U C T EN ผู้ ป่ วยชายไทย อายุ 47 ปี อาชี พ รั บ จ้ า ง ภู มิลาํ เนาจั ง หวั ด สมุ ท รปราการ CC : เริ่ ม คลํา ได้ ก้ อ นที่ ค อข้ า งซ้ า ยมา 3 เดื อ น 3 เดือนก่อน เริ่ มคลําได้ ก้อนที่คอข้ างซ้ ายขนาดประมาณ 1 ซม. ก้ อน EN T C U ค่อยๆโตขึ ้นและปวดเล็กน้ อย ต่อมาเริ่ มมีก้อนใหม่ขึ ้นที่คอข้ างขวา ขนาดประมาณ 1 ซม. ไม่มีอาการกลืนอาหารลําบากและไม่สําลักอาหาร ไม่มีเสียงเปลี่ยน หายใจปกติ ไม่มีอาการเบื่ออาหารหรื อนํ ้าหนักลด ไม่ไข้ ปฏิเสธโรคประจําตัว C ดื่มเบียร์ 1 กระป๋ อง/วัน นาน 10 ปี U สูบบุหรี่ 2 ซอง/วัน นาน 10 ปี EN T ปฏิเสธประวัติแพ้ ยาและอาหาร EN T C 14/min, BP 110/60mmHg Neck 1 fixed and firm to hard mass 4x4 cm at Lt neck zone III Multiple subcentimeter LN at Lt neck zone II-IV 2 movable and soft masses 1.5 cm (each nodes) at Rt neck zone III Thyroid : Can’t palpated U V/S : BT 37, PR 80/min, RR Normal skin of scalp, face and neck U Ear : Normal EAC and TM, Rinne +ve BE, Weber test : C EN T Not lateralized Nasal cavity and nasopharynx (Nasal endoscope): Normal Oral cavity : Normal, Can’t palpable mass Orolpharynx-Hypopharynx and Larynx (FOL) : Normal Heart, Lungs and Abdomen : Normal Cranial nerve : Normal 1. 47 years old Thai male U 2. Multiple bilateral neck mass (Lt neck zone III,II-IV, Rt T C neck zone III) 3. Smoking and alcohol drinking EN Differential diagnosis ? •Lymphadenopathy/Lym phadenitis •Granulamatous disease •Sialadenitis/sialolithiasi s •Thyroglossal duct cyst •Brachial cleft anomalies •Dermoid cyst •Teratomas •Lymphangiomas •Hemangiomas C U Congenital EN •Lymph node •Metastatic neoplasm •Lymphoma •Salivary glands neoplasm •Thyroid neoplasm •Neurogenic neoplasm •Schwannoma •Neurofibroma •Vascular neoplasm •Paraganglioma •AVM •Lipoma 2nd Inflammation T 1st Neoplastic 1. Laboratory C T EN 3. Imaging U 2. Pathology CBC Hb 12.6 g/dl, Hct 38.6% T LFT C Plalate 218,000/ul U WBC 7,730/ul (PMN 46.7%, LYM 37.7%, Eo4.3%) EN TP 7.3, Albumin 4.2 TB 1.3, DB 0.4, SGOT 25, SGPT 23 ALP 63 BUN 13 mg/dl, Cr 0.8 mg/dl Anti HIV : Negative Fine needle aspiration : Thin needle (usually 25-gauge) U First : Presence of malignant tumor (Lt,Rt), Morphologically C favor SCCA Second : Metastatic SCCA (Lt,Rt) Sensitivity and specificity : 97% EN T Core needle aspiration (12-16 gauge) Open biopsy : Last resort for diagnosis Further management Prepared to proceed with comprehensive neck dissection CXR : Normal U CECT EN T C Finding Heterogeneous enhancing with central hypodensity with ring enhancing mass at Lt neck level III and IV Invade Lt internal jugular vein Metastatic Lymph node ? Metastatic lymph node 1. Size •Nodes >10-15 mm •Potentially malignant •LN zone I : >15 mm •LN zone II-V : >10 mm •Nodes >20 mm •Frequently MRI •Heterogeneously enhancing malignant •Best on post-contrast, fatnodes •Retropharyngeal nodes suppressed T1WIs 1. Muscle intensity on T1WI •>10 mm in children 2. Ring enhancement on or >5 mm in adults postgadolinium fat•>8 mm suppressed T1WI 2. Invasion or displacement 3. Very bright on STIR of adjacent structures 4. Bright on T2WI •Invasion of carotid artery 3. Indistinct margins Invasion of carotid artery Ultrasound 4. Enhancement pattern •Best method : Tumor invasion •Loss of echogenic fascial 5. Location plane between vessel wall and 6. Number of carotid by extracapsular spread from metastatic nodes tumor 7. Clustering •Ultrasound combined with 8. Calcification FNA T C U •Size larger than 15 mm •Ring enhancement •Focal defect •Round, rather than bean shaped nodes •Clusters of nodes •Indistinct margins EN CECT •Gold stand •Most suprahyoid and infrahyoid tumors or inflammation Squamous cell carcinoma of cervical LN (Stage N2c) Metastatic lesion U 1. Primary site 2. Primary lesion T Unknown primary C From region and distant sites EN Rare : 4-20 cases/year (Limited publication) Primary site : Common primary site ? Location of neck mass ? Common primary site ? 1. Ipsilateral tonsil Occult primary 20-40% C Levels 1, 2, and 3 U Oral cavity Oropharynx and hypopharynx, and Can present with very small EN T larynx Levels 2, 3, and 4 Nasopharynx Level 5 Supraclavicular Esophageal and pulmonary primary sites Abdominal and pelvic locations 2. BOT : 2nd common Poorly prognosis tonsil and BOT cancer with enlarged neck node and initially classified as unknown primary Regional Distance More common U 1. Unknown primary 3. Other sites in H&N region Skin of ear, face, scalp, and neck T Enlarged LN in parotid, cheek, EN submandibular, or cervical region 4. Major and minor salivary glands neoplasm Initially appears to be metastatic lesion to neck mass level 1 or 2 5. Thyroid gland Not uncommonly initially presents as neck mass Pulmonary C 2. SCCA of aerodigestive tract Esophageal Renal Ovarian Cervical Prostate T EN U C PET/CT Imaging Additional study Adjunct to complete work up EBV Determining site of disease of HPV-16 H&N Pinpoint specific area of increase metabolic activity Specificity of 81.9% positive results U To customize radiation target T Significant number of false- occult primary = Tonsil or BOT C Sensitivity 62% Positive : Strongly suggests EN Performed before pan-endoscopy and biopsy Provide site to target Prevent false-positive T EN U C 1. Palpation of oropharyngeal subsites U BOT, tonsillar fossae and glossotonsillar sulci Directed biopsies of BOT, nasopharynx and hypopharynx 3. +/- Ipsilateral tonsillectomy 2. If not had previous tonsillectomy Or in those with adequate lymphoid tissue remaining T 1. C 2. EN Therapeutic benefit : Uncertain Because if treated without tonsillectomy : Only few develop clinical significant primary tumor Panendoscope with biopsy Finding U Primary site C Minimal irregular surface of lateral wall of Lt pyriform sinus Erythema at laryngeal surface of epiglottis and posterior esophageal wall T Biopsy at posterior esophageal wall (17 cm), laryngeal surface of EN epiglottis, both pyriform sinus, BOT, tonsil, and nasopharynx Pathology report : Negative for malignancy Distance metastasis Ultrasound liver : Normal Bone scan : Normal T Group stage : 4A C Staging : T0N2cM0 U Unknown primary SCCA of cervical LN EN Treatment : Choice ? T EN U C C U Finding 3x4 cm firm Lt neck mass and invaded IJV zone II,III and IV Multiple LN 1 cm along Lt neck zone II-IV 2 cm firm Rt neck mass EN T Pathology report Sift tissue with skin Mass 7.5x5.8x3.2 cm, composed of 5 LN ranging 1-1.6 cm Moderately differentiated SCCA Very close to deep resection line <0.1 cm Diffuse vascular emboli LN zone I-V : Metastatic SCCA with extranodal extension 1/10 nodes LN zone IIA : No tumor metastasis Unknown primary SCCA of cervical LN (T0N2cM0) C Pathology Report U S/P LT MRND Extranodal extension EN T Very close margin Further treatment ? T EN U C T EN U C T EN U C
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