38 y/o man has swelling in right side of his neck which developed several weeks previously. He states it's nontender, nonpulsatile, and doesn't really bother him. He denies hoarsness, dysphagia, or dyspnea. Denies any recent trauma to the neck or recent illness. No fevers, chills, night sweats, weight loss.
GEN: Alert, orientedx3. NAD
Eyes: EOMI, PERRLA
Ears: TM's clear, w/o erythema/bulging, +LR, +LM sign, mobile
Nose: Nares patent, turbinates non-swollen
Throat: Swelling right nasopharynx. Well mucolized, no ulcerations, non-exophytic.
Neck: 2-3cm firm neck mass posterior to mandible, mobile, nontender, non pulsatile.
Heart: RRR, norm S1,S2. no m/r/g
Lung: CTAB no w/r/r
Abd: nondistended, soft nontender, no organomegaly, masses
Ext: No c/c/e
Neuro: CNII-XII grossly intact
MRI neck mass:
Just deep to the right sternomastoid muscle is a T1 dark T2 bright fluid collection measuring 4.5 cm in craniocaudal dimension by 3.3 cm AP by 2.6 cm transverse. The wall is thin and demonstrating mild enhancement, but no internal enhancement is noted. No additional adenopathy in the neck is noted.
CT neck s/p excisional biopsy of neck mass:
Nasopharyngeal mass measures 1.6 x 1.8 cm anterior to posterior x 1.5 cm superior to inferior. Enlarged lymph node at C2 vertebral level in left parapharyngeal space measuring 1.8cm on long axis.
There are surgical changes in the right neck, consistent with the resected metastatically enlarged right level 5 lymph node. There is air/gas and fluid in the resection site.
NM-PET s/p excisional biopsy of neck mass:
1) Extending from the fossa of Rosenmueller in the right nasopharyngeal space is an irregular mass which measures approximately 2.6 x 1.7 cm and demonstrates avid FDG uptake with an SUV of 12.3. There is an enlarged level II lymph node
on the left just adjacent to the oropharynx which demonstrates FDG uptake with an SUV of 8.0. Additionally, several small level V lymph nodes also seen on the left which demonstrate mild FDG uptake with SUV of 2.5.
2) Surgical changes are seen on the right in the region of the angle of the mandible adjacent to the right sternocleidomastoid muscle to include soft tissue emphysema, inflammatory fat stranding, and mild FDG uptake in this region. Focal region of FDG uptake with an SUV of 5.0 likely represents lymph node which may represent metastatic focus or may be reactive in nature. No other enlarged or FDG avid lymph nodes are seen.
â€¢ Brachial Cleft Cyst
â€¢ Reactive lymphadenopathy
â€¢ Peritonsilar/retropharyngeal abscess
â€¢ Warthins tumor
â€¢ Nasopharyngeal Carcinoma
â€¢ Hodgkins Lymphoma
Neck mass excised and biopsied. Following biopsy, CT with contrast of H&N obtained in addition to full body NM-PET scan.
â€¢ Radiation therapy
â€¢ Chemotherapy: Cisplatin 2cycles (6wks total)
â€¢ Incidence 0.5-2/100,000 in US
â€¢ Endemic in southern China where incidence is 15-20/100,000.
â€¢ Additional populations with intermediate risk include SE Asia, northern Africa and North American Eskimos.
â€¢ More common in males (3:1), bimodal age distribution
â€¢ EBV is almost always present in NPC, indicating that this virus plays an oncogenic role. The viral titer can be used to monitor therapy or possibly as a diagnostic tool in the evaluation of patients who present with a metastasis from an unknown primary.
â€¢ Exposure to environmental carcinogens, especially high levels of volatile nitrosamines (specifically, those in Cantonese-style salted fish), has been implicated in this complicated disorder; carcinogens related to smoking, formaldehyde exposure, and radiation have also been implicated.
â€¢ Diets of salted fish, nitrates, preserved vegetables, Chinese herbs have been implicated in this disease. The cooking of salt-cured foods releases volatile nitrosamines which distribute over the nasopharyngeal mucosa when carried by steam.
â€¢ Having a first degree relative with NPC incrses odds of NPC 7.6-fold; this has led to recommended screening of all first degree relatives of pt with NPC.
â€¢ NPC classic clinical triad consists of a neck mass, nasal obstruction with epistaxis, and serous otitis media.
â€¢ The most common presenting complaints in patients with NPC are headache and a mass in the neck.
â€¢ Nasopharyngeal carcinoma produces few symptoms early in its course, with the result that most cases are quite advanced when detected.
â€¢ Once the tumor has expanded from its site of origin in the lateral wall of the nasopharynx, it may obstruct the nasal passages and cause nasal discharge or nosebleed.
â€¢ Obstruction of the auditory tubes may cause chronic ear infections, and patients may experience referred pain to the ear.
â€¢ Metastasis of cancer to the lymph nodes of the neck may also be the first noticeable sign of the disease.
â€¢ Characteristic radiology findings include the early triad of nasopharyngeal mucosal asymmetry, ipsilateral
retropharyngeal LAD, mastoid opacification.
â€¢ Invades superiorly > inferiorly
â€¢ Anatomical sites of tumor invasion (>30% in one study):
Lateral/Posterior: levator/tensor pallatini, pharyngobasilar fascia, parapharyngeal fat space, pre-vertebral muscle
Anterior: nasal cavity
Superior: skull base (pterygoid process, clivus, spenoid body, and petrous), foramens lacerum > ovale > rotundum, sinuses cavernous > sphenoid > ethmoid, orbit
â€¢ Compared to other head/neck cancers has tendency for early metastatic spread.
-Lymph node metastases occur in 75 to 90 percent and bilateral neck nodes are present in over 50 percent of patients .
-Distant metastases are detected at initial diagnosis in approximately 5 to 11 percent of patients, and 38 to 87 percent have evidence of distant dissemination at autopsy.
-The most frequent sites of distant metastases are bone (70 to 80 percent of metastases), lung, and liver.
â€¢ External beam radiation therapy is the primary mode of management of NPC, both at the primary site and in the neck
â€¢ Chemotherapy adjunctive to radiotherapy in advanced NPC has been controversial with conflicting literature reports.
â€¢ Nasopharyngectomy is reserved only for treatment of recurrent NPC with limited disease
â€¢ Prognosis for NPC is based on multiple factors: primary tumor extension, disease level in the neck, histologic subtype, and patient's sex (increased survival rate for women).
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