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Man With Persistent Neck Swelling

Man With Persistent Neck Swelling

About 1 month ago, a 58-year-old man experienced malaise
and fatigue accompanied by mild diffuse swelling in his neck.
After 3 days, the malaise and fatigue began to abate. They resolved
after a week; however, minimal swelling on the left side
of the neck remains. The patient has no other symptoms.

Two years earlier, squamous cell carcinoma of the larynx
was diagnosed; the tumor was excised and radiation therapy
given. The rest of his medical history is unremarkable. He
smokes a pack of cigarettes daily and drinks alcohol socially.

The patient is slightly overweight. Temperature is 37.2oC
(99oF); heart rate, 92 beats per minute; respiration rate, 18
breaths per minute; and blood pressure, 138/92 mm Hg.
Heart and lungs are normal, as is the oral cavity. Examination
of the neck reveals mild fullness without significant tenderness
on the left side at the level of the mandible, along the jugular
chain of lymph nodes; inferior extension may be present.

Figure 1
Figure 1
Figure 2
Figure 2

A CT scan is ordered to evaluate the soft tissues of the
neck. Although the CT images obtained before the patient's
surgery 2 years earlier are not available, the radiologic report
describes minimal fullness of the larynx on the left side (the
site of the primary tumor) and no evidence of adenopathy.

New CT images at the level of the mandible and at the
level of the submandibular glands reveal prominent lymph nodes
lateral to the left internal jugular vein and posterior to the vessels
deep to the left sternocleidomastoid muscle (Figure 1).
These lymph nodes measure less than 1 cm in short axis; 1 cm
or greater is the CT criterion for designating a lymph node abnormal.
However, the patient's nodes demonstrate decreased
central density—especially the node in the posterior triangle.

Which diagnostic test would you order next and why?

WHICH TEST—AND WHY: A positron emission tomography
(PET) scan is the best test to determine whether the
tumor has recurred and, if it has, to assess the extent of
disease. Because the patient currently has no symptoms
other than mild neck swelling, the key concern is recurrence
of the squamous cell carcinoma of the neck. Decreased
central density on CT suggests more active
pathology than a node with homogeneous soft tissue
density.

Figure 3
Figure 3
Figure 4
Figure 4
Figure 4
Figure 4

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