Large neck metastasis with unknown primary tumor - a case report

Abstract

Introduction. Metastatic head and neck carcinoma (HNC) from an unknown primary tumor is defined as a metastatic disease in the neck's lymph nodes without evidence of a primary tumor after appropriate investigation. Multiple na-tional guidelines recommend taking essential steps in diag-nostic protocols which involve a detailed clinical exam with radiological imaging, fine-needle aspiration (FNA) biopsy of the cervical tumor, esophagogastroduodenoscopy (EGD) with palatine and lingual tonsillectomy, immunohistochemi-cal staining, and human papillomavirus (HPV) detection. Treatment of HNCs of unknown primary origin involves surgery (neck dissection) with radiotherapy (RT), while some authors recommend chemo-radiotherapy in cases of advanced regional disease. Case report. A 44-year-old male was referred to the tertiary medical center because of a large ulcero-infiltrative cervical mass on the right side. Examina-tion of the head and neck and flexible nasopharyngolaryn-geal endoscopy was conducted, followed by computed to-mography (CT) of the head, neck, and thorax with intrave-nous contrast. The primary localization of the tumor was not confirmed by these diagnostic methods. An open biop-sy of the neck mass established a histopathology diagnosis of metastatic squamous cell carcinoma (SCC). Results of EGD with biopsies and bilateral tonsillectomy were nega-tive for malignancy. Treatment included extended radical neck dissection with reconstruction and postoperative ipsi-lateral RT. The patient presented with an extensive pharyn-golaryngeal tumor five years after the first surgery. Biopsy with histopathology examination confirmed the diagnosis of SCC. Conclusion. A structured step-by-step diagnostic ap-proach to identifying the primary site of the metastatic HNC is mandatory. Substantial advances in diagnostics and operative techniques have increased the likelihood of prima-ry tumor identification and detection of the disease's region-al and systemic spread. The purpose of adherence to guide-lines results in higher overall survival and longer regional disease-free survival in these patients. © 2022 Inst. Sci. inf., Univ. Defence in Belgrade. All rights reserved.