DOI: http://dx.doi.org/10.18203/issn.2454-5929.ijohns20213904

Diagnostic value of tonsillectomy in positron emission tomography and computerised tomography negative carcinoma of unknown primary

Meenu Induchoodan, Rajeev Kumar Madhavan, Shibu George

Abstract


Carcinoma of unknown primary (CUP) represents a heterogeneous group of malignancy metastasis unique biology of which remains poorly understood. Even after a complete diagnostic workup including positron emission tomography and computerised tomography (PET-CT) scans the primary site of origin may remain unclear. This case series analysed the diagnostic value of bilateral palatine tonsillectomy in evaluating PET-CT negative head and neck squamous cell CUP. From retrospective analysis of cluster of 68 cases with metastatic cervical nodes with no obvious primary referred for ENT evaluation during a period of 20 months, we identified 5 cases where pan endoscopy and radiological evaluation including PET-CT were negative in detecting the primary. All 5 patients underwent bilateral palatine tonsillectomy along with biopsies from base of tongue and nasopharynx as a part of completion of diagnostic work-up. Tonsillar squamous cell carcinoma was revealed by subsequent histopathology examination in 4 out of 5 patients despite negative PET-CT evaluation. Blind biopsies from other sites like nasopharynx and base of tongue were unfruitful. Our experience strongly emphasises the fact that bilateral palatine tonsillectomy has a high yield in detecting primary even in PET negative CUP, though it needs a larger evidence base.


Keywords


Carcinoma of unknown primary, Head and neck, PET-CT, Tonsillectomy

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References


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(10):1024-9.

Chorost MI, Lee MC, Yeoh CB, Molina M, Ghosh BC. Unknown primary. J Surg Oncol. 2004;87(4):191-203.

Delgado-Bolton RC, Fernández-Pérez C, González-Maté A, Carreras JL. Meta-analysis of the performance of 18F-FDG PET in primary tumor detection in unknown primary tumors. J Nucl Med. 2003;44(8):1301-4.

Kazak I, Haisch A, Jovanovic S. Bilateral synchronous tonsillar carcinoma in cervical cancer of unknown primary site (CUPS). Eur Arch Otorhinolaryngol. 2003;260(9):490-3.

Lapeyre M, Malissard L, Peiffert D. Cervical lymph node metastasis from an unknown primary: is a tonsillectomy necessary? Int J Radiat Oncol Biol Phys. 1997;39(2):291-6.

Nakamoto Y, Tatsumi M, Hammoud D, Cohade C, Osman MM, Wahl RL. Normal FDG distribution patterns in the head and neck: PET/CT evaluation. Radiology. 2005;234(3):879-85.

Rosenbaum SJ, Lind T, Antoch G, Bockisch A. False-positive FDG PET uptake-the role of PET/CT. Eur Radiol. 2006;16(5):1054-65.

Berta E, Atallah I, Reyt E, Boyer E, Karkas A, Righini CA. The role of tonsillectomy in the initial diagnostic work-up of head and neck squamous cell carcinoma of unknown primary. Eur Ann Otorhinolaryngol Head Neck Dis. 2014;131(5):305-8.

Koch WM, Bhatti N, Williams MF, Eisele DW. Oncologic rationale for bilateral tonsillectomy in head and neck squamous cell carcinoma of unknown primary source. Otolaryngol Head Neck Surg. 2001;124(3):331-3.

Davis KS, Byrd JK, Mehta V, Chiosea SI, Kim S, Ferris RL, et al. Occult primary head and neck squamous cell carcinoma: utility of discovering primary lesions. Otolaryngol Head Neck Surg. 2014;151(2):272-8.

Haas I, Hoffmann TK, Engers R, Ganzer U. Diagnostic strategies in cervical carcinoma of an unknown primary (CUP). Eur Arch Otorhinolaryngol. 2002;259(6):325-33.

Cianchetti M, Mancuso AA, Amdur RJ, Werning JW, Kirwan J, Morris CG, et al. Diagnostic evaluation of squamous cell carcinoma metastatic to cervical lymph nodes from an unknown head and neck primary site. Laryngoscope. 2009;119(12):2348-54.

Nassenstein K, Veit-Haibach P, Stergar H, Gutzeit A, Freudenberg L, Kuehl H, et al. Cervical lymph node metastases of unknown origin: primary tumor detection with whole-body positron emission tomography/computed tomography. Acta Radiol. 2007;48(10):1101-8.

Freudenberg LS, Fischer M, Antoch G, Jentzen W, Gutzeit A, Rosenbaum SJ, et al. Dual modality of 18F-fluorodeoxyglucose-positron emission tomography/computed tomography in patients with cervical carcinoma of unknown primary. Med Princ Pract. 2005;14(3):155-60.

Rohren EM, Turkington TG, Coleman RE. Clinical applications of PET in oncology. Radiology. 2004;231(2):305-32.

Roh JL, Kim JS, Lee JH, Cho KJ, Choi SH, Nam SY, et al. Utility of combined (18)F-fluorodeoxyglucose-positron emission tomography and computed tomography in patients with cervical metastases from unknown primary tumors. Oral Oncol. 2009;45(3):218-24.

Gutzeit A, Antoch G, Kühl H, Egelhof T, Fischer M, Hauth E, et al. Unknown primary tumors: detection with dual-modality PET/CT-initial experience. Radiology. 2005;234(1):227-34.

Mawlawi O, Townsend DW. Multimodality imaging: an update on PET/CT technology. Eur J Nucl Med Mol Imaging. 2009;36(1):15-29.

Zhu L, Wang N. 18F-fluorodeoxyglucose positron emission tomography computed tomography as a diagnostic tool in patients with cervical nodal metastases of unknown primary site: a meta-analysis. Surg Oncol. 2013;22(3):190-4.

Price T, Pickles J. Synchronous bilateral tonsillar carcinoma: role of fluorodeoxyglucose positron emission tomography scanning in detecting occult primary tumours in metastatic nodal disease of the head and neck. J Laryngol Otol. 2006;120(4):334-7.

Kothari P, Randhawa PS, Farrell R. Role of tonsillectomy in the search for a squamous cell carcinoma from an unknown primary in the head and neck. Br J Oral Maxillofac Surg. 2008;46(4):283-7.

Sève P, Billotey C, Broussolle C, Dumontet C, Mackey JR. The role of 2-deoxy-2-[F-18]fluoro-D-glucose positron emission tomography in disseminated carcinoma of unknown primary site. Cancer. 2007;109(2):292-9.

Rusthoven KE, Koshy M, Paulino AC. The role of fluorodeoxyglucose positron emission tomography in cervical lymph node metastases from an unknown primary tumor. Cancer. 2004;101(11):2641-9.

Delgado-Bolton RC, Fernández-Pérez C, González-Maté A, Carreras JL. Meta-analysis of the performance of 18F-FDG PET in primary tumor detection in unknown primary tumors. J Nucl Med. 2003;44(8):1301-14.

Mackenzie K, Watson M, Jankowska P, Bhide S, Simo R. Investigation and management of the unknown primary with metastatic neck disease: United Kingdom National Multidisciplinary Guidelines. J Laryngol Otol. 2016;130(2):170.

Rumboldt Z, Gordon L, Gordon L, Bonsall R, Ackermann S. Imaging in head and neck cancer. Curr Treat Options Oncol. 2006;7(1):23-34.

Wouw AJ, Jansen RL, Speel EJ, Hillen HF. The unknown biology of the unknown primary tumour; a literature review. Ann Oncol. 2003;14():191-6.

Isles MG, McConkey C, Mehanna HM. A systematic review and meta‐analysis of the role of positron emission tomography in the follow-up of head and neck squamous cell carcinoma following radiotherapy or chemoradiotherapy. Clin Otolaryngol. 2008;33:210–22.

Cheung MK, Ong SY, Goyal U, Wertheim BC, Hsu CC, Yi SK. False Positive Positron Emission Tomography / Computed Tomography Scans in Treated Head and Neck Cancers. Cureus. 2017;9(4):e1146.

Kwee TC, Kwee RM. Combined FDG-PET/CT for the detection of unknown primary tumors: systematic review and meta-analysis. Eur Radiol 2009;19(3):731-44.

Dale E, Moan J, Osnes T, Bogsrud T. Cervical lymph node metastases of squamous cell carcinoma of unknown origin: the diagnostic value of FDG PET/CT and clinical outcome. Eur Arch Otorhinolaryngol. 2017;274(2):1015-9.

Pattani K, Goodier M, Lilien D, Kupferman T, Caldito G, Nathan CO. Utility of panendoscopy for the detection of unknown primary head and neck cancer in patients with negative PET/CT scan. Ear Nose Throat J. 2011;90(8):16-20.

Haas I, Hoffman TK, Engers R, Ganzer U. Diagnostic strategies in cervical carcinoma of an unknown primary (CUP). Eur Arch Otorhinolaryngol. 2002;259(6):325-33.

Waltonen JD, Ozer E, Schuller DE, Agrawal A. Tonsillectomy vs. deep tonsil biopsies in detecting occult tonsil tumors. Laryngoscope 2009;119(1):102-6.

Fletcher JW, Djulbegovic B, Soares HP, Siegel BA, Lowe VJ, Lyman GH, et al. Recommendations on the use of 18F-FDG PET in oncology. J Nucl Med. 2008;49(3):480-508

Rege S, Maass A, Chaiken L, Hoh CK, Choi Y, Lufkin R, et al. Use of positron emission tomography with fluorodeoxyglucose in patients with extracranial head and neck cancers. Cancer. 1994;73(12):3047-58.

Theodoraki MN, Veit JA, Hoffmann TK, Greve J. Synchronous bilateral tonsil carcinoma: case presentation and review of the literature. Infect Agent Cancer. 2017 Jun 26;12:38.

Guntinas-Lichius O, Peter Klussmann J, Dinh S, Dinh M, Schmidt M, Semrau R, et al. Diagnostic work-up and outcome of cervical metastases from an unknown primary. Acta Otolaryngol. 2006;126(5):536-44.

Roeser MM, Alon EE, Olsen KD, Moore EJ, Manduch M, Wismayer DJ. Synchronous bilateral tonsil squamous cell carcinoma. Laryngoscope. 2010;120(4):181.

Skilbeck CJ, Jeannon JP, O'Connell M, Morgan PR, Simo R. Squamous cell carcinoma of the tonsillar remnant-clinical presentation and oncological outcome. Head Neck Oncol. 2011;3:4.