We present a case of a 55 years old man with a lateral cervical left mass, and an expansive lesion in lingual epiglottis versant, on the right side (involving ipsilateral epiglottic vallecula).
The patient underwent staging procedures including contrast enhancement CT (c.e.CT) of the head and neck region and a whole body [18F]-FDG PET/CT. Accurate pre-treatment staging of cervical lymph nodes is essential for proper treatment planning. Moreover, regional lymph nodes involvement is one of the utmost prognostic factors regarding the patient’s outcome. To date, there is still no consensus on the best imaging modality that should be used in head and neck cancer staging, between CT, MRI and [18F]-FDG PET/CT (Kastrinidis et al., 2013).
The first staging examination, a c.e.CT, showed a neck paramedian right lesion presenting an intense contrast enhancement (measuring 18 × 8 mm), contralateral confluent lymph nodes compressing the jugular vein and ipsilateral small lymph nodes, of unclear nature. Figure 1-a: transaxial c.e.CT scan shows primary epiglottic lesion (white arrow); Fig. 1-b: transaxial c.e.CT scan shows both the increased left lateral cervical lymph nodes (white arrow), both some small right lateral cervical lymph nodes with contrast enhancement (red arrow).
Overall, in the radiological report, c.e.CT was doubtful for ipsilateral adenopathy.
Staging continued with a whole body [18F]-FDG PET/CT to assess possible metastatic disease foci and to define the nature of the ipsilateral cervical lymph-nodes.
A whole-body PET scan was acquired, 3 min per bed position, one hour after the injection of a standard activity (3,5 MBq/Kg) of 18F–FDG. It was also performed a low-dose CT for the attenuation correction (120 kV, 80 mA, 0.8 s per rotation, thickness 3,75 mm).
PET scan showed an increased FDG uptake of the primary lesion in the right epiglottis (SUVmax = 10, SUVmean = 6.3, MTV = 1.9 cm3, TLG = 12) and also in correspondence of the II and III level in the contralateral side (SUVmax = 15, SUVmean = 8.5, MTV = 14.9 cm3, TLG = 126.6). Figure 1-c: transaxial PET/CT scan shows an increased [18F]-FDG uptake area on the right versant of the epiglottis (white arrow); Fig. 1-d: transaxial PET/CT scan demonstrates clearly that right lateral cervical lymph nodes are not pathological (red arrow) and confirm, on the left side, the adenopathy (white arrow).
Noticeably, [18F]-FDG PET/CT showed no significant FDG uptake areas in the ipsilateral right cervical chain. The minimal activity of the right-sided lymph node was indistinguishable from the background activity (SUVmax = 1.5), suggesting its benign nature (Lim et al., 2016).
After staging (T1-N2b), patient underwent surgical supraglottic laryngectomy and bilateral lateral cervical lymph nodes dissection.
Histopathology results showed a squamous cell carcinoma of the right lingual epiglottis side, no malignant cells in the right lateral cervical lymph nodes, while metastatic cells in the left lateral cervical lymph nodes were detected (pT1-N2b).