Necrotic Cervical Lymph Node HPV-related Oropharyngeal Cancer MCQ — NEET PG Practice Question | NEETPGAI
Necrotic Cervical Lymph Node HPV-related Oropharyngeal Cancer
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A 54-year-old non-smoker with a 3-month history of painless right-sided neck mass presents to the ENT clinic. Oropharyngoscopy reveals an ulcerative lesion at the right palatine tonsil with extension to the base of tongue. Contrast-enhanced CT of the neck shows an enlarged level IIA lymph node measuring 3.4 cm with the feature marked **B** (central low-attenuation necrosis) and a thin peripheral rim of enhancement. FNAC demonstrates squamous cell carcinoma with P16 immunohistochemistry strongly positive. Which of the following best explains the clinical significance of the imaging finding marked **B** in this patient?
A. Central necrosis is pathognomonic for lymphoma and requires immediate chemotherapy without histologic confirmation
B. Central necrosis is a highly specific sign of metastatic squamous cell carcinoma and essentially confirms malignant involvement over reactive adenopathy
C. Central necrosis indicates a branchial cleft cyst and requires surgical excision rather than oncologic management
D. Central necrosis represents cystic degeneration of a benign lymph node and is commonly seen in patients over 40 years with viral infections
Explanation
Why "Central necrosis is a highly specific sign of metastatic squamous cell carcinoma and essentially confirms malignant involvement over reactive adenopathy" is right
The clinical anchor directly states that central necrosis in a cervical lymph node, particularly at level II in a patient with an oropharyngeal primary, is a highly specific sign of metastatic squamous cell carcinoma and must not be mistaken for other benign conditions. In this case, the presence of central low-attenuation necrosis (marked B) combined with a thin enhancing rim in a level IIA node adjacent to an oropharyngeal primary essentially confirms metastatic disease. This imaging finding, supported by FNAC showing squamous cell carcinoma with strong P16 positivity, establishes the diagnosis of HPV-associated oropharyngeal squamous cell carcinoma with cervical metastasis. Per Cummings Otolaryngology (7th Edition, Chapter 96), this necrotic pattern is the single most discriminating imaging feature distinguishing metastatic SCC from reactive adenopathy.
Why each distractor is wrong
Central necrosis indicates a branchial cleft cyst and requires surgical excision rather than oncologic management: The clinical anchor explicitly states that central necrosis must NOT be mistaken for a branchial cleft cyst in adults over 40. While branchial cleft cysts can appear cystic, they lack the thin enhancing rim and are typically seen in younger patients. This patient's imaging and histology confirm malignancy, not a developmental cyst.
Central necrosis represents cystic degeneration of a benign lymph node and is commonly seen in patients over 40 years with viral infections: Cystic degeneration in benign reactive nodes is not associated with the thin peripheral enhancement pattern seen here, nor does it correlate with a confirmed malignant primary lesion on oropharyngoscopy and FNAC. Reactive adenopathy does not show central necrosis.
Central necrosis is pathognomonic for lymphoma and requires immediate chemotherapy without histologic confirmation: While lymph node necrosis can occur in lymphoma, the presence of an oropharyngeal primary lesion with histologically confirmed squamous cell carcinoma and P16 positivity establishes the diagnosis as metastatic SCC, not lymphoma. The thin enhancing rim is more typical of metastatic carcinoma than lymphoma.
High-YieldNEET PG
Central necrosis in a level II cervical lymph node adjacent to an oropharyngeal primary is the single imaging feature that essentially confirms metastatic squamous cell carcinoma and mandates oncologic rather than surgical management.
Cummings Otolaryngology Head and Neck Surgery, 7th Edition, Chapter 96: HPV-Related Oropharyngeal Cancer
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