Neck dissection and ipsilateral radiotherapy in the management of cervicalmetastatic carcinoma from an unknown primary

Background: In a small proportion of patients presenting with metastases to cervical lymph nodes the primary cancer remains occult despite thorough ev aluation. The present report examines patterns of failure and outcome follo wing an initial treatment strategy directed principally at the clinically i nvolved side of the neck. Methods: From a prospectively compiled computerized database 38 patients we re identified with metastatic squamous cell carcinoma from an occult primar y site. These patients were evaluated with respect to initial treatment, su bsequent detection of a primary tumour, neck recurrence and survival charac teristics. Results: Thirty-seven of 38 patients were treated with curative intent and all had neck dissection. Adjuvant radiotherapy was given to 34 of the 37 (9 0%; 32 postoperatively and two pre-operatively). Radiotherapy was directed at the ipsilateral neck alone in 24 patients while 10 received comprehensiv e treatment to both sides of the neck and potential occult primary sites. T he rate of control of disease in the ipsilateral neck was 91% while the fai lure rate in the contralateral neck was 16% (six patients). A primary cance r was ultimately identified in five patients (13%). Disease-specific surviv al was 63% at 4 years. Clinical N-3 stage, extracapsular tumour extension a nd involved surgical margins predicted for poorer survival on univariate an alysis. Analysis using multiple risk factors found that only involved surgi cal margins predicted for treatment failure. Conclusions: Despite generally advanced disease at presentation, patients p resenting with cervical metastasis from an unknown primary carcinoma have a reasonable survival expectation and aggressive treatment is warranted, but approximately half will develop recurrent disease. Careful follow-up is re quired if effective salvage treatment is to be instituted.