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Metastatic Squamous Neck Cancer with Occult Primary Treatment

Metastatic squamous neck cancer with occult primary is a disease in which squamous cell cancer spreads to lymph nodes in the neck and it is not known where the cancer first formed in the body.

Squamous cells are thin, flat cells found in tissues that form the surface of the skin and the lining of body cavities such as the mouth, hollow organs such as the uterus and blood vessels, and the lining of the breathing and digestive tracts. Some organs with squamous cells are the esophagus, lungs, kidneys, and uterus. Cancer can begin in squamous cells anywhere in the body and spread through the blood or lymph system to other parts of the body.

When squamous cell cancer spreads to lymph nodes in the neck or around the collarbone, it is called metastatic squamous neck cancer. The doctor will try to find the primary tumor (the cancer that first formed in the body), because treatment for metastatic cancer is the same as treatment for the primary tumor. For example, when lung cancer spreads to the neck, the cancer cells in the neck are lung cancer cells and they are treated the same as the cancer in the lung. Sometimes doctors cannot find where in the body the cancer first began to grow. When tests cannot find a primary tumor, it is called an occult (hidden) primary tumor. In many cases, the primary tumor is never found.

Signs and symptoms of metastatic squamous neck cancer with occult primary include a lump or pain in the neck or throat.

Check with your doctor if you have a lump or pain in your neck or throat that doesn't go away. These and other signs and symptoms may be caused by metastatic squamous neck cancer with occult primary. Other conditions may cause the same signs and symptoms.

Tests that examine the tissues of the neck, respiratory tract, and upper part of the digestive tract are used to detect (find) and diagnose metastatic squamous neck cancer and the primary tumor.

Tests will include checking for a primary tumor in the organs and tissues of the respiratory tract (part of the trachea), the upper part of the digestive tract (including the lips, mouth, tongue, nose, throat, vocal cords, and part of the esophagus), and the genitourinary system.

The following procedures may be used:

Physical exam and history: An exam of the body, especially the head and neck, to check general signs of health. This includes checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also betaken. This includes a fiber optic examination of your entire throat in clinic.

Biopsy: The removal of cells or tissues so they can be viewed under a microscope by a pathologist or tested in the laboratory check for signs of cancer. Three types of biopsy may be done:

• Fine-needle aspiration (FNA) biopsy: The removal of tissue or fluid using a thin needle.
• Core needle biopsy: The removal of tissue using a wide needle.
• Excisional biopsy: The removal of an entire lump of tissue.

The following procedures are used to remove samples of cells or tissue:

• Tonsillectomy: Surgery to remove both tonsils.
• Endoscopy: A procedure to look at organs and tissues inside body to check for abnormal areas. An endoscope is inserted through an incision (cut) in the skin or opening in the body, such as the mouth or nose. An endoscope is a thin,tube-like instrument with a light and a lens for viewing. It may also have a tool to remove abnormal tissue or lymph node samples, which are checked under a microscope for signs of disease. The nose, throat, back of the tongue, esophagus,  stomach, voice box, windpipe, and large airways will be checked.

One or more of the following laboratory tests may be done to study the tissue samples:

• Immunohistochemistry: A laboratory test that uses antibodies to check for certain antigens (markers) in a sample of a tissue from the patient's lymph node. The antibodies are usually linked to an enzyme or a fluorescent dye. After the antibodies bind to a specific antigen in the blood or bone marrow, the enzyme or dye is activated, and the antigen can then be seen under a microscope. This type of test is used to help diagnose cancer and to help tell one type of cancer from another type of cancer.
• Light and electron microscopy: A test in which cells in a sample of tissue are viewed under regular and high-powered microscopes to look for certain changes in the cells.
• Epstein-Barr virus (EBV) and human papillomavirus (HPV) test: A test that checks the cells in a sample of tissue for EBV and HPV DNA.

CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an xray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography or computerized axial tomography.

MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).

PET scan (positron emission tomography scan): A procedure to find malignant tumor cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do.

A diagnosis of an occult tumor is made if the primary tumor is not found during testing or treatment.

Certain factors affect chance of recovery and treatment options.

Prognosis (chance of recovery) depends on the following:

• The number and size of lymph nodes that have cancer in them.
• Whether the cancer has responded to treatment or has recurred (come back).
• How different from normal the cancer cells look under a microscope.
• The patient's age and general health. 

Treatment options depend on the following:

• Which part of the neck the cancer is in.
• Whether certain tumor markers are found.

Stages of Metastatic Squamous Neck Cancer with Occult Primary

After metastatic squamous neck cancer with occult primary has been diagnosed, tests are done to find out if cancer cells have spread to other parts of the body.

The process used to find out if cancer has spread to other parts of the body is called staging. The results from tests and procedures used to detect and diagnose the primary tumor are also used to find out if cancer has spread to other parts of the body.

There is no standard staging system for metastatic squamous neck cancer with occult primary. The tumors are described as untreated or recurrent. Untreated metastatic squamous neck cancer with occult primary is cancer that is newly diagnosed and has not been treated, except to relieve signs and symptoms caused by the cancer.

There are three ways that cancer spreads in the body.

Cancer can spread through tissue, the lymph system, and the blood:

• Tissue. The cancer spreads from where it began by growing into nearby areas.
• Lymph system. The cancer spreads from where it began by getting into the lymph system. The cancer travels through the lymph vessels to other parts of the body.
• Blood. The cancer spreads from where it began by getting into the blood. The cancer travels through the blood vessels to other parts of the body.

Treatment Options Overview

Two types of standard treatment are used:

Surgery

Surgery may include neck dissection. There are different types of neck dissection, based on the amount of tissue that is removed.

• Radical neck dissection: Surgery to remove tissues in one or both sides of the neck between the jawbone and the collarbone, including the following:
  • All lymph nodes.
  • The jugular vein.
  • Muscles and nerves that are used for face, neck, and shoulder movement, speech, and swallowing. 

The patient may need physical therapy of the throat, neck, shoulder, and/or arm after radical neck dissection. Radical neck dissection may be used when cancer has spread widely in the neck.

• Modified radical neck dissection: Surgery to remove all the lymph nodes in one or both sides of the neck without removing the neck muscles. The nerves and/or the jugular vein may be removed.
• Selective neck dissection: Surgery to remove some of the lymph nodes in the neck.

After the doctor removes all the cancer that can be seen at the time of surgery, some patients may be given radiation therapy after surgery to kill any cancer cells that are left. Treatment given after surgery, to lower the risk that the cancer will come back, is called adjuvant therapy.

Radiation therapy is a cancer treatment that uses high-energy xrays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy:

• External radiation therapy uses a machine outside the body to send radiation toward the cancer.
• Certain ways of giving radiation therapy can help keep radiation from damaging nearby healthy tissue.
  • Intensity-modulated radiation therapy (IMRT): IMRT is a type of 3-dimensional (3-D) radiation therapy that uses a computer to make pictures of the size and shape of the tumor. Thin beams of radiation of different intensities (strengths) are aimed at the tumor from many angles. This type of radiation therapy is less likely to cause dry mouth, trouble swallowing, and damage to the skin.
• Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer.

The way the radiation therapy is given depends on the type of cancer being treated. External radiation therapy is used to treat metastatic squamous neck cancer with occult primary.

Radiation therapy to the neck may change the way the thyroid gland works. Blood tests may be done to check the thyroid hormone level in the body before treatment and at regular checkups after treatment.

Chemotherapy

Medications through a special IV called a chemoport may also be prescribed to treat cancer of unknown primary. Often chemotherapy is prescribed when more than two lymph nodes are present and no human papillomavirus is found. If surgical removal of the lymph nodes is performed and certain other aggressive features are found by the pathologies, your doctors may recommend chemotherapy with the radiation.

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