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Forum Name: Lymphoma

Question: '80/80' rule for neck masses - is it true?


 suntower - Mon Nov 12, 2007 2:53 pm

Hi,

I am a 36-yr old male, with no real history of illness or surgeries, and little to no family history of cancer. I currently am taking vytorin, fluoxetine, and fish oil capsules.

A few weeks ago I noticed a lump in the left side of my neck, near the carotid I think. I noticed it a few weeks ago but who knows how long it has been there. It is moveable (it can kind of be 'popped' from side to side), probably between 1-2cm (I guess...rough estimate), and I really can't say whether it is hard or soft. It is painless, and I can feel a pulse in it although it may just be because it is near the artery. I haven't been sick for months, although my kids have been trading illnesses constantly for the past year. I became nervous when I could not locate a similar lump on the other side of my neck. After doing some research (which always gets me into trouble), I thought it sounded like a carotid body tumor, although I know that's rare and I really don't know my neck anatomy well.

I went to my doctor last Friday and he felt it and said it was a lymph node, and not all that big, but he also felt another that seemed a bit large (which I can't seem to find), and my thyroid was a little 'big'. I've looked in the mirror and felt and I can't feel or see any lump on my thyroid. My doctor ordered some bloodwork for me...I didn't really get to see all that he ordered but it included some sort of lymph panel or something among other things...he also mentioned sedimentation or something.

Here's what really scared me: when I had done research on this stuff I came upon the '80/80' rule for neck masses, which is that in adults, 80% of neck masses are neoplasms, and 80% of those are malignant! When i mentioned this to my doctor, he didn't say anything, and I asked, "So what should I think right now" he said "You shouldn't think anything". I asked, "If it is cancer, would it be treatable?" and he said "It depends".

I left feeling very anxious and have been absolutely terrified out of my mind since. I am so worried that I will be dying soon. I know it sounds ridiculous but now that I have 2 little kids I get so worried about this stuff.

I guess my questions are:
1) does my description of the lump sound particularly ominous to you?
2) how confident should I be that a doctor can differentiate a lymph node from, say, a tumor in my neck?
3) will bloodwork really tell us much? If it comes back abnormal, I'd assume he'll want to biopsy or something. But if it comes back normal, and he says not to worry about it, do you think that is smart? I wasn't under the impression that bloodwork was very useful in this type of case
4) Does the fact that bloodwork was ordered indicate real concern?
5) I had an abdominal CT scan earlier this year, which was normal, as well as a chest x-ray earlier this year to look for heart issues (chest pain), which was normal. Should I take these normal tests as evidence that there is nothing bad going on elsewhere? Would a chest x-ray, for example, pick up something bad even if they were looking at it for heart reasons?

I know that's a lot of questions. Yes, I am an admitted hypochondriac. But I'm just so scared!

Thank you so much for taking the time to answer questions here.

Thanks,
Kevin
 Dr. Tamer Fouad - Sat Nov 17, 2007 7:27 pm

User avatar Hi there,

A lymph node on the side of the neck is always a concern and should always be investigated even if it doesn't look ominous.

The blood work helps rule out some of the ominous causes. Obviously a more ominous presentation would have called for a pathologic examination but I am just guessing here.

You asked an interesting question about the 80/80 rule. Yes its a good rough indication when studies were performed on patients sent for biopsy / FNA. Obviously, there was a good reason to send these patients for biopsy in the first place (e.g. night sweats, gets worse after 2 weeks of antibiotics, high risk for disease, etc.). However, in the primary care setting (such as the one you are in) where your primary care provider is the one still examining you, the incidence of malignant disease in neck nodes in several studies (a Dutch as well as a Greek study) was extremely low. What that means is that in these studies, rather than wait for your primary care doctor's opinion on whether a node warrants a biopsy or not, they just went ahead and did it. As I mentioned earlier the number of people who turned out malignant was low.

Studies that were performed at specialized centers such as an oncology service, showed a much higher incidence (hence the 80/80 rule).

Please do not worry your heart out reading about every possibility, you are on the right course and no matter how much you do read you will never be able to make a better opinion than your provider. If at the end you are not satisfied with his opinion you can always seek another opinion.

Good luck and please update this thread after your results come out.
 suntower - Sun Nov 18, 2007 2:05 am

Thanks, Dr.

I received my bloodwork results earlier this week but didn't want to piggy-back on my first post until it was answered. Now that you've answered it, I'll go ahead and post the results and my concerns...but I'm worried I won't like what you'll say.

Most of the values are within normal range, but some are on the definite low end. That concerned me a bit, but then I checked my results from another CBC 9 months ago, and it looks like these low values have clearly dropped since then. I don't know how much variation occurs over time from test to test and how concerned I should be, especially in the context of this lump. Here are the results from February 2007 and Nov 2007:

Feb 2007:
Triglycerides 127
Total cholesterol 150
HDL 49
LDL 76
WBC 5.4
RBC 4.66
Hemoglobin 13.9
Hematocrit 40.6
Abs neutrophils 2884 53.4%
Abs lymphocytes 1750 32.4%
Abs monocytes 690 12.8%
Abs eosinophils 49 0.9%
Abs basophils 27 0.5%

Nov 2007:
Triglycerides 78
Total cholesterol 113
HDL 54
LDL 43
WBC 4.5
RBC 4.36
Hemoglobin 13.4
Hematocrit 38.0
Abs neutrophils 2961 65.8%
Abs lymphocytes 1112 24.7%
Abs monocytes 396 8.8%
Abs eosinophils 27 0.6%
Abs basophils 5 0.1%

The ranges for the lab on these indicate that nothing was out of range for Feb. For Nov, total cholesterol is out of range (ref 125-200), as is hematocrit (ref 38.5-50). Lymphocytes are low in Nov but the normal range is listed as 850-3900. Similar with the other -phils and -cytes.

Since Feb a few things have changed: I now run 3miles 4-5 times per week, whereas I did no exercise back in Feb. I also now take psyillium fiber twice a day. I've been on vytorin for a couple of years now, and also take fluoxetine and fish oil.

I'm really worried about the across-the-board drop in lymphocytes, monocytes, eosinophils, and basophils from Feb to Nov is worrisome, especially in the context of my lump. I know they are in normal range but it is the consistent decrease from then to now (almost 50%!) that worries me. I'd also read that really low cholesterol like mine can be due to cancer, so that's what concerns me too.

I should point out that my doctor seemed completely unconcerned after seeing these blood tests. Perhaps I should just trust him but sometimes I feel like just one of a million of his patients, and I've read the stories of missed cancer diagnoses by PCPs. But he felt that the results were normal, period...and basically considered the case closed. He did, however, say he'd refer me to an ENT since I am so worried and won't calm down!

Do you feel these blood results are worrisome, or consistent with possible lymphoma?

As for the 80/80 rule, you are saying that applies to a pre-selected population of high-risk patients, right? i.e. it applies if you pre-screen out the majority of patients which are likely to benign? That's reassuring.

Thanks again for taking the time to answer. I know time is precious!

-Kevin
 Dr. Tamer Fouad - Sun Nov 18, 2007 2:45 am

User avatar Hello again,

I am not concerned at all by your results either. Your tests are normal and there is a good reason why the lab reference offers a range for normal rather than a single number. It's normal for lab results to vary within the normal range.

I should remind you that cancer is a much less subtle disease than that. Cancer can be missed if you were simply not assessed properly.

You should follow the size of the lymph node and report any change in size to your PCP. If you are not confident of your doctor's opinion please consider getting a second opinion. The ENT doctor can help you with that.

Good luck and best regards,
 suntower - Sun Nov 18, 2007 1:34 pm

Thank you so much, Dr. I feel a lot better about this since you're not concerned about these results in the context of cancer.

The lump really is pretty small...I haven't noticed any growth in a month or so, so I'm hoping this is nothing. I just wish I could understand why there isn't one on the other side of my neck.
 Dr. Tamer Fouad - Sun Nov 18, 2007 1:41 pm

User avatar I am glad you feel better - yes the results are not concerning. I still see no harm in getting checked by the ENT doctor. I would still recommend you do this.

Good luck!
 suntower - Tue Nov 27, 2007 7:39 pm

Thanks a ton doc. I have an ENT appt in a couple of weeks...the waiting is hard. I have a couple of quick questions:

1) if I assume that this lump is a lymph node, and is not bigger than 1cm (it may be just about 1cm...reminds me of a small pumpkin seed), how alarming/abnormal is it to have a clearly palpable but not 'enlarged' lymph node in one side of the neck but not the other? Could it be a normal, non-enlarged node that for some reason is palpable, while on the other side I can't find anything like it?

2) if this little thing turned out to be lymphoma, does the small size, mobility, clean CBC results, and lack of other symptoms indicate that I would be catching it early, and can feel more confident about a prognosis?

Thanks again!
 Dr. Tamer Fouad - Tue Nov 27, 2007 8:38 pm

User avatar Hi there,

Thanks for updating the thread.

1. Normally a lymph node is not palpable. Please remember, however, that lymph nodes are there to protect against infection. As soon as they are exposed to an infection they swell as the the cells that fight infection multiply inside them. Then they become palpable. That would be the most common cause for lymph node enlargement as it is simply performing its duty. In oncology a lymph node that is 1 cm or less in size is not considered "clinically significant". It wouldn't make it to the 80/80 rule in any setting.

2. If this were lymphoma, the size of the node wouldn't matter. The prognosis would depend on the stage and the type (pathology) as well as other factors rather than the size. The stage is determined by the number of lymph node locations affected.

You are on the right track now, I wouldnt worry about it any more.
 suntower - Wed Nov 28, 2007 12:43 am

Thanks for the super quick reply, Dr. I really appreciate it. I'll update after my visit with the ENT.
 suntower - Mon Dec 03, 2007 3:14 pm

Just got back from the ENT. He felt my neck pretty carefully. At first he couldn't find the lump. Then I helped him and he definitely found it, because he could pop it back and forth.

He said it was nothing to worry about. He seemed very convinced in that. He said it was smaller than a cm, and that he feels a lot of necks and these types of 'scarred' nodes are very common, and that it could likely stay palpable for my whole life. He understood my fears but was very firm but reassuring that I should not worry about this.

I certainly feel a lot better now. My attempts at measuring the node had it at 1.0-1.5cm or so, but I never felt like I could get a good measurement. I had thought it was at least a cm, though!

So I guess I should just let it go. There is still a part of me that worries about those cases where something like this turns out to be bad, but I expect those are rare.

Thanks so much for your help, Dr. You've been a real blessing and you should be proud of the help you provide scared patients like myself.

-Kevin

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