Diagnosis and Treatment of a Neck Node Swelling Suspicious for a Malignancy: An Algorithmic Approach

Aim. To present an up-to-date algorithm incorporating recent advances regarding its diagnosis and treatment. Method. A Medline/Pubmed search was performed to identify relevant studies published in English from 1990 until 2008. Only clinical studies were identified and were used as basis for the diagnostic algorithm. Results. The eligible literature provided only observational evidence. The vast majority of neck nodes from occult primaries (>90%) represent SCC with a high incidence among middle aged man. Smoking and alcohol abuse are important risk factors. Asiatic and North African patients with neck node metastases are at risk of harbouring an occult nasopharyngeal carcinoma. The remainder are adenocarcinoma, undifferentiated carcinoma, melanoma, thyroid carcinoma and Merkel cell carcinoma. Fine needle aspiration cytology (FNAC) reaches sensitivity and specificity percentages of 81% and 100%, respectively and plays an important role as the second diagnostic step after routine ENT mirror and/or endoscopic examination. FDG-PET/CT has proven to be helpful in identifying occult primary carcinomas of the head and neck, especially when applied as a guiding tool prior to panendoscopy, and may induce treatment related clinical decisions in up to 60% of cases. Conclusion. Although reports on the diagnostic process offer mainly descriptive studies, current information seems sufficient to formulate a diagnostic algorithm to contribute to a more systematic diagnostic approach preventing unnecessary steps

Unfavorable biological behavior and treatment response of neuroendocrine ovarian metastases of midgut neuroendocrine tumors

Neuroendocrine ovarian metastases (NOM) predominantly derive from midgut neuroendocrine tumors (NETs) and develop in about 25% of women with advanced stage of this malignancy. Little is known of the growth rate and treatment response of NOM. We therefore evaluated the efficacy of different management options for patients with NOM, including peptide receptor radionuclide therapy (PRRT), somatostatin analogues (SSAs) and oophorectomy. Records were screened for patients with well-differentiated NOM of midgut origin that presented in our NET referral center between 1991 and 2022. Progression-free survival (PFS) and tumor growth rate (TGR) of ovarian and extra-ovarian metastases were determined using RECIST (response evaluation criteria in solid tumors) 1.1. In 12 available patients undergoing PRRT, NOM were associated with a shorter PFS than extra-ovarian metastases (P = 0.003). While PRRT induced a similar decrease in TGR for ovarian and extra-ovarian lesions in nine patients with available data (-2.3 vs -1.4, P &gt; 0.05), only the TGR of NOM remained positive after PRRT. In 16 patients treated with SSAs, the TGR of NOM was almost three times that of extra-ovarian lesions during treatment (2.2 vs 0.8, P = 0.011). Oophorectomy was performed in 46 of the 61 included patients and was significantly associated with a prolonged OS (115 vs 38 months, P &lt; 0.001). This association persisted after propensity score matching and correction for tumor grade and simultaneous tumor debulking. In conclusion, NOM have a higher TGR compared to extra-ovarian metastases, resulting in a shorter PFS after PRRT. Bilateral salpingo-oophorectomy should be considered for postmenopausal women with NOM undergoing surgery for metastatic midgut NETs.</p

Biochemical basis of 5-aminolaevulinic acid-induced protoporphyrin IX accumulation: a study in patients with (pre)malignant lesions of the oesophagus.

Administration of 5-aminolaevulinic acid (ALA) leads to porphyrin accumulation in malignant and premalignant tissues, and ALA is used as a prodrug in photodynamic therapy (PDT). To understand the mechanism of porphyrin accumulation after the administration of ALA and to investigate whether ALA-induced protoporphyrin IX might be a suitable photosensitizer in Barrett's oesophagus and adenocarcinoma, we determined the activities of porphobilinogen deaminase (PBG-D) and ferrochelatase (FC) in various malignant and premalignant as well as in normal tissues of the human oesophagus. A PDT power index for ALA-induced porphyrin accumulation, the ratio of PBG-D to FC normalized for the normal squamous epithelium of the oesophagus, was calculated to evaluate intertissue variation in the ability to accumulate porphyrins. In malignant and premalignant tissue a twofold increased PBG-D activity and a marginally increased FC activity was seen compared with normal squamous epithelium. A significantly increased PDT power index in Barrett's epithelium and adenocarcinoma was found. Our results suggest that, after the administration of ALA, porphyrins will accumulate in a greater amount in Barrett's epithelium and adenocarcinoma of the oesophagus because of an imbalance between PBG-D and FC activities. The PDT power index here defined might be a useful indicative parameter for predicting the susceptibility of these tissues to ALA-PDT

Tumour thickness in oral cancer using an intra-oral ultrasound probe

To investigate tumour-thickness measurement with an intra-operative ultrasound (US) probe. A retrospective data analysis was undertaken for a total of 65 patients with a T1-2 oral cavity cancer, who were seen at a tertiary referral centre between 2004 and 2010. The correspondence between tumour thickness measured by ultrasonography and histopathology was assessed by Pearson's correlation coefficient, and also between tumour thickness and the development of neck metastasis. In 11 cases, intra-oral measurement was not optimal due to limited mouth opening (n = 2) or impossibility to depict the lesion (n = 9). Tumour thickness measured by US correlated well with histopathology (n = 23, R = 0.93). Tumour thickness of a parts per thousand currency sign7 mm carries a risk of lymph node metastasis of 12%, whereas in tumours exceeding 7 mm this risk is 57% (p = 0.001). Twenty-five percent developed neck metastasis and 19% had local recurrence. Tumour thickness is an important predictive marker for lymph node metastases. As such, it can help in decision-making with regard to management of the primary tumour and neck. Based upon our findings, a wait-and-see policy is only warranted for superficial lesions with tumour thickness of less than 7 mm, but only if regular follow-up using US-guided aspiration of the neck is ensure

Risk of breast cancer in women after a salivary gland carcinoma or pleomorphic adenoma in the Netherlands

Salivary and mammary gland tumors show morphological similarities and share various characteristics, including frequent overexpression of hormone receptors and female preponderance. Although this may suggest a common etiology, it remains unclear whether patients with a salivary gland tumor carry an increased risk of breast cancer (BC). Our purpose was to determine the risk of BC in women diagnosed with salivary gland carcinoma (SGC) or pleomorphic adenoma (SGPA). BC incidence (invasive and in situ) was assessed in two nationwide cohorts: one comprising 1567 women diagnosed with SGC and one with 2083 women with SGPA. BC incidence was compared with general population rates using standardized incidence ratio (SIR). BC risk was assessed according to age at SGC/SGPA diagnosis, follow-up time and (for SGC patients) histological subtype. The mean follow-up was 7.0 years after SGC and 9.9 after SGPA diagnosis. During follow-up, 52 patients with SGC and 74 patients with SGPA developed BC. The median time to BC was 6 years after SGC and 7 after SGPA. The cumulative risk at 10 years of follow-up was 3.1% after SGC and 3.5% after SGPA (95% Confidence Interval (95%CI) 2.1%-4.7% and 2.6%-4.6%, respectively). BC incidence was 1.59 times (95%CI 1.19-2.09) higher in the SGC-cohort than expected based on incidence rates in the general population. SGPA-patients showed a 1.48 times (95%CI 1.16-1.86) higher incidence. Women with SGC or SGPA have a slightly increased risk of BC. The magnitude of risk justifies raising awareness, but is no reason for BC screening