A 64-year-old woman comes to the office for evaluation of a painless neck lump. The patient first noticed right-sided neck swelling a month ago. She has not had fevers, chills, cough, or shortness of breath but has had decreased appetite and weight loss. Medical history is significant for obesity, type 2 diabetes mellitus, and nonalcoholic fatty liver disease. The patient has smoked a pack of cigarettes daily for the past 29 years. She drinks alcohol socially. Vital signs are within normal limits. Physical examination reveals a 2-cm, hard, nontender cervical lymph node close to the right submandibular gland. There is no other lymphadenopathy. The lungs are clear to auscultation and heart sounds are normal. The abdomen is soft and nontender; mild hepatomegaly is present. The remainder of the examination is normal. Fine-needle aspiration of the lymph node reveals squamous cell carcinoma. Which of the following would be most helpful to establish the primary source of this patient's malignancy?

Question

A 64-year-old woman comes to the office for evaluation of a painless neck lump.  The patient first noticed right-sided neck swelling a month ago.  She has not had fevers, chills, cough, or shortness of breath but has had decreased appetite and weight loss.  Medical history is significant for obesity, type 2 diabetes mellitus, and nonalcoholic fatty liver disease.  The patient has smoked a pack of cigarettes daily for the past 29 years.  She drinks alcohol socially.  Vital signs are within normal limits.  Physical examination reveals a 2-cm, hard, nontender cervical lymph node close to the right submandibular gland.  There is no other lymphadenopathy.  The lungs are clear to auscultation and heart sounds are normal.  The abdomen is soft and nontender; mild hepatomegaly is present.  The remainder of the examination is normal.  Fine-needle aspiration of the lymph node reveals squamous cell carcinoma.  Which of the following would be most helpful to establish the primary source of this patient's malignancy?

Quizplus · Accepted Answer

Malignancy is extremely likely in a patient with a persistent (>2 weeks), palpable (>1.5 cm), firm neck mass, who has a smoking history and no history of a preceding infection. By far the most common malignancy to manifest in an upper cervical lymph node is mucosal head and neck squamous cell carcinoma (SCC). Head and neck SCC is common in patients with a significant history of alcohol and tobacco use (as in this patient). The first (and only) apparent manifestation is often a palpable cervical lymph node, which represents regional nodal metastasis. Identification of the primary source of SCC is of paramount importance because it directs all treatment decisions. Although SCC can originate from many sites (eg, skin, uterine cervix, upper esophagus), the vast majority of cervical nodal SCC arises from the mucosal surfaces of the head and neck (ie, nasopharynx, oral cavity, oropharynx, larynx). Thorough examination of these structures must include endoscopic visualization using laryngopharyngoscopy. (Choices A and C) Abdominal malignancies (eg, stomach, pancreas, colon, ovaries) can spread via the thoracic duct to the left supraclavicular lymph nodes (Virchow node)-an ominous sign. However, most of these abdominal malignancies are adenocarcinomas rather than SCC. In addition, submandibular lymphadenopathy (as seen in this patient) reflects lymphatic drainage from the head and neck rather than the thoracic duct, making abdominal malignancy less likely. (Choice B) Although breast cancer commonly affects the axillary and internal mammary lymph nodes, it occasionally metastasizes to the cervical nodes. However, it generally affects the supraclavicular nodes rather than the submandibular nodes, and most types of breast cancer are adenocarcinomas rather than SCC. (Choice E) Hepatomegaly can sometimes reflect liver neoplasm, either primary (eg, hepatocellular carcinoma [HCC]) or metastatic. HCC typically metastasizes to the lungs, portal vein, and portal lymph nodes and is unlikely to cause cervical adenopathy. Conversely, head and neck SCC does not commonly spread to the liver. This patient's hepatomegaly is likely due to nonalcoholic fatty liver disease. (Choice F) Thyroid cancer metastasizes to cervical nodes. However, thyroid cancers are papillary, follicular, medullary, or anaplastic, not squamous cell. Educational objective: Squamous cell carcinoma in a cervical lymph node, especially in a smoker, likely has a mucosal head and neck primary site and requires examination of the laryngopharyngeal mucosa. References: Clinical practice guideline: evaluation of the neck mass in adults. (http://www.ncbi.nlm.nih.gov/pubmed/28891406) Diversity of breast carcinoma: histological subtypes and clinical relevance. (http://www.ncbi.nlm.nih.gov/pubmed/26740749)

A 64-Year-Old Woman Comes to the Office for Evaluation of a Painless