Positron‐emission tomography pitfalls related to oral prosthesis

This case report describes false‐positive positron‐emission tomography/computed tomography (PET/CT) findings related to oral prostheses and its implications in cancer surveillance. In head and neck cancer management, F18‐flurodeoxyglucose (FDG) PET/CT is widely accepted for evaluating treatment response and detecting recurrence. Interpretation of FDG PET/CT images in this setting is often challenging due to various prostheses and reconstruction methods. Following surgery for squamous cell carcinoma of the maxillary alveolus, a 61‐year‐old female had a FDG PET/CT scan on a 7‐month follow‐up that showed high FDG uptake along the resection site. Clinical examination showed no signs of inflammation or recurrence. Repeat FDG PET/CT without the prosthesis was normal. The PET/CT attenuation‐corrected images demonstrated high FDG uptake (standardized uptake value: 11.6) along the resection site corresponding to contrast‐enhanced CT images of the lesion. PET/CT nonattenuation‐corrected images also confirmed increased activity. Repeat PET/CT without the prosthesis was normal. FDG is not tumor specific; it can accumulate in inflammation, infection, and post‐therapy settings. Metallic and high‐density prostheses show radial artifacts on CT and falsely elevated FDG uptake on PET/ CT in adjacent areas. Salivary pooling may concentrate FDG. The presence of oral prostheses has not been described as a cause of this high level of activity. PET/CT images that demonstrate intense activity corresponding to dense structures should be viewed with caution. A detailed history and physical exam as well as knowledge of artifacts are pertinent for the managing physician. Laryngoscope, 2012     

经鼻内镜手术治疗硬脑膜外来源的海绵窦区肿瘤

目的探讨经鼻内镜切除硬脑膜外来源的海绵窦肿瘤的可行性,并介绍手术入路选择、海绵窦重要结构保护和出血控制。方法硬脑膜外侵犯海绵窦的肿瘤39例,其中为垂体腺瘤17例、鼻咽纤维血管瘤5例、神经鞘膜瘤6例、脊索瘤6例、腺样囊性癌2例、软骨瘤2例、纤维肉瘤1例。根据肿瘤原发的部位和范围,分别选择内镜下经鼻中隔经蝶、扩大鼻中隔经蝶、扩大上颌窦后壁、翼突根和鼻外上颌骨等入路切除肿瘤。结果33例肿瘤获得全切（全切率84．6％）;6例肿瘤获得次全切（次全切率15．4％）,无致残和致死性手术并发症。结论只要选择手术入路恰当,手术中保护海绵窦重要结构,采取合理的措施控制海绵窦出血,经鼻内镜切除硬脑膜外来源的海绵窦肿瘤是可行的。     

A case report of FSH-producing nasal ectopic pituitary adenoma extending to the frontal cranial fossa

We report the first case of an ectopic pituitary adenoma in the nasal cavity that produced follicle-stimulating hormone (FSH). A 60-year-old man complaining of left nasal bleeding had a polypoid tumor in the left nasal cavity. Findings of computed tomographic scanning and magnetic resonance imaging showed that the tumor originated from the olfactory cleft, occupied the nasal cavity, and extended to the frontal cranial fossa. Results of histologic examination suggested ectopic pituitary adenoma. Magnetic resonance imaging results showed the pituitary gland to be normal. Electron microscopy findings demonstrated a large number of secretory granules in the tumor cells that were positive for FSH on immunohistochemical analyses. Serum gonadotropin levels were normal, and no clinical signs of hypersecretory syndrome were noted. The above findings led us to establish the diagnosis of FSH-producing ectopic pituitary adenoma. The patient underwent craniofacial resection of the tumor followed by an uneventful recovery. The pathologic findings and clinical course of the case were comparable to those of FSH-producing adenomas arising from the pituitary gland.     

Transphenoidal endoscopic approaches for pituitary adenomas: a critical review of our experience

BackgroundThe surgical approach to the pituitary fossae has evolved from transcranial to sublabial and transseptal microscopic ones, up to the current transsphenoidal endoscopic approach.ObjectivesTo present our experience in the transnasal transsphenoidal approach for pituitary adenomas and the modifications introduced to improve tumoral resection and to lower iatrogenia.Material and methodsOver nine years, we operated on 37 patients with pituitary adenomas using the transsphenoidal endoscopic approach. We utilised optical lens of 0° (approach) and 30° (adenoma resection), optic navigator, surgical instruments for nasal endoscopic and pituitary surgery. During the neurosurgical step, the endoscope was fixed by an articulated arm. We acceded to the pituitary fossae by a bilateral sphenoidotomy.ResultsSphenoid pneumatisation was sufficient in all the patients. The more common postoperative complications were diabetes insipidus and endocrinology deficiencies. Postoperative rhinoliquorrhea affected only one patient. No alterations of nasal fossae were observed. Mean patient hospitalisation was five days.ConclusionsTranssphenoidal endoscopic approach guided by navigator gives significant advantages: Shorter operating time and fewer complications, greater safety and preservation of the nasal passages. Resecting the sphenoidal rostrum and a fragment of adjacent nasal septum improves surgical instrument management into the pituitary fossae and therefore adenoma resection. Endoscope fixation stabilises the vision and allows the second surgeon to help more effectively.     

鼻内镜脑垂体瘤手术

目的探讨鼻内镜脑垂体瘤手术的方法与疗效。方法鼻内镜单鼻孔蝶窦口入路手术治疗11例脑垂体瘤患者,其中生长激素瘤2例,泌乳素瘤2例,无功能腺瘤7例。11例患者均有不同程度头痛,泌乳异常2例,肢端肥大症2例,不同程度视力异常6例。结果11例患者均一次性切除脑垂体瘤,随访2年无复发,所有患者头痛症状消失,视力异常与泌乳异常恢复,肢端肥大症状无变化。术后1例患者出现短暂多尿现象,1例患者出现短暂脑脊液漏,经保守治疗均治愈。结论鼻内镜脑垂体瘤手术优点为微创、无面部切口、视野清晰、操作简单、安全有效且恢复快;不足之处在于单手操作,内镜容易被血液污染,出血较多时手术操作有一定困难。     

鼻内镜下鼻蝶入路垂体腺瘤显微切除术(附19例报告)

目的探讨鼻内镜下鼻中隔蝶窦入路垂体腺瘤切除术的方法及并发症的防止。方法唇龈沟切口鼻内镜下经鼻中隔蝶窦径路显微切除垂体腺瘤19例,16例微腺瘤施行全切,3例大腺瘤行囊内次全切除并用无水酒精烧灼,全部病人用唇筋膜和鼻中隔骨片重建鞍底。结果肿瘤全切除16例,次全切除3例。7例术前视力损害者6例得到不同程度的恢复,所有病例症状改善,术后除1例视力一过性减退和2例嗅觉一过性减退外,其余病例均无脑脊液漏和脑膜脑膨出等并发症。术后随访3~36个月,16例肿瘤无复发,3例次全切除者肿瘤生长缓慢。结论鼻内镜唇下-鼻中隔-蝶窦入路是切除垂体腺瘤的较理想径路,术中囊内烧灼可有效地防止或减缓术后肿瘤复发,术后唇筋膜和鼻中隔骨片重建鞍底可防止相应并发症。     

Endoscopic Sinus Surgery Using Intraoperative Computed Tomography Imaging for Updating a Three‐Dimensional Navigation System

Objectives: The use of three‐dimensional navigation systems provides information on the structures surrounding the field of operation and thereby reduces the risk of iatrogenic damage. The computed tomography (CT) data conventionally used are provided by preoperative scanning procedures, which means that tissue changes coming about during surgery are not seen on the screen. An intraoperative CT scanning procedure being able to update the CT data could provide a solution. Study Design: Endoscopic sinus operations using an intraoperative CT updating the three‐dimensional navigation system were performed on six persons to find out, whether the above is true. Methods: Different parameters, advantages, and disadvantages in the cases of these six patients were compared with a group of 22 patients who underwent conventional endoscopic sinus surgery with different three‐dimensional navigation systems without updating the CT data set. Results: The intraoperative CT for updating the three‐dimensional navigation system provides useful information for the surgeon. Conclusion: Balancing its advantages against its disadvantages, the updating of the CT data set with intraoperative CT cannot be recommended for conventional standard endoscopic sinus surgery.     

蝶窦后鼻孔息肉的鼻内镜治疗(附3例报告)

目的探讨蝶窦后鼻孔息肉的临床特征、诊断和鼻内镜手术治疗效果。方法对3例蝶窦后鼻孔息肉病人术前行冠状位CT扫描并行鼻内镜手术治疗。结果鼻内镜检查和冠状位CT扫描可确定息肉的起源。所有病人均一次治愈,术后随访8~26个月未见复发。结论临床特征、鼻内镜检查和冠状位CT扫描对蝶窦后鼻孔息肉的诊断起重要作用,鼻内镜手术是最佳治疗方法。     

Acromegaly presented as a cause of laryngeal dyspnea

Acromegalic patients can develop obstructive sleep apnea syndrome or upper airflow obstruction. The development of dyspnea is unusual and the fixation of both vocal cords is exceptional. We report the case of a patient with bilateral vocal cord paralysis. Fiberoptic laryngoscopy and computed tomography (CT) of the neck showed a supra-glottic stenosis due to a swelling of the soft tissue. A tracheostomy was first performed. Thereafter, micro-laryngoscopy using laser vaporisation of the supra-glottic soft tissue was attempted but failed to remove the tracheostomy canula. Finally, blood tests and cerebral MRI revealed an acromegaly. The patient underwent a trans-sphenoidal resection of the pituitary adenoma. Fifteen months later, fiberoptic laryngoscopy showed bilateral restoration of vocal cord mobility and the tracheostomy canula was successfully removed after 18 months.

Vocal cord fixation is probably due to hypopharyngeal and laryngeal soft tissue swelling and can be reversible after successful treatment of the adenoma.     

鼻内镜扩大经鼻蝶窦入路切除巨大垂体腺瘤13例

目的:探讨鼻内镜扩大经蝶窦入路切除巨大垂体腺瘤的可行性。方法:回顾性分析2000～2003年 间通过鼻内镜扩大经蝶手术入路治疗的13例巨大垂体腺瘤的临床资料。结果:所有患者术中镜下全部切除肿 瘤,术后10例患者给予放射治疗;术后影像学检查显示肿瘤有残余者6例,平均随访12个月肿瘤无复发或继续 生长。术后发生短暂性尿崩症6例,脑脊液鼻漏2例及急性腺垂体功能低下者1例;无死亡及颅内感染,无鼻腔 通气障碍、鼻腔粘连、鼻中隔穿孔等并发症。结论:扩大经蝶手术是治疗巨大垂体腺瘤的一种可行、安全、有效的 方法,但应掌握熟练的经蝶手术技术;术后应给予放射或药物辅助治疗。     

Hypophysis surgery with or without endoscopy

OBJECTIVE: Hardy's operation with microscope has long been the standard method for pituitary adenoma. But a new approach via the nasal cavity using an endoscope has been adopted recently. In this study, the postoperative outcome as well as the preoperative evaluation of endoscopic hypophysectomy and non-endoscopic one were compared at our faculty. METHOD: We performed the non-endoscopic transnasal hypophysectomy on 18 patients and the endoscopic transnasal hypophysectomy on thirteen patients who had a pituitary lesions from February 1996 to October 1999. As to these patients the situations from preoperation through postoperation such as chief complaints, serum hormone level, final diagnosis, tumor size, as well as operating time or blood loss during the operation were discussed precisely. Then the merits and demerits of endoscopic hypophysectomy were discussed. RESULT: Five PRL-producing adenoma, three GH-producing adenoma, nine non-functioning adenoma, and two ACTH or TSH-producing adenoma were included in this discussion as endoscopic group. The age of non-endoscopic group are from 23 to 73 (49.4 in average), and they include ten males and eight females. On the other hand three PRL-producing adenoma, two GH-producing adenoma, two non-functioning adenoma, and one Rathke's cyst were included in this discussion as endoscopic group. The age of endoscopic group are from 19 to 73 (49.1 in average), and they include seven males and six females. As to non-endopscopic group the blood loss during each operation is 568 ml and operating time is 256 min in average. For endoscopic group the blood loss is 296 ml and operating time is 234 min in average. CONCLUSION: By microsurgery in the pituitary operation with endoscopy, the minimal invasive surgery becomes possible by reducing blood loss and shortening operating time. During the operation cooperation between neurosurgeon and ENT surgeon is indispensable in order to perform hypophysectomy smoothly. The development of optical better aids and operation instruments for endonasal hypophysectomy is desired in the future. The navigation system was more useful than X-ray fluoroscopy to obtain the detailed information.     

Transnasal endoscopic repair of congenital defects of the skull base in children.

OBJECTIVE: To examine imaging findings and methods of endoscopic treatment of congenital skull base defects in children. DESIGN: Retrospective study and case series. SETTING: Academic tertiary care center. PATIENTS: Four patients (aged 12 and 14 months and 8 and 13 years) were included from 1995 to 1997. Three presented with a nasal glioma, which was recurrent in 1 case. The fourth patient presented with bacterial meningitis due to a spontaneous cerebrospinal fluid leak. Computed tomography and magnetic resonance imaging were used to locate the defect of the skull base. INTERVENTION: Transnasal endoscopic resection of the glioma or the meningocele, with immediate repair of the skull base defects using free mucosal flaps and/or pediculized mucosal flaps and/or conchal cartilage together with fibrin glue and nasal packing during a 3-week period. RESULTS: None of the 4 patients has experienced recurrent cerebrospinal fluid leaks or postoperative meningitis. CONCLUSIONS: The transnasal endoscopic repair of congenital meningoceles is a reliable technique in select pediatric patients. Computed tomography and magnetic resonance imaging provide information that can be used to help the surgical procedure.     

Assessment of the efficacy of endoscopy in pituitary adenoma resection

OBJECTIVE: To obtain objective evidence that the use of endoscopy in the surgical management of pituitary tumors improves intraoperative visualization and significantly impacts operative outcomes. DESIGN: Case series of pituitary adenomas treated surgically by endoscope-assisted microscopic resection. SETTING: University-affiliated tertiary care medical center. PATIENTS: Consecutive sample of 9 patients referred for surgical management of pituitary adenoma. INTERVENTIONS: Each patient underwent transseptal transsphenoidal microscopic tumor resection. The procedure was modified by the use of intrasellar endoscopy as an adjunctive imaging modality. Following complete microscopic resection of tumor, rigid 0 degrees and 30 degrees 4.0-mm endoscopes were used to conduct a final survey of the sellar and parasellar spaces. Residual tumor fragments identified during this endoscopic examination were removed. OUTCOME MEASURES: Endoscopes were thought to have a significant impact on surgical therapy in cases where residual tumor that was not detected microscopically was identified and removed during endoscopic examination. Analysis of each case included correlation between intraoperative findings and retrospective review of dictated operative reports and intraoperative videotape. RESULTS: Three of the patients with macroadenoma (33% of total, 43% of macroadenoma cases) had tumor fragments that were only identified and removed endoscopically. CONCLUSIONS: Endoscopy provides distinct advantages over microscopy in imaging intrasellar and parasellar structures during pituitary tumor resection. These data support the numerous anecdotal accounts of the usefulness of pituitary endoscopy and are consistent with the small amount of objective evidence offered on the subject. Arch Otolaryngol Head Neck Surg. 2000;126:1487-1490     

Dual ectopic thyroid

Ectopic thyroid is an uncommon embryological aberration characterized by the presence of thyroid tissue in a site other than in its usual pre-tracheal region. It occurs along the path of descent of the developing thyroid primodium from the foramen cecum. It most commonly presents itself as a lingual thyroid and is the only thyroid in 70% of all cases. It is extremely rare for two ectopic foci of thyroid tissue to be present simultaneously. The authors report a recent case of dual ectopic thyroid present in the lingual and infrahyoid areas with no thyroid tissue in the pre-tracheal area in a 15-year-old girl. The patient had originally been scheduled for surgery under the impression of thyroglossal duct cyst; however, a pre-operative computed tomography scan of neck and thyroid scans revealed the presence of dual ectopic thyroid, thus preventing unnecessary surgery. Therefore, thyroid scan, along with either neck CT or neck ultrasonogram, should be performed routinely to avoid unnecessary surgery if the clinical picture is at all compatible with thyroid ectopia. Received: 11 June 2001 / Accepted: 31 August 2001     

Ectopic nasopharyngeal pituitary adenoma resected with endoscopic technique

We describe the case of an 80-year-old man with diabetes who presented with nonspecific dizziness. He was found on magnetic resonance imaging to have a 3.2-cm mass within the posterior and central aspect of the nasopharynx. Nasal endoscopy showed that the mass, which arose from the posterior edge of the nasal septum and was attached to the superior nasopharynx, was narrowing the patient's airway. Although initially the mass was suspected to be a minor salivary gland tumor, histopathologic analysis led to a diagnosis of pituitary adenoma. The ectopic tumor was removed via transnasal en bloc resection with partial adjacent septal resection. Final pathology confirmed the diagnosis. The patient had an uneventful recovery and no sequellae at 2-year follow-up.     

The role of positron emission tomography/computed tomography in the management of recurrent papillary thyroid carcinoma

OBJECTIVES/HYPOTHESIS: The aim of the study was to evaluate the role of combined positron emission tomography/computed tomography (PET/CT) fusion imaging in the detection and management of recurrent papillary thyroid cancer. STUDY DESIGN: A retrospective analysis of 33 patients with suspected recurrent papillary thyroid carcinoma who had undergone PET/CT was performed. PET/CT was compared with standard imaging techniques in each patient to determine whether PET/CT contributed to the therapeutic management plan. Histopathological findings were correlated to PET/CT in patients who underwent surgery. METHODS: The senior author reviewed the charts of 33 patients with recurrent papillary thyroid carcinoma to determine the impact PET/CT had on management. PET/CT was compared with conventional imaging results. In surgical patients, PET/CT was compared with histopathological findings to determine its sensitivity, specificity, accuracy, positive predictive value, and negative predictive value. RESULTS: In 67% of the cases (22 of 33), PET/CT supplied additional information that altered or confirmed the management plan. Twenty of 33 patients underwent surgery with 36 sites assessed by histopathological analysis. PET/CT correlated with histopathological findings in 25 of 36 distinct anatomical sites, with an accuracy of 70%. The sensitivity of PET/CT in identifying recurrence was found to be 66%, with a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 27%. CONCLUSION: Combined PET/CT fusion scanning was most useful in the detection and management of recurrent papillary thyroid cancer in patients who had average thyroglobulin levels greater than 10 ng/mL and when the tumor no longer concentrated radioactive iodine. In 100% of the cases in which PET/CT localized a region suspicious for malignancy, histopathological analysis confirmed the results. When PET/CT is positive, it is a powerful tool for predicting exact locations of recurrent papillary thyroid cancer, thus making it a reliable guide for surgical planning. PET/CT is a supplement to conventional imaging and fine-needle aspiration in the workup of recurrent papillary thyroid cancer. A negative finding on PET/CT is not sufficiently reliable to preclude further investigation and treatment.     

Pleomorphic adenoma of the nasal cavity: a case arising from the wall of the maxillary sinus

INTRODUCTION: Pleomorphic adenoma is a common and benign tumour, originating from sero-mucous glands. Location in the nasal cavity and particularly on the medial wall of the maxillary sinus is very rare. PATIENTS AND METHODS: One patient with a pleomorphic adenoma of the nasal cavity and a review of literature are reported in order to describe the diagnostic and therapeutic management of this tumour. RESULTS: A 63-year-old woman was referred to our institution for evaluation of an unilateral nasal tumour. Clinical and radiological studies revealed an intra-nasal tumour, slightly lytic in nature, arising from the mucosa of the medial wall of the maxillary sinus. More than 2 years after complete excision of the tumour using an endoscopic procedure, the nasal cavity was free of tumour. DISCUSSION: Pleomorphic adenoma of the nasal cavity is a rare and benign tumour, usually presenting as a unilateral nasal tumour. Prognosis of this tumour is mainly linked to recurrences in cases of incomplete resection and to possible metastasis, such as an eventual malignant evolution. The gold standard treatment is complete surgical resection. After a complete imaging study for patient selection (CT scan and MRI), endonasal endoscopic surgery seems to be a reliable therapeutic treatment. CONCLUSION: Intra-nasal pleomorphic adenoma originates from nasal seromucous glands. Radiological study reveals a slightly lytic tumour developed from the septum of the medial wall of the maxillary sinus. Resecton can be performed with endoscopic endonasal surgery as long as the orbital bony framework and the ethmoidal roof are free of tumour. Whatever technique is employed, long term follow-up has to be used to detect any recurrence.     

Are Somatostatin Analogs Therapeutic Alternatives in the Management of Head and Neck Paragangliomas?

BACKGROUND: Although mostly benign, head and neck paragangliomas require active management because of injury to adjacent neurovascular structures. Surgery, usually preceded by embolization, allows for complete tumor removal. However, surgery carries a significant risk of iatrogenic injury, related to tumor volume. Because paragangliomas express somatostatin receptors with high density, we investigated the effect of a long-acting somatostatin analogue (OCT-LAR) on the size of such tumors to reduce iatrogenic injury and related the percentage of tumor shrinkage to a tracer uptake index calculated on somatostatin receptor scintigraphy (SRS). METHODS: In eight of the first nine patients, 30 mg of OCT-LAR was given intramuscularly every 28 days for 3 doses; one patient withdrew after the first dose because of side effects. Conventional imaging with computed tomography (CT) scan or magnetic resonance imaging plus SRS revealed 18 paraganglioma sites. For each lesion, a tracer uptake index was calculated on pretreatment SRS. All 18 tumors were measured by CT scan before treatment and 1 month after the third injection. RESULTS: The average percent tumor shrinkage was 4.0 +/- 10.0%, and the average tumor reduction was 1.0 +/- 3.8 cm (P = .27, NS). Only 2 of the 18 paragangliomas shrank by more than 20%; these two tumors belonged to the only one secreting patient. There was no significant relation between tracer uptake index and tumor response. CONCLUSION: These results suggest 1) that SRS results do not predict OCT-LAR efficacy on paraganglioma size, and 2) OCT-LAR is not useful in the preoperative management of paragangliomas.     

Endoscopic transnasal transethmosphenoidal approach for pituitary tumors: assessment of technique and postoperative findings of nasal and paranasal cavities

OBJECTIVE: Transnasal endoscopic surgery is the most common approach to removal of pituitary tumors. This study evaluated the transnasal transethmosphenoidal approach (TTES) in terms of its operative manipulability and the postoperative status of the paranasal cavities. METHODS: A total of 132 patients with pituitary tumors underwent surgery by one of the following three approaches: (1) bilateral TTES, in which the surgical procedures were performed via the bilateral paranasal cavities, (2) unilateral TTES, in which the procedures were performed via one side only, and (3) unilateral TTES and resection of the posterior portion in the nasal septum approach (RPS), which is a modification of approach (2) and enables performance of the procedures from both sides. RESULTS: The degree of freedom for the surgical procedures with each of the approaches decreased in the following order: bilateral TTES, unilateral TTES and RPS, and unilateral TTES. The postoperative CT images and endoscopic findings were good with each of the surgical approaches, but the incidences of olfactory disturbance and nasal dryness were significantly higher with the bilateral TTES compared with the unilateral TTES and RPS and the unilateral TTES. CONCLUSION: The unilateral TTES and RPS was for us most suitable approach of the three methods. In the case of advanced tumors, the bilateral TTES should be selected because it permits superior operative manipulability. Finally, the unilateral TTES is most appropriate for removal of tumors that are deviated to one side and localized within the sella.     

FDG PET and PET/CT for the detection of the primary tumour in patients with cervical non-squamous cell carcinoma metastasis of an unknown primary

In patients with a neck metastasis from an unknown primary with non-squamous cell cancer (non-SCC) histology, the primary is often located outside the head and neck area. We retrospectively evaluated 326 patient records and found 14 patients with non-SCC neck lymph node metastasis from an unknown primary undergoing whole body F-18-fluorodeoxyglucose (FDG) positron emission tomography (PET) with or without coregistered computed tomography (PET/CT). The PET or PET/CT findings were verified by pathological work-up, additional imaging tests, and clinical follow-up. PET detected pathological FDG uptake suspicious for the primary in eight patients. PET or PET/CT findings were true positive in seven patients, true negative in 4, false positive in 1, and false negative in two patients. In one patient PET/CT revealed a synchronous ovarian carcinoma. The results suggest that whole body imaging with FDG PET and PET/CT can be useful to identify unknown primaries of non-SCC origin. However, the work-up of patients undergoing PET or PET/CT in our study was very heterogeneous and the primary was more likely found in patients without extensive imaging before PET scanning. Further studies should evaluate if the histology of a neck nodal metastasis should influence the choice of the imaging method and the role of PET and PET/CT imaging for the work up of patients with a non-SCC neck lymph node metastasis of an unknown primary.