Head and Neck Cancer - 50 year-old man

History
50 year-old man who presented with a left neck mass and underwent an excisional biopsy showing metastatic squamous cell carcinoma, but had no known mucosal primary by physical exam or traditional anatomical imaging. PET/CT ordered for further evaluation.

Treatment
Excision of this base of tongue lesion and a modified radical neck dissection type 2. The pathology revealed the left base of tongue to be his primary mucosal lesion. Postoperatively, the patient has done very well. He progressed quite well, and in his initial postoperative period, he fared well with his tracheostomy. The cuff remained inflated for the first four days postoperatively, after which time it was deflated, and he was downsized to a 4-0 cuffless Shiley. He did well with this. However, he had significant secretions on the next postoperative day, so we did not decannulate then. The patient was later decannulated successfully and began taking p.o. and has tolerated p.o. quite well. His NG tube was then removed. Staples were removed, and the patient was discharged home in good condition.

Imaging Findings
Initial PET/CT: Focal area of intense FDG accumulation in the left base of tongue with no identifiable correlative CT abnormality consistent with tumor. This likely represents the patient's mucosal primary.

Treatment
The patient underwent resection of the lesion in the left base of the tongue. The pathology after resection revealed the left base of tongue to be his primary mucosal lesion. The patient had a tracheostomy and external beam radiation with no chemotherapy.

Imaging Findings
Follow up PET/CT: No evidence for residual or recurrent tumor.

Discussion/References
This is a very good illustration of the ability of PET/CT to identify primary head and neck malignancies when they might not be detected by other imaging modalities. This patient presented after feeling an enlarged left neck mass. After an exam by an otolaryngologist, an FNA, and excisional biopsy which was positive for metastatic squamous cell carcinoma, the patient was sent for PET/CT, which has become standard protocol prior to patients going for definitive surgery.

PET/CT identified the primary mucosal lesion to be in the left base of tongue. The follow up PET/CT after resection and radiation was negative.