Most patients ultimately diagnosed with malignant neck masses did not undergo a streamlined diagnostic pathway, and empiric antibiotic use, delayed biopsy after the initial specialist visit, and the need for multiple biopsies were associated with longer diagnostic intervals, according to a retrospective study published in The Permanente Journal.
Primary care physician–ordered imaging was also associated with a longer time to specialist evaluation, although not with a longer total time to pathologic diagnosis.
Researchers reviewed electronic consult records for 4,103 adults aged 18 to 89 years who were referred for evaluation of neck or salivary gland masses within a large integrated health care system in Northern California from January 1 to December 31, 2017. They cross-referenced the cohort with the institutional cancer registry and identified 205 patients with newly diagnosed malignancy. After excluding 13 patients who underwent biopsy of another anatomic site, 192 patients who had neck mass biopsy were included in the primary analysis.
The most common diagnoses were lymphoma, oropharyngeal carcinoma, and thyroid carcinoma. Overall, 5% of patients referred for neck masses were ultimately diagnosed with malignancy.
The median interval from first primary care evaluation for a neck mass to pathologic diagnosis was 21 days. However, 25% of patients had diagnostic intervals of at least 38 days.
Researchers defined a diagnostic biopsy as one that provided enough information to initiate definitive oncologic treatment without additional tissue sampling. Nondiagnostic biopsies included those with inadequate cellularity, necrotic or acellular samples, insufficient tissue architecture for lymphoma subtyping, or indeterminate cytology requiring repeat sampling.
Primary care physicians prescribed antibiotics in 16% of cases. Patients who received antibiotics had a median time to diagnosis of 41 days, compared with 20 days among those who did not receive antibiotics.
The researchers noted that empiric antibiotic use likely stems from the difficulty of distinguishing benign from malignant lymphadenopathy in primary care, where established risk factors are nonspecific or uncommon. The analysis used unadjusted comparisons, and the researchers cautioned that the findings should be interpreted as exploratory rather than confirmatory.
The researchers noted that the American Academy of Otolaryngology–Head and Neck Surgery Clinical Practice Guideline advises against empiric antibiotics for unexplained adult neck masses and recommends a thorough head and neck examination, including laryngoscopy. They also discussed specialist evaluation before imaging as part of an optimized diagnostic pathway.
Primary care physician–ordered imaging occurred in 54% of cases. These patients had a longer median interval from primary care evaluation to otolaryngology–head and neck surgery consultation than patients whose imaging was ordered following specialist evaluation. However, the median total interval from primary care visit to pathology report was 21 days in both groups.
Biopsy timing was another factor associated with diagnostic efficiency. Biopsy was performed at the initial otolaryngology–head and neck surgery visit in 58% of patients. When biopsy occurred at a follow-up visit, the interval from specialist evaluation to diagnostic biopsy was longer by a median of 9 days.
Multiple biopsies were required in 42% of patients and were associated with longer total diagnostic intervals. Among nondiagnostic biopsies, common limitations included inadequate tissue architecture for lymphoma diagnosis and insufficient cellularity.
Among first biopsy procedures, fine-needle aspiration accounted for 70% of cases, core needle biopsy for 28%, and excisional biopsy for 2%. Diagnostic success rates were 56% for fine-needle aspiration, 74% for core needle biopsy, and 100% for excisional biopsy.
Among biopsies performed by otolaryngology–head and neck surgery clinicians, core needle biopsy had a higher diagnostic yield than fine-needle aspiration. The researchers also reported that point-of-care ultrasound was used in only 18% of otolaryngology–head and neck surgery needle biopsies and wrote that wider adoption could help expedite neck mass assessment.
Interventional radiology clinicians had higher overall diagnostic success rates than otolaryngology–head and neck surgery clinicians, but the researchers noted that interventional radiology clinicians more often performed core needle biopsy. When only core needle biopsy procedures were compared, diagnostic yields were similar between specialties.
Only 18% of patients underwent the streamlined pathway defined by the researchers: specialist referral without empiric antibiotics or primary care physician–ordered imaging, followed by diagnostic biopsy at the initial otolaryngology–head and neck surgery visit. These patients received a diagnosis in a median of 6 days.
The study was limited by its retrospective design, unadjusted exploratory comparisons, and inclusion of patients from a single integrated health care system. The cohort included only patients ultimately diagnosed with malignancy and did not include a comparator group of patients with benign neck masses. The analysis also reflected practice patterns from 2017 and did not evaluate patient-related delays before seeking care, out-of-system encounters before presentation, treatment initiation, survival outcomes, or whether expedited diagnostic pathways improve clinical outcomes. The researchers also cautioned that the number of comparisons increased the possibility of type I error.
The researchers concluded that the findings establish baseline data for performance improvement and support further study of whether expedited diagnostic pathways can improve patient satisfaction or survival.
Disclosures: The researchers reported no conflicts of interest and no funding.
Source: The Permanente Journal