Presentation
Smooth firm swelling along angle of right jaw. Right supraglottic mass on endoscopy. Not managing to eat solids. No stridor. Positive smoking history.
Patient Data
Large (around 6 cm) heterogenous and partial necrotic mass in the right side of the neck (occupying levels 2A and 2B at least). No significant internal vascularity.
Huge mass centered on the right palatine tonsil and piriform fossa.
This starts at the level of the soft palate, with invasion into the tissues above the hyoid bone lateral to the oropharynx. The right aryepiglottic fold is partly eroded, with posterior pharyngeal tumor crossing midline.
Circumferential tumor in the right hypopharynx involving the posterior pharyngeal wall, post cricoid space and piriform fossa, with tissue invading through and around the thyroid cartilage with strap muscle invasion. The cervical esophagus is in contact with this tumor, with possible invasion / perforation, and displaces the right thyroid gland. No definite prevertebral space invasion.
The primary tumor has approximate dimensions of 33 x 57 x 100 mm (AP x TR x CC).
This is in direct contact with a predominantly cystic right 2A node, which itself measures 68 x 50 x 69 mm. There are a couple more tiny (4 mm) asymmetric right sided nodes, but no other convincing ipsilateral or contralateral nodal disease.
The right internal jugular vein is compressed by node and primary mass, with probable thrombus in the vessel at the C3/C4 level, but the included intracranial dural sinuses remain patent. The right carotid (atheromatous) bulb and ICA are encased by primary and nodal disease.
Normal orbits and included intracranial structures.
There are a number of subpleural and perifissural nodules throughout all lobes of the lungs, largest 8 mm. While some of these may be benign / inflammatory in this context metastatic disease is considered most likely. No pleural abnormality. No large / central PE.
No hilar or mediastinal nodal enlargement. Bilaterally the axillary nodes are enlarged, but this is nonspecific.
Normal included abdominal structures. Likely left adrenal adenoma.
Normal included skeleton.
Case Discussion
Core biopsy of the right nodal mass demonstrate P16 positive squamous cell carcinoma.
This is an extensive primary tumor, with local destruction of mucosal structures and extension beyond the central neck.
The large (predominantly cystic) nodal mass measures over 6 cm, with venous invasion - even in the absence of contralateral disease this results in the highest clinical nodal stage of cN3.
The suspected pulmonary metastases then push the classification higher still into group IV.
The patient was subsequently managed with best supportive care.
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