Unknown/Occult Primary Cancers (CUP) of Head & Neck: Treatment modifications in poorly resourced settings

Endoscopic equipment
- To diagnose, biopsy and follow NPC
- May need to examine and biopsy NPC under general anaesthesia
FNAC or core needle biopsy unavailable/unreliable: Excise lymph node for histology (and TB culture)
Imaging (CT / MRI / PET) not readily available/affordable
- CXR for staging and to exclude lung primary
- Guided biopsies of nasopharynx, base of tongue, tonsillectomies and suspicious areas
Radiotherapy +/- Platinum-based adjuvant chemotherapy
- Limited access: primary surgery to neck and watchful waiting for potential primary sites
- With 2D or 3D CRT, consider including oropharynx in radiation fields as it is almost impossible to miss the ipsilateral oropharynx
- Even with IMRT the oropharynx will receive some RT
- With marginal indications, consider
  - Patient’s fitness
  - Morbidity and mortality related to treatment
  - Social support and likelihood of completing treatment
  - Expense
  - Competing institutional needs for radiation therapy or for operating time