From the Guidelines
CT neck with IV contrast is the most appropriate imaging modality for evaluating supraclavicular swelling, as it offers detailed visualization of masses or lymphadenopathy in the neck, supraclavicular fossa, or axilla, and can provide complementary information to MRI in the setting of malignant tumor invasion. This recommendation is based on the most recent and highest quality study, which suggests that CT neck with IV contrast can improve delineation of tumor margins and/or fibrosis, and can better evaluate the lung apex 1.
When evaluating supraclavicular swelling, it is essential to consider the potential causes, including malignancy, lymphadenopathy, and neurogenic tumors. The choice of imaging modality depends on the suspected pathology based on clinical presentation.
- Ultrasound may be considered as an initial imaging modality, as it is non-invasive and provides excellent visualization of superficial structures in the neck and supraclavicular region.
- However, if ultrasound findings are concerning or inconclusive, CT or MRI may be warranted as second-line imaging options.
- CT with contrast offers detailed evaluation of the extent of disease and relationship to surrounding structures, while MRI provides superior soft tissue contrast and is particularly useful for evaluating neurogenic tumors or vascular malformations.
- For suspected malignancy, PET-CT may be considered after initial imaging to assess for metastatic disease, as suggested by the ACR Appropriateness Criteria topic on “Noninvasive Clinical Staging of Primary Lung Cancer” 1.
It is crucial to note that the role of imaging in the setting of breast cancer or lung cancer is addressed in specific ACR Appropriateness Criteria topics, and the choice of imaging modality should be guided by these recommendations 1. Ultimately, tissue diagnosis through fine needle aspiration or biopsy guided by imaging may be necessary for definitive diagnosis of concerning masses.
From the Research
Imaging Modalities for Supraclavicular Swelling
- Ultrasound is a useful modality for evaluating supraclavicular lymph nodes, especially in patients with suspected lung cancer 2.
- Fine-needle aspiration cytology (FNAC) guided by ultrasound can help diagnose and stage lung cancer, avoiding more invasive procedures in some cases 2.
- For diagnostic evaluation of supraclavicular lymphadenopathy, biopsy or FNAC can be used to determine the cause of the swelling, with tuberculosis and malignancy being common causes 3.
Comparison of Imaging Modalities
- Positron emission tomography-computed tomography (PET-CT) has been shown to have high sensitivity and specificity in detecting metastatic lymph nodes in patients with cervical cancer, outperforming CT and MRI 4.
- PET-CT can also be used to assess early metabolic response to treatment and aid in treatment decisions 5.
- Ultrasound can be used to document the presence of branches of the subclavian vein and artery adjacent to the brachial plexus in the supraclavicular region, which is relevant for brachial plexus block 6.
Specific Uses of Imaging Modalities
- Ultrasound-guided FNAC is a relatively non-invasive procedure that can be used to diagnose and stage lung cancer 2.
- PET-CT is commonly used in the oncology setting and can provide one-stop staging for cancer patients 5.
- CT and MRI can also be used to detect metastatic lymph nodes, but may have lower sensitivity and specificity compared to PET-CT 4.