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When does an enlarged cervical lymph node in a child need excision? A systematic review
Richard Locke1, Rachael Comfort1, Haytham Kubba1
1Department of Paediatric Otolaryngology, Royal Hospital for Sick Children, Yorkhill, Glasgow G3 8SJ, Scotland, United Kingdom.
Insights
Diagnosing pediatric cervical lymphadenopathy requires careful evaluation. While large or supraclavicular nodes warrant biopsy, ultrasound shows promise, and fine needle aspiration cytology (FNAC) is unreliable for excluding malignancy.
Area of Science:
- Pediatric Oncology
- Diagnostic Imaging
- Head and Neck Surgery
Background:
- Palpable cervical lymphadenopathy is common in children, necessitating differentiation between malignancy and benign causes.
- Open biopsy, while diagnostic, carries complication risks and often reveals benign conditions like reactive hyperplasia.
Purpose of the Study:
- To evaluate the diagnostic accuracy of clinical exams and investigations for pediatric cervical lymphadenopathy.
- To minimize the need for open biopsies by identifying reliable non-invasive diagnostic tools.
Main Methods:
- A systematic literature review was conducted using major medical databases (Medline, Embase, CINAHL, Cochrane).
- References from standard pediatric ENT and head and neck textbooks were also examined.
Main Results:
- Evidence for malignancy predictors is weak; large and supraclavicular nodes are concerning.
- Ultrasound shows potential for differentiating benign from malignant nodes, but requires further pediatric studies.
- Fine needle aspiration cytology (FNAC) has variable sensitivity and cannot reliably exclude malignancy.
Conclusions:
- Biopsy is recommended for large and supraclavicular lymph nodes.
- Ultrasound shows promise but needs more research in pediatric cases.
- Current evidence does not support using FNAC to rule out malignancy in children; further research on predictive models is needed.
Background:
Palpable cervical lymphadenopathy is very common in children. The clinician's job is to exclude malignancy as a cause and reach a diagnosis. In children selected for open biopsy, reactive hyperplasia and other inflammatory causes are far more common as a final diagnosis than malignancy. Furthermore complications can occur after open biopsy.
Objective:
To assess the diagnostic utility of clinical examination and investigations to exclude malignancy and other serious causes of paediatric cervical lymphadenopathy and minimise open biopsy.
Type Of Review:
A systematic review of the literature with defined search strategy.
Search Strategy:
A structured search of Medline, Embase, CINAHL and Cochrane databases. The references within standard paediatric ENT and head and neck textbooks were also examined.
Results:
The quality of evidence regarding predictors of malignancy is poor. Large lymph nodes and supraclavicular nodes are potential indicators of serious pathology. Fever, weight loss and organomegaly may be indicators but duration of symptoms and consistency are not. Abnormalities on chest X-ray are associated with serious causes but the diagnostic utility of routine chest X-ray is unknown. Ultrasound assessment of nodal architecture, margins, and shape (and possibly vascularity) shows considerable promise as a means of differentiating reactive hyperplasia from malignancy but further studies in children are required. Abnormalities in the full blood count (FBC) seem to be uncommon but when present are associated with serious causes of cervical lymphadenopathy, again the diagnostic utility is unclear. Serological testing may identify a specific cause and therefore avoid excision biopsy in around 10% of cases. Cutting needle biopsy requires further evaluation before it can be recommended. Fine needle aspiration cytology (FNAC) is very specific, but sensitivity varies in different studies to the extent that it cannot yet be relied upon to exclude malignancy.
Conclusions:
Large and supraclavicular nodes should be biopsied. Ultrasound is likely to be useful but further study is required. FNAC cannot be relied upon to exclude malignancy in children. The diagnostic utility of chest X-ray and FBC are unclear. Work is required on multivariate predictive models.
