Excisional Biopsy is the Appropriate Test
In an HIV-positive patient with chronic diffuse lymphadenopathy who develops a new discrete 4 cm inguinal mass with constitutional symptoms, excisional biopsy (Option C) is the definitive diagnostic test required to distinguish between lymphoma, metastatic disease, infectious etiologies, and Kaposi sarcoma. 1
Why Excisional Biopsy is Superior
Diagnostic Necessity in HIV Context
NCCN guidelines specifically recommend excisional biopsy as the preferred method for suspicious lymphadenopathy in people living with HIV because it provides adequate tissue for comprehensive evaluation including flow cytometry, immunohistochemistry, molecular studies, and cultures 1
The patient's presentation contains multiple red flags mandating excisional biopsy: a new discrete mass distinct from chronic lymphadenopathy, constitutional symptoms (fever, malaise, sweats), HIV infection, mass size of 4 cm, and immigration history raising concern for endemic infections 1
HIV infection increases lymphoma risk 25-fold and anal cancer risk 25-35 fold, making definitive tissue diagnosis essential rather than presumptive 1
Size-Based Exclusion of FNA
Fine needle aspiration is only recommended for palpable inguinal nodes <4 cm when metastatic carcinoma is suspected 1
This patient's mass is 4 cm, making FNA unreliable due to inadequate tissue yield and risk of non-diagnostic results 1
FNA cannot provide the architectural assessment needed to distinguish between the multiple diagnostic possibilities in this HIV patient 1
Limitations of Core Biopsy
Core needle biopsy has only 83.8% full diagnostic ability for lymphomas and may miss low-grade lymphomas, requiring repeat biopsy in 7.4% of cases 1
In an HIV patient with systemic symptoms where diagnostic accuracy is paramount, excisional biopsy is the better option to avoid delays from inadequate sampling 1
Why PET Scan is Inappropriate Now
FDG-PET scan cannot provide histologic diagnosis, and non-malignant causes for lymphadenopathy must be considered in people living with HIV, making biopsy confirmation necessary before any imaging 1
PET/CT is useful for staging after diagnosis is established, but tissue diagnosis is mandatory first 1
Imaging cannot differentiate between the multiple etiologies possible in this clinical scenario (lymphoma, infection, Kaposi sarcoma, metastatic disease) 1
Critical Clinical Context
The New Mass is the Key
Do not assume chronic lymphadenopathy explains the new mass—the discrete nature and 4 cm size suggest new pathology requiring immediate tissue diagnosis 1
Lymph nodes that become palpable during follow-up in patients with chronic lymphadenopathy are malignant in nearly 100% of cases in some contexts, though this patient's HIV status broadens the differential 2
Procedural Approach
The excisional biopsy should remove the entire 4 cm left inguinal mass intact for complete architectural assessment 1
Send tissue for bacterial, fungal, and mycobacterial cultures given the patient's HIV status and immigration history 1
Infectious disease consultation should occur parallel to biopsy, as HIV patients require concurrent infectious workup regardless of biopsy results 1
Common Pitfalls to Avoid
Do not delay biopsy for imaging—tissue diagnosis is mandatory and should not be postponed for PET or CT scanning 1
Do not use FNA for masses ≥4 cm, as inadequate tissue yield risks non-diagnostic results and delays definitive diagnosis 1
Do not forget that the patient's well-controlled HIV (viral load below threshold, CD4 >200) does not eliminate the significantly elevated cancer risk that persists in HIV patients 1