Published: June 26, 2025 | Updated: July 14, 2025
A 75-year-old male presented with a left neck mass, referred by his community otolaryngologist. The patient reported a history of sleep apnea, cough and recurrent upper respiratory infections. Imaging and fine needle aspiration of the neck mass confirmed p16 positive squamous cell carcinoma (SCC).
Positron emission tomography (PET)/CT demonstrated a hypermetabolic left level II lymph node and mild avidity in the left tongue base. The patient’s medical history included prostate cancer in remission for over 10 years, cardiac stents and prior smoking (last smoked in the 1990s). He denied dysphagia, weight loss or other typical symptoms of oropharyngeal cancer.
Diagnostic imaging and pathology suggested an oropharyngeal cancer with an unidentified primary site. The patient had p16-positive SCC in the left level II neck node with mild left tongue base avidity on PET/CT, consistent with HPV-mediated oropharyngeal carcinoma. Despite directed biopsies, the primary tumor site remained elusive. Our multidisciplinary tumor board recommended a robotic base of tongue mucosectomy and ipsilateral neck dissection. Imaging also revealed minor findings in the mediastinum and lung, complicating definitive staging and requiring careful evaluation to guide treatment planning.
Joshua D. Horton, M.D.
Head and Neck Surgical Oncologist
Norton Cancer Institute
Michael J. Hahl, M.D.
Radiation Oncologist
Katharine E. Adelstein, Ph.D., APRN
Psychiatric Oncology Nurse Practitioner
Jennifer Alvey M.S., CCC/SLP
Speech-language PathologistNorton Hospital
Abbey Overstreet, R.N., OCN
Head and Neck Patient NavigatorNorton Cancer Institute Resource Center
The patient underwent robotic-assisted tongue base resection and ipsilateral neck dissection. Intraoperative findings identified a small, well-hidden tumor at the left tongue base, subsequently confirmed as p16-positive SCC on final pathology. The surgery was uneventful, and the patient tolerated the procedure well. Due to its occult nature, the tongue base tumor was incompletely excised during the diagnostic mucosectomy. On final pathology, he was noted to have a less than 2 centimeter primary tumor and two positive lymph nodes without extracapsular extension; therefore, his disease was staged as T1N1M0 HPV-associated tongue base SCC.
The patient recovered well from surgery and began adjuvant radiation therapy targeting the oropharynx and involved neck levels. Postoperative pathology provided clarity on the disease stage, ensuring that radiation was appropriately tailored.
He experienced moderate psychological distress due to the diagnosis and intensity of treatment. He benefitted greatly from the integrated care of our behavioral oncology team.
The patient has completed postoperative radiation therapy with no significant complications to date. Liquid biopsy measuring circulating tumor DNA (NavDx) cleared as expected, bolstering our confidence in the effectiveness of the administered treatment.
He remains under the close care of our speech therapy and nutrition providers to ensure appropriate rehabilitation of his swallowing abilities during and after treatment. Follow-up imaging and evaluations have confirmed complete disease response to treatment. He is optimistic about his future and expressed gratitude for the coordinated care provided by the multidisciplinary team.
Note: Treatment and results may not be representative of all similar cases.