Metastatic Cervical Squamous Cell Carcinoma from Occult Head and Neck Primary: A ‘Conservative’ Approach

A conservative approach to treatment of patients with squamous cell carcinoma from unknown head and neck primary cancers compares favorably with results of other reported more aggressive protocols utilizing comprehensive irradiation or concurrent chemoradiation, according to study results reported by Rajan S. Patel, MBChB, MD, April 29 at the American Head and Neck Society’s program during the Combined Otolaryngology Spring Meeting.

Representing the Sydney Head and Neck Cancer Institute in Australia, Dr. Patel told the audience that over the past 20 years, his facility had adopted a conservative approach with the intent of minimizing morbidity and reserving additional treatment for salvage. Treatment has been focused on the clinically involved neck only, by way of ipsilateral neck dissection and adjuvant postoperative neck irradiation in selected cases.

The optimal treatment of metastatic cervical squamous cell carcinoma arising from an unknown primary site [SCCUP] in the head and neck is unclear, Dr. Patel said. There is no real evidence that survival is greater with aggressive treatment.

Analysis of Protocol

The purpose of Dr. Patel’s study was to determine the efficacy of the treatment protocol followed at the Sydney Head and Neck Cancer Institute, and to analyze recurrence and survival following treatment, with particular reference to patterns of treatment failure.

The 20-year retrospective study looked at 70 patients with SCCUP. Neck dissection alone was done in patients with pathological neck stage 1 (pN1) disease confined to the lymph node. All remaining patients received neck dissection and adjuvant postoperative irradiation of the involved, dissected neck. Indications for adjuvant postoperative neck irradiation included previous open biopsy, extracapsular spread (ECS), and advanced neck disease (pN2 or pN3).

Rajan S. Patel, MBChB, MD

Dr. Patel said that primary tumors subsequently emerged in eight patients, at a median of 18 months after neck dissection. Postoperative adjuvant radiotherapy was planned for all of these patients according to the Sydney protocol, but two patients refused. Three patients had undergone negative biopsy of what ultimately proved to be the primary site. Salvage treatment was undertaken in six of the eight and included surgery and adjuvant radiotherapy in four patients and surgery alone in two. Of the six patients who had salvage treatment, three are alive and disease-free, while three died. One patient died two months after treatment and the eighth patient was lost to follow-up.

Fourteen patients experienced cancer recurrence with a median time of nine months. Histology demonstrated ECS in all but one patient. Ipsilateral (dissected) neck failure occurred in nine patients who were rated pN2 or pN3. All these patients had received postoperative adjuvant neck irradiation.