A 66-year-old man presented with a mass in the right neck. He had had this for a couple of months but it had not increased in size. He had been a smoker but had given up 5 years previously. He was otherwise fit and well apart from having had a transurethral resection of his prostate. On examination he had a 3 cm × 3 cm firm lymph node in the right midcervical region. There was no other palpable lymphadenopathy, hepatosplenomegaly or abnormality to be seen in the head and neck region.
What is the differential diagnosis in this patient and what investigations should be performed to establish a diagnosis?
In a man of this age with a node of this size the most likely cause is a malignant process. As he has been a smoker the most likely diagnosis is metastatic disease from an occult primary tumour in the upper aerodigestive tract. The other possibilities include a lymphoproliferative disease or metastatic disease from elsewhere. An infective aetiology is possible but in the absence of other symptoms or lymphadenopathy it is relatively unlikely.
Investigations should include:
a fine needle aspirate (FNA) of the node. It is essential to establish a histological diagnosis and the patient should be referred to a head and neck surgeon with an interest in oncology;
full blood count, which might be abnormal in infection or some lymphoproliferative diseases;
serum urea, creatinine, electrolytes, calcium and phosphate and liver function tests. Head and neck cancer is more common in people who drink alcohol to excess;
chest X-ray to exclude lung metastases or a primary lung cancer.
The patient attended the head and neck outpatient clinic and had a FNA performed on the lymph node. This was reported as showing no evidence of malignancy. The patient also had a fibre-optic nasoendoscopy, which did not reveal an obvious primary tumour. A computed tomography (CT) scan of the head and neck region showed no abnormality apart from the enlarged right mid-cervical lymph node. The patient was then admitted for an examination under anaesthetic and a formal lymph node biopsy.
The lymph node biopsy revealed nodular sclerosing Hodgkin lymphoma of classical variety. It is relatively common for a FNA of lymph nodes to be normal in patients with lymphoproliferative diseases (LPD) and a normal FNA does not exclude LPD. A formal biopsy, preferably with excision of the whole lymph node, is required to establish a diagnosis of lymphoma.
The patient’s staging investigations were completed with a CT scan of the chest, abdomen and pelvis and a bone marrow aspirate and trephine. There was no abnormality detected on any of these investigations.
Hodgkin lymphoma is staged using the Cotswold modification of the Ann Arbor classification (Table 27.1).1