Lateral Retropharyngeal Nodes Research Articles

Knowing nodal Rouviére: the power of human intelligence in toxicity reduction.

Patients with nasopharyngeal carcinoma (NPC) represent a distinct group of head and neck cancer patients. They are often non-smokers, non-drinkers, and on average 10 to 20 years younger than those with cancers of other head and neck sites. Given good baseline health status and the effectiveness of contemporary treatment [1], patients with NPC typically have long projected life expectancies and commonly develop late treatment adverse effects, such as dysphagia and swallowing dysfunction. Delineation and coverage of microscopic disease within the clinical target volume (CTV) are crucial in head and neck radiation treatment planning. The retropharyngeal lymph node (RPLN) is the first echelon nodal drainage for NPC. RPLN represents a special entity as they are usually not clinically detectable. Their diagnosis is based on computed tomography (CT) and magnetic resonance imaging (MRI). RPLN was identified almost one hundred years ago. French anatomist Henri Rouviére (1875-1952), through his extensive work in the delineation and classification of human lymph nodes using fresh cadavers, identified a set of lymph nodes in the lateral retropharyngeal space (RPS) [2]. These lateral RPLNs were later named nodes of Rouviére. The nodes of Rouvière, along with the medial RPLN, form the retropharyngeal nodal group, which is located within the RPS. Above the level of the hyoid, RPS contains RPLN and adipose tissues. At the infrahyoid level, the RPS contains only adipose tissues. It is a common practice to delineate the entire RPS up to the level of the hyoid as a CTV target. In this era when technology dominates the field of oncology, tremendous resources have been invested in the development of high-tech radiation delivery machines and pharmaceuticals. Much less effort has been put into the artistry of oncology, such as refining the delineation of target volumes in radiation planning, albeit a significantly less cost-effective and labor-intensive approach [3-6]. Recently, Mao et al. [7], in a multicenter randomized phase III trial, demonstrated how sparing of the medial retropharyngeal nodal group alone in radiation planning – a process that solely relies on human intelligence without any additional human effort or technological resources – results in 39% reduction in ≥ grade one clinician-rated acute dysphagia and 24% reduction in ≥ grade one weight loss. In addition, there was a significant improvement in patient-reported quality-of-life outcomes at 3 years, such as global health status, role-social function and swallowing function. No recurrence was observed in the medial RPLN sparing group. After adjusting for covariates, the regional relapse-free survival rates were similar in medial RPLN sparing and the medial RPLN non-sparing groups [7]. In the study by Mao et al. [7], utilizing the medial RPLN sparing approach, the mean dose to the middle pharyngeal constrictors decreased from 54 Gy to 49 Gy. Why would such a mild decrease in dose result in such modest improvement in clinician- and patient-rated swallowing function? It is a common misunderstanding that swallowing dysfunction from radiation is a direct result of muscle damage. The neural contribution of swallowing dysfunction is commonly overlooked. By sparing pharyngeal constrictor muscles, one also inevitably spares the pharyngeal nerve plexus, which lies on the posterior surface of the middle pharyngeal constrictor muscle. The pharyngeal nerve plexus contains fibers of cranial nerves IX, X, and superior sympathetic ganglion - the main sensory and motor nervous supply of the pharynx. Objective assessment of swallowing function using video fluoroscopic swallow study or high-resolution manometry of pharyngeal swallow pressure would help us to define the objective outcome of this medial RPLN and pharyngeal plexus sparing approach. Developmentally, medial RPLN undergoes atrophy before puberty, and it usually disappears by the age of 5. Lateral RPLN, however, persists in adulthood. Tumor involvement of the medial RPLN is very rare [8]. In a study of 3,100 newly diagnosed NPC, using contemporary MRI techniques, medial PRLN involvement was only identified in 0.2% of the patients, and they were all located at the level of the second or third cervical vertebra [8]. The group by Mao et al. [7], by leveraging and transferring the knowledge of lymphatic development and pattern of tumor spread – human intelligence – into clinical treatment planning and toxicity reduction. Much of the practice in medicine is based on myth and tradition. In the field of radiation oncology, it is common for clinicians to follow the one-size-fits-all rule by following national or protocol guidelines without understanding patterns of tumor spread or employing the-bigger-the-better approach while believing that a larger CTV would result in improved local control. It is not until we combine human intelligence with technological advancements will we see improved tumor control and quality of life in our patients. Annie W. Chan contributed substantially to the conception and drafted the article. The author has nothing to report. The author declares no conflicts of interest. Not applicable. Not applicable. Not applicable. Not applicable.

Medial retropharyngeal nodal region sparing radiotherapy versus standard radiotherapy in patients with nasopharyngeal carcinoma: open label, non-inferiority, multicentre, randomised, phase 3 trial

ObjectivesTo address whether sparing the medial retropharyngeal lymph node (MRLN) region from elective irradiation volume provides non-inferior local relapse-free survival versus standard radiotherapy in patients with nasopharyngeal carcinoma.DesignOpen-label, non-inferiority, multicentre,...

Long-term survival outcomes and recurrence patterns of olfactory neuroblastoma: A 13-year experience at a single institution

Objectives: Olfactory neuroblastoma (ONB), also known as esthesioneuroblastoma, is a rare malignant neoplasm of the nasal vault and anterior skull base. The results of treatment for ONB are relatively good; however, regional and distant metastases can develop several years after definitive treatment. This study aimed to validate the treatment modality of ONB for oncological outcomes, especially for regional recurrence.Methods: We retrospectively reviewed the medical records of 22 patients diagnosed with ONB at Kyoto University Hospital between 2009 and 2020. Descriptive statistics were calculated, and Kaplan–Meier curves were used.Results: The median follow-up time was 58.2 months. One (4.5%) patient was clinically node positive, (cN+) and the remaining 21 (95.5%) were clinically node negative (cN0) at presentation. Eighteen patients underwent an endoscopic endonasal approach (EEA) for primary resection, and the remaining four patients underwent a combined EEA and transcranial approach. Elective neck dissection was not performed for 21 patients with cN0 ONB, whereas unilateral neck dissection with removal of ipsilateral lateral retropharyngeal node was performed for one patient with cN+ ONB. Postoperative radiotherapy without concurrent chemotherapy was performed only at the primary tumor bed for 21 patients with cN0 ONB, and at the primary tumor bed and bilateral neck for one patient with cN+ ONB. The 5-year overall, disease-specific, and disease-free survival rates were 94.1%, 100%, and 69.6%, respectively. No patients developed local recurrence, but 6 (27.2%) patients experienced recurrence with a median time to recurrence of 36.4 months, including four and two patients who initially developed regional recurrences and bone metastases, respectively. Five (22.7%) patients had delayed neck recurrence. The salvage rate was only 60.0% in the five patients who had delayed neck recurrence. Regarding the level of delayed neck recurrence, 4 (18.2%) patients had lateral retropharyngeal lymph node metastases.Conclusion: Patients with ONB have excellent survival outcomes after endoscopic surgical resection of the primary lesion with postoperative radiotherapy only to the primary tumor bed. Despite excellent survival, delayed neck recurrence, including the lateral retropharyngeal lymph node, remains high. Because salvage surgery for lateral retropharyngeal lymph node recurrence is sometimes technically difficult, it may be better to extend the field of postoperative radiotherapy from the primary tumor bed only to include bilateral lateral retropharyngeal lymph node regions in patients with clinically N0 ONB. Further prospective studies with a large number of patients are needed to determine the extent of postoperative radiotherapy.

Verification of the Efficacy of New Diagnostic Criteria for Retropharyngeal Nodes in a Cohort of Nasopharyngeal Carcinoma Patients.

Purpose: A multistage approach to diagnose lateral retropharyngeal nodes (LRPNs) of nasopharyngeal carcinoma (NPC) had been proposed and warranted for validation.Methods: Between 2012 and 2017, the patients with newly diagnosed NPC were enrolled. The responsive nodes or those that progressed during follow-up were positive. The criteria for the multistage approach delimited LRPNs with a minimal axial diameter (MIAD) ≥ 6.1 mm were assessed as positive and if the mean standard uptake value ≥ 2.6, or if the maximal coronal diameter ≥ 25 mm and maximal axial diameter ≥ 8 mm with nodes MIAD < 6.1 mm were also considered as positive. The outcomes were compared with the MIAD cutoff value ≥ 6 mm (traditional method). A chi-squared test was used to compare two areas under the curve of the receiver operating characteristic curves.Results: A total of 67 eligible NPC cases and 155 LRPNs (72 positive and 83 negative) were analyzed. The accuracy, specificity, and sensitivity of the traditional method were 0.91, 0.93, and 0.89, respectively. The values for the multistage approach all reached 0.94. The area under the curve was significantly greater for the multistage approach compared with the traditional method (p = 0.023).Conclusion: The results support the advantage of the multistage approach.

Biopsy and Tracheobronchial Aspirates as Additional Tools for the Diagnosis of Bovine Tuberculosis in Living European Bison (Bison bonasus).

Simple SummaryIn this study, additional methods of collecting material for bovine tuberculosis diagnosis in living European bison were introduced. We showed a potential usage of tracheobronchial aspirates and ultrasound-guided biopsies from lateral retropharyngeal lymph nodes in living animals for diagnostics. We confirmed that the isolation of Mycobacterium caprae in living European bison is possible, as is the respiratory shedding of viable M. caprae in this host. This study is important as tuberculosis is a real threat for European bison which is an endangered species and the improvement of diagnostics can help with better health monitoring and further restitution. The diagnosis of bovine tuberculosis (BTB) in living wildlife remains a complex problem, and one of particular importance in endangered species like European bison (Bison bonasus). To identify infection and avoid the unnecessary culling of such valuable individuals, current best practice requires the collection and culture of material from living animals, as mycobacteria isolation remains the gold standard in BTB diagnosis. However, such isolation is challenging due to the need for the immobilization and collection of appropriate clinical material, and because of the sporadic shedding of mycobacteria. In the present study, we evaluated the potential of sampling for the detection of BTB in a group of seven living European bison suspected of being infected with Mycobacterium caprae. The specimens were collected both as swabs from the nasal and pharyngeal cavities, tracheobronchial aspirates (TBA), ultrasound-guided biopsies from lateral retropharyngeal lymph nodes, and post mortem, from mandibular, retropharyngeal and mediastinal lymph nodes. Clinical samples were tested for mycobacterial species via mycobacteriological culture and PCR. M. caprae was isolated from collected material in two out of four living infected individuals (TBA, biopsy) and mycobacterial DNA was detected in three out of four (TBA, pharyngeal swab) bison. This is the first report of isolation of M. caprae in living European bison. Our findings demonstrate the value of diagnostic tests based on both molecular testing and culture in European bison and confirm the respiratory shedding of viable M. caprae in this host species.

Lateral retropharyngeal lymph node metastasis in oral squamous cell carcinomas: a review of the Japanese literature

Lateral retropharyngeal lymph node metastasis in oral squamous cell carcinomas: a review of the Japanese literature

False Identity: Lymphoid Hyperplasia Imitating a Large Paraganglioma.

The danger of the parapharyngeal space mass comes from the small space and vital neighboring structures. Its differential diagnosis is broad, however benign lymphoid hyperplasia in this region has not been previously reported. The clinical presentation, imaging, surgical findings and pathology slides were reviewed in an adult patient with a parapharyngeal space mass. The literature on somatostatin-positive parapharyngeal space lesions was reviewed. A 51-year old male with otalgia for 3months, hearing loss, and tinnitus underwent audiogram, revealing asymmetric hearing loss. Laryngoscopy demonstrated a paretic true vocal cord. Subsequent MRI demonstrated 4.5cm post-styloid parapharyngeal space mass displacing the carotid artery anterolaterally. Octreoscan scan showed significant uptake of the somatostatin analog. Angiogram showed prominent vascular blush. The mass was excised transcervically and histopathology demonstrated lymphoid hyperplasia. This case demonstrates that post-styloid parapharyngeal masses may be lateral retropharyngeal nodes. An octreotide-positive lymphoid hyperplasia has never been previously reported.

Abstract: Swallowing Outcomes of Hypopharyngeal Reconstruction with Free Jejunal Flap - Retrospective Statistical Analysis of 83 Consecutive Cases in Japanese Single Institution -

INTRODUCTION: Total pharyngo-laryngo-esophagectomy (TPLE) and free jejunal flap (FJ) reconstruction has been a widely used procedure for extensive hypopharyngeal or laryngeal cancer. There are several reports that assess swallowing outcomes of hypopharyngeal reconstruction with FJ flap. Pre/postoperative irradiation, chemotherapy and resection of lateral retropharyngeal (Rouviere) lymph nodes are known factors to influence postoperative swallowing outcomes in Caucasian people. However, to date, little is known regarding the influential factors in Asian people. In the current report, we retrospectively analyze postoperative functional outcome of patients in one institution in Japan and statistically assessed influential factors for swallowing outcome. PATIENTS and METHODS: From January of 2007 to October of 2017, 83 cases that underwent FJ transfer for hypopharyngeal reconstruction in Nagoya University hospital are included in the study. The patients were 58 males and 25 females, with a mean age at the operation of 66.2 years. Indication for the operation included 67 hypopharyngeal cancers, 10 laryngeal cancers and 6 esophageal stenoses due to irradiation or operative scar formation. Pre/postoperative chemoradiotherapy, operative technique as well as postoperative complication are listed for possible influential factors associated with postoperative outcomes. Swallowing functions were extracted from medical records. Statistical analysis was performed utilizing (SAS 9.4, SAS Institute, United States), and univariate regression analysis as well as multivariate regression analysis were performed. P value under 0.05 was considered as statistically significant. RESULTS: FJ flap failure resulted from venous thrombosis in one patient and was rescued with staged pectoralis major flap transfer. 3 months post-operatively, 55.6 % of patients could tolerate normal diet. This rate was 66.1 % at 6 months and 76.9 % at 12 months after the operation. Anastomotic stapler was found to be a risk factor for dysphagia at 3 and 6 months postoperatively, but was not a risk factor at 12 months. Neither preoperative nor postoperative radiotherapy was found to be risks for dysphagia. DISCUSSION: Swallowing outcome is a result of a complex relationship of multiple factors such as age, pre/postoperative chemoradiotherapy, surgical intervention and rehabilitation. In this study, the anastomotic stapler was found to be a risk factor for dysphagia in the early postoperative phase; however, this relationship disappeared at one year. Balloon dilation procedure or rehabilitation might have improved the outcome during the course. These analysis may help to improve operative procedure to achieve best postoperative functional outcome.

Lateral retropharyngeal lymph node metastasis from squamous cell carcinoma of the upper gingiva: A case report.

Lateral retropharyngeal lymph node (LRPLN) is located between the internal carotid artery and the prevertebral muscles. Metastasis to the LRPLN is frequent in nasopharyngeal cancer, but is rare in oral cancer. The prognosis of patients with oral cancer with LRPLN metastasis is usually poor. The present study reported a patient with LRPLN metastasis from squamous cell carcinoma of the upper gingiva, who survived for >7 years. Docetaxel, cisplatin and fluorouracil (TPF) therapy was performed as induction chemotherapy and it was planned to subsequently conduct chemoradiotherapy or surgery. As the tumor only exhibited a transient response to TPF, surgery was selected. Postoperatively, only radiotherapy was performed and a favorable outcome was achieved.

Upper bound of IIb region in clinical target volume for intensity-modulated radiotherapy for nasopharyngeal carcinoma

Objective To explore the upper bound of Ⅱb region in the clinical target volume (CTV) for intensity-modulated radiotherapy (IMRT) for nasopharyngeal carcinoma (NPC), and to establish a standard for personalized reduction in the range of Ⅱb region. Methods A retrospective analysis was performed on the IMRT results of 142 patients newly diagnosed with NPC who were admitted to our hospital from 2012 to 2014. According to the American Joint Committee on Cancer 2010 staging system, there were 8 patients with stageⅠ disease, 37 stage Ⅱ, 41 stage Ⅲ, and 56 stage Ⅳ. The distribution pattern of cervical lymph nodes in NPC was studied based on the imaging results. Comparison of the dose to parotid glands between patients with and without reduction in the range of Ⅱb region was made by t test and t' test. Results The metastasis rates of the most common diseased lymph nodes, lateral retropharyngeal lymph node and Ⅱb lymph node, were 75.4% and 67.6%, respectively. In the patients with metastases in Ⅱb region, 51.0% had high-risk positive lymph nodes and 6.3% had positive lymph nodes beyond the upper bound of Ⅱb region defined by the Radiation Therapy Oncology Group system. It was safe to narrow down Ⅱb region in patients who met the formulated standard. The D50 and V26 values for parotid glands were significantly reduced after optimization of CTV (P=0.000). Conclusions The upper bound of Ⅱb region, in principle, should reach the lateral skull base during the delineation of the cervical CTV for NPC. In order to protect the parotid glands, however, personalized reduction in the upper bound of Ⅱb region is recommended for patients who meet the formulated standard. Key words: Nasopharyngeal neoplasms/intensity-modulated radiotherapy; Clinical target volume; External expansion margin

Can Parameters Other than Minimal Axial Diameter in MRI and PET/CT Further Improve Diagnostic Accuracy for Equivocal Retropharyngeal Lymph Nodes in Nasopharyngeal Carcinoma?

PurposeMinimal axial diameter (MIAD) in magnetic resonance imaging (MRI) was recognized as the most useful parameter in diagnosing lateral retropharyngeal lymph (LRPL) nodes in nasopharyngeal carcinoma (NPC). This study aims to explore the additional nodal parameters in MRI and positron emission tomography–computed tomography for increasing the prediction accuracy.Materials and MethodsA total of 663 LRPL nodes were retrospectively collected from 335 patients with NPC. The LRPL nodes ascertained on follow-up MRI were considered positive for metastases. First, the optimal cutoff value of each parameter was derived for each parameter. In addition, neural network (NN) nodal evaluation was tested for all combinations of three parameters, namely MIAD, maximal axial diameter (MAAD), and maximal coronal diameter (MACD). The optimal approach was determined through brute force attack, and the results of two methods were compared using a bootstrap sampling method. Second, the mean standard uptake value (NSUVmean) was added as the fourth parameter and tested in the same manner for 410 nodes in 219 patients.ResultsIn first and second analysis, the accuracy rate (percentage) for the MIAD was 89.0% (590/663) and 89.0% (365/410), with the optimal cutoff values being 6.1 mm and 6.0 mm, respectively. With the combination of all three and four parameters, the accuracy rate of the NN was 89% (288/332) and 88.8% (182/205), respectively. In prediction, the optimal combinations of the three and four parameters resulted in correct identification of three (accuracy: 593/663, 89.4%) and six additional nodes (371/410, 90.5%), representing 4% (3/73) and 13.3% (6/45) decreases in incorrect prediction, respectively.ConclusionNPC LRPL nodes with an MIAD ≥ 6.1 mm are positive. Among nodes with an MIAD < 6.1 mm, if the NSUVmean ≥ 2.6 or MACD ≥ 25 mm and MAAD ≥ 8 mm, the nodes are positive; otherwise, they are negative.

外側咽頭後リンパ節転移に対し同時化学放射線療法が著効した舌扁平上皮癌の1例

舌扁平上皮癌における外側咽頭後リンパ節（ルビエールリンパ節；以下RN）転移はきわめてまれであり，予後は不良である。今回われわれは舌扁平上皮癌のRN転移に対して同時化学放射線療法（concurrent chemoradiotherapy；以下CCRT）が著効した1例を経験したので報告する。 患者は59歳男性。左側舌縁部の疼痛を主訴に当科を受診した。生検の結果は扁平上皮癌で，T2N1M0，stageⅢと診断した。左側選択的頸部郭清術，舌可動部半側切除術および前腕皮弁による即時再建術を施行した。術後4か月の画像検査にて左側オトガイ下リンパ節に転移を認め，左側オトガイ下部および右側肩甲舌骨筋上頸部郭清術を施行した。術後27日目よりシスプラチン（CDDP）の総投与量200mg/m2および2Gy/回で計60Gyの放射線照射によるCCRTを開始した。8Gy照射後のCTおよびPET-CTにてRN転移を認めたため，RNを照射野に含めた。CCRT終了後1か月の画像検査ではRNの不明瞭化を認め臨床治療効果はCRであった。現在，CCRT終了後29か月経過しているが腫瘍の再発，転移等認めず経過良好である。

Magnetic Resonance Imaging Findings in Childhood Period Nasopharynx Cancer.

SummaryBackgroundNasopharyngeal carcinoma is a rarely seen tumor in childhood. It is mostly detected late as the clinical features are similar to other childhood tumors which affect the nasopharynx and adenoidal hypertrophy. Therefore, the radiological features of childhood tumors of the nasopharynx must be well known. The aim of this study was to investigate the contribution of MR imaging features of childhood nasopharynx cancer.Material/MethodsThe study included 10 nasopharyngeal carcinoma patients under the age of 18 years who presented at hospital between February 2008 and March 2014 and who had tissue diagnosis and MRI of the nasopharynx region. The MRI scans were evaluated by two radiologists. Loco-regional spread, asymmetry, signal intensity of the tumors, and lymph nodes were evaluated.ResultsIn all the patients there was a mass which narrowed the nasopharynx. In all cases, unilateral mastoid opacification was observed. In 9 cases (90%), parapharyngeal extension was found. In 8 cases (80%), the mass showed an extension into the nasal cavity or oropharynx. In 5 cases (50%), there was an involvement of the skull base. In 3 patients (30%), an extension to the masticator space and pterygopalatine fossa was found. There were enlarged cervical lymph nodes bilaterally in 10 cases (100%). In 4 cases (40%), a lateral retropharyngeal lymph node was detected.ConclusionsChildhood nasopharyngeal cancers are often diagnosed at an advanced stage. MR imaging can be helpful in diagnosis and differential diagnosis of childhood nasopharynx cancer from other diseases of the nasopharynx.

Partial Volume Correction for Equivocal Retropharyngeal Nodal Metastases of Nasopharyngeal Carcinoma with Fluorodeoxyglucose Positron Emission Tomography–Computed Tomography

The objective of this study is to determine the size range where the recovery coefficient (RC) method of fluorodeoxyglucose (FDG) positron emission tomography–computed tomography (PET–CT) is helpful in detecting lateral retropharyngeal lymph (LRPL) nodal metastases of nasopharyngeal carcinoma (NPC) patients previously treated with radiation therapy. A total of 142 LRPL nodes assessed by magnetic resonance imaging (MRI) in 71 NPC patients were chosen for investigation. LRPL nodes with central necrosis, extracapsular invasion, or asymmetric grouping or those ascertained on follow-up MRI scans were considered positive for metastases. The criterion for positive diagnosis of nodal metastasis on FDG PET–CT scans was defined as maximal standard uptake value (SUVmax) ≥ 2.5. Nodes not separated from main tumors were excluded. An established RC method, the sphere-to-background ratio, was employed. Nodes were further categorized into three groups of minimal axial diameters: below 6, 6–7 mm, and above 7 mm. A total of 88 nodes were examined by FDG PET. Thirty-five nodes were positive and 53 nodes were negative. The RC method significantly improved sensitivity (from 20 to 100 %) and accuracy (from 14 to 71 %) for nodes sized 6–7 mm. In LRPL nodes above 7 mm, the RC method also provided slight improvement, with sensitivity and accuracy both increasing from 92 to 96 %. However, the nodal sizes below 6 mm were too small for valid comparisons. In conclusion, partial volume correction in FDG PET–CT enhances the accuracy of detecting nodes in the equivocal size range of 6–7 mm for LRPL nodal metastases of NPC.

Genotypic characterization by spoligotyping and VNTR typing of Mycobacterium bovis and Mycobacterium caprae isolates from cattle of Tunisia

This work is an approach to the molecular epidemiology of Mycobacterium tuberculosis complex (MTBC) bovine infections in Tunisia. A total of 35 MTBC isolates from both lateral retropharyngeal lymph node samples of cattle slaughtered in different Tunisian regions were genotyped by spoligotyping and variable number tandem repeat typing (VNTR)-typing. Spoligotyping allowed to identify two profiles not previously registered, namely SB2024, a Mycobacterium caprae isolate from Nabeul Region (North East Tunisia), the first description of this species in the country, and SB2025 (Mycobacterium bovis) from Sfax Region (Southern Tunisia). A second M. caprae isolate with a spoligotyping profile previously described in Europe mainland, SB0418, was also isolated from a bovine of Sfax region. Both isolates suggest the possibility of a widespread distribution of this species in the country. The predominant spoligotype was SB0120, present in all Tunisian regions selected for the study but Nabeul. Molecular typing also allowed to describe a mixed infection caused by two different M. bovis isolates (SB0120 and SB0848) in the same animal. VNTR typing was highly discriminant by testing a panel of six loci. Loci QUB3232 and QUB11b were the most discriminant, whereas ETR-D and QUB11a had the lower diversity index. The value of allelic diversity can significantly vary among countries; thus, it is important to standardize a panel of loci for future inter-laboratory comparisons. Although VNTR typing proved to be useful for an efficient discrimination among MTBC isolates, especially in combination with spoligotyping, further studies are needed in order to assess the genetic diversity of the MTBC in Tunisia.

Castleman’s Disease Masquerading as a Large Paraganglioma

Objective: 1) To describe a case of Castleman’s disease with unusual clinical and radiographic presentation as a somatostatin-positive mass in the poststyloid parapharyngeal space (PPS). 2) To review the literature, which does not report Castleman’s disease of the PPS, somatostatin-positive disease, or disease resulting in cranial neuropathy. Method: The clinical presentation, imaging features, surgical findings, and pathology slides were reviewed in the case of an adult patient with a parapharyngeal space mass. The literature on Castleman’s disease was reviewed as was that on somatostatin-positive parapharyngeal space lesions. Permission was obtained from the patient to publish the findings. Results: A 51-year-old male with 3 months of otalgia, hearing loss, and tinnitus underwent audiogram, revealing asymmetric hearing loss. Laryngoscopy showed a paretic true vocal cord. Magnetic resonance imaging (MRI) showed a 4.5-cm poststyloid PPS mass displacing the carotid artery anterolaterally. Octreoscan scan showed a significant uptake. Angiogram showed prominent vascular blush and feeders from the occipital artery. The patient underwent preoperative embolization of arterial feeders to the mass. A transcervical approach was used to access and remove the mass. Final histopathology is consistent with Castleman’s disease. Our review of the literature did not identify previously reported cases of octreotide-positive lymphoproliferative diseases. Conclusion: This case demonstrates that poststyloid parapharyngeal masses in the medial portion of the parapharyngeal space may actually be lateral retropharyngeal nodes. Paragangliomas may also grow medially and present atypically and may be associated with vocal cord paralysis. This case is particularly unusual in that octreotide-positive Castleman’s has never been reported.

Retropharyngeal Lymph Nodes in Children: A Common Imaging Finding and Potential Source of Misinterpretation

The retropharyngeal lymph nodes are the least well-described portion of the Waldeyer ring. Originally described as occurring in medial and lateral groups, reports have described only the presence of lateral nodes in children. We have seen cases of MRI sleep studies in children with obstructive sleep apnea (OSA) in which lateral and medial retropharyngeal lymph nodes are present and have been misinterpreted. Our purpose is to describe the frequency and appearance of retropharyngeal lymph nodes in children with and without OSA. Axial and sagittal T2-weighted MRI scans were reviewed in 150 children with OSA and 150 control subjects without OSA, who underwent imaging for other indications. The presence, size, and location of the retropharyngeal lymph nodes were evaluated. Retropharyngeal lymph nodes were evaluated for frequency of medial nodes, frequency of lateral nodes, size as indicated by the anterior-to-posterior diameter, laterality (bilateral or unilateral), and superior-to-inferior location compared with the cervical vertebral body level. Analyses were performed using the chi-square or Fisher's exact test (for categorical data) and generalized linear model or two-sample Wilcoxon's Mann-Whitney test (for continuous data). Lateral retropharyngeal lymph nodes were common in both children with OSA (137/150 [91.3%]) and children without OSA (146/150 [97.3%]). Medial retropharyngeal lymph nodes occurred not uncommonly in both children with OSA (32/150 [21.3%]) and those without OSA (26/150 [17.3%]). Lateral retropharyngeal lymph nodes were more commonly bilateral (95% CI, 88.4-97.4%; p < 0.0001) and located at the skull base (C1) or C1-C2 level (99%; p < 0.0001). Medial retropharyngeal lymph nodes were more commonly unilateral (95% CI, 71.9-84.6%; p < 0.0004) and located at the C2-C3 level (95% CI, 78.13-84.62%; p < 0.0001). There were no statistically significant differences in the proportion of medial or lateral retropharyngeal lymph nodes in the OSA group compared with the control group. Retropharyngeal lymph nodes are seen commonly in children in both lateral (95% CI, 91.3-97.3%) and medial (95% CI, 17.3-21.3%) locations. Media nodes are present more frequently than previously described. Such nodes occur almost equally frequently in populations with and without OSA. Retropharyngeal lymph nodes should be considered normal in children and not be interpreted as abnormal or misdiagnosed.

Spread patterns of retropharyngeal lymph nodal metastasis of nasopharyngeal carcinoma

Objective To explore the spread patterns of retropharyngeal lymph node (RLN) metastasis of nasopharyngeal carcinoma. Methods From July 2003 to March 2005, three hundred and three patients with nasopharyngeal carcinoma in initial treatment were enrolled in this study. All patients underwent magnetic resonance imaging (MRI) before treatment, meanwhile measured the minimal and maximal axial diameters, the longitudinal diameter and the central and craniocaudad locations of each positive RLN. Results A total number of 264 positive RLN were found in 177 patients. The minimal and maximal axial diameters and longitudinal diameter of positive RLN were 9.9, 12.9 and 22.4 mm, respectively. Ipsilateral metastatic RLN were noted as follows: two nodes in 21 patients, three nodes in 3 patients and four nodes in 1 patient. According to the longitudinal central location of 263 positive lateral RLN, the numbers of nodes at occipital bone, C1, C1/C2, C2, C2/C3 and C3 were 27, 166, 40, 23, 5 and 2, respectively; the mean minimal axial diameters of nodes were 6.8, 9.9, 12.5, 10.4, 9.3 and 8.0 mm, respectively. Conclusion Multiple metastatic ipsilateral RLN are not common in NPC. The rate of RLN metastasis shows the trend of decreasing from vertebral C1 to C3.The maximal diameters of RLN are in the C1/C2 intervertebral space, and reveal a decreasing frequency along the craniocaudal directions of occipital and vertebral C1. Key words: Nasopharyngeal neoplasms; Diagnosis; Magnetic resonance imaging; Retropharyngeal lymph node; Metastasis

外側咽頭後リンパ節転移を生じた頬粘膜癌の2例と本邦報告例に関する文献的考察

外側咽頭後リンパ節転移を生じた頬粘膜癌の2例と本邦報告例に関する文献的考察

Metastasis to the lateral retropharyngeal lymph node from squamous cell carcinoma of the oral cavity: Report of three cases

Carcinoma of the oral cavity sometimes metastasizes to the lateral retropharyngeal lymph node (LRPLN), especially when posteriorly invading the soft palate or oropharynx. CT or MRI imaging has enabled detection of LRPLN metastasis in the early stage, but the prognosis of patients with metastasis to this node is extremely poor. The authors report three patients with squamous cell carcinoma of the oral cavity with no posterior invasion who developed metastasis to LRPLN during observation. The primary sites of these three cases were gingiva of the upper incisor region, gingiva of the lower premolar region, and maxillary bone of the upper incisor region. Each patient underwent surgery as their initial therapy, but a recurrent tumor in the LRPLN was detected by CT or MRI despite good loco-regional control. A salvage operation with postoperative radiation therapy was performed for two patients, but only one is still alive with no evidence of tumor 14 months after the last surgery. Management of LRPLN metastasis in oral cancer patients is a challenge for oral surgeons, but early detection by CT or MRI and surgery with postoperative radiation therapy is likely to yield the best local control.