AJR 2003; 180:1403-1409
© American Roentgen Ray Society
Sonographically Guided Biopsy of Supraclavicular Lymph Nodes: A Simple Alternative to Lung Biopsy and Other More Invasive Procedures
Patrick J. Fultz1,
Amy R. Harrow1,
Simone P. Elvey1,
Richard H. Feins2,
John G. Strang1,
John C. Wandtke1,
David W. Johnstone2,
Thomas J. Watson2,
Ronald H. Gottlieb1,
Susan L. Voci1 and
Deborah J. Rubens1
1 Department of Radiology, University of Rochester Medical Center, 601 Elmwood
Ave., Rochester, NY 14642-8648.
2 Department of Surgery, University of Rochester Medical Center, Rochester, NY
14642-8648.
Received August 6, 2002;
accepted after revision October 4, 2002.
Address correspondence to P. J. Fultz.
Introduction
The supraclavicular area is a final common pathway for metastatic nodal
involvement from multiple cancers and other conditions such as sarcoidosis.
Most of the supraclavicular area is included on chest CT, but in our
experience disease in this area is frequently overlooked.
Background
Our objectives are to review the normal anatomy and the appearance of nodal
disease in this area on CT and sonography, to summarize and illustrate
conditions that typically involve supraclavicular lymph nodes, and to describe
the technique of sonographically guided biopsy of these lymph nodes.
Palpable supraclavicular lymph nodes can be biopsied without imaging
guidance. However, abnormal nodes are frequently nonpalpable
[1]. Sonographic guidance for
biopsy of these typically superficial nodes is a quick, simple, and safe
procedure. Percutaneous lung biopsies have one of the highest complication
rates of all imaging-guided biopsy procedures
[2]. Sonographically guided
supraclavicular node biopsy may obviate some lung biopsies (Figs.
1A,
1B,
1C and
1D), other more invasive
time-consuming biopsies with greater complication rates, and even unnecessary
major surgery in some instances.
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Fig. 1A. —50-year-old woman with superior vena cava syndrome from
metastatic poorly differentiated non–small cell lung cancer. Patient had
nondiagnostic needle lung biopsy complicated by tension pneumothorax.
Supraclavicular node was overlooked on patient's initial CT. Axial
contrast-enhanced CT scans show right upper lobe lesion (arrow,
A) and superior vena cava (arrow, B) narrowed from
metastatic lymph nodes.
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Fig. 1B. —50-year-old woman with superior vena cava syndrome from
metastatic poorly differentiated non–small cell lung cancer. Patient had
nondiagnostic needle lung biopsy complicated by tension pneumothorax.
Supraclavicular node was overlooked on patient's initial CT. Axial
contrast-enhanced CT scans show right upper lobe lesion (arrow,
A) and superior vena cava (arrow, B) narrowed from
metastatic lymph nodes.
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Fig. 1C. —50-year-old woman with superior vena cava syndrome from
metastatic poorly differentiated non–small cell lung cancer. Patient had
nondiagnostic needle lung biopsy complicated by tension pneumothorax.
Supraclavicular node was overlooked on patient's initial CT. Chest radiograph
after fluoroscopically guided lung biopsy shows tension pneumothorax
(arrowheads) that required chest tube (samples were nondiagnostic).
Subsequent bronchoscopic tracheal biopsy yielded diagnosis.
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Fig. 1D. —50-year-old woman with superior vena cava syndrome from
metastatic poorly differentiated non–small cell lung cancer. Patient had
nondiagnostic needle lung biopsy complicated by tension pneumothorax.
Supraclavicular node was overlooked on patient's initial CT. Chest CT scan at
base of neck obtained before lung biopsy shows supraclavicular adenopathy
(arrow) that should have been biopsied but was overlooked and grew
larger.
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Additional benefits of a supraclavicular node biopsy include its usefulness
for simultaneous diagnosis and staging of various malignancies such as
metastatic lung cancer. Furthermore, the biopsy can be performed with patients
sitting upright if they have positional dyspnea from airway or superior vena
caval compromise by mediastinal adenopathy.
Supraclavicular Anatomy Revealed on CT and Sonography
The supraclavicular lymph node area lies above the manubrium, laterally to
the medial edge of the common carotid artery, and medially to the clavicle and
the lateral rib margin [3].
Some normal round and elliptic neck base structures need to be distinguished
from supraclavicular lymph nodes; these structures include the external and
internal jugular veins, common carotid arteries, and the scalene and longus
colli muscles (Figs. 2A,
2B,
2C,
2D and
2E).
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Fig. 2B. —32-year-old man with normal supraclavicular anatomy. Section
1, most superior axial contrast-enhanced CT section, displays some
supraclavicular anatomy: ASM = anterior scalene muscle, IJV = internal jugular
vein, CCA = common carotid artery, T = thyroid, LCM = longus colli muscle.
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Fig. 2D. —32-year-old man with normal supraclavicular anatomy. Section
3, next inferior axial section, shows anterior scalene muscle (ASM), thyroid
(T), subclavian artery (SCA), longus colli muscle (LCM), and esophagus
(E).
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Fig. 2E. —32-year-old man with normal supraclavicular anatomy. Section
4, lower axial section with continuation of normal structures in this area,
shows subclavian artery (SCA), internal jugular vein (IJV), and common carotid
artery (CCA).
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Most supraclavicular lymph nodes are at, to just above, the internal
jugular vein–subclavian vein junction
[4]. Other CT and sonographic
landmarks for these nodes include proximity to the lower anterior scalene
muscle just posterolateral to the inferior margin of the thyroid gland (Figs.
2A,
2B,
2C,
2D and
2E). The supraclavicular lymph
nodes may also lie more laterally along the upper margin of the clavicle.
Criteria for Recognizing Abnormal Lymph Nodes
In one sonographic series, 15.8% of 505 healthy patients had
supraclavicular lymph nodes detected with sonography
[5]. Of the nodes seen on
sonography in that study, 90% had a short axis of less than 5 mm, and all
short axes were smaller than 7 mm.
In this area, we define adenopathy as a node with a short axis of 5 mm or
greater on CT or sonography, having a rounded shape (generally a
longitudinal-axis-to-short-axis ratio < 2), and having no significant
echogenic nodal hilum on sonography
[6].
Diseases That May Involve Supraclavicular Lymph Nodes
The supraclavicular area is the final common pathway of the lymphatic
system as it joins the central venous system. Malignancies with a propensity
to metastasize to supraclavicular lymph nodes include lung, head and neck,
breast, esophageal, gastric, pancreatic, gynecologic, and prostate cancers.
Other conditions such as lymphoma and sarcoidosis may involve this area as
well.
Lung Cancer
The best chance for cure of a lung cancer is surgery. Supraclavicular nodal
metastases in lung cancer are considered a contraindication to surgery.
Twelve to 31% of patients presenting with lung cancer will have nonpalpable
neck lymph node metastases at sonographically guided fine-needle aspiration
biopsy using a lymph node short-axis threshold for biopsy of 5 mm or greater
[4,
7].
Almost 50% of lung cancer patients with mediastinal adenopathy (short axis
1 cm) on CT have supraclavicular metastases, and most are recognizable on
chest CT [4]. Therefore, in the
presence of mediastinal adenopathy in suspected or known lung cancer, even
when supraclavicular nodes are not shown on CT, it is sometimes worthwhile to
investigate further with sonography (Figs.
3A,
3B and
3C). In the absence of
mediastinal adenopathy on CT, supraclavicular nodes are unlikely to be
enlarged [4].
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Fig. 3A. —78-year-old woman with metastatic lung adenocarcinoma where
pacemaker metallic artifact obscured left supraclavicular adenopathy on CT
images. CT scan of this patient with right lower lobe lesion shows mediastinal
adenopathy (arrows). Many lung cancer patients with mediastinal
adenopathy seen on CT have supraclavicular lymph node metastases
[4].
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Fig. 3B. —78-year-old woman with metastatic lung adenocarcinoma where
pacemaker metallic artifact obscured left supraclavicular adenopathy on CT
images. CT scan shows where pacemaker metallic artifact obscured
supraclavicular area.
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Fig. 3C. —78-year-old woman with metastatic lung adenocarcinoma where
pacemaker metallic artifact obscured left supraclavicular adenopathy on CT
images. Sonogram shows enlarged left supraclavicular lymph nodes
(arrows) that were biopsied with sonographic guidance. Biopsy yielded
adenocarcinoma consistent with origin from primary lung tumor.
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In our experience, most lung cancer patients presenting with a superior
vena cava syndrome and many patients presenting with neurologic symptoms and
signs from brain metastases also have supraclavicular adenopathy that can be
easily biopsied with sonographic guidance.
Esophageal Cancer
Researchers who used both CT and sonography found 15% of patients with
esophageal cancer to have nonpalpable supraclavicular lymph node metastases at
presentation, as determined by sonographically guided fine-needle biopsy using
a threshold for biopsy of 5 mm for the nodal short axis
[8]. We have found the
supraclavicular area to be a useful site for sampling both at initial
presentation and to confirm recurrent metastatic disease (Figs.
4A,
4B and
4C).
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Fig. 4A. —68-year-old man with recurrent metastatic esophageal
adenocarcinoma. Postoperative CT scan shows suspected metastatic recurrence of
esophageal adenocarcinoma in difficult-to-access portacaval lymph node
(arrow).
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Fig. 4C. —68-year-old man with recurrent metastatic esophageal
adenocarcinoma. Sonogram shows right supraclavicular lymph node
(arrow) that was biopsied with sonographic guidance. (Arrowhead
indicates internal jugular vein.) Biopsy yielded material consistent with
recurrent metastatic esophageal adenocarcinoma.
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Uterine Cervical Cancer
A prior review estimated that one third of patients with cervical cancer
that is metastatic to abdominal paraaortic nodes (Figs.
5A,
5B and
5C) have occult
supraclavicular lymph node metastases
[9].
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Fig. 5A. —40-year-old woman with metastatic squamous cell cervical
carcinoma who underwent CT of abdomen, chest (arms up), and neck (arms down).
Abdominal CT scan shows cervical cancer metastasis to paraaortic node
(arrow). Note obstructed left kidney from pelvic tumor.
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Fig. 5B. —40-year-old woman with metastatic squamous cell cervical
carcinoma who underwent CT of abdomen, chest (arms up), and neck (arms down).
Chest CT scan (arms up, deep inspiration) shows metastatic squamous cell
carcinoma in left supraclavicular lymph node (arrow); metastasis was
subsequently proven at sonographically guided needle biopsy.
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Fig. 5C. —40-year-old woman with metastatic squamous cell cervical
carcinoma who underwent CT of abdomen, chest (arms up), and neck (arms down).
Corresponding neck CT image (arms down, quiet respiration) shows appearance
and location of supraclavicular lymph node (arrow) similar to that
seen on B.
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Sarcoidosis
In one study, approximately 10% of patients with suspected sarcoidosis had
sonographically guided fine-needle aspiration biopsy of supraclavicular lymph
nodes that yielded the diagnosis of sarcoidosis. Those investigators used a
threshold for biopsy of 10 mm in the long axis of the node
[10]. By using a smaller size
threshold for biopsy, the procedure may eliminate the need for bronchoscopy or
mediastinoscopy in even more instances of suspected sarcoidosis (Figs.
6A,
6B and
6C).
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Fig. 6B. —51-year-old man with sarcoidosis. CT scan shows right
supraclavicular lymph node (arrow) on first chest image. When
scanning is begun higher (2 cm above lung apices), recognition of node is
easier.
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Sonographically Guided Supraclavicular Node Biopsy Technique
Supraclavicular lymph nodes are typically superficial, less than 3 cm deep
in relation to the skin (Figs.
7A,
7B and
7C).
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Fig. 7A. —56-year-old man with metastatic, poorly differentiated
non–small cell lung carcinoma and superior vena cava syndrome.
Contrast-enhanced CT scan shows right hilar mass and compression of superior
vena cava (arrow) by mediastinal adenopathy.
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Fig. 7B. —56-year-old man with metastatic, poorly differentiated
non–small cell lung carcinoma and superior vena cava syndrome. CT scan
shows right supraclavicular adenopathy (arrow). Right internal
jugular vein (arrowhead) was thrombosed.
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Fig. 7C. —56-year-old man with metastatic, poorly differentiated
non–small cell lung carcinoma and superior vena cava syndrome. Oblique
sonogram at time of 22-gauge fine-needle (arrows) aspiration biopsy
shows same right supraclavicular node (arrowheads). Biopsy material
was consistent with poorly differentiated non–small cell carcinoma.
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Patients can be positioned supine or sitting, as tolerated. The sampling
can be performed by a single operator with sonographic biopsy guide
attachments or a freehand technique. For suspected metastatic epithelial
tumors or sarcoidosis, one can attach a 22-gauge needle to a syringe (stylet
removed), then introduce the needle to the node for sampling. We typically
obtain two or three samples, have the specimens checked by our
cytopathologist, and then obtain additional samples as needed.
Complications are rare; none have occurred in our patients. Potential risks
of invasive procedures (from surgical series) in this area include bleeding,
infection, pneumothorax, lymphatic leak, air embolism, and impairment of
neural function (including the phrenic and recurrent laryngeal nerves) by
direct neural injury or by the effects of local anesthesia
[1].
Conclusion
Chest or neck CT and sonography with guided fine-needle aspiration biopsy
of supraclavicular lymph nodes are complementary techniques for recognition
and definitive diagnosis of adenopathy in this area. Beginning chest CT
scanning at least 2 cm above the lung apices facilitates the detection of
supraclavicular lymph nodes without additional CT of the neck.
Sonographically guided percutaneous biopsy of these typically superficial
nodes (<3 cm from the skin in most patients) is a quick, simple, and safe
procedure. Sonographically guided fine-needle aspiration biopsy of
supraclavicular lymph nodes may simultaneously diagnose and stage various
malignancies and eliminate the need for other, more time-consuming invasive
procedures with their associated greater risks.
Acknowledgments
We thank Jeanette Griebel and Margaret Kowaluk for assistance with
manuscript preparation and Iona Mackey for assistance with reference
material.
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Introduction
Background
