Oropharyngeal Carcinoma: Nodal Drainage and Differential Dx
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Hello everyone.
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Dr. Sidney Levy here, continuing our discussion of diagnosis
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and staging of base of tongue squamous cell malignancy.
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I would like to go through the patterns of drainage
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of lymph nodes of base of tongue malignancy.
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We have an example case that we are using.
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This is a base of tongue squamous cell carcinoma,
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which is involving both the right and left sides and
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we can see that there is one abnormal lymph node here.
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I will, uh, point it out to you.
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So this lymph node here is situated within level 2A.
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And we know that because it is posterior to the posterior
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margin of the submandibular gland, which is here.
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We also know that this lymph node is less than
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3 centimeters, which we can measure easily.
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So given that information and the fact that there aren't any
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other lymph nodes on the right side or the left side of the
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neck, we can say that this lymph node is a level 2A lymph
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node, and the only one which is morphologically abnormal.
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Base of tongue malignancy can drain to levels 2, 3, or
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4, and often is bilateral, the reason being that many
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tumors do cross the midline and involve the other side.
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Oropharyngeal malignancy, including base of tongue
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malignancy, can often be human papillomavirus
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positive, particularly in more recent years.
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These lymph nodes tend to have a more cystic morphology
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and can be easily mistaken for benign pathology
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such as second branchial cleft cysts.
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So this is a major pitfall when assessing lymph nodes in the neck.
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Don't mistake
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a morphologically abnormal cystic or necrotic lymph
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node in the neck for a second branchial cleft cyst.
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Often, cystic lymph nodes are more irregular, they have
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a thicker peripheral margin, and, in particular, you must
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look very carefully at the upper aerodigestive tract to
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see if there is a lesion, which might be quite small.
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If there is any doubt whatsoever, people
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often sample these lymph nodes to make sure.
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The last thing I'd like to go through are the
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differentials for base of tongue squamous cell malignancy.
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The differentials for base of tongue squamous cell
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malignancy include minor salivary gland malignancy,
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lingual tonsillar hyperplasia, lymphoma, other
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oropharyngeal malignancy, so palatine tonsil malignancy,
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which has spread to the base of tongue,
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and benign mixed tumors such as pleomorphic adenomas.
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So in summary, base of tongue oropharyngeal malignancy
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often drains to levels 2 to 4 within the neck,
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may often be bilateral. A significant proportion of
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these malignancies are human papillomavirus positive
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and therefore the nodes may be of cystic morphology.
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And it is extremely important not to dismiss
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a cystic lesion within the neck in this
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region as a second branchial cleft cyst.
Sidney Levy, PhD, MBBS
Radiologist and Nuclear Medicine Specialist
I-MED
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