Sinnathamby K, Peters L J, Laidlaw C, Hughes P G
Cancer Institute, Maharagama, Sri Lanka, Australia.
Clin Oncol (R Coll Radiol). 1997;9(5):322-9. doi: 10.1016/s0936-6555(05)80066-4.
In patients with cervical node metastases from an unknown primary malignancy, there is unresolved controversy regarding the utility of elective irradiation of putative pharyngeal primary sites as part of the management plan. We analysed the experience of the Peter MacCallum Cancer Institute to assess the risk of withholding mucosal irradiation in relation to the diagnostic algorithm used to exclude a primary lesion at the time of initial presentation. Between 1983 and 1992, 69 patients were seen with metastatic squamous or undifferentiated carcinoma in cervical nodes from an unknown primary site. Neck nodal stage was NX or N1 13%; N2 52%; N3 35%. Nodal disease was bilateral in 12% of patients. Investigations included examination under anaesthesia, with or without random biopsies, in 84%, and CT scanning of the head and neck in 55%. Treatment was by surgery alone in four patients, by radiotherapy alone in 23, and by combined modalities in 40. Two patients received no treatment. Seventeen were treated with palliative intent. The radiotherapy fields provided comprehensive coverage of the pharynx in only eight patients and partial coverage in five. The estimated overall 5-year survival was 36%. Eleven primary tumours were detected between 7 months and 7 years after the initial treatment, of which nine were in head and neck sites. This yielded an estimated incidence of 30% at 10 years, which is similar to the risk of the development of a second primary after the successful treatment of a known head and neck cancer. Only three patients (none of whom had a CT scan as part of their initial evaluation) manifested a primary in an unirradiated pharyngeal site within 2 years of treatment. As the accuracy of imaging improves, the risk of missing an occult primary lesion will decrease further. We conclude that the use of standardized diagnostic investigations incorporating modern imaging substantially eliminates the indication for comprehensive elective mucosal irradiation with its consequent morbidity. The overriding priority in patients who present with advanced neck disease is to secure regional control.
对于原发恶性肿瘤不明但有颈部淋巴结转移的患者，作为治疗方案的一部分，对假定的咽原发部位进行选择性放疗的效用仍存在争议。我们分析了彼得·麦卡勒姆癌症研究所的经验，以评估在初次就诊时用于排除原发病变的诊断算法与不进行黏膜放疗风险之间的关系。1983年至1992年间，69例患者因不明原发部位的颈部淋巴结转移性鳞状或未分化癌前来就诊。颈部淋巴结分期为NX或N1的占13%；N2的占52%；N3的占35%。12%的患者淋巴结病变为双侧。检查包括84%的患者在麻醉下进行检查，有或无随机活检，以及55%的患者进行头颈部CT扫描。4例患者仅接受手术治疗，23例仅接受放疗，40例接受综合治疗。2例患者未接受治疗。17例患者接受姑息性治疗。放疗野仅对8例患者的咽部提供了全面覆盖，对5例患者提供了部分覆盖。估计总体5年生存率为36%。在初始治疗后7个月至7年之间发现了11例原发肿瘤，其中9例位于头颈部。这得出10年时的估计发病率为30%，与已知头颈部癌成功治疗后发生第二原发癌的风险相似。仅3例患者（均未将CT扫描作为初始评估的一部分）在治疗后2年内出现未照射咽部部位的原发肿瘤。随着成像准确性的提高，漏诊隐匿性原发病变的风险将进一步降低。我们得出结论，采用包含现代成像的标准化诊断检查基本上消除了进行全面选择性黏膜放疗及其相关发病率的指征。对于出现晚期颈部疾病的患者，首要任务是确保区域控制。
