0:00

Okay, so this was the first case of a right neck mass.

0:06

So what I've got up is the T one weighted scan and the stir T two Wade scan

0:11

and stir, because there's inversion recovery and good fat suppression. Um,

0:16

I like looking at the T one weighted scans to define the anatomy because you

0:21

have the bright fat that helps you in the head and neck.

0:26

Um, and then the, the stir helps identify the pathology.

0:31

So if we initially look at the stir images and we start at the, at the top,

0:36

in almost all situations in the head neck,

0:40

the pathology's gonna be bright because the muscles are very, very dark.

0:45

So if you look at the mass term muscle and the OID muscle, it's very dark. So,

0:49

and the tongue muscle.

0:50

So usually the things that are brighter are the things that are the pathology.

0:53

And here we see a mass that is on the right side,

0:57

and it looks like it's in the floor of the mouth.

1:00

The floor of the mouth is synonymous with the sublingual space,

1:05

and it includes the sublingual gland as well as all the mucosa there.

1:09

So if we look on the contralateral side, we see the sublingual glandular tissue,

1:14

which is this gray stuff.

1:17

And on either side of the sublingual grandular tissue, we have muscle.

1:23

The muscle that's lateral to it is the mylohyoid muscle.

1:27

And the muscle that's medial to it is the stylos is hilos, is complex.

1:32

The stylos is obviously going from the sty process to the tongue,

1:37

and then it intertwines with the hilos,

1:39

which goes from the tongue to the hyoid bone. So on the contralateral side,

1:44

here's our mylohyoid muscle. Here's the lesion. It's in the sublingual space.

1:49

Here's the other muscle.

1:51

The muscle on either side here is the genial gloss muscle,

1:54

which is the main muscle of the, uh, extrinsic muscle of the tongue.

1:58

And this is the intrinsic musculature of the tongue.

2:01

So we have a for of mouth mass,

2:04

and it looks like it's projecting inferiorly along that

2:08

sublingual space. And then, uh, continuing downward,

2:13

we come into this large conglomerate of something that is

2:18

lateral to the carotid sheath.

2:21

And when we have a lesion in the mucosal space and a lesion

2:26

outside in the neck, more likely than not, we're dealing with a cancer with a,

2:30

um, with a lymph node. So on the t one way scan, again,

2:34

we can see the anatomy pretty nicely, the mylohyoid being displaced laterally.

2:40

Here's again, our sublingual glandular tissue,

2:42

our stylo Hilo complex.

2:45

This point's pretty much high glosses the displacement of the genial glos muscle

2:50

on either side.

2:51

And then we get a better sense of the irregularity of this mass as it

2:57

infiltrates into the sty, uh,

2:58

Sternal clid mastoid muscle lateral to the carotid sheath.

3:03

So, um, on the post contrast scan,

3:07

we can see the kind of speculated edge to this, uh,

3:12

nodal mass, um,

3:14

and how it's infiltrating the sternal CID mastoid muscle.

3:18

And that would imply extra nodal extension. Um,

3:22

extra nodal extension is sort of a pathologic term,

3:27

but it does, um, it, it,

3:30

we do have imaging findings that correlate well with the pathology.

3:34

So primary tumor

3:39

with nodal metastasis. And on the stir,

3:44

we also, incidentally, when we went down lower, we, uh,

3:49

saw some thyroid nodules, which, you know,

3:52

are pretty common in humans. And,

3:57

um, here we're getting a little bit of the bright signal of the, uh,

4:01

brachial plexus. And I think that Dr.

4:03

Mukerjee will be talking to you about the brachial plexus shortly. Um,

4:08

if we go down here, it,

4:09

it's really vessels and brachial plexus more than anything.

4:12

So we're looking at all the bright stuff.

4:14

Basically what we're not seeing is contralateral enlarged lymph nodes,

4:18

which is a pertinent negative.

4:20

So we have little small lymph nodes that are less than a centimeter,

4:23

so we don't, uh, necessarily have to call that.

4:26

So with regard to the primary tumor,

4:29

far and away primary tumors in the aero digestive system,

4:33

we're gonna be squamous cell carcinomas.

4:36

That's what should be number one in this location where you do have

4:41

sublingual glandular tissue, you might think, uh,

4:44

in your differential diagnosis of a salivary gland neoplasm,

4:48

but you'd have to go with an a malignancy because we have a nodal metastasis.

4:53

So yeah, it could potentially be also in,

4:56

we could consider lymphoma. That's usually not in this location,

5:00

but more in the ER's ring of the nasal pharynx, adenoids,

5:05

the palatine tonsils, and lingual tonsor tissue. So, um,

5:11

we wanna measure this lesion because that will help with the T staging.

5:17

So this is the, uh, t staging for oral cavity cancers.

5:22

The floor of the mouth is considered an, uh, location of the oral cavity,

5:26

not the oral pharynx, but the oral cavity.

5:29

And therefore we have to measure the size of the lesion.

5:33

This depth of invasion is how deep it's going from the

5:37

mucosal surface. Again, although this is a pathologic definition,

5:42

we can usually make some statements about by looking at the lesion,

5:46

usually in a superior inferior dimension on the tongue or in the

5:51

floor of mouth. Again, superior inferior to see how far deep it's going, and

5:56

Make some estimation. Uh, two to four centimeters

6:02

or five to 10 depth of invasion greater than four

6:06

centimeters. This was in the two to four centimeter range. So T two.

6:10

And then does it invade cortical bone, maxillary sinus,

6:14

or does it get into the masticator space musculature, the OID plate,

6:18

the skull base, or the internal car artery? So we don't have any of those.

6:23

For the nodal staging, it's usually three to six centimeters,

6:26

three centimeters or less, or T one, if it's bilateral, uh,

6:30

lymph nodes, it would be T two B, if it's con, uh,

6:35

if it's, um, greater than three to six, if it's in the three to six centimeters,

6:39

also T two cancer. And then we have these issues about extra nodal extension.

6:43

In this case, if there is extra nodal extension, let me, uh,

6:46

pull up the nodal staging. So, uh,

6:51

ipsilateral three centimeters to a three,

6:55

three less than three centimeters. Um,

6:59

two B multiple,

7:02

two C bilateral contralateral.

7:05

So single node and, um, multiple nodes,

7:09

and then nodes greater than six centimeters, three A,

7:14

and then if you have extra nodal extension, it bumps it up to three B.

7:18

So in this case, we have a extra nodal extension. So that,

7:23

uh, makes it a higher grade lesion. Here again, pathologically,

7:29

extra nodal extension, negative versus positive, et cetera.

7:34

So as far as the thyroid gland goes,

7:37

almost all of us have a macro,

7:39

which refers to the a c r guidelines on thyroid nodules,

7:44

depending upon whether the patient's 35 years of age or more.

7:49

And those guidelines say that you don't have to pursue with an ultrasound if

7:53

you're less than 35 years old and the node is less than one centimeter

7:58

inside. But if it's greater than one centimeter in sizing, you're 35 years or,

8:03

or more, you, you re you have to, you should recommend an ultrasound.

8:06

So there's a macro that we all put into when we see these, uh, thyroid nodules.

8:10

In a lot of ways the clinicians would prefer, we just don't even mention them.

8:13

But there you go.