From the Guidelines
The most appropriate diagnostic study for this patient is a fine-needle aspiration (FNA) biopsy of the neck nodule, combined with ultrasound guidance, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1. This approach would provide tissue for cytological examination while being minimally invasive. Given the patient's history of radiation-treated lymphoma, concerning symptoms (difficulty swallowing, hoarseness, fatigue, dry cough), and the rapidly enlarging neck nodule, there is a high suspicion for either recurrent lymphoma or a radiation-induced secondary malignancy such as thyroid cancer. The FNA should be performed promptly, and the specimen should be sent for cytology, flow cytometry, and culture if infection is suspected. Depending on the FNA results, additional imaging such as CT or MRI of the neck might be warranted to assess the extent of the lesion and its relationship to surrounding structures, as suggested by the ACR Appropriateness Criteria 1. Blood tests including thyroid function tests, complete blood count, and lactate dehydrogenase (LDH) would provide complementary information. The urgency of this workup is heightened by the patient's symptoms suggesting compression of adjacent structures (dysphagia and hoarseness), which could indicate a more aggressive process requiring immediate intervention. It is worth noting that while core needle biopsy or excisional lymph node biopsy may provide more tissue for diagnosis, FNA biopsy is a reasonable initial approach, especially when combined with ultrasound guidance and ancillary tests such as flow cytometry, as indicated by studies on lymphoma diagnosis 1.
From the Research
Diagnostic Study Options
The patient's symptoms, including a rapidly enlarging neck nodule, difficulty swallowing, hoarseness, fatigue, and dry cough, along with a history of lymphoma treated with radiation therapy, suggest the need for a diagnostic study to determine the cause of the neck nodule. The most appropriate diagnostic study for this patient would be:
Rationale for FNAB
The rationale for choosing FNAB as the most appropriate diagnostic study is based on the following points:
- FNAB has a high overall diagnostic accuracy of 95% for all head and neck masses, 95% for benign lesions, and 87% for malignant ones 2
- FNAB is safe, simple, and well-tolerated by patients, with minimal complications and virtually no contraindications 2
- FNAB can be performed as an outpatient procedure and is cost-effective in the managed care environment 2
- The use of ultrasound-guided FNAB (UGFNAB) can improve the sensitivity and specificity of the procedure, especially in the assessment of nodal involvement in patients with squamous cell carcinoma of the head and neck 5
- FNAB has been shown to be a useful modality for the diagnosis of head and neck masses, with a high success rate for identifying both malignant and benign lesions 4, 6