Abstract
Purpose
Cystic masses of the supraclavicular fossa (SCF) are uncommon. The diverse anatomical structures within the SCF create an extended differential diagnosis for any mass arising in the SCF. This study describes the presenting symptoms, radiologic findings, medical and surgical management, and posttreatment outcomes of various cystic mass presenting in the SCF. A review of the literature and diagnostic and therapeutic algorithms are also provided.
Methods
A retrospective study of an academic tertiary care head and neck cancer center was done. Seven cases of treated cystic masses of the SCF were identified. Diagnostic and therapeutic interventions are described.
Results
Cross-sectional imaging and needle aspiration or biopsy were obtained in all 7 cases. Aspirates accurately differentiated benign from malignant lesions in 6 cases, identified the offending pathology in 3 cases, and provided inoculum for culture-directed antibiotic therapy in 1 case. Surgical intervention was used for definitive therapy in 6 cases. All patients achieved complete resolution of signs and symptoms of the mass.
Conclusions
Effective evaluation of a cystic lesion within the SCF mandates a thorough understanding of the anatomy and differential diagnosis. A well-defined algorithm allows successful management of benign and malignant lesions in the SCF.
1
Introduction
By virtue of location, masses in the supraclavicular fossa (SCF) present one of the broadest differential diagnoses in the head and neck. The variety of structures both within and adjacent to the SCF contribute to the multiplicity of pathology found in this region. Because SCF masses may represent benign or malignant, congenital or acquired, and localized or systemic processes, a thorough and structured evaluation and workup should be used to facilitate diagnosis and guide medical and surgical intervention. Although somewhat less common, the cystic mass of the SCF has an especially interesting differential diagnosis.
We present 7 cases of supraclavicular cystic masses demonstrating the breadth of lesions within this region. A review of the literature focused on cystic pathology of the SCF is presented along with an anatomical description and a clinical diagnostic strategy using imaging and fine needle aspiration (FNA) to guide management and therapy.
2
Case Illustrations
2.1
Case 1
A 49-year-old woman presented with an asymptomatic, slowly enlarging left supraclavicular neck mass. Examination was unremarkable expect for a diffuse fullness in left SCF extending from the sternocleidomastoid muscle (SCM) 10 cm laterally and from the clavicle to the mid jugular region. The lesion was soft, nontender, and without involvement of overlying skin.
Imaging with contrast-enhanced computed tomographic (CT) and magnetic resonance imaging (MRI) revealed a multiloculated, cystic, T2-bright, nonenhancing lesion posterior and lateral to the SCM and anterior to the scalene muscles. FNA revealed scant epithelial cells without evidence of malignancy. Surgical excision of the lesion as well as selective neck dissection of levels II to V revealed a dark, cystic mass that was excised with surrounding lymph nodes and adipose tissue. Intraoperative frozen section demonstrated a hemorrhagic cyst wall with a denuded lining and fibrous capsule. Final pathology revealed cystic hygroma.
2.2
Case 2
A 58-year-old woman presented with an asymptomatic right supraclavicular neck mass progressively enlarging over a period of several months. Prior imaging revealed the mass to be cystic with moderate rim enhancement and a deep medial component abutting the right thyroid lobe with an inferior tail extending to the superior mediastinum. Head and neck examination revealed only soft, nontender fluctuant right supraclavicular fullness without overlying skin changes. FNA of the lesion produced only nondiagnostic serosanguinous fluid. The patient underwent elective surgical excision of the mass through a low lateral neck incision ( Fig. 1 A ). A tail of the mass extended posteroinferiorly into the superior mediastinum anterior to the prevertebral fascia. The mass was removed en bloc with levels IV and V lymph nodes and surrounding adipose tissue ( Fig. 1 B). All critical neurovascular structures were preserved. Pathologic gross sectioning of the mass revealed cystic tissue with hemorrhagic fluid. Final pathology was consistent with cystic lymphangioma.
2.3
Case 3
A 25-year-old man with a history of successfully treated testicular cancer presented with a 6-month history of an asymptomatic, enlarging left supraclavicular neck mass. Examination revealed a soft, mobile, nontender, and well-circumscribed 5 × 7-cm lesion extending medially from the left SCF deep to the SCM.
Ultrasound showed a compressible, multiloculated, cystic lesion measuring 5 × 3 × 6 cm, located lateral to the carotid sheath. An MRI scan of the neck demonstrated a multilocular, T2 hyperintense complex cystic mass between the SCM and anterior scalene muscle with no obvious invasion of surrounding structures or extension into the mediastinum ( Fig. 2 ). FNA revealed serosanguinous fluid and cytology consistent with a benign cystic lesion. Surgical excision demonstrated a mass situated just deep to the external jugular vein within the SCF dissectible from surrounding structures. Final pathology showed clear serous fluid within a cuboidal and ciliated respiratory epithelium-lined cyst with a smooth muscle wall consistent with a bronchogenic cyst.
2.4
Case 4
A 36-year-old woman presented with a 4-month history of asymptomatic right supraclavicular neck fullness. Examination revealed several identifiable masses in the right SCF and lower internal jugular lymph node chain. The right lobe of the thyroid gland was appreciably enlarged.
Magnetic resonance imaging revealed a multilobular T1 and T2 hyperintense mass adjacent to the right lobe of the thyroid gland and deep to the SCM, extending posterior and lateral to the inferior aspect of the internal jugular vein into the SCF. The thyroid gland was noted to be diffusely enlarged and multinodular with the right lobe larger than the left. Ultrasound demonstrated a 3 × 2 × 4-cm right mid-to-lower pole solid thyroid nodule with ill-defined borders and scattered microcalcifications concerning for malignancy. Multiple cystic and mixed solid and cystic lymph nodes were noted along the right internal jugular vein. FNA was performed on the cystic lymph nodes and the right lobe of the thyroid, revealing brown cyst fluid and cytology consistent with papillary thyroid carcinoma. The patient underwent total thyroidectomy with central and right selective neck dissection, requiring mediastinal dissection and partial thymectomy. All critical neurovascular structures were preserved. Final pathology was consistent with metastatic papillary thyroid carcinoma.
2.5
Case 5
A 55-year-old man presented with a 7-year history of a right neck mass extending from the submandibular region to the level of the thyroid gland, resulting in fullness of the supraclavicular region. Imaging, including contrast-enhanced CT and MR scans, revealed a right cystic neck mass measuring 8 × 6 × 3 cm with smooth rim enhancement on CT and hyperintensity on both T1 and T2 sequences ( Fig. 3 ). The mass resided deep to the SCM, extending posteriorly into the SCF and superiorly to the angle of the mandible. No pathologic lymph nodes were seen. Fine needle aspiration revealed turbid yellow fluid, and cytologic analysis was consistent with a branchial cleft cyst. The patient underwent surgical excision of the mass with preservation of all cranial nerves and major vascular structures. The patient recovered uneventfully. Final pathology was a lymphoepithelial (branchial cleft) cyst.
2.6
Case 6
A 28-year-old man presented with a 4-week history of high fevers and a slowly enlarging, painful right supraclavicular neck mass. After a previous positive tuberculin test, a core needle biopsy of the mass had demonstrated necrotizing granulomas. Despite initiation of antituberculous therapy, his symptoms had failed to improve. On examination, a 7 × 4-cm nonmobile tender right supraclavicular mass without overlying skin changes could be appreciated. CT imaging revealed the mass to be a multiloculated cystic fluid collection extending from the SCF medially to efface the internal jugular vein and shift both the esophagus and trachea to the left ( Fig. 4 ).
Given the progression of the mass despite medical therapy, the patient was initiated on a 5-drug maximal antituberculous regimen and underwent an incision and drainage of cystic fluid collection. Appropriate cultures later grew Mycobacterium tuberculosis . Postoperatively, the patient developed a small draining fistula, which eventually resolved with continued medical therapy and wound care, and at last follow-up, the patient was without symptoms or recurrence of the lesion.
2.7
Case 7
A 73-year-old gentleman with a smoking and drinking history presented with a 2-week history of mild odynophagia and otalgia. A large mass was noted in the left SCF, and a workup for a presumed malignancy was commenced. Positron emission tomography-CT imaging revealed a 3 × 2-cm necrotic loculated fluid collection with intense radiolabeled glucose uptake in the left supraclavicular neck. However, no other foci of hypermetabolic activity were seen. FNA of the mass demonstrated necrotic debris without evidence of malignancy, and cultures from aspirates grew α hemolytic Streptococcus . The patient was admitted for intravenous antibiotic therapy.
Repeat CT imaging demonstrated a stable cystic mass ( Fig. 5 ), and with symptomatic improvement with medical therapy over the course of several days, the patient was discharged on a 2-week course of amoxicillin-clavulanate. Over the course the following 2 months, the mass regressed completely and follow-up CT imaging demonstrated no evidence of persistent adenopathy.
2
Case Illustrations
2.1
Case 1
A 49-year-old woman presented with an asymptomatic, slowly enlarging left supraclavicular neck mass. Examination was unremarkable expect for a diffuse fullness in left SCF extending from the sternocleidomastoid muscle (SCM) 10 cm laterally and from the clavicle to the mid jugular region. The lesion was soft, nontender, and without involvement of overlying skin.
Imaging with contrast-enhanced computed tomographic (CT) and magnetic resonance imaging (MRI) revealed a multiloculated, cystic, T2-bright, nonenhancing lesion posterior and lateral to the SCM and anterior to the scalene muscles. FNA revealed scant epithelial cells without evidence of malignancy. Surgical excision of the lesion as well as selective neck dissection of levels II to V revealed a dark, cystic mass that was excised with surrounding lymph nodes and adipose tissue. Intraoperative frozen section demonstrated a hemorrhagic cyst wall with a denuded lining and fibrous capsule. Final pathology revealed cystic hygroma.
2.2
Case 2
A 58-year-old woman presented with an asymptomatic right supraclavicular neck mass progressively enlarging over a period of several months. Prior imaging revealed the mass to be cystic with moderate rim enhancement and a deep medial component abutting the right thyroid lobe with an inferior tail extending to the superior mediastinum. Head and neck examination revealed only soft, nontender fluctuant right supraclavicular fullness without overlying skin changes. FNA of the lesion produced only nondiagnostic serosanguinous fluid. The patient underwent elective surgical excision of the mass through a low lateral neck incision ( Fig. 1 A ). A tail of the mass extended posteroinferiorly into the superior mediastinum anterior to the prevertebral fascia. The mass was removed en bloc with levels IV and V lymph nodes and surrounding adipose tissue ( Fig. 1 B). All critical neurovascular structures were preserved. Pathologic gross sectioning of the mass revealed cystic tissue with hemorrhagic fluid. Final pathology was consistent with cystic lymphangioma.
