TNM Classification. FNAC / histopathological study of the tumour is done and age and sex incidence of disease also done RESULTS: The results of the study like histopathological types, age and sex incidence of diseases and topographical distribution of disease are identified and put on the tables CONCLUSION: With all the available investigations the unknown primary sites were being tried to identified and treatment like neck dissection and or adiotherapy/chemotherapy were done for the patients

Diagnostic accuracy of colour Doppler ultrasonography in evaluation of cervical lymph nodes in oral cancer patients

This study was conducted in the Department of Oral Medicine and Radiology, Tamil Nadu Government Dental College and Hospital, Chennai-3; Barnard Institute of Radiology, Madras Medical College, Chennai-3; Goschen Institute of Pathology, Madras Medical College, Chennai-3.Study comprised 80 Adult Subjects with clinically and histopathologically diagnosed Oral cancer of either gender with age range of 20-60 years. To avoid over-diagnosis of lymph nodes in patients with oral cancer, study was divided in two groups based on clinical criteria. Group-I included 40 patients with clinically suspected Metastatic cervical lymph nodes, Group-II included 40 patients with clinically suspected Reactive Cervical lymph nodes. In summary our study support the fact that each node involved in patient with oral cancer should not be considered as metastatic, which can lead to unnecessarily treatment of neck. Our study also showed that risk of metastasis is more in oral cancer patient with advance staging (T4 in 58.75% patients) as well as in patient with bone involvement. In this study we found that most commonly involved cervical lymph nodes in patients with oral cancer are Level (85.4%) followed by Level II (10.7%) and Level III (3.9%). Bilateral lymph node was more common with oral cancer involving tongue followed by alveolus. Cervical lymph node involvement is a single most important factor in treatment and prognosis in patient with oral cancer, as regional metastasis decreases the survival rate significantly. So there is need to evaluate the neck thoroughly for any lymph node involvement in oral cancer patients which is not possible clinically (sensitivity=79.8%, specificity=100%, accuracy=84.8%) as our study have shown. CDUS being a non-invasive, real-time procedure and easily applicable tool for the detection of alterations in the vasculature of lymph nodes may reduce the patient morbidity and therefore is of great clinical importance. In our study all of the findings suggested superiority of CDUS over clinical evaluation. In CDUS evaluation, flow pattern (sensitivity = 94.1%, specificity = 100%, accuracy = 95.4%) is more accurate than the vascular indices (sensitivity = 81.4%, specificity = 100%, accuracy = 85.5%) in differentiating metastatic from reactive lymph nodes in oral cancer patients. From our study we conclude that CDUS plays a definitive role as an adjunct to clinical evaluation of differentiating metastatic from reactive cervical lymph involvement in patients with oral cancer as it aid in grading and staging of oral cancer and can determine the treatment plan prognosis and morbidity by diminishing the possibility nodal dissection. However, results of our study on diagnostic accuracy of Colour Doppler ultrasonography in evaluation of cervical lymph nodes in oral cancer patients can be validated with more studies involving large number of oral cancer patients

Clinico Pathological study of Secondaries in Neck with Unknown Primary Cancer Prospective study

BACKGROUND: Cancer of Unknown Primary (CUP) constitute of a heterogenous group of malignancies presenting with lymph nodes of distant metastases. Metastasis of Neck lymph node from an occult primary contribute to 5-10% of patients. With advancements in diagnostics and detection techniques incidence appears decreasing. Management of metastases from unknown origin remains a therapeutic challenge. Hence this study is done to assess the Clinicopathological patterns of presentation of neck lymph node metastases and its multimodality of managements. OBJECTIVES: 1. To assess the clinico-pathological patterns of presentation of cervical lymph node metastases among patients with Carcinoma of Unknown Primary in a tertiary care hospital in Coimbatore, Tamil Nadu. 2. To study the various modalities of treatment for them. METHODOLOGY: All patients presenting to the department of general surgery, Coimbatore Medical College Hospital during one year period with neck node as the presentations were evaluated. After institute ethical clearance and informed written consent detailed clinical examination of the patient were done, followed by the pathological and radiological examination. RESULTS: Total of 30 patients with FNAC confirmed malignant cervical Lymphadenopathy were included in the study. The mean age of the study participantswas 57 + 12.5 years.(60%) were squamous cell carcinoma followed by adenocarcinoma in 26.7%.90% of had stage III cancer and 10% of them had stage IV cancer. Primary site of malignancy was unidentified and patient underwent multimodality of treatment. CONCLUSION: The commonest histology was squamous cell carcinoma followed by Adenocarcinoma and the primary site of cancer could not be diagnosed. Males and elderly were commonly involved compared to females. Combined modality of approaches involving surgery, radiotherapy and chemotherapy were used to manage the patient with carcinoma of unknown primary

A Meta-analysis of the randomized controlled trials on elective neck dissection versus therapeutic neck dissection in oral cavity cancers with clinically node negative neck

Die optimale Behandlung des klinischen N0 Halses bei Mundhöhlenkarzinomen wird in der Literatur kontrovers diskutiert. Je nach Größe und Lage des Primärtumors sowie der Histologie liegt die okkulte Metastasierungsrate bei Patienten mit klinischem N0-Hals bei circa 30%. Kopf-Hals-Onkologen und - Chirurgen stehen daher vor der Herausforderung, die Untergruppe der Patienten mit zervikalen, nodalen Mikrometastasen zu identifizieren, die einer elektiven Neck dissection zugeführt werden sollten. Die alleinige Palpation ist zur Bestimmung des Lymphknotenstatus absolut unzureichend. Die Sensitivitätsraten der bildgebenden Verfahren liegen trotz Verbesserungen in den letzten Jahren jedoch weiterhin nur bei 70 - 80%. Trotz der Zunahme an Wissen und Fortschritt in der Krebstherapie gibt es noch keine Methode zur korrekten Bestimmung der tatsächlichen Metastasierungssituation im Bereich des Halses. Obwohl Plattenepithelkarzinome des Kopf-Hals-Bereiches eine große Neigung zur Bildung von locoregionären und distanten Metastasen haben, konnten verschiedene Studien zeigen, dass vor allem Tumore in frühen Stadien häufig nicht metastasieren. Die Operation von Patienten ohne manifeste Lymphknotenmetastasen führt zu unnötigen Kosten, einer Verlängerung des Krankenhausaufenthalts und vermeidbaren Komorbiditäten. Wird der Hals jedoch nicht in das Therapiekonzept miteinbezogen obwohl nicht identifizierte Mikrometastasen vorliegen, kann dies zu einem unvorteilhaften Behandlungsergebnis mit erhöhter Morbidität und Mortalität führen. Die Realität ist, dass bei einigen Patienten mit klinischem N0-Hals keine Lymphknotenmetastasen bestehen und diese Patienten nicht überbehandelt werden dürfen. Die optimale onkologische Therapie der Halslymphknoten muss daher zum Ziel haben, die Funktion zu erhalten und die Morbidität nach Möglichkeit zu minimieren, was eine multidisziplinäre Behandlung erfordert. Obwohl viele retrospektive Studien zu oralen Karzinomen mit klinischen N0- Hals und deren Therapiemodalitäten vorliegen, gibt es keinen Konsens über die optimale Therapie und den etwaigen Nutzen einer elektiven Neck dissection bei Patienten mit Mundhöhlenkarzinomen und N0-Hals. Es gibt in der Literatur nur wenige prospektive Studien zu diesem Thema und es gibt bisher keine Evidenz, ob eine elektive Neck dissection einer therapeutischen Neck dissection bei Patienten mit Mundhöhlenkarzinomen und N0-Hals überlegen ist. Eine systematische Analyse der vorliegenden prospektiven, randomisierten, kontrollierten Studien ist daher erforderlich, um diese Frage zu beantworten. Insgesamt gibt es nur wenige randomisierte, kontrollierte Studien und keine dieser Studien hat eine Patientenpopulation über 80 Patienten untersucht. Die vorliegende Analyse untersuchte systematisch publizierte randomisierte, kontrollierte Studien hinsichtlich ungelöster Fragen zur elektiven Neck dissection versus therapeutischen Neck dissection bei Patienten mit oralen Karzinomen und klinischem N0-Hals und erstellte eine Metaanalyse ihrer Daten. Die Studie folgte den PRISMA-Leitlinien (Preferred Reporting Items for Systematic reviews and Meta-Analyses). Das Ziel dieser Arbeit war, die Wirksamkeit der elektiven Neck dissection hinsichtlich der Verringerung von Lymphknotenrezidiven bei Patienten mit oralen Karzinomen mit klinischem N0-Hals zu evaluieren und die krankheitsspezifische Mortalität sowie das Überleben von Patienten nach elektiver Neck dissection gegenüber Patienten, die keine Neck dissection erhielten, zu bestimmen und zu vergleichen. Aus 613 Studien, die während der umfassenden Suche identifiziert wurden, erfüllten nur 4 randomisierte, kontrollierte Studien die Einschlusskriterien und wurden in die Meta-Analyse eingeschlossen. Die Gesamtzahl der Patienten aus den Studien betrug 283. In allen Studien waren die Patienten in zwei Gruppen randomisiert: Elektive Neck dissection (END)-Gruppe und Observation (OBS)-Gruppe. Es gab keinen statistischen Unterschied zwischen diesen beiden Gruppen in Bezug auf Geschlecht und Alter der Patienten, histologischen Typ und Staging. Alle Studien untersuchten histologische Entität, Rezidive im Bereich des Halses, Metastasen, Überleben und Follow- Up. Trotz der Absicht, andere Faktoren als primäre Zielparameter in dieser Meta- Analyse zu erfassen, ist der einzige klinisch bedeutungsvolle Endpunkt, um den Nutzen der elektiven Neck dissection zu messen, die krankheitsspezifische Mortalität. Die Meta-Analyse dieser Studien zeigte, dass die elektive Neck dissection die krankheitsspezifische Mortalität signifikant reduzieren kann und damit das Überleben verbessert {Fixed Effects-Modell RR = 0,57, 95% CI von 0,36 bis 0,89 , p = 0,014} oder {Random Effects-Modell RR = 0,59, 95% CI von 0,37 bis 0,96, p = 0,034}. Es ist jedoch möglich, dass dieser beobachtete Unterschied zwischen OBS- und END-Gruppe durch das Alter der Studien beeinflusst wurde und nicht zu beobachten wäre, wenn die Studien heute mit den neuesten Untersuchungsmethoden durchgeführt worden wären. Zusätzlich konnte gezeigt werden, dass die Durchführung einer elektiven Neck dissection das Risiko eines Lymphknotenrezidivs verringert. Eine verbesserte Überlebensrate nach elektiver Neck dissection bei Patienten mit frühen Stadien oraler Karzinome wurde ebenfalls in einigen retrospektiven Studien berichtet. Nur die Studie von Kligerman et al. [79] aus dieser systematischen Übersichtsarbeit zeigte einen statistisch signifikanten Nutzen der elektiven Neck dissection gegenüber engmaschiger Kontrolle hinsichtlich des krankheitsfreien Überlebens. Die systematische Übersichtsarbeit zeigte jedoch keinen signifikanten Vorteil der elektiven Neck dissection gegenüber wait-andsee hinsichtlich des Überlebens. Zusammenfassend kann festgehalten werden, dass die statistisch signifikante Verringerung der krankheitsspezifischen Mortalität und Lymphknotenrezidivrate die Notwendigkeit einer elektiven Neck dissection bei Patienten mit Mundhöhlenkarzinomen und klinischem N0-Hals rechtfertigen

Metastatic Squamous Cell Carcinoma to the Cervical Lymph Nodes From an Unknown Primary Cancer : Management in the HPV Era

Background Patients with metastases in the lymph nodes of the neck and no obvious primary tumor, neck cancer with unknown primary (NCUP), represent a management challenge. A majority of patients have metastatic squamous cell carcinoma (SCC), although other histologies do occur. Methods We comprehensively reviewed the literature, compared available guidelines, and conferred with an international team of experts. Results Positron emission tomography-computed tomography (PET-CT) and fine needle aspiration (FNA) under ultrasound guidance increase accuracy of diagnosis. Immunohistochemistry (IHC), determination of human papilloma virus (HPV) status, by p16 staining or by in situ hybridization (ISH), and next-generation gene sequencing can guide us regarding probable primary sites and tumor biology. Narrow Band Imaging (NBI) has been introduced for the early detection of subtle mucosal lesions. Direct laryngoscopy (DL) and tonsillectomy have long been procedures used in the search for a primary site. More recently, TransOral Robotic Surgery (TORS) or Transoral LASER Microsurgery (TLM) have been introduced for lingual tonsillectomy. Conclusions New technologies have been developed which can better detect, diagnose, and treat occult primary tumors. Decisions regarding therapy are based on the primary tumor site (if discovered) and N stage. Options include neck dissection with or without postoperative adjuvant therapy, primary irradiation, or combined chemotherapy with irradiation. The preferred treatment of patients whose primary remains unidentified is controversial.Peer reviewe

Imaging findings in craniofacial childhood rhabdomyosarcoma

Rhabdomyosarcoma (RMS) is the commonest paediatric soft-tissue sarcoma constituting 3–5% of all malignancies in childhood. RMS has a predilection for the head and neck area and tumours in this location account for 40% of all childhood RMS cases. In this review we address the clinical and imaging presentations of craniofacial RMS, discuss the most appropriate imaging techniques, present characteristic imaging features and offer an overview of differential diagnostic considerations. Post-treatment changes will be briefly addressed