Chapter 57 Supraclavicular Lymph Node Biopsy

INTRODUCTION

The supraclavicular lymph node biopsy was first described in the literature in 1949 by Daniels.¹ It has remained a diagnostic tool for intrathoracic and/or metastatic disease, even with the development of more noninvasive procedures such as ultrasound-guided biopsy and scalene biopsy during mediastinoscopy.²^–⁴ The supraclavicular lymph nodes are also called the scalene nodes because of their close proximity with the scalene muscles.

The supraclavicular fossa or scalene triangle is bounded medially by the sternal head of the stenocleidomastoid, laterally by the clavicular head of the same muscle, and inferiorly by the clavicle. The lymph nodes are invested in a fat pad that lies directly over the anterior scalene muscle, just lateral to the carotid sheath. The phrenic nerve and the transverse cervical and suprascapular arteries run through this region, as does the thoracic duct on the left.⁵ In experienced hands, the procedure is very simple; however, a lack of understanding of the anatomy may result in complications including bleeding, thoracic duct injury, and phrenic or recurrent laryngeal nerve injury. Studies have reported an 8% morbidity rate and a 3% mortality rate.^6,⁷

The scalene lymph nodes are a common location for metastasis of several cancers, the most common of which is lung cancer.⁸ In the United States, lung cancer has the highest mortality of all cancers, and disease spread to the scalene lymph nodes (N3) may contraindicate surgical therapy.⁴ Esophageal cancer studies have also demonstrated that 15% of patients have positive scalene nodes at presentation.⁹ Sarcoidosis, a benign but debilitating condition, has also been shown to present with supraclavicular lymphadenopathy.¹⁰