After determining a diagnosis and completing a full pre-treatment evaluation, doctors will recommend a course of treatment for their patients. The treatment for metastatic lymph nodes will ultimately be determined by the type and location of the primary tumor that spread to the neck.
In general, there are three different options for the treatment that can be used alone or in combination:
Surgery
For metastatic lymph nodes, treatment with surgery generally involves a neck dissection to remove lymph nodes from the neck and test to see if they are cancerous. This is usually performed at the same time that the primary tumor is removed, although not always. Neck dissection provides accurate pathologic nodal staging that can be used to determine if further treatment will be necessary. Sometimes surgery is not performed, and treatment decisions are instead based on clinical nodal staging.
Even if surgery is not performed as the primary treatment, it may be required in the future if the lymph nodes were incompletely treated or if they recur after treatment. At this point, a neck dissection will be performed to remove a group of lymph nodes in the neck that are either positive for cancer or at risk of harboring microscopic metastatic disease.
Radiation
Radiation treatment involves directing an external beam of radiation at cancerous lymph nodes in the neck in order to destroy rapidly dividing cancer cells. For the treatment of metastatic lymph nodes, radiation treatment can either be given as the main treatment or as adjuvant treatment after surgery is performed in order to decrease the chances that the tumor will come back. Adjuvant radiation treatment is usually necessary if multiple lymph nodes are found to be cancerous on the final pathology from the neck dissection.
Chemotherapy
Chemotherapy is added to radiation therapy in advanced stage cancers that are treated with primary nonsurgical treatment or with adjuvant radiation. Additionally, chemotherapy may be used in cases where extranodal extension from the cancerous lymph nodes was identified on final pathology.
Unknown (Occult) Primary
In rare cases, the primary tumor is never found and these cases are classified as unknown primaries.
Treatment Recommendations
Cancerous Lymph Nodes in the Neck with an Unknown Primary
- Metastatic lymph nodes with Squamous Cell Carcinoma:
- Further investigation with endoscopy and biopsy or transoral robotic surgery (TORS) should be performed to ensure a small primary is not present. This will often involve the removal of the tonsils, as small cancers in these structures may not be visible on imaging and may only be identified when the tonsils are removed and examined under the microscope.
- If the primary tumor remains unknown, radiation treatment to the most likely sites of the primary tumor may be performed. Alternatively, these areas may be closely monitored with frequent physical exam and imaging.
- Nodal disease is treated as follows:
Treatment for Nodal Disease
N1
- For N1 disease (a single cancerous lymph node less than 3 cm in size), the treatment is generally a neck dissection. Radiation therapy is also an option.
- If the neck dissection confirms only one cancerous lymph node without any adverse features, such as extranodal extension, then radiation or observation are possible options.
N2
- For N2 or greater disease (more and larger lymph nodes) without adverse features, such as extranodal extension, radiation, generally with some form of chemotherapy, is recommended.
Lymph Nodes with Adverse Features
- If the metastatic lymph nodes are found to have adverse features, such as extranodal extension, radiation, generally with some form of chemotherapy, is recommended.
