Lymphadenopathy (adults) - Draft

Overview

Lymphadenopathy is defined as one or more enlarged lymph nodes >1cm. Does this mean if LN <1cm it is not classified as lymphadenopathy or does it mean that it is just less concerning?

Localised lymphadenopathy refers to only one region effected

Generalised being more than one region effected.

Regions include neck, axillae, groins, mediastinal and abdominal.

Lymphadenopathy is most commonly due to infection, but can be due to inflammation (e.g. sarcoidosis), autoimmune disorders or malignancy including lymphoproliferative diseases (lymphoma).

Malignancies are identified in 14% of people presenting with lymphadenopathy which increases to 28% if patients are >65 years. A core or excision biopsy of a lymph node will be required to make a diagnosis.

Please also see the following pages:

• Head & Neck incl Thyroid - USC (2WW)- lists USC criteria for referral of neck lumps
• Neck Lumps (including Goitre)- advice on different neck lumps in adults and when and where to refer
• Axillary masses - advice on management of axillary masses in adults
• Children & Young People – USC (2WW) - contains information on lymphadenopathy in children.

Before Referral

Assessment in Primary care

• Is it localised or generalised? 
• If localised, is there a local infective or neoplastic cause (examine area that drains nodal group)? 
• Duration of lymph node enlargement and any change in size (especially progressive enlargement)? 
• Any symptoms of infection e.g. URTI, glandular fever or bacterial infection? Any foreign travel or animal exposure (e.g. tick bites, cat scratches)?
• Any accompanying ‘B’ symptoms (poor appetite, >10% weight loss in 6 months, drenching night sweats, unexplained fevers)? 
• Any symptoms of suspected airway obstruction or superior vena cava obstruction or dysphagia?
• Any hepatosplenomegaly?
• Any abnormalities of the FBC e.g. lymphocytosis or cytopenias? 

• Repeatedly waxing and waning lymphadenopathy does not necessarily exclude a diagnosis of lymphoma. 
• Small volume inguinal lymphadenopathy is a common normal finding. Refer if >2cm 

Investigations in primary care

• Infection screening: Monospot (?) I don't think we have access to this in primary care), EBV and CMV serology, HIV
• If unexplained lymphadenopathy urgent FBC within 48 hours (to exclude leukaemia)
• FBC, CRP, LDH, calcium
• Chest Xray (looking for lung malignancy and mediastinal lymphadenopathy)
• If patient well with unexplained small volume lymphadenopathy and above tests normal, consider USS of area to assess nature of lymph nodes – if demonstrates normal or reactive lymph nodes no need for further investigation. See Ultrasound guidance - I am concerned that this advice does not tie in with USS guidance where advice is USS is not beneficial if clinically the lymph nodes are benign.

Red Flags

Red flags

• B symptoms
• Rapidly enlarging lymphadenopathy
• Symptoms of SVCO (facial/upper limb swelling, cough, inability to lie flat), dysphagia, stridor – require immediate discussion with on call haematology SpR for emergency hospital admission
• Abnormal FBC
• For those age <25 years unexplained widespread lymphadenopathy or splenomegaly – seek urgent advice as may represent acute leukaemia

Who to Refer

Head and Neck USC/2WW Referral

Use the Head & Neck incl Thyroid - USC (2WW) pathway for patients with:

• An unexplained palpable lump in the neck i.e. of recent onset or a previously undiagnosed lump that has changed over a period of 3 – 6 weeks.

Breast USC/2WW Referral

Use the Breast - USC (2WW) pathway for patients with: 

• An unexplained axillary lump, without a vaccination in preceding 6 weeks (male and female)

Other Localised Lymphadenopathy

For other localised unexplained lymphadenopathy with concern about a metastatic node refer to appropriate surgical team (I am not sure about pathway here - is this USC/2WW?)

Haematology USC/2WW Referral

Use the Haematology - USC (2WW) pathway for patients with:

• Lymphadenopathy >2cm persisting for >6 weeks with no obvious infective precipitant 
• Lymphadenopathy for <6 weeks in association with:
• B symptoms (see above)
• Hepatic or splenic enlargement
• Rapid nodal enlargement or generalised nodal enlargement
• Abnormal FBC, raised LDH 
• (The above section differs from the wording on the USC/2WW referral form - should we use the same wording for consistency)

If in any doubt over whether to refer urgently or observe then please consider either:

• Haematology Advice & Guidance or,
• Discuss with on call haematology SpR via switchboard (if patient acutely unwell)  -is this BRI only or can patients also be referred via NBT

Referral

URGENT ADVICE: 9am to 5pm via hospital switchboard for haematology SpR. ONLY for emergency advice. Out of hours and weekends – emergency advice may be obtained from the on-call haematology clinician via hospital switchboard.

NON-URGENT ADVICE: use Haematology advice and guidance service which can be accessed through the NHS e-referral system. Your query will be responded by a consultant haematologist within 3 working days.

REFERRAL: via e-RS or cancer fast track pathways as indicated.

Minimal information: the referral letter should include abnormal clinical findings (location, size, any associated features) and any abnormal full blood count results or other relevant test results, particularly if these investigations were not done in laboratories of the hospital to which the referral is made.

Resources

SWAG guideline Lymphadenopathy (swagcanceralliance.nhs.uk)

BMJ best practice guideline: Assessment of lymphadenopathy.pdf (bmj.com)

NICE guidelines: Scenario: Lymphadenopathy | Management | Neck lump | CKS | NICE

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