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Management of the Neck Mass

About 5% of all cancer patients will present with neck masses. About 12% of head and neck cancer patients present with neck masses. So it is a fairly common presenting symptom. Unfortunately it just about has your prognosis for almost any site when you see a neck mass, but it is frequently the first symptom that we will see. Especially for head and neck cancers. If at all possible you should avoid an open biopsy of a neck mass.

There are a lot of reasons oncologically. It does compromise where we can put our incisions if you have an incision in the neck. It does obstruct the lymphatics and it may indicate a poor prognosis for the patient who has had an open neck biopsy. It usually is not necessary. We almost always can find a primary site or we almost always can do it either with a fine needle aspiration or something like that, prior to an open neck biopsy. So try to do all these other things first, prior to an open neck biopsy.

Any neck mass in an adult is malignant until proven otherwise. Some of the statistics as we go through them are really kind of shocking, at least they were to me. At what a high percentage of malignancies you will find in your adult patients. At biopsy, the primary site is always best and before we launch on any type of treatment, whether it’s chemotherapy, radiation or surgical approach, we have to have a diagnosis. So that patient is going to have to have a biopsy at some point. Again, the history and physical directs what we do.

The jugular nodes along the internal jugular vein, especially the junctional nodes up here are the most important nodes that you are going to find in them, and really from a head/neck oncologists standpoint, those nodes are involved in almost all cancers that we treat up there. Also lots of lymphomas as well. Submandibular nodes and then posterior triangle nodes, supraclavicular nodes and that’s the way I would break them down. Remember, when you get that patient in the chair when you are examining for a neck mass, those nodes lie right underneath.

When you look at all comers with nodes in the neck, you’ll find that about 90% of nodes in children are going to be benign. Vast, vast majority and that may even be an understatement. Almost always they are benign. Malignancy is the second thought when they don’t respond to antibiotics, when they don’t respond to all these other things that you are doing. But in adults that’s basically reversed.

Risk factors, of course, the number one risk factor that you have to know when a patient walks through the door with a neck mass, the first question that we ask them other than how long has I been there and these kind of things, is "Are you a cigarette smoker?" because then that increases the likelihood of that being cancer by a very very high percentage. And of course alcohol is synergistic with tobacco. The duration of the mass is also important. If the mass has been there for a couple of days, it may not be quite so significant as a mass that’s been there for a couple of months. Anything over a couple of weeks is probably significant. Something that’s been there for 10 years, 15 years, then of course that takes on a different significance. Then the size also. We talked about the size being relative. A mass greater than 2 cm is unlikely to be inflammatory. Some chronic infections - TB, histoplasmosis, toxoplasmosis - you’ll see bigger nodes in those patients but they are very very rare. For the most part, any node over 2 cm is significant. If it’s a family that you are taking care of and you know that other members have had melanomas, have had cancers, I think that raises your suspicion too. Certainly there are a number of syndromes that you see, and those are very very rare.

Obviously associated symptoms, weight loss being the biggest one, but hoarseness, dysphasia, hemoptysis, those things guide you how you are going to look at that neck mass and also always ask them about fullness. Do they have fullness of the ear or pain in the ear, especially unilaterally. If it happens to be on the same side as the neck mass then those people are invariably going to have a cancer that you need to find. Visual changes for sinus cancers. Of course if you find those, they are in trouble. Fevers, chills that go along with your lymphomas can be important.

A good history is going to outline what most of these people have if you just listen to the patients. Of course, you’ve heard that. Location, size, consistency, we’ll go through all these things in just a little more detail. Whether it’s fixed or not. A fixed mass is extremely ominous, with the exception of some infections, that’s going to mean malignancy in almost every patient. Variation in size. Although certain larger tumors, especially those that are necrotic, necrotic lymph nodes can respond to antibiotics, can get smaller, can fluctuate to some extent.

The next thing, when you’ve outlined the history you may ask the patient, if it looks like an enlarged mass - it doesn’t feel like cancerous, it’s not rock hard. It’s a little bit spongy, it could be lymphoma. You’ve asked them about night sweats, fevers, chills, weight loss, those kinds of things and you’ve asked them, "Have you been exposed to TB? Do you have a cat? Do you clean the litter box?" you know, for toxoplasmosis. We see these things occasionally, but after you’ve kind of gone through those things then it’s time to start looking a little bit more at the mass itself. Number one, where is it located? Anterior border of the sternocleidomastoid could basically be anything. You know, that’s where your branchial clefts occur, that’s where your nodes are, so you could have inflammatory nodes and then that’s also the primary area where we are going to find metastatic disease from the upper digestive tract.

Midline masses are almost always benign. You can get some thyroid cancers that will present to a delphian node, but for the most part these are all benign thyroglossal duct cysts, dermoids, etc. And the age of your patient, smoking history, etc. If it’s a child you are going to be thinking more of the congenital things. Dermoid cysts, etc. Close to the border of the sternocleidomastoid you can get metastatic disease from the nasal pharynx and that’s the classic spot for that, but usually those are inflammatory nodes. Especially in a kid they are invariably inflammatory and even in adults, those are much less likely to be a cancer. You can see lymphomas there but again that’s much less likely. Basically what we are trying to do is get the original Gestalt as to how we are going to follow this patient up. Should I get a CAT scan first? Should I get a fine needle? Should I get a barium swallow? What’s the first thing? Does somebody need to put them to sleep and look? Where do we need to go? Supraclavicular masses - although cystic hygromas in kids - but usually, in about 90% of supraclavicular that are malignant you are looking at a malignancy below the clavicles. The classic is stomach and GI tract, but the most common in a woman is either breast or lung and most common in a man is lung by far.

We talked about size. Size over 2 cm rarely inflammatory except in some of these stranger diseases that we don’t see very often. Consistency is important to some degree. Cancer nodes, especially squamous cell - which is 95% of head and neck cancers - are usually rock hard. They are fixed to things. They are non-tender of course and patients - virtually every patient that I have will tell me - "Well, I had this mass but I didn’t get too concerned about it because it didn’t hurt." Well, those are the ones that you get concerned about, the ones that don’t hurt, because those are the ones that are tumors. If they are attached to the skin you need to think about the things that occur in the skin. The inclusion cysts etc. but also tumors can fixate to the skin. Again, that’s a late effect and usually the patient is in trouble. If they are deep to the skin but non-tender, soft, very very soft spongy, discreet, certainly lipomas, fibromas, neurofibromas, those things can all occur there as well.

Congenital lesions: frequently cystic. They are all non-tender. They can sometimes transilluminate. I haven’t found that to be too useful. If they are pulsatile or if you have a bruit, and again we have to remember to do this occasionally - especially when you get a high jugular node - I will always tell them that when you are feeling it, to have the residents or whoever is examining a patient.

These are the characteristics of malignancy: fixed, hard, non-tender, matted, etc. I always ask the patient. If they do say, "Yeah, it changed. It’s bigger now it’s smaller, and it’s getting bigger." Try to get a time. When does it happen. When you wake up in the morning is it bigger? Does it get bigger throughout the day? Does it get bigger when you are eating or when you are preparing food, or when you walk in the house and you smell food and get ready to eat? Anything that might indicate a salivary gland obstruction then of course you could be thinking stones, chronic infections, strictures, those kinds of things. Tumors can also cause it but those would be the things from a salivary gland standpoint. Other generalized adenopathy in the axilla and throughout. Mono, cat scratch, lymphoma, certainly sarcomas, TB, atypical TB.

What do you do when faced with a patient with a unilateral, asymptomatic, neck mass? You’ll be the first one to see them. The patient comes in and says, "I noticed this when I was shaving." How long ago? It’s always two weeks. I don’t care how many months. You know it’s been there for eight months, it’s always two weeks. And then what do you do? Well, a complete head and neck exam is the first thing that needs to be done. You need to look at the oral cavity, oropharynx if you’ve got a mirror or a scope,.

The next step, I believe, is if you have fine needle capacity in your office, is to go ahead and get a fine needle on it. While you are waiting for a fine needle - if you are talking to a 65-year-old who smokes two packs a day and is also hoarse - then I think it’s reasonable to go ahead and assume this is going to be cancer and go ahead and get your workup going. All these patients need chest x-rays.