Metastasis to head and neck area: a 16-year retrospective study

Article Outline

• Abstract
• 1. Introduction
• 2. Materials and methods
• 3. Results
• 4. Discussion
• 5. Conclusion
• References
• Copyright

Abstract 

Purpose

One of the most striking qualities of cancer is its spread throughout the body. The location of a metastatic mass may help to identify the primary tumor. Metastases to head and neck area can occur either from local structures or from distant organs.

Materials and methods

This study was a retrospective review of patients from a University Hospital in Tehran, Iran, during the period 1992 to 2008. The data were analyzed for sex, age, primary site of tumors, metastatic site, and histology of the tumors. The tumors were classified into 2 groups: intraoral and extraoral.

Results

A total of 191 cases were found; of these, 118 (62%) were men and 73 (38%) were women. The most common intraoral primary site was tongue (anterior and posterior parts). Thyroid gland was the most frequent primary extraoral site. The most frequent metastatic site was the lymph node, and level II most commonly involved lymph nodes, followed by level I.

Conclusion

Metastases are an infrequent finding in head and neck region and they may represent the initial manifestation of the disease. Diagnostic evaluation of metastatic lesion will detect the primary tumor.

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1. Introduction 

One of the most striking qualities of cancer is its spread throughout the body. The location of a metastatic mass may help to identify the primary tumor. Previous studies have demonstrated that all malignant cervical tumors are metastatic, except for lymphoma. In addition, asymmetric enlargement of one or more cervical lymph nodes in an adult is almost always cancerous and is usually due to metastasis from a primary lesion in the mouth or pharynx [1]. Metastases to head and neck area can occur either from local structures or from distant organs. In most cases, the head and neck region is the primary site for metastasis [2], but metastases may arise from outside of the head and neck region, including the lung, liver, bone, brain, and lymph nodes. Most metastases in the head and neck target the neck lymph nodes [3].

Metastatic tumors of the oral cavity are rare, representing about 1% of oral tumors. They affect the jaws much more frequently than soft tissues [4]. Metastasis to the mandible makes up more than 70% of all malignant metastatic tumors in the oral cavity [5]. To determine the frequency of metastasis to head and neck area, a retrospective study was conducted. The clinical and pathological data are reported here.

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2. Materials and methods 

This study was a retrospective review of patients from a University Hospital in Tehran, Iran. During the period 1992 to 2008, records from the Department of Pathology were reviewed with attention to metastatic tumors in head and neck area. Histological confirmation of the metastatic lesion was obtained in 191 cases. The data were analyzed for sex, age, primary site of tumors, metastatic site, and histology of the tumors. For better detailed analysis, the tumors were classified into 2 groups: intraoral and extraoral.

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3. Results 

Within the 16-year period of study, a total of 191 cases were found; of these, 118 (62%) were males, and 73 (38%) were females (Table 1). Average age for men was 57.2 years (range, 45–83 years), and for women, 30 years (range, 12–49 years).

Table 1. Distribution of metastatic tumors by sex, age, and location

Variable (191 patients)	No. of patients
Sex
Male	118
Female	73
Age
<15	3
16-40	56
>40	132
Tumor primary site
Intraoral site	33
Extraoral site	158
Lymph node metastases	180
Extranodal metastases	11

As shown in Table 2 the most common intraoral primary site was tongue (anterior and posterior parts) with 19 cases (9%). According to Table 3, thyroid gland was the most frequent primary extraoral site (n = 59; 30%). The most frequent metastatic site was the lymph node with 180 cases (94%), and level II was the most commonly involved in lymph nodes with 129 cases (67%), followed by level I with 21 cases (10%). Supraclavicular lymph node involvement was detected in 10 cases (5%). Histologically, there was a predominance of squamous cell carcinoma (SCC) (55 cases, 28%) of which 23 cases (12%) developed in oral cavity. Papillary carcinoma with 49 cases (25%) formed the second largest group. The 2 most frequent primary sites histologically diagnosed as SCC were the tongue with 18 cases (9%) and the larynx with 10 cases (5%). Salivary gland metastases developed in 23 cases (12%), of which one was distant metastasis to the brain. Among the salivary glands, submandibular gland was the most commonly found primary site in 12 cases (12%). Lymph node metastases from lesions of salivary glands occurred in 22 cases (11.5%). Metastases to the parotid lymph nodes occurred in 15 cases (7.8%).The dominant histologic type for salivary gland tumors was mucoepidermoid carcinoma (n = 13; 6.8%). Cutaneous metastases occurred in 10 cases (5%). Metastases to the parotid gland (n = 2; 1%) were associated with cutaneous primary malignancies in the head and neck area. Among patients with SCC, level II was the most frequently involved in lymph nodes (n = 39; 20%). The breast, with 4 cases (2%), was the most common primary site with distant metastases, followed by the stomach with 3 cases (1%). The bladder, with 2 cases (1%), was the most frequent site metastasizing to oral cavity, both to buccal mucosa. There was one unknown primary tumor.

Table 2. Distribution of intraoral metastatic tumors by site and type

Table 3. Distribution of Extraoral metastatic tumors by site and type

SCC, squamous cell carcinoma; LN, lymph node.

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4. Discussion 

Metastasis has been defined as the transfer of disease from one organ or part of an organ to another not directly connected to it. Tumoral cells penetrate into vascular or lymphatic channels, providing the opportunity for spread. Spread is dictated by local anatomy, and each site has its own pattern [6].

In the current study, most of the metastatic tumors to the head and neck region were found in men (n = 118, 62%). Patients were mostly older than 40 years (n = 132, 69%). This finding is in agreement with published reports [1].

In this series, lymph node metastases accounted for 180 cases (94%), of which level II metastases were the most frequent, with 129 cases (67%). Nodal metastases at level I (n = 16) and level II (n = 17) were the most common involved in lymph nodes from intraoral tumors. Level II was the most common lymph node metastasis from extraoral site tumors such as thyroid (n = 59), nasopharynx, and larynx (each 12 cases). Shah found the most common lymph node metastases from oral cavity tumors in level I, II and III, and level II, III and IV lymph nodes were at greatest risk for nodal metastases from the oropharynx, hypopharynx, and larynx [7].

In the present series, involvement of supraclavicular lymph nodes (n = 12) with metastatic cancer occurred due to metastases from infraclavicular sites. This finding is in agreement with previous published reports [3].

In this study, the thyroid gland was the most frequent extraoral primary site with 59 cases (30%), and papillary carcinoma was the most frequent thyroid tumor with 49 cases (25%). By contrast, in one series, the rate of nodal metastases for papillary carcinoma, the most frequent metastatic thyroid tumor, was 50% [8].

In the current series, submandibular gland (n = 12) was the most frequent salivary gland to metastasize to lymph nodes (n = 11), followed by the parotid gland (n = 10), and mucoepidermoid carcinoma was the most frequent histological type (n = 13). These results were similar to those showing that submandibular gland had the highest frequency of lymph node metastases, followed by parotid gland, and mucoepidermoid carcinoma was the most common histologic tumor [8].

Metastasis to the salivary glands is unusual but the parotid is the most common affected site [9]. The present report indicates that metastasis to the parotid gland was noted in 2 cases: one was undifferentiated tumor, and one was malignant trichoepithelioma. This is contrary to previous studies that revealed that SCC was the most frequent histologic tumor metastases to the parotid gland [10].

In the current study, the breast was the most common distant primary site. This finding disagrees with other studies showing the gastrointestinal tract as the most common distant primary site [3].

In this study, the most frequent primary intraoral site was the tongue with 19 cases, followed by the floor of mouth with 6 cases. In the Talmi et al [7] series, the most frequent primary intraoral site was the tongue with 16 cases, followed in frequency by the retromolar trigone with 3 cases.

Here, metastases to the oral cavity were seen in 5; among them, 4 cases developed in oral soft tissues, all to buccal mucosa. This result disagrees with other studies showing that the jaw bones were the most frequent site for intraoral metastases [5] and also that the attached gingival was the most common metastatic site, followed by the tongue [4].

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5. Conclusion 

Metastasis is an infrequent finding in head and neck region, and it may represent the initial manifestation of the disease. Diagnostic evaluation of metastatic lesion will detect the primary tumor.

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References 

1. McGuirt WF. Differential diagnosis of neck masses. In:  Cummings ChW,  Flint PW editor. Cummings Otolaryngology Head & Neck Surgery. 2nd ed.. Philadelphia (PA): Elsevier Mosby; 2005;p. 2540–2553
   • View In Article
2. Jones AS, Cook JA, Phillips DE, et al. Squamous carcinoma presenting as an enlarged cervical lymph node. Cancer. 1993;72:1756–1761
   • View In Article
   • CrossRef
3. Imamura SI, Suzuki H. Head and neck metastases from occult abdominal primary site: a case report and literature review. Acta Otolaryngol. 2004;124:107–112
   • View In Article
   • MEDLINE
   • CrossRef
4. Hirshberg A, Shnaiderman-Shapiro A, Kaplan I, et al. Metastatic tumors to the oral cavity: pathogenesis and analysis of 637 cases. Oral Oncol. 2008;44:743–752
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (160 KB)
   • CrossRef
5. Irani S, Moshref M, Lotfi A. Metastasis of a gastric adenocarcinoma to the mandible: a case report. Oral Oncol EXTRA. 2004;40:85–87
   • View In Article
6. McGuirt WF. Differential diagnosis of neck masses. In:  Cummings ChW,  Fredrickson JM editor. 3rd ed.. Otolaryngology head & neck surgery. vol. 3:Philadelphia (PA): Mosby; 1998;p. 1743–1746
   • View In Article
7. Talmi YP, Hoffman HT, Horowitz Z, et al. Patterns of metastases to the upper jugular lymph nodes (the ‘submuscular recess’). Head Neck. 1998;20:682–686
   • View In Article
   • MEDLINE
   • CrossRef
8. Johns ME, Nachlas NE. Salivary gland tumors. In:  Paparella MM,  Shumrick DA editor. 3rd ed.. Otolaryngology. vol. 3:Philadelphia (PA): Saunders; 1991;p. 2099–2127
   • View In Article
9. Spiegel JH, Brys AK, Bhakti A, et al. Metastasis to the submandibular gland in head and neck carcinomas. Head Neck. 2004;26:1064–1068
   • View In Article
   • MEDLINE
   • CrossRef
10. Raut V, Sinnathuray AR, Primrose WJ. Aggressive treatment of metastasis to the parotid. Ulster Med J. 2004;73:85–88
    • View In Article
    • MEDLINE