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Introduction Approach to the Non-Thyroid Neck Mass

BC Surgical Oncology Network

Diversity of neck masses involves multimultidisciplinary interests


Family Physician Head and Neck surgeon Otolaryngologist General surgeon Plastic surgeon Dentist/Oral surgeon

Differential Diagnosis
Congenital/Developmental Acquired
Inflammatory/Infectious Neoplastic Benign or Malignant
primary or secondary

Congenital/Developmental
Midline
Thyroglossal duct cyst Dermoid

Lateral
Brachial cleft cyst FNA showing debris, cholesterol clefts / may present with acute infection Normal anatomy C1, hyoid, etc. Muscular torticollis

Vascular AVM, ectatic vessels, aneurysms Traumatic Hematoma

Inflammatory Lesions
Infectious

Inflammatory

Bacterial strep/staph, ), TB strep/staph, cat scratch (bartonella (bartonella), Fungal actinomycosis Viral (HIV, EBV, mumps) Parasitic toxoplasmosis Granulomatous disease sarcoid Reactive

Salivary Lesions
Typical locations
anterior to tragus angle of mandible

Most common tumour is parotid benign


pleomorphic adenoma process Sjogren Sjogrens

Bilateral/diffuse suggest infiltrative

Tumour of Neurogenic Origin


Neurofibroma Schwannoma Paraganglioma (carotid body tumour) tumour)

Lymphoma
Hodgkin Hodgkins lymphoma NonNon-Hodgkin Hodgkins lymphoma

Metastatic Cervical Nodes


Head and Neck Primary (upper aerodigestive
s node) Remote Primary (Virchow (Virchow tract) esophagus, lung, breast, stomach, renal cell carcinoma Malignant Melanoma Skin Cancer Unknown Primary

Incidence of Pathologic Lesions in Neck Masses in Adults


Primary thyroid disease 50%
benign, malignant and metastatic Metastatic cervical adenopathy 35% epithelial, other 12% Congential Inflammatory 3%

Lymphadenopathy
Normal nodes <1 cmcm-1.5 cm Inflammatory nodes usually resolve within 2 wks First Rule: Any neck mass in an adult patient
must be approached as being neoplastic and possibly malignant Second Rule: Immediate removal of enlarged lymph node for diagnostic purposes is a disservice to the patient with metastatic cervical carcinoma Third Rule: Any incision in neck can compromise future surgery

Terminology of Lymph Node Groups


Level I Level II Level III Level IV Level V Level VI submental, submental, submandibular upper jugular middle jugular lower jugular posterior jugular paratracheal, paratracheal, perithyroidal

Drainage Patterns and Neck Levels


Level I (Submandibular (Submandibular / Submental) Submental)
drain lip, oral cavity and submandibular gland

Drainage Patterns and Neck Levels


Level IV (Lower jugular)
drain subglottic larynx, hypopharynx, hypopharynx, esophagus, and thyroid

Level II (Upper jugular)


drain nasopharynx, nasopharynx, oropharynx, oropharynx, parotid, and supraglottic larynx

Level V (Posterior triangle)


drain nasopharynx and oropharynx

Level III (Mid jugular)


drain oropharynx, oropharynx, hypopharynx, hypopharynx, and supraglottic larynx

) Level VI (Paratracheal (Paratracheal)


drain thyroid and larynx

Clinical Evaluation of Neck Mass History


age (kids 80% benign, adults over 40

Clinical Evaluation of Neck Mass Physical


Complete head and neck examination,
including ear, nose, thyroid, facial nerve and including examination of oral cavity with mirror and by palpation Assessment for other nodes, liver, spleen Examination of skin of the scalp/neck for lesions or scars

80% malignant), duration, growth, fluctuation, tenderness, B symptoms, oral/nasal/ear, skin, voice change, cough, weight loss, SOB, dysphagia Smoking/EtOH Smoking/EtOH Hx, Hx, Personal Ca History, Previous irradiation, Family Ca Hx

Fine Needle Aspiration of Neck Masses


Sensitivity of 85 97% for tumours Specificity of 88 98% Non diagnostic 8 16% Useful even for salivary lesions to rule out
nonnon-salivary pathology (mets (mets to intraparotid lymph node)

FNA Results
Inadequate repeat ?US guided Lymphoid cannot rule out lymphoma lymphoma SCC search for primary flexible

Laboratory Investigations
Base on suspicion from Hx and Px CBC, LDH PPD CXR for lower neck mass or lymphoma , cat scratch, EBV) Serology (toxoplasma (toxoplasma, US node character lucency, lucency, shape, hilar fat Other imaging function of FNA result, eg CT with
SCC, or MRI if unlocalized primary

nasopharyngoscopy Adenocarcinoma Melanoma Other small cell, poorly differentiated ca Necrotic this is suspicious for SCC

Further Management
Function of FNA result SCC examination under anaesthesia and
random biopsy Lymphoid open biopsy Other directed search for primary

1. Nasopharynx posterior pharyngeal


wall, Fossa of Rosenm Rosenmller base Hypopharynx pyriform fossa Cervical esophagoscopy Bronchoscopy Laryngoscopy

Examination Under Anaesthesia and Random Biopsy

2. Oropharynx unilateral tonsil, tongue 3. 4. 5. 6.

Open Biopsy
Reserved primarily for suspected
lymphoma or persistent undiagnosed node Caution with posterior triangle anatomy (accessory nerve) Lymphoma protocol not in formalin Specimen for cultures

Treatment of Metastatic Squamous Cervical Cancer of Unknown Primary

Summary
Wide differential FNA for diagnosis useful at all sites Full upper aerodigestive exam for SCC Careful open biopsy for undiagnosed mass

Indication for primary radiotherapy


1. Posterior triangle node(s) SupraSupra-clavicular node(s) 2. Oriental ethnic background

Radical neck dissection may be

indicated when open biopsy proven metastic squamous carcinoma