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Metastatic Lymph Nodes

Diagnosing Metastatic Lymph Nodes

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.

If your doctor is looking for your primary tumor, he or she will most likely begin with a CT scan, MRI and/or PET scan.

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 to prescribe a sedative to help you relax.

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 if your doctor is looking for your primary tumor.

As discussed above, your doctor should also test a biopsy specimen from the metastatic lymph node for certain proteins, including:

  • HPV (and P16) and EBV testing for a squamous cell carcinoma or undifferentiated cancer
  • Thyroglobulin (and TTF) and calcitonin testing if the biopsy shows adenocarcinoma or an anaplastic undifferentiated tumor; this would indicate a thyroid cancer

Next, your doctor will recommend you go to the operating room for the following procedures. These procedures might be guided by the results of the imaging studies.

  • Direct laryngoscopy, nasopharyngoscopy, cervical esophagoscopy with biopsies: In any of these procedures, your doctor will feel the entire neck, as well as the mouth and throat, and then he or she will look at all the regions of your throat and upper esophagus. Some surgeons will even take blind biopsies of four main regions: nasopharynx, piriform sinuses, hypopharynx tonsils and base of tongue.
  • Tonsil removal: Also, after a thorough look around, if no primary cancer is found, your surgeon will remove the tonsil. This should be performed only if the above biopsies are negative on frozen section. The tonsil on the side of the metastatic lymph node will be removed, but in many cases both tonsils will be removed. A tumor on the left side can lead to a metastatic lymph node on the right side.

If a primary tumor is not found after all of these tests and examinations and analysis of all of the biopsy specimens, you will be diagnosed with cancer with an unknown primary (CUP).

Known primary tumor

If you have a known primary cancer site in the head and neck, your doctor will try to find out if the cancer has spread to any of the lymph nodes.

There are a few ways your doctor might consider a diagnosis of cancer with metastatic spread to the lymph nodes:

  • By feel: Either you or your doctor might be able to feel an abnormally enlarged lymph node somewhere in the face or neck. This involves thoroughly feeling all around, including all along and if possible under the big neck muscle called the sternocleidomastoid. Even if an enlarged or abnormal lymph node is felt, you won’t know that it is cancer until either a few cells and/or the entire lymph node is examined under a microscope by a pathologist.
  • Imaging and/or functional studies: For many cancers, your doctor might decide to get some type of imaging study to look at the main tumor and/or signs of spread to any regional lymph nodes. This might include either an ultrasound, CT scan, PET scan or MRI. These studies can identify enlarged lymph nodes, abnormal-appearing lymph nodes or (with a PET scan) overactive lymph nodes. All of these can raise the suspicion of cancerous cells within the lymph node, but this can’t be confirmed until either a few cells and/or the entire lymph node is examined under a microscope by a pathologist.

While certain clinical or imaging or functional tests might raise the suspicion of cancer spread to the neck, the only way to confirm the diagnosis is to actually look at cells from the lymph node under a microscope. There are few different ways to confirm metastatic spread to a lymph node.

A biopsy is the removal of a small piece of tissue to examine under a microscope to see if it is cancerous. At some point, you will need a biopsy of the suspicious lesion in your nasal or sinus cavities (or a mass in your neck).

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 or all of the 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.
  • Sentinel lymph node biopsy (SLNB): A sentinel lymph node biopsy is a new type of lymph node biopsy being used for some cancers of the head and neck. They are mainly used in skin cancers, such as melanomas and Merkel cell cancers, but some doctors are using them in oral cancers as well.4, Morton DL, Wen DR, Foshag LJ, Essner R, Cochran A. Intraoperative lymphatic mapping and selective cervical lymphadenectomy for early-stage melanomas of the head and neck. J Clin Oncol. 1993;11:1751-1756.5 Civantos FJ, Zitsch RP, Schuller DE, Agrawal A, Smith RB, Nason R, Petruzelli G, Gourin CG, Wong RJ, Ferris RL, El Naggar A, Ridge JA, Paniello RC, Owzar K, McCall L, Chepeha DB, Yarbrough WG, Myers JN. Sentinel lymph node biopsy accurately stages the regional lymph nodes for T1-T2 oral squamous cell carcinomas: results of a prospective multi-institutional trial. J Clin Oncol. 2010;28(8):1395-400. Cancer cells spread from a tumor to regional lymph nodes by traveling through a channel of lymph and making a stop in the first lymph node along the way—the sentinel node. In SNLB, special techniques are used to figure out where that first lymph node is located. Then that lymph node is removed and analyzed. If there is cancer in that lymph node, the rest of the lymph nodes in the region are removed. If there is no cancer in that lymph node, your doctor will closely watch the area and save you from undergoing additional treatment that might not be necessary.
  • Microscopic evaluation after “elective neck dissection”: In some cases, your doctor will advise that you undergo an “elective neck dissection.” This is recommended when the chances of cancer spreading to your lymph nodes are high enough that the benefits of undergoing the procedure outweigh the risks. Many surgeons and guidelines use a 20-percent chance of hidden metastatic cancer as enough reason to recommend an elective neck dissection. After an elective neck dissection, every lymph node removed will be examined under a microscopic. In some cases, the pathologist might find that cancer has spread into the lymph node(s).
References

1 Patterns of cervical lymph node metastasis from squamous carcinomas of the upper aerodigestive tract. Patterns of cervical lymph node metastasis from squamous carcinomas of the upper aerodigestive tract. The American Journal of Surgery. 1990;160(4):405-409.

2 Patterns of Cervical Node Metastases From Squamous Carcinoma of the Larynx. Arch Otolaryngol Head Neck Surg. 1990;116(4):432-435.

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 Morton DL, Wen DR, Foshag LJ, Essner R, Cochran A. Intraoperative lymphatic mapping and selective cervical lymphadenectomy for early-stage melanomas of the head and neck. J Clin Oncol. 1993;11:1751-1756.

5 Civantos FJ, Zitsch RP, Schuller DE, Agrawal A, Smith RB, Nason R, Petruzelli G, Gourin CG, Wong RJ, Ferris RL, El Naggar A, Ridge JA, Paniello RC, Owzar K, McCall L, Chepeha DB, Yarbrough WG, Myers JN. Sentinel lymph node biopsy accurately stages the regional lymph nodes for T1-T2 oral squamous cell carcinomas: results of a prospective multi-institutional trial. J Clin Oncol. 2010;28(8):1395-400.

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 Balaker AE, Abemayor E, Elashoff D, St. John MA. Cancer of unknown primary: does treatment modality make a difference? Laryngoscope.2012;122(6):1279-82. doi: 10.1002/lary.22424. Epub 2012 Apr 26.