What are the next steps for a patient with a CT impression of persistent scattered reactive lymphadenopathy in the neck, which is slightly smaller compared to a prior study, and is predominantly located within the perivertebral fat planes bilaterally?

Management of Persistent Reactive Neck Lymphadenopathy

For persistent scattered reactive lymphadenopathy in the perivertebral fat planes that is stable or decreasing in size, clinical observation with short-term follow-up imaging in 3 months is the appropriate next step, as this presentation lacks high-risk features requiring immediate biopsy. 1

Risk Stratification and NI-RADS Classification

The described findings align with NI-RADS category 1 or 2, which carry low risk for malignancy:

• NI-RADS 1 (no evidence of recurrence) has only a 3.5% rate of positive disease and warrants routine surveillance 1
• NI-RADS 2 (low suspicion) has a 17% rate of positive disease and indicates short-term follow-up or additional imaging 1
• Lymph nodes that are decreasing in size without morphologically abnormal features (necrosis, extracapsular spread, or irregular borders) fall into these lower-risk categories 1

The perivertebral location and "reactive" appearance without concerning features make immediate biopsy unnecessary at this stage. 1

Key Clinical Decision Points

Features That Would Require Immediate Biopsy (NI-RADS 3):

• Lymph nodes >2 cm in diameter 2, 3
• Hard, matted, or fused nodes 2
• Supraclavicular location (highest malignancy risk) 4, 2
• Development of new necrosis or extracapsular spread 1
• Increasing size with morphologically abnormal features 1
• Presence of systemic symptoms (fever, night sweats, unexplained weight loss) 4, 2

Your Patient's Favorable Features:

• Decreasing size compared to prior study 1
• Scattered distribution rather than focal mass 1
• Described as "reactive" without specific concerning morphology 1
• Perivertebral location (not supraclavicular) 4, 2

Recommended Management Algorithm

Step 1: Clinical Assessment

• Evaluate for systemic symptoms (fever, night sweats, weight loss) that would escalate concern 4, 2
• Assess for localized infectious sources or recent infections that could explain reactive adenopathy 4, 2
• Review medication history and recent vaccinations 2
• Examine for other nodal regions to determine if lymphadenopathy is localized or generalized 4, 2

Step 2: Short-Term Imaging Follow-Up

• Repeat CT in 3 months to assess for interval change 1
• If nodes continue to decrease or remain stable without developing concerning features, continue routine surveillance 1
• Consider PET-CT if nodes show mild increase without definitive morphologic abnormalities, as PET can help differentiate reactive from malignant nodes 1

Step 3: Escalation Criteria

Proceed to biopsy if any of the following develop:

• Increasing size with new morphologic abnormalities 1
• Persistence beyond 4 weeks with concerning features 2, 3
• Development of FDG avidity on PET-CT (if obtained) 1
• New systemic symptoms 4, 2

Critical Pitfalls to Avoid

• Do not perform immediate biopsy on ill-defined, decreasing lymph nodes without high-risk features, as this represents overtreatment 1
• Do not use corticosteroids without a definitive diagnosis, as they can mask lymphoma or other malignancy 4, 2
• Do not assume benignity indefinitely—any lymphadenopathy persisting beyond 4 weeks or showing concerning evolution requires tissue diagnosis 2, 3
• Do not ignore supraclavicular nodes if they develop, as these have the highest malignancy risk and require immediate biopsy 4, 2

When Biopsy Becomes Necessary

If clinical or imaging evolution warrants tissue diagnosis:

• Excisional biopsy is preferred for suspected lymphoma to provide adequate tissue architecture 3, 5
• Ultrasound-guided FNA or core needle biopsy is acceptable for suspected metastatic disease 1, 6
• Target the most abnormal node for biopsy 7