From the Guidelines
Adverse clinical change to a lymph node is indicated by a size greater than 1.5 cm in the long axis, regardless of the short axis, or an increase of at least 50% from nadir in the size of previously involved nodes. This definition is based on the revised response criteria for malignant lymphoma 1. The criteria emphasize the importance of careful history and physical examination, as well as additional testing such as CBC, serum chemistries, and imaging studies, in monitoring patients after treatment.
Key features that may indicate adverse clinical change include:
- Lymph nodes with a long axis greater than 1.5 cm
- Increase of at least 50% from nadir in the size of previously involved nodes
- Appearance of new lesions more than 1.5 cm in any axis during or at the end of therapy
- Increased FDG uptake in a previously unaffected site, confirmed by other modalities
A more recent study 1 provides guidance on managing incidental findings on thoracic CT, including mediastinal and cardiovascular findings. This study suggests that lymph nodes greater than 1 cm in short axis may be considered abnormal, and that size, texture, and distribution of nodes should be taken into account when determining the need for follow-up or further evaluation. However, the criteria from 1 remain the most relevant and widely accepted guidelines for defining adverse clinical change in lymph nodes.
In clinical practice, the evaluation of concerning lymph node changes typically includes physical examination, imaging studies, and possibly biopsy for definitive diagnosis. The clinical significance of lymph node changes depends on the patient's age, medical history, and associated symptoms. Prompt evaluation and management of adverse clinical changes to lymph nodes are crucial to prevent morbidity, mortality, and to improve quality of life.
From the FDA Drug Label
Hemic and Lymphatic Systems: Anemia, including hemolytic anemia, thrombocytopenia, thrombocytopenic purpura, eosinophilia, leukopenia, and agranulocytosis have been reported. The adverse clinical change to the lymph node is not directly mentioned, but changes in the Hemic and Lymphatic Systems are reported, including:
- Anemia
- Thrombocytopenia
- Thrombocytopenic purpura
- Eosinophilia
- Leukopenia
- Agranulocytosis 2
From the Research
Adverse Clinical Change to Lymph Node
- Adverse clinical change to lymph nodes can be indicated by various factors, including an increase in size, tenderness, or the presence of systemic symptoms such as fever, night sweats, and unexplained weight loss 3.
- The presence of certain clinical features, such as age > 45, B symptoms, history of malignancy, and lymphadenopathy that is ≥ 2 cm, in multiple regions, bilateral, multiple nodes, or supraclavicular, can be significantly associated with malignancy 4.
- Lymphadenopathy can be a part of the clinical spectrum of several primary immunodeficiencies, including diseases with immune dysregulation and autoinflammatory disorders, and can pose a significant diagnostic dilemma when it represents the first sign of a disorder of the immune system 5.
- Secondary lymphoid organs, such as lymph nodes, play a crucial role in controlling autoreactive T cells and preventing immune responses to self-antigen, and their failure can lead to chronic inflammation and tissue destruction in autoimmune diseases 6.
Diagnostic Approaches
- Ultrasonography can be a useful tool in detecting malignant lymphadenopathy, with a sensitivity of 98% and negative predictive value of 97% 4.
- The workup for lymphadenopathy may include blood tests, imaging, and biopsy, depending on clinical presentation, location of the lymphadenopathy, and underlying risk factors 3.
- Biopsy options include fine-needle aspiration, core needle biopsy, or open excisional biopsy, and the choice of biopsy method depends on the clinical context and the suspected underlying cause of the lymphadenopathy 3.
Associated Conditions
- Lymphadenopathy can be associated with various conditions, including malignancy, infection, autoimmune disorders, and immunodeficiency disorders 3, 5.
- The presence of lymphadenopathy in a patient with diagnosed immunodeficiency can raise the question of the differential diagnosis between benign lymphoproliferation and malignancies 5.
- Lymph nodes can play a role in the pathogenesis of autoimmune diseases, and their study can provide insight into the mechanisms underlying these conditions 6.