CASE PRESENTATION
A 78-year-old white woman presented with a 6-month history of progressive left neck swelling, and she had recently developed pain on lateral neck movement. She had no other symptoms, and her medical history was negative history except for a clear cell renal cell carcinoma removed in May 2014 and without recurrence. Exam demonstrated a firm, hypomobile mass of the Level V neck, without any palpable masses in the clavicular fossa or other regions of the neck. Flexible endoscopy revealed no evident mucosal lesions of the upper aerodigestive tract, and ultrasound-guided biopsy was non-diagnostic.
Because of her cancer history, neck magnetic resonance imaging (MRI) with gadolinium, neck and thorax contrast computed tomography (CT), and total body Positron Emission Tomography (PET) CT were performed. Head and neck MRI (Figure 1AB ) and CT (Figure 1CD ) imaging demonstrated an enhancing posterolateral neck lesion measuring 37 x 35 x 15 mm mass adjacent to and invading the sternocleidomastoid muscle. Thoracic imaging did not show presence of masses or lymph nodes.\sout. Repeat fine needle aspirates performed under ultrasound guidance were non-diagnostic; the patient wished surgical removal and was therefore taken to surgery for endoscopy of the upper respiratory tract, excisional biopsy of the mass, and plan for formal neck dissection if squamous cell carcinoma was identified. Endoscopy showed no abnormality, and removal of the neck mass was performed with surrounding fibro-adipose tissue and sternocleidomastoid muscle.
Pathology of frozen section demonstrated cellular atypia consistent with gastric carcinoma (Figure 2 ABC) . Subsequent gastric endoscopy (performed under general anesthesia) identified a gastric ulcer located in the larger curvature of the stomach/anterior wall of pre-pyloric area. Several biopsies were performed in the stomach close and far from the identified lesion. The histologic analysis of the finding confirmed the diagnosis of signet-ring cell carcinoma pathology, HER2 negative.
Following multidisciplinary review, the patient started chemotherapy with FOLFOX. There was tumor progression despite therapy, and the regimen was therefore changed to FOLFIRI, with tumor regression at 10-months. The patient was still in remission at the last follow-up in August 2020.