A 62-year-old man presents to the clinic with a 2-month history of a painless lump on the right side of his neck. He denies recent fevers, weight loss, or night sweats, but mentions some mild, persistent "scratchiness" in his throat. He has a 40-pack-year smoking history and drinks alcohol socially. Vital signs are within normal limits. On physical examination, there is a 3-cm, firm, non-tender, immobile lymph node in the right Level II (upper jugular) region. The remainder of the head and neck exam is unremarkable.
Which of the following is the most appropriate next step in the management of this patient?
The correct answer is:
C) Fine-needle aspiration (FNA) of the lymph node
In an adult over the age of 40 years with a firm, fixed, and painless neck mass, the rule of 80s applies: 80% are neoplastic, and 80% of those are metastatic. The gold standard for the initial evaluation of a suspicious neck mass is fine-needle aspiration. FNA is preferred over excisional biopsy because an open biopsy of a metastatic node from an unknown primary, often squamous cell carcinoma, can disrupt tissue planes, complicate future neck dissection, and increase the risk of regional recurrence. FNA provides a tissue diagnosis with minimal morbidity and high sensitivity.
Answer choice A: 2-week trial of broad-spectrum antibiotics, is incorrect. This is appropriate for a patient with signs of infection, such as a tender, red, and warm lymph node) In a smoker with a firm, painless mass, delaying the workup for malignancy is dangerous.
Answer choice B: Excisional biopsy of the lymph node, is incorrect. This should only be performed if FNA is non-diagnostic or if lymphoma is strongly suspected and a whole node is needed for architecture, and only after a thorough search for a primary site (e.g., laryngoscopy/imaging) has been completed.
Answer choice D: PET/CT scan of the whole body, is incorrect. While useful for staging once a diagnosis is made, PET/CT scan of the whole body is not the initial step. A contrast-enhanced CT of the neck or a directed FNA comes first.
Answer choice E: Reassurance and follow-up in 3 months, is incorrect. A firm, fixed mass in an older patient with smoking history is a red flag for malignancy until proven otherwise.
Key Learning Point
Any firm, non-tender, enlarging neck mass in an adult should be considered metastatic squamous cell carcinoma (SCC) until proven otherwise. The primary site is usually in the upper aerodigestive tract, such as the tonsil, base of tongue, or larynx) The diagnostic workup includes: 1) fiberoptic laryngoscopy to look for a primary tumor; 2) fine-needle aspiration; and 3) contrast-enhanced CT or MRI of the head and neck.
