A 33-year-old man comes to the office due to trouble swallowing and a chronic sore throat. He has no chronic medical conditions and does not use tobacco or alcohol. Physical examination shows an enlarged, ulcerated right tonsil. Biopsy of the ulcerated lesion reveals infiltrating nests of moderately differentiated squamous cells. Immunohistochemistry is positive for p16, suggesting that the tumor is likely due to human papilloma virus. Further imaging studies for cancer staging are planned. This patient's tumor is most likely to spread first to which of the following locations?

Question

A 33-year-old man comes to the office due to trouble swallowing and a chronic sore throat.  He has no chronic medical conditions and does not use tobacco or alcohol.  Physical examination shows an enlarged, ulcerated right tonsil.  Biopsy of the ulcerated lesion reveals infiltrating nests of moderately differentiated squamous cells.  Immunohistochemistry is positive for p16, suggesting that the tumor is likely due to human papilloma virus.  Further imaging studies for cancer staging are planned.  This patient's tumor is most likely to spread first to which of the following locations?

Quizplus · Accepted Answer

Most carcinomas, including head and neck squamous cell carcinoma, spread first from the primary site of the tumor to regional lymph nodes via the lymphatics. In this patient with a tonsillar squamous cell carcinoma, this spread would be to the upper anterior cervical (ie, jugular) lymph nodes. Assessment of regional lymph node status is important for tumor staging based on the TNM staging system, which evaluates the size and characteristics of the Tumor, regional lymph Node involvement, and distant Metastases. (Choice A) Similar to the tonsils, adenoid tissue is also lymphatic tissue in the head and neck that can harbor a primary site of head and neck squamous cell carcinoma. However, it is located in the nasopharynx rather than the oropharynx. The spread of cancer is typically to regional lymph nodes rather than to other mucosal sites in the head and neck. (Choices B, C, and F) Although these are possible sites of distant cancer metastases, they are less commonly associated with metastatic head and neck cancer. Common primary sources for metastases to these sites include: However, the first site of spread of most carcinomas (including head and neck cancer) is the regional lymph nodes. (Choice E) The lung parenchyma is the most common site for distant metastases from head and neck cancer. However, regional lymph node spread is typically seen first. Educational objective: Head and neck squamous cell carcinomas typically spread first to the anterior cervical (ie, jugular) lymph nodes via the lymphatics. Distant spread occurs after regional lymph node involvement. __________ References: Incidence and sites of distant metastases from head and neck cancer. (http://www.ncbi.nlm.nih.gov/pubmed/11408812)

A 33-Year-Old Man Comes to the Office Due to Trouble