From the Guidelines
If an enlarged cervical lymph node is detected on ultrasound, fine needle aspiration (FNA) biopsy should be performed as the first-line modality for histologic assessment, especially in patients over 40 years old, due to the increased incidence of malignancy in this age group 1. When evaluating an enlarged cervical lymph node, it is crucial to consider the patient's age, clinical presentation, and imaging characteristics. According to the clinical practice guideline for the evaluation of the neck mass in adults 1, the incidence of cancer in a cystic neck mass increases to 80% in patients over 40 years old.
- Key factors to consider in the management of an enlarged cervical lymph node include:
- Patient's age and clinical presentation
- Imaging characteristics, such as size, central necrosis, and extracapsular spread
- Presence of multiple enlarged lymph nodes or asymmetric thickness of the wall
- FNA biopsy is recommended as the initial diagnostic step, with repeated FNA or image-guided FNA considered if the initial results are inadequate or benign 1. In cases where malignancy is suspected and FNA results are inconclusive, an expedient open excisional biopsy may be necessary to establish a definitive diagnosis 1.
- It is essential to prioritize the evaluation of an enlarged cervical lymph node, as delayed diagnosis or misdiagnosis can have significant implications for patient outcomes, particularly in cases of malignancy 1.
From the Research
Management of Enlarged Cervical Lymph Node
The management of an enlarged cervical lymph node detected on ultrasound involves several steps, including:
- Evaluation of the lymph node's characteristics, such as size, shape, and internal echo, to determine the likelihood of malignancy 2
- Fine needle aspiration (FNA) or core biopsy to obtain a tissue sample for histopathological examination 3, 4, 5
- Correlation of ultrasonographic findings with clinical findings and histopathologic results to determine the diagnosis and guide further management 3, 6
Diagnostic Criteria
The diagnostic criteria for enlarged cervical lymph nodes include:
- Size and shape of the lymph node, with larger and rounder nodes being more suspicious for malignancy 2
- Internal echo characteristics, such as hypoechoic or isoechoic levels, punctate bright echogenic spots, and hilus echogenic line 2
- Presence of suspicious features, such as calcifications, necroses/cysts, and peripheral vascularity 3, 6
Role of Fine Needle Aspiration
Fine needle aspiration (FNA) plays a crucial role in the diagnosis of cervical lymph node lymphomas, with a sensitivity of 95.5%, specificity of 98.7%, and positive predictive value of 97.7% 4 FNA can also be used to diagnose other conditions, such as metastatic squamous cell carcinoma and chronic lymphocytic leukemia 5
Ultrasonographic Features
Ultrasonographic features of enlarged cervical lymph nodes can be used to predict the likelihood of malignancy, with features such as absence of an echogenic hilus and presence of suspicious features being associated with an increased risk of malignancy 3, 6 The presence of enlarged cervical lymph nodes with suspicious features can also be used to guide further management, such as FNA or core biopsy 6