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Pediatric Lymph Node Disorders Workup

  • Author: Kenneth William Gow, MD, MSc, FRCSC, FACS, FAAP; Chief Editor: Robert K Minkes, MD, PhD  more...
 
Updated: Mar 11, 2016
 

Approach Considerations

Lymphadenopathy in children commonly arises from benign etiologies. A thorough history usually points the clinician in this direction. Furthermore, the physical examination guides the physician to the correct etiology by focusing on the distribution of the enlarged nodes (ie, regional or systemic), the exact characteristics of the involved nodes, and any other suspicious findings.

Alternatively, if the etiology remains unclear, laboratory studies, diagnostic imaging, or biopsy may be warranted, depending on the presumed diagnosis. If malignancy is suspected, a biopsy for histologic examination and testing is indicated.

Histologic findings vary, depending on the etiology. Staging is relevant only in cases involving a malignant etiology.

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Laboratory Studies

In most patients, only the history and physical examination are needed to establish the likely diagnosis. However, if the diagnosis must 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 testing 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 [ESR], C-reactive protein [CRP], glycoproteins, fibrogen levels) do not contribute much to establishing the diagnosis, because most of the results are invariably elevated and do not provide useful suggestions 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 complete blood count (CBC) with a manual differentiation provides useful information. Leukemias are often accompanied by pancytopenia. A predominantly lymphocytic elevation (>1 × 109 cells/L) is practically diagnostic of mononucleosis; when the proportion of these cells is less elevated but still predominant, cytomegalovirus (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 Epstein-Barr virus (EBV), CMV, cat-scratch disease, or toxoplasmosis, may be performed to evaluate for specific etiologies.

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Imaging Studies

Chest radiography may be useful to assess for potential sources of infection (eg, 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 the image below).

A preoperative radiograph showing a narrowed trach A preoperative radiograph showing a narrowed trachea secondary to an anterior mediastinal mass.

Ultrasonography may be performed to distinguish the nature of the node if it is difficult to palpate. 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 relations to contiguous structures and offer information about the content of the enlarged lymph node or nodes (ie, solid vs liquid or gas, homogeneous vs nonhomogenous). Finally, in some studies, this modality has been used in an effort to establish etiology on the basis of ultrasonographic characteristics.

Computed tomography (CT) 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 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 the images below).

A CT scan showing an anterior mediastinal mass and A CT scan showing an anterior mediastinal mass and compression of the trachea.
A CT scan showing an anterior mediastinal mass and A CT scan showing an anterior mediastinal mass and compression of the left mainstem bronchus.

18F-fluorodeoxyglucose positron emission tomography (18FFDG-PET) has been used in adult patients with lymphoma and, subsequently, in children to assist in diagnosis and to monitor disease during therapy.[13] It has been applied to both Hodgkin and non-Hodgkin lymphomas, with promising findings. However, clinicians must be cautious with the use of 18FFDG-PET because a high number of false-positive results in children have been reported as a consequence of a higher inflammatory reaction to inciting agents.

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Tissue Diagnosis

Fine-needle aspiration (FNA) biopsy has been used extensively in adults and has also been described in children.[14, 15, 16] The cited advantages of FNA biopsy include the following[14] :

  • It can be performed in the outpatient department
  • It is simple and rapid
  • It does not require general anesthesia
  • It has low morbidity
  • It is cost-effective
  • It produces minimal scarring

The sensitivity and specificity of FNA biopsy in determining the etiology of lymphadenopathy are higher than 90%.[14, 16] Most patients who have a benign diagnosis on FNA biopsy do not undergo surgical biopsy. However, in most centers, FNA biopsy is still not practiced in children. Furthermore, whether the advantages of FNA outweigh the perceived limits remains to be established. These limits include the following:

  • Center dependence on pathologists who are accustomed to making diagnoses on the basis of FNA alone
  • Potential risk of seeding a tract with malignancy
  • 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 ultrasonographic or CT guidance.[17] This allows procurement of more tissue, which may be needed in difficult diagnoses.

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Contributor Information and Disclosures
Author

Kenneth William Gow, MD, MSc, FRCSC, FACS, FAAP Associate Professor of Surgery and Pediatrics, Department of Surgery, University of Washington School of Medicine; Consulting Staff, Children's Hospital and Regional Medical Center and University of Washington Hospitals

Kenneth William Gow, MD, MSc, FRCSC, FACS, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association for Academic Surgery, Society of Surgical Oncology, Children's Oncology Group, Canadian Association of Pediatric Surgeons, College of Physicians and Surgeons of British Columbia

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Andre Hebra, MD Chief, Division of Pediatric Surgery, Professor of Surgery and Pediatrics, Medical University of South Carolina College of Medicine; Surgeon-in-Chief, Medical University of South Carolina Children's Hospital

Andre Hebra, MD is a member of the following medical societies: Alpha Omega Alpha, Florida Medical Association, Society of American Gastrointestinal and Endoscopic Surgeons, Children's Oncology Group, International Pediatric Endosurgery Group, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Society of Laparoendoscopic Surgeons, South Carolina Medical Association, Southeastern Surgical Congress, Southern Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Robert K Minkes, MD, PhD Professor of Surgery, University of Texas Southwestern Medical Center at Dallas, Southwestern Medical School; Medical Director and Chief of Surgical Services, Children's Medical Center of Dallas-Legacy Campus

Robert K Minkes, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Phi Beta Kappa

Disclosure: Nothing to disclose.

Additional Contributors

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, Association of Women Surgeons, American College of Surgeons, American Pediatric Surgical Association, Physicians for Social Responsibility, Wilderness Medical Society

Disclosure: Nothing to disclose.

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

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  17. 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. 2005 May-Jun. 29(3):369-72. [Medline].

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A preoperative radiograph showing a narrowed trachea secondary to an anterior mediastinal mass.
A CT scan showing an anterior mediastinal mass and compression of the trachea.
A CT scan showing an anterior mediastinal mass and compression of the left mainstem bronchus.
A lymph node biopsy is performed. Note that a marking pen has been used to outline the node before removal and that a silk suture has been used to provide traction to assist the removal.
A lymph node after removal by means of biopsy, which was performed completely under a local anesthetic technique.
A gross image of a node following excision. The cut surface of the node shows the typical fish-flesh appearance seen with lymphoma.
 
 
 
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