Tumor Board 2007-064 96-04-16 Name : Chart No: Age: 43 Sex: F



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Tumor Board

2007-064 96-04-16
Name : Chart No: Age:43 Sex: F
Diagnosis:

Left submandibular gland adenoid cystic carcinoma s/p operation, s/p CCRT, with tongue base recurrence s/p operation, with liver metastasis, stage IVC
Initial present: numbness with hypogeusia over left anterior border of tongue for 2 years



P.H.

Underlying disease(-), A(-), B(-), C(-)

90

Tongue numbness for 2 yrs NTUH ENT OPD: mild tongue atrophy, left

90-12-03

Neck CT: small LNs in neck, bilateral

91-03-01

Extirpation of Lt submandibular gland Patho(S0204744): adenoid cystic carcinoma, with peripheral n. invasion

91-03-22

Regional neck dissection, Lt Patho(S0206619):

Lt lingual n. metastatic adenoid cystic carcinoma

Soft tissue, neck, mets(+), (section margin involvement)

Skin, LN(6/6), Lt hypoglossal n. no mets



91-09-09

Neck CT: prominent low density at Lt mouth floor r/o post-radiation change

92-07-30

Neck MRI: post-op change at Lt tongue base

95-08-31

Lt mouth floor tumor for 6 months, neck MRI: r/o recurrent tumor (to be presented)

95-09-14

Excision of Lt mouth floor tumor Patho(S0625743): adenoid cystic carcinoma, recurrent (the section margins are very close)

95-12-11

Neck MRI: post-op change

96-03-02

Whole body PET: multiple CT hypodensed lesions in liver

96-03-27

Liver biopsy(S0708685): metastatic adenoid cystic carcinoma


Local findings:

2007-64

Image:


2001-12-03  

Neck CT without/with contrast enhancement shows


1. bil. submandibular and parotid glands appear normal
2. several small LNs at bil. submandibular, carotid and posterior cervical spaces.
3. no abnormal skull base destruction.
2002-09-09  

Neck CT with contrast enhancement shows


1. s/p left submandibulectomy
2. prominent low density change at left mouth floor, which could be post-radiation change. suggest F/U study 
2003-07-30  

MRI of neck without and with intravenous contrast enhancement shows:


> post-op change at left tongue base with increased volume which reveals fat transformation. No definite abnormal enhancement is detected. Please correlate with the clinical information and suggest f/u.
> Nonspecific small LNs are present at bilateral carotid space and right anterior cervical triangle.
> Nasopharynx are essentially intact.
> No definite evidence of intracranial abnormal SI or enhancement.
> MRA reveals essentially intact extracranial and intracranial vessels.  

Imp: Post-op change. 


2006-08-31  

MRI of the neck without and with i.v. chelated Gd contrast medium enhancement shows:


1. Post-op change of the left tongue, pharynx and neck.
2. There is focal irregular lesion (2.3x1.3x1.1) with low SI on T1WI, slightly high SI on T2WI and enhancement at left tongue base. That could be recurrent tumor or fibrosis.
3. No enlarged neck lymph node.
4. R/T change with fatty replacement of the marrow at skull base and C spine.  

Imp: Post-op, r/o recurrent tumor.


2006-12-11  

MRI of the neck without and with i.v. chelated Gd contrast medium enhancement shows:


1. Post-op change of the left tongue which is deformed and parenchymal loss, pharynx and neck desscting on the left.
2. The focal irregular lesion (2.3x1.3x1.1) with low SI on T1WI, slightly high SI on T2WI and enhancement at left tongue base shown in prior study, which is no more seen on current
study.
3. No enlarged neck lymph node.
4. R/T change with fatty replacement of the marrow at skull base and C spine.
5. thickening mucosa of paranasal sinuses.
6. no organic lesions detected at the nasopharynx.  

Imp: left oral tumor ,post-op. change.


2007-03-02  

NUCLEAR MEDICINE STUDY: Whole body Positron Emission Tomography (PET).


RADIOPHARMACEUTICAL : Intravenous 10 mCi 18FDG.
CLINICAL HISTORY: Left submandibular gland adenoid cystic carcinoma with lingual nerve invasion s/p dissection and CCRT, recurrence s/p excision.
SCINTIGRAPHIC FINDINGS:
Whole body PET from vertex of the skull to mid thighs was performed 45 minutes after intravenous injection of 2-[Flurorine-18]fluoro-2-deoxy-D-glucose(FDG).The computer reconstructed images disclosed:
* Multiple CT hypodensed lesions in liver with FDG isometabolism (Fig. 7,8, SUV=1.8-2.0) or hypermetabolism (Fig. 4,5, SUV=3.7-5.3)
* A focal FDG hypermetabolic area at right side uterus (SUV=10.5, Fig.6).
* Mild hot areas at right mastoid region (SUV=2.8, Fig.1), right oropharyngeal wall (SUV=2.8, Fig.2) and left mandible (SUV=3.0, Fig.3).

* SUV: standard uptake value.

Imp: 1. Probable multiple metastastic lesions in liver. 2. probably physiological uptake in the menstration cycle or myoma in the uterus. Suggest GYN workup if clinically indicated. 3. Probably post-therapy inflammation at right mastoid, right oropharyngeal and left mandibular regions.
2007-03-28  

Chest,Abdomen,Pelvis CT without/with enhancement showed


1.Clinical Hx: Submandibular galnd adenoid cystic carcinoma, operated, s/p CCRT, with recurrence.
2.multiple heterogeneous hypodense tumors in both hepatic lobes, some with target appearance, metastasis is considered first.
3.multiple small hypodense lesions of both kidneys, renal cysts is considered first, suggest correlation with US and F/U.
4.bil ovarian small cysts.
5.well distension of urinary bladder with smooth wall.
6.anteverted uterus without definite abnormal density or enhancement.
7.no definite inguinal or iliac LAP.
8.no definite mediastinal LAP.
9.no definite pleural effusion.
10.multiple small round nodules and ill-defined consolidations in both lungs, metastasis is suspected.

Imp: Multiple metastasis in both hepatic lobes, and suspicious in both lungs.


Discussion

Ap柯: 會排PET是因為病人lip一直在麻,懷疑inferior alveolar n.來的. Liver mets 是意外發現。Meta大部分以lung比較多,liver的meta比較少,一般第九第十年才distant mets



Dr洪: 國外有幾個liver mets的case report, 大部分看到還是lung, 我們有一個6個病人的study, PET uptake都蠻強的,他的uptake較低,位置在liver,比較奇怪,所以才建議biopsy

Asp 婁: 之前有遇到palatal和tongue base的adenoid cystic carcinoma各一例


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