Female, 66 years old, with extensive history of multiply recurrent head and neck cancers, initially diagnosed as tongue cancer in 1991, status post multiple recurrences, including in 2011 at the tongue treated with left partial glossectomy, left neck dissection and radial forearm free flap reconstruction, and again in May 2015 at the right tongue, status post composite hemiglossectomy, marginal mandibulectomy, mandibular splitting, right neck dissection and ALT free flap. Patient now presents with rapidly growing dermal nodules in the neck and upper chest, biopsy proven as squamous cell carcinoma. Sequelae of extensive prior surgery are seen including right hemiglossectomy and floor of mouth dissection with soft tissue flap reconstruction; mandibular surgery with orthopedic fixation instruments in place; and bilateral neck dissection.A large enhancing mass with central necrosis is evident centered in the right floor of mouth, along the right lateral margin of the flap construct. This lesion measures up to 64 mm in the coronal plane, and up to 40 x 39 mm in the axial plane (see image 64 series 18, and image 26 series 16).This lesion extends superiorly along the medial surface of the mandible to the level of the retromolar trigone. There is questionable anterior extension from here into the right buccal space. The lesion extends inferiorly from the floor of mouth along the superficial cutaneous and subcutaneous tissues of the right neck. There may be infiltration of the sternocleidomastoid muscle and some of the strap muscles of the neck. Tumor extends deep to at least the level of the hyoid bone and thyroid cartilage.The soft palate and supraglottic mucosa is thickened and enhancing which may be inflammatory in nature. The supraglottic airway is displaced towards the left. No definite pathologic lymph nodes are seen within the neck, though scattered subcutaneous nodules are noted in the right lower neck which could represent metastatic lymph nodes. The right-sided neck vessels course along the posterior margin of the tumor and are not clearly encased by it.Marrow replacement and enhancement of the right mandible are nonspecific findings. Elsewhere, marrow signal characteristics are relatively unremarkable. A significant thoracic scoliotic curvature is partially visualized.
1.Extensive surgical findings are seen including evidence of hemiglossectomy and floor of mouth dissection with flap reconstruction, mandibular surgery, and bilateral neck dissection.2.A large centrally necrotic tumor is seen centered on the right floor of mouth. This lesion extends superiorly along the medial margin of the right mandible, reaching the retromolar trigone and potentially extending anteriorly into the buccal space. The tumor extends inferiorly along the cutaneous and subcutaneous tissues of the right lower neck, with deep invasion at least to the level of the hyoid bone and thyroid cartilage.3.Marrow replacement and enhancement of the right mandible is nonspecific but concerning for tumor involvement. The possibility of a treatment related or inflammatory process can also be considered.