Close

Metastatic Lymph Nodes

What to Expect at Your Doctor’s Visit

Step 1: History

First, your head and neck specialist will take a thorough history of your health and address any specific concerns you may have.

Your doctor might ask questions such as:

  • How long has the problem been there?
  • Is it getting worse, better or staying the same?
  • Does it come and go?
  • Have you tried anything to make it better?
  • Is it painful?
  • Do you have numbness or tingling anywhere in your face or mouth?
  • Do you have any changes in your vision or hearing?
  • Do you have a change in your sense of smell?
  • Do you have any lumps or bumps in your neck?
  • Are you losing weight?
  • Do you have any other medical conditions?
  • Have you had any surgeries in the past?
  • What medications do you take? And do you have any allergies?
  • Have you ever been exposed to radiation in the head and neck?
  • What do you (or did you) do for a living?
  • Do you have a family history of cancer?
  • Have you been exposed to a cat?
  • Have you travelled anywhere or been around anyone with an infectious disease such as tuberculosis?

Step 2: Physical Exam

Next, your doctor will examine you. Typically, if you’re seeing a specialist in head and neck disorders, you will get a thorough physical examination focused on the area of concern.

Your doctor will look at and feel your neck to get an idea of the nature of the lump. Is it fixed or mobile? Is it tender? Are there skin changes over it?

Then you’ll get a complete examination of your face, scalp, mouth, ears, nose and throat. The throat typically takes a specialist to examine because it is difficult to see and feel by a general doctor. In general, your specialist might do some of the following:

  • Look and feel inside your mouth
  • Feel your neck extensively and carefully to check for any lumps or bumps
  • Look inside your ears
  • Look inside the front of your nose
  • Check your cranial nerves by asking you to move your face, stick your tongue out, lift your shoulders, follow his or her fingers around with your eyes, do some simple hearing tests and test your sense of touch all over your face

Once a diagnosis of a metastatic cancerous lymph node in the neck has been made, the most important next step is to try to find a primary tumor if at all possible. There are some clues that will help direct that search:

  • The type of cancer found in the needle biopsy: The needle biopsy should be able to determine what type of cancer it is. For example:
    • If the lymph node has thyroid tissue within it (or proteins related to the thyroid such a Thyroglobulin or TTF), your doctor will look for a tumor in the thyroid gland and follow treatment guidelines for thyroid cancer.
    • If the lymph node shows evidence of a lymphoma, your doctor will refer you to an oncologist who specializes in blood cancers.
    • If the lymph node has a salivary gland cancer, then it will direct your doctor’s examination and tests toward areas that have salivary glands.
    • If the lymph node biopsy shows a squamous cell carcinoma, you will get a thorough examination of areas that have squamous cells (mouth, throat nose and even skin).
    • If there is evidence of the human papillomavirus (HPV) in the biopsy specimen (or a protein related to HPV such as P16), your doctor will direct his or her examination to the oropharynx as a primary source.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.
    • If there is evidence of the Epstein-Barr Virus (EBV) in the biopsy specimen, your doctor will direct the examination toward the nasopharynx as a primary source.
  • The location of the metastatic lymph node: As discussed above, where the lymph node is located can sometimes help guide the search. For example:
    • A metastatic lymph node within the parotid gland can be from a scalp or skin cancer.
    • A metastatic lymph node behind the big muscle in the neck, called the sternocleidomastoid, can be from a skin or scalp cancer.
    • A metastatic lymph node in the submandibular (or Level I) region can be spread from a primary cancer in the oral cavity (mouth).
    • Metastatic lymph nodes in Level IV or low Level V (these can be called supraclavicular—above the collarbone—nodes) can be from cancers in the chest, abdomen or pelvis.

Step 3: Reviewing Tests

After getting your history and performing a physical exam, your doctor will review any imaging, laboratory work and pathology results you may have already had. Be sure to bring all of these with you to your appointment. Bring actual discs of any scans you’ve had, as well as any reports of those scans. If you are seeing a head and neck cancer specialist after a lesion was removed by a non-cancer specialist, you need a thorough review of the pathology to discuss whether additional treatment is necessary. Try to obtain the actual glass slides that were prepared by the pathologist with the specimen taken during your biopsy procedure so your doctor can conduct a complete review. You might need more tissue removed or further treatment.

Step 4: Recommendations

Finally, your doctor will make recommendations about your next steps. This will likely include reviewing some of the studies you’ve already had done or ordering more tests. The next steps might depend on whether your doctor finds a primary site of cancer associated with the metastatic lymph node. If a primary tumor site is still not identified, you will probably be sent for more tests and procedures before establishing a treatment plan.

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.