Cervical nodal metastasis in head and neck cancer: a clinical conundrum.

To cite: Revannasiddaiah S, Sood A, Kumar S, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2013010364 DESCRIPTION Within a month of being treated with a partial maxillectomy for a stage T2N0M0 (staged as per preoperative MRI and CT) left maxillary antral carcinoma, a patient suffered symptoms of ‘sore throat’ and also tested positive for a streptococcal infection on a swab test. Though appropriate antibiotics relieved symptoms, a minimal dysphagia persisted which was conveniently attributed by the patient as ‘being related to the streptococcal infection’. However, after two months, the F-fluorodeoxyglucose positron emission tomography/CT (F-FDG-PET/CT) which was performed as part of a post-treatment follow-up, demonstrated multiple contralateral avid necknodes (levels II–IV). This was histopathologically confirmed to be harbouring metastatic deposits of squamous cell carcinoma (figure 1). Given the sparsity of lymphatics to the maxillary antrum, the possibility that lymph nodal spread from a T2-staged maxillary antral carcinomas is very unlikely. In this described case, the postoperative histopathology demonstrated negativemargins also the FDG-PET scans ruled out recurrence at the primary site. The use of FDG-PET for the assessment of the N0 neck may be constrained by the combination of limited sensitivity for small metastatic deposits and a relatively high number of false-positive findings in PET/CT, thus highlighting the point that the surgical management of the clinically N0 neck should not be solely based on the findings on a standard CT or a FDG-PET/CTscan. Owing to the low likelihood of the metastatic neck nodes having originated from the maxillary antral cancer, that too to the contralateral side, a search for another site of head and neck mucosal malignancy was performed. However, as no other aerodigestive mucosal malignancy was found, he has since been initiated on chemoradiotherapy on the lines of a ‘metastatic-neck-node from unknown-primary’.