0:00

Localized swelling mass in the right neck.

0:05

So you had a MR of this case. Again, um,

0:10

we can use the stir to identify the

0:15

pathology, and

0:20

here we are at the nasopharyngeal level,

0:22

and then we come down to the soft palate level. Here's our soft palate,

0:26

and we're at the oral pharyngeal level.

0:29

And here we have our lesion that is extending into the,

0:35

uh, right side of the neck. And it's pretty clear that there's once again,

0:39

extra nodal extension.

0:42

We have multiple lesions here. That's a nodal conglomerate. Um,

0:47

one of the questions on this case, which I think is valid is,

0:50

is this all contiguous with the lesion over here

0:55

in the tonsil? And the other valid question is,

1:00

um, it sure looks like the pharyngeal mucosa, uh,

1:04

the pharyngeal musculature, which is a dark thing,

1:07

is being displaced inward by this mass.

1:11

How do we know that this is primarily in the tonsil as opposed to

1:16

outside the tonsil? Uh, it is centered on the tonsil here.

1:23

Um, so, uh, all of which I think are, are valid questions.

1:28

When you see this little muscular thing,

1:30

the problem is that the tonsil, um,

1:34

obviously is the lymphoid tissue,

1:36

and it may not be on the mucosa surface.

1:41

Uh, it may be in the,

1:44

starting in the crypts of the tonsil where it looks like a submucosal mass.

1:49

And so, although tonsil is part of the oral pharynx,

1:52

which is part of the aero digestive system, uh,

1:55

it is a site where the growth may be quickly

2:01

submucosal and into the soft tissues of the

2:05

neck. Um, on this, uh,

2:10

stir image, we do get the sense that there are multiple nodules here,

2:14

more likely to represent lymphadenopathy than just a tonsil

2:19

cancer gone wild that's growing into the neck,

2:23

even as far down here as the, um, thyroid cartilage.

2:28

So

2:31

my interpretation of this would be that there's a submucosal mass

2:36

at the level of the tonsil with associated contiguous

2:42

multiple lymph nodes with extra nodal extension.

2:45

So let's look at it on the T one way scan and see how this helps us.

2:50

So I'm gonna, all right, it's a little bit brighter that way.

2:55

So clearly there

2:58

Is a component of this that's outside the, the mucosal surface,

3:03

but as you get down to the tonsil level, that's harder to say.

3:08

And we recognize that tonsil cancer can grow in this fashion

3:13

as it grows laterally. Here we wanna look at a couple of things.

3:18

We wanna look at the prevertebral musculature,

3:21

which is the longest coi, longest capita muscle complex,

3:25

because if this tumor grows into the prevertebral musculature,

3:30

it makes it more likely to be unresectable disease.

3:34

And a T four cancer prevertebral or skull base involvement is

3:39

going to be a T four B cancer.

3:41

So when we see this flattening of the muscle,

3:45

we wanna go back to the stir and say,

3:48

is that muscle bright to suggest that it's been infiltrated?

3:53

It doesn't look like here's our normal musculature,

3:56

and here it is flattened by the lesion. So it's,

3:59

it's opposed to it, but not infiltrating it.

4:04

And the other way we would look at that would be with the post gad to see

4:08

whether we see asymmetric contrast enhancement of that musculature

4:13

right here. You might be worried about that,

4:21

but it didn't correspond to the, uh, stir as far as,

4:26

so we're right at the uvula, so let's go to the uvula.

4:30

Not really seeing that, but that,

4:32

that's an issue that would have to be addressed because

4:36

fixation to the prevertebral musculature makes things unresectable.

4:43

The other thing that we wanna look at is the relationship of this to the

4:48

vasculature,

4:48

because infiltration in and around the carotid artery with

4:53

fixation also makes it unresectable disease and, um,

4:59

T four B disease. So in this instance,

5:02

those vessels fortunately are displaced laterally,

5:05

but they're not encased by the tumor. It is going,

5:10

you know, into the carotid space,

5:12

but it's not surrounding the carotid artery.

5:15

The next thing lower down that we wanna look at is,

5:19

and we're pretty far away from it, is the scaling musculature.

5:21

This is the anterior scaling behind the anterior scaling muscle is the brachial

5:25

plexus tumor into the brachial plexus also becomes unresectable.

5:29

We're pretty far away from that here.

5:31

We can see pretty clearly that there's a retropharyngeal lymph node.

5:35

So that will help us to say that this is not all continuous tumor,

5:39

that this is lymphadenopathy. So,

5:44

um, let's go back to the, um,

5:48

and look at t staging of oropharyngeal cancer,

5:52

which is this tonsil. So the key

5:56

Here is that there's two different staging. One is for

6:02

H P V positive oropharyngeal cancer,

6:07

two centimeters, two to four centimeters greater than four sonometers,

6:11

and then infiltration of soft tissues, larynx, muscle,

6:16

et cetera,

6:17

versus those T oropharyngeal cancers,

6:23

which are not H P V positive.

6:26

The reason why we separate these is because H P V positive cancers are very

6:32

responsive to radiation and chemotherapy and are curable

6:37

even when they're in the T four stage. However, if it's H P V negative,

6:42

and this is the staging for H P V negative, you can see that

6:47

T four B is very advanced, usually unresectable disease, skull base involvement,

6:52

internal carat artery encasement, lateral nasopharyngeal involvement,

6:56

all these things make it T four B and skull base.

6:59

We would also include infiltration of the longest coline long ca capus muscle

7:03

complex. So, um, we would measure this,

7:08

it looks to mean like it's gonna measure over four centimeters in size.

7:11

So we probably have a T three cancer.

7:14

We would then go to our end staging and look

7:19

at the lymph nodes and there's multiple ipsilateral lymph nodes

7:24

with extra nodal extension. So that would be N three B disease

7:31

and, um, advanced cancer. So the,

7:36

the pertinent findings here are what's it doing to the skull base

7:41

prevertebral musculature, what's it doing to the carotid artery? Um,

7:47

and with the lymph nodes, again,

7:50

are the lymph nodes infiltrating around the carotid artery?

7:52

Is there extra nodal extension, et cetera? Remember again,

7:55

the extra nodal extension is a pathologic diagnosis,

7:58

but we usually can imply it with our imaging findings.

8:03

Let's go back to the images and just see whether there was anything else worth

8:08

pointing out in this case. Um,

8:11

so here is our OID musculature.

8:15

We wanna look at that once again on our stir imaging

8:21

to see whether those muscles are infiltrated.

8:28

So it looks like it's up to the muscle,

8:30

but not infiltrating the muscle important negative

8:36

and no bone involvement. So for bone involvement,

8:40

I prefer to look at the T one wave scan because usually you're able to see the

8:43

bone marrow bright signal as well as the cortical very dark signal

8:48

and we're not seeing anything there.

8:52

No contralateral lymphadenopathy.

8:55

So again, best to look for that with our

9:00

stir image that shows whether or not, um, we have right lymph node.

9:06

Here's the CT scan. Again, kinda looks like everything's all contiguous.

9:11

We see that there is necrosis in these small lymph nodes.

9:14

So there is lymphadenopathy, it's a conglomerate,

9:17

massive of lymph nodes here with necrosis.

9:21

And this fuzzy fat defining sort of the extracapsular

9:27

or extra nodal extension. There's some edema in the, uh,

9:33

retro pharyngeal space here is that little retropharyngeal lymph node.

9:37

And here we're a little bit,

9:39

looks a little bit more primary tonsil cancer.

9:45

Um,

9:47

some people asked about whether this could be a schwannoma or a, um,

9:53

paraganglioma.

9:54

The argument against paraganglioma is it's not really that vasculature,

9:58

no big vessels,

9:59

and it's coming into the mucosal space here,

10:05

um, in a way that is, would be unusual for any type of paraganglioma.

10:09

For a schwannoma. Again, we have these necrotic lymph nodes that are, uh,

10:14

evident. Um, and that would,

10:18

for a benign tumor would be unusual.