Lymphadenopathy

1. Clinical Overview

Summary

Lymphadenopathy refers to the enlargement of lymph nodes (> 1cm in diameter), a common clinical finding that serves as a sentinel for local or systemic disease. The lymphatic system acts as the body's drainage and filtration network; thus, enlarged nodes typically represent either a reactive proliferation (to infection/inflammation) or infiltration (by malignancy cells).

The generalist's challenge is to filter the "benign majority" from the "malignant minority". While less than 1% of primary care patients with lymphadenopathy have malignancy, this rises to 40-60% in specialist referral clinics. The history must focus on the "Three T's": Time (Acute vs Chronic), Tenderness (Painful usually suggests infection), and Trajectory (Progressive vs Fluctuating).

The management algorithm pivots on "Red Flags" (Supraclavicular nodes, B-symptoms) and the "Unexplained Rule": Any unexplained node > 1cm persisting for > 6 weeks warrants biopsy (NICE NG12). Key etiology mnemonics include MIAMI (Malignancy, Infection, Autoimmune, Miscellaneous, Iatrogenic) and CHICAGO (Cancers, Hypersensitivity, Infections, Connective Tissue, Atypical, Granulomatous, Others).

Key Facts

• Definition: Node > 1cm (> 2cm for inguinal, > 0.5cm for epitrochlear).
• Most Common Cause: Viral Upper Respiratory Tract Infection (URTI).
• Most Worrying Site: Supraclavicular (Virchow's Node) - 90% risk of malignancy (Lung/Gastric).
• Most Common Malignancy (Adults): Non-Hodgkin Lymphoma or Metastatic Squamous Cell Carcinoma (SCC).
• B-Symptoms: Fever > 38°C, Drenching Night Sweats, Weight Loss > 10% in 6 months.

Clinical Pearls

Clinical Pearl: The "Supraclavicular" Rule: There is no benign cause for a supraclavicular node in an adult. Left-sided (Virchow's) drains the gut (Stomach/Pancreas). Right-sided drains the mediastinum (Lung/Esophagus).

Clinical Pearl: Alcohol Pain: Pain in lymph nodes immediately after drinking alcohol is rare but highly specific for Hodgkin's Lymphoma.

Clinical Pearl: The Antibiotic Test: Do NOT give antibiotics "just to see" if it's a solid, painless node. This delays diagnosis. If it's clearly infective (red/tender), treat for 1 week. If no resolution, refer.

Clinical Pearl: Epitrochlear Nodes: Nodes above the medial epicondyle (elbow) are pathological. Causes: Syphilis, Sarcoidosis, Lymphoma, or Hand infections (Cat Scratch Disease).

Clinical Pearl: The "Shotty" Node: Small (less than 0.5cm), pea-sized, firm, mobile nodes in the cervical chain (children) or inguinal chain (adults) are often normal ("Shotty" = like buckshot pellets) and represent past benign reactivity.

Clinical Pearl: The Pulsatile Mass: Never stick a needle in a pulsatile mass in the anterior triangle. It is likely a Carotid Body Tumor or Aneurysm.

Why This Matters Clinically

Why This Matters Clinically

Early Recognition: The difference between Stage I and Stage IV lymphoma is often a watchful GP. Avoidable Biopsies: Distinguishing reactive viral nodes prevents unnecessary surgery (scarring). Tuberculosis: In immigrants, cervical lymphadenopathy ("Scrofula") is the most common form of extrapulmonary TB.

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2. Epidemiology

Prevalence & Incidence

• Primary Care: 0.6% annual incidence of lymphadenopathy presentation. [26]
• Malignancy Rate: In primary care, only 1.1% of unexplained lymphadenopathy is malignant. [27] In specialist referral centers, this rises to 40-60%. [28]
• Age-Stratified Malignancy Risk: Under 40 years: 4%; 40-50 years: 40%; over 50 years: 60%. [29]
• Site-Specific Malignancy Risk: Supraclavicular: 90%; Cervical: 15%; Axillary: 12%; Inguinal: 8%. [30]
• Duration: Nodes persisting beyond 6 weeks carry 5-fold increased malignancy risk compared to those resolving within 2 weeks. [31]

Age-Related Probability ("The Rule of Age")

The etiology shifts dramatically with age:

1. Children (less than 18): Highly likely benign (Viral/Bacterial). Malignancy chance less than 5% (Leukemia/Neuroblastoma). [32]
2. Young Adults (18-40): Reactive (75%), EBV (15-20%), but Lymphoma peak incidence starts here (Hodgkin's has bimodal peak at 20-30 and over 55 years). [33]
3. Older Adults (> 50): Malignancy risk rises sharply (> 60%). [34] Metastatic Carcinoma (Lung/Head & Neck) becomes most common, followed by Non-Hodgkin Lymphoma.

Geographical and Infectious Epidemiology

• Tuberculosis: In endemic regions (South Asia, Sub-Saharan Africa), TB accounts for 30-50% of persistent lymphadenopathy. [35] Cervical nodes (scrofula) are most common extrapulmonary manifestation.
• HIV: Persistent Generalized Lymphadenopathy (PGL) affects 50-70% of untreated HIV patients, defined as nodes greater than 1cm in two or more non-contiguous sites for greater than 3 months. [36]

Demographics and Risk

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3. Pathophysiology

Anatomy of the Lymph Node

The node acts as a "Police Station" for the immune system.

1. Afferent Lymphatics: Bring fluid/antigens from tissues.
2. Cortex (B-Zones): Follicles where B-cells proliferate (Germinal Centers).
3. Paracortex (T-Zones): Where T-cells reside and interact with Dendritic cells.
4. Medulla: Output cords and sinuses.
5. Efferent Lymphatic: Exits the hilum.

Mechanisms of Enlargement

Mechanism 1: Reactive Hyperplasia (Infection/Autoimmune)

• Follicular Hyperplasia: Expansion of B-cell germinal centers. Seen in bacteria (Staph) or Rheumatoid Arthritis.
• Paracortical Hyperplasia: Expansion of T-cell zones. Seen in Viral infections (EBV, CMV, HIV) or Drug reactions (Phenytoin).
• Sinus Histiocytosis: Expansion of macrophages in sinuses. Seen in drainage of cancers (reactive but not malignant) or Rosai-Dorfman disease.

Mechanism 2: Infiltration (Malignancy)

• Lymphoma: The lymphocytes themselves are malignant and cloning uncontrolledly.
• Metastasis: Foreign cancer cells (e.g., Breast Duct Cells) arrive via lymphatics and lodge in the subcapsular sinus, growing to replace the node.

Mechanism 3: Infiltration (Cells/Deposits)

• Granulomatous: Macrophage collections (Granulomas). Caseating (TB) vs Non-Caseating (Sarcoidosis).
• Storage: Lipid-laden macrophages (Gaucher's Disease).

Stepwise Pathophysiology: The Immune Cascade (Reactive Hyperplasia)

Step 1: Antigen Entry

• Pathogen (e.g., EBV) enters tissues (Oropharynx) and is captured by Dendritic Cells (APCs).
• APCs migrate via afferent lymphatics to the regional node (Level II).

Step 2: Antigen Presentation

• Dendritic cells enter the Paracortex (T-zone) and present antigen to Naive T-cells via MHC Class II.
• T-cell activation and proliferation occurs (Paracortical Hyperplasia).

Step 3: B-Cell Activation

• Activated T-cells stimulate B-cells in the primary follicle.
• B-cells undergo clonal expansion and somatic hypermutation.

Step 4: Germinal Center Formation

• The follicle expands rapidly to form a "Germinal Center" (Secondary Follicle).
• This physical expansion stretches the node capsule -> Pain/Tenderness.

Step 5: Affinity Maturation

• B-cells compete for antigen. High-affinity clones survive; others undergo apoptosis.
• Macrophages ("Tingible Body Macrophages") clear the apoptotic debris.

Step 6: Effector Output

• Plasma cells (antibody factories) and Memory B-cells exit via efferent lymphatics.
• Systemic immune response initiated (Fever, CRP rise).

Step 7: Resolution or Chronicity

• Resolution: After antigen clearance, the follicle shrinks (apoptosis). Node returns to normal size (weeks).
• Chronicity: Persistent antigen (HIV/TB) leads to chronic fibrosis and persistent adenopathy.

Detailed Anatomical Patterns (Where is the lump?)

Neck Levels Classification (The Surgeon's Map)

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4. Clinical Presentation

Symptom Profiling

1. Lump characteristics:

   • Painful/Tender: Acute Infection (Capsule stretch).
   • Painless: Chronic Infection (TB), Malignancy (Slow growth).
   • Hard/Stony: Carcinoma Metastasis.
   • Rubbery: Lymphoma.
   • Matted: TB (nodes stuck together) or advanced malignancy.

2. Systemic Symptoms:

   • Fever/Sweats: Infection, Lymphoma (B-symptoms), TB.
   • Itch (Pruritus): Hodgkin's Lymphoma (severe, generalized).
   • Arthralgia/Rash: SLE, Sarcoidosis, Serum Sickness, Still's Disease.

Etiology Classification (Mnemonic: CHICAGO)

Red Flags

[!CAUTION] Lymphadenopathy Red Flags - Urgent Referral (2-Week Wait):

• Supraclavicular Node: Any age. (Chest/Abdo malignancy).
• Persistent > 6 Weeks: No resolution.
• Size: > 2cm and growing.
• Texture: Hard, fixed to underlying tissue.
• Systemic: Night sweats, Weight loss > 10%.
• Dysphagia/Hoarseness: Suggests Head & Neck Cancer (vocal cord palsy).

Comprehensive Differential Diagnosis by Clinical Pattern

Pattern 1: Tender, Localized Lymphadenopathy

Pattern 2: Painless, Progressive Lymphadenopathy

Pattern 3: Generalized Lymphadenopathy (≥2 non-contiguous sites)

Pattern 4: Drug-Induced Lymphadenopathy

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5. Clinical Examination

Structured Approach

1. Inspection

• Look for visible asymmetry.
• Look for overlaying skin changes: Redness (Abscess), Sinus tract (TB), Scars (Previous surgery).

2. Palpation (The 6 S's)

• Site: Use the Levels I-VII logic.
• Size: Measure with calipers or compare to tip of finger (approx 1cm).
• Shape: Ovoid (Normal/Reactive) vs Round (Malignant).
• Surface: Smooth vs Irregular (Craggy).
• Surroundings: Fixed to skin/deep tissue vs Mobile.
• Sensitivity: Tender vs Non-tender.

3. Examination of Drainage Areas

• Cervical Node: Examine Scalp, Ear, Nose, Throat (Tonsils), Thyroid.
• Axillary Node: Examine Breast, Arm, Hands (Infection?).
• Inguinal Node: Examine Genitalia (Ulcers?), Legs, Feet.
• Epitrochlear Node: Examine Hands/Forearm.

4. General Exam

• Spleen: Splenomegaly + Lymphadenopathy = Lymphoma/Leukemia/EBV/Malaria.
• Liver: Hepatomegaly.
• Skin: Purpura, Petechiae, Exanthem.

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6. Investigations

The "Lymphadenopathy Screen"

Tier 1: Primary Care (The Basics)

1. FBC: Leukocytosis (Infection), Lymphocytosis (Viral/CLL), Blasts (Acute Leukemia), Cytopenias (Marrow infiltration).
2. Blood Film: Atypical lymphocytes (EBV), Basket cells (CLL).
3. ESR/CRP: High in Infection/Inflammation/Hodgkin's.
4. Viral Serology: EBV (Monospot), CMV, HIV (Critical!), Toxoplasmosis.
5. LDH: High cell turnover (Lymphoma).

Tier 2: Targeted Testing 6. CXR: Mandatory for persistent nodes. Look for Mediastinal widening (Lymphoma) or Hilar Adenopathy (TB/Sarcoid). 7. Autoimmune Panel: ANA, RF (if arthralgia present). 8. Mantoux/IGRA: If TB suspected.

Imaging Strategy

• Ultrasound (US): First line for neck. Can define architecture (Hilum present? = Benign. Round/Hypoechoic? = Malignant). Can guide Biopsy.
• CT Neck/Chest/Abdo: Staging for Lymphoma/Ca.
• PET-CT: Gold standard for Lymphoma staging (metabolic activity).

Ultrasound Interpretation Guide:

Differential Diagnosis of Neck Lumps (Non-Nodal)

Contraindications to Biopsy

[!WARNING] Do NOT Biopsy (FNAC/Core) if:

• Pulsatile Mass: Exclude Carotid Body Tumor or Aneurysm first. Puncture can be fatal.
• Suspected Vascular Malformation: High flow lesion.
• Coagulopathy: INR > 1.5 or Platelets less than 50. Correction needed.
• Testicular Mass (Inguinal node scenario): Scrotal masses should be removed via radical orchiectomy, not biopsied trans-scrotally (seeding risk).

The Biopsy Debate (FNAC vs Core vs Excision)

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7. Management

Management Algorithm

AI-Generated Management Algorithm Image Required:

Image

Content for Algorithm:

1. Node Detected: History + Exam.
2. Red Flags?: Supraclavicular? Hard/Fixed? B-Symptoms? -> Urgent Referral.
3. Obvious Infection?: Dental/Tonsil/Skin source. -> Treat source + Review 2-4 weeks.
4. Unexplained?: FBC, Film, CRP, EBV/CMV/HIV, CXR.
5. Reactive?: Observe.
6. Persistent > 6w: Urgent Diagnosis (US -> Biopsy).

1. Conservative (Watch and Wait)

For young patients with small (less than 2cm), mobile, tender nodes and recent URTI.

• Safety Net: "Come back if it gets bigger or persists > 3 weeks."
• Avoid Antibiotics unless bacterial source confirmed.

2. Medical Management

Antibiotic Selection for Acute Lymphadenitis:

Evidence-Based TB Management

For cervical TB lymphadenitis, standard 6-month regimen (2RHZE/4RH) achieves 95% cure rate. Paradoxical reaction (node enlargement during treatment) occurs in 20-30% and does not indicate treatment failure. [35] Surgery reserved for diagnostic uncertainty or cosmetic concerns post-treatment.

3. Surgical/Oncological Management

Lymphoma Management:

• Hodgkin Lymphoma (HL): ABVD chemotherapy (Adriamycin, Bleomycin, Vinblastine, Dacarbazine). Early-stage (I-II): 2-4 cycles + involved-field radiotherapy. Advanced-stage (III-IV): 6 cycles. 5-year survival greater than 85%. [2,15]
• Non-Hodgkin Lymphoma (NHL): R-CHOP (Rituximab + Cyclophosphamide, Doxorubicin, Vincristine, Prednisolone) for DLBCL. 6-8 cycles. Addition of Rituximab improved 3-year OS from 57% to 76%. [1]
• Indolent NHL (Follicular, CLL): Watch-and-wait acceptable for asymptomatic disease. Treat when symptomatic or organ compromise.

Head & Neck Cancer - Neck Dissection: Classified by Memorial Sloan Kettering system:

• Radical Neck Dissection: Removal of Levels I-V + SCM muscle + Internal Jugular Vein + Spinal Accessory Nerve. Reserved for extensive disease. [7]
• Modified Radical: Preserves one or more non-lymphatic structures (nerve/vein/muscle).
• Selective Neck Dissection: Specific levels only (e.g., Levels II-IV for oral cavity primary).

Post-operative radiotherapy indicated if: 2 or more positive nodes, extracapsular spread, positive margins.

5. Follow-up and Monitoring Protocols

Post-Biopsy Reactive Nodes:

• Re-examine at 4-6 weeks. If persisting but stable, consider repeat imaging at 3 months.
• Patient safety netting: Return immediately if rapid growth, B-symptoms, or new lumps develop.

Post-Treatment Lymphoma:

• PET-CT at end of treatment (Deauville score 1-3 indicates complete metabolic response). [25]
• Follow-up schedule: Every 3 months for 2 years, then every 6 months to 5 years, then annually.
• Surveillance imaging not routinely recommended for asymptomatic patients in remission.
• Late effects surveillance: Cardiac (anthracycline cardiotoxicity), Pulmonary fibrosis (bleomycin), Secondary malignancies (solid tumors, AML/MDS).

HIV-Associated Lymphadenopathy:

• Antiretroviral therapy (ART) usually causes regression of Persistent Generalized Lymphadenopathy within 3-6 months. [36]
• Failure to regress or asymmetric enlargement warrants biopsy (increased lymphoma risk: 200-fold vs general population).
• Opportunistic infection screen: TB, CMV, Toxoplasma, Cryptococcus.

• Head & Neck Cancer: Neck Dissection (Removal of Levels I-V) + Chemoradiotherapy.

4. Paediatric vs Adult Lymphadenopathy

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8. Complications

1. Compression Syndromes

• Mediastinal Nodes: Superior Vena Cava Obstruction (SVCO) - Facial swelling, dilated veins. Emergency.
• Airway: Stridor/Dyspnea.
• Retroperitoneal: Ureteric obstruction (Hydronephrosis).

2. Abscess Formation

• Bacterial lymphadenitis can suppurate (turn to pus). Requires incision and drainage.

3. Lymphedema

• Post-treatment (surgery/radiotherapy). Disruption of drainage causes chronic swelling of limbs/face.

4. Post-Biopsy Nerve Injury

• Spinal Accessory Nerve: Winging of the scapula (Level V node biopsy).
• Marginal Mandibular Nerve: Lip weakness (Level I/II).

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9. Prognosis & Outcomes

• Reactive: Self-limiting. Resolves in 2-4 weeks.
• Hodgkin's Lymphoma: > 85% cure rate (one of the most curable cancers).
• Non-Hodgkin's: Variable (Indolent vs Aggressive).
• Metastatic SCC: Poor prognosis (5-year survival less than 50% if N2/N3 disease).

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10. Evidence & Guidelines

Key Guidelines

1. NICE NG12 (2015) — Suspected cancer: recognition and referral.
   • Rec: Refer adults with unexplained persistent lymphadenopathy.
   • Rec: Refer any supraclavicular mass.
2. NICE CKS (2021) — Lymphadenopathy - Not yet diagnosed.
   • Rec: Do not routinely treat with antibiotics. Screen for EBV/HIV.

Landmark Trials

The REAL Classification Study (1994)

• Study: Reclassification of lymphoid neoplasms.
• Impact: Established the modern WHO classification (B-cell vs T-cell, Indolent vs Aggressive), replacing the vague "Rappaport" system.

The ABVD Trial (CALGB)

• Study: Comparison of MOPP vs ABVD for Hodgkin's.
• Finding: ABVD (Adriamycin, Bleomycin, Vinblastine, Dacarbazine) superior effectiveness with less toxicity (sterility/leukemia risk).
• Impact: ABVD became standard of care.

The R-CHOP Trial (GCLA)

• Study: Rituximab added to CHOP in Diffuse Large B-cell Lymphoma (DLBCL).
• Finding: Significant survival advantage.
• Impact: Biological therapy (Anti-CD20) became standard.

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11. Patient/Layperson Explanation

What are Lymph Nodes?

Think of lymph nodes as "Police Stations" located along the "Highways" (lymph vessels) of your body. Their job is to arrest and interrogate any viruses, bacteria, or cancer cells traveling through the fluid. When they find "bad guys", they call for backup (immune cells). This fills the police station, making it swell up.

Why are they swollen?

90% of the time, it's a "Riot at the Station"

• the nodes are fighting a virus (like a cold or glandular fever). This is a good sign that your immune system is working. Rarely, the "bad guys" take over the station completely (Cancer).

When to worry?

We worry if:

• The node is hard like a rock.
• It keeps growing for weeks.
• You have night sweats or unexplained weight loss.
• It is just above your collarbone.

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11b. Detailed Clinical Case Studies

Case 1: The Student (Glandular Fever)

Presentation: A 19-year-old university student presents with 5 days of severe sore throat, profound fatigue, and "lumps in the neck". Examination:

• Large, tender, mobile lymph nodes in the Posterior Triangle (Level V) and anterior chain.
• White exudate on tonsils ("Kissing tonsils").
• Palpable spleen tip.
• Faint macular rash (he took Amoxicillin yesterday - "Amoxicillin Rash"). Diagnosis: Infectious Mononucleosis (EBV). Action:

1. Stop Antibiotics: It's viral.
2. Blood Film: Atypical Lymphocytes. Monospot positive.
3. Advice: No contact sports (Splenic rupture risk) for 6 weeks. Rest.

Case 2: The Smoker (SCC Metastasis)

Presentation: A 62-year-old heavy smoker presents with a painless lump in the right neck noticed while shaving. No other symptoms. Examination:

• Hard, fixed, non-tender 3cm mass in Level II (Upper Jugular).
• Oral exam reveals a small ulcer on the lateral border of the tongue. Diagnosis: Metastatic Squamous Cell Carcinoma (Primary: Tongue). Action:

1. Urgent 2-week Wait Referral to ENT/MaxFax.
2. Process: FNAC (confirm cancer) -> Panendoscopy + Biopsy of tongue -> CT Neck/Chest.
3. Treatment: Neck Dissection + Resection + Radiotherapy.

Case 3: The Night Sweats (Hodgkin's Lymphoma)

Presentation: A 25-year-old female presents with "drenching sweats" needing pajama changes, and unexplained itchiness. She felt a lump in her left neck. Examination:

• Rubbery, firm, non-tender mass in the Left Supraclavicular Fossa.
• Also palpable axillary nodes. Diagnosis: Suspected Lymphoma. Action:

1. Urgent Referral to Haematology.
2. Excision Biopsy: Shows Reed-Sternberg cells ("Owl's Eyes").
3. Staging: PET-CT shows mediastinal involvement.
4. Treatment: ABVD Chemotherapy. Curative intent.

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12. References

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2. Canellos GP, et al. Chemotherapy of advanced Hodgkin's disease with MOPP, ABVD, or MOPP alternating with ABVD. N Engl J Med. 1992;327:1478-1484. PMID: 1383821
3. National Institute for Health and Care Excellence (NICE). Suspected cancer: recognition and referral [NG12]. 2015.
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5. Bazmore RS, et al. Lymphadenopathy and malignancy in general practice. Am Fam Physician. 2002;66(11):2103-10. PMID: 12484548
6. Pangalis GA, et al. Clinical approach to lymphadenopathy. Semin Oncol. 1993;20(6):570-82. PMID: 8296200
7. Robbins KT, et al. Neck dissection classification update. Arch Otolaryngol Head Neck Surg. 2002;128(7):751-8. PMID: 12117328
8. Slap GB, et al. Risk factors for malignancy in adult patients with peripheral lymphadenopathy. J Gen Intern Med. 1986;1(6):348-51. PMID: 3772594
9. Harris NL, et al. A revised European-American classification of lymphoid neoplasms. Blood. 1994;84(5):1361-92. PMID: 8068936
10. Freise S, et al. Sonographic evaluation of cervical lymph nodes. Journal of Ultrasound in Medicine. 2021. PMID: 33502013
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12. Mohseni S, et al. Peripheral lymphadenopathy: approach and diagnostic tools. Iran J Med Sci. 2014;39(2):158-70. PMID: 24719532
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22. Diehl V, et al. Increased-dose BEACOPP. N Engl J Med. 2003;348:2386. PMID: 12802024
23. Fisher RI, et al. CHOP vs three intensive regimens. N Engl J Med. 1993;328:1002. PMID: 7680764
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13. Examination Focus

Common Exam Questions

"Examine this patient's neck lumps." "This patient has a lump in the left supraclavicular fossa. What is the likely primary?" "Demonstrate your examination of the spleen."

Viva Points

Opening Statement: "Lymphadenopathy is abnormal enlargement of lymph nodes, which can be classified by anatomy (Axonal vs Demyelinating), time course (Acute vs Chronic), and etiology. The most common cause is reactive (infection), but malignancy must be excluded."

"What is Virchow's Node?"

• "An enlarged Left Supraclavicular lymph node (Troisier's sign). It receives lymphatic drainage from the thoracic duct, which drains the abdomen. It strongly suggests Gastric or Pancreatic malignancy."

"What is the difference between a Lymphoma node and a Reactive node?"

• "Reactive: Tender, Soft/Ovoid, Mobile, usually less than 2cm.
• Lymphoma: Painless (usually), Rubbery, Round, often 'matted', progressively enlarging."

"Why do we assume a Cystic Neck Mass in an adult is cancer?"

• "A cystic mass in the lateral neck of an adult (> 40) is a Cystic Metastasis from Squamous Cell Carcinoma (typically Tonsil/Base of Tongue HPV+) until proven otherwise. It is often misdiagnosed as a Branchial Cyst."

Common Mistakes

• ❌ Prescribing repeated courses of antibiotics for a painless lump.
• ❌ Performing an Open Biopsy on a neck mass before ruling out Head & Neck Cancer (Should do FNAC first. Open biopsy can seed tumor cells and compromise definitive Neck Dissection).
• ❌ Missing the Scalp (Melanoma can drain to posterior triangle).
• ❌ Ignoring the Gums/Teeth (Commonest source of submandibular nodes).

Examiner's Follow-up

• "If the FNAC shows 'reactive changes' but the node persists for 3 months, what do you do?"
  • "I would perform an Excision Biopsy to rule out Lymphoma, as FNAC can miss architectural changes."

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Last Reviewed: 2026-01-02 | MedVellum Editorial Team

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Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists and current guidelines.