Cervical Lymphadenopathy

Diagnosis and Management

Case 1

• Case 1:

– 6/12 hx of enlarging left level 2 neck mass

• no dysphonia, dysphagia, weight loss, stridor

• Ex smoker x 28 years

• 6-8 units of Ethanol weekly

– Med Hx- HTN, dyslipidemia

– O/E

• Non-tender, Firm, Mobile, 2cm lesion

• FiberopticNasendoscopy- Normal

• Normal oral cavity and TM’s

– CT- Solid cystic 2.5cm nodule ?necrotic

lymph node ?branchial cleft cyst.

– FNA- hypocellular fluid- non-diagnostic

– Open biopsy

• Histology- Poorly differentiated SCC with heavy

P16 staining.

– Referred to Head and Neck subspecialist

for review

• Subsequent Left Modified radical neck

dissection

– PET CT + MRI neck – No evidence of

Primary

– Subsequent Left Modified radical neck

dissection + tonsillectomy + biopsy of

tongue base and pharyngeal wall

• 0/74 nodes positive

• Tonsils normal

• No evidence of malignancy on Biopsy

– Metastatic SCC with Unknown Primary

• MDT discussion- radiotherapy to neck

• Pt well post-op

• Case 2:

– 4/12 hx of malaise, night sweats, weight

loss, with painless enlarging right (level 2)

neck mass.

• No dysphonia, dysphagia, stridor, cough

• Non-smoker, rare ethanol consumption

• Med Hx- Asthma, allergic rhinitis

– On exam: Firm 2cm nodule, mobile.

• Nasendoscopy: NAD

• TM’s normal + CN’s intact

• No palpable axillary on inguinal nodes

– CXR: Hilarlymphadenopathy

– FNA- hypocellular

– U/S- hypoechoic 2.5cm nodule. No visible

fatty hilum

– Open biopsy: Non-hodgkin’s lymphoma.

– Referred for oncologic opinion.

SCC of Unknown/Occult

Primary

Rare: 1-5% of head and neck malignancies

Up to 90% are said to originate from Waldeyer’s Ring

Treatment remains controversial:

Surgery Vs Radiotherapy Vs Combined Therapy

Unknown Primary:

5 year survival 75% for N2 and N3

disease treated with MRND and

chemoradiotherapy (Argiris et al 2002)

2012 meta-analysis (Balaker et al):

No statistically significant 5 year survival

between MRND followed by chemo-RT

vsChemoRT alone

SIGNIFICANCE OF CERVICAL NODES

1. NUMBER OF INVOLVED NODES

• HISTOLOGICALLY NEGATIVE NODE FIVE YEAR SURVIVAL. 75%

• SINGLE NODE INVOLVEMENT,

FIVE YEAR SURVIVAL 49%

• TWO NODES INVOLVED,

FIVE YEAR SURVIVAL 30%

• THREE NODES OR GREATER INVOLVEMENT,

FIVE YEAR SURVIVAL. 13%

DILEMMA No Disease

• ELECTIVE NECK VERSES CLINICAL

OBSERVATIONION

THERE IS NO DOCUMENTATION OF IMPROVED

SURVIVAL, FOLLOWING ELECTIVE NECK

DISSECTION FOR CLINICAL No DISEASE.

(SPIRO, STRONG 1973)

REGIONAL LYMPH NODE METASTESIS

DETECTION

1. CLINICAL ASSESMENT (ERROR RATE) 15 - 35%

1. LYMPHANGIOFRAPHY

2. NEEDLE ASPIRATION (ACCURATE IN CLINICALLY POSITIVE NODES)

3. CT SCAN (ERROR RATE - HIGH IN NODES LESS THAN 1CM)

INDICATIONS FOR PROPHYLACTIC NECK

DISSECTION

1. 20% OR GREATER RISK OF REGIONAL LYMPH NODE NETASTESIS BASED ON HISTORICAL DATA

2. DIFFICULT TO EVALUATE NECK DISEASE DUE TO SHORT STATURE, MUSCULAR HYPERTROPHY, OR PREVIOUS SURGICAL SCARRING

3. CT SCAN SUGGESTION OF INVOLVED CERVICAL LYMPH NODES

4. WHERE NECK MUST BE ENTERED IN ORDER TO RESECT PRIMARY TUMOR

5. UNWILLINGNESS OF PATIENT TO REMAIN UNDER CONSTANT EVALUATION.

FNA

• FNA

– Fast

– Minimally invasive

– Cheap

– Sensitive

– Few complications

• Limited utility in lymphoma (additional

testing i.e. flow cytometry can be

diagnostic)

Open Biopsy

• Highly sensitive and specific

• Often requires GA

• Disrupts Lymphatic tissue may lead to

further spread (Adoga et al 2009)

• May lead to technical problems with

later MRND

– Compromise of skin flap vascularity

– Need to excise biopsy tract

• Balaker, A. E., Abemayor, E., Elashoff, D. and St. John, M. A. (2012), Cancer of

unknown primary: Does treatment modality make a difference?. The

Laryngoscope, 122: 1279–1282. doi: 10.1002/lary.2242

• A. Argiris, S. M. Smith, K. Stenson, B. B. Mittal, H. J. Pelzer, M. S. Kies, D. J.

Haraf, and E. E. Vokes. Concurrent chemoradiotherapy for N2 or N3 squamous

cell carcinoma of the head and neck from an occult primary Ann Oncol (2003)

14 (8): 1306-1311 doi:10.1093/annonc/mdg330

• Adeyi A Adoga, Olugbenga A Silas, Tonga L NimkuOpen cervical lymph node

biopsy for head and neck cancers: any benefit?Head Neck Oncol. 2009; 1: 9.

Published online 2009 April 29. doi: 10.1186/1758-3284-1-9 PMCID:

PMC2679005

• M.K. Herd, M. Woods, R. Anand, A. Habib, P.A. BrennanLymphoma

presenting in the neck: current concepts in diagnosis British Journal of Oral

and Maxillofacial SurgeryVolume 50, Issue 4, June 2012, Pages 309–313