Unknown Primary Head and Neck

[metview]

82 yo woman who presents with a large L level Ib lymph node (4 cm, ENE, P16+/HPV-), staged as T0N3bM0. Imaging with CT neck and PET have been negative and no primary found. She has significant co-morbidities CAD, hx of PEs, COPD, etc which makes her a very poor surgical candidate.

Ib node makes me think oropharynx or oral cavity primary. However, P16+/HPV- status suggests that this may be a cutaneous SCC instead? Given Ib, traditional volumes would be VERY large including entire oral cavity, ipsilateral tonsil, BL BOT, soft palate, and ipsilateral II-V. I would not include NPX or larynx. She would likely not tolerate this well especially with concurrent chemo which is recommended given ENE. Could this be a cutaneous SCC, and if so, would it be reasonable to just treat nodal levels and exclude mucosal sites?

Wonder what others think!

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[gmsquid]

82 yo woman who presents with a large L level Ib lymph node (4 cm, ENE, P16+/HPV-), staged as T0N3bM0. Imaging with CT neck and PET have been negative and no primary found. She has significant co-morbidities CAD, hx of PEs, COPD, etc which makes her a very poor surgical candidate.

Ib node makes me think oropharynx or oral cavity primary. However, P16+/HPV- status suggests that this may be a cutaneous SCC instead? Given Ib, traditional volumes would be VERY large including entire oral cavity, ipsilateral tonsil, BL BOT, soft palate, and ipsilateral II-V. I would not include NPX or larynx. She would likely not tolerate this well especially with concurrent chemo which is recommended given ENE. Could this be a cutaneous SCC, and if so, would it be reasonable to just treat nodal levels and exclude mucosal sites?

Wonder what others think!

This is most likely a cutaneous scc given hpv dna negative and p16 positive and clinical history. No known history of skin cancer or skin lesions?

 

[RADONC4285]

Any prior neck procedures that could have altered lymphatic flow?

 

[communitydoc13]

I think likely cutaneous. Facial cutaneous squamous will drain through facials to IB. Scalp/infratemporal fossa squamous will drain through parotid but IB often 2nd in line.

Less is more for an 82 y/o. I would avoid mucosal sites and treat ipsilateral neck. Have good review of parotid as well for intraparotid adenopathy. If present, COSTAR trial has excellent atlas.

 

[FrostyHammer]

Agree with the above, you should be good with treating nodes but not mucosal areas. Question is which nodal levels. Ib-IV for sure, plus more superior facial lymphatics, unclear about V, no RPs. Unilateral or bilateral neck? Lots of judgment calls, none is wrong.

 

[thecarbonionangle]

Was EBER done? I agree sounds like it could be skin.

 

[metview]

Thanks for the help! No suspicious skin lesions and no prior neck dissections. I'll take a close look at her parotid when i see her. I was planning to treat ipsilateral only, Ib-IV, buccofacial, possibly parotid if any palpable nodes.

 

[Palex80]

I'd rarely irradiate elective mucosa in 80+ year old patients with CUP.