Squamous carcinoma presenting as an enlarged cervical lymph node

Patients presenting with an enlarged cervical lymph node containing squamous cell carcinoma are a difficult problem for head and neck surgeons. In most cases, the primary site lies in the head and neck region. The advent of fine-needle aspiration cytologic study means that this group of patients can be accurately identified in the clinic and investigated accordingly.

The current report studies the records of 267 such patients presenting to the Head and Neck Unit at The University of Liverpool over a 29-year period.

The 5-year survival rate for all patients presenting with a cervical lymph node metastasis was 27%. The 5-year survival rate for patients with a detected primary in the head and neck was 31% and the primary site was identified during the patient's life time in all but 36 patients (13%). In 53% of patients, the primary site was discovered during routine clinical examination, and in a further 16% it was discovered at panendoscopy. Most diagnostic tests proved relatively unhelpful but 10 patients in our series had the primary site discovered by radiograph and 9 of these had carcinoma of the lung. In the current study when the primary site was discovered it was in the head and neck region in 74% of patients. Primary sites other than head and neck occurred in 11% of the patients and no 5-year survivors existed. Multivariate analysis suggested that open biopsy of the lymph node metastasis appeared to have an adverse effect on survival as did advanced age and advanced N stage. The late diagnosis of the primary site, if it proved to be in the head and neck region, on the other hand, had a positive association with survival.

Patients presenting with a lymph node metastasis in the head and neck region from an unknown primary have a prognosis identical to that of other patients with head and neck squamous carcinoma with neck node metastases. The prognosis for patients in whom the primary site is never discovered or in whom the primary site is not head and neck, however, is disastrous. If the primary tumor proves to be in the head and neck region, treatment is worthwhile since almost a third of patients are cured of their disease. When the primary carcinoma is not in the head and neck region, treatment must be considered palliative.