Metastatic Neck Node-A Study of 60 Cases

Objectives: To find out the incidence, distribution, level and staging of cervical nodal metastasis. Methods: This is a retrospective study carried out in the Department of Otolaryngology Head and Neck Surgery, BSMMU and Dhaka Medical College Hospital, Dhaka, from January 2005 to December 2005. Total 60 cases were studied. The diagnosis was made by detailed history, clinical examination, investigation. Analyzed data presented by various tables, graphs and figures. Results: In this study primary lesion was identified in 88.33% cases and undetected cases were 11.7%, 81.13% were squamous lining and 18.87% non-squamous. Highest frequency of metastatic node was found with carcinoma larynx (36.66%). Male and age of 41-50 years was had highest incidence. About 43.33% had dysphagia, 38.33% had hoarseness of voice, 13.33% respiratory distress, 8.33% strider and 8.33% had referred otalgia. The disease was unilateral 81.67%, 63.33% multiple node involvement, highest involvement in level II & III and stage N 2 larynx was commonest site of involvement.


Introduction
A common denominator to all malignancies is in their ability to metastasize.Why & how this phenomena occurs has been the subject of much research and investigation.We do The incidence of metastatic neck node is quoted in different countries are almost similar.One study in USA revealed about 90% cases of known and 10% cases of unknown primary and another study in UK showed 89.3% cases of known and 10.3% cases of unknown primary. 5,6Another Bangladeshi study showed 93.2% cases of known primary and 6.8% cases of unknown primary sites. 7etastatic cervical lymph nodes may occur from various primary sites.85% of the tumours deposited in the neck nodes originate from above the calvicle and 15% below the clavicles. 8About 90% of the supraclavicular primaries are squamous, common sites are nasopharynx, base of the tongue, tonsils, piriform fossa and larynx. 9,10 small percentage of the supraclavicular primaries may be nonsquamous origin arising from thyroid gland, salivary gland and skin of head and neck region.Infraclavicular primary foci may be found in the chest (Ca lung, Ca breast) or abdomen (carcinoma of stomach, colon, ovary, testis).Unknown primary sites are fossa of Rosenmuller, base of the tongue, piriform fossa, tonsil and retromolar trigon.
In general, lesions in well-lateralized primary sites (piriform fossa, lateral floor of the mouth) tend to metastasize to the ipsilateral site of the neck and lesion in the more midline position (supraglottic larynx, base of the tongue, posterior pharyngeal wall) show higher incidence of bilateral metastasis. 11A thorough knowledge of neck and neck lymph node group is essential to identify the site of primary tumour. 12storically, more than 60% of metastatic neck node, primary sites can be identified by taking comprehensive history and initial physical examination. 7,8However, further evaluation by endoscopy and biopsy is required for confirmatory diagnosis and effective management.Fine needle aspiration cytology is helpful in demonstrating metastatic carcinoma in lymph node.This technique is not valuable as a routine but may be helpful in the evaluation of a difficult clinical situation.The treatment options for metastatic neck disease are radiotherapy, surgery (a variety of procedures) or a combination of two. 13e 5 years survival rate of the metastatic neck is by approximately 50%.The survival rate reduced further when multiple nodes are involved as extra nodal spread 5 .With further progression the incidence of distant metastasis also increases dramatically making the disease incurable. 6So early treatment of the primary tumors and lymph nodes are essential for good loco-regional control and reduce the incidence of distant metastasis and improve survival.
Metastatic cervical lymph node is a common aliment in clinical practice in otolaryngology in Bangladesh.So, this study has been undertaken to show different types of Head and Neck cancer metastasizing to cervical lymph nodes and also to note the age and sex distribution and clinical presentation of patients with metastatic neck nodes.Total 60 cases were selected with metastatic neck node consisting of different age and sex.Metastatic neck node with a known primary both squamous and nonsquamous origin in head and neck region and those with an unknown primary were included in this study.

It is a retrospective study carried out inpatient
After taking a comprehensive history every patient was examined thoroughly with particular emphasis to ear, nose and throat region.Neck was examined very carefully for the presence of a primary disease as well as the side, size, number and level of lymph node involvement, their consistency and mobility.All cases were advised for FNA biopsy of enlarged neck node.Cases revealed metastatic deposits in enlarged neck gland in FNA biopsy entered into this series and relevant investigations like CT scan, MRI etc. Data were collected in a pre-designed data collection sheet and analyzed by using standard statistical methods.
In the present series altogether 60 cases of metastastic neck node had been studied.A Primary lesion could be identified in 53 (88.33%) cases.However primary sites remained undetected in 7 (11.7%)cases.A study in our country with the metastatic neck node shows 93.2% cases of known primary & 6.8% cases of unknown primary sites 23 .However, two studies carried out abroad showed similar rate of incidence.One in the Liverpool, England showed 89.3% cases of known & 10.3% cases of unknown primary and another in USA revealed about 90% cases of known & 10% cases of unknown primary 14,17 .
Among the primary sites 43 (81.13%)cases were seen to arise from squamous lining of upper aerodigestive tract & 10 (18.87%) cases were having a nonsquamous origin arising from thyroid gland (13.33%) & parotid gland (3.33%).The study shows that metastasis from thyroid gland carcinoma is not a very uncommon entity.The incidence of metastatic neck node of thyroid origin in other series varied from 6.25% to 9.5%.In the present series metastatic neck node of thyroid origin was found in 8 (13.33%) cases.other study with metastatic neck node in Khartoum Teaching Hospital, Sudan, most common primary site was found nasopharyx. 18It might be due to their social habits and genetic predisposition.Other studies showed highest incidence of metastasis from Ca-pyriform fossa 16  The primary sites in bilateral neck metastases were 3 (30%) in larynx, 2 (20%) in thyroid gland, 1 (10%) case in nasopharynx, 1 (10%) in base of the tongue and 3 (30%) unknown primary.

Conclusion
Enlarged cervical node in an elderly patient should always be considered as metastatic until proved otherwise.Because delay in the diagnosis will eliminate the best opportunity for effective treatment with curative intention.
Department of Otolaryngology Head and Neck surgery, BSMMU and Dhaka Medical College Hospital, Dhaka, from January 2005 to December 2005.

Table - I
Incidence 9his is supported by other works done with metastatic neck disease in our countly with high incidence of unilateral metastatic neck node9.In a work on metastatic neck disease done by G. B snow and his team in Netherland Cancer Institute, Amsterdam, ipsilateral enlargement of lymph node demonstrated in 87% cases.That work also showed bilateral enlargement in 8.6% & contralateral enlargement in 3.6% cases.