55 year old chronic smoker presents with complaints of hoarseness of voice, and single enlarged painless lymphnode in left supraclavicular region. Next step to be done -
Ans. is 'd' ie. Excision biopsy of the node Pts age and history of chronic smoking & hoarseness are pointing towards laryngeal cancer & lung cancer (lung cancer can cause hoarseness of voice by involving the recurrent laryngeal nerve). But laryngeal cancer does not drain to supraclavicular lymph node. So no need of doing a laryngoscopy. Supraclavicular lymph node drains from following areas ? a Retroperitoneal space d testis b Lung e ovaries c breasts f GIT. An enlarged supraclavicular lymph node is always abnormal, so whenever we find one we do an excisional biopsy to know the histology (it would point towards the primary cause). Harrison writes - " The indications for lymph node biopsy are imprecise yet it is a valuable diagnostic tool. The decision to biopsy may be made early in a pts. evaluation or delyayed for upto 2 weeks. Prompt biopsy should occur if the pts. history and physical finding suggest a malignancy, examples include a solitary hard, nontender, cervical node in an older pt. who is a chronic user of tobacco; Supraclavicular adenopathy and solitary or generalized denopathy that is firm, movable and suggestive of lymphoma."
CT Scan of chest
Sputum exam. for AFB
Laryngoscopy and chest x-ray
Excision biopsy of the node