Controversies in radiotherapy/chemotherapy in patients with neck lymph node metastases from an unknown primary tumor

Autori:

Marin Prpić, Neva Purgar, Davor Kust, Petar Suton, Ana Fröbe

Sažetak
Incidencija karcinoma nepoznatoga primarnog sijela s metastazama u limfne čvorove glave i vrata je niska te prema literaturi varira između 2 i 9%, te je u daljnjem padu zbog sve preciznije dijagnostike. Histološki, najčešći su planocelularni karcinomi. Osim općega fizikalnog pregleda s osobitim usmjerenjem na područje glave i vrata, nužan je endoskopski pregled s vizualizacijom nazofarinksa, orofarinksa, larinksa i hipofarinksa te radiološka slikovna obrada (CT i/ili MR te u slučaju indikacije PET/CT). Kirurško liječenje najstarija je, no još uvijek vrlo važna metoda liječenja ovih bolesnika te je preferirana opcija inicijalnog liječenja. S druge strane, primarna radioterapija predstavlja važnu opciju liječenja za tumore glave i vrata, posebno u bolesnika koji nisu kandidati za kirurško liječenje, a kod bolesnika s uznapredovalim nalazom na vratu (N2-3) preporučuje se kombinirati je s kemoterapijom. Nakon inicijalnog kirurškog liječenja i patohistološkog nalaza N2 ili N3 bolesti, radioterapija s kemoterapijom ili bez nje indicirana je u svih bolesnika, a može se razmotriti i kod onih sa statusom N1. Neovisno radi li se o primarnoj ili adjuvantnoj radioterapiji, opseg polja zračenja i nadalje je kontroverzna tema. Opcije liječenja se kreću od operativnog liječenja ipsilateralne strane vrata bez adjuvantnog liječenja, operativnog liječenja s adjuvantnom primjenom (kemo)radioterapije do primarnog liječenja – zračenja obje strane vrata i svih mjesta potencijalnog sijela primarnog tumora. Ranije je u smjernicama zagovaran agresivniji pristup koji je uključivao radioterapiju cijelog volumena ždrijela (nazofarniks, orofarinks i hipofarinks) i grkljana te obje strane vrata. S vremenom je primjetan pomak prema poštednijem liječenju, najčešće u smislu operativnog liječenja metastaza na vratu s primjenom adjuvantne ipsilateralne radioterapije, bez zračenja čitave sluznice ždrijela i grkljana. Najvažniji parametri u odluci o primjeni konkomitantne kemoterapije jesu proboj čahure limfnog čvora i resekcija R1/2.
Summary

The incidence of cancer of unknown primary site with metastases to neck lymph nodes is low, according to literature it varies between 2% and 9%, and is further declining due to more precise diagnostics. Histologically, squamous cell carcinomas are most common. In addition to general physical examination with special focus on the head and neck region, endoscopic examination with visualization of nasopharynx, oropharynx, larynx and hypopharynx, and radiological imaging (CT and/or MRI, and in case of indication PET/CT) is necessary. Surgical treatment is the oldest but still very important method of treating these patients and is the preferred option for initial treatment. On the other hand, primary radiotherapyis an important treatment option for head and neck tumors, especially in patients who are not candidates for surgical treatment, and it is recommended to combine it with chemotherapy in patients with advanced disease (N2-3). After initial surgical treatment and pathohistological findings of N2 or N3 disease, radiotherapy with or without chemotherapy is indicated in all patients, and may also be considered in those with N1 status. For both primary and adjuvant radiotherapy the volume of radiation fields remains a controversial topic. Treatment options range from surgical treatment of the ipsilateral side of the neck without adjuvant treatment, surgical treatment with adjuvant (chemo)radiotherapy, to primary treatment – irradiation of both sides of the neck with all the sites from which the primary tumor could originate. Earlier, the guidelines advocated a more aggressive approach that included radiotherapy of the entire volume of the pharynx (nasopharynx, oropharynx, and hypopharynx) and larynx and both sides of the neck. Over time, there has been a noticeable shift towards more conservative treatment, most often in terms of surgical treatment of neck metastases with the use of adjuvant ipsilateral radiotherapy, without irradiating all pharyngeal and laryngeal mucosa. The most important parameters in the decision regarding concomitant chemotherapy are lymph node capsule perforation and R1 / 2 resection.

Volumen: 5-6, 2022

Liječ Vjesn 2022;144:163–168

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