Where to Refer for Lymphadenopathy
Patients with lymphadenopathy should be referred based on anatomical location, size >1.5 cm, and clinical context, with supraclavicular nodes always requiring hematologist-oncologist referral due to high malignancy risk. 1
Immediate Referral to Hematologist-Oncologist
The following scenarios mandate urgent referral to a hematologist-oncologist:
- Supraclavicular lymphadenopathy - this location carries high malignancy risk regardless of other features 1
- Multiple non-contiguous sites of lymphadenopathy (generalized lymphadenopathy) 1
- Lymph nodes >1.5 cm in diameter that persist beyond 2-4 weeks of observation 1, 2
- Cancer survivors presenting with new lymphadenopathy due to recurrence risk 1
- Popliteal or iliac nodes that are palpable (these are always abnormal) 2
- Epitrochlear nodes >5 mm in diameter 2
Location-Specific Referral Pathways
Head and Neck Lymphadenopathy
- Refer to ENT specialist or head and neck surgeon when associated with upper respiratory symptoms, ear infections, oral lesions, or parotitis 1, 3
- In Sjögren's patients specifically, head and neck lymphadenopathy with unexplained weight loss, fevers, or night sweats requires investigation for lymphoma with multidisciplinary review involving rheumatologist, pulmonologist, pathologist, radiologist, and hematologist/oncologist 3
Axillary Lymphadenopathy
- Refer to breast surgeon if female patient with suspicious breast findings 1
- Otherwise, refer to hematologist-oncologist if nodes >1.5 cm or persistent 1
Inguinal Lymphadenopathy
- Refer to urologist if associated with genital lesions 1
- Otherwise, refer to hematologist-oncologist if nodes >1.5 cm or persistent 1
Cervical Lymphadenopathy (Non-Head/Neck Region)
- Refer to hematologist-oncologist for persistent nodes >1.5 cm, especially if bilateral or accompanied by systemic symptoms 1, 2
High-Risk Features Requiring Specialist Referral
Beyond location, certain clinical features indicate higher malignancy risk and warrant immediate specialist referral 2:
- Age >40 years with unexplained lymphadenopathy
- Male sex (higher malignancy risk)
- Systemic B symptoms: fever, night sweats, unexplained weight loss
- Hard, fixed, or matted nodes on palpation
- Nodes that continue enlarging despite observation
Special Population Considerations
HIV-Infected Patients
- Refer to infectious disease specialist for initial evaluation, as both opportunistic infections and HIV itself can cause FDG-avid lymphadenopathy 3
- If neoplasm suspected after infectious workup, refer to hematologist-oncologist 3
- Focal or rapidly progressive lymphadenopathy may require biopsy 3
Sjögren's Patients
- Multidisciplinary referral (rheumatologist, pulmonologist, pathologist, radiologist, hematologist/oncologist) is strongly recommended when neoplasm confirmed or suspected, given 5-18% lymphoma risk 3
Diagnostic Workup Prior to Referral
While awaiting specialist evaluation, primary care can initiate 1, 2:
- Ultrasound to characterize lymph node features (size, presence of hilum, vascularity patterns)
- Documentation of precise measurements, location, consistency, and mobility
- Basic laboratory work if systemically ill (CBC, inflammatory markers)
Critical pitfall: Do not delay referral waiting for imaging results if high-risk features present (supraclavicular location, size >1.5 cm, systemic symptoms) 1, 2.
Observation vs. Immediate Referral
Observation for 3-4 weeks is appropriate only for 2, 4:
- Localized lymphadenopathy <1.5 cm
- Clear infectious etiology in drainage area
- Clinically stable patient
- No suspicion of malignancy
- Exception: Supraclavicular and infraclavicular nodes should never be observed - always refer immediately 4
Immediate referral without observation period is required for all high-risk features listed above 1, 2.