What is the appropriate management for an elderly woman with xerostomia, submandibular mass, and bilateral cervical lymphadenopathy while on warfarin?

From the Guidelines

For an elderly woman with xerostomia, submandibular mass, and bilateral cervical lymphadenopathy while on warfarin, the most appropriate initial management would be to perform a Fine Needle Aspiration Cytology (FNAC) after ensuring her INR is within a safe range, ideally below 3.0, to minimize bleeding risk. This approach is preferred because FNAC is minimally invasive and can provide valuable diagnostic information with a lower risk of bleeding for a patient on anticoagulation 1. The patient's chronic dry mouth suggests possible Sjögren's syndrome, which increases the risk for lymphoma, making tissue diagnosis essential.

Key Considerations:

• The patient's anticoagulation status with warfarin necessitates caution to avoid bleeding complications, thus favoring a minimally invasive diagnostic approach like FNAC.
• Checking the patient's INR before the procedure is crucial to ensure it's within an acceptable range, reducing the risk of bleeding 1.
• While imaging, such as CT scans, would be valuable for staging if malignancy is confirmed, it should not precede tissue diagnosis.
• Core biopsy and immediate excision are less favorable initial steps due to their higher invasive nature and associated bleeding risks in an anticoagulated patient.

Management Approach:

• Initially, manage the patient's anticoagulation to ensure a safe INR level for the procedure.
• Perform FNAC as the first-line diagnostic approach.
• Based on the FNAC results, plan further management, which may include imaging for staging if malignancy is suspected, and consider consultation with specialists such as hematologists for anticoagulation management and oncologists if cancer is diagnosed.
• The use of novel oral anticoagulants (NOACs) or bridging anticoagulation with heparin may be considered in the periprocedural period, but the current evidence base for these strategies in such specific clinical scenarios is evolving 1.

From the Research

Diagnostic Approach

• The patient's presentation of xerostomia, submandibular mass, and bilateral cervical lymphadenopathy requires a thorough diagnostic workup to determine the underlying cause of these symptoms 2, 3, 4, 5.
• Imaging studies such as ultrasonography, CT scan, and MRI can be useful in evaluating the submandibular mass and lymphadenopathy 3, 5, 6.
• Fine-needle aspiration cytology (FNAC) or core-needle biopsy can be used to obtain a tissue diagnosis, especially if a malignant tumor is suspected 2, 3, 5.

Management of Submandibular Mass

• Benign tumors of the submandibular gland, such as pleomorphic adenoma, can be managed with local excision of the tumor along with the gland 2, 4, 5.
• Malignant tumors of the submandibular gland require a more aggressive approach, including radical surgery and postoperative radiotherapy 4.
• The patient's use of warfarin should be taken into consideration when planning surgical intervention, and appropriate measures should be taken to minimize the risk of bleeding complications.

Consideration of Differential Diagnoses

• Other potential causes of submandibular masses, such as sialadenitis, sialolithiasis, and lymphadenitis, should be considered in the differential diagnosis 5.
• Anatomical variations, such as mylohyoid defects and sublingual gland protrusion, can also present as submandibular masses and should be considered in the diagnostic workup 6.