Newly diagnosed base of tongue cancer status post bilateral tonsillectomy, biopsy: staging. There is an infiltrative heterogeneously enhancing mass centered in the right tongue base that measures up to approximately 45 mm. The tumor also extends into the oral tongue, floor of mouth, and across the glossotonsillar sulcus into the tonsillar fossa, perhaps slightly across the midline. There is no gross invasion of the pterygoid musculature or perineural tumor. There is an irregular right level 2A lymph node that measures 12 x 15 mm in axial cross-section. A right level 3 lymph node measures 9 x 14 mm. The left cervical lymph nodes are not particularly enlarged. The salivary glands are unremarkable. The osseous structures are intact. There is a subcentimeter left maxillary sinus retention cyst. The orbits and imaged intracranial structures are grossly unremarkable.
1. An infiltrative heterogeneously enhancing mass centered in the right tongue base that measures up to approximately 45 mm is compatible with squamous cell carcinoma. The tumor also extends into the oral tongue, floor of mouth, and across the glossotonsillar sulcus into the tonsillar fossa, perhaps slightly across the midline, although biopsy effects can confound the extend of disease. 2. At least one suspicious right cervical lymph node suspicious for metastatic disease and extracapsular extension, but no definite left cervical lymphadenopathy. PET may be useful for further staging.