What is the workup for cervical lymphadenopathy?

Workup for Cervical Lymphadenopathy

The standard workup for cervical lymphadenopathy should begin with a thorough history, physical examination, and basic laboratory tests, followed by ultrasound as the first-line imaging modality, with progression to excisional biopsy if lymphadenopathy persists beyond 3 weeks or has concerning features. 1

Initial Evaluation

History and Physical Examination

• Key history elements:

  • Duration of lymphadenopathy
  • Associated symptoms (fever, night sweats, weight loss)
  • Exposure history (travel, animals, infectious contacts)
  • Medication use
  • Past medical history (especially malignancy)

• Physical examination focus:

  • Size, location, consistency, and mobility of nodes
  • Presence of tenderness
  • Skin changes overlying nodes
  • Examination of all lymph node regions
  • Note: Palpable supraclavicular, popliteal, and iliac nodes are always abnormal, as are epitrochlear nodes >5mm 2

Laboratory Testing

• Complete blood count with differential
• Erythrocyte sedimentation rate (ESR)
• Serum lactate dehydrogenase (LDH)
• Liver and renal function tests 3, 1
• Consider additional tests based on clinical suspicion:
  • HIV testing
  • Hepatitis B and C serology
  • EBV serology
  • Tuberculin skin test or interferon-gamma release assay

Imaging Studies

Ultrasound (First-line)

• Evaluates size, morphology, presence/absence of hilum, vascularity patterns
• Risk factors for malignancy on ultrasound:
  • Absence of hilum
  • Bulky lesion
  • Blurred outer contour
  • Low Solbiati index (ratio of longest to shortest diameter) 1, 4

Advanced Imaging

• CT scan with contrast (neck, chest, abdomen, pelvis) when:

  • Malignancy is suspected
  • Need to evaluate deep cervical nodes
  • Need to assess adjacent structures 1

• PET/CT scan when:

  • Lymphoma is suspected
  • Need to evaluate extent of disease 3, 1

Biopsy Procedures

Fine-Needle Aspiration Cytology (FNAC)

• Initial diagnostic procedure for accessible nodes
• Can be combined with cell block preparation for improved yield
• Ultrasound guidance improves accuracy 1

Core Needle Biopsy

• Higher diagnostic yield than FNAC
• Preserves tissue architecture
• Allows for additional studies (flow cytometry, molecular testing) 1

Excisional Biopsy (Gold Standard)

• Indicated when:
  • FNAC/core biopsy is non-diagnostic
  • Lymphoma is strongly suspected
  • Lymphadenopathy persists >3 weeks with risk factors for malignancy
  • Risk factors include: age >40 years, supraclavicular location, fixed nodes, systemic symptoms 1, 2, 4

Special Considerations

HIV-Infected Individuals

• Different spectrum of etiologies:
  • Higher prevalence of opportunistic infections (non-tuberculous mycobacteria, cryptococcosis, Talaromyces marneffei)
  • Non-Hodgkin lymphoma is the most common malignancy
  • Mycobacterial infections more common (38.4% vs 12.5% in non-HIV patients) 1, 5

Location-Based Considerations

• Supraclavicular nodes: High risk for malignancy, particularly metastatic disease
• Level II nodes: More likely to be benign
• Level IV and V nodes: Higher malignancy rate 4

Algorithm for Cervical Lymphadenopathy Workup

1. Initial assessment: History, physical examination, basic laboratory tests
2. First-line imaging: Ultrasound of involved area
3. Decision point:
   • If clear infectious cause → Appropriate antibiotics
   • If concerning features (age >40, supraclavicular location, fixed nodes, systemic symptoms) → Proceed to biopsy
   • If uncertain → Observation for 3 weeks with follow-up
4. After 3 weeks:
   • If resolved → No further workup
   • If persistent → Biopsy (FNAC, core, or excisional)
5. Based on biopsy results:
   • If malignancy → Advanced imaging (CT or PET/CT) for staging
   • If granulomatous disease → Specific testing for tuberculosis or fungal disease
   • If reactive/non-specific → Consider observation or additional testing based on clinical suspicion

Common Pitfalls to Avoid

• Delaying biopsy beyond 3 weeks in patients with risk factors for malignancy
• Relying solely on FNAC when lymphoma is suspected (excisional biopsy preferred)
• Failing to consider HIV testing in patients with unexplained lymphadenopathy
• Using corticosteroids before establishing a diagnosis, which can mask lymphoma
• Neglecting to evaluate all lymph node regions when generalized lymphadenopathy is present

By following this systematic approach, clinicians can efficiently diagnose the cause of cervical lymphadenopathy and initiate appropriate management to improve patient outcomes.