From the Guidelines
The appropriate workup for large axillary and elbow lymph nodes begins with a thorough history and physical examination to identify potential causes such as infection, malignancy, or autoimmune conditions. Initial laboratory tests should include a complete blood count with differential, comprehensive metabolic panel, erythrocyte sedimentation rate, and C-reactive protein, as recommended by 1. Specific serologic tests may be warranted based on clinical suspicion, including HIV testing, EBV serology, or autoimmune markers. Imaging studies should start with ultrasonography of the affected lymph nodes to assess their characteristics, with concerning features prompting further evaluation with CT or PET-CT scans to determine the extent of lymphadenopathy, as suggested by 1 and 1. A lymph node biopsy is often necessary for definitive diagnosis, with fine-needle aspiration being less invasive but excisional biopsy providing more comprehensive information, as noted in 1. The biopsy specimen should undergo histopathological examination, flow cytometry, and microbiological studies as appropriate. This systematic approach is essential because enlarged lymph nodes can result from various conditions ranging from benign reactive processes to malignancies, and proper diagnosis guides appropriate treatment. The workup should be tailored to the patient's clinical presentation, risk factors, and associated symptoms, with prompt referral to specialists such as hematology-oncology if malignancy is suspected, as recommended by 1 and 1.
Some key points to consider in the workup include:
- The use of ultrasonography as the initial imaging modality, as recommended by 1 and 1
- The importance of lymph node biopsy for definitive diagnosis, as noted in 1
- The need for a thorough history and physical examination to identify potential causes of lymphadenopathy, as recommended by 1
- The consideration of specific serologic tests based on clinical suspicion, such as HIV testing or autoimmune markers, as suggested by 1
- The potential use of CT or PET-CT scans for further evaluation of concerning features, as recommended by 1 and 1
From the Research
Workup for Large Axillary and Elbow Lymph Nodes
- The workup for large axillary and elbow lymph nodes typically involves a combination of physical examination, imaging studies, and biopsy to determine the cause of lymphadenopathy 2.
- Imaging studies such as ultrasonography, mammography, and magnetic resonance imaging (MRI) can be used to evaluate the size and characteristics of the lymph nodes, but may not always be able to predict axillary lymph node positivity 2.
- Fine-needle biopsy (FNB) and flow cytometry (FC) can be useful tools in the diagnosis of lymphomas, allowing for the analysis of lymph node cells and the detection of abnormal cell populations 3, 4.
- The Lugano classification system incorporates symptoms and the extent of the disease as shown on positron emission tomography/computed tomography (PET/CT) to stage lymphoma, which is then used to determine treatment 5.
Diagnostic Approaches
- Open lymph node biopsy is preferred for diagnosis, as it allows for the examination of the lymph node architecture and the detection of malignant cells 5.
- Flow cytometry can be used to analyze the surface antigens on lymph node cells, helping to diagnose lymphoma and distinguish between different subtypes 3.
- Ultrasonography and color-Doppler US can be used to evaluate the epitrochlear lymph nodes and detect abnormalities such as metastases, lymphadenitis, and lymphoma 6.
Limitations and Considerations
- Physical examination and imaging studies may not always be able to predict axillary lymph node involvement, and biopsy is often necessary to confirm the diagnosis 2.
- Flow cytometry may not be able to detect all types of lymphoma, such as Hodgkin's disease, and may produce normal results in some cases of malignant disease 3.
- The preanalytical phase of FNB and FC is critical, and technical limitations and difficulties may pose problems in differential diagnosis 4.