Interface modification of Cr/Ti multilayers with C barrier layer for enhanced reflectivity in the water window regime

The influence of a carbon barrier layer to improve the reflectivity of Cr/Ti multilayers, intended to be used in the water window wavelength regime, is investigated. Specular grazing-incidence X-ray reflectivity results of Cr/Ti multilayers with 10 bilayers show that interface widths are reduced to ∼0.24 nm upon introduction of a ∼0.3 nm C barrier layer at each Cr-on-Ti interface. As the number of bilayers increases to 75, a multilayer with C barrier layers maintains almost the same interface widths with no cumulative increase in interface imperfections. Using such interface-engineered Cr/C/Ti multilayers, a remarkably high soft X-ray reflectivity of ∼31.6% is achieved at a wavelength of 2.77 nm and at a grazing angle of incidence of 16.2°, which is the highest reflectivity reported so far in the literature in this wavelength regime. Further investigation of the multilayers by diffused grazing-incidence X-ray reflectivity and grazing-incidence extended X-ray absorption fine-structure measurements using synchrotron radiation suggests that the improvement in interface microstructure can be attributed to significant suppression of inter-diffusion at Cr/Ti interfaces by the introduction of C barrier layers and also due to the smoothing effect of the C layer promoting two-dimensional growth of the multilayer.

Successful Multimodality Management of Atypical Teratoid/Rhabdoid Tumour of the Lower Dorsal Spine with Spinal Drop Metastasis: Illustrated Review

INTRODUCTION

Spinal atypical teratoid/rhabdoid tumour (AT/RT) is exquisitely rare and constitutes 2% of all AT/RTs.

CASE PRESENTATION

A 6-year-old boy presented with low backache for the last 5 months. MRI of the spine showed a 1.5 × 1.5 × 4.7 cm intradural extramedullary mass extending from D10 to D12, causing compression of the conus medullaris. With a preoperative diagnosis of ependymoma, a gross total resection (GTR) of tumour was performed. Post-operative histopathology showed AT/RT. The tumour cells were immunopositive for cytokeratin, epithelial membrane antigen, smooth muscle actin, and p53 and immunonegative for MIC2, desmin, glial fibrillary acidic protein, and INI1. Post-operative neuraxis MRI revealed post-operative changes (D10-D12) with a 9 mm enhancing lesion at L5-S1 junction suggesting drop metastasis. There was no lesion in brain. Cerebrospinal fluid cytology did not show any malignant cell. The metastatic work-up was normal. He received 3 cycles of chemotherapy with ICE regimen (ifosfamide, carboplatin, and etoposide). Subsequently, he received craniospinal irradiation (CSI)-36 Gy/20 fractions/4 weeks followed by focal boost to primary tumour bed and spinal drop metastasis-14.4 Gy/8 fractions/1.5 weeks. Thereafter, he received 3 more cycles of ICE regimen. End-of-treatment MRI spine showed post-op changes (D10-D12) and 38.9% reduction of the L5-S1 lesion suggesting partial response. Six monthly spinal MRI showed serial reduction of the metastatic lesion leading to complete response (CR) 1 year after completion of treatment. On last follow-up (30 months from the initial diagnosis), he was neurologically intact and in CR.

CONCLUSION

Multimodality management comprising GTR of tumour, CSI followed by focal boost, and multiagent chemotherapy (ICE) can lead to successful outcome in patients with this rare and aggressive spinal tumour.

ATRT-31. SUCCESSFUL MULTIMODALITY MANAGEMENT OF ATRT OF THE LOWER DORSAL SPINE WITH SPINAL DROP METASTASIS

A 6 year old boy presented with low backache for the last 5 months. MRI of the spine showed a 1.5x1.5x4.7cm intradural mass extending from D10-D12, causing compression of the conus medullaris. With a preoperative diagnosis of intradural ependymoma, a gross total resection (GTR) of tumour was performed. Post-operative histopathology showed a markedly cellular, malignant tumour with frequent mitotic figures. Cells were round to polygonal with vesicular nuclei, prominent nucleoli and were immunopositive for CK,EMA,p53 and immunonegative for MIC2,desmin,SMA,GFAP,INI-1(MIB1 labeling index-35–40%). The overall impression was spinal atypical teratoid rhabdoid tumour(ATRT). Post-operative neuraxis MRI revealed post-operative changes(D10-D12) with a 9 mm enhancing lesion at L5-S1 junction suggesting drop metastasis. There was no brain lesion. CSF cytology did not show any malignant cell. The metastatic work-up was normal. He was started on chemotherapy with ICE regimen (Ifosfamide-2g/m²IVD1–D3,Carboplatin-500mg/m²IVD3,Etoposide-100mg/m²IVD1–D3q3weeks). Subsequently he received craniospinal irradiation (CSI)-36Gray/20fractions/4weeks→ focal boost to primary tumour bed and spinal drop metastasis-14.4Gray/8fractions/1.5 weeks. Thereafter he received 3 more cycles of ICE regimen. End-of-treatment MRI spine showed post-op changes(D10-D12) and 38.9%reduction of the L5-S1 lesion suggesting partial response. Six monthly spinal MRI showed serial reduction of the metastatic lesion leading to complete response (CR) 1 year after completion of treatment. On last follow-up (30 months from initial diagnosis), he was neurologically intact and in CR. Multimodality management comprising GTR,CSI followed by focal boost and multiagent chemotherapy(ICE) can lead to successful outcome in patients with this rare and aggressive spinal tumour.

LINC-33. MULTIMODALITY MANAGEMENT OF PAEDIATRIC PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA- UPDATED EXPERIENCE FROM A REGIONAL CANCER CENTRE IN NORTH INDIA

Paediatric primary central nervous system lymphoma(PCNSL) constitutes 1% of all PCNSLs. Data pertaining to paediatric PCNSL (2016–19) was abstracted by retrospective chart review. We identified 7 paediatric patients with PCNSL. None had congenital or acquired immunodeficiency. The median age at presentation was 13 years. The male to female ratio was 4:3. The median ECOG performance status was 2. On neuro-imaging, 3 patients had solitary and 4 patients had multiple lesions. CSF cytology showed atypical cells in 1 patient. None had ocular involvement. Systemic lymphoma work-up was negative in all. Biopsy and resection of tumour were done in 4 patients each. Histopathology revealed DLBCL in 6 and B-cell NHL in 1 patient. All patients underwent induction chemotherapy (median-5 cycles)- modified DeAngelis protocol (IV Methotrexate-2.5g/m²,IT Methotrexate-12 mg,Vincristine,Procarbazine and Rituximab-375mg/m² every 2 weeks) in 6 and single agent Methotrexate -3.5g/m² every 3 weeks in 1 patient. Severe haematological toxicities included grade 3 neutropenia, leucopenia and febrile neutropenia in 2,1 and 1 patient respectively. Radiotherapy(RT) was administered in all-whole brain RT(36-45Gy/20-25fractions/4-5weeks) in 6 patients and craniospinal RT(36Gy/18fractions/3.5weeks) followed by whole brain RT(9Gy/5fractions/1week) in 1 patient(with positive CSF cytology). Subsequently consolidation chemotherapy with 2 cycles of Cytarabine(3g/m² IV D1-2 every 3 weeks) was administered in 5 patients. After a median follow-up of 14 months(mean-18.2 months), all patients are in complete radiological remission. Paediatric PCNSL is a rare tumour entity and multimodality management with high dose Methotrexate and Rituximab based chemo-immunotherapy and cranial radiotherapy leads to excellent early clinical outcome.

Outcome of Children with Stage IV Wilms Tumor - Our Experience of 15 Years

Context:

Stage IV Wilms tumor is associated with poor prognosis, and recent changes in management have been suggested based on genetic markers and response to chemotherapy in this subgroup of patients.

Objective:

The objective was to evaluate the outcomes of children with Stage IV Wilms tumor who were managed with the AIIMS-WT-99 protocol.

Materials and Methods:

All the children with Stage IV Wilms tumor who were managed by us from October 2000 to December 2012 were included in the study. All the patients who had received primary treatment elsewhere were excluded from the study. All patients were managed as per the AIIMS-WT-99 protocol. After appropriate investigations, tumors that were deemed resectable underwent an upfront surgery. Unresectable and inoperable tumors received chemotherapy after cytological confirmation of the diagnosis. Chemotherapy was administered as per the NWTS-5 study. Pulmonary and flank radiotherapy was advised to all patients. Patients with poor response to chemotherapy or with recurrence were managed with an alternative chemotherapy regimen. The outcomes that were assessed the 4-year overall survival (OS) and the 4-year event-free survival (EFS).

Statistical Analysis Used:

Kaplan–Meier survival estimates.

Results:

During the study period, 219 patients with Wilms tumor were treated. Of these, 36 (16.4%) had Stage IV disease, and they formed the study group. The 4-year OS was 48% with a mean survival time of 59 months limited to 115 months (95% confidence interval: 41.3–75.9 months). The 4-year EFS was 42.4%. Patients with liver metastases had a poor outcome, whereas patients with good response to chemotherapy had a good outcome.

Conclusion:

Stage IV Wilms had a poor prognosis, and the survival rates in the index study are lower than those quoted in the literature. Although the exact reason for this poor result eludes us, these patients may benefit from the intensification of chemotherapy.

Multiple Myeloma-Effect of Induction Therapy on Transplant Outcomes

BACKGROUND

Patients with multiple myeloma (MM) aged ≤ 65 to 70 years, with a good Eastern Cooperative Oncology Group performance status and no major comorbid conditions, are considered potential candidates for autologous stem cell transplant (ASCT) and will be treated with novel agent-based induction therapy for 4 to 6 cycles before ASCT.

PATIENTS AND METHODS

We analyzed the data from 326 patients with MM who had received novel agent-based induction before ASCT at our center to evaluate the effect of induction therapy on ASCT response, stem cell mobilization, engraftment characteristics, and survival. The median age was 52 years (range, 29-72 years), 216 patients were men (66.3%), 32.7% had stage III using the Revised Multiple Myeloma International Staging System, and 15.8% had high-risk cytogenetics. Of the 326 patients, 75 (23.0%) had undergone ASCT in second remission after salvage therapy for relapse. Also, 194 patients (59.5%) had received doublet induction therapy and 132 (40.5%) had received triplet induction therapy.

RESULTS

Triplet-based induction therapy was superior to doublet-based therapy for response (95.4% vs. 84.02%; P < .003), stem cell mobilization (CD34⁺ ≥ 2 × 10⁶/kg; 88.6% vs. 76.8%; P < .005), and lower 100-day transplant-related mortality (P < .001). The ≥100 day post-ASCT overall response (97.4% vs. 91.7%; P = .124) and complete response (72.5% vs. 68.0%; P = .38) rates were similar. At a median follow-up of 62.5 months, the overall survival (97.5 months vs. 100.0 months; P = .606) and progression-free survival (54.5 months vs. 57 months; P = .515) were similar between the triplet and doublet induction groups.

CONCLUSION

An initial response (chemosensitivity) to induction therapy will prepare patients better for subsequent consolidation therapy and ASCT, leading to favorable outcomes.

Expanding the Neuroimaging Phenotype of Neuronal Ceroid Lipofuscinoses

BACKGROUND AND PURPOSE

Neuronal ceroid lipofuscinoses are a group of neurodegenerative disorders characterized by the accumulation of autofluorescent lipopigments in neuronal cells. As a result of storage material in the brain and retina, clinical manifestations include speech delay, cognitive dysfunction, motor regression, epilepsy, vision loss, and early death. At present, 14 different ceroid lipofuscinosis (CLN) genes are known. Recently, the FDA approved the use of recombinant human proenzyme of tripeptidyl-peptidase 1 for CLN2 disease, while phase I/IIa clinical trials for gene therapy in CLN3 and CLN6 are ongoing. Early diagnosis is, therefore, key to initiating treatment and arresting disease progression. Neuroimaging features of CLN1, CLN2, CLN3, and CLN5 diseases are well-described, with sparse literature on other subtypes. We aimed to investigate and expand the MR imaging features of genetically proved neuronal ceroid lipofuscinoses subtypes at our institution and also to report the time interval between the age of disease onset and the diagnosis of neuronal ceroid lipofuscinoses.

MATERIALS AND METHODS

We investigated and analyzed the age of disease onset and neuroimaging findings (signal intensity in periventricular, deep, and subcortical white matter, thalami, basal ganglia, posterior limb of the internal capsule, insular/subinsular regions, and ventral pons; and the presence or absence of supratentorial and/or infratentorial atrophy) of patients with genetically proved neuronal ceroid lipofuscinoses at our institution. This group consisted of 24 patients who underwent 40 brain MR imaging investigations between 1993 and 2019, with a male preponderance (male/female ratio = 15:9).

RESULTS

The mean ages of disease onset, first brain MR imaging, and diagnosis of neuronal ceroid lipofuscinoses were 4.70 ± 3.48 years, 6.76 ± 4.49 years, and 7.27 ± 4.78 years, respectively. Findings on initial brain MR imaging included T2/FLAIR hypointensity in the thalami (n = 22); T2/FLAIR hyperintensity in the periventricular and deep white matter (n = 22), posterior limb of the internal capsule (n = 22), ventral pons (n = 19), and insular/subinsular region (n = 18); supratentorial (n = 21) and infratentorial atrophy (n = 20). Eight of 9 patients who had follow-up neuroimaging showed progressive changes.

CONCLUSIONS

We identified reported classic neuroimaging features in all except 1 patient with neuronal ceroid lipofuscinoses in our study. CLN2, CLN5, and CLN7 diseases showed predominant cerebellar-over-cerebral atrophy. We demonstrate that abnormal signal intensity in the deep white matter, posterior limb of the internal capsule, and ventral pons is more common than previously reported in the literature. We report abnormal signal intensity in the insular/subinsular region for the first time. The difference in the median time from disease onset and diagnosis was 1.5 years.

Spin-Reorientation-Induced Band Gap in Fe_{3}Sn_{2}: Optical Signatures of Weyl Nodes

Temperature- and frequency-dependent infrared spectroscopy identifies two contributions to the electronic properties of the magnetic kagome metal Fe_{3}Sn_{2}: two-dimensional Dirac fermions and strongly correlated flat bands. The interband transitions within the linearly dispersing Dirac bands appear as a two-step feature along with a very narrow Drude component due to intraband contribution. Low-lying absorption features indicate flat bands with multiple van Hove singularities. Localized charge carriers are seen as a Drude peak shifted to finite frequencies. The spectral weight is redistributed when the spins are reoriented at low temperatures; a sharp mode appears suggesting the opening of a gap due to the spin reorientation as the sign of additional Weyl nodes in the system.

Clinicopathological features and outcome of diffuse large B-cell lymphoma patients treated in a resource-limited setting

e20062

Background: Diffuse large B cell lymphoma (DLBCL) is the most common lymphoma worldwide. Clinicopathological features and outcome of DLBCL patients and the prognostic significance of cell of origin (COO) on outcome are scarce from developing countries. Methods: We carried out an ambispective analysis of newly diagnosed DLBCL patients (n = 417) over a period of 5 years (2014-2018).Clinicopathologic features and outcome data were collected from prospectively maintained clinical case records. Prognostic factors were identified using Cox-regression analyses. Results: Median age of our population was 50 years (18-86) with male to female ratio of 2:1. B symptoms was seen in 42% patients and bulky disease in 36%. Sixty percent of patients were having ECOG performance status (ECOG PS) of 0 or 1 and advanced disease was present in 60%. Extra nodal involvement was documented in 53% cases, most common sites being bone (17.5%) followed by gastrointestinal tract (16.5%).RCHOP was used in 62.8% of cases .COO data (based on Hans algorithm) was available in 80% patients with germinal center B cell like (GCB) and non GCB forming 50% each. Bone marrow involvement was present in 7.2% patients. Low risk International Prognostic Index (IPI) was seen in 44% and 15% were having high IPI. The overall response rate was 76% with a complete response (CR) rate of 65.5%. After a median follow up of 26 months the 3 year event free survival (EFS) and overall survival (OS) were 62% and 81% respectively. Low albumin, bulky disease, central nervous system (CNS) involvement, non GCB histologic subtype, high IPI and use of non R-CHOP regimens were associated with inferior EFS. Age > 60 years, poor ECOG PS, raised LDH, involvement of extranodal sites (stomach, kidney, adrenals and central nervous system) were associated with poor overall survival on multivariate analysis. Conclusions: This is one of the largest studies from India. Non GCB subtype was found to be associated with inferior EFS. Non R-CHOP regimen and high IPI were associated with inferior survival.

Clinicopathologic features and outcome of extra-nodal diffuse large B-cell lymphoma: An institutional experience from North India

e20079

Background: Primary extranodal diffuse large B cell lymphoma (DLBCL) forms upto 40-50% of all cases of DLBCL . Clinicopathological features and outcome of extranodal DLBCL patients especially in the rituximab era are scarce from developing countries. Methods: We carried out an ambispective analysis of newly diagnosed DLBCL patients (n = 417) over a period of 5 years (2014-2018).Of this total cohort 224 (53.7%) were found to have primary or predominant extranodal involvement. Prognostic factors were identified using Cox-regression analyses. Results: Median age was 50 years (18-86) with male female ratio of 2:1. B symptoms were seen in 48% patients and bulky disease in 39%. ECOG performance status of 0 or 1 was present in 50% and 63% presented with advanced disease. Bone was the most common site of extranodal involvement (32%) in our study followed by gastrointestinal tract ( 30%).Cell of origin (based on Hans algorithm) was available in 80% patients with Germinal center subtype (GCB) forming 44% and non-GCB forming 36% of all patients. Bone marrow involvement was present in 13 % patients. Low risk International Prognostic Index (IPI) was seen in 32 % and 41% were having intermediate risk IPI, the remaining being high risk. CHOP based treatment was used in 80 % of cases and rituximab was used in 76% of all cases. The overall response rate was 76% with a complete response rate (CR) of 65.5%. Presence of B-symptoms, central nervous system (CNS) involvement, non R-CHOP regimen and non-radiotherapy treatment protocols were associated with inferior CR rate. After a median follow up of 26 months, the 3-year event free survival and overall survival were 65 % and 82.7 % respectively. Involvement of specific extranodal sites (kidney, adrenals and CNS), high IPI score and use of non R-CHOP regimens were associated with poor EFS and OS on multivariate analysis Conclusions: This is one of the largest studies from India on extranodal DLBCL in the rituximab era. Involvement of specific extranodal sites, high IPI score and use of non R-CHOP regimens were associated with inferior survival.

Non-Hodgkin lymphoma: The Indian scene

e20063

Background: There is a lack of data available regarding the distribution of Non-Hodgkin lymphoma (NHL) subtype, according to a recent WHO- 2016 classification and outcome of diffuse large B cell lymphoma (DLBCL) on the basis of cell of origin (COO) from developing country in Rituximab era. Methods: This is an ambispective study of newly diagnosed patients with NHL, treated in the Department of Medical Oncology, AIIMS, New Delhi. A total of 775 cases of adult ( > 18 years) lymphoma were registered over a period of 5 years (January 2014 to December 2018). Outcome of DLBCL patients who have received uniform RCHOP protocol separately analysed. The patients were classified as germinal center B-cell like (GCB) or activated B-cell (ABC) type using the Hans classification Results: NHL constituted 622 (80.26%) and Hodgkin's lymphoma 153 (19.74%) of the cases. B- cell constituted 553 (88.9%) among all NHL and rest 69 (11.1%) cases were T cell in origin.. Diffuse large B cell lymphoma (DLBCL) was the most common NHL 417(67%) followed by follicular lymphoma 60 (9.64%), mantle cell lymphoma 35 (5.62%), PTCL-NOS 25 (4.01%), ALCL 16 (2.57%),marginal zone lymphoma 14 (2.25%), T-LBL 13(2.1%) and the rest of the cases were rare NHL( < 1% cases each) for e.g. SLL, NK-T, BL, SLVL, AITL etc. Among the 417 cases of DLBCL, 262 (62.8%) cases received rituximab along with CHOP regimen. The median age of RCHOP treated patients was 47.6 years with male female ratio of 2.3:1. B symptoms were seen in 39% patients and bulky disease in 33%. ECOG performance status of 0-2 was present in 67% and 51% presented with advanced disease. GCB was seen in 42% and 44% were ABC. Low risk IPI was seen in 48 % and 40% were intermediate risk IPI. The overall response rate (ORR) was 82 % with a complete response rate (CR) of 75.6 %. Presence of bulky disease and non-radiotherapy treatment protocols were associated with inferior CR rate. After a median follow up of 30 months, the 3-year event free (EFS) survival and overall survival (OS) were 78 % and 88 % respectively. Low albumin ( < 4 gm/dl) and age > 60 years were associated with inferior EFS whereas high IPI risk score was associated with inferior OS. Pre-phase was used in 20% of cases. Grade III/ IV anaemia, neutropenia and thrombocytopenia were seen in 5%, 13% and 2% of patients respectively. Febrile neutropenia was seen in 7 % of patients and there were 3 treatment related death. Rituximab infusion related toxicity was seen in 7 patients. Conclusions: DLBCL is the most common NHL ( GC-42%, ABC-44%). The distribution according to COO dose not impact on CR rate and EFS and OS . RCHOP is well tolerated in our patients and results are comparable with the western data.

High-dose chemotherapy followed by autologous stem cell transplant for multiple myeloma: Predictors of long-term outcome

Background & objectives

Survival of patients with multiple myeloma (MM) has improved in the past two decades following use of novel agents and autologous stem cell transplantation. To determine predictors of long-term outcome, data of MM patients who underwent autologous stem cell transplantation (ASCT) at a tertiary care centre in north India were retrospectively analyzed.

Methods

Between 1995 and 2016, 349 MM patients underwent ASCT. Patients' median age was 52 yr, ranging from 29 to 68 yr, 68.2 per cent were males. Thirty three per cent patients had international staging system (ISS) Stage III and 68.5 per cent had received novel agents-based induction. High-dose melphalan (200 mg/m²) was used for conditioning; patients with renal insufficiency (estimated glomerular filtration rate <40 ml/min) received melphalan 140-150 mg/m².

Results

Post-transplant, 317 of 349 (90.8%) patients responded; complete [complete response (CR)] -213 (61%)], very good partial response (VGPR) -62 (17.8%) and PR in 42 (12%)]. Induction with novel agents, pre-transplant chemosensitive disease, transplant in first remission and serum albumin (≥3.5 g/dl) were predictors of significant response. At a median follow up of 73 months, median overall survival (OS) was 90 months [95% confidence interval (CI) 70.8-109.2], and progression-free survival (PFS) was 41 months (95% CI 33.0-49.0). On multivariate analysis, achievement of CR post-transplant, transplant in first remission, ISS Stages I and II (vs. III), absence of extramedullary disease and serum albumin ≥3.5 g/dl were predictors of prolonged OS. For PFS, achievement of post-transplant CR and transplant in first remission were predictors of superior outcome.

Interpretation & conclusions

Treatment with novel agents, achievement of complete remission post-transplant, ISS Stages I and II, absence of extramedullary disease and transplant in first remission were predictors of long-term survival for patients with MM.

Radiation-Associated Glioblastoma after Prophylactic Cranial Irradiation in a Patient of ALL: Review of Literature and Report of a Rare Case

INTRODUCTION

The cumulative incidence of radiation-induced second malignancy is 1-2% per decade after radiotherapy (RT). Radiation-induced malignant glioma (RIMG) is a rare complication of cranial RT.

CASE PRESENTATION

We herein describe a case of left frontal glioblastoma arising 5 years after prophylactic cranial irradiation (12.6 Gy/7 fractions/1.5 weeks) as a part of INCTR-02-04 protocol in a 3-year-old boy with B-cell ALL. He underwent gross total excision (GTE) of the tumour followed by post-operative intensity modulated RT (59.4 Gy/33 fractions/6.5 weeks) and concurrent and adjuvant (3 cycles) temozolomide. Thereafter, he had rapid disease progression, which entailed re-excision of the recurrent tumour. Subsequently, there was widespread subependymal and leptomeningeal spread of tumour, leading to death 10.5 months after the initial diagnosis.

CONCLUSION

RIMG is an aggressive malignancy with a dismal prognosis, and in spite of multimodality management, it exhibits relentless progression, occasionally characterized by subependymal and leptomeningeal dissemination, leading to eventual death within a year of diagnosis.

Squamous cell carcinoma as a somatic-type malignancy in an extragonadal immature teratoma of the sinonasal region

Somatic-type malignancy arising in a teratoma of the sinonasal region is extremely unusual, creating a diagnostic dilemma. There are no definite guidelines for management of such cases. A 15-year-old male with a maxillary mass was misdiagnosed as angiomyolipoma, maxillary carcinoma, mucoepidermoid carcinoma, and teratocarcinosarcoma, followed by the final diagnosis of squamous cell carcinoma arising in an immature teratoma. He received neoadjuvant chemotherapy, followed by surgery and chemo-radiotherapy, and is disease-free at 21 months. This case highlights the difficulty faced when diagnosing neoplasms unusual to the head and neck region, particularly on small biopsies, and good outcome following appropriate multimodality management.