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Zur Therapie von zervikalen Lymphknotenmetastasen ohne bekannten Primärtumor

Treatment for cervical metastases from an unknown primary

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Zusammenfassung

Hintergrund

Bei 3 bis 9% aller Patienten mit zervikalen Lymphknotenmetastasen kann der Primärtumor nicht gefunden werden. Die Prognose dieser Patienten wird häufig als infaust angesehen; die Behandlungskonzepte sind uneinheitlich. In einer retrospektiven Analyse haben wir prognostische Faktoren identifiziert und den Einfluß der Therapie untersucht.

Patienten und Methode

Von 1979 bis 1993 wurden 64 Patienten mit zervikalen Lymphknotenmetastasen und unbekanntem Primärtumor bestrahlt. 40 Patienten litten an Metastasen eines Plattenenepithelkarzinoms. 48/64 Patienten wurden entweder vor (n=41) oder nach (n=7) der Bestrahlung am Hals lymphdisseziert. 12/64 Patienten erhielten eine Chemotherapie (einmal sequentiell, elfmal simultan) zusätzlich zur Radiotherapie. Die Bestrahlung erfaßte prinzipiell den gesamten Rachenraum einschließlich der zervikalen Lymphabflußgebiete mit einer durchschnittlichen Dosis von 59 Gy. 32 Patienten erhielten einen zusätzlichen Boost von durchschnittlich 12 Gy am Epipharynx (n=23) und/oder auf die befallene Lymphknotenregion (n=11). Zweimal erfolgte ein interstitieller Boost (22 Gy) am befallenen Lymphknoten. Die Nachbeobachtungszeit betrug im Mittel acht Jahre (sieben Monate bis 15 Jahre, Median: neun Jahre).

Ergebnisse

52/64 (81,2%) Patienten erreichten eine komplette Remission, zwölf Patienten lediglich eine Teilremission. Nach fünf Jahren betrugen die tumorspezifische Überlebensrate 51,0±7%, das Gesamtüberleben 38,8±7%, die Kontrollrate im bestrahlten Volumen 68,3±7% und die fernmetastasenfreie Überlebensrate 70,0±7%. Die beste Fünf-Jahres-Überlebensrate hatten operierte Patienten (n=48) mit 67% gegenüber 0% (Median: 9,2 Monate) ohne Operation und Patienten mit oberhalb der Glottisebene gelegenen Lymphknotenmetastasen (n=49) mit 63,2% gegenüber 9,0% (Median: 1,2 Jahre, n=12). Der vermeintliche Primärtumor trat in neun Fällen (14%) innerhalb der folgenden drei Jahre auf, davon einmal im Bestrahlungsbereich.

Schlußfolgerung

Patienten mit zervikalen Lymphknotenmetastasen bei unbekanntem Primärtumor haben keine schlechtere Prognose als Patienten mit anderen manifesten Tumoren im HNO-Bereich und sollten mit kurativer Zielsetzung kombiniert radiotherapeutisch und operativ behandelt werden.

Abstract

Background

The primary tumor remains unknown in approximately 3 to 9% of patients with lymph node metastases in the neck. Management of these patients is still controversial particularly because of the commonly as poor assessed prognosis. The treatment outcome was surveyed by a retrospective analysis, trying to identify prognostic factors.

Patients and Method

From 1979 through 1993, 64 patients with metastatic carcinoma of unknown primary tumor involving neck lymph nodes were treated. Most of them (n=40) were squamous cell carcinomas. Forty-eight patients underwent surgical resection of the involved nodes by neck dissection or excisional biopsy. Surgery was performed in 41 patients before and in 7 patients after radiotherapy. Additional chemotherapy was administered to 12 patients (simultaneously to 11 patients). The irradiated volume included both sides of the neck, the supraclavicular region and the whole pharynx. The mean radiation dose was 59 Gy. In 32 patients, an additional boost to epipharynx (n=23) and/or large lymph nodes (n=11) was given (mean: 12 Gy) by external beam therapy, in 2 cases by interstitial implants (22 Gy). Mean follow-up time was 8 years (range: 7 months to 15 years, median: 9 years).

Results

Fifty-two out of 64 (81.2%) patients came into a complete remission and 12 into a partial remission. The cause specific survival after 5 years for the whole group was 51.0±7%, the overall survival 38,8±7%. Within the irradiated area the tumor control was (68.3±7%, the distant metastatic-free survival 70.0±7%. Best results showed patients after surgery + radiation (n=48) with 67% overall survival at 5 years versus 0% (median: 9.2 months) without surgery (n=16), and patients with lymph nodes located above the glottic level (n=49) 63.2% versus 9,0% (median: 1.2 years, n=12). The primary tumor appeared in 9 patients (4 times above the clavicles), once in the irradiated volume.

Conclusion

Patients with cervical metastases of unknown primaries do not fare worse than patients with advanced carcinoma of head and neck and should be treated with a curative intent preferably by surgery and radiotherapy.

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Kirschner, M.J., Fietkau, R., Waldfahrer, F. et al. Zur Therapie von zervikalen Lymphknotenmetastasen ohne bekannten Primärtumor. Strahlenther. Onkol. 173, 362–368 (1997). https://doi.org/10.1007/BF03038239

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