What is the appropriate evaluation and treatment for a swollen lymph node?

Evaluation and Management of Swollen Lymph Nodes

For a swollen lymph node, obtain an excisional lymph node biopsy for definitive diagnosis rather than fine needle aspiration or core biopsy, as these are inadequate for reliable diagnosis of lymphoid pathology. 1, 2

Initial Clinical Assessment

Key Historical Features to Elicit

• Duration of lymphadenopathy (nodes persisting >4 weeks require tissue diagnosis) 3
• Systemic symptoms: fever, night sweats, unintentional weight loss (B symptoms suggest malignancy or lymphoma) 3
• Node location: supraclavicular and epitrochlear nodes carry highest malignancy risk 3, 4
• Exposure history: tuberculosis contacts, animal exposures, travel history, sexual history, recent vaccinations 3
• Age: older patients have higher malignancy risk 4

Physical Examination Priorities

• Distinguish localized vs. generalized lymphadenopathy (generalized suggests systemic disease) 3, 5
• Node characteristics:
  • Size >1-2 cm is abnormal 5
  • Hard, matted/fused, or fixed nodes suggest malignancy or granulomatous disease 3, 4
  • Supraclavicular location is most concerning for malignancy 4, 5
• Search for adjacent infection source in localized adenopathy 5
• Examine all nodal regions to rule out generalized involvement 5

Diagnostic Algorithm

For Localized Lymphadenopathy with Benign Features

• Observe for 3-4 weeks if clinical picture suggests benign etiology (e.g., adjacent infection, soft mobile nodes <2 cm) 4, 5
• Initiate antibiotics only if bacterial lymphadenitis is strongly suspected 3
• Avoid corticosteroids as they mask histologic diagnosis of lymphoma 3

For Lymphadenopathy Requiring Further Workup

Proceed with workup if:

• Nodes persist >4 weeks 3, 4
• Systemic symptoms present 3
• High-risk features (supraclavicular, epitrochlear, hard/fixed, >2 cm) 3, 4, 5

Initial laboratory studies: 3

• Complete blood count
• C-reactive protein and erythrocyte sedimentation rate
• Tuberculosis testing

Imaging: CT scan of relevant regions (neck, chest, abdomen, pelvis) based on node distribution 1

Tissue Diagnosis Strategy

Excisional lymph node biopsy is the gold standard and initial diagnostic procedure of choice. 1, 4, 5

Why Excisional Biopsy is Preferred:

• Provides entire node architecture necessary for accurate lymphoma diagnosis 1
• Fine needle aspiration alone is not acceptable for initial diagnosis of lymphoid lesions 1, 2
• Core needle biopsy should only be used when lymph nodes are not easily accessible (e.g., retroperitoneal) 1

Processing Requirements for Excisional Biopsy:

• Submit entire node cut into 3-4 mm slices 1
• Provide fresh frozen and formalin-fixed samples 1
• Immediate processing by experienced pathology institute 1
• Multiple H&E-stained levels examined 1

Alternative Approaches (Only in Specific Circumstances):

• Ultrasound-guided FNA or core biopsy: acceptable if patient has known malignancy history and heterogeneous echogenicity on ultrasound 6
• Core needle biopsy: 94-96% accuracy, particularly valuable if lymphoma suspected, but excisional biopsy remains preferred 6
• Combination of core biopsy + FNA with ancillary techniques (PCR, FISH, immunophenotyping): may suffice when node not easily accessible 1

Common Pitfalls to Avoid

• Do not perform cervical node biopsy until all other diagnostic modalities exhausted 7
• Do not rely on FNA alone for initial lymphoid diagnosis—it lacks architectural information 1, 2
• Do not use corticosteroids empirically—they obscure lymphoma diagnosis 3
• Do not dismiss supraclavicular nodes—these have highest malignancy association 4, 5
• Re-evaluate diagnosis if new systemic symptoms develop after initial benign diagnosis 2

Special Considerations

Tuberculosis as Leading Cause

In many populations, tuberculous lymphadenitis is the most common cause of lymphadenopathy (52.7% in some series), followed by reactive hyperplasia (16.1%) and metastatic carcinoma (8.7%) 7. Maintain high index of suspicion based on exposure history and demographics 3.

Malignancy Risk Stratification

High-risk features mandating prompt tissue diagnosis: 4

• Age >40 years
• Firm, fixed nodal character
• Duration >2 weeks with progressive enlargement
• Supraclavicular location
• Absence of adjacent infection source