One evening while rubbing your neck as you’re accustomed to do while pondering the mysteries of the universe, you feel a lump on one side. Odd, you’ve never felt such a thing before. You look in the mirror and indeed notice a bulge when you turn your neck to one side. You begin to panic, since you’ve seen pictures of neck surgery like the one above. You immediately call your doctor but it’s a Saturday night and you know he’s out somewhere having fun, so you wait sleeplessly until Monday. Meanwhile, you have recurrent nightmares about the type of neck surgery you’ll need, and whether you’ll even have a neck at all to support your rather large head.
That picture may appear gruesome to the untrained eye, but this is the end-result of an elegant surgery called a neck dissection. This surgery is done to remove certain cancers in the neck. However, if you happen to find an unusual lump in your neck, don’t despair; this doesn’t automatically qualify you an extensive surgery like this, though these are rather fun surgeries to do. As with all things in medicine (and life in general) we must discover the cause in order to render a proper plan to deal with this.
We first must determine whether you have a tumor or not.
To understand this further, let’s talk a little bit about neck anatomy.
The neck has numerous structures and sometimes one may incidentally feel something normal and mistake it for something abnormal. It’s beyond the scope of this discussion to go into the gritty details of anatomy, but the drawing above touches upon an important point--the neck has lots of lymph nodes, connected by microscopic lymphatic channels, the purpose of which is to drain various areas of the head and neck and all the stuff inside, from the nose and mouth down to the throat and larynx. This complicated array of nodes and channels is part of the immunologic system--the body’s means of defending itself from a variety of bad-stuff to which it can be exposed.
Types of Neck Masses
Not every abnormal or unusual finding in the neck is a tumor. Following is a slide from a lecture I give to medical students and residents:
The take-away here is depending on one’s age, your doctor will have heightened suspicion for one type of disease versus another. For instance, the younger you are, the more likely the neck mass is inflammatory or infectious in nature and the less likely a tumor. As Arnold Schwartzenegger famously said to a youngster in the movie, Kindergarten Cop, “It’s not a toomaah!” though in some cases it really is. Yet with regards to the age-group he was addressing, he was for the most part correct. One the other hand, if you’re an older person like Arnold or me, then a tumor is at the top of the list. Though age is the first consideration, keep in mind it is not the ONLY consideration.
“I’m lost!” I hear some of you shouting. “What’s with all the medical lingo? This was supposed to be a blog for nonmedical folk!”
Okay, we’ll define a few medical terms in order to make this more understandable.
Inflammatory: Inflammation occurs when cells react in response to an injury or abnormal stimulation. The process involves reactions and changes to the cells and tissues, followed by destruction or removal of the injurious substance, followed by repair and healing. Inflammation is the body’s response to an insult, such as trauma, exposure to foreign substances or infections. An infection is an inflammatory response from parasitic organisms such as bacteria, viruses, fungi, tuberculosis, and rarely exotic/freaky stuff such as deeply embedded worms or bugs (I’ve never encountered worms or bugs but have heard of such discoveries from other surgeons). In the neck, lymph nodes often get bigger as part of this reactive process.
Congenital: Congenital means something that existed at birth. These masses are present at birth but often can be unnoticeably small and remain dormant, presenting themselves sometimes years later. Examples: branchial cleft cysts (which arise from pouches formed in utero—ie, in the mother’s uterus), thyroglossal duct cysts (arising from ductal tract remnants of the thyroid gland as it descends down in the neck during in utero development).
Neoplastic: A neoplasm is any new formation or growth of tissue that wasn’t there before. A neoplasm is a lump or mass of abnormal tissue that can keep on growing.
However, age is only one part of the history, and doctors will obtain a more thorough history and then do an examination to guide them towards the proper course of action, leading to a diagnosis and ultimately treatment.
Most people are concerned more with the neoplastic part of the equation and rightly so. Tumor = neoplasm. So let’s talk a bit about neoplasms.
Some Oncologic Terminology
Let’s define certain terms used in oncology (the medical discipline dealing with cancers). A tumor is literally defined as “swelling” and as such is very nonspecific. Any abnormal growth of tissue that forms a lump or mass, and is not a result of inflammation or infection, is called a neoplasm, where neo- = “new” and –plasm = “formation”
Neoplasms however can be benign or malignant:
Benign: a benign neoplasm does not invade into adjacent tissues, nor does it metastasize (spread beyond) to other sites in the body. Benign tumors are less aggressive and often not life-threatening compared to malignant tumors. Oftentimes the cells in benign tumors are normal cells—they just happen to continually proliferate, causing a growing mass.
Malignant: a malignant neoplasm on the other hand invades and destroys surrounding tissues or spreads distally (metastasizes) to other parts in the body. The cells are abnormal, having features that are much different from the normal cells from where they originally arose. Often there is a stimulus that causes this, such as a carcinogen (cancer producing substance). The DNA in malignant cells is altered such that they grow and divided faster than normal cells. Cells can potential break away from the neoplastic mass and seed to other parts of the body through the bloodstream or lymphatics; this is called metastasis. Malignant tumors are potentially life threatening if left untreated.
Metastasis: spread of the tumor to a site in the body remote from the primary malignant neoplasm. This can occur via the bloodstream or lymphatic system, as these systems of vessels and channels pervade the entire body.
Cancer: a general term for a malignant neoplasm
Types of Malignant Neck Neoplasms
Malignant neck neoplasms come in one of two forms: metastatic and primary. These oncologic terms are also used to describe cancers anywhere else in the body in general.
Primary: less common in the neck. A primary neoplasm refers to where the malignancy originally occurred, and is the site or organ of this origination. Regrettably, any organ or tissue in the body is at risk of going haywire and develop into a cancer; the neck is no exception. The different primary tumor types is numerous so I won’t delve into this, only to say that primary neck tumors (other than originating from the salivary glands) is uncommon.
One can have a primary neoplasm found in the mouth, throat, tonsil, larynx, etc. and not even know it. These are structures found in the head and neck that can be involved with a cancerous growth (a malignant neoplasm) and be the source of an enlarged lymph node(s) via the metastatic process. More on this to follow.
Lymphoma: the only cancer that arises de novo (anew) in a lymph node. In other words, the lymph node itself is the primary site. There are multiple different types of lymphoma, varying widely in degree with regards to severity and prognosis and treatment. There’s entire textbooks devoted to lymphoma and as such the details are far beyond the scope of this discussion. Let’s just say lymphoma is a cancer that starts in a lymph node or lymphatic structure (by the way, tonsils and adenoids also have lymphatics and can be involved with lymphoma. The spleen is another lymphatic organ) and can involve any other node or organ in the body.
Metastatic: spread to other sites from the primary site, namely via lymphatics and to lymph nodes. For neck cancers, there is a distinction between regional metastasis and distant metastasis. In regional we generally refer to nodes in the neck. Distant metastasis refers to outside of the neck, such as the lungs, liver, bone, etc. Distant metastasis occurs via lymphatics or from hematologic spread—meaning spread from seeding of the tumor through the blood stream. Metastatic malignant lymph node involvement is one of the most common malignant masses in the neck.
Side note: node = lymph node for the purpose of this discussion.
Example: A primary cancer arising in the tongue can metastasize to the neck, creating an enlarged neck node(s) filled with cancerous cells. Therefore, this would be considered a malignant cancer of the tongue with regional neck metastasis.
Neoplasms of the neck occur more in adults than children. Typically a mass in the neck of a child often is an enlarged lymph node from an infection, and often decreases in size or resolves once the infection resolves. Children tend to have nodes that are easily palpable (felt with the fingers) and these typically are benign. Also, children can have congenital masses; a mass that occurs during fetal development that can progress and become noticeable even much later after birth. Tumors or neoplasm are less likely, though are still possible.
In adults with a neck mass that is suspicious for a neoplasm requires a rather involved workup prior to jumping in and simply removing the mass. Since most neck masses arise for lymph nodes, there must at first be a diligent search for the primary site, or cause of the tumor, since as mentioned before, most neoplasms (other than lymphoma) in the neck area a metastasis from some other site. The details on this workup is far too great to get into right now, and is a subject for a future blog post.
Keep in mind that the neck mass might not even be a malignant neoplasm, and all that discussion above may have left you in a cold sweat for nothing. There are, of course, benign neoplasms—tumors that are less aggressive, typically are not life-threatening, and require less involved means of treatment where less extensive surgery often is curative, or one might not need surgery at all.
However, don’t ignore something that looks or feels out of the ordinary. Have it checked out by your doctor, who might refer you to an ENT or head and neck surgeon for further consultation. I’ve had patients wait a considerably long time before being seen. One guy came after TWO YEARS of having a growing, malignant neck mass. Fortunately, he survived after aggressive treatment and leads a high-quality life. But I’ve seen others who waited too long and were beyond cure and ultimately died of their cancer. Another guy had a mass that was covered by his beard and when he shaved it in preparation for surgery, you could easily see it a mile away (well, actually it was about 20-30 feet away but still, it was THAT big). For some strange reason, these were usually men, even despite their wives harping on them to see the doctor sooner. As I’ve said in a prior post, I believe this is related to the short male Y chromosome which hypothetically carries the DNA for common sense.
The caveat: Please don’t wait until your neck mass is larger than your head before seeking medical attention.
©Randall S. Fong, M.D.