Scottish Cancer Network: Clinical Management Pathways
- Patients referred with new neck lump should be vetted as urgent suspected cancer and to a dedicated neck lump clinic where available.
- Offer patients with cervical neck mass ultrasound assessment and guided sampling. Open biopsy is not recommended as first line investigation.
- Where outpatient clinic evaluation (including flexible nasal endoscopy) fails to identify a primary mucosal cancer, complete all radiological investigations prior to diagnostic surgical procedures.
- Consider chromoendoscopy, in addition to white light endoscopic evaluation.
- Offer a timely open biopsy/conservative excision in the presence of non-diagnostic ultrasound guided core-biopsy procedure. Consider repeat ultrasound guided biopsy that samples the wall of a cystic mass prior to an open procedure, if it does not entail significant delay. Consider PET-CT prior to open biopsy where malignancy seems probable.
- For patients, with p16/HPV+ve nodal metastasis, it is thought that the overwhelming majority of primary tumours reside in oropharyngeal tissue. Consider bilateral tonsillectomy, bilateral tongue base mucosectomy, ipsilateral tonsillectomy and/or ipsilateral mucosectomy.
Cancer of unknown primary of the head and neck
Warning
This consensus document is not a rigid constraint on clinical practice, but a concept of good practice against which the needs of the individual patient should be considered. It therefore remains the responsibility of the individual clinician to interpret the application of the Clinical Management Pathway (CMP), taking into account local service constraints and the needs and wishes of the patient. It is not intended that these consensus documents are applied as rigid clinical protocols.
- Consider ipsilateral neck dissection in both human papillomavirus (HPV) -ve and +ve SCC of unknown primary (SCCUP) with a single node ≤3cm in maximum diameter with no radiological extranodal tumour extension (ENE).
- Consider neck dissection prior to radiotherapy in patients with HPV -ve SCCUP who have N2 disease (judged to be resectable) who are unsuitable for concomitant chemotherapy.
- Consider neck dissection prior to (chemo)radiotherapy in HPV -ve SCCUP with resectable N3 disease.
- Adenocarcinoma unknown primary: for metastasis in levels I-III offer neck dissection and consider ipsilateral parotidectomy; for metastasis in levels IV-V refer for work-up as infraclavicular adenocarcinoma unknown primary.