The patient was a 74-year-old woman with chronic obstructive pulmonary disease. In June 20XX, she observed a lump in her right supraclavicular fossa, which increased in size over 2 months, and she consulted a local doctor in mid-September. Computed tomography (CT) images showed a nodule in the upper lobe of the right lung and enlargement of the mediastinal and right supraclavicular fossa lymph nodes, and she was referred to our department. At the first visit, she had right cervical lymphadenopathy with hard consistency. The T-SPOT . TB test result was positive, whereas the tumor marker levels were not elevated. On chest radiography, the right mediastinal lymph node appeared to protrude into the right lung (Fig. 1). Dynamic CT revealed a significantly enlarged lymph node in the right supraclavicular fossa (Fig. 2), a small nodule (maximum diameter, 13 mm) in the upper lobe of the right lung, and an enlarged lymph node in the right supraclavicular fossa and mediastinum.
Fluorodeoxyglucose (FDG)-positron emission tomography/CT performed at the first visit showed high FDG accumulation in the longitudinal and right supraclavicular fossa lymph nodes, whereas little FDG uptake was observed in the right upper lobe lesion (Fig. 3). In late September, the patient underwent supraclavicular lymph node puncture aspiration, and cytological examination confirmed class IV suspected malignancy on cytology, but the cytological diagnosis of malignancy could not be concluded because of few viable cells. Concomitantly, the culture of Mycobacterium tuberculosis (M. tuberculosis) from the punctured lymph nodes became positive within 1 week of culture in the Mycobacterium growth indicator tube (MGIT), and the patient was diagnosed with lymph node tuberculosis. In the middle of October, anti-tuberculosis treatment was started with isoniazid, rifampicin, ethambutol, and pyrazinamide. Although experimental resistance to the drugs was not observed using the MGIT 960 SIRE kit (Nippon Becton Dickinson Company, Ltd.), the right supraclavicular fossa and mediastinal lymph nodes continued to increase in size. Moreover, the patient's pain increased, and airway compression was noted. Incision and drainage of the enlarged lymph nodes were scheduled, but in mid-December, the patient's dyspnea worsened, and she was transported to our hospital via ambulance for respiratory failure. Wheezing was observed, and blood examination showed elevated levels of SCC (5.4 ng/mL), CYFRA (10.19 ng/mL), and NSE (28.13 mg/dL). CT showed further enlargement of the right supraclavicular fossa lymph nodes and airway displacement (Fig. 4).
Airway displacement by the tumor was considered to cause an aggravation of dyspnea. After admission, we performed a partial resection of the right supraclavicular lymph node, in which we initially conducted puncture aspiration to alleviate the airway displacement, as well as a tissue biopsy. No pus was observed, and the specimen was pathologically diagnosed as squamous cell carcinoma. Radiation therapy was initiated to relieve the symptoms, and tumor reduction was observed. Endoscopic examinations were performed in the otolaryngology and gastroenterology departments, but no primary lesions could be identified. A small nodule in the right lung was suspected to be the primary site. Chemotherapy with carboplatin and nab-paclitaxel was administered for stage IIIC squamous cell carcinoma of the lung. CT images acquired after radio- and chemotherapy showed resolution of the airway displacement due to the enlarged right supraclavicular lymph node (Fig. 4).
Image changes from hospitalization to post-treatment. CT images taken after radiotherapy and chemotherapy show a reduction in the enlarged right supraclavicular lymph nodes. This is well recognized by comparing the anterior and posterior diameters of the tumors. The tumor volume has decreased and the patient is in the supine position, which results in a lateral tumor pushing the orbit laterally, and a sheath-shaped airway is captured on CT. The nodule in the right lung field has not changed after treatment.