What imaging would you order for a patient with multiple hard, enlarged lymph nodes in the neck and supraclavicular area, concerned about lymphoma (lymphatic system cancer)?

Imaging for Enlarged Supraclavicular/Cervical Lymph Nodes Concerning for Lymphoma

Order a contrast-enhanced CT scan of the neck, chest, abdomen, and pelvis as the initial imaging study for this patient with persistent hard supraclavicular lymphadenopathy concerning for malignancy. 1

Primary Imaging Recommendation

• CT with contrast (neck, chest, abdomen, pelvis) is the standard imaging modality for staging suspected lymphoma and evaluating the full extent of lymphadenopathy 1
• This imaging must include the chest and abdomen because supraclavicular nodes frequently represent metastatic disease from thoracic or abdominal primary tumors, or systemic lymphoproliferative disease 1, 2
• The duration (>1 year) and hard consistency of these nodes significantly increases malignancy risk, particularly in adults, making comprehensive staging imaging essential before tissue diagnosis 1, 3, 4

Critical Next Step: Tissue Diagnosis

However, imaging alone is insufficient—you must obtain tissue diagnosis through excisional lymph node biopsy or core needle biopsy (minimum 4mm) as the definitive diagnostic test. 1, 5, 4

• Excisional biopsy is strongly preferred over fine-needle aspiration (FNA) because FNA provides inadequate tissue architecture for definitive lymphoma diagnosis and subtyping 1, 5, 4
• Supraclavicular lymphadenopathy carries up to 80% malignancy risk in adults, and hard, fixed nodes are particularly concerning for malignancy 1, 3
• The biopsy specimen requires comprehensive analysis including morphology, immunohistochemistry (minimum CD45, CD20, CD3), flow cytometry, and potentially cytogenetics to distinguish between lymphoma subtypes 1, 5

Additional Imaging Considerations

• PET/CT scan is strongly recommended if available, as it better delineates disease extent and is now incorporated into lymphoma staging criteria 1
• PET/CT may eliminate the need for bone marrow biopsy if it shows adequate skeletal assessment 1, 5
• If PET/CT is unavailable, proceed with contrast-enhanced CT as described above 1

Baseline Laboratory Studies Required

Before or concurrent with imaging, obtain: 1, 4

• Complete blood count with differential
• Lactate dehydrogenase (LDH)
• Comprehensive metabolic panel including liver function tests
• Erythrocyte sedimentation rate (ESR)
• Hepatitis B, C, and HIV screening (mandatory before potential chemotherapy)

Critical Pitfall to Avoid

Do not delay tissue diagnosis while waiting for imaging results or hematology/oncology records. 1, 6 A case report specifically warns that deferring lymph node biopsy in favor of less invasive tests (even when considering differential diagnoses) can result in fatal delays in lymphoma diagnosis 6. The patient in that report died during chemotherapy after delayed diagnosis of Hodgkin's lymphoma because lymph node biopsy was postponed 6.

Practical Algorithm

1. Order CT neck/chest/abdomen/pelvis with IV contrast immediately 1
2. Simultaneously arrange excisional lymph node biopsy (do not wait for imaging) 1, 5, 6
3. Obtain baseline labs as listed above 1
4. Request outside records from hematology/oncology 1
5. Consider PET/CT if available for more accurate staging 1

The imaging serves to stage disease extent, but tissue diagnosis through biopsy remains the gold standard and should not be delayed. 1, 4, 6