Cervical Lymphadenopathy. Diagnosis and Management

Transcription

1 Cervical Lymphadenopathy Diagnosis and Management

2 Case 1

3 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

4 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

5 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

6 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

7 CXR: Hilarlymphadenopathy FNA- hypocellular U/S- hypoechoic 2.5cm nodule. No visible fatty hilum Open biopsy: Non-hodgkin s lymphoma. Referred for oncologic opinion.

8 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

9 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

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12 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%

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)

14 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)

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16 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.

17 FNA FNA Fast Minimally invasive Cheap Sensitive Few complications Limited utility in lymphoma (additional testing i.e. flow cytometry can be diagnostic)

18 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

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22 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: doi: /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): doi: /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: / PMCID: PMC 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