Left Supraclavicular Mass/Edema

[premed3341]

I was wondering if anyone out there could help me out. About two months ago felt a mass above my left clavicle. I went to the doctor, he ordered a full spectrum of labs and a CT with and w/o contrast. The labs all came back normal, and the ct was normal as well. My dr told me that if the mass persisted to contact him for a follow up that would probably accompany a referral to a surgeon for a biopsy. Ive had no abnormal symptoms, and am a little worried about the probable biopsy/diagnosis. Could it still be something pathological even though the CT was fine? Could what Im feeling just be a normal anatomical structur/muscle? Am I automatically doomed because of the masses location? Please help!
-Thanks

[Dr. Tamer Fouad]

Hello premed3341,
Thank you for using The Doctors Lounge.
As you already know an enlarged supraclavicular lymph node is always an indication that your doctor must exclude malignancy by all possible means. So I will focus my discussion mainly on excluding cancer.

I am assuming your Dr. has already determined by examination that this indeed a lymph node enlargement, or is he still confused about its nature.
Did your CT involve the supraclavicular area as well or was it only performed on the head and neck? This would confirm the presence of a lymph node and may indicate if it is abnormal or not. More easily, an ultrasound scan would also be able to detect a supraclavicular lymph gland enlargement. It may show cortical necrosis which is an indication fo possible malignancy.

Once the presence of a lymph node enlargement is established then many things are taken into consideration: your age (incidence of cancer increases with age especially above 40 years), history of malignant disease, the size of the lymph node (>1cm) and the presence or absence of constitutional symptoms among other things.

Given the presence of risk factors, your doctor may consider observation for a period of time and then decide on further investigation. This may include a fine needle aspiration which usually does not yield significant information. On the other hand a biopsy may be warranted in persistant cases.

Please do not consider yourself doomed. If your doctor was sure you had cancer he would not have waited to give you therapy. Trust in your doctor's judgement as he appears to care about you.

[premed3341]

Thanks for the reply. The CT scan was of the Suprclavicular fossa and Chest. The results said that everything looked normal, although I can still paplate the mass. So I have an appointment next Monday to see my PCP, and Im pretty sure hes going to refer me to a surgeon for a biopsy. Like I said, I havent had any signifigant symptoms, but Im 24 and Have smoked for about 7 years. Im really worried about what the results of the biopsy are going to be. Im not sure what to think or do. Should I ask my doctor anything specific when I see him?

[Dr. Tamer Fouad]

Hello premed3341,
Obviously I am in no position to challenge your doctor's opinion as he has the advantage of being able to examine you. If I was examining a patient and could feel a supraclavicular mass I would be worried even if the CT scan turned out negative. However, let me give you a few thoughts.
Palpation of lymph nodes is known to be much less sensitive in detecting lymph node enlargement. Both the sensitivity and specificity are in the range of 60-70%, depending on the tumor studied. This means that there is a rather high possibility of false negative and false positive results (as in your case). A false positive result means that the doctor feels an enlarged lymph node when in reality there is none. Nodes had to have a diameter of 22.3 mm or greater to be palpated in 50% of cases in one study (van Overhagen et al, 2004).
In that study, the sensitivity of ultrasonography was triple that of palpation for the detection of metastases in supraclavicular lymph nodes and CT scans were found to be as sensitive as ultrasonography. Ultrasonography can be combined with fine needle aspiration cytology which gives more conclusive results.
PET scans have been reported to be more sensitive than CT scans in the detection of malignant disease in lymph nodes. However, PET scans are expensive and not always available.

Let me also add that in another study, patients 40 years of age and older with unexplained lymphadenopathy have about a 4 percent risk of cancer versus a 0.4 percent risk in patients younger than age 40 (Fijten et al, 1988).

Given the high probability of false positives by palpation and the results of your CT scan and your age, the surgeon may opt to perform any of the other methods of diagnosis above. If he decides that a biopsy is warranted he will dissect a very small opening in the skin remove any masses he can see and analyze them.

I have given you a list of different modalities which are used to diagnose lymph node enlargement which you can discuss with your doctor. Keep us updated.

References:
---------------
Fijten GH, Blijham GH. Unexplained lymphadenopathy in family practice. An evaluation of the probability of malignant causes and the effectiveness of physicians' workup. J Fam Pract 1988;27: 373-6.

Hans van Overhagen, MD, PhD, Koen Brakel, MD, PhD, Mark W. Heijenbrok, MD, Jan H. L. M. van Kasteren, MD, Cees N. F. van de Moosdijk, MD, Albert C. Roldaan, MD, PhD, Ad P. van Gils, MD, PhD and Bettina E. Hansen, MSc. Metastases in Supraclavicular Lymph Nodes in Lung Cancer: Assessment with Palpation, US, and CT. Radiology 2004;232:75-80.

[premed3341]

Thanks for the reply and words of encouragement. I will definetely post and let you know what my primary care doc tells me this Monday. Are there any specific blood tests that my doc can order to help establish a diagnosis. He already had ordered a CBC w/ Diff , Complete Chem Panel, Sed rate...and they all came back normal. One more question...How would could my doctor come to a conclusion that what we both felt was a false positive? Biopsy?

Thanks again

[Dr. Tamer Fouad]

Hello premed3341,
Unfortunately, there are no blood tests that are specific to a particular cancer. Even tumor markers have a low sensitivity and specificity when it comes to diagnosing cancer (except in prostate cancer and choriocarcinoma).
There are basically two ways a doctor will reach the conclusion that what he felt was not an enlarged lymph node due to a malignancy. If on follow up the swelling does not increase steadily with time and all your scans remain negative or by requesting a biopsy that turns out negative for malignancy. A biopsy of course is the gold standard by which all the other tests are measured. Which course the doctor will choose will depend on how risky he considers the situation (based on clinical examination).
Let's wait and see what the PCP has to say, I have a feeling it will all turn out fine.
Best regards,

[premed3341]

So I saw my PCP this week and he said that a referal to a surgeon would be the next step even though all my test have come back negative. He also said that he was very confident that I did not have any malignancy based on my CT and Lab result. My CBC with Diff was normal, Chemistry was normal and I had a sed rate of 1. He said that was usually a good sign although not a diagnostic marker. He told me that the surgeon would either do a biopsy or tell me to wait and see, but that i shouldnt be worried. Ill keep you posted; and thank you for all the insight and help thus far.

[Dr. Tamer Fouad]

This all sounds very good.
Good luck with the surgeon!