Predictors of malignancy in childhood peripheral lymphadenopathy

Outcomes of Referrals in Pediatric Patients With Peripheral Lymphadenopathy

Lymphadenopathy is a common reason for referral to a subspecialist, which may result in significant anxiety for parents. Understanding which patients require a subspecialty referral for lymphadenopathy is key to streamlining health care utilization for this common clinical entity. This is an IRB-approved retrospective study examining pediatric patients consecutively referred to pediatric hematology oncology, otolaryngology, or surgery for lymphadenopathy from 2012 to 2021 at a free-standing tertiary-care children's hospital. Logistic regression was fitted to examine the association between the maximum size of the lymph nodes (LN) and a diagnosis of malignancy. The odds ratio, area under the receiver operator curve, sensitivity, and specificity were estimated. We found a significant association between LN size and cancer diagnosis. For every centimeter increase in the maximal dimension of LN, there was an estimated 2.3 times increase in the odds of malignancy (OR=2.3, 95% CI: 1.65-3.11; P<0.0001). The estimated area under the curve (0.84, 95% CI: 0.78-0.90) indicated that LN size correlated well with cancer diagnosis. A LN cut-off size of 2 cm resulted in an estimated sensitivity of 1.0 (95% CI: 0.87-1.00) and specificity of 0.54 (95% CI: 0.46-0.61). Maximum LN size may be a predictor of malignancy among pediatric patients with lymphadenopathy.

Machine Learning Logistic Regression Model for Early Decision Making in Referral of Children with Cervical Lymphadenopathy Suspected of Lymphoma

While cervical lymphadenopathy is common in children, a decision model for detecting high-grade lymphoma is lacking. Previously reported individual lymphoma-predicting factors and multivariate models were not sufficiently discriminative for clinical application. To develop a diagnostic scoring tool, we collected data from all children with cervical lymphadenopathy referred to our national pediatric oncology center within 30 months (n = 182). Thirty-nine putative lymphoma-predictive factors were investigated. The outcome groups were classical Hodgkin lymphoma (cHL), nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL), non-Hodgkin lymphoma (NHL), other malignancies, and a benign group. We integrated the best univariate predicting factors into a multivariate, machine learning model. Logistic regression allocated each variable a weighing factor. The model was tested in a different patient cohort (n = 60). We report a 12-factor diagnostic model with a sensitivity of 95% (95% CI 89-98%) and a specificity of 88% (95% CI 77-94%) for detecting cHL and NHL. Our 12-factor diagnostic scoring model is highly sensitive and specific in detecting high-grade lymphomas in children with cervical lymphadenopathy. It may enable fast referral to a pediatric oncologist in patients with high-grade lymphoma and may reduce the number of referrals and unnecessary invasive procedures in children with benign lymphadenopathy.

Comparison of clinical estimations and radiological measurements in the context of paediatric cervical masses: How accurate are we?

OBJECTIVES

Cervical masses represent a common presentation to the paediatric ENT outpatient clinic. Despite their high prevalence, few represent an underlying malignant pathology. Currently, there is no universally accepted algorithm for management of such cases in the United Kingdom. Local guidance often centres around clinical interpretation of size when determining the need for investigation. With such emphasis placed on size, the authors sought to investigate the accuracy of physician palpation and in turn explore the validity of common referral pathways.

METHODS

A retrospective methodology was used to address the research objective. All paediatric ultrasound scans conducted during a 24-month period were reviewed to compare the clinical and radiological assessments of diameter. A 2 tailed paired student's t-test was selected to evaluate the differences between the two measurements and ultimately assess clinician accuracy.

RESULTS

753 paediatric cervical ultrasound scans were conducted during the 2-year period. Initial analysis identified three discrete ultrasonographically diagnostic groups: lymph nodes (n = 532), non-lymph node masses (n = 162) and normal anatomy (n = 59). Further analysis of clinical estimation and radiological measurement demonstrated a statistically significant difference (p < 0.02) for the lymph-node group. A statistically significant difference was not demonstrated within the non-lymph node group (p = 0.66). When clinician assessment resulted in a value outside of what was considered accurate, lymph node sizes were predominantly overestimated (62/91, 68%). Conversely, non-lymph node masses where the clinical measurement was not within 5 mm of the ultrasound measurement were more commonly underestimated in size (11/45, 55%) but this was not statistically significant.

CONCLUSIONS

Our study demonstrates a statistically significant tendency for clinicians to overestimate paediatric cervical lymphadenopathy. Calliper measurement may further improve accuracy of assessment.

The Evaluation of Lymphadenopathy in a Resource-Limited Setting

Lymphadenopathy (LAP) refers to abnormalities in the size or consistency of lymph nodes. A wide range of etiologies contributes to the difficulty in diagnosing LAP, from mild self-limited viral infections to grave autoimmune diseases and malignancies. Detailed history-taking and a thorough physical examination are essential. Some physicians in developing countries may consider therapeutic testing. Certain groups may require additional evaluations and special treatment. When treating LAP, the etiology is targeted, but corticosteroids should not be administered before a complete diagnosis has been established due to their ability to mask the histological diagnosis of lymphoma and malignancy. This review aims to provide more straightforward and affordable methods available in almost all healthcare settings, especially those with limited resources.

A 14-Year-Old Female With Chest Mass, Shortness of Breath, and Hypertension

BACKGROUND

A previously healthy 14-year-old girl was evaluated in the emergency department (ED) with 2 months of shortness of breath and fatigue.

METHODS

She initially presented to her primary pediatrician, where a complete blood count was only significant for mild anemia, thyroid function tests were normal, and a chest x-ray revealed a chest mass. This prompted her primary pediatrician to order a computed tomography scan and refer to the ED.

RESULTS

Her computed tomography scan confirmed a mediastinal mass versus necrotic lymphadenopathy. Her initial physical exam was unremarkable, except for hypertension. From the ED, she was admitted to the pediatric hospital medicine service. Infectious disease, oncology, and nephrology services were consulted to guide diagnostic evaluation.

CONCLUSIONS

Eventually, during her hospitalization, further history and workup led to a definitive diagnosis.

Cervical lymph node biopsies in the evaluation of children with suspected lymphoproliferative disorders: Experience in a tertiary pediatric setting

BACKGROUND/PURPOSE

The objectives of this study were: (1) to determine the incidence of lymphoproliferative disorders in a cohort of patients requiring a biopsy at a tertiary pediatric center; and (2) to elucidate the demographic, clinical, laboratory and diagnostic imaging characteristics associated with a malignant diagnosis.

METHODS

A retrospective review of pediatric cervical lymph node biopsies performed between 2012 and 2019 at a tertiary center was undertaken. Demographic data, clinical presentations, laboratory results, diagnostic imaging findings, and pathology results were compiled and analyzed to identify characteristics associated with a malignant diagnosis.

RESULTS

Malignancy was identified in 49.5% of patients (55/111) subjected to a cervical lymph node biopsy. The median age of patients with a benign diagnosis was lower than malignant diagnosis (11.0 vs. 14.0 years, p < 0.01). Mediastinal lymphadenopathy based on chest radiography and/or computed tomography scan was identified in 37/49 malignant cases (75.5%) CONCLUSION: In this retrospective study, 49.5% of biopsies performed at a tertiary pediatric setting yielded a malignant diagnosis. Traditional clinical characteristics such as weight loss, night sweats and nodal texture were not informative when derived retrospectively. The most valuable features identified were increased age, increased long and short axis measurements of the involved node(s), and the presence of mediastinal lymphadenopathy.

LEVEL OF EVIDENCE

Level III.

Chronic Generalized Lymphadenopathy in a Child—Progressive Transformation of Germinal Centers (PTGC)

Background: Enlarged lymph nodes are a common complaint in a Pediatrician’s office. Diagnosis of reactive lymphadenopathy secondary to infectious, inflammatory, immune dysregulation calls for clinical investigation, including a thorough history, physical exam, imaging, and less often, a biopsy of the lymph node. Here we discuss a rare presentation of extensive generalized, chronic, waxing, and waning lymphadenopathy diagnosed as Progressive Transformation of Germinal Centers (PTGC) and the course of illness over eight years follow up period. Discussion: Progressive Transformation of Germinal Centers (PTGC) is considered a benign condition, but extensive recurrent generalized lymphadenopathy in a very young child has not been reported before. This case demonstrates the importance of long-term follow-up and tailoring the diagnostic work-up and management based on new signs and symptoms. Here we focus on the clinical considerations and management of complex presentation of a common clinical finding.

Peripheral adenopathies in children - an attempt of clinical morphological profile

AIM

The authors have proposed to assess peripheral adenopathies in a series of hospitalized children in order to identify and define clinical and morphological profiles of different types of lymph node (LN) diseases.

MATERIALS AND METHODS

The studied group consisted of 58 patients less than 18 years of age. The investigation algorithm included: gender, age, site, involvement, side, extension and histopathological (HP) type of LN lesions. Tissue fragments were processed using classical histological techniques (formalin fixation and paraffin embedment) and stained with Hematoxylin-Eosin (HE). In some cases (tuberculous lesions and lymphomas), special stainings (Ziehl-Neelsen) and immunohistochemistry were used. Stratification scales of cases were defined according to each parameter in order to compare the data. All obtained data were assessed individually, compared to each other and with similar data from the literature with the help of a statistical apparatus [χ² (chi-squared) test and analysis of variance (ANOVA) test] in some cases.

RESULTS

The young patients were slightly more frequently boys, of all ages but with a mean age of 10 and half years. The affected LNs belonged most often to neck region, either on the left or on the right side but sometimes bilateral or even on the midline; usually, more than one LN was involved in the area. In most of the cases, the lesions were localized in only one LN area. HP picture was dominated by the inflammatory processes, firstly the nonspecific ones, followed by tuberculosis.

DISCUSSIONS

Our observations fitted, for each parameter, with the wide ranges found in the literature. Comparisons between parameters' variations revealed differences, sometimes significant that we tried to organize in clinical and morphological profiles.

CONCLUSIONS

The assessment of our data allowed us to define some clinical and morphological profiles of different types of adenopathy that, by improvement on studies including larger series, could be of real use in daily pediatric practice.

Normal head and neck lymph nodes in the paediatric population

AIM

To determine the normal range of head and neck lymph nodes in a paediatric population.

MATERIALS AND METHODS

A retrospective review was undertaken of 200 brain magnetic resonance imaging (MRI) examinations in patients aged between 5 months to 16 years. Exclusion criteria included possible causes for lymphadenopathy. Studies were reported previously as normal. Eight regions were assessed for the presence of nodes, short and long axis of the largest node measured, and the ratio was calculated.

RESULTS

Most commonly identifiable nodes were the deep cervical, submandibular, and posterior cervical in 100%, 99.5%, and 92.5% of studies. In the long axis, the three largest were the submandibular, deep, and posterior cervical with mean values of 19.7, 18.1, and 15.4 mm, respectively. For the S/L ratio, the three with the most oval shape were the pre-auricular, occipital, and submental with ratios of 0.64, 0.63, and 0.6, respectively. A positive correlation between the occipital and deep cervical lymph node groups with age was found to be stronger than the rest of localisations.

CONCLUSION

This study characterises the normal distribution, size, and shape of head and neck lymph nodes in a healthy paediatric population, demonstrating that rounder and larger lymph nodes may be a normal finding, depending on their location and patient age.

Ultrasound evaluation of persistent cervical lymph nodes in young children

AIM

To review the ultrasonographic outcomes of persistent lymph nodes, in the absence of other concerning signs or symptoms, in patients <6 years of age.

MATERIALS AND METHODS

A retrospective analysis was undertaken of 98 patients <6 years old who had neck ultrasound for persistent lymph nodes at a single university hospital over a 3.5 year period between January 2016 and June 2019.

RESULTS

There were no cases of malignant disease or serious systemic illness. Ninety-two of the 98 examinations showed normal or reactive lymph nodes. There were three sonographically indeterminate cases and two non-lymph-node structures: haemangioma and dermoid cyst. One examination reported an abnormal lymph node, which had resolved by the time of review in clinic.

CONCLUSION

Persistently enlarged or abnormal lymph nodes should be investigated; however, a distinction should be made between lymph nodes that have regressed to <1 cm but are still palpable and persistently enlarged or abnormal lymph nodes. The findings of the present study indicate that persistence of non-enlarged lymph nodes is not a predictor for malignancy. It is advised that clear guidelines are used, which state the criteria for further investigation, to promote the best use of imaging.

Lymphadenopathy in children: A streamlined approach for the surgeon - A report from the APSA Cancer Committee

BACKGROUND/PURPOSE

Lymphadenopathy is a common complaint in children. Pediatric surgeons are often called upon to evaluate, treat, and/or biopsy enlarged lymph nodes. With many nonsurgical causes in the differential diagnosis, the surgeon plays the important role of providing reassurance and timely diagnosis while minimizing the pain and morbidity associated with surgical interventions in children. The purpose of this summary paper is to provide a management guide for surgeons working up children with lymphadenopathy.

MATERIALS/METHODS

The English language literature was searched for "lymphadenopathy in children". All manuscript types were considered for review, regardless of medical specialty, with emphasis placed on published guidelines, algorithms, and reviews. After thorough review of these manuscripts and cross-referencing of their bibliographies, the attached algorithm was developed, with emphasis on the role and timing of surgical intervention.

RESULTS

The APSA Cancer Committee developed the attached algorithm to fill a gap in the surgical literature. It outlines lymphadenopathy workup and treatment with emphasis on the role and timing of surgical intervention.

CONCLUSION

This review defines and summarizes the common etiologies and presentations of lymphadenopathy in children, and offers a straightforward algorithm for evaluation of and treatment with an emphasis on malignancy risk and surgical management.

TYPE OF STUDY

Summary paper.

LEVEL OF EVIDENCE

Level V.

Otolaryngologist and pediatric oncologist perspectives on the role of fine needle aspiration in diagnosing pediatric head and neck masses

OBJECTIVE

To determine how otolaryngologists and pediatric oncologists differ in their initial approach to diagnosing head and neck masses in children and adolescents.

METHODS

We designed an electronic 28-question survey consisting of 4 clinical cases and one referral case varying by patient age, history, and physical exam findings. The survey was sent anonymously to pediatric oncologists and otolaryngologists at institutions in the United States and Canada.

RESULTS

Two hundred and thirty one pediatric oncologists (29.4%) and 87 otolaryngologists (39.5%) completed the survey. Otolaryngologists were significantly more likely to recommend performing an FNA than oncologists in all four cases; less than 7% of pediatric oncologists recommended FNA for head and neck mass evaluation. Of providers who recommended FNA, otolaryngologists were more likely to do so because of diagnostic yield when compared to pediatric oncologists. However, when referred a patient with an FNA demonstrating non-Hodgkin lymphoma, the majority of pediatric oncologists (73.6%) and otolaryngologists (78.7%) would complete the staging work-up and begin treatment. If the same patient was referred with an FNA that demonstrated non-specific inflammation, most oncologists (91.0%) and otolaryngologists (94.4%) would biopsy the mass.

CONCLUSION

Otolaryngologists and pediatric oncologists differ in their initial approach to diagnosing head and neck masses in children, yet they both would recommend treating a patient with a positive FNA. This highlights important differences in the diagnostic process depending on which provider sees the patient first. Further studies assessing the sensitivity and specificity are needed to determine the true diagnostic yield of FNAs in the assessment of head and neck masses in children and adolescents, especially with increasing need for molecular and genomic profiling.

Pediatric Cervical Lymphadenopathy

Cervical lymphadenopathy affects as many as 90% of children aged 4 to 8 years. With so many children presenting to doctors' offices and emergency departments, a systematic approach to diagnosis and evaluation must be considered. In the following review, we aim to provide the pediatric clinician with a general framework for an appropriate history and physical examination, while giving guidance on initial diagnostic laboratory testing, imaging, and potential need for biopsy. The most common cause of cervical lymphadenopathy in the pediatric population is reactivity to known and unknown viral agents. The second most common cause includes bacterial infections ranging from aerobic to anaerobic to mycobacterial infections. Malignancies are the most concerning cause of cervical lymphadenopathy.The explosion in the use of ultrasonography as a nonradiating imaging modality in the pediatric population has changed the diagnostic algorithm for many clinicians. We aim to provide some clarity on the utility and shortcomings of the imaging modalities available, including ultrasonography, computed tomography, and magnetic resonance imaging.

Utilization of Flow Cytometry in Pediatric Fine-Needle Aspiration Biopsy Specimens

BACKGROUND

Fine-needle aspiration (FNA) coupled with flow cytometry (FC) can be helpful in suspicious pediatric lymph nodes or masses to exclude a lymphoproliferative disorder. The aim of this study was to analyze FC findings in a series of pediatric FNAs and to correlate abnormal findings with follow-up information.

MATERIALS AND METHODS

All pediatric FNAs performed at a tertiary-care children's hospital over a 46-month period that had FC performed were retrospectively analyzed and correlated with follow-up.

RESULTS

A total of 163 FNA procedures were performed in children (age ≤21 years), and 47 (28.8%) of these cases had FC performed. Specimens were mostly obtained from the head and neck (72.3% of cases). Nine cases (19.1%) had abnormal FC findings, including double-negative T cells (n = 3; 33.3%), double-positive T cells (n = 3; 33.3%), excess λ light chains (n = 1; 11.1%), weak CD34 positivity (n = 1; 11.1%), and T-lymphoblastic lymphoma (n = 1; 11.1%).

CONCLUSION

Unusual FC results that are not diagnostic of malignancy can be seen in lymph node FNA in a minority of young patients. In our series, these findings were seen mainly in small populations of T cells and occurred primarily in the setting of reactive lymphoid hyperplasia or ectopic thymic tissue. Cytopathologists performing FNA on children should be aware of these abnormalities and, although they may warrant further investigation and follow-up, they are unlikely to be associated with malignancy.

Development of an algorithm for the management of cervical lymphadenopathy in children: consensus of the Italian Society of Preventive and Social Pediatrics, jointly with the Italian Society of Pediatric Infectious Diseases and the Italian Society of Pediatric Otorhinolaryngology

Cervical lymphadenopathy is a common disorder in children due to a wide spectrum of disorders. On the basis of a complete history and physical examination, paediatricians have to select, among the vast majority of children with a benign self-limiting condition, those at risk for other, more complex, diseases requiring laboratory tests, imaging and, finally, tissue sampling. At the same time, they should avoid expensive and invasive examinations when unnecessary. The Italian Society of Preventive and Social Pediatrics, jointly with the Italian Society of Pediatric Infectious Diseases, the Italian Society of Pediatric Otorhinolaryngology, and other Scientific Societies, issued a National Consensus document, based on the most recent literature findings, including an algorithm for the management of cervical lymphadenopathy in children.

METHODS

The Consensus Conference method was used, following the Italian National Plan Guidelines. Relevant publications in English were identified through a systematic review of MEDLINE and the Cochrane Database of Systematic Reviews from their inception through March 21, 2014.

RESULTS

Basing on literature results, an algorithm was developed, including several possible clinical scenarios. Situations requiring a watchful waiting strategy, those requiring an empiric antibiotic therapy, and those necessitating a prompt diagnostic workup, considering the risk for a severe underling disease, have been identified.

CONCLUSION

The present algorithm is a practice tool for the management of pediatric cervical lymphadenopathy in the hospital and the ambulatory settings. A multidisciplinary approach is paramount. Further studies are required for its validation in the clinical field.

Cervical lymphadenopathy secondary to rhabdomyosarcoma presenting as Horner syndrome in an infant

A 4-week-old boy with left ptosis, anisocoria, and a mass on his left hand was diagnosed with Horner syndrome. The diagnosis precipitated a work-up for a possible malignant etiology. Magnetic resonance imaging demonstrated enlarged left cervical and axillary lymph nodes. A biopsy of the hand lesion confirmed embryonal rhabdomyosarcoma, but a biopsy of the axillary lymph node was negative. Mechanical pressure by noncancerous enlarged lymph nodes is hypothesized to cause the Horner syndrome.

Lymphadenopathy in a series of Egyptian pediatric patients and the role of pathology in the diagnostic workup

Assessment of lymphadenopathy in children represents a diagnostic challenge because of the extensive differential diagnoses, including reactive and malignant conditions. Knowledge of the etiologic pattern of lymphadenopathy in a given geographical region is essential for making a confident diagnosis or for suspecting a disease. Hence, the present study was carried out to identify different etiologies of lymphadenopathy in children in our region and to assess parameters commonly associated with malignancy, with an emphasis on the role of pathology. One hundred and twenty patients aged 1 month to 18 years were included in the study. They were sorted into neoplastic and nonneoplastic (infectious and noninfectious) groups. In 56 patients, biopsy (fine needle aspiration cytology [FNAC], core needle, or excision biopsy) was essential to reach the final diagnosis. Sensitivity of FNAC in the differentiation between neoplastic and nonneoplastic lymphadenopathy was 92.3%, and specificity was 90.0%, with a diagnostic accuracy of 91.3%. We concluded that malignancy should be suspected in the following conditions: presence of abdominal or multiple symptoms; symptom duration of 1-6 months; generalized lymphadenopathy; multiple groups of lymph node (LN) involved; LN size > 2 cm; amalgamated, hard, fixed, and nontender LNs; certain abnormal complete blood count findings; blast cells in blood film; and elevated lactate dehydrogenase level. In such cases, LN biopsy is highly recommended. A final diagnosis was achieved after integrating information from history and clinical findings with the laboratory, radiological, pathological, and microbiological findings. Accordingly, an algorithm for primary diagnostic evaluation of children with lymphadenopathy is suggested.

Pediatric cervical lymphadenopathy

This article provides an overview for evaluation and management of the pediatric patient with cervical lymphadenopathy. A thorough history and physical examination are crucial in developing a differential diagnosis for these patients. Although infectious causes of lymphadenopathy are more prevalent in the pediatric population compared with adults, neoplasms should also be considered. Judicious use of imaging studies, namely ultrasound, can provide valuable information for accurate diagnosis. Common and uncommon infectious causes of cervical lymphadenopathy are reviewed. Surgical intervention is occasionally necessary for diagnosis and treatment of infections, and rarely indicated for the possibility of malignancy. Indications for surgery are discussed.

When does an enlarged cervical lymph node in a child need excision? A systematic review

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.

Incidence and predictors of malignancy in children with persistent cervical lymphadenopathy

OBJECTIVE

The aim of this study was to analyze the clinical and histopathologic aspects of persistent cervical lymphadenopathies in children.

METHODS

This retrospective study included 98 children who underwent surgical excision for persistently swollen cervical lymph nodes between 2001 and 2013. Lymph nodes greater than 1.5 cm that persisted for more than 4 weeks and were unresponsive to an initial antibiotic treatment were considered "persistent". The largest lymph node with an abnormal ultrasonographic appearance was selected for surgical biopsy. The patients were divided into 2 groups according to the histopathologic outcome: benign or malignant.

RESULTS

No significant differences were found between the groups regarding the mean size and mean duration of the swollen cervical lymph nodes (p = 0.147 and p = 0.446, respectively). The area under the ROC curve was 0.567 (95% confidence interval = 0.463-0.667, p = 0.259) for lymph node size and 0.507 (95% confidence interval = 0.404-0.609, p = 0.909) for the duration of the cervical lymphadenopathy. There was no significant difference in the presence of B symptoms between the two groups (p = 0.519). No significant difference was found between benign and malignant groups regarding bilaterality (p=0.913).

CONCLUSIONS

The findings of our study demonstrated that the size and duration of cervical lymphadenopathy, bilateral or unilateral involvement and the presence or absence of B symptoms are not indicators of malignancy. We found a high incidence of malignancy in pediatric cervical lymphadenopathy cases in contrast to other current studies.

Paediatric cervical lymphadenopathy: when to biopsy?

PURPOSE OF REVIEW

Cervical lymphadenopathy is common in the paediatric population and persistent lymphadenopathy of unknown cause is a frequent reason for otolaryngology referral. Diagnostic work-up is variable among physicians and deciding when excisional biopsy is necessary remains a challenge. This update reviews the recent literature on the work-up and diagnosis of paediatric cervical lymphadenopathy, with a focus on factors that may influence the need for excisional biopsy.

RECENT FINDINGS

The majority of paediatric cervical lymphadenopathy cases are benign, with infection and reactive lymphoid hyperplasia being far more common than malignancy. Ultrasound is the initial imaging modality of choice for paediatric cervical lymphadenopathy and can provide critical information to aid in diagnosis. Clinical factors that may predict malignancy include lymph node size greater than 2 cm, multiple levels of adenopathy and supraclavicular location. Biopsy should be strongly considered in patients with a combination of these factors or other suspicious findings such as severe systemic symptoms.

SUMMARY

Paediatric cervical lymphadenopathy is commonly encountered in general and paediatric otolaryngology practice; however, absolute guidelines for biopsy do not exist. Careful consideration of history, physical examination, laboratory work-up and diagnostic imaging must be used to guide the clinician in decision-making for biopsy.

Standardising reporting of cervical lymphadenopathy in paediatric neck ultrasound: a pilot study using an evidence-based reporting protocol

OBJECTIVES

Cervical lymphadenopathy is common in children and can arise from a wide range of aetiologies. Ultrasound can be a useful imaging tool for initial investigation but is known to be operator dependent. We aimed to compare the content of ultrasound reporting in this clinical scenario before and after the introduction of an evidence-based reporting protocol.

METHODS

We performed a prospective 8-month pilot study assessing the content of ultrasound reports generated from scans to investigate suspected cervical lymphadenopathy in children referred to our tertiary referral otolaryngology service. We found wide variation in report content and inconsistent reporting of certain radiological features. In response to this we performed a literature search to identify key, clinically relevant ultrasonographic features for cervical lymphadenopathy and then in consultation with our radiology colleagues, devised a protocol to facilitate the reporting of these key features. Content of reports was then prospectively re-audited over a further 8-month period.

RESULTS

23 reports were assessed before and 26 after introduction of the reporting protocol. Fisher's exact test was used to analyse the data. We found a statistically significant (p < 0.05) improvement in the frequency of reporting of various key features such as nodal distribution, shape, echogenicity, calcification, necrosis and vascular pattern.

CONCLUSIONS

The introduction of a standardised protocol has helped to streamline the reporting of ultrasounds to investigate cervical lymphadenopathy within our department. In the absence of any national guidelines on the reporting of paediatric neck ultrasound in this scenario, we propose that our protocol could be used by other departments to improve standardisation and as a teaching aid.

Enlarged neck lymph nodes in children

Pediatric cervical lymphadenopathy is a challenging medical condition for the patient, family, and physician. There are a wide variety of causes for cervical lymphadenopathy and an understanding of these causes is paramount in determining the most appropriate workup and management. A thorough history and physical examination are important in narrowing the differential diagnosis. Diagnostic studies and imaging studies play an important role as well. This article reviews the common causes of lymphadenopathy, and presents a methodical approach to a patient with cervical lymphadenopathy.

Unexplained cervical lymphadenopathy in children: predictive factors for malignancy

PURPOSE

The purpose of this study was to determine clinical factors that are able to predict the likelihood of malignancy of unexplained cervical lymphadenopathy in children.

METHODS

The data of 175 cases with unexplained cervical lymphadenopathy, including sex, age, fever, number of involved regions, and location and size of the largest node, were collected. Receiver operating characteristic analysis was performed to find out the optimal parameter for size of the largest node. Logistic regression was applied to determine independent predictors for malignancy.

RESULTS

On the basis of receiver operating characteristic analysis, the ratio of maximal width to maximal length (ratio) was confirmed as the optimal parameter of size for malignancy prediction, and its threshold, which maximized sensitivity and specificity, was 0.5. Multivariate binary logistic regression model indicated that number of involved regions (odds ratio [OR], 5.169; 95% confidence interval [CI], 1.291-20.691; P = .020), location of the largest node (OR, 12.423; 95% CI, 3.657-42.205; P = .000), and ratio (OR, 52.080; 95% CI, 16.089-168.588; P = .000) were significant independent predictors of malignancy.

CONCLUSIONS

Higher ratio (>0.5), multiple cervical regions of adenopathy (> or =2), and region II or III location of the largest node are associated with malignancy. These data should be helpful to supplement clinical judgment in determining which enlarged cervical nodes harbor cancer.

The ongoing problem with peripheral lymphadenopathies: which ones are malignant?

PURPOSE

Peripheral lymphadenopathy is frequently encountered in children, but it is difficult to determine the etiology. Our aim in this study was to evaluate the risk of malignancy in childhood peripheral lymphadenopathy, determine the factors accompanying a malignant etiology and find out which additional findings strongly indicate malignancy.

METHODS

Patients from whom a peripheral lymphadenopathy biopsy had been obtained between January 2005 and December 2007 were retrospectively reviewed. The patients were divided into two groups as malignant and benign.

RESULTS

There were 32 patients in the malignant group and 52 in the benign group. The mean age was higher (P < 0.001), lymphadenopathy duration shorter (P = 0.007) and lymphadenopathy size larger (P = 0.019) in the malignant group. The incidence of malignancy was higher in supraclavicular and axillary lymphadenopathies. Hodgkin's disease was the most common disease in the malignant group, while it was reactive lymphoid hyperplasia in the benign group. The biopsy result was malignant in 58.3% of abdominal and 60% of mediastinal lymphadenopathy cases. The best indicator for malignancy was a hypoactive spleen nodule.

CONCLUSIONS

Increased patient age, supraclavicular lymphadenopathy localization, presence of abdominal or mediastinal lymphadenopathy and especially a hypoactive spleen nodule increase the risk of malignancy.

Diagnosis of childhood cancer

Childhood cancer is uncommon but remains the leading cause of disease-related death in children. Symptoms are often vague or insidious; they may suggest a more common alternative diagnosis, and they are quite different from those associated with adult malignancy. The skilled office practitioner must consider cancer as a diagnosis when symptoms/signs persist or when multiple symptoms point toward a possible diagnosis of malignancy. Early diagnosis is critical, as survival rates have increased dramatically over the past decades. Prolonged delay in diagnosis is common, especially for brain tumors and certain lymphomas (Hodgkin disease). When one encounters symptoms suspicious for a childhood malignancy, it is imperative that the child be referred to a pediatric cancer center. These centers possess not only the ability to further evaluate and manage children with malignancy, but also are able to provide support for patients and their families. This evaluation may include further imaging, but often involves obtaining tissue for histologic review. This will require appropriate tumor or bone marrow biopsy, preferably before the start of treatment. Depending upon the type of suspected malignancy, direct tumor biopsy can be facilitated by imaging-guided biopsy (ultrasound, CT, or MRI), which spares the patient additional surgery. This optimally is performed by a skilled team: hematologist/oncologist, surgeon, radiologist, and pathologist. Best results depend upon early referral by the thoughtful practitioner.

Cervical lymphadenopathy in children--incidence and diagnostic management

OBJECTIVE

Palpable lymph nodes are common due to the reactive hyperplasia of lymphatic tissue mainly connected with local inflammatory process. Differential diagnosis of persistent nodular change on the neck is different in children, due to higher incidence of congenital abnormalities and infectious diseases and relative rarity of malignancies in that age group. The aim of our study was to analyse the most common causes of childhood cervical lymphadenopathy and determine of management guidelines on the basis of clinical examination and ultrasonographic evaluation.

MATERIAL AND METHODS

The research covered 87 children with cervical lymphadenopathy. Age, gender and accompanying diseases of the patients were assessed. All the patients were diagnosed radiologically on the basis of ultrasonographic evaluation.

RESULTS

Reactive inflammatory changes of bacterial origin were observed in 50 children (57.5%). Fever was the most common general symptom accompanying lymphadenopathy and was observed in 21 cases (24.1%). The ultrasonographic evaluation revealed oval-shaped lymph nodes with the domination of long axis in 78 patients (89.66%). The proper width of hilus and their proper vascularization were observed in 75 children (86.2%). Some additional clinical and laboratory tests were needed in the patients with abnormal sonographic image.

CONCLUSIONS

Ultrasonographic imaging is extremely helpful in diagnostics, differentiation and following the treatment of childhood lymphadenopathy. Failure of regression after 4-6 weeks might be an indication for a diagnostic biopsy.

Analysis of children with peripheral lymphadenopathy

In this study, the clinical and laboratory features of children with lymphadenopathy were evaluated. Over a 3-year period, 126 patients were referred to the clinic for lymphadenopathy. Twenty-eight of cases have diseases mimicking lymphadenopathy; 98 (mean age: 86+/-55 months) have lymphadenopathy. Localized, limited, and generalized involvement was found in 52%, 30%, and 18% of patients. The most common localization was the head and neck region. The causes of lymphadenopathy were benign diseases in 75 patients. Sixty percent were reactive lymphadenopathy, 39% were lymphadenitis. Lymphadenitis was more frequently localized and bigger than 3 cm compared with reactive adenopathy (p=.02, p=.004). Twenty-three patients have malignant diseases whose mean age was higher than others (p=.002). The enlargement of supraclavicular nodes was more likely due to malignant disease (p=.001). The risk of malignant disease was higher in patients who had generalized lymphadenopathy, lymph nodes bigger than 3 cm, hepatosplenomegaly, and high lactate dehydrogenase levels. In conclusion, this study pointed out the important clues for the differential diagnosis, which were present in the history, physical, and laboratory findings.

Virchows node: rare presentation of childhood hepatocellular carcinoma

Cervical (supra-clavicular) lymphadenopathy may not always be due to tuberculosis in children. Hepatocellular carcinoma in children even may present as supra clavicular lymphadenopathy (Virchow's node).

Diagnostic cervical lymphadenectomy in children: a case for multidisciplinary assessment and formal management guidelines

A retrospective review was carried out of all children under 16 years of age that underwent cervical lymphadenectomy in our department within a 7-year period. The pathway of their referral from the community to hospital care was noted. The circumstances surrounding the decision for surgery, including clinical features of lymph nodes and investigation results were also recorded. We concluded that cervical lymphadenectomy is an uncommon occurrence in children with an incidence of 2.5/100,000 per year and a yield rate of 15.8% for serious conditions requiring treatment. We demonstrate the importance of joint decision-making between surgeons and paediatricians to reduce the rate of unnecessary biopsies. We also reveal the inconsistency in the pre-operative investigation of these children leading to a low number of positive biopsies and highlighting the need for formal management guidelines.

The Klebsiella pneumoniae O antigen contributes to bacteremia and lethality during murine pneumonia

Bacterial surface carbohydrates are important pathogenic factors in gram-negative pneumonia infections. Among these factors, O antigen has been reported to protect pathogens against complement-mediated killing. To examine further the role of O antigen, we insertionally inactivated the gene encoding a galactosyltransferase necessary for serotype O1 O-antigen synthesis (wbbO) from Klebsiella pneumoniae 43816. Analysis of the mutant lipopolysaccharide by sodium dodecyl sulfate-polyacrylamide gel electrophoresis confirmed the absence of O antigen. In vitro, there were no detectable differences between wild-type K. pneumoniae and the O-antigen-deficient mutant in regard to avid binding by murine complement C3 or resistance to serum- or whole-blood-mediated killing. Nevertheless, the 72-h 50% lethal dose of the wild-type strain was 30-fold greater than that of the mutant (2 x 10(3) versus 6 x 10(4) CFU) after intratracheal injection in ICR strain mice. Despite being less lethal, the mutant organism exhibited comparable intrapulmonary proliferation at 24 h compared to the level of the wild type. Whole-lung chemokine expression (CCL3 and CXCL2) and bronchoalveolar inflammatory cell content were also similar between the two infections. However, whereas the wild-type organism produced bacteremia within 24 h of infection in every instance, bacteremia was not seen in mutant-infected mice. These results suggest that during murine pneumonia caused by K. pneumoniae, O antigen contributes to lethality by increasing the propensity for bacteremia and not by significantly changing the early course of intrapulmonary infection.

Diagnostic aspects of cervical lymphadenopathy in children in the developing world: a study of 1,877 surgical specimens

Chronic cervical lymphadenopathy is a common clinical problem frequently requiring surgical biopsy. To evaluate the characteristics of surgically excised cervical lymph nodes (LN) in children in a developing country, we studied 1,332 children less than 15 years old (1,877 surgically removed cervical LNs) over a 23-year period (1976-1999). Indications for biopsy included failure to respond to antibiotic therapy, rapid increase in size, hard, matted LNs in the preauricular, supraclavicular, and posterior triangle of the neck, and difficulty in diagnosis. Clinical and pathological characteristics investigated included age, malignancy, and granulomatous disease such as tuberculosis (tbc). The mean age was 7 years (tbc 5.8/neoplastic disease 8.5 years). Twenty LNs (1.5%) were histologically normal. There were 637 (47.8%) with nonspecific reactive lymphoid hyperplasia and 484 with chronic granulomatous changes (36.3%). Tuberculous lymphadenitis was confirmed in 332 of these (25%). In 181 (54.5%) Mycobacterium tuberculosis was cultured and a further 149 had acid-fast bacilli. Other granulomatous diseases identified included sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfmann disease) (3), syphilis (4), yaws (2), and toxoplasmosis (1). No mycobacteria other than M. tuberculosis were encountered. More than two-thirds (108) of 154 patients with neoplastic LN involvement had a lymphoma; in a further 10 lymphadenopathy was associated with leukemia. Pyogenic organisms were identified in 32, and 5 were positive for human immunodeficiency virus, 1 of whom had Kaposi's sarcoma. A second pathology was identified in 18 of the 637 cases of reactive lymphoid hyperplasia (3 with tuberculosis); in 15 (1.3%) a diagnosis of lymphoma was made from other sites (pleural fluid, etc.) within 6 months of initial biopsy. This represents a diagnostically difficult subgroup requiring further investigation. Chronic lymphadenopathy in children in developing countries has a high incidence of infective causes, including a significant incidence of M. tuberculosis. The incidence of serious pathology in more than one-half of the cervical LNs examined justifies aggressive surgical investigation.

The role of fine-needle aspiration cytology in children with persistent or suspicious lymphadenopathy

PURPOSE

The aim of this study was (1) To determine the value of fine-needle aspiration cytology (FNAC) in children with persistent or suspicious peripheral lymphadenopathy and (2) to analyze whether a history of previous malignancy influenced the accuracy of FNAC.

METHODS

A retrospective study in an Academic Children's Hospital of 73 FNACs of peripheral lymph nodes in 64 patients (35 boys and 29 girls; median age, 9 years; range, 15 months to 20 years) was performed between 1992 and 1997. Eleven patients were excluded because aspirated material appeared inadequate. Outcome was compared with results of subsequent surgical biopsies, clinical follow-up, or both. Patients were divided into group A "de novo" lymphadenopathy (n = 39) and group B lymphadenopathy and a history of previous malignancy (n = 23).

RESULTS

Group A: FNAC showed a benign diagnosis in 25 cases, a malignancy in 13, and was inconclusive in 1. Outcome was false-negative in 2 and false-positive in 1. Sensitivity and specificity were 86% and 96%, respectively. FNAC helped avoid additional surgical procedures in 27 cases (61%). However, if FNAC showed malignant lymphoma, open biopsy was inevitable (8 of 13) to establish proper classification. Group B: FNAC showed a benign diagnosis in 10 cases and a malignancy in 13. Outcome was false-negative in 1, and false-positive in 1. Sensitivity and specificity were 92% and 90%, respectively. FNAC helped avoid additional surgical diagnostic procedures in 25 cases (86%).

CONCLUSIONS

(1) Fine-needle aspiration cytology is a rapid, simple and accurate diagnostic procedure to differentiate between benign and malignant peripheral lymphadenopathy in children. FNAC can avoid open biopsy in at least 60% of cases. (2) A history of previous malignant disease does not influence the accuracy of the test.