Oropharynx - Palatine Tonsil SCC - N/M Staging
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Hello, everyone.
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Dr. Sidney Levy here, continuing our staging of this
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right palatine tonsillar squamous cell malignancy.
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I would like to focus on N staging.
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We do not know if this patient is human papillomavirus
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positive or negative, and therefore we need
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to stage, keeping both possibilities in mind.
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In this case, the patient has a single
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ipsilateral right level 2A lymph node,
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measuring less than three centimeters
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without extranodal extension.
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So let me take you through what all of that means.
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First thing to say is, how do we know that it's level 2A?
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It is level 2A because it is abutting the internal
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jugular vein, which is here, with the lymph node being
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here, and there is no fat plane between the two.
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So although it is posterior or posterolateral to
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the internal jugular vein, because there is no
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fat plane separating it from the internal jugular
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vein, it is still considered a level 2A lymph
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node as opposed to a level 2B lymph node.
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Next thing, how much does it measure?
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It is two and a half centimeters,
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so therefore less than three centimeters.
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Next thing, is there evidence of extranodal extension?
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Remembering that this is a clinical or pathological
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diagnosis, we can only infer that it may be present
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if there is macroscopic evidence of infiltration of
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nodal metastatic tissue into surrounding soft tissue.
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In this particular case, on our T1-weighted
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imaging, we see a well-circumscribed lymph node
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without any evidence of infiltrative properties,
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blurred margins, or other worrisome features.
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So therefore, no radiological evidence
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to suggest extranodal extension.
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So, everything I've been saying
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so far applies to HPV-negative tumors.
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This single ipsilateral level 2A lymph node
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measuring less than 3 cm without evidence of
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extranodal extension means that the tumor may be
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staged as an N1 tumor if found to be HPV-negative.
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In this particular instance, if the tumor is found
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to be HPV-positive, it still remains N1 due to the
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fact that it is an ipsilateral lymph node measuring
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less than or equal to 6 cm, with no evidence
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of contralateral or bilateral nodal disease.
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From an M stage point of view, in the head and
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neck, there was no evidence of distant disease,
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which usually involves bone, lung, or liver.
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But remember, we need other imaging, such as
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CT or PET-CT, in order to confirm this.
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So in summary, this tumor is a T3 N1 M0 tumor,
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irrespective of human papillomavirus status,
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by virtue of the fact that it measures more than
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4 centimeters in maximal dimension and has a single
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ipsilateral lymph node measuring less than
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3 centimeters with no evidence of extranodal extension and
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no evidence of distant disease within the head and neck.
Sidney Levy, PhD, MBBS
Radiologist and Nuclear Medicine Specialist
I-MED
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