Neck Lumps and Bumps Rapid Fire Session: Update Course 2015

What I did was I limited it to neck lumps and bumps because those are the ones that seem to cause the most anxiety um in trying to decide what to do. So here's our case study. I have a 14-year-old male with a 3 centimeter left mid anterior cervical node for 2 months. It has increased in size during a trial of antibiotic treatment. It is firm, hard, and fixed, and he has no other symptoms. I know this is not, this is not, this one is not rocket science, but it does give us an opportunity to talk about, uh, the evaluation and decision tree, uh, management, uh, for neck masses. Neck masses are developmental. They are inflammatory and reactive. Or they are neoplastic. Here is a modified slide, I apologize for the size, um, that attempts to talk about what is the most likely diagnosis depending upon the location that you find it. Anterior anterior to the sternocleidomastoid muscle, midline, submandibular, submental, supraclavicular, um, these are the most common types of diagnosis, but you can see that for the most part they all include the potential for neoplasm. OK. Well, what do we know? We know that palpable nodes in children are very common. We know that most of them are benign. Reactive nodes tend to be small or fluctuate in size. It's a, a, a, a, a cervical node that decreases in size is, uh, will be extraordinarily unlikely to be a neoplastic. Uh, the symptoms of fever, weight loss, or gainomegaly may be indicators of neoplasia, but the duration and consistency of the symptoms, they are not good indications that it's a neoplasm. The diagnostic utility of a chest X-ray in these children is actually unknown. Some people do it routinely, but the diagnostic yield appears to be very minimal. If you see something on the chest X-ray, obviously that's going to be helpful, but seeing nothing on the chest X-ray doesn't tell you anything really about the lymph nodes. Uh, in these patients with enlarged nodes, whether they're malignant or not, abnormalities of the white, uh, the complete blood counts, red cells, white cells, etc. are, uh, very uncommon. The utility of a fine needle biopsy in pediatric population in the evaluation of lymph nodes is unclear. There are several papers that show that it has a good diagnostic yield in adults. There are some suggestions in pediatric papers that it does have some efficacy. The problem is, is if you get necrotic tissue, um, and that doesn't help. And it's also occasionally difficult to do with a child, um, because they're not going to be sitting still while you're sitting in a needle in their neck, and if you have to do it a second time because of, you know, poor diagnostic yield the first time that they came in, it's probably just easier just to take the thing out. But even when suspicious, most enlarged lymph nodes are not malignant in children. So when do we operate on these children? Enlarged nodes persistent for greater than 6 weeks, these are considered indications for surgery. So if it's an enlarged, would someone do that? Do you do that? large node, let's say it's enlarged. Let's say it's 1 centimeter. 1 centimeter node for for no, no, when I say enlarged, I apologize. Enlarged to me is going to be greater than 2 centimeters centimeters. OK, well, 1 centimeter node that has not, you know, that has been there, I'm not going to do anything about and lymph nodes that are, you know, necessarily bilateral are associated with an upper respiratory infection and such. I mean those types of things are going to be reasonable to watch. But if you have an enlarged lymph node greater than 2 centimeters that has not changed in 6 weeks. It is reasonable to consider operation in this job. 2 centimeters. I'm close to doing something. 2 centimeters is big. So the question is, I'm not even, I mean, you, I probably wouldn't even wait 6 weeks. I say it's hard to wait 6 weeks, but that's probably prudent because some of those will go away. Talking to our oncologists, they say to wait. I mean, would everyone here wait 6 weeks with a 2 centimeter node? Yeah, that's usually my, what's that? No symptoms, no symptoms, no symptoms, yeah. So if they have night sweats or any B type symptoms, then yeah, I think this is one area that you really have to get the parental buy-in. Some parents can't sleep at night. They've got a cousin or or an uncle who's got, you know, uh, some lymphoma, and they can't sleep at night. Others say that's fine. I'm not too concerned about it. And so I, I really think you have to talk to them and get their sense. I think medically waiting 6 weeks is just fine. But practically I just think there's some families who don't want to wait 6 weeks, and if you get them to 4 weeks, that's doing pretty good. Yeah, I'd book. At that time I say I'm gonna book this right now for 4 or 6 weeks or so, and if it shrinks we'll cancel it. That's end up doing that's actually a very good plan, but, but by the time they see you, it's probably been 3 or 4 weeks at least because they've seen their pediatrician at least once, maybe twice, so it's probably 43 to 4 weeks by the time they've seen you and you put it on the schedule for a couple of weeks and that gives you 6 weeks. There you go, OK. Uh, another indication to operate if the size of the lymph node increases while on antibiotic treatment. OK, OK, good. Do you test for, uh, cat scratch? Oh yeah, we do, yeah, well, I mean, I'm assuming that all the, all those tests and stuff have been done. The child's been worked up, that they've just come to our office and they have a note and they've not been able to find any other etiology. So you're just dealing with a child with no other anything except a lump in their neck. When do you check for a cat scratch because I don't routinely send it. So you know it's interesting is a lot of the kids with cat scratch, you know, you don't have to be scratched. They can be licked and then rubbed their eye, and if you get a history of conjunctive, either a history of a cat scratch or a history of conjunctivitis of a couple weeks beforehand are, uh, very indicative of cat scratch, and it doesn't necessarily have to be cats, but if they're around, but do you send it, like I, I don't send it unless they've persisted for their 3rd follow-up with me. Like I don't send it on their first by then you're at 6 weeks. Exactly. And then sometimes, and then, and other kids, a lot of kids I'll get, well, I've already had a Z-Pak, so that should effectively, if it was cat scratch, it's now been treated. So, so a lot of you send it on their first visit. They come to you with a note and you send off cat scratch. I would go a little farther than Mark, and I ask, do they, do they play with cats? Yeah, you don't know if they're around cats. Are they around cats? And if the answer is no, then I don't worry too much about cat scratch. OK, OK, all right, um, another reason to have the slide again, please, uh, another indication would be a firm rubbery node greater than 2 centimeters. That's fairly obvious to all of us. A hard immobile mass. And a mass located in the supraclavicular area that is completely abnormal and um not associated with anything inflammatory as a rule and those need to be biopsied and obviously a thyroid mass. Great. That's it, thank you. All right, that was great and that's, those are the very kind.