Cancerinfiltrated Cervical Lymph Nodes as Part of a Cancer with Unknown Primary

When cancer infiltration of an enlarged cervical lymph node is confirmed by FNAC and no primary can be found in the oral cavity, the oro- or nasopharynx or the larynx, a search for other putative primary localizations is urgently indicated (e. g. eso-phageal cancer, stomach cancer with Virchow gland involvement, lung cancer with supraclavicular metastases, Pancoast cancer, Schmincke cancer and thyroid gland cancer including the medullary subtype). In addition, malignant paraganglioma with local spread must be taken into account.

Subtyping of the cancer infiltration of the lymph node is often helpful to detect the primary. Subtyping of the cancer tissue of the node again after additional detection of the putative primary can provide further help toward answering the question of what adjuvant therapeutic strategies are appropriate.

The most important antibodies used for immu-nohistochemical detection of primary tumors are listed in Table 6.

After localization of the primary and definition of the tumor type by histological examination there are two possibilities:

• A "wait-and-see" approach, with metastases looked for in the local drainage fields during follow-up.

• SLN detection techniques, with extirpation and histological and immunohistochemical exclusion or confirmation of metastasis in subsequent basins.

The putative SLNs are often located in the proximal course of the jugular vein. The most important node, i.e., the jugular vein junctional node, must be checked very carefully. Concerning squamous cell cancers opinions differ on whether SLN detection would really be helpful in terms of cure, because efficient radiotherapy (RT) can be offered. On the other hand, high doses of RT are necessary for tumor clearance. Therefore, reliable detection of involved lymph nodes by lymphography would be helpful in an adequate surgical program and allow the avoidance of high-dose RT in more or less extended fields and early or late side effects of RT if RT were not necessary.

Table 5. Localization of the primaries (malignant melanomas) with sentinel nodes in pre- and intraparotidean localizations: detection rates and recurrences

Facial melanomas with SLN detec- Localization of the primaries No. of senti- Recurrence

SLN near or in intraparo- tion rate nels per pa- rate tid gland Scalp Auricle Face tient; range

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