A 50-year-old male presents with a 3 cm firm, mobile level III lymph node. FNAC shows metastatic squamous cell carcinoma. Panendoscopy and PET-CT fail to identify the primary tumor. The most appropriate next step in management is:
- A Bilateral tonsillectomy with directed biopsies of the base of tongue and pyriform sinuses ✓
- B Radical neck dissection followed by observation
- C Empirical radiotherapy to the entire pharyngeal mucosa and larynx
- D Chemotherapy alone without further investigation
Correct answer: A. Bilateral tonsillectomy with directed biopsies of the base of tongue and pyriform sinuses
Explanation
In cervical metastasis from an unknown primary, the most common occult sites are the palatine tonsil and base of tongue. Bilateral tonsillectomy (not just biopsy) with directed biopsies of the base of tongue and pyriform sinuses significantly increases primary detection rates. This approach is superior to random biopsies and guides subsequent targeted therapy. Empirical wide-field irradiation without identifying the primary increases morbidity without clear survival benefit.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.