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September 2011 Otologic, Head & Neck Newsletter >>
Clinical Scenarios: Head and Neck Masses
Clinical Scenario 1
History and Exam
A 45-year-old female was seen in our annual free head and neck cancer-screening clinic. This clinic is organized and staffed by the head and neck oncology team each year during Head and Neck Cancer Awareness Week. She was noted to have several firm non-tender lymph nodes in her right level 3 neck. She was then referred for formal clinic evaluation. The woman had no concerns prompting her visit in the free clinic and denied any prior awareness of neck fullness. She had no symptoms related to the oral cavity, pharynx, or larynx, and denied symptoms of fever, chills, night sweats, or weight loss. She was otherwise in outstanding health with no history of tobacco or excess alcohol use. She had no prior radiation exposure and no family history of malignancy.
Her exam revealed two firm non-tender but fully mobile lymph nodes in the right level 3 neck and a mass in the right superior thyroid pole. No other abnormalities were noted on her full head and neck exam. She had normal vocal cord mobility on indirect laryngoscopy.
Evaluation and Management
Needle aspiration of her right mid-jugular chain mass on the day of her initial evaluation confirmed papillary carcinoma of the thyroid. Subsequent ultrasound of the neck confirmed a 1.0×1.7×.07 cm mass in the superior pole of her right thyroid gland and enlargement of both lateral and central compartment lymph nodes in the right neck with heterogeneity and micro-calcifications suggestive of metastasis. Thyroid function studies and serum calcium levels were normal.
This patient’s case was reviewed in our weekly multi-disciplinary head and neck tumor board conference and she was seen by endocrinology for pre-surgical discussion and overall treatment planning. She then had a total thyroidectomy with right lateral and central lymph node dissections (levels 2, 3, 4, 5, and 6). Her recovery was uneventful. Histopathology revealed both central and lateral compartment nodal metastasis (5/26) and a multifocal primary tumor without extrathyroidal extension and with clear margins. Her postoperative RAI ablation was planned three months after surgery for personal reasons and she was begun on thyroxin postoperatively. Her two month postoperative unstimulated thyroglobulin level was 0.1. She had pathologic staging of Stage IVA disease and has undergone thyrogen stimulated I-131 ablation.
Clinical Scenario 2
History and Exam
A 67-year-old male presented to his primary care physician with a three-week history of left sided sore throat. He denied other symptoms of URI and also denied constitutional symptoms. He had a history of coronary artery disease, diabetes mellitus and hypertension and no history of tobacco and alcohol use. On exam he was noted to have unilateral fullness of his left tonsil. His neck exam revealed fullness in his left level 2 necks. He was referred for further evaluation in the head and neck oncology clinic given his primary care physician’s suspicion for a tonsillar neoplasm.
History and physical exam in the oncology clinic concurred with his primary physician’s evaluation. Flexible endoscopy of the pharynx and larynx better defined the apparent tonsillar neoplasm as being limited to the tonsillar fossa without tongue base extension.
Evaluation and Management
Biopsy was obtained in clinic from the tonsillar lesion and histopathology revealed a basaloid squamous cell carcinoma with a positive p16 screen and subsequent positive HPV-16 in-situ hybridization testing. CT with contrast of the neck confirmed a 3.7cm mass of the left tonsil and two concerning lymph nodes each having a long axis of over 2cm in the left level 2 neck. This gave the patient a clinical staging of aT2N2bM0, HPV-16 positive carcinoma of the left tonsil.
This patient’s case was reviewed at our multidisciplinary head and neck tumor board conference and options of surgical excision versus primary chemo-radiotherapy were then presented to the patient.
This patient elected surgical resection and was treated with transoral robotic surgery (TORS) to address the primary tumor and selective neck dissection to manage the suspicious nodes. UW Hospital is the first and only hospital in Wisconsin to offer TORS as a technique to remove cancers of the oropharynx in a minimally invasive fashion.
Surgical pathology revealed clear margins and all 47 lymph nodes removed were free of disease. Given his pathologic staging of a T2N0 lesion, adjuvant radiotherapy was not required.
Both cases illustrate the value of a multi-disciplinary team approach to the management of head and neck malignancies. The team at UW Hospital includes head and neck surgeons, dedicated head and neck radiation and medical oncologists, neuroradiologists, speech and language pathologists and more. This group meets weekly to discuss the care of our patients at the head and neck tumor board conference.
To learn more about our head and neck tumor board, or to join us, please click here.