Journal of Surgical Oncology 9:503-507 (1977)
An Unusual Presentation of Carcinoma of the lung: 26 Patients With Cervical Node Metastases .......................................................................................... ..........................................................................................
RAY S. DAVIS, MICHAEL B. FLYNN, M.D., F.A.C.S., and CONDICT M001RE,M.D., F.A.C.S. Carcinoma of the lung should be considered in the search for an unknown primary lesion when there is evidence of cervical lymph node involvement. Of 1,686 patients with a final diagnosis of bronchogenic carcinoma seen during a 10-year period a t the University of Louisville Hospitals, 26 presented with one or more clinically positive cervical nodes. The frequency of lung cancer in such instances varies from 1.5% (in the present report) to 32%, possibly because t h e term “cervical node” is used without clarification. More precise description of such metastases is urged.
.......................................................................................... .......................................................................................... Key words: carcinoma of t h e lung, lung cancer, cervical node metastases
INTRODUCTION The incidence of lung cancer as the occult primary lesion in patients presenting with cervical node metastases of unknown origin has been thoroughly documented (Ban-ie et al., 1970; Engzell et al., 1971; Jesse and Neff, 1966; Lee and Helmus, 1970; Marchetta et al., 1963; Probert, 1970). Review of the recent medical literature disclosed no study designed t o indicate the frequency with which patients with lung cancer present with cervical node metastases. The incidence and the prognostic implication of this unusual finding are considered in this report.
MATERIALS AND METHODS The charts of all patients with a final diagnosis of carcinoma of the lung from January 1963 through December 1973 were reviewed at three University of Louisville Hospitals: Louisville General Hospital, Veterans Administration Hospital, and NortonChldren’s Hospitals. Of 1,686 total charts reviewed, 509 were from Louisville General
From the Department of Surgery, the University of Louisville School of Medicine, Health Sciences Center, Louisville, Kentucky. Address reprint requests to Department of Surgery, Health Sciences Center, Louisville, KY 40201.
503
0 1977 Alan R. Liss, Inc., 150 Fifth Avenue, New York, NY 10011
504
Davis, Flynn, and Moore
Hospital, 804 were from Veterans Administration Hospital, and 373 were from NortonChildren’s Hospitals. Because the terms “cervical node,” “scalene node,” and “supraclavicular node” were often used synonymously, clarification of the specific sites in the neck was needed. For purposes of this study, lymph nodes of the lower neck anatomically defined as the inferior deep cervical nodes were excluded (Wanvick and Williams, 1973). The terminology used in the clinical description of these nodes included scalene, supraclavicular, lower jugular, and lower posterior cervical (Jesse, 1970). Primarily for simplicity, we prefer the descriptive technique illustrated in Fig. 1 for the localization of metastases by node levels (Barrie et al., 1970). Level I refers t o the nodes of the diagastric triangle; Levels 11, 111, and IV refer, respectively, to the upper, middle, and lower thirds of the deep jugular chain; Level V represents the posterior triangle nodes. Eleven patients with both cervical and supraclavicular involvement were excluded.
Fig. 1. Metastatic sites in the neck divided into Levels I-V. SC designates the supraclavicular area.
RESULTS
Of the 1,686 patients with carcinoma of the lung 26, or 1.576, were found to present with one or more clinically positive cervical nodes. The relative frequency varied from 3.0% (1 1/373) at Norton-Children’s Hospitals, to 1.6% (8/509) at Louisville General Hospital, and 0.9%(7/804) at Veterans Administration Hospital. The average age of the 26 patients at first hospital admission was 52 years; 19 were male and 7 female. The relative frequencies of each histologic type of primary lesion and of each lobe of the lung as the site of the primary lesion are shown in Tables I and 11, respectively.
Carcinoma of the Lung
505
TABLE I. Relative Frequency of Types of Lesions Histologic type
Number of patients
Squamous cell Poorly differentiated Oat cell Adenocarcinoma Alveolar cell
8 I 5 1
1
TABLE 11. Relative Frequency of Locations in Lung Lobe of lung Right upper lobe Right middle lobe Right lower lobe Right hilus Left upper lobe Left lower lobe Left hilus
Number of patients 12
2 4 4 0 3
4
Of the 26 patients 24 had metastases in Level 111; one patient had metastases in Level 11, and both levels were involved in the remaining patient. In 73% (19/26) of the patients distant metastases t o viscera, bone, and brain were discovered at some time during hospitalization or were confirmed at autopsy. No patients in this study were treated by pulmonary resection; 9 patients received radiation therapy, 4 received chemotherapy, 6 received a combination of irradiation and chemotherapy, and 7 were only treated symptomatically. Follow-up information was available in 24 of the 26 patients. Within 6 months of their hospital admission 58%(14/24) were dead of cancer; 21 of the 24 died within 2 years, and nlo patient survived 3 years. Survival rate at 2 years was 12.5% (3/24).
DISCUSSION In industrialized nations, lung cancer is the most common visceral malignancy in men, causing approximately 40% of all male cancer deaths. The annual number of deaths in the United States from lung cancer has risen from 18,313 in 1950 t o 74,933 in 1973 (Robbins, 1974; Seidman et al., 1976). Although women have only one-sixth the mortality rate of men from lung cancer, mortality doubled in this group from 1954 t o 1974 (Robbins, 1974). Lung cancer is characterized by a high degree of metastases. often early in the identifiable course of illness. Garland and colleagues (1963) concluded that it may take many years for primary tumors in the lung t o reach large enough size to demand clinical atten-
506
Davis, Flynn, and Moore
tion. During this pathologic evolution, the tumor often metastasizes by hematogenous and lymphatic routes. More than half the malignant lesions of the lung drain lymphatically into the tracheal, bronchial, and mediastinal lymph nodes. Above the clavicle, scalene and lower jugular nodes are commonly involved, with the incidence reported as high as 50%(Robbins, 1974). Cervical node metastases in patients with an occult primary tumor have been the subject of numerous articles. One purpose of these studies has been to determine the incidence of each organ as the primary site. Positive findings in supraclavicular nodes generally are considered to suggest a primary lesion below the clavicle; cervical nodes at other levels usually suggest a primary lesion above the clavicle. Lower cervical nodes other than supraclavicular may suggest a primary lesion either above or below the clavicle. In a study by Lee and Helmus (1970), 32% (15/48) of the patients had a primary lesion later found in the lung, and 14.5%were later diagnosed with a primary lesion in the larynx or pharynx. The reported frequency with which occult primary tumors subsequently were found in the lung has varied between 5 and 32% (Table 111). TABLE HI. Reported Frequency ofOccult Primary Tumor in Lung
Jesse and Neff Lee and Helmus Barrie et al. Marchetta et al. Prober t Engzell et al.
Total number of patients with occult primary
Primary site was discovered
Primary site with lung
121 163 123 33 61 1,101
48 48 38 15 21 1,051
10 (20%) 15 (32%) 2 ( 5%) 2 (13%) 4 (19%) 115 (10.4%)
Instead of studying a series of patients with neck masses t o determine the frequency with which the occult primary lesion appeared in the lung, we studied a series of lung cancer patients to determine the frequency with which they metastasized t o the neck. The present study points out that a small number of patients with lung cancer present with higher cervical node metastases. The relative frequency of histologic types of lung cancer was found by Robbins (1974) to be squamous cell carcinoma 70%, adenocarcinoma lo%,and undifferentiated 20% (10% oat cell and 10% giant cell). In our series of the 2 2 patients who had histologically classified primary tumors, 55% (1 2/22) had undifferentiated primary tumors, whereas only 23% ( 5 / 2 2 ) had squamous cell carcinomas.
CONCLUSION Although an unusual occurrence, primary carcinoma of the lung should be considered in the search for an unknown primary lesion when there is evidence of cervical lymph node involvement. The relative frequency of lung cancer as the occult primary tumor in patients presenting with cervical node metastases varies from 5 t o 32% (Barrie et al., 1970; Engzell et al., 1971; Jesse and Neff, 1966; Lee and Helmus, 1970; Marchetta et al., 1963; Probert 1970). Of the 1,686 cases of bronchogenic carcinoma seen during
Carcinoma of the Lung
507
a 10-year period at the University of Louisville Hospitals, only 26 (1.5%) patients presented ,with cervical node metastases. This wide variation is probably attributable t o the tendency t o describe all adenopathy in the neck as involving a cervical node without making a distinction between the multiple anatomic areas, both above and below the clavicle, that may drain into the neck. More accurate identification of cervical lymph nodes must become an immediate goal. The loosely used term “cervical nodes” could apply t o any lymph node from the clavicle to the base of the skull. If one of the more precise methods of identifying the position of the node is not used, an accurate anatomic description should be attempted. As well as providing a more exact representation of the clinical situation for diagnostic and therapeutic purposes, it will prevent misinterpretation of the data in later studies. The majority of the 26 patients with cervical node metastases in our series were dead within 6 months, and none were alive at 3 years. The extraordinarily dismal prognosis is probably attributable t o several factors: 1) 19 of the 26 patients (73%) had conclusive or suggestive evidence of distant metastases at the time of diagnosis; 2) twice the expected frequency of poorly differentiated histologic findings of the primary tumor was encountered; 3) none of the tumors were resectable. Cervical node metastasis in patients with carcinoma of the lung is therefore considered t o be a manifestation of distant spread and incurability.
REFERENCES Bairie, J . R., Knapper, W. H., Strong, E. W. (1970): Cervical nodal metastases of unknown origin. Am. J. Surg. 120:466. Engzell, U., Jakobsson, P. A., Sigurdson, A,, Zujicek, J. (1971): Aspiration biopsy of metastatic carcinoma in lymph nodes of the neck. A review of 1101 consecutive cases. Acta Otolaryngol. 72: 138. Garland, L. H., Coulson, W., Wollin, E. (1963): The rate of growth and apparent duration of untreated primary bronchial carcinoma. Cancer 16:694. Jesse, R. H. (1970): Management of the suspicious cervical lymph node. Postgrad. Med. 48:99. Jesse, R. H . , Neff, L. E. (1966): Metastatic carcinoma in cervical nodes with an unknown primary lesion. Am. J. Surg. 112:547. Lee, J . G., Helmus, C. (1970): Cervical lymph node biopsy. Mich. Med. 6 9 5 8 1 . Marchetta, F. C., Murphy, W. T., Kovaric, J. J. (1963): Carcinoma of the neck. Am. J. Surg. 106:974. F’robert, J . C. (1970): Secondary carcinoma in cervical lymph nodes with an occult primary tumour. A review of 6 1 patients including their response t o radiotherapy. Clin. Radiol. 21:211. Robbins, S. L. (1974); “Pathologic Basis of Disease.” Philadelphia: W. B. Saunders, pp. 832-841. Seidman, H., Silverberg, E., Holleb, A. I. (1976): Cancer statistics, 1976. A comparison o f white and black populations. CA-A Cancer Journal for Clinicians 26:2. Warwick, R.,-Williams, P. L. (eds.) (1973): “Gray’s Anatomy.” Philadelphia: W. B. Saunders, pp. 729-730.
An Unusual Presentation of Carcinoma of the lung: 26 Patients With Cervical Node Metastases .......................................................................................... ..........................................................................................
RAY S. DAVIS, MICHAEL B. FLYNN, M.D., F.A.C.S., and CONDICT M001RE,M.D., F.A.C.S. Carcinoma of the lung should be considered in the search for an unknown primary lesion when there is evidence of cervical lymph node involvement. Of 1,686 patients with a final diagnosis of bronchogenic carcinoma seen during a 10-year period a t the University of Louisville Hospitals, 26 presented with one or more clinically positive cervical nodes. The frequency of lung cancer in such instances varies from 1.5% (in the present report) to 32%, possibly because t h e term “cervical node” is used without clarification. More precise description of such metastases is urged.
.......................................................................................... .......................................................................................... Key words: carcinoma of t h e lung, lung cancer, cervical node metastases
INTRODUCTION The incidence of lung cancer as the occult primary lesion in patients presenting with cervical node metastases of unknown origin has been thoroughly documented (Ban-ie et al., 1970; Engzell et al., 1971; Jesse and Neff, 1966; Lee and Helmus, 1970; Marchetta et al., 1963; Probert, 1970). Review of the recent medical literature disclosed no study designed t o indicate the frequency with which patients with lung cancer present with cervical node metastases. The incidence and the prognostic implication of this unusual finding are considered in this report.
MATERIALS AND METHODS The charts of all patients with a final diagnosis of carcinoma of the lung from January 1963 through December 1973 were reviewed at three University of Louisville Hospitals: Louisville General Hospital, Veterans Administration Hospital, and NortonChldren’s Hospitals. Of 1,686 total charts reviewed, 509 were from Louisville General
From the Department of Surgery, the University of Louisville School of Medicine, Health Sciences Center, Louisville, Kentucky. Address reprint requests to Department of Surgery, Health Sciences Center, Louisville, KY 40201.
503
0 1977 Alan R. Liss, Inc., 150 Fifth Avenue, New York, NY 10011
504
Davis, Flynn, and Moore
Hospital, 804 were from Veterans Administration Hospital, and 373 were from NortonChildren’s Hospitals. Because the terms “cervical node,” “scalene node,” and “supraclavicular node” were often used synonymously, clarification of the specific sites in the neck was needed. For purposes of this study, lymph nodes of the lower neck anatomically defined as the inferior deep cervical nodes were excluded (Wanvick and Williams, 1973). The terminology used in the clinical description of these nodes included scalene, supraclavicular, lower jugular, and lower posterior cervical (Jesse, 1970). Primarily for simplicity, we prefer the descriptive technique illustrated in Fig. 1 for the localization of metastases by node levels (Barrie et al., 1970). Level I refers t o the nodes of the diagastric triangle; Levels 11, 111, and IV refer, respectively, to the upper, middle, and lower thirds of the deep jugular chain; Level V represents the posterior triangle nodes. Eleven patients with both cervical and supraclavicular involvement were excluded.
Fig. 1. Metastatic sites in the neck divided into Levels I-V. SC designates the supraclavicular area.
RESULTS
Of the 1,686 patients with carcinoma of the lung 26, or 1.576, were found to present with one or more clinically positive cervical nodes. The relative frequency varied from 3.0% (1 1/373) at Norton-Children’s Hospitals, to 1.6% (8/509) at Louisville General Hospital, and 0.9%(7/804) at Veterans Administration Hospital. The average age of the 26 patients at first hospital admission was 52 years; 19 were male and 7 female. The relative frequencies of each histologic type of primary lesion and of each lobe of the lung as the site of the primary lesion are shown in Tables I and 11, respectively.
Carcinoma of the Lung
505
TABLE I. Relative Frequency of Types of Lesions Histologic type
Number of patients
Squamous cell Poorly differentiated Oat cell Adenocarcinoma Alveolar cell
8 I 5 1
1
TABLE 11. Relative Frequency of Locations in Lung Lobe of lung Right upper lobe Right middle lobe Right lower lobe Right hilus Left upper lobe Left lower lobe Left hilus
Number of patients 12
2 4 4 0 3
4
Of the 26 patients 24 had metastases in Level 111; one patient had metastases in Level 11, and both levels were involved in the remaining patient. In 73% (19/26) of the patients distant metastases t o viscera, bone, and brain were discovered at some time during hospitalization or were confirmed at autopsy. No patients in this study were treated by pulmonary resection; 9 patients received radiation therapy, 4 received chemotherapy, 6 received a combination of irradiation and chemotherapy, and 7 were only treated symptomatically. Follow-up information was available in 24 of the 26 patients. Within 6 months of their hospital admission 58%(14/24) were dead of cancer; 21 of the 24 died within 2 years, and nlo patient survived 3 years. Survival rate at 2 years was 12.5% (3/24).
DISCUSSION In industrialized nations, lung cancer is the most common visceral malignancy in men, causing approximately 40% of all male cancer deaths. The annual number of deaths in the United States from lung cancer has risen from 18,313 in 1950 t o 74,933 in 1973 (Robbins, 1974; Seidman et al., 1976). Although women have only one-sixth the mortality rate of men from lung cancer, mortality doubled in this group from 1954 t o 1974 (Robbins, 1974). Lung cancer is characterized by a high degree of metastases. often early in the identifiable course of illness. Garland and colleagues (1963) concluded that it may take many years for primary tumors in the lung t o reach large enough size to demand clinical atten-
506
Davis, Flynn, and Moore
tion. During this pathologic evolution, the tumor often metastasizes by hematogenous and lymphatic routes. More than half the malignant lesions of the lung drain lymphatically into the tracheal, bronchial, and mediastinal lymph nodes. Above the clavicle, scalene and lower jugular nodes are commonly involved, with the incidence reported as high as 50%(Robbins, 1974). Cervical node metastases in patients with an occult primary tumor have been the subject of numerous articles. One purpose of these studies has been to determine the incidence of each organ as the primary site. Positive findings in supraclavicular nodes generally are considered to suggest a primary lesion below the clavicle; cervical nodes at other levels usually suggest a primary lesion above the clavicle. Lower cervical nodes other than supraclavicular may suggest a primary lesion either above or below the clavicle. In a study by Lee and Helmus (1970), 32% (15/48) of the patients had a primary lesion later found in the lung, and 14.5%were later diagnosed with a primary lesion in the larynx or pharynx. The reported frequency with which occult primary tumors subsequently were found in the lung has varied between 5 and 32% (Table 111). TABLE HI. Reported Frequency ofOccult Primary Tumor in Lung
Jesse and Neff Lee and Helmus Barrie et al. Marchetta et al. Prober t Engzell et al.
Total number of patients with occult primary
Primary site was discovered
Primary site with lung
121 163 123 33 61 1,101
48 48 38 15 21 1,051
10 (20%) 15 (32%) 2 ( 5%) 2 (13%) 4 (19%) 115 (10.4%)
Instead of studying a series of patients with neck masses t o determine the frequency with which the occult primary lesion appeared in the lung, we studied a series of lung cancer patients to determine the frequency with which they metastasized t o the neck. The present study points out that a small number of patients with lung cancer present with higher cervical node metastases. The relative frequency of histologic types of lung cancer was found by Robbins (1974) to be squamous cell carcinoma 70%, adenocarcinoma lo%,and undifferentiated 20% (10% oat cell and 10% giant cell). In our series of the 2 2 patients who had histologically classified primary tumors, 55% (1 2/22) had undifferentiated primary tumors, whereas only 23% ( 5 / 2 2 ) had squamous cell carcinomas.
CONCLUSION Although an unusual occurrence, primary carcinoma of the lung should be considered in the search for an unknown primary lesion when there is evidence of cervical lymph node involvement. The relative frequency of lung cancer as the occult primary tumor in patients presenting with cervical node metastases varies from 5 t o 32% (Barrie et al., 1970; Engzell et al., 1971; Jesse and Neff, 1966; Lee and Helmus, 1970; Marchetta et al., 1963; Probert 1970). Of the 1,686 cases of bronchogenic carcinoma seen during
Carcinoma of the Lung
507
a 10-year period at the University of Louisville Hospitals, only 26 (1.5%) patients presented ,with cervical node metastases. This wide variation is probably attributable t o the tendency t o describe all adenopathy in the neck as involving a cervical node without making a distinction between the multiple anatomic areas, both above and below the clavicle, that may drain into the neck. More accurate identification of cervical lymph nodes must become an immediate goal. The loosely used term “cervical nodes” could apply t o any lymph node from the clavicle to the base of the skull. If one of the more precise methods of identifying the position of the node is not used, an accurate anatomic description should be attempted. As well as providing a more exact representation of the clinical situation for diagnostic and therapeutic purposes, it will prevent misinterpretation of the data in later studies. The majority of the 26 patients with cervical node metastases in our series were dead within 6 months, and none were alive at 3 years. The extraordinarily dismal prognosis is probably attributable t o several factors: 1) 19 of the 26 patients (73%) had conclusive or suggestive evidence of distant metastases at the time of diagnosis; 2) twice the expected frequency of poorly differentiated histologic findings of the primary tumor was encountered; 3) none of the tumors were resectable. Cervical node metastasis in patients with carcinoma of the lung is therefore considered t o be a manifestation of distant spread and incurability.
REFERENCES Bairie, J . R., Knapper, W. H., Strong, E. W. (1970): Cervical nodal metastases of unknown origin. Am. J. Surg. 120:466. Engzell, U., Jakobsson, P. A., Sigurdson, A,, Zujicek, J. (1971): Aspiration biopsy of metastatic carcinoma in lymph nodes of the neck. A review of 1101 consecutive cases. Acta Otolaryngol. 72: 138. Garland, L. H., Coulson, W., Wollin, E. (1963): The rate of growth and apparent duration of untreated primary bronchial carcinoma. Cancer 16:694. Jesse, R. H. (1970): Management of the suspicious cervical lymph node. Postgrad. Med. 48:99. Jesse, R. H . , Neff, L. E. (1966): Metastatic carcinoma in cervical nodes with an unknown primary lesion. Am. J. Surg. 112:547. Lee, J . G., Helmus, C. (1970): Cervical lymph node biopsy. Mich. Med. 6 9 5 8 1 . Marchetta, F. C., Murphy, W. T., Kovaric, J. J. (1963): Carcinoma of the neck. Am. J. Surg. 106:974. F’robert, J . C. (1970): Secondary carcinoma in cervical lymph nodes with an occult primary tumour. A review of 6 1 patients including their response t o radiotherapy. Clin. Radiol. 21:211. Robbins, S. L. (1974); “Pathologic Basis of Disease.” Philadelphia: W. B. Saunders, pp. 832-841. Seidman, H., Silverberg, E., Holleb, A. I. (1976): Cancer statistics, 1976. A comparison o f white and black populations. CA-A Cancer Journal for Clinicians 26:2. Warwick, R.,-Williams, P. L. (eds.) (1973): “Gray’s Anatomy.” Philadelphia: W. B. Saunders, pp. 729-730.
