A 65-year-old smoker presents with hoarseness, hemoptysis and a hard painless lump in the left supraclavicular fossa. Which of the following is the MOST appropriate diagnostic step in this patient?
This patient presenting with a history of smoking along with symptoms and presence of hard painless mass in left supraclavicular fossa probably indicates the presence of an underlying lung malignancy which has metastasised to the lymph node. Open biopsy is especially indicated when the patients history and physical findings suggest malignancy i.e solitary, hard, nontender cervical node in an older patient who is a chronic user of tobacco, supraclavicular adenopathy and in solitary or generalized adenopathy that is firm and mobile suggestive of lymphoma. Fine-needle aspiration should be reserved for thyroid nodules and for confirmation of relapse in patients whose primary diagnosis is known. Supraclavicular and scalene lymph node enlargement is always abnormal. As these nodes drain regions of the lung and retroperitoneal space they can reflect lymphomas, other cancers or infectious processes arising in these areas. Virchow's node refers to enlarged left supraclavicular node infiltrated with metastatic cancer from a gastrointestinal primary. Metastases to supraclavicular nodes also occur from lung, breast, testis, or ovarian cancers. Tuberculosis, sarcoidosis, and toxoplasmosis are non neoplastic causes of supraclavicular adenopathy. Ref: Harrison's Principles of Internal Medicine, 18e chapter 59.
Undeake an open biopsy of the neck lump
Undeake a radical neck dissection
Do fine needle aspiration cytology
Give a trial of Anti tuberculous therapy