Neck%metastases%from%unknown%primary:%role% of%the%h&n%surgeon%
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1 SIMPOSIO:2Strategie2terapeu&che2nelle2metastasi2laterocervicali2da2focus2ignoto( Neck%metastases%from%unknown%primary:%role% of%the%h&n%surgeon% Palude'(G,(Bussu(F( Dipar&mento(di(Scienze(Chirurgiche(per(le(Patologie(della(Testa(e(del(Collo( ( Università(Ca>olica(del(Sacro(Cuore( Policlinico(Agos@no(Gemelli,(Rome(
2 NECK%MASSES%(persisting%more%than%3A4%wks,% no%clear%infectious%causes,%no%regression%with% medical%therapy):%diagnostic%work%up% Age Groups Pediatric (0 to 15 years): 90% benign Young adult (16 to 40 years): similar to children Late adult (>40 years): rule of 80 Guidelines (most of the diagnostic work up rely on the technical abilities of the H&N surgeon)
3 DeGinition%of%occult%primary% the(careful(work(up(no(primary(site(has((been( found( The(diagnosis(must(be(obtained(by(an(algorithm( pivoted(on( the(achievement(of(the(definite(histological( diagnosis((of(the(neck(mass( primary(sites( Both(the(tasks(require(a(wide(range(of(technical( skills(and(notable(clinical(experience,(which(are( head(and(neck(surgeon(
4 ?(
5
6 Diagnostic%work%up%in%suspected%occult%T:% ofgices%of%%h&n%surgeon% Hystory (always ask for previous underestimated skin lesions) Complete H&N physical exam (including skin) and in particular: Ispection of UADS (mirror and/or fiberoptic) Palpation of the oropharynx FNAB (preferably US guided) For levels II and Va and, to a lower extent, I and III, biopsies of the areas of clinical concern and random biopsies of rhino-and oropharynx (elective tonsillectomy?! Mono- or bilateral?) Open biopsy only if repeated FNAB and previous work up is negative
7 OfGices%of%H&N%surgeon%in%the%diagnostic% work%up:%%pearls% % Palpation is the most sensible diagnostic tool for base of tongue masses after CE MRI The old-fashioned indirect laryngoscopy is the workhorse for diagnosis of UADs cancers: Extremely low cost Uncomparable one-sight, tridimensional overview of laryngopharyngeal complex, with true colors Possibility for the experienced clinician to biopsy pharyngolaryngeal lesions without general anesthesia (patients with comorbidities) Also rhinopharynx can usually be biopsied in local anesthesia if needed (posterior rhinoscopy or with fibroscope assistance)
8 %and%pitfalls% IV and Vb nodes always don t forget to check thorax and abdomen If a sure histology has not been obtained by FNAB nor a primary site identified by a careful diagnostic work up open biopsy is the extrema ratio, in these cases frozen section is mandatory If frozens are positive for a solid malignancy a comprehensive neck dissection must be immediately accomplished, as a previous opening of the cervical fasciae compromises the possibilities of a delayed surgical or non-surgical clearance of the neck Never perform an open biopsy of a hard mass in the lateral neck if you cannot have frozen sections or if you are not able/ready to perform a comprehensive neck dissection at the same time
9
10 Metastatic%SCC%from%occult%T:% role%of%h&n%surgeon%in%treatment% Neck dissection mainstay of treatment Option for primary treatment Salvage for residual disease Salvage for recurrence Definite staging data
11 From%neck%dissection% pathological%data% We(evaluated(fresh(samples(from((a( for(metastases(from(unknown(primary(scc( between(2010(and(2012( (median(62)( We(looked(for(high(risk(HPV(mRNA(and(
12 Our%Gindings% Primarily(involved(nodal(level( Presence(of(viruses(in(neck(metastases( neg HPV18 HPV16 EBV-HPV HR EBV 15,0 3 5,0 1 10,0 2 20,0 4 50,0 10
13 Our%Gindings% Viruses(are(most(oGen(present(in(level(IIA((73%)(and(VA((100%)( metastases((p=0,0051)(
14 Viruses%in%occult%T% Neck(metastasis(from(unknown(primary(SCC( and(neck(carcinogenesis(as(rhinopharyngeal( and(oropharyngeal(carcinoma(
15 Viruses%in%occult%T% for(head(and(neck((oropharynx)( carcinogenesis(is(hpv16( HPV18(has(never(been(found(in(our(40( oropharyngeal(cases( Nevertheless(HPV18(is(the(most(frequently( detected(genotype(in(our(series(of(nodal(scc( from(occult(t?(
16 Clinical%implications%of%virus%related% neck%metastases%from%unknown% primary% and(on(thindprep(samples(from(fnab(
17 Nodal%metastases%from%virus%induced% head%and%neck%scc%should%be%always%be% considered%in%the%diagnostic/ therapeutic%algorythm%
18 Thank(you(
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