eMedicine Specialties > Pediatrics: Surgery > General Surgery

Lymph Node Disorders: Workup

Author: Kenneth William Gow, MD, FRCSC, MSc, BSc, FACS, FAAP, Associate Professor of Surgery and Pediatrics, Department of Surgery, University of Washington; Consulting Staff, Children's Hospital and Regional Medical Center and University of Washington Hospitals
Contributor Information and Disclosures

Updated: Jan 14, 2008

Workup

Laboratory Studies

  • In most patients, only the history and physical examination are needed to establish the likely diagnosis. However, if the diagnosis needs to be further refined, several tests can be performed. Generally, clinicians should perform the least invasive test that provides the most information. Furthermore, clinicians should tailor tests to the most likely diagnosis instead of performing a battery of tests on all patients with lymphadenopathy. Tests may include laboratory or radiologic investigations.
  • Various laboratory tests are available. In general, most laboratory indices of inflammation (eg, erythrocyte sedimentation rate, C-reactive protein, glycoproteins, fibrogen levels) do not contribute much to establishing the diagnosis because most of the results are invariably elevated and do not provide a suggestion regarding the exact etiology of the lymphadenopathy. Tests that are more specific are much more likely to help the clinician with the treatment of the patient.
  • A CBC count with a manual differentiation provides useful information. Leukemias are often accompanied by pancytopenia. A predominantly lymphocytic elevation (>1 X 109 cells/L) is practically diagnostic of mononucleosis; when the proportion of these cells is less elevated but still predominant, CMV and toxoplasmosis must be considered. Finding medium-to-large lymphocytes that can be classified as in transformation or activated is useful to indicate a viral infection.
  • Other useful tests may be performed to confirm or exclude specific clinical suspicions. Serum lactate dehydrogenase (LDH) may be used to determine the turnover rate of cells in the case of leukemia or lymphoma. Other tests, such as tuberculin skin test; monospot; and titers for EBV, CMV, catscratch disease, or toxoplasmosis, may be performed to evaluate for specific etiologies.

Imaging Studies

  • Chest radiography may be useful to assess for potential sources of infection, such as bacterial pneumonias or tuberculosis, and hilar adenopathy in the case of malignancy. Indeed, because numerous reports describe airway collapse with anesthetics in the case of a large anterior mediastinal mass, chest radiography should be considered before any general anesthetic is administered (see Media file 1).
  • Ultrasonography may be performed to distinguish the lymph nodal nature if palpation is not sufficient. Furthermore, it may be used to distinguish the abnormality from other potential anatomic structures (eg, dermoid cysts, thyroglossal duct cysts, branchial cleft cysts, inguinal hernias, undescended testicles). Ultrasonography may reveal relationships to contiguous structures and offer information about the content of the enlarged lymph node or nodes (ie, solid, liquid, gas, homogeneous or nonhomogenous). Finally, in some current studies, ultrasonography has been used in an effort to establish etiology based on ultrasonographic characteristics.
  • CT scanning is useful to depict deep lymph nodes, especially in the thoracic and abdominal cavities. This may be the only noninvasive technique available to evaluate these areas for other potential areas of lymphadenopathy and determine a potential source of malignancy (eg, neuroblastoma, Burkitt lymphoma, rhabdomyosarcoma). Furthermore, chest CT scanning may add to the information obtained from chest radiography and may depict an anterior mediastinal mass, as well as the extent of tracheal or bronchial airway compression (see Media files 2-3).
  • 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) has been used in adult patients with lymphoma and, more recently, in children to assist in diagnosis and to monitor disease during therapy.7 Its use has been applied to both Hodgkin and non-Hodgkin lymphomas, with promising findings. However, clinicians must be cautious with use of 18F-FDG PET because a high number of false positive results in children have been reported due to higher inflammatory reaction to inciting agents.

Diagnostic Procedures

  • Fine-needle aspiration (FNA) biopsy has been used extensively in adults and is now being described in children.8,9,10 The cited advantages of FNA biopsy include the fact that it can be performed in the outpatient department, that it is simple and rapid, that it does not require a general anesthetic, that it has low morbidity, that it is cost effective, and that it produces minimal scarring.8
  • The sensitivity and specificity of FNA biopsy in determining the etiology of lymphadenopathy are more than 90%.8,10 Most patients who have a benign diagnosis on FNA biopsy do not undergo surgical biopsy. However, in most centers, FNA is still not practiced in children. Furthermore, whether the advantages of FNA outweigh the perceived limits has not been established. These limits include center dependence on pathologists who are accustomed to making diagnoses on FNA alone, the potential risk of seeding a tract with malignancy, and the continued need for at least conscious sedation in most children. Most oncology protocols now require special studies to be performed on the nodal tissue, including cytogenetics, flow cytometry, electron microscopy, and special stains that FNA does not allow.
  • To obtain more tissue, some investigators have used core needle techniques with ultrasonography or CT guidance.11 This allows procurement of more tissue, which may be needed in difficult diagnoses.

More on Lymph Node Disorders

Overview: Lymph Node Disorders
Workup: Lymph Node Disorders
Treatment: Lymph Node Disorders
Follow-up: Lymph Node Disorders
Multimedia: Lymph Node Disorders
References
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References

  1. Ghirardelli ML, Jemos V, Gobbi PG. Diagnostic approach to lymph node enlargement. Haematologica. Mar 1999;84(3):242-7. [Medline].

  2. Kelly CS, Kelly RE Jr. Lymphadenopathy in children. Pediatr Clin North Am. Aug 1998;45(4):875-88. [Medline].

  3. Segal GH, Perkins SL, Kjeldsberg CR. Benign lymphadenopathies in children and adolescents. Semin Diagn Pathol. Nov 1995;12(4):288-302. [Medline].

  4. Karadeniz C, Oguz A, Ezer U, et al. The etiology of peripheral lymphadenopathy in children. Pediatr Hematol Oncol. Nov-Dec 1999;16(6):525-31. [Medline].

  5. Soldes OS, Younger JG, Hirschl RB. Predictors of malignancy in childhood peripheral lymphadenopathy. J Pediatr Surg. Oct 1999;34(10):1447-52. [Medline].

  6. Karmazyn B, Werner EA, Rejaie B, Applegate KE. Mesenteric lymph nodes in children: what is normal?. Pediatr Radiol. Aug 2005;35(8):774-7. [Medline].

  7. Depas G, De Barsy C, Jerusalem G, et al. 18F-FDG PET in children with lymphomas. Eur J Nucl Med Mol Imaging. Jan 2005;32(1):31-8. [Medline].

  8. van de Schoot L, Aronson DC, Behrendt H, Bras J. The role of fine-needle aspiration cytology in children with persistent or suspicious lymphadenopathy. J Pediatr Surg. Jan 2001;36(1):7-11. [Medline].

  9. Ponder TB, Smith D, Ramzy I. Lymphadenopathy in children and adolescents: role of fine-needle aspiration in management. Cancer Detect Prev. 2000;24(3):228-33. [Medline].

  10. Buchino JJ, Jones VF. Fine needle aspiration in the evaluation of children with lymphadenopathy. Arch Pediatr Adolesc Med. Dec 1994;148(12):1327-30. [Medline].

  11. Sklair-Levy M, Amir G, Spectre G, et al. Image-guided cutting-edge-needle biopsy of peripheral lymph nodes and superficial masses for the diagnosis of lymphoma. J Comput Assist Tomogr. May-Jun 2005;29(3):369-72. [Medline].

  12. Loeffler AM. Treatment options for nontuberculous mycobacterial adenitis in children. Pediatr Infect Dis J. Oct 2004;23(10):957-8. [Medline]. [Full Text].

  13. Casaccia M, Torelli P, Cavaliere D, et al. Laparoscopic lymph node biopsy in intra-abdominal lymphoma: high diagnostic accuracy achieved with a minimally invasive procedure. Surg Laparosc Endosc Percutan Tech. Jun 2007;17(3):175-8. [Medline].

  14. Bodenstein L, Altman RP. Cervical lymphadenitis in infants and children. Semin Pediatr Surg. Aug 1994;3(3):134-41. [Medline].

  15. Luu TM, Chevalier I, Gauthier M, et al. Acute adenitis in children: clinical course and factors predictive of surgical drainage. J Paediatr Child Health. May-Jun 2005;41(5-6):273-7. [Medline].

  16. Evans MJ, Smith NM, Thornton CM, et al. Atypical mycobacterial lymphadenitis in childhood--a clinicopathological study of 17 cases. J Clin Pathol. Dec 1998;51(12):925-7. [Medline].

  17. Pumberger W, Hallwirth U, Pawlowsky J, Pomberger G. Cervicofacial lymphadenitis due to atypical mycobacteria: a surgical disease. Pediatr Dermatol. Jan-Feb 2004;21(1):24-9. [Medline].

  18. Waagner DC. The clinical presentation of tuberculous disease in children. Pediatr Ann. Oct 1993;22(10):622-8. [Medline].

  19. Oguz A, Karadeniz C, Temel EA, Citak EC, Okur FV. Evaluation of peripheral lymphadenopathy in children. Pediatr Hematol Oncol. Oct-Nov 2006;23(7):549-61. [Medline].

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Further Reading

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Keywords

lymph node disorders, lymphadenopathy, lymphadenitis, enlarged lymph node, swollen lymph node, lymph node removal, jugular trunk, viral-associated lymphadenopathy, Epstein-Barr virus, EBV, cytomegalovirus, CMV, bacterial-associated lymphadenopathy, Staphylococcus aureus, group B streptococci, atypical mycobacterium, Mycobacterium scrofulaceum, Mycobacterium avium-intracellulare, Mycobacterium tuberculosis, scrofula, catscratch disease, lymphoma, Hodgkin disease, HD, non-Hodgkin lymphoma NHL, leukemia, metastatic solid tumors, Kawasaki disease, mucocutaneous lymph node syndrome, sarcoidosis, Kikuchi lymphadenitis, histiocytic necrotizing lymphadenitis, systemic lupus erythematous, SLE, Langerhans cell histiocytosis, histiocytosis X, rhabdomyosarcoma, neuroblastoma

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Contributor Information and Disclosures

Author

Kenneth William Gow, MD, FRCSC, MSc, BSc, FACS, FAAP, Associate Professor of Surgery and Pediatrics, Department of Surgery, University of Washington; Consulting Staff, Children's Hospital and Regional Medical Center and University of Washington Hospitals
Kenneth William Gow, MD, FRCSC, MSc, BSc, FACS, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Association for Cancer Research, American College of Surgeons, American Pediatric Surgical Association, American Society of Clinical Oncology, Association for Academic Surgery, Canadian Association of Pediatric Surgeons, Children's Oncology Group, College of Physicians and Surgeons of British Columbia, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Surgical Oncology, and Southeastern Surgical Congress
Disclosure: Nothing to disclose.

Medical Editor

Aviva L Katz, MD, Assistant Professor of Surgery, University of Pittsburgh School of Medicine; Consulting Staff, Division of General and Thoracic Surgery, Children's Hospital of Pittsburgh
Aviva L Katz, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association of Women Surgeons, Physicians for Social Responsibility, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Andre Hebra, MD, Chief, Division of Pediatric Surgery, Medical University of South Carolina
Andre Hebra, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Association for Academic Surgery, Society of Laparoendoscopic Surgeons, South Carolina Medical Association, Southeastern Surgical Congress, and Southern Medical Association
Disclosure: Nothing to disclose.

CME Editor

H Biemann Othersen Jr, MD, Professor of Surgery and Pediatrics, Emeritus Head, Division of Pediatric Surgery, Medical University of South Carolina
H Biemann Othersen Jr, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, American Cancer Society, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, American Society for Parenteral and Enteral Nutrition, American Surgical Association, American Thoracic Society, British Association of Paediatric Surgeons, Pediatric Oncology Group, Society for Surgery of the Alimentary Tract, Society of Critical Care Medicine, South Carolina Medical Association, Southeastern Surgical Congress, Southern Medical Association, Southern Society for Pediatric Research, and Southern Thoracic Surgical Association
Disclosure: Nothing to disclose.

Chief Editor

Marleta Reynolds, MD, Professor of Surgery, Feinberg School of Medicine, Northwestern University; Interim Head, Division of Pediatric Surgery, Department of Surgery, Children's Memorial Hospital of Chicago
Marleta Reynolds, MD is a member of the following medical societies: American Pediatric Surgical Association
Disclosure: Nothing to disclose.

 
 
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