Fun Case!

[Reaganite]

Try to keep up!

60 year old guy presents with large (>5cm) right forehead SCC >1cm from midline. Preoperative imaging shows a LEFT level 1 cystic mass ddx not given in report. Of note, also has biopsy proven basal cell carcinoma of left nares AND right mid-neck BCC. Undergoes:

1. Excision R forehead SCC.
2. R Neck dissection
3. Excision of Left nares and R neck BCC
4. Excision of left neck level 1 mass.

Final path:

Forehead lesion: 5cm SCC, margins negative.
R neck dissection: 38 nodes negative.
Left Nares: BCC with PNI
Right Neck: BCC.
L level 1: Basaloid SCC in a lymph node measuring 3.5 cm, not consistent with any of the above primary sites. (Path already reviewed by outside academic center and agree). Of note, had pan endo and PET prior to any surg and no obvious oral cavity lesion.

What would you radiate???

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[evilbooyaa]

Smoker? P16 positivity on the neck node? Given inconsistency with primary sites (including the 5cm SCC), I'd send to ENT for consideration of Tonsil biopsy if clinically indicated on exam (patient probably hasn't seen an ENT to date?) along with full nasopharyngolaryngoscopy (not sure if pan endo includes that).

If all negative (except p16+, hopefully) would treat like HNSCC of unknown origin.

Suspicion for a separate cutaneous SCC metastatic to LN is low.

Would be interested in hearing other thoughts.

 

[Mandelin Rain]

I'm assuming you're going to do all the stuff to work up occult primary.

Bummer that he had a right neck dissection.

Depending on the size of the positive left sided node (N1 vs N2) and presence/absence of extra nodal extension, I think I'd send him back for a left neck dissection, hope for no further positivity, and then watch him if everyone on the team agreed.

I'm not irradiating an entire oral cavity for occult primary if I don't need to.

EDIT: I missed that you stated his node was 3.5 cm. Not sure what the right answer is, but I'd still try to avoid comprehensive irradiation for a single positive node. If there is more positivity or extranodal spread on dissection, I'd treat neck only if truly limited to level I. If not, I'd observe.

 

[nkmiami]

Agree with p16. cystic nodes are often seen with HPV positive cancer, which are often also poorly diff and non-keratinizing. would consider tonsillectomy at least on left.

 

[Reaganite]

Agree with p16. cystic nodes are often seen with HPV positive cancer, which are often also poorly diff and non-keratinizing. would consider tonsillectomy at least on left.

Forgot to mention...weakly p16+. No ECE.

 

[Reaganite]

I'm assuming you're going to do all the stuff to work up occult primary.

Bummer that he had a right neck dissection.

Depending on the size of the positive left sided node (N1 vs N2) and presence/absence of extra nodal extension, I think I'd send him back for a left neck dissection, hope for no further positivity, and then watch him if everyone on the team agreed.

I'm not irradiating an entire oral cavity for occult primary if I don't need to.

EDIT: I missed that you stated his node was 3.5 cm. Not sure what the right answer is, but I'd still try to avoid comprehensive irradiation for a single positive node. If there is more positivity or extranodal spread on dissection, I'd treat neck only if truly limited to level I. If not, I'd observe.

FWIW, my initial feeling was to just radiate the left neck since technically he has N2 disease. I agree with not radiating the whole oral cavity. That would technically be lips, tongue, gingiva, buccal mucosa, etc. Doesn't sound very fun!

 

[evilbooyaa]

Assuming cutaneous scc is p16-

Any ENE on the LN?

I agree that radiating the oral cavity with low dose is less feasible than if this was a level 2 LN and you were to radiate the oropharynx.

No ENE = no chemo. Can stop level 2 coverage without going all the way to RSF to spare some of ipsilateral parotid.

 

[nkmiami]

Radiating the left neck alone is appropriate-
Radiotherapeutic Management of Cervical Lymph Node Metastases From an Unknown Primary Site | Head and Neck Cancer | JAMA Otolaryngology–Head & Neck Surgery | The JAMA Network

 

[Palex80]

I would irradiate the affected neck side. I wouldn't treat anything in the pharynx.

It would be interesting to know if the pathologists looked at the entire 5cm primary. Perhaps its a mixed type tumor and only some part of it metastasized to the neck only. On the other hand P16 on the node is weakly positive which speaks against this theory.

Next generation sequencing on both primary and the node?