Close

Neck Cancers

Diagnosing Neck Cancer

Getting to a diagnosis begins with a history and physical examination. If the symptoms haven’t been present for very long, or if the history and physical examination make the doctor less suspicious that your lump is cancer, your doctor might try some medications and rehabilitation before jumping to a diagnosis of cancer.

At some point, if your doctor is not certain of a diagnosis, and if symptoms aren’t getting better (and definitely if symptoms are getting worse), your doctor should raise the possibility of starting a cancer work-up. As with most cancers in the head and neck, this will include some combination of biopsy and imaging tests, which is the term that doctors use to refer to X-rays, MRIs, CT scans, etc.

Imaging

Imaging refers to radiologic studies, or scans, that create pictures of the structures inside your head and neck. In general, imaging might not be necessary for small tumors easily evaluated on physical examination. For larger tumors, or tumors in locations difficult to examine, your doctor will probably order some sort of imaging to get more information about the tumor location and possible spread to regional lymph nodes. Spread into other structures will influence what treatment your doctor recommends for you.

The two main techniques used in the U.S. are computed tomography (CT) scans and magnetic resonance imaging (MRI) scans. Ultrasound is a quick and inexpensive way to get information about disease in the neck. PET scans are studies that look at the function of cells in the body, and they are being used more and more in oncology. PET scans can be combined with other imaging methods such as CT scans to get more information.

  • CT scan: This is a quick series of X-rays that can show very good detail of the anatomy. It is helpful in seeing the extent of the main tumor mass and what structures it has invaded. It can also help pick up spread into the neck.
  • Advantages: A CT scan is a quick test that is readily available and gives a great deal of useful information.
  • Disadvantages: A CT scan involves radiation, and the images can be degraded by movement and dental work. It only shows late changes associated with invasion into nerves (such as destruction of the bone where the nerve enters the skull).
  • Important points: A CT scan looking for throat tumors should be done with contrast injected into your veins, unless there is some reason that you cannot receive contrast.
  • What to expect: First, a nurse will insert an intravenous line into a vein to allow for contrast injection. Then you will have to lie flat on a table with your head in a little holster to help keep it totally still. CT scans are typically open, so you shouldn’t feel enclosed. You will then get an injection of contrast, and soon after, the scanner will start moving and taking pictures; this part should take only one or two minutes. Try not to swallow, speak or move during this quick test.
  • MRI: This test uses magnets to create a picture of the inside of the neck. It is good for showing more subtle details of how extensive the main tumor mass is. It can also help pick up spread of cancer to lymph nodes in the neck.
  • Advantages: There is no radiation involved, and the details of the soft tissues are better than that of a CT scan.
  • Disadvantages: An MRI takes much longer than a CT scan and is more expensive. Some people feel enclosed inside the MRI machine. Images can be degraded with movement and dental work. There can be loud banging inside the machine, which can be uncomfortable.
  • Important points: This test should be done with and without contrast injected into your veins, unless there is some reason you can’t have contrast. Closed MRI machines usually give better pictures than open MRI machines.
  • What to expect: First, a nurse will insert an intravenous line into a vein to allow for contrast injection. Then you will have to lie flat on a table with your head in a holster to help keep it totally still. You will then enter the scanner, and the MRI machine will start moving and taking pictures. You will hear loud noise, but that is normal so do not be concerned. The process can take 30 to 60 minutes, depending on how the scan is done. Try to stay as still as possible throughout the test. If you are prone to claustrophobia, you should ask your doctor about prescribing a sedative to help take the edge off.
  • Positron Emission Tomography (PET): Doctors are still studying the most appropriate uses of PET scans for head and neck cancer. The main uses of PET scans at this point are to see if there is spread to sites in the neck or other parts of the body or to help find a primary tumor when the only evidence of cancer is a lymph node that has cancer in it. It is often combined with a CT scan (or in some cases an MRI) to help pinpoint the location of active cells.
  • Neck ultrasound: An ultrasound is a way to look at vessels, structures and lymph nodes all over the body, particularly in the neck and thyroid gland. You are not exposed to any radiation, and it doesn’t hurt. Basically, a technician or a radiologist will place some cold jelly over the area he or she is examining and rub a plastic probe over the area to take pictures. The technician can see enlarged lymph nodes and nodules deep in the neck and describe details about them such as whether they have fluid inside, have a lot of blood vessels around and so on. At the same time as he or she is performing an ultrasound, a doctor can place a needle into a lymph node or nodule and draw off cells (this is an ultrasound-guided biopsy).
  • Chest X-ray: This is a quick, inexpensive and easy way to look for signs of spread of cancer into the lungs or the possibility of a different cancer in the lungs. Some doctors will recommend a chest X-ray every few months or every year as follow-up if you have had a head and neck cancer. This is because patients who have had head and neck cancer are at a higher risk of getting lung cancer as well.

Biopsy

A biopsy is the removal of a small piece of tissue to examine under a microscope to see if it is cancerous.

For cancers in the neck, when performing a biopsy, your doctors should test for certain viruses such as human papillomavirus (HPV) and Epstein-Barr Virus (EBV). They can also test for proteins related to these viruses (e.g., P16 as it relates to HPV infection). Cancerous lymph nodes that have the HPV virus (or P16 protein) are very likely to be related to a primary cancer in the oropharynx.3 Zhang MQ, El-Mofty SK, Dávila RM. Detection of human papillomavirus-related squamous cell carcinoma cytologically and by in situ hybridization in fine-needle aspiration biopsies of cervical metastasis: a tool for identifying the site of an occult head and neck primary. Cancer. 2008;114(2):118-23. Likewise, EBV in the biopsy of a cancerous lymph node in the neck should raise the suspicion of a nasopharyngeal cancer. Another example of getting extra information from a neck biopsy is looking for proteins that might lead to a primary cancer site. For example, a cancerous neck lymph node that stains for Thyroglobulin or TTF-1 indicates that there is probably a cancer in the thyroid gland. A pathologist focused in head and neck cancer should run the appropriate tests on a neck biopsy to help find the source of cancer that has spread to the neck.

In most cases, the first type of biopsy should always be a fine needle aspiration biopsy (FNAB). For sarcoma, the grade and type of sarcoma should be obtained.

There are a few different ways to do a biopsy of the neck:

  • Fine needle aspiration biopsy: The most common and easiest way to biopsy is fine needle aspiration biopsy (FNAB), in which a tiny needle is placed into the tumor and some cells are drawn out through a syringe. The pathology doctor, known as a cytologist or cytopathologist, will then immediately look at the cells under the microscope and let your doctor know if there were enough cells to make a diagnosis. A number of “passes” might be done to increase the likelihood that there are enough cells to make a diagnosis. The final diagnosis may take a few days to come back, so be patient.

 

Different Types of Fine Needle Aspiration Biopsies

By Feel” FNAB Ultrasound-guided FNAB CT-guided FNAB
When your doctor might use this technique If the lump can be easily felt by your doctor If your doctor thinks it will be difficult to get the needle directly into the lump with certainty If your doctor doesn’t think he or she will be able to get into the tumor by feel or with ultrasound guidance
What to expect Your doctor will feel the lump and place a tiny needle directly into it to extract some cells. Your doctor will use a gentle probe on your face or neck, identify the tumor with the ultrasound and then watch the needle go directly into the tumor on the ultrasound machine. You will be placed into a CT scanner, and a few low-dose CT scans will be performed—first to localize the tumor and then to make sure the needle that is placed is actually within the tumor.There is new technology known as fluoroscopic CT scanning, in which the radiologist can quickly take a few scans without leaving the room, moving the needle around to get it into the right place.
  • Core biopsy: Core biopsy is an alternative to fine needle aspiration. A core biopsy is done in the same way as an FNA biopsy, but it uses a larger needle and removes a core of tissue from the tumor rather than just a few cells. The likelihood of false positives and false negatives is much lower with a core needle biopsy than with a fine needle biopsy, but it is not always clear which patients should have core biopsies rather than FNA biopsies.
  • Open neck biopsy: An open biopsy involves making an incision over the tumor and removing a piece of or the entire tumor to make a diagnosis. An open biopsy of a neck mass is performed through an incision over the lump, and either a piece (incisional open neck biopsy) or the entire lump (excisional open neck biopsy) is removed to make a diagnosis. Except in a few special circumstances (such as if the tumor is likely a lymphoma or if other methods of diagnosis have not worked), this method should not be used to find the diagnosis of a neck mass.

Serology

Serology involves checking your blood for certain proteins, including viral proteins, antibodies to certain bacteria and markers for inflammation. Also, your doctor might test you for tuberculosis by injecting some antigen just under your skin on your forearm. If you are diagnosed with lymphoma, your doctor will perform a whole host of additional lab tests, and possibly even biopsies.

References

1 Gurney JG, Young JL, Roffers SD, Smith MA, Bunin GR. SEER pediatric monograph – soft tissue sarcomas. National Cancer Institute. Page 111. http://seer.cancer.gov/publications/childhood/softtissue.pdf.

2 Fletcher CDM, Rydholm A, Singer S, Sundaram M, Coindre JM. Soft Tissue Tumours. In: Barnes EL, Eveson JW, Reichart P, Sidransky D, editors. World Health Organization classification of tumours: pathology & genetics WHO Classification. Lyon: IARCPress; 2005.

3 Zhang MQ, El-Mofty SK, Dávila RM. Detection of human papillomavirus-related squamous cell carcinoma cytologically and by in situ hybridization in fine-needle aspiration biopsies of cervical metastasis: a tool for identifying the site of an occult head and neck primary. Cancer. 2008;114(2):118-23.

4 Cunningham MJ, Myers EN, Bluestone CD. Malignant tumors of the head and neck in children – a 20 year review. International Journal of Pediatric Otorhinolaryngology. 1987;(13)3:279-292.

5 Edge SB, et al. The AJCC Cancer Staging Manual – Seventh Edition. American Joint Committee on Cancer 2010. Page 611.

6 Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers V.2.2013. © National Comprehensive Cancer Network, Inc 2013. All rights reserved. Accessed June 20, 2013. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.

7 Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Soft Tissue Sarcoma V.1.2013. © National Comprehensive Cancer Network, Inc 2013. All rights reserved. Accessed July 17, 2013. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.

8 Ries LAG, Young JL, Keel GE, Eisner MP, Lin YD, Horner M-J (editors). SEER Survival Monograph: Cancer Survival Among Adults: U.S. SEER Program, 1988-2001, Patient and Tumor Characteristics. National Cancer Institute, SEER Program, NIH Pub. No. 07-6215, Bethesda, MD, 2007.