What is the most appropriate diagnostic study for a 54-year-old woman with a history of lymphoma, radiation therapy, and tobacco use, presenting with difficulty swallowing, hoarseness, fatigue, dry cough, and a hard nodule on the right anterior aspect of the neck?

Diagnostic Approach for a Neck Mass with Concerning Features

CT scan with intravenous contrast of the neck is the most appropriate initial diagnostic study for this patient with multiple high-risk features for malignancy. 1, 2

Rationale for CT with IV Contrast

This 54-year-old woman presents with several concerning features that significantly increase her risk for malignancy:

• Hard nodule on the right anterior neck (firm consistency is suspicious for malignancy)
• History of lymphoma (prior malignancy increases risk)
• History of radiation therapy (increases risk of secondary malignancies)
• Tobacco use (synergistic risk factor for head and neck cancers)
• Dysphagia (may indicate mass effect or aerodigestive involvement)
• Hoarseness (suggests possible laryngeal involvement)
• Fatigue and dry cough (systemic symptoms)

Key advantages of CT with IV contrast:

• Provides excellent anatomic detail of lymph nodes and surrounding structures 2
• Distinguishes vessels from lymph nodes 2
• Characterizes masses (cystic vs. solid) 2
• Maps lesion borders 2
• Identifies potential primary sites in the upper aerodigestive tract 2
• Short scanning time (<5 minutes) and better tolerated by patients 2

Important Technical Considerations

• The scan should extend from the skull base to the thoracic inlet to capture all relevant structures 2
• IV contrast is crucial - ordering CT without contrast significantly limits evaluation 2
• Communicating relevant clinical information to the radiologist is essential 2

Alternative Diagnostic Approaches

While CT with IV contrast is the first-line imaging choice, other diagnostic studies may be considered in specific circumstances:

• MRI with contrast: May be preferred if there are suspected nasopharyngeal tumors, cranial nerve abnormalities, concerns for perineural spread, or contraindications to iodinated contrast 2

• PET-CT: While not the initial test of choice, PET-CT is valuable for staging once malignancy is confirmed, particularly for lymphoma 1

• Ultrasound with FNA: Useful for characterizing superficial nodes and allowing immediate biopsy, but limited in evaluating deep structures 2

Clinical Pearls and Pitfalls

• Pitfall: Ordering CT without contrast significantly limits evaluation of soft tissue structures and vascular relationships 2
• Pitfall: Dual-phase CT (without and with contrast) doubles radiation exposure without significant diagnostic benefit 2
• Pearl: The American Academy of Otolaryngology-Head and Neck Surgery guidelines recommend CT with IV contrast as the initial imaging study for evaluating neck masses with suspicious features 1

This patient's presentation with a hard neck mass, history of lymphoma and radiation therapy, along with concerning symptoms like dysphagia and hoarseness, strongly warrants CT with IV contrast as the most appropriate initial diagnostic study to evaluate for recurrent lymphoma or a secondary malignancy.