Adénopathies métastatiques

1. Adénopathies métastatiques Jean-Pascal Machiels Cliniques Universitaires Saint-Luc Université Catholique de Louvain

2. Adénopathie cervicale • Mr H., 62 ans • Tuméfaction cervicale droite

3. Anamnèse • AP: • Consommation tabagique>40 UAP • Infarctus mésentérique avec péritonite traités chirurgicalement • Ulcère gastrique • Coma éthylique

4. Depuis 5 mois: masse cervicale gauche indolore • Pas d’AEG ou de symptômes B • Signale des lourdeurs épigastriques • Pas de traitement au domicile

5. Examen clinique • Paramètre nx • Souffle syst. 2/6 au FM • Crépitants base pulm. gauche • Abdomen: sp • Masse mal délimitée indolore non inflammatoire au niveau cervical droit

6. Biologie • Normale • CEA=8.3 ng/ml (N<3)

7. RX thorax • normale

8. Echographie cervicale • Nombreux ggl le long du SCM (dont certains>2 cm d’axe). Un d’entre eux semble infiltrer le muscle. Certains ggl sont partiellement nécrotiques.

9. Scanner thoraco-abdominal • Présence de ggl médiastinaux. • Au niveau abdo: thrombose de l’artère mésentérique sup avec suppléance via l’arcade de Riolan. Présence de ggl rétropéritonéaux, mésentériques, inguinaux et iliaques, infracm.

11. PET Scanner • Adénopathies hypermétaboliques cervicales gauches

12. Fibroscopie ORL • Sp à part une compression extrinsèque du pharynx au niveau de sa paroi postérieure à droite

13. Fibroscopie normale • Gastroscopie normale

14. Quelle mise au point complémentaire?

15. Exérèse chirurgicale • Carcinome peu différencié d’origine indéterminée au niveau cervical droite

16. Evaluation and Management of the Patient with a Neck Mass

17. General Considerations • Patient age • Pediatric (0 – 15 years): 90% benign • Young adult (16 – 40 years): similar to pediatric • Late adult (>40 years): “rule of 80s” • Location • Congenital masses: consistent in location • Metastatic masses: key to primary lesion

18. Differential Diagnosis

19. Diagnostic Steps • History • Developmental time course • Associated symptoms (dysphagia, otalgia, voice) • Personal habits (tobacco, alcohol) • Previous irradiation or surgery • Physical Examination • Complete head and neck exam (visualize & palpate) • Emphasis on location, mobility and consistency

20. Empirical Antibiotics • Inflammatory mass suspected • Two week trial of antibiotics • Follow-up for further investigation

21. Diagnostic Tests • Fine needle aspiration biopsy (FNAB) • Computed tomography (CT) • Magnetic resonance imaging (MRI) • Ultrasonography • Radionucleotide scanning

22. Fine Needle Aspiration Biopsy • Standard of diagnosis • Indications • Any neck mass that is not an obvious abscess • Persistence after a 2 week course of antibiotics • Small gauge needle • Reduces bleeding • Seeding of tumor – not a concern • No contraindications (vascular ?)

23. Fine Needle Aspiration Biopsy

24. Computed Tomography • Distinguish cystic from solid • Extent of lesion • Vascularity (with contrast) • Detection of unknown primary (metastatic) • Pathologic node (lucent, >1.5cm, loss of shape) • Avoid contrast in thyroid lesions

25. Magnetic Resonance Imaging • Similar information as CT • Better for upper neck and skull base • Vascular delineation with infusion

26. Ultrasonography • Less important now with FNAB • Solid versus cystic masses • Congenital cysts from solid nodes/tumors • Noninvasive (pediatric)

27. Radionucleotide Scanning • Salivary and thyroid masses • Location – glandular versus extra-glandular • Functional information • FNAB now preferred for for thyroid nodules • Solitary nodules • Multinodular goiter with new increasing nodule • Hashimoto’s with new nodule

28. Thyroid mass Lymphoma Salivary tumors Lipoma Carotid body and glomus tumors Neurogenic tumors Primary Tumors

29. Lymphoma • More common in children and young adults • Up to 80% of children with Hodgkin’s have a neck mass • Signs and symptoms • Lateral neck mass only (discrete, rubbery, nontender) • Fever • Hepatosplenomegaly • Diffuse adenopathy

30. Lymphoma • FNAB – first line diagnostic test • If suggestive of lymphoma – open biopsy • Full workup – CT scans of chest, abdomen, head and neck; bone marrow biopsy

31. Salivary Gland Tumors • Enlarging mass anterior/inferior to ear or at the mandible angle is suspect • Benign • Asymptomatic except for mass • Malignant • Rapid growth, skin fixation, cranial nerve palsies

32. Salivary Gland Tumors

33. Carotid Body Tumor • Rare in children • Pulsatile, compressible mass • Mobile medial/lateral not superior/inferior • Clinical diagnosis, confirmed by angiogram or CT • No biopsy !!! • Treatment • Irradiation or close observation in the elderly • Surgical resection for small tumors in young patients • Hypotensive anesthesia • Preoperative measurement of catecholamines

34. Carotid Body Tumor

35. Lipoma • Soft, ill-defined mass • Usually >35 years of age • Asymptomatic • Clinical diagnosis – confirmed by excision

36. Lipoma

37. Congenital and Developmental Mass • Epidermal and sebaceous cysts • Branchial cleft cysts • Thyroglossal duct cyst • Vascular tumors

38. Epidermal and Sebaceous Cysts

39. Branchial Cleft Cysts • Most common as smooth, fluctuant mass underlying the SCM • Skin erythema and tenderness if infected • Treatment • Initial control of infection • Surgical excision, including tract • May necessitate a total parotidectomy (1st cleft)

40. Branchial Cleft Cysts

41. Inflammatory Disorders • Lymphadenitis • Granulomatous lymphadenitis

42. Our Patient • squamous cell carcinoma metastatic to cervical lymph nodes from an unknown primary site

43. Incidence Author # pts % Jungehulsing 723 3.7 Lefebvre 8,500 2.2 Martin 3,896 5.6 Randall 829 4.0 Richard 5,137 3.3 Jungehulsing, 2000 Lefebvre, 1990 Martin, 1944 Randall, 2000 Richard, 1977

44. 5% 12% 60% 22% 11% 13% Diagnosis 7 series (n=797) Bataini, 1987 Coker, 1977 Jesse, 1972 Marcial-Vega, 1990 Maulard, 1992 Wang, 1990

45. Metastasis Location according to Various Primary Lesions

46. Nodal Mass Workup in the Adult • Panendoscopy • FNAB positive with no primary on repeat exam • FNAB equivocal/negative in high risk patient • Directed Biopsy • All suspicious mucosal lesions • Areas of concern on CT/MRI • None observed – nasopharynx, tonsil (ipsilateral tonsillectomy for jugulodigastric nodes), base of tongue and piriforms • Synchronous primaries (10 to 20%)

47. Nodal Mass Workup in the Adult • Open excisional biopsy • Only if complete workup negative including FNA • Occurs in ~5% of patients • Be prepared for a complete neck dissection • Frozen section results (complete node excision) • Inflammatory or granulomatous – culture • Lymphoma or adenocarcinoma – close wound

48. Biopsy-proven primary 43% Unknown Primary Clinical ex. CT/(NMR) 5% Unknown Primary 3% PET-guided biopsy Tonsillectomy Diagnosis 130 suspected H&N unknown primaries Mendenhall, 1998

49. TNM/AJCC 1997 Staging • N0: no regional node metastasis • Nx: regional nodes cannot be assessed • N1: single ipsilateral node, ≤ 3 cm • N2a: single ipsilateral node, > 3 cm and ≤ 6 cm • N2b: multiple ipsilateral nodes, ≤ 6 cm • N2c: controlateral or bilateral nodes, ≤ 6 cm • N3: node > 6 cm AJCC, 1997

50. Treatment: survival 5 year survival median (min-max) All patients (23 series, n=2,167) 38% (15-65) N stage (n=932) N1 58% (19-90) N2a 41% (15-87) N2b 40% (15-63) N2c-N3 21% (0-62) Treatment Surgery (n=439) 66% (65-86) Surgery + RxTh (n=856) 50% (28-63) RxTh ± excision (n=553) 37% (16-74)