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American Head & Neck Society
July 21-25, 2012
Metro Toronto Convention Centre
Toronto, ON, Canada


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READING THE FINE PRINT ON PET/CT INTERPRETATION: AN UNUSUAL PRESENTATION OF METASTATIC ORAL CAVITY SQUAMOUS CELL CARCINOMA

Presentation: P095
Topic: Larynx/Oral Cavity
Type: Poster
Date: Sunday - Tuesday, July 22 - 24, 2012
Session: Designated Poster viewing times
Authors: Nicole M Hsu, MD, David I Kutler, MD, William I Kuhel, MD, Andrew M Schreiner, MD, Marc A Cohen, MD
Institution(s): New York Presbyterian Hospital – Weill Cornell Medical College. New York, NY.

Introduction: The incidence of non-lymphatic distant metastasis has been reported in up to 11% of cases of head and neck squamous cell carcinoma (HNSCC). The lungs are the most common site of distant metastases, followed by bone, liver, skin, and mediastinum. Distant soft tissue metastasis from HNSCC is exceedingly rare with only isolated cases or limited case series reported in the literature. Furthermore, parameters for assessing distant metastasis using PET/CT, are unclear and have not been adequately studied. We report an unusual case of a 60-year-old patient with floor of mouth squamous cell carcinoma (SCC) metastasizing to the subcutaneous tissue of the left lower extremity.

Case description: A 60-year-old man with history of left floor of mouth SCC initially diagnosed in August 2010 underwent definitive chemoradiation therapy at an outside institution. He presented with residual versus recurrent disease at the primary site less than one year after treatment. On preparation for potential salvage surgery, the patient underwent a PET/CT scan which revealed FDG avidity at the primary site, as well as a hypermetabolic 2 cm left level II lymph node and 1.8 cm left upper lobe pulmonary nodule. On extensive review of the PET images, an incidental 8mm FDG avid subcutaneous soft tissue nodule of the left lower posterior thigh. This nodule not previously noticed by the patient, and there was no musculoskeletal pain, surrounding tenderness, or overlying skin changes of the left posterior thigh noted on examination. An ultrasound-guided FNA biopsy of the left thigh nodule was performed and cytologic examination revealed SCC with morphology consistent with the primary oral cavity SCC.

Discussion: Distant soft tissue metastasis from HNSCC is extremely rare. Previous reports of patients with distant soft tissue metastases have indicated these patients presented with pain and discretely palpable masses at the metastatic sites. While there have been reports of isolated muscular metastases managed with surgical excision, the presence of soft tissue metastases is typically associated with poor prognosis because they generally occur in the setting of systemic spread. Our patient’s presentation was unusual in that he was unaware of his lower thigh nodule until it was detected on the PET scan. This scenario highlights the importance of examining hypermetabolic foci identified on PET/CT scans. Although small areas of hypermetabolic activity may be non-specific and secondary to various other etiologies, such as inflammation or infection, it is essential to investigate areas of FDG avidity to evaluate for possible metastatic disease in HNSCC.

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