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A Nordic Survey on the Management of Head and Neck CUP

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A Nordic Survey on the Management of Head and Neck CUP Acta Oto-Laryngologica ISSN: 0001-6489 (Print) 1651-2251 (Online) Journal homepage: http://www.tandfonline.com/loi/ioto20 A Nordic survey on the management of head and neck CUP Lovisa Farnebo, Göran Laurell & Antti Mäkitie To cite this article: Lovisa Farnebo, Göran Laurell & Antti Mäkitie (2016) A Nordic survey on the management of head and neck CUP, Acta Oto-Laryngologica, 136:11, 1159-1163, DOI: 10.1080/00016489.2016.1193894 To link to this article: http://dx.doi.org/10.1080/00016489.2016.1193894 © 2016 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group Published online: 16 Jun 2016. Submit your article to this journal Article views: 140 View related articles View Crossmark data Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ioto20 Download by: [University of Helsinki] Date: 22 November 2016, At: 04:54 ACTA OTO-LARYNGOLOGICA, 2016 VOL. 136, NO. 11, 1159–1163 http://dx.doi.org/10.1080/00016489.2016.1193894 RESEARCH ARTICLE A Nordic survey on the management of head and neck CUP Lovisa Farneboa , Goran€ Laurellb and Antti M€akitiec,d aDepartment of Otorhinolaryngology, Department of Clinical and Experimental Medicine, Link€oping University, Link€oping, Sweden; bDepartment of Clinical Sciences, ENT, Uppsala University, Uppsala, Sweden; cDepartment of Otorhinolaryngology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; dDivision of Ear, Nose and Throat Diseases, Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden ABSTRACT ARTICLE HISTORY Conclusion: The management of Head and Neck Cancer of Unknown Primary (HNCUP) patients varies Received 10 April 2016 both between centres within and also between the Nordic countries. This study contributes to a con- Revised 2 May 2016 tinuing discussion of how to improve the accuracy of diagnosis and quality of treatment of HNCUP Accepted 3 May 2016 patients. KEYWORDS Objectives: The initiative for this study was based on the lack of common guidelines for diagnostic Cancer of unknown origin; procedures and for treatment of HNCUP patients in the Nordic countries constituting a region having a follow up; multidisciplinary rather homogeneous population. tumour board meeting; Method: A structured questionnaire was sent to all university hospitals in the five Nordic countries. PET-CT Results: Four of the five Nordic countries use either national guidelines or specific protocols when han- dling HNCUP. The main diagnostic tools are PET-CT, fine needle aspiration, endoscopic evaluation with biopsies, and most often bilateral tonsillectomy. At 21 of 22 university hospitals the treatment decision is made at a multidisciplinary conference. Three of seven Swedish centres use only radiotherapy or che- moradiotherapy to treat Nþ HNCUP patients. Robotic surgery for biopsy of the tongue base is begin- ning to become an alternative to targeted biopsies in Sweden and Finland. Narrow Band Imaging is used only in Finland. Introduction and Finland). The recommendation is that the diagnostic work-up should include both PET-CT and panendoscopy The definition of Head and Neck Cancer of Unknown with biopsies, including bilateral tonsillectomy [2,6]. Such an Primary (HNCUP) is the presence of a cervical lymph node action may offer the greatest likelihood of successfully identi- metastasis, for which therapy will be initiated even though fying an occult primary tumour. However, the availability of there is no specific evidence of a primary tumour. Extensive PET-CT varies, as do the guidelines to use it. clinical and radiological examinations are typically under- Therapeutic approaches vary between centres, and treat- taken before initiating treatment of HNCUP. The incidence of HNCUP varies between 3–7% of all neck ment modalities include surgery (lymph node excision or lumps [1]. Many patients with an occult neck lump initially neck dissection) with or without post-operative radiotherapy; diagnosed as a HNCUP are later identified with a primary radiotherapy, alone or in combination with chemotherapy; tumour. Waltonen et al. [2] found that nearly half of all pri- and radiotherapy, followed by surgery. In the early stage mary tumours could be located using PET-CT and endoscopy. (N1), neck dissection and radiotherapy seem to have similar A more recent report suggested that males constitute 72% of efficacy, whereas more advanced cases (N2, N3) necessitate a all cases, the median age at onset being 55 years combination of modalities [6]. One retrospective study con- (range ¼ 42–87 years) [3]. Lymph node metastases located in cluded that radiotherapy after neck dissection influenced the the supraclavicular fossa are frequently found to be of infra- overall survival [7], while another study suggested that IMRT clavicular origin. Fine needle aspiration cytology and modern was the most beneficial radiotherapeutic approach [8]. molecular diagnostics have improved the assessment of cancer Mistry et al. [9] reported that the overall 5-year survival was of unknown primary. Accurate cytological diagnosis of better for HNCUP patients than for those with a known pri- HNCUP is essential when choosing treatment modality, and mary of comparable nodal stage. The overall 5-year survival may become increasingly important in the HPV era [4,5]. rate for the HNCUP group was found to be 55%.In It has been recognized that the diagnostic and treatment line with this, another study reported the 5-year survival rate modalities for HNCUP cases differ, and the present study is to be poorer among HNCUP patients where a primary the first attempt to systematically assess these differences in tumour was later detected, when compared with patients the Nordic countries (Iceland, Norway, Denmark, Sweden, having a persistent unknown primary (22% vs 52%). CONTACT Lovisa Farnebo, MD, PhD [email protected] Department of Otorhinolaryngology, Department of Clinical and Experimental Medicine, Linkoping€ University, SE-58185 Link€oping, Sweden ß 2016 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, dis- tribution, and reproduction in any medium, provided the original work is properly cited. 1160 L. FARNEBO ET AL. Figure 1. Map showing all the university hospitals managing HNCUP included in this study; (1) Reykjavik, (2) Oslo, (3) Bergen, (4) Trondheim, (5) Tromsoe, (6) Aalborg, (7) Aarhus, (8) Odense, (9) Herlev, (10) Copenhagen, (11) Lund, (12) Gothenburg, (13) Link€oping, (14) Orebro,€ (15) Stockholm, (16) Uppsala, (17) Umeå, (18) Helsinki, (19) Turku, (20) Tampere, (21) Kuopio, and (22) Oulu. Significant prognostic factors in HNCUP were M-class, questionnaire was revised accordingly by the authors. It now smoking, alcohol consumption, and tonsillectomy [6]. comprised four parts (General information (2 questions), The aim of this study was to compare diagnostic proce- Diagnostic procedures for HNCUP (11 questions), Treatment dures for and treatment of HNCUP at the head and neck of HNCUP (15 questions), Follow-up of HNCUP (3 ques- cancer centres of university hospitals in the five Nordic tions)). Early in 2015 the revised questionnaire was sent to countries. all university hospitals in the Nordic countries (Figure 1), representing a total population of 25 million people. All university hospitals in Iceland (1), Sweden (7), Materials and methods Norway (4), and Finland (5) kindly responded to the ques- A multiple-choice questionnaire was designed in English by tionnaire. Denmark referred to their national guidelines for the three authors, based on clinical experience and on appro- HNCUP (www.DAHANCA.oncology.dk/Brows_Web_ priate current literature. The questionnaire was designed to Guidelines 2013), and a senior oncologist representing identify differences in diagnostic and treatment protocols DAHANCA completed the questionnaire accordingly. between the Nordic university hospitals. Questions regarding outcome data were not included in this survey. The question- Results naire was first tested at the Finnish university hospitals. Consequently, physicians in Finland were used as a pilot The management of HNCUP in Iceland and Sweden fol- group in order to fine-tune the questions. After collecting lowed a specific protocol based on local routines regarding the comments from the Finnish university hospitals, the diagnostic procedure and treatment. Finland had national ACTA OTO-LARYNGOLOGICA 1161 Table 1. Diagnostic procedures. Table 2. Treatment. n % n % Imaging modality N1 PET/CT 14 64 Treatment CT 7 32 Surgery 5 23 MRI 1 5 RT 2 9 Cytological method (needle aspiration) CRT 7 32 Fine 22 100 Surgery þ RT 1 5 Middle 0 0 Surgery þ CRT 7 32 Thick 0 0 Radiotherapy dose (Gy) Sites included for scopy 50–70 16 72 B, E, H, L 11 50 0ther 1 5 H, L 11 50 No RT 5 23 Biopsies Radiotherapy of the neck* N, TB, T 17 77 Ipsilateral 5 24 N, TB 2 9 Bilateral 11 52 TB, T 2 9 No RT 5 24 T15N2 Tonsillectomy Treatment Unilateral 2 9 Surgery — — Bilateral 17 77 RT 2 9 Bilateral in selected cases 3 14 CRT 2 9 Robotic surgery Surgery þ RT 7 32 Yes 5 23 Surgery þ CRT 11 50 No 17 77 Radiotherapy dose (Gy) Assessment under anaesthesia 50–70 21 95 Palpation 22 100 0ther 1 5 Narrow band imaging 5 23 Radiotherapy of the neck* Toluidine blue 0 0 Ipsilateral 4 19 B: bronchoscopy; E: esophagoscopy; H: hypopharyngoscopy; Bilateral 17 81 L: laryngoscopy; N: nasopharynx; TB: tongue base; T: tonsil. N3 Treatment Surgery — — guidelines for the treatment of head and neck cancer, but no RT 1 5 specific protocol for the diagnostics of HNCUP. In CRT 2 9 Surgery þ RT 7 32 Denmark, all centres applied the same national guidelines, Surgery þ CRT 12 54 while, in Norway, two university hospitals used local proto- Radiotherapy dose (Gy) 50–70 22 100 cols, but no specific protocol was followed at the remaining Radiotherapy of the neck* two centres.
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