Metastatic Lymph Nodes

Deciding on a Treatment Plan


Before starting treatment, your doctor will make sure that the following steps are completed.

Preoperative Evaluation

  • A full history and physical examination
  • An evaluation by the members of a head and neck cancer team
  • A biopsy to confirm a diagnosis of cancer
  • Possibly, testing for HPV and EBV
  • Evaluation of the lungs to check for spread
  • Imaging of the primary tumor (if known) and the neck
  • Maybe a PET-CT for advanced cancers
  • A dental evaluation with or without jaw imaging
  • Nutrition, speech and maybe even a hearing evaluation
  • Preoperative medical clearance and optimization of medical conditions

Then your doctor will recommend a course of treatment for you, depending on a number of factors. As with all cancers in the head and neck, there are three general therapeutic options to consider, which may be used alone, together, or one after the other:

The treatment recommendation will be influenced by the type of cancer found in the needle aspiration biopsy of the metastatic lymph node.

The following treatments are indicated for metastatic cancer in neck lymph nodes with an unknown primary:

  • If the metastatic lymph node is an adenocarcinoma with tests negative for thyroid cancer (negative for thyroglobulin and calcitonin), and the metastatic nodes are in specific areas of the neck (i.e., levels I, II or III), you should have a neck dissection (removal of lymph nodes in the neck) and possible parotidectomy followed by radiation to the neck and possibly the parotid bed. If the metastatic lymph nodes are in levels IV and V, your doctor must look for a primary cancer below the collarbones somewhere in the body and still consider removing the lymph nodes in the neck (neck dissection).
  • If the metastatic lymph node is a squamous cell carcinoma, poorly differentiated carcinoma, anaplastic (non-thyroid) or not otherwise specified cancer, treatment options are as follows:
    • For N1 disease (a single lymph node less than three centimeters in size), surgery to remove the lymph nodes of the neck (neck dissection) is the preferred treatment; RT is also an option. For N2 or greater disease, some form of chemotherapy with radiation is preferred.
    • If the neck dissection confirms only a single cancerous lymph node without any signs of spread outside of the node capsule, then either radiation or observation are the two possible treatment options.
    • If a neck dissection shows N2 or N3 disease, without extracapsular spread of the cancer, radiation is recommended. Chemotherapy with radiation therapy may be considered.
    • If a neck dissection finds spread of tumor cells beyond the capsule of the lymph node, chemotherapy with radiation is recommended. Radiation alone is an option.

1 Patterns of cervical lymph node metastasis from squamous carcinomas of the upper aerodigestive tract. Patterns of cervical lymph node metastasis from squamous carcinomas of the upper aerodigestive tract. The American Journal of Surgery. 1990;160(4):405-409.

2 Patterns of Cervical Node Metastases From Squamous Carcinoma of the Larynx. Arch Otolaryngol Head Neck Surg. 1990;116(4):432-435.

3 Zhang MQ, El-Mofty SK, Dávila RM. Detection of human papillomavirus-related squamous cell carcinoma cytologically and by in situ hybridization in fine-needle aspiration biopsies of cervical metastasis: a tool for identifying the site of an occult head and neck primary. Cancer. 2008;114(2):118-23.

4 Morton DL, Wen DR, Foshag LJ, Essner R, Cochran A. Intraoperative lymphatic mapping and selective cervical lymphadenectomy for early-stage melanomas of the head and neck. J Clin Oncol. 1993;11:1751-1756.

5 Civantos FJ, Zitsch RP, Schuller DE, Agrawal A, Smith RB, Nason R, Petruzelli G, Gourin CG, Wong RJ, Ferris RL, El Naggar A, Ridge JA, Paniello RC, Owzar K, McCall L, Chepeha DB, Yarbrough WG, Myers JN. Sentinel lymph node biopsy accurately stages the regional lymph nodes for T1-T2 oral squamous cell carcinomas: results of a prospective multi-institutional trial. J Clin Oncol. 2010;28(8):1395-400.

6 Balaker AE, Abemayor E, Elashoff D, St. John MA. Cancer of unknown primary: does treatment modality make a difference? Laryngoscope.2012;122(6):1279-82. doi: 10.1002/lary.22424. Epub 2012 Apr 26.

7 Cooper, J. S., et al. (2004). "Postoperative Concurrent Radiotherapy and Chemotherapy for High-Risk Squamous-Cell Carcinoma of the Head and Neck." New England Journal of Medicine 350(19): 1937-1944.

8 Bernier, J., et al. (2004). "Postoperative irradiation with or without concomitant chemotherapy for locally advanced head and neck cancer." N Engl J Med 350(19): 1945-1952.

9 Doescher, J., et al. (2017). "[The 8th edition of the AJCC Cancer Staging Manual: Updates in otorhinolaryngology, head and neck surgery]." HNO 65(12): 956-961.

10 Cohen, E. E., LaMonte, S. J., Erb, N. L., Beckman, K. L., Sadeghi, N. , Hutcheson, K. A., Stubblefield, M. D., Abbott, D. M., Fisher, P. S., Stein, K. D., Lyman, G. H. and Pratt‐Chapman, M. L. (2016), American Cancer Society Head and Neck Cancer Survivorship Care Guideline. CA: A Cancer Journal for Clinicians, 66: 203-239. doi:10.3322/caac.21343