Unknown/Occult Primary Cancers (CUP) of Head & Neck: Diagnostic approach

  1. Determine pathology of lymph node: Fine needle aspiration cytology (FNAC) / core needle biopsy / surgical biopsy
  2. Try to identify primary tumour
    • Symptoms related to upper aerodigestive tract, prior skin cancers
    • Examine nose, nasopharynx, oral cavity, oropharynx, hypopharynx, larynx, skin, thyroid
    • Palpate tonsils, base of tongue and retract tonsillar pillars, and then re-examine for bleeding
    • Cystic nodes: suspect oropharynx / skin cancer
    • Nodal location and laterality suggest location of primary
      • Levels 1a,b: Oral cavity, nose, sinuses
      • Levels 2, 3: Oral cavity, oropharynx, hypopharynx, larynx, nose, sinuses
      • Level 4: Larynx, hypopharynx, thyroid, oral tongue, floor of mouth
      • Level 5: Nasopharynx, posterior scalp, thyroid
      • Level 6: Thyroid, subglottis, hypopharynx, oesophagus
      • Nodes along external jugular vein: Facial skin
      • Bilateral: Midline, base of tongue, soft palate, supraglottis, hypopharynx, nasopharynx (NPC)
    • Immunohistochemistry: EBV (NPC); P16 (oropharynx, skin, nasopharynx, oral cavity); melanoma; thyroid; salivary; lymphoma etc.
    • CT or MRI or PET (Law of diminishing returns and additional costs with >1 imaging modality)
    • Panendoscopy, guided biopsies, tonsillectomy
  3. Exclude distant metastases: CXR / CT / PET
  4. Stage the cancer
  5. Select appropriate treatment, preferably as a multidisciplinary team
    • Cure vs palliation
    • General fitness to undergo surgery +/ (chemo)radiation
    • Ability to deal with consequences of treatment

Index: Clinical Practice Guidelines for CUP

Resource Appropriate CUP Guideline Scenarios