Neck Lumps: How not to miss neck cancer

July 11, 2019

Head and neck carcinoma is on the rise and is now the fifth most common cancer worldwide. In New Zealand between 2000 and 2010....

1,916 cases were diagnosed, and this rate continues to increase.

This article was featured in the July 2019 issue of NZ Doctor Magazine. please click here to read the original article.

Risk factors include smoking, alcohol consumption, UV light exposure, and trending upwards is the human papillomavirus (HPV) type 16.

headandneckNeck lumps in adults are a common presentation in general practice. Neck masses may develop from infectious, inflammatory, congenital, traumatic, benign, or malignant neoplastic processes. While many of these neck lumps are benign, a thorough history, examination and investigation panel is necessary to ensure a head and neck cancer diagnosis is not overlooked.

Timely diagnosis of a neck lump due to metastatic head and neck squamous cell cancer is paramount because delayed diagnosis directly affects tumour stage and worsens prognosis. Unfortunately, despite substantial advances in testing modalities over the last few decades, diagnostic delays are common. The primary purpose of this guideline is to promote the efficient, effective, and accurate diagnostic workup of neck lumps to ensure that adults with potentially malignant disease receive prompt diagnosis and intervention to optimise outcomes. Specific goals include reducing delays in diagnosis of head and neck squamous cell cancer, promoting appropriate testing, including imaging, pathologic evaluation, and empiric medical therapies, reducing inappropriate testing, and promoting appropriate physical examination when cancer is suspected.

When an adult presents with a neck lump, it is recommended that the following pathway should
be followed:

History

  • Location, duration, number, change in size of lump
  • Associated symptoms - dysphagia, hoarseness, referred otalgia, fever, night sweats and weight loss
  • Risk factors – smoking, alcohol consumption, upper aerodigestive tract malignancy and skin malignancy


Examination

  • Best performed with the patient seated
  • Inspect the neck and face noting lump location, scars, suspicious skin lesions
  • Palpate the lump positioned behind the patient noting if the lump is midline or lateral, soft or hard,mobile or fixed
  • Complete the head and neck examination including the remainder of the neck, thyroid, oral cavity, oropharynx, nose and ears, and the skin of the scalp and the back of the neck
  • If lump is in parotid region, assess facial nerve
  • If lymphoma is suspected, assess for regional lymphadenopathy (axillary and inguinal regions) and hepatosplenomegaly

 

Be aware of patients with HPV-positive oropharyngeal (tonsil or tongue base) cancer, which presents in patients lacking exposure to tobacco and alcohol and who are younger than those patients with HPV-negative cancer. Furthermore, since neck metastases from HPV-positive oropharyngeal cancer may be cystic, they are often mistaken for branchial cleft cysts, further contributing to a delay in diagnosis.

Investigations

  • Serology may be useful in cases of reactive lymphadenopathy (toxoplasmosis, brucellosis, bartonella, CMV). However, serology suggesting a past or current infection does not exclude a cancer diagnosis
  • Ultrasound scan is used to assess neck lumps and select suspicious cases for fine needle aspiration biopsy (FNAB)
  • Imaging of neck lumps has minimal place in primary care because it can delay cancer diagnosis, except in young low risk patients with small likely reactive lymph nodes and no other red flag symptoms – confirmation of a reactive lymph node may avoid need for referral
  • FNAB is best performed with ultrasound guidance and produces a diagnosis in 99% of cases compared to 66% for FNAB performed without ultrasound guidance
  • FNAB with ultrasound guidance is not accessible to GPs. However, GPs have referral access to the MercyAscot multidisciplinary Neck Lump clinic where a radiologist (ultrasound and FNAB with ultrasound guidance), pathologist (immediate FNAB cytology assessment), and surgeon are available.

REFERRAL GUIDELINES

Cases considered appropriate for referral to the MercyAscot Neck Lump Clinic include:

  • Lymph nodes increasing in size
  • Lymph nodes greater than 2 cm in size
  • Neck lump present for more than 3 weeks that has changed
  • Neck lump present for 6 weeks or more
  • Widespread lymphadenopathy (refer directly to haematology).
  • Presence of ‘B’ symptoms - drenching nightsweats, generalised itching, weight loss, fever.