Systemic Nodal Metastases in Neck

Patricia A. Hudgins, MD

Key Facts

Terminology

Cervical metastatic adenopathy from infraclavicular primary tumor
Virchow node is left supraclavicular nodal metastasis

Imaging

Nodes generally in lower neck, especially on left
Variable size nodes, often > 1.5 cm
May be cluster of small nodes
May form conglomerate mass > 5-6 cm
Calcification may be evident on CT when primary tumor is adenocarcinoma

Top Differential Diagnoses

Reactive lymph nodes
Sarcoidosis nodes
SCCa metastatic nodes
Non-Hodgkin lymphoma nodes

Pathology

Esophageal, breast, and lung malignancies are most common primary tumors
May be unknown primary tumor
Focal nonenhancement on CT/MR corresponds to nest of tumor cells or necrosis

Clinical Issues

Systemic neck metastases less common than head and neck SCCa nodes

Diagnostic Checklist

If patient presents with nodal mass, 1st look for head and neck primary tumor
If infrahyoid nodal metastasis, suspect systemic primary tumor
When neck nodes are calcified, suspect thyroid primary or systemic adenocarcinoma

Figure 1 (Left) Axial CECT shows enlarged, noncalcified, solidly enhancing bilateral level IIA neck nodes

. No primary source was evident in neck, but patient was found to have primary lung carcinoma. (Right) Coronal PET/CT in a patient with ovarian carcinoma reveals a single enlarged left supraclavicular node

with FDG avidity. The patient had been previously treated for abdominal metastases and had known pulmonary metastases at the time of study.

Figure 1 (Left) Axial CECT shows large complex conglomerate left supraclavicular nodal mass

with extensive necrosis & infiltration of scalene and sternocleidomastoid muscles. Patient had neural deficits from invasion of brachial plexus. Fine needle aspiration revealed metastatic colonic adenocarcinoma. (Right) Axial CECT reveals multiple small nodes

in lower left neck in a patient with known metastatic breast carcinoma. Nodes are heterogeneous, many with focal eccentric low density, indicating necrosis.

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