Episode 17: Right sided neck lump
Author: Dr. Suneet Sood
Editor: Dr. Suneet Sood
Narrators: Thong Yi Kun, Alan Koay
There’s a buzz of excitement in the ward: it’s the grand round day. Every Wednesday Professor Azim, the head of Surgery, comes in to take a long, long round. All the housemen have been busy ensuring that the case records are complete. The Professor has a tendency to be slightly caustic, but there’s usually a lot of learning during the round.
It’s patient number seven, and you are it. “Who is presenting this patient?” the Professor asks.
“It’s me, Prof”, you answer
“This is a 41-year-old male who presents with weight loss and altered bowel habit for the past month.”
You go on to present the history in detail, then move on to the findings.
“There’s a mass in the right lower abdomen. It’s non-tender, firm, but not hard.”
“Supraclavicular nodes?” asks Professor Azim.
“No palpable nodes in the left supraclavicular region” you say, a little hopefully. This seems to be going well, and you are glad you remembered to examine the left neck.
“I’m thinking abdominal tuberculosis as my first diagnosis, and I’m keeping colon cancer as a possibility. He’s a little young for cancer, but after 40 we always want to rule it out.” This is a direct dig at the professor. One of his favorite aphorisms is “Rule out cancer in all patients above 40”.
“TB, huh? What does the chest show on examination?”
“It’s normal,” I say. I’ve looked at the respiratory system, the cardiovascular system, and have even done a neurological examination. I don’t want the professor to make his famous sarcastic crack about “In my days the head was part of the body. How the human being has evolved!”
“What’s your plan?” he asks.
“We will start with a workup for TB. Chest film, Mantoux. CT scan for the lump. If it’s consistent with TB we’ll start anti-tubercular therapy. If there’s evidence of a stricture we’ll plan surgery. If any node had been enlarged we would have biopsied it, but he has no enlargement of the axillary nodes or the left supraclavicular node.”
The professor moves forward to examine the patient, but I’m confident of my findings. This will go well. He looks carefully at the abdomen, then palpates it, percusses it, asks about auscultatory findings. Then he moves to the neck, and, after about fifteen seconds, his voice booms. My heart skips a beat.
“What’s this?” he asks.
You palpate the patient’s neck again. It feels like a node in the right supraclavicular fossa. Where did that come from? Should I pretend it’s a cervical rib? No, it’s clearly a node. Hard, malignant.
“What does this mean?” he asks.
I’m not sure,” I answer. “Maybe TB?” I know that’s the wrong answer. The node is too hard. But it’s on the right side!
“TB?” he asks.
“No, it’s too hard. Does he have a cancer in the head or neck? Maybe a laryngeal cancer? But there’s no hoarseness. And he’s not a smoker.”
“Could it have come from the abdominal mass?”
“No, abdominal masses metastasize up the thoracic duct to the Virchow’s nodes in the left supraclavicular fossa, not right.”
“Anybody comments from anyone else?”
The professor looks around. Nobody answers. The junior consultant too is quiet. The professor continues.
“Okay. What is the equivalent of the thoracic duct on the right?”
“There’s the right lymphatic duct. It drains into the right subclavian vein, corresponding to the drainage of the thoracic duct on the left side. But it’s not connected to the abdomen.”
” Actually, studies show that there IS a cross-communication between the thoracic duct on the left and the right lymphatic duct on the right in many persons. About 5% of the lymph from the thoracic duct crosses over and enters the right lymphatic duct. Which means that…?”
“Which means that in about 5% of cases mets from the abdomen can end up in the right supraclavicular nodes?”
“Yes. This means that in a patient with suspected abdominal cancer, always examine both the right and the left supraclavicular fossae.”
The registrar takes over, asking me to arrange a fine needle aspiration cytology of the lump.
The professor exchanges a glance with the junior consultant.
“Nobody reads anatomy these days,” he complains.
Rabin ER, Meyer EC. Cardiopulmonary Effects of Pulmonary Venous Hypertension with Special Reference to Pulmonary Lymphatic Flow. Circulation research 1960;8:324-35