Ch. 13 Lump on Neck Increasing in Size

Question 1

Differential Dx for Lump on Neck

Answer 1

Question 2

What risk factors are associated with H & N cancer in general?

Answer 2

Question 3

What risk factors are associated with specific H & N cancers?

Type of cancer:

• Oropharyngeal cancer
• Nasopharyngeal cancer, Burkitt’s lymphoma
• Nasopharyngeal cancer
• Laryngeal cancer
• Pharyngeal and upper esophageal cancer

Answer 3

Question 4

What premalignant lesions should be looked for on physical exam?

Answer 4

Question 5

What is Virchow’s Node? Why is it concerning?

Answer 5

Enlarged L supraclavicular node

Occurs on the L as this is where the cisterna chyli (dilated lymph sac at end of the thoracic duct) empties into subclavian vein

Virchow’s node = suggestive of metastatic lung or GI malignancy

Question 6

What does a newly discovered malignant neck mass most likely represent?

Answer 6

Spread of cancer via lymphatic system until proven otherwise

In these cases, the primary site of cancer is unknown and thus represents an “unknown primary.” The primary site is most frequently in the upper aerodigestive tract and must be found in order to appropriately treat the cancer.

Question 7

What is the most common pathology of H & N cancer?

Answer 7

SCC = 90% of cases

Question 8

Work-Up:

Is observation an acceptable strategy for a newly discovered, isolated, and enlarged cervical lymph node?

Answer 8

Observation is only appropriate for patients that do not present with any red-flag symptoms (e.g., dysphagia, odynophagia, dysphonia, hoarseness, weight loss) and if the lymph node has been present for less than 3 weeks

Patients should be re-examined in 3 weeks.

If the node disappears, it most likely was inflammatory in nature.

Question 9

What initial imaging modality is the dx test of choice to search for the primary tumor?

Answer 9

CT scan of the H & N with contrast

CXR also recommended

Question 10

What is the best way to obtain a tissue sample to determine if the neck mass is a metastatic lymph node?

Answer 10

FNA = highly sensitive and specific and is diagnostic in the majority of cases with minimal morbidity

Question 11

Once FNA confirms that neck mass is a metastasis, what is the next step in determining the location of the primary tumor?

Answer 11

Panendoscopy (performed in the OR under general anesthesia)

Panendoscopy = triple endoscopy (laryngoscopy, esophagoscopy, bronchoscopy)