Question of the Week # 432

432) A 62-year-old man presents with painless, progressive enlargement in the left side of his neck over the past 3 months. He denies any fever, night sweats or chills. He denies any pain, dysphagia, cough, hemoptysis, chestpain, shortness of breath, history of trauma or dental infection. His past medical history is significant for  100 pack-year history of smoking and daily alcohol abuse. On examination, he is afebrile. He has a large 5 cm , hard, non-tender and matted lymphadenopathy on the left lateral aspect of his neck . He has no other lymph node enlargement. No rash. Reminder of the exam including oral cavity examination is normal. There are no obvious tongue, pharyngeal or tonsillar lesions.  HIV and VDRL are negative. A CT scan of the chest, abdomen and pelvis does not reveal any lymphadenopathy or obvious mass lesions. Which of the following is the most appropriate next step in management?

A) Open biopsy of the neck mass

B) Pan-endoscopy

C)  Fine Needle Aspiration Cytology ( FNAC)

D) Test for HPV ( Human Papilloma Virus) and EBV ( Ebstein Barr Virus)

E) Prescribe antibiotic therapy and re-evaluate in 4 weeks

23 Responses

  1. B

  2. FNAC is the next best option then can be followed after getting the histology which could be endoscopy, excision of the mass, or chemo or anti tb treatment. HPV and EBV test is not helpful for a 60 year old and antibiotics is not apt since there are no signs of infection.

  3. pan endoscopy followed by biopsy of neck mass

  4. C

  5. b

  6. squamous cel carcinoma is the most common cause as i in this scenario in elderly patient with lymhadenopathy with smoking history for so long. we need to do panendoscopy to rule out squamous cell carcinoma.

  7. C- is best choice. if not helpful then will proceed for open biopsy.

  8. C FNAC
    EGD if the patient had dysphagia and if you think this is a local extension

  9. D)

  10. C FNAC

    Hi! Good morning! I’m new to the blog, someone could tell me how I learned the correct answer in each case?


  11. Pan-endoscopy to rule out Virchow’s node due to gastric cancer.

  12. B, Pan endoscopy
    Virchow’s nodule is supraclavicular, not lateral neck. Squamous cel carcinoma is the most common cause, special in a patient with history of smoking. the mos common location could be nasopharingeal, hypopharyngeal, laryngeal, mesopharyngeal. Also we have to considarate the lung, but first we need a X ray.

  13. Pan-Endoscopy is the correct answer, although FNAC would be the best wrong answer! Even if you biopsy a 5cm matted hard nodule which is screaming i’m cancer, it’ll most probably give you a squamous cell ca histology. So, for a 100 pack year smoker it’s best to rule out sq. cell ca in the oro, hypo pharynx including the larynx and the esophagus. 😉

  14. I think the Chest CT did not show abnormality. Can’t this be an aggressive lymphoma that might be identified by FNAC. I don’t now. If they said most apporpirate next step, I might have chosen FNAC.

  15. I think B.. Any person with weight loss,dysphagia internal bleeding or age above 50 needs endoscopy..warning signs for cancer..Correct me if I’m wrong

    • The patient has neck lymphadenopathy as evidenced by the clinical exam. There is no information in the clinical history regarding a pre-existing cancer. Therefore, work up should start with approach to the neck mass directly.. The first step should be to get the tissue to confirm that this is cancer and to know the type – carcinoma ( ? type ? squamous etc) vs. lymphoma . The patient has 100 pk year smoking and most likely etiology here for persistent lymphadenopathy is a Head and Neck CA however, tissue will offer valuable information and define further approach with regard to approach of searching the primary.
      An FNAC is the best initial step to obtain the tissue in any neck mass except in cases of pulsatile mass. In cases of Lymphoma, excisional (Open) biopsy will be needed and this should be performed only if FNAC gives preliminary evidence of Lymphoma.

      Open biopsy almost has NO ROLE in the initial work up of a neck mass. Open biopsy is helpful to get the tissue however, if this turns out to be a Head and Neck squamous cell cancer having an open wound will interfere with treatment options that include Local Radiotherapy. It is not necessary to diagnose carcinoma however, if FNAC shows Lymphoma further tissue via. Open biopsy is needed for accurate sub-type diagnosis of Lymphoma.

      Panendoscopy is the next step after FNAC and should be done only if FNAC shows squamous cell cancer in order to identify the Primary site of cancer and to obtain biopsies from these sites. This includes EGD, Bronchoscopy and Laryngoscopy to examine Oropharynx, Hypopharynx, Laerynx and Esophagus. Blind biopsies of Nasopharynx and Unilateral tonsillectomy is also performed if the above measures do not readily identify the primary. A CT imaging done prior to panendoscopy may also show a lesion in any of these areas suggesting a primary.

      Testing for HPV is not indicated here. It is usually recommended in Head and Neck cancers NOT associated with Smoking. In such cancers, a positive HPV has significant treatment implications since positive HPV is usually associated with oral cavity, base of tongue and tonsilar lesions. HPV positive head and neck CA carries better prognosis and do well with radiotherapy alone without radical surgery or chemotherapy. If the HPV is positive in the lymph node mass and primary could not be found, common HPV positive primary sites such as Tonsil and Oral cavity can be included in the Radiation field.

      Antibiotics is not a correct answer. Painless lymphadenopathy, prolonged duration mass of 3 months and absence of fever argues against infection. Patient has this persistent neck mass for about three months and risk factors such as heavy smoking that raises Red Flag for cancer etiology

  16. I’m sorry sir but a HARD, MATTED lymph node in a 100 pack year smoker with daily alcohol abuse is metastasis to the lymph node until proven otherwise! If this was a lymphoma then it would be rubbery in consistency and there would be grade B symptoms. There would be some more lymph nodes that would be palpable.

    This is how the clinical exam goes for a neck swelling:

    Firm, rubbery: lymphoma
    Soft : infection or cold abscess
    Multiple, firm, shotty: syphilis, viral
    Matted (connected): tuberculosis, sarcoidosis
    Rock hard, immobile, fixed to skin and more than 2 cm: metastatic

    In a 65 year old patient with a 100 pack year smoking history and daily alcohol abuse, the cause is squamous cell carcinoma.

    We need to check what is seen in older patients:
    Level 1: oral cavity
    Level 2, 3, 4: larynx, oropharynx, hypopharynx, thyroid
    Level 5: nasopharynx
    and finally Esophagus!

    For this a PAN-ENDOSCOPY needs to be done! Moreover, the question says, what is the most appropriate next step, which means concentrating on the etiology and not just doing an FNAC which will almost always give you a squamous etiology.

  17. Differential diagnosis must always be considered, neck mass palpation is not an exact science, and FNAC is the best next step to exclude differentials, pan endoscopy can be performed once lymphoma has been ruled out. I agree with archer’s explanation. a hard immobile neck mass is highly suggestive of head or neck malignancy, and based on the history of smoking and alcohol abuse, but still lymphoma must be ruled out, and FNAC is the least invasive procedure.

  18. panendoscopy …
    elder + smoker +non febrile +unil. LN = carcinoma untill proved others …
    cx larynx
    cx oesphagus
    cx postcricoid
    so we need panendoscopy
    negative : no stridor no dysphagia no hoarsness

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