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In head and neck oncology, the term "unknown primary tumour" means a primary neoplasm that has not been found in a patient with neck metastasis, even after a

Table 9.2. Location of lymph node metastasis and predominant sites of their primary tumours (extracted from [75, 99, 125]. ENT ear nose throat, GI gastrointestinal, GU genitourinary

Lymph node region affected by metastasis

Sublevel IA (submental) Sublevel IB (submandibular) Sublevel IIA (upper jugular)

Sublevel IIB (upper jugular) Level III (middle jugular)

Level IV (lower jugular)

Sublevels VA, VB (posterior cervical) Supraclavicular

Predominant sites(s) of primary tumour

Anterior floor of mouth; anterior oral tongue, anterior mandibular ridge lower lip

Oral cavity, anterior nasal cavity, midface, submandibular gland

Waldeyer's ring, oral cavity, nasal cavity, oropharynx, supraglottis, floor of mouth, pyriform sinus

Anterior tongue, nasopharynx, tonsil

Hypopharynx, base of tongue posterior pharyngeal wall, supraglottic larynx

Hypopharynx, thyroid

Nasopharynx, thyroid, oropharynx Lungs (40%), thyroid (22%) GI tract (12%), GU tract (8%) all ENT regions (20%)

thorough work-up. The neck metastasis may represent regional or distant primary disease.

shows the probable primary sites by region of metastasis [75, 109, 125].

9.6.2 Clinical Features

An enlarged cervical lymph node is frequently the first clinical manifestation of a neoplastic process in the head and neck. Cervical lymph node metastasis is the presenting symptom in 25% of patients with cancer of the oral cavity or pharynx, in 47% of patients with nasopharyngeal carcinoma, and in 23% of patients with thyroid carcinoma. In some instances, however, despite a thorough search, a primary tumour cannot be found [45, 64, 72, 79, 93, 123].

Patients with a high probability of a metastatic tumour in the cervical lymph nodes are men (male: female ratio 4:1) older than 40 years, who smoke and drink alcohol heavily. They usually present with a painless node larger than 2 cm along the jugular chain or the supraclavicular fossa. Various groups of lymph nodes can be affected by metastatic neoplasms, but the most frequently involved are the upper jugular (71%), the midjugular (22%), the supraclavicular (18%), and the posterior cervical nodes (12%). Approximately 14% of patients with such disease have more than one lymph node group affected by metastases and 10% have bilateral lymph node metastases [45, 123]. The lymphatic drainage of the head and neck region is highly predictable, and the location of the adenopathy may provide a clue to the location of the primary lesion. Table 9.2

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