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LETTER TO THE EDITOR
Year : 2017  |  Volume : 13  |  Issue : 3  |  Page : 599-601

Metastatic adenocarcinoma of unknown primary presenting with cervical lymphadenopathy: A diagnostic challenge


Department of Surgical Oncology, Cancer Institute (WIA), Chennai, Tamil Nadu, India

Date of Web Publication31-Aug-2017

Correspondence Address:
Arvind Krishnamurthy
Department of Surgical Oncology, Cancer Institute (WIA), 38, Sardar Patel Road, Adyar, Chennai - 600 036, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.183179

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How to cite this article:
Krishnamurthy A. Metastatic adenocarcinoma of unknown primary presenting with cervical lymphadenopathy: A diagnostic challenge. J Can Res Ther 2017;13:599-601

How to cite this URL:
Krishnamurthy A. Metastatic adenocarcinoma of unknown primary presenting with cervical lymphadenopathy: A diagnostic challenge. J Can Res Ther [serial online] 2017 [cited 2020 May 27];13:599-601. Available from: http://www.cancerjournal.net/text.asp?2017/13/3/599/183179



Sir,

Carcinoma of unknown primary accounts for about 2–9% of all cases of head and neck cancers; a majority of the reported cases are in fact metastatic squamous cell carcinomas.[1] Although metastatic adenocarcinoma from an unknown primary outside the head and neck region is relatively common, presentation as metastatic cervical lymphadenopathy is very uncommon. We present possibly for the first time a unique case of a patient with metastatic adenocarcinoma from an unknown primary, presenting with bilateral cervical lymphadenopathy and further discuss the challenges involved in its management.

A 61-year-old female reported to our center for evaluation of painless swellings in both her submandibular regions of 6 months duration. The swelling in the right submandibular region measured 6 cm × 4 cm while the left submandibular swelling measured 3 cm × 3 cm [Figure 1]. General physical examination and examination of the rest of the upper aerodigestive track, including a pan-endoscopy, was unremarkable. Fine needle aspiration cytologies (FNACs) from the bilateral submandibular swellings were suggestive of metastatic carcinoma of glandular origin (immunohistochemistry for thyroid transcription factor-1 was negative). A positron emission tomography-computed tomography (PET-CT) scan revealed uptakes in both the submandibular regions and no other uptake in the rest of the body [Figure 2]a,[Figure 2]b,[Figure 2]c,[Figure 2]d. A provisional diagnosis of metastatic adenocarcinoma from an unknown primary was made, a possible primary from the submandibular salivary gland was considered as a differential.
Figure 1: Clinical photograph of patient at presentation

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Figure 2: Positron emission tomography-computed tomography scan. (a and b) Axial views, (c and d) coronal views: revealed uptakes only in the multicystic lobulated hypodense lesions in both the submandibular regions (standardized uptake value: 2.8)

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The patient was taken up for an upfront definitive surgery which entailed a bilateral modified radical neck dissection type III [Figure 3]. The final histopathology revealed metastatic adenocarcinomatous deposits in 1/20 nodes in the left neck and 2/24 nodes in the right neck. Both the submandibular salivary glands were unremarkable [Figure 4]a and [Figure 4]b. The patient was considered for adjuvant radiotherapy after confirming it to be a case of metastatic adenocarcinoma from an unknown primary and is currently disease free for over a year posttreatment.
Figure 3: Postoperative clinical photograph after bilateral modified neck dissections type III

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Figure 4: (a and b) Sections showing metastatic adenocarcinomatous deposits in the cervical lymph nodes, with the submandibular salivary glands being uninvolved (H and E, ×10)

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The initial evaluation and subsequent management of metastatic adenocarcinoma from an unknown primary presenting as cervical neck nodes are riddled with controversies.[2] It is generally believed that metastases in the upper/middle neck are associated with head and neck cancers, metastatic lower neck involvement is often attributable to infraclavicular primaries. While there is a consensus on the management strategies following a FNAC diagnosis of metastatic squamous cell carcinoma in the cervical lymph nodes presenting as an unknown primary, no such consensus exists for metastatic adenocarcinomas.[3] The few published series that address this relatively rare subgroup suggests a CT scan of the neck/chest/abdomen and pelvis to be the ideal next investigation of choice and a PET-CT to be done only if the CT scans are not contributory.[3] PET-CT over the years has emerged as a useful investigation in the management of metastasis of unknown primaries.[4],[5],[6] An upfront PET-CT in our patient not just proved to be a cost-effective option but also effectively guided the further course of management by ruling out distant metastasis. In conclusion, our report adds to the limited literature and will guide oncologists to make better-informed choices with regards to the use of PET-CT scans in patients with metastatic adenocarcinoma of unknown primary presenting with cervical lymphadenopathy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
Calabrese L, Jereczek-Fossa BA, Jassem J, Rocca A, Bruschini R, Orecchia R, et al. Diagnosis and management of neck metastases from an unknown primary. Acta Otorhinolaryngol Ital 2005;25:2-12.  Back to cited text no. 1
    
2.
Strojan P, Ferlito A, Langendijk JA, Corry J, Woolgar JA, Rinaldo A, et al. Contemporary management of lymph node metastases from an unknown primary to the neck: II. A review of therapeutic options. Head Neck 2013;35:286-93.  Back to cited text no. 2
    
3.
Pepper C, Pai I, Hay A, Deery A, Wilson P, Williamson P, et al. Investigation strategy in the management of metastatic adenocarcinoma of unknown primary presenting as cervical lymphadenopathy. Acta Otolaryngol 2014;134:838-42.  Back to cited text no. 3
    
4.
Prowse SJ, Shaw R, Ganeshan D, Prowse PM, Hanlon R, Lewis-Jones H, et al. The added value of 18F-fluorodeoxyglucose positron emission tomography computed tomography in patients with neck lymph node metastases from an unknown primary malignancy. J Laryngol Otol 2013;127:780-7.  Back to cited text no. 4
    
5.
Waltonen JD, Ozer E, Hall NC, Schuller DE, Agrawal A. Metastatic carcinoma of the neck of unknown primary origin: Evolution and efficacy of the modern workup. Arch Otolaryngol Head Neck Surg 2009;135:1024-9.  Back to cited text no. 5
    
6.
Paul SA, Stoeckli SJ, von Schulthess GK, Goerres GW. FDG PET and PET/CT for the detection of the primary tumour in patients with cervical non-squamous cell carcinoma metastasis of an unknown primary. Eur Arch Otorhinolaryngol 2007;264:189-95.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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