cervical lymphadenopathy diagnosis and management1].pdf · –pet ct + mri neck –no evidence of...
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• 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