Diagnostic Approach for Cervical Nodule
The diagnostic workup for a cervical nodule depends critically on the clinical context: if this is a neck mass in a patient without known malignancy, begin with high-resolution ultrasound followed by fine needle aspiration cytology (FNAC); if this is a cervical lymph node in a patient with known or suspected cervical cancer, proceed with MRI for staging and consider PET/CT for nodal assessment.
Initial Assessment Based on Clinical Context
For Neck Mass Without Known Malignancy
High-resolution ultrasound is the first-line imaging modality for evaluating cervical lymph nodes, as it can distinguish between benign and malignant causes based on specific sonographic features. 1
Key ultrasound features to assess include:
- Distribution of lymphadenopathy 1
- Echogenicity patterns 1
- Presence of calcification 1
- Intranodal cystic necrosis 1
- Matting and soft tissue edema 1
Fine needle aspiration cytology (FNAC) should be combined with ultrasound to establish tissue diagnosis. 1
For Cervical Lymph Node in Known/Suspected Cervical Cancer
MRI is superior to CT scan for tumor extension assessment and should be the preferred imaging modality for pelvic and abdominal evaluation. 2, 3, 4
Clinical gynecological examination remains fundamental for FIGO staging and must include assessment of tumor size, vaginal extension, parametrial involvement, and potential bladder or rectal extension. 2, 4
Comprehensive Staging Workup for Cervical Cancer
Essential Laboratory Tests
Complete blood count including platelets is required. 4
Renal function tests are critical, as hydronephrosis defines stage IIIB disease. 4
Liver function tests must be obtained. 4
Squamous cell carcinoma (SCC) antigen is useful for follow-up if initially elevated in patients with squamous histology. 2, 3, 4
Imaging Strategy
MRI is mandatory for any clinically visible tumor or microscopic tumor with >5 mm invasion (stage IB or greater). 4
MRI is essential for measuring tumor size accurately, which is critical for distinguishing IB1 vs IB2 and IIA1 vs IIA2 stages. 4
Thoracic CT scan may be included for metastasis assessment. 2, 3, 4
PET/CT shows high sensitivity and specificity for nodal disease and is increasingly important with 2018 FIGO staging incorporating lymph node status. 4
CT pelvis is equal to MRI for nodal assessment but inferior for local tumor extension. 2, 4
Special Diagnostic Considerations
Enlarged Cervical Lymph Nodes (>1 cm)
Enlarged cervical lymph nodes are found in 46.5% of patients with papillary thyroid cancer compared to only 17.8% with benign nodules, making size an important discriminator. 5
The presence of suspicious ultrasonographic features on cervical lymph nodes increases the positive predictive value: benign-appearing enlarged nodes have 41.54% PPV, nodes with one suspicious feature have 70.97% PPV, and nodes with two or more suspicious features have 73.91% PPV for malignancy. 5
Laparoscopic Ultrasound for Nodal Assessment
Laparoscopic ultrasound has 87.8% accuracy, 63.6% sensitivity, and 95.6% specificity in detecting pelvic lymph node metastasis in cervical cancer. 6
This technique is sensitive for detecting macroscopic but not microscopic metastatic pelvic lymph nodes. 6
Surgical pelvic and para-aortic nodal staging remain optional, with PET under evaluation. 2
Critical Pitfalls to Avoid
Do not rely on clinical examination alone for nodal assessment in cervical cancer—imaging is essential for accurate staging. 4
Do not assume a cervical nodule is benign based on size alone; ultrasound characteristics and tissue diagnosis are required. 1, 5
Do not overlook the possibility of metastatic disease from cervical cancer to unusual sites, including cutaneous metastases, which carry grave prognosis. 7
Remember that lymphovascular space invasion (LVSI) does not alter FIGO stage but may influence treatment decisions in early-stage disease. 4