What is the recommended workup for cervical lymphadenopathy?

Cervical Lymphadenopathy Workup

For cervical lymphadenopathy, the recommended workup includes a risk-stratified approach with ultrasound as first-line imaging, followed by appropriate laboratory testing and biopsy for persistent or suspicious nodes. 1

Initial Risk Assessment

High-Risk Features for Malignancy

• Duration: Mass present ≥2 weeks or uncertain duration 2
• Physical characteristics: Fixed to adjacent tissues, firm consistency, size >1.5 cm, and/or ulceration of overlying skin 2
• Patient factors: Age >40 years, male sex, white race, supraclavicular location 3
• Systemic symptoms: Fever, night sweats, unexplained weight loss 3

Low-Risk Features

• Recent history of upper respiratory infection, dental problem, trauma, or insect bites 2
• Signs of infection (warmth, erythema, tenderness, fever) 2
• Duration <2 weeks with fluctuation in size 2

Diagnostic Algorithm

Step 1: Laboratory Testing

• Complete blood count with differential
• Erythrocyte sedimentation rate (ESR)
• Serum lactate dehydrogenase (LDH)
• Liver and renal function tests
• HIV, Hepatitis B and C testing (especially in high-risk patients)
• Serum protein electrophoresis
• β-microglobulin 1

Step 2: Imaging

• Ultrasound: First-line imaging modality

  • Evaluates size, morphology, hilum presence, vascularity patterns
  • Safe regardless of platelet count 1

• Advanced imaging (for suspicious cases):

  • CT with contrast of neck/chest/abdomen/pelvis (when malignancy suspected)
  • PET-CT (when lymphoma suspected or to evaluate disease extent) 1

Step 3: Biopsy

• Fine-needle aspiration cytology (FNAC):

  • Initial diagnostic procedure for accessible nodes
  • May be combined with cell block preparation
  • Can be performed with ultrasound guidance 1

• Core biopsy:

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

• Excisional biopsy:

  • Gold standard for diagnosis
  • Indicated when:
    • FNAC/core biopsy is non-diagnostic
    • Lymphoma is strongly suspected
    • Complete architectural assessment needed
    • Lymphadenopathy persists beyond 3 weeks 1

Special Considerations

Antibiotic Use

• Only prescribe antibiotics if there is evidence of bacterial infection
• If treated with antibiotics, patient should be reassessed within 2 weeks
• If mass has not completely resolved after antibiotics, proceed with further workup for malignancy 2

HIV-Positive Patients

• Higher prevalence of opportunistic infections and non-Hodgkin lymphoma
• Mycobacterial infections more common (38.4% vs 12.5% in general population)
• More extensive infectious disease workup recommended 1

Autoimmune Lymphoproliferative Syndrome (ALPS)

• Consider in cases with persistent lymphadenopathy affecting multiple sites
• Diagnostic criteria include:
  • Lymphadenopathy/splenomegaly persisting >6 months
  • Elevated TCR α/β-DNT cells ≥1.5% of total lymphocytes 2

Common Pitfalls to Avoid

1. Delaying biopsy: Patients with persistent cervical lymphadenopathy for over 3 weeks despite antibiotics should undergo biopsy, especially with risk factors for malignancy 4

2. Empiric antibiotics without indication: Avoid prescribing antibiotics without evidence of infection, as this may delay diagnosis of malignancy 2

3. Inadequate follow-up: Even if infectious lymphadenopathy resolves, patients should be reassessed in 2-4 weeks to monitor for recurrence 2

4. Overlooking systemic disease: Generalized lymphadenopathy (≥2 regions) often indicates underlying systemic disease requiring comprehensive evaluation 3

5. Missing malignancy in certain locations: Palpable supraclavicular, popliteal, and iliac nodes are abnormal and warrant thorough investigation 3