Characteristics of malignancy
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These are the characteristics of malignancy: fixed, hard, non-tender, matted, etc. I always ask the patient. If they do say, “Yeah, it changed. It’s bigger now it’s smaller, and it’s getting bigger.” Try to get a time. When does it happen. When you wake up in the morning is it bigger? Does it get bigger throughout the day? Does it get bigger when you are eating or when you are preparing food, or when you walk in the house and you smell food and get ready to eat? Anything that might indicate a salivary gland obstruction then of course you could be thinking stones, chronic infections, strictures, those kinds of things. Tumors can also cause it but those would be the things from a salivary gland standpoint. Other generalized adenopathy in the axilla and throughout. Mono, cat scratch, lymphoma, certainly sarcomas, TB, atypical TB, those kinds of things may make you want to get a chest x-ray, get other titers, get other studies prior to taking that patient to the operating room and doing an open biopsy. Color: certainly if you have pigmented lesions you can always ask the patient – especially for nodes in the parotid region and the external jugular, these are superficial nodes very frequently associated with skin cancer. So you need to ask the patient, “have you had any lesions removed? Any lesions burned off? Have you ever had any skin cancers?” and keep that in mind. Again, if you have them strain, do they blush like a hemangioma would.
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What do you do when faced with a patient with a unilateral, asymptomatic, neck mass? You’ll be the first one to see them. The patient comes in and says, “I noticed this when I was shaving.” How long ago? It’s always two weeks. I don’t care how many months. You know it’s been there for eight months, it’s always two weeks. And then what do you do? Well, a complete head and neck exam is the first thing that needs to be done. You need to look at the oral cavity, oropharynx if you’ve got a mirror or a scope, otherwise you need to look at that. These patients need to have an indirect exam so you can evaluate the larynx and the hypopharynx. You need to feel their thyroid and their salivary glands. And then you need to look at their skin. Did they have a lesion taken off? These skin cancers can go bad and can go to lymph nodes, so you need to look their skin over a little bit as well. Do they have a melanoma, do they have something that’s suspicious that you may need to biopsy first before you go to a fine needle.
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The next step, I believe, is if you have fine needle capacity in your office, is to go ahead and get a fine needle on it. While you are waiting for a fine needle – if you are talking to a 65-year-old who smokes two packs a day and is also hoarse – then I think it’s reasonable to go ahead and assume this is going to be cancer and go ahead and get your workup going. All these patients need chest x-rays. A high percentage of them are smokers and you need to know what’s going on in the lungs. That’s a good time to get them. These things are low yield and I don’t usually order them until after I have a diagnosis and I don’t have a primary and I’m looking for a primary. I don’t get sinus films or an esophagram unless the patient presents with an obstruction, a unilateral obstruction of the nose and a lymph node. Then it’s reasonable. Probably at that point you are going to go straight to a CT scan. Viagra super active at our pharmacy shop.
Then we get the fine needle aspiration. When the fine needle comes back, what do we do with it? If it’s adenocarcinoma then that’s a problem. They will usually say, “It’s malignant. Looks like it’s an adenocarcinoma.” Well, before we take them to the operating room and try to figure out what’s going on, we need to make sure if it’s in the upper neck, then you are thinking salivary glands. You need to feel that base of the tongue. Probably going to have to put the patient to sleep to do all this. If it’s lower, then they need to have a good breast exam. Probably a mammogram, GI studies, etc. and again, of course, a good chest x-ray. If there is any suspicion whatsoever, probably a CT of the chest as well. If they think it’s lymphoma, then they are going to get all their studies but we’re going to have to get some tissue for them. They won’t type them and stage them on fine needle, so that patient is going to need an open neck biopsy. But you don’t want to find out that they were wrong and it’s not lymphoma and you took out a squamous cell node and then you look in their mouth and find that they have a 4 cm base of tongue lesion. It happens all the time and it’s something that needs to be avoided.