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"From F. de Braud and M. Al-Sarraf (1993). Diagnosis and management of squamous cell carcinoma of unknown primary tumor site of the neck. Semin. Oncol. 20, 273-278.

"From F. de Braud and M. Al-Sarraf (1993). Diagnosis and management of squamous cell carcinoma of unknown primary tumor site of the neck. Semin. Oncol. 20, 273-278.

TABLE 2a.4 Diagnostic Workup for Cervical Lymph Node Metastases: Unknown Primary Tumor3

General History

Physical examination

Careful examination of the neck and supraclavicular regions Examination of the oral cavity, pharynx, and larynx (indirect laryngoscopy)

Radiographic studies Chest roentgenogram

Computed tomography of the head and neck (special attention to nasopharynx, pharynx, and larynx) Upper gastrointestinal series and barium enema (in patients with adenocarcinoma involving supraclavicular lymph nodes)

Laboratory studies

Complete blood cell count Blood chemistry profile

Direct laryngoscopy and directed biopsies

Nasopharynx, both tonsils, base of tongue, both pyriform sinuses, and any suspicious or abnormal mucosal areas Fine needle aspirate or core needle biopsy of the cervical node

"From W. M. Mendenhall, J. T. Parsons, A. A. Mancuso, S. P. Stringer, and N. J. Cassisi (1997). Head and neck: Management of the neck. In "Principles and Practice of Radiation Oncology," (C. A. Perez and L. W. Brady, eds.), 3rd Ed., pp. 1151-1154. Lippincott-Raven, Philadelphia.

entiated carcinoma. In patients for whom a nasopharyngeal carcinoma is high, probability includes an involvement of posterior chain nodes, a histology of lymphoepithelioma or undifferentiated carcinoma, and an ethnic background with a high incidence of nasopharyngeal carcinoma, such as Chinese. In these patients, an IgA titer against the viral capsid antigen of Epstein-Barr virus (EBV) may be helpful in ruling out a primary nasopharyngeal carcinoma. Using polymerase chain reaction (PCR), genome products of Epstein-Barr virus can be identified from a FNA specimen from neck nodes [13,14]. In a study of 41 FNA specimens, Feinmesser et al. [14] reported a presence of EBV in specimens from nine patients. Seven of these patients were found to have a nasopharyngeal primary; in the remaining two patients, a nasopharyngeal primary appeared within 1 year. Another study reported a high sensitivity of the in situ hybridization technique in detecting EBV in a FNA specimen of the neck node [15].

If a physical examination is unrevealing, panendoscopy (nasopharyngoscopy, laryngoscopy, bronchoscopy, and esophagoscopy) should be performed under general anesthesia with a biopsy of all suspicious lesions. If no suspicious lesions are noted, a directed biopsy of potential primary sites (nasopharynx, tonsil, base of tongue, and pyriform sinus) should be performed. If repeated physical examination and computed tomography (CT) or magnetic resonance imaging (MRI) is negative, the yield of a directed biopsy is low. The base of tongue and tonsil are sites of highest positive biopsy yield. Because a superficial biopsy of the tonsil can

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