Hot Seat #43: 15 yo with a neck mass
Posted on: September 20, 2014, by : Adam Kochman MD
by Adam Kochman, Inova Children’s Hospital
with Karen O’Connell, Children’s National
The Case
15 y/o previously healthy male referred form PCP office with 4-5 weeks of right neck mass. Began as round swelling which enlarged over first 2 weeks and then evolved to flattened mass w/o significant progression in size over last 2 weeks. Pt describes mild tenderness to palpation and “tightness” with lateral neck rotation. He endorses mild odynophagia but denies dysphagia. Had mild URI 2 m/a but o/w been healthy.
No fevers, night sweats, fatigue, or weight loss. No cough, dyspnea, SOB or CP. No other rashes, skin lesions or masses. No recent travel or known insect bites.
PMH: asthma
Social: 10th grade honor roll student, denies tobacco, alcohol or illicit drugs
FH: Father died of MI in early 40s. No FH malignancy
Medications/Allergies: None
ROS negative aside from HPI
Vitals: BP 119/68, HR 66, T 37.3º, RR 20, SpO2 99% (RA), Wt 68.9kg
Gen: Well appearing, well hydrated, no distress
ENT: Nl TMs bilaterally, moist mucous membranes w/o erythema or tonsillar inflammation, no oral lesions, handling secretions well
Neck: Firm mass in right medial supraclavicular region, roughly 2 x 6cm but with indiscrete borders, nonfluctuant and immovable. Mild tenderness with minimal overlying erythema. Full ROM despite discomfort with lateral rotation, no meningismus or torticollis.
Chest: No dyspnea, tachypnea or increased WOB
Skin: Warm and dry, no rashes or petechiae
Lymphatic: No cervical adenopathy, supraclavicular or axillary adenopathy aside from previously described mass
(Head, eyes, CV, abdominal and neuro exams all normal)
Questions for you:
Interim Update:
CBC: 8.3>13.4/40.2, ESR/CRP: 17/0.8
CMP WNL
CK: 164
LDH: 177, Uric Acid: 4.8
CXR WNL
How would you approach this case? Please share your opinions by clicking on “What do you think?” below.
Neck masses are a great topic. kudos! and i think they’re mismanaged frequently so good to talk about. Neck masses really are about the clinical exam first and foremost!
My first step is to isolate the LOCATION. is this in parotid distribution? cervical chain? brachial cleft area?
My second step is to DIFFERENTIATE lymphadenitis from lymphadenopathy, since those are the most common problems. Lymphadenitis is tender! +/- erythema, and +/- fluctuance if a fluid collection is present (abscess). Ultrasound can help identify deep fluid collections and differentiate from lymphadenopathy, but the ladder part should be clinical. Lymphadenopathy is typically non-tender (or minimally tender) and not erythematous or fluctuant and takes you down a different path. Makes me think of tracking localized infection (bartonella), malignancy (lymphoma), or other inflammatory diseases.
This case doesn’t really sound like either lymphadenopathy or lymphadenitis. a non-movable firm large mass in mid-lateral neck…….hmmmm. the non-movable part makes me think of a soft tissue tumor like rhabdomyosarcoma. the location makes me think of tuberculous or non-tuberculous mycobaterium.
This sounds like a case where the tissue is the issue, but figuring out who needs to get the sample is the key.
So I would place a PPD and get an ultrasound. If the ultrasound showed this to be lymphadenopathy or lack of deep tissue involvement, i would refer to ID to culture the thing (for MAC) or do further testing for infectious diseases like bartonella etc. I think you have to r/o infection before going down the lymphoma pathway. If the ultrasound showed a soft-tissue tumor, I would consult oncology to coordinate a biopsy for suspected rhabdomyosarcoma.
I try to do neck CT’s almost never in kids older than 5. Maybe for an ill-appearing kid with suspected Lemierre’s disease.
A single enlarged lymph node is usually of infectious or malignant origin. In thinking about infection, this sounds like lymphadenopathy and not adenitis, since there is little pain, redness or warmth. In terms of adenopathy, the supraclavicular area is not a typical drainage area for infections, nor is it usually involved in viral processes. Nevertheless, I would perform a careful physical exam of all of the lymph nodes– axillary, epitrochlear, cervical chains, liver, spleen and inguinal areas. If there is regional adenopathy, I would consider viral causes and Bartonella. Generalized adenopathy can be caused by viruses, and HIV can be considered in a 15yo. As mentioned, a single enlarged LN can also be caused by TB and by atypical mycobacterium.
In thinking about malignancies, leukemia is the most common childhood cancer and can cause adenopathy. But usually if there is one very enlarged LN in leukemia, then there are typically others as well, since there is a significant whole body tumor burden. Also, the cbc shows no abnormal cell lines. So under the malignant category, there is less concern for leukemia and high concern for lymphoma, which can present with a normal CBC (no bone marrow involvement) and a solitary LN with poor mobility and with the consistency of hard rubber. Not sure whether a rhabdomyoscarcoma would present in this way. In the adult world, there are a series of cancers that present with supraclavicular adenopathy- stomach, and others I no longer know.
Plan:
– more history around travel, TB exposure, soil exposures (MAC)
– identify if any more LNs involved
– US to identify if any evidence of abscess
– PPD (+ in TB and in MAC)
– EBV, CMV, HIV, and B henselae testing
– CXR for mediastinal involvement
– admit given that LN is fixed to underlying tissue, since excisional biopsy likely needed for dx in general and for treatment of MAC in particular
If this subacute-chronic, large, firm, nonfluctuant, indiscreet, inmovable, matted mass was in the left supraclavicular region, this would be very concerning for a Virchow’s node — sentinel node from abdominal malignancies (gastric cancer classically). Despite this mass being on the right, I’m still quite concerned about this being a sentinel node. As Dave states, “tissue is the issue”. I think this mass needs to be biopsied.
Agree with all of these excellent clinicians on ddx (onco including sarcomas or lymphoma > teratoma, neuroblastoma, thyroid) (less likely infection by sx unless a subacute presentation, eg. TB although these are often more tender and continue to grow not flatten without treatment).
ISSUE = TISSUE.
We’re not getting it ourselves in the ED, so I would go straight to surgery consult while basic labs are still cooking. Ultrasound will be interesting (“soft tissue mass, 2.3 x 5.6 x 1.45 cm, with enhanced echogenicity distinct from surrounding tissue with scant surrounding inflammatory changes, suggest clinical correlation for infectious versus oncologic causes; more imaging is needed…”) but is not likely to lead us to the promised land in this case (although u/s is often very helpful just maybe not in this case).
The person who will be sticking a needle or knife into this guy’s neck should determine the imaging of choice.
So, my excellent colleagues beat me to the punch with much of the differential laid out. When I approach an adolescent with a slowly expanding neck mass (4-5 weeks in this case) my immediate work up is guided by the top etiologies in this age group (which are often not so benign). With patient safety at the top of my agenda, I start with the worst case scenario and work my way backwards.
First question: respiratory distress -yes or no (in this case no)
Second question: traumatic -yes or no (no in this case)
Third question: “hot” or not (no in this case)
Fourth question: what is the location? (Right medial supraclavicular)
Most pediatric neck masses are reactive LAD or lymphadenitis. I rarely initiate lab testing. In cases of lymphadenitis, a trial course of antibiotics to cover staph, strep, and occasionally anaerobes may be reasonable. Close follow up with the PCP is imperative.
This case, however, is more concerning. The thorough history and PE detailed in this case are enough to get an ED doc’s attention. This adolescent was referred by his PCP who had been closely following the neck mass (no mention of a trial of antibiotics in the case). The consistency, size, location, and progression of symptoms is concerning for malignancy. The lack of systemic symptoms, supraclavicular LAD, and normal labs and cxr make this less likely to be a secondary manifestation of malignancy and more likely a primary neck malignancy. In addition, the margins are irregular, consistency firm, size larger than 3cm, and non immobile nature. Ugh :(.
So now to the academic part. I divide my DDx into 4 categories: 1. Inflammatory;2. Congenital;3. Neoplasticism;4. Traumatic. My colleagues have listed the components that full each category diligently in the previous posts.
Next, I divide the neck into 3 parts: 1. Anterior triangle;2. Midline:3. Posterior triangle.
My DDx: rhabdomyosarcoma; lymphoma; neuroblastoma; cystic hygroma; infectious (MAC, TB, bartonella)
Work up recommendations: time for lab work: CBC, esr, crp, uric acid, LDH, cmp (all of which were normal in this case); CXR; Neck US; and possible CT depending on US findings. A PPD should be placed and biopsy planned.
This can be arranged as an outpatient in this case where the patient has no resp symptoms and can tolerate PO, but may be expedited as an inpatient.
More to discuss tomorrow. Cheers!