Story
Imaging Case 33:
Head & Neck cancer - Right Oral Tongue Squamous Cell Carcinoma
Achieving adequate surgical margins is a critical determinant of oncological outcomes in head and neck cancer. In anatomically complex regions such as the oral tongue, complete tumor resection must be balanced with preservation of function, making intraoperative decision-making particularly challenging. Close or involved margins may necessitate additional treatment, including re-excision or adjuvant therapy, both of which can significantly impact patient morbidity and quality of life. [1]Intraoperative specimen PET-CT imaging has emerged as a technique that may provide real-time insight into tumor location and extent within excised tissue, thereby supporting surgical assessment during resection. [2]
Patient History
A 37-year-old male patient presented with a lesion of the rightlateral oral tongue, which was biopsied and confirmed to be squamous cell carcinoma. Preoperative imaging demonstrated a 2.5cm right oral tongue lesion without adenopathy.Given these findings, the patient was scheduled for a right partial glossectomy and neck dissection.
SURGICAL PROCEDURE
The procedure was performed at Vanderbilt University Medical Center by a surgical team led by Dr. Topf. The patient underwent a right partial glossectomy involving resection of approximately one-third of the tongue, extending toward the right tonsil and base of tongue.
[Fig. A] High-resolution PET-CT image from the anterior oral cavity opening.[Fig. B] Medial (left) aspect; ¹⁸F-FDG uptake reaches the superior border.
[Fig. C] Axial/transversal plane.
[Fig. D]3D PET-CT rendering
Specimen PET-CT images
During surgery, the patient received an injection of 0.8 MBq/kg of¹⁸F-FDG, followed by resection of the tumor specimen. Intraoperative specimen PET-CT imaging was performed immediately after resection, enabling visualization of radiotracer uptake.
The imaging demonstrated focal uptake corresponding to the tumor. No evidence of radiotracer uptake extending to the specimen margins was observed, indicating no suspicion of invasive tumor involvement at the margins. These findings were consistent with the frozen section assessment.
The imaging demonstrated focal uptake corresponding to the tumor. No evidence of radiotracer uptake extending to the specimen margins was observed, indicating no suspicion of invasive tumor involvement at the margins. These findings were consistent with the frozen section assessment.
Histopathological Evaluation
After PET-CT specimen imaging, the resected specimen was sent to the pathology department for histopathological evaluation.Final histopathological evaluation confirmed a moderately differentiated squamous cell carcinoma measuring 3.1 cm, located at the lateral border of the tongue. The tumor demonstrated a depth of invasion of 13 mm and was classified as pT3.
All surgical margins were negative for invasive carcinoma. The closest margin measured 5 mm at the medial soft tissue margin. Additional margin assessment confirmed negative margins across all sampled margins, including medial, lateral, and deep margins, with distances up to 7 mm.
Discussion and Conclusion
This case demonstrates the potential role of intraoperative specimen PET-CT imaging in supporting surgical decision-making during partial glossectomy for oral tongue cancer.Specimen PET-CT imaging enabled real-time visualization of tumor localization and provided additional confirmation that no invasive tumor extended to the specimen margins. These findings were consistent with both frozen section analysis and final histopathological evaluation. All sampled margins were within 1mm on PET-CT and final histopathology. This highlights the importance of integrating imaging findings with intraoperative pathology to guide balanced surgical decision-making, particularly when functional preservation is a priority.
By providing immediate intraoperative feedback, specimen PET-CT imaging may enhance surgical confidence and support a more tailored approach to resection, while avoiding unnecessary removal of additional tissue.
References
1. Machiels JP, Leemans CR, Golusinski W, et al. Squamous cell carcinoma of the oral cavity, larynx, oropharynx and hypopharynx: EHNS–ESMO–ESTRO Clinical Practice Guidelines.Ann Oncol. 2020;31(11):1462–1475.
2. Lambert B. et al. (2025) Feasibility study on the implementation of a mobile high-resolution PET/CT scanner for surgical specimens. Eur J Nucl Med Mol Imaging. https://doi.org/10.1007/s00259...