Differential diagnosis of neck lumps is a routine issue in daily ENT practice. However, in case of adenopathy from cancer of unknown primary it may be very challenging, and integration between medical history and clinical, radiological, and cytological findings becomes fundamental. We present a case of a very late recurrence of a seminoma in cervical nodes, occurring more than 20 years after the primary treatment, together with a review of the scientific literature. A 59-year-old man presented to our attention with left indolent neck swelling, which had increased progressively over 6 months. It was a huge mass at level VB, fixed to underlying tissues, with intact overlying skin. In the patient’s clinical history, a left testicular seminoma treated with surgery and adjuvant chemotherapy 20 years earlier was reported. No lesions of the upper aerodigestive tract (UADT) were found after pan-endoscopic examination in white light and narrow band imaging. Neck ultrasound (US) and contrast-enhanced neck-chest computed tomography (CT) showed a 5 cm left colliquated adenopathy in level VB, and other adenopathies in left level III and VA (Fig.?1A), without radiological signs of extracapsular nodal extension. Total-body fluorodeoxyglucose positron emission tomography (PET) highlighted the presence of the multiple hypermetabolic adenopathies, from level II to V without other findings. Fine needle aspiration cytology (FNAC) of the largest adenopathy showed necrotic material mixed with poorly differentiated large-sized cells, positive for cytokeratin (CK) CAM 5.2 and CK7, and negative for CK20, TTF1, p40, SOX10, p16 and EBV, which was therefore consistent with neck metastasis from a poorly differentiated carcinoma. The tumour was staged as cTxN2bM0 (according to TNM staging system 8th edition), and consequently, under general anaesthesia, pan-endoscopy of the UADT (resulted macroscopically negative for disease) and left level II to V dissection were performed.
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