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

Index: Clinical Practice Guidelines for CUP

Resource Appropriate CUP Guideline Scenarios