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Abstract
Jump to Section1. Introduction2. Materials and methods 2.1. Case 13. Discussion4. ConclusionsDisclosuresAcknowledgementsReferences
Background
Metastasis of squamous cell carcinoma (SCC) to the superior cervical ganglion (SCG) has never been reported. Its anatomic location may easily be mistaken for a retropharyngeal lymph node. We present the first case of SCC metastasis to the SCG.
Methods
We report a case of a 69 year-old never smoking male, who presented with right retropharyngeal PETCT-avid disease following chemoradiation for squamous cell carcinoma of the tonsil. He was brought to the operating room for resection, intraoperative radiation and reconstruction.
Results
Intraoperatively, visualization and frozen section confirmed squamous cell carcinoma located in the superior cervical ganglion. The ganglion was resected, intraoperative radiation was given and the patient was reconstructed with a radial forearm free flap. Postoperatively, the patient displayed features of a Horner's syndrome.
Conclusions
The superior cervical ganglion may be mistaken for a retropharyngeal lymph node. Although extremely rare, these entities may be differentiated on the basis of radiological studies.
1. Introduction
Jump to Section1. Introduction2. Materials and methods 2.1. Case 13. Discussion4. ConclusionsDisclosuresAcknowledgementsReferences
The nodes of Rouviere are the main lymph nodes in the suprahyoid retropharyngeal space and are located ventral to the longus colli muscle, and medial to the internal carotid artery [1]. These nodes may be involved by squamous cell carcinoma (SCC), primarily of the nasopharynx and of the oropharynx, but also in supraglottic, oral cavity and sinonasal tumors [1]. Other disease entities such as papillary thyroid carcinoma, melanoma, and esthesioneuroblastoma may spread to these nodes [1].
The superior cervical ganglion (SCG) is the most superiorly positioned and largest ganglion forming the cervical portion of the sympathetic trunk [2]. It is located posterolateral to the retropharyngeal space, deep to the carotid artery and can easily be confused with a retropharyngeal lymph node [2]. This is especially important in cancer patients, where the SCG may be mistaken for a retropharyngeal node [2]. Previous case reports have identified enlarged SCG in nasopharyngeal cancer patients without documented histological involvement by SCC, and concluded that an adaptive response to radiotherapy may occur in the SCG [[2], [3]]. We describe the first case of SCC metastatic to the SCG. We outline the radiological and anatomical challenges in identifying this condition, as well as the proposed pattern of spread. It is important for surgeons to be cognizant of this entity when performing surgery in this region.
2. Materials and methods
Jump to Section1. Introduction2. Materials and methods 2.1. Case 13. Discussion4. ConclusionsDisclosuresAcknowledgementsReferences
2.1. Case 1
Jump to Section1. Introduction2. Materials and methods 2.1. Case 13. Discussion4. ConclusionsDisclosuresAcknowledgementsReferences
A 69 year-old male never-smoker underwent combined chemoradiotherapy for HPV-positive squamous cell carcinoma of the right tonsil, stage T2N2BM0. The patient suffered otherwise from hypertension and factor V Leiden. The retropharyngeal nodes had received at least 57 Gy of intensity-modulated radiation therapy (IMRT). On pre-treatment imaging, the patient had a right hypermetabolic mass (SUV 8.5) at the level of the occipital condyle evident as expansion of the right longus colli muscle which abuts and is inseparable from the right internal carotid artery and carotid sheath (Fig. 1A ). The patient underwent PETCT scanning 3 months after treatment completion which showed regression of all tumor including the retro-carotid component (Fig. 1B). Nine months after treatment completion, another PETCT showed recurrence of the retro-carotid mass, which measured 3.1 cm transverse × 1.5 cm anteroposterior × 3.0 cm craniocaudal dimension, with new hypermetabolism (SUV 5.6) (Fig. 1C). MRI was obtained (Fig. 2) and showed abnormal signal lateral to the right longus colli muscle at the level of the occipital condyles extending to and posterior to the right internal carotid artery and carotid sheath. This was felt to be a possible retropharyngeal nodal recurrence of SCC. In light of the increasing size and the increasing SUV, the decision was made to proceed with surgery without a biopsy.
Fig. 1
Axial PETCT images at the level of the occipital condyles showing a retro-carotid hypermetabolic mass (arrow) on pre-treatment (A), three months post-treatment (B), and nine months post-treatment (C).
Fig. 2
Right retro-carotid mass (arrow) displacing the carotid artery (red circle) anteriorly and the longus capitis (star) medially on axial T1 images with contrast. Contralateral carotid artery is shown in red. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
The patient was brought to the operating room for resection through a mandibulotomy approach. Intraoperatively, exposure of the retropharyngeal space did not reveal an abnormal lymph node, and the mass was encountered after dividing the alar fascia posterior to the carotid sheath. Clinically, the mass appeared as the SCG, and involvement with SCC was confirmed with frozen section analysis. A wide resection of the mass was performed while sparing the carotid artery and vagus nerve. Intraoperative radiation therapy was administered at a dose of 6 Gy, and reconstruction with a radial forearm free flap was performed. Postoperatively, the patient presented features of Horner's syndrome on the right side. There was no identifiable Horner's syndrome preoperatively. He developed a salivary fistula on postoperative day 7 through a breakdown of the floor of mouth incision which was treated with washout, drainage, and negative pressure therapy. He was discharged on postoperative day 25 after resuming a normal oral diet. Final histopathology confirmed the invasion of SCC into neural tissue containing ganglion cells in the resected SCG (Fig. 3). (SeeFig. 4.)
Fig. 3
Histopathological H&E slide (10 × 10) showing squamous cell carcinoma invading neural tissue containing ganglion cells at the level of the SCG.
Fig. 4
Anatomical diagram illustrating the location of the superior cervical ganglion (SCG) (green arrowhead) in comparison with retropharyngeal lymph nodes (RPLNs) (yellow arrowhead) and the carotid sheath contents (red arrowhead) (A). With enlargement of the SCG, the carotid sheath contents are displaced anteriorly and the prevertebral musculature medially (B). With enlargement of RPLNs, the carotid sheath contents are displaced laterally and the prevertebral musculature are pushed posteriorly (C). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
3. Discussion
Jump to Section1. Introduction2. Materials and methods 2.1. Case 13. Discussion4. ConclusionsDisclosuresAcknowledgementsReferences
We present the first case of SCC metastatic to the SCG. This unusual disease poses several challenges, especially in terms of preoperative recognition. Anatomically, the SCG is located posterior to the carotid sheath at the level of the second to third cervical vertebrae and anterior to the longus capitis muscle, and posteriorly to the carotid sheath (Fig. 3A). It is posterolateral to the retropharyngeal space, and is separated from it by the alar fascia [3]. The alar fascia is not visible radiographically. The retropharyngeal space encloses the retropharyngeal lymph nodes, lies posterior to the pharynx, anterior to the prevertebral musculature, and extends from the clivus to the superior mediastinum [1]. It is divided into a superficial retropharyngeal space proper (extending down to T1–T6) and a deeper danger space (extending down to the diaphragm) by the alar fascia [1]. Deep to the danger space lies the prevertebral fascia [1]. It is also divided into an infrahyoid and a suprahyoid component, and the suprahyoid component contains fat and lymph nodes [1]. Two groups of lymph nodes can be encountered in the suprahyoid retropharyngeal space proper: medial and lateral [1]. The medial component is often absent, and thus, when commonly referring to retropharyngeal lymph nodes, or nodes of Rouviere, one often refers to the lateral node group of the suprahyoid retropharyngeal space proper [1]. These nodes lie anterior to the longus colli muscle [1] (Fig. 3A), which are located medially to the longus capitis muscles. In the eventuality that the SCG is expanded in size, anatomically, the carotid sheath contents are pushed anteriorly, and the longus colli and longus capitis are displaced medially (Fig. 3B). If the retropharyngeal lymph nodes are increased in size on the other hand, the carotid sheath contents will be displaced laterally and the prevertebral musculature will be pushed posteriorly (Fig. 3C).
Radiologically, it is important to be able to distinguish retropharyngeal lymph nodes from a SCG that is increased in size, and the anatomic relationships are described above. The most important study in distinguishing SCG from retropharyngeal lymph nodes is MRI. The imaging characteristics are presented inTable 1. Histopathological diagnosis is essential to proving metastatic SCC, as shown in Fig. 3.
| Retropharyngeal nodes | Superior cervical ganglion | |
|---|---|---|
| Location | Anterior to longus colli Medial to carotid | Posterior to longus colli Posterior to carotid |
| T1 | Hypointense [3] | Hypointense [3] |
| T2 | Hyperintense [3] | Hypointense [3] |
| T1 with contrast | Enhancement with a central hyperintense fatty hilum [2] | Enhancement with a central black dot [2] |
It is important to distinguish metastatic SCC to SCG from retropharyngeal nodes to appropriately guide the surgeon intraoperatively. When looking for the SCG, it is imperative to divide the fascia posterior to the carotid sheath rather than dissecting behind the pharynx for retropharyngeal nodes.
The proposed pathophysiology of spread is perineural in origin, possible through the laryngopharyngeal branches of the superior cervical ganglion. In our patient, it is possible that disease had spread to this location before initial treatment, and that treatment with chemoradiation did not eradicate microscopic disease that recurred in this location.
Other authors have suggested that radiation therapy may induce a reaction in the SCG that may be mistaken for a lymph node. These authors presented the case studies of patients previously treated by radiation therapy for nasopharyngeal carcinoma, where salvage surgery for retropharyngeal disease correctly identified the SCG that was not involved by SCC [[2], [3]]. They describe a "central black dot" in the SCG, as opposed to a central fatty hilum seen in lymph nodes [2]. Histologically, the black dot represents interlacing neurites and vessels clustered in the central portion of the SCG [2].
Other disease processes that may occur in the SCG include primary nerve neoplasms that can be benign [4]or malignant [5] such as malignant nerve sheath tumors, and that can be recognized in the same way. Difficulties in preoperative biopsy require an individualized approach to treatment for each patient.
4. Conclusions
Jump to Section1. Introduction2. Materials and methods 2.1. Case 13. Discussion4. ConclusionsDisclosuresAcknowledgementsReferences
We have reported the first case of metastatic SCC to the SCG. We have outlined the pattern of spread, as well as the anatomical, radiographic and histopathological basis for diagnosis of this entity. The importance lies in distinguishing it from retropharyngeal lymph nodes, which can aid the surgeon in performing the appropriate operation.
Disclosures
Jump to Section1. Introduction2. Materials and methods 2.1. Case 13. Discussion4. ConclusionsDisclosuresAcknowledgementsReferences
None.
Acknowledgements
Jump to Section1. Introduction2. Materials and methods 2.1. Case 13. Discussion4. ConclusionsDisclosuresAcknowledgementsReferences
The authors wish to thank Jill Gregory for the artwork and the Mount Sinai Health System for research support.
References
Jump to Section1. Introduction2. Materials and methods 2.1. Case 13. Discussion4. ConclusionsDisclosuresAcknowledgementsReferences
- Debnam, J.M. and Guha-Thakurta, N. Retropharyngeal and prevertebral spaces: anatomic imaging and diagnosis. Otolaryngol. Clin. N. Am. 2012; 45: 1293–1310
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© 2017 Published by Elsevier Inc.
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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,