PMC7756967_01
(a) Axial contrasted computed tomography (CT) scan demonstrates a small ovoid iso-attenuating mass in the left tonsil. The large mixed solid-cystic nodal-mass conglomerate in the left side of the neck exerts mass effect on the left carotid space and displaces it medially. (b) Coronal contrasted CT scan demonstrates the cranio-caudal extent of the nodal-mass conglomerate in the left side of the neck. The cranial aspect is solid and enhancing, and the caudal portion is cystic and multiseptated.
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The neck CT demonstrated an ovoid iso-attenuating mass in the left tonsil, measuring 16 mm x 12 mm x 24 mm in diameter (anteroposterior x transverse x craniocaudal, Figure 1a). In addition, a large, mixed solid-cystic nodal-mass conglomerate was present in the left side of the neck, with a solid and enhancing component at its cranial aspect and, inferiorly, a multiseptated cystic component (Figure 1b).
(a) Sagittal T1-weighted, post-gadolinium, fat-saturated magnetic resonance (MR) image shows the mixed solid-cystic nature of the cervical nodal-mass with enhancement of the cranial solid portion. Superficial parotid gland infiltration was suspected based on MR imaging findings. Axial T1-weighted MR images with (b) gadolinium and (c) fat suppression demonstrating heterogenous enhancement of the solid cranial portion of the cervical nodal-mass conglomerate. The left carotid arteries and internal jugular vein were not infiltrated.
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On MR imaging, left parotid gland invasion by the cervical nodal conglomerate was strongly suspected (Figure 2a). The tonsillar mass demonstrated T1-weighted iso- to hyperintense signal to cervical muscles, T2-weighted and fluid attenuated inversion recovery (FLAIR) hyperintense signal to muscle and minimal post-contrast enhancement (Figure 2b and 2c).
Intra-operative image of the left cervical nodal-mass conglomerate. It was dissected off the left common carotid artery, with ligation of the left internal jugular vein.
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TNM] 8th edition). The patient underwent a left-sided, modified radical neck dissection with a superficial partial parotidectomy ('en block') and bilateral tonsillectomy (Figure 3). The post-operative course was uncomplicated, and the patient was discharged on Day 5 post surgery.
Follicular dendritic cell sarcoma of the left tonsil: (a) The tumour appears very cellular, displaying a typical storiform and whorled growth pattern (haematoxylin and eosin, 100x); (b) By immunohistochemistry, the tumour shows diffuse membranous positivity with follicular dendritic cell markers D2-40 (haematoxylin and eosin, 400x), as well as CD21, CD23, CD35 (not shown).
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The tumour comprised spindle-to-ovoid cells arranged in fascicles, in whorled and storiform patterns, demonstrating a pushing invasive front (Figure 4a). The tumour cells were positive for follicular dendritic cell markers such as CD21, CD23, CD35 and D2-40 (podoplanin) but negative for cytokeratin markers (Figure 4b).