FIGURE 7.1 This is a fused axial image of a PET/CT scan at the level of the oropharynx. Note the hypermetabolic left level II neck mass. There is fairly symmetric low‐intensity uptake in the patient's lingual tonsil tissue.
Answer: PET/CT. Multiple studies have demonstrated that PET/CT compared with contrast‐enhanced CT alone has a significantly improved rate of detecting the primary site of carcinoma. A prior systematic review of 7 studies demonstrates a sensitivity of 44% and a specificity of 97% with PET/CT.
PET/CT neck is performed showing a solid left level IIA lymph node without extranodal extension measuring 22 × 27 × 29 mm that demonstrates high‐grade hypermetabolism with max SUV of 16.4 (see Figure 7.1). No other lymph nodes meet the radiographic criteria for significance or demonstrate hypermetabolism. Symmetric FDG uptake is seen when comparing the left tongue base to the right (max SUV 4.2). There are no imaging findings to suggest systemic metastatic disease.
Question: Which of the following would be appropriate treatment options in the management of this patient?
Panendoscopy: yes/no. This is an essential component of the patient's treatment since a primary site must be investigated.
Tonsillectomy: yes/no. The palatine and lingual tonsils often harbor occult primary tumors. This particular patient has already undergone palatine tonsillectomy as a child but lingual tonsillectomy should be performed.
Treatment with surgical resection: yes/no. As the patient has only one lymph node that is PET avid, surgical resection of the primary tumor (if identified) and left neck dissection may be curative.
Treatment with radiation: yes/no. This disease may be cured with XRT to the neck and primary site (if identified).
Treatment with chemotherapy: yes/no. Treatment with chemotherapy alone would have no role here. If upfront surgery is performed, the addition of chemotherapy to XRT is not indicated unless significant extracapsular spread or positive margins of the primary tumor are observed on final pathology. Clinical trials are currently underway to evaluate the safety and efficacy of de‐escalation of therapy.
After discussion in the multidisciplinary tumor board, an upfront surgical approach is advocated. The patient is taken to the operating room for panendoscopy, left selective II–IV neck dissection, and bilateral lingual tonsillectomy. Palatine tonsillectomy is not performed given the patient's prior tonsillectomy as a child and lack of residual tonsil tissue. No obvious primary site is identified on panendoscopy.
The final pathology report shows one out of 54 positive nodes. The pathologic node is 2.7 cm in maximum diameter without evidence of extranodal extension. A 0.7 mm primary tumor is identified within the left lingual tonsillectomy specimen with negative margins. There is no evidence of perineural invasion or lymphovascular invasion.
Question: Per the AJCC 8th Edition guidelines, what is the TNM stage for this carcinoma?
Answer: T1N1M0, Stage I. For HPV‐positive oropharyngeal SCC, there are separate staging systems for clinical versus pathologically confirmed disease following surgery. A 0.7 mm primary is staged as T1 disease. Following neck dissection, the presence of only one positive 2.7 cm node is staged as N1 disease. This disease is staged as T1N1M0 (given negative PET/CT for distant metastases) and is an overall stage I given the HPV positive nature of the cancer.
The patient is rediscussed in the multidisciplinary tumor board. Given the staging and clear margins, consensus decision is made for observation following surgery without the need for adjuvant therapy.
Key Points
Presentation of a neck mass in an adult should be considered cancer until proven otherwise. All patients should have a thorough assessment of the upper aerodigestive tract at the time of the initial office evaluation.
PET/CT is the best imaging modality for thorough assessment of the neck and upper aerodigestive tract when assessing a patient with an unknown primary carcinoma.
Viruses are an etiologic factor in head and neck carcinoma, and testing for HPV and EBV can be performed on the FNA specimen to yield valuable additional information.
Patients with a single lymph node and without evidence of extranodal extension of disease may be successfully treated with a surgical approach involving complete resection of the primary and neck dissection if there is no perineural or lymphovascular invasion and if the primary site is small and has negative margins.
Lingual tonsillectomy and palatine tonsillectomy should be performed in cases of an unknown primary as the tonsils are often the site of unknown primary tumors.
CASE 8
Jason I. Kass and Glenn J. Hanna
History of Present Illness
A 55‐year‐old man presents with a 6‐month history of a persistent sore throat, which did not improve with antibiotics. He presented to his local otolaryngologist, who identified a right anterior tonsil mass. Biopsy of this mass showed nonkeratinizing, invasive, poorly differentiated SCC, which was p16 positive by immunostaining.
Question: What additional questions would you want to ask?
Any trouble opening his mouth? Yes. He reports right‐sided jaw pain that limits his mouth opening.
Any trouble swallowing? Patient denies., but he does have a globus sensation in his throat.
Any voice changes? Patient denies.
Any other lumps that have been noticed? Patient denies.
Any ear pain? Yes. He has pain in his right ear that radiates to his shoulder.
Has he received any treatment for this? Yes. He is taking acetaminophen‐oxycodone every 3 hours for relief.
Past Medical History
Type II diabetes mellitus and hypertension.
Past Surgical History
Cholecystectomy 10 years ago.
Social History
50 pack‐year history of tobacco use.
A glass of wine with dinner on a regular basis.
Physical Examination
Well‐developed middle‐aged male in no distress. Voice strong.
Skin: no suspicious lesions.
Oral cavity: limited mouth opening to 2.5 cm. Teeth in good condition. No lesions seen or palpated.
Oropharynx exam: 2.5 cm mass in the right anterior tonsillar pillar extending to the retromolar trigone. The mass is firm and fixed.
Neck exam: salivary gland exam is normal and there is no adenopathy.
Cranial nerves II–XII intact.
Flexible laryngoscopy: right oropharynx mass producing some displacement of the right palate superiorly, but no other lesions noted in any level of the pharynx or larynx. The true vocal folds move well.