From the Guidelines
The workup for cervical lymphadenopathy should begin with a thorough history and physical examination, followed by standard laboratory tests, and imaging studies such as PET/CT, CT, or MRI with contrast, with a core needle biopsy or excisional lymph node biopsy being the preferred diagnostic method for lymphoma diagnosis, as recommended by the NCCN guidelines 1.
Key Historical Elements
The history should include:
- Duration of lymphadenopathy
- Associated symptoms (fever, night sweats, weight loss)
- Risk factors for infection
- Exposure history
Physical Examination
The physical examination should document:
- Size, location, consistency, tenderness, and mobility of the lymph nodes
- Complete head and neck examination
Laboratory Testing
Initial laboratory testing should include:
- Complete blood count with differential
- Comprehensive metabolic panel
- Erythrocyte sedimentation rate
- C-reactive protein
- Specific serologic tests based on clinical suspicion, such as EBV, CMV, HIV, toxoplasmosis, or tuberculosis testing
Imaging Studies
Imaging studies like:
- Ultrasound to characterize the nodes
- CT or MRI with contrast for deeper nodes or to evaluate for malignancy
- PET/CT for staging and evaluation of lymphoma, as recommended by the NCCN guidelines 1
Diagnostic Procedures
- Fine needle aspiration (FNA) is often the first invasive diagnostic procedure, providing cytology and material for culture
- If FNA is non-diagnostic or malignancy is strongly suspected, an excisional biopsy should be performed for definitive diagnosis, as recommended by the NCCN guidelines 1
Specialist Referral
The timing of specialist referral depends on clinical features, with immediate referral indicated for patients with concerning features such as:
- Rapidly enlarging nodes
- Nodes larger than 2 cm
- Supraclavicular location
- Systemic symptoms This systematic approach helps differentiate between reactive, infectious, and malignant causes of cervical lymphadenopathy, allowing for appropriate management. In addition to the above workup, the NCCN guidelines also recommend evaluation of ejection fraction for patients undergoing doxorubicin-based chemotherapy, and HIV and hepatitis B or C testing for patients with risk factors 1.
From the Research
Initial Workup for Cervical Lymphadenopathy
The initial workup for cervical lymphadenopathy typically involves a combination of the following:
- A thorough history and physical examination to develop a differential diagnosis 2
- Complete blood count (CBC) to aid in detecting critical diseases and predicting the likelihood of open biopsy 3
- Imaging studies, such as ultrasound, to provide valuable information for accurate diagnosis 2, 4
- Fine-needle aspiration (FNA) and/or core-needle gun biopsy to obtain histopathological diagnoses 3, 4
- Tuberculin test and/or Tb-PCR to diagnose tuberculous lymphadenitis 5, 3
Laboratory Tests and Imaging Studies
Laboratory tests and imaging studies that may be used in the workup for cervical lymphadenopathy include:
- Chest X-ray to evaluate for pulmonary tuberculosis or other thoracic abnormalities 5, 4
- Monospot test and/or indirect fluorescent antibody test for toxoplasmosis to diagnose infectious mononucleosis or toxoplasmosis 5
- Detection of cytomegalovirus antibodies to diagnose cytomegalovirus infection 5
- Ultrasound B-Mode gray scale examination to evaluate lymph node characteristics and guide biopsy 6
- Computed tomography (CT) or magnetic resonance imaging (MRI) scans may also be used in some cases to further evaluate the extent of disease
Histopathological Examination
Histopathological examination of lymph node biopsy specimens is crucial in establishing a definitive diagnosis of cervical lymphadenopathy 5, 6, 3, 4. The most common pathological conditions diagnosed by histopathological examination include: