The lymph nodes are tiny, kidney-shaped structures that act as filters within this system. Their role is to trap and kill viruses and bacteria before these pathogens can return to the bloodstream. Sometimes, the cervical lymph nodes may swell. This article outlines the potential causes of this swelling, as well as information on treatment options and when to see a doctor. Cervical lymph nodes are located in the sides and back of the neck. These glands are usually very small.
However, when a lymph node is greater than 1 centimeter in diameter, it is enlarged. The cervical lymph nodes sit deep inside the neck. For this reason, most people without medical training are unable to feel them, even when they are swollen. However, a doctor may be able to feel one or more bumps beneath the skin when examining the neck region.
In some cases, a person with swollen cervical lymph nodes may experience pain and swelling in the neck area. Many conditions can cause swollen cervical lymph nodes. Each cause is usually accompanied by additional symptoms. Infection is one of the most common causes of swollen lymph nodes anywhere in the body. When there is an infection somewhere in the body, the lymph nodes in that area fill with white blood cells.
The white blood cells then start to destroy the pathogens responsible for the infection. Lymph nodes that swell as a result of infection are usually painful when a person touches them.
However, they also tend to return to their normal size once the infection clears. Less commonly, swollen cervical lymph nodes may be a sign of cancer. Cancers that affect the lymph nodes are called lymphomas. These cancers typically cause swelling of the lymph nodes in more than one area of the body.
There are two main types of lymphoma: Hodgkin lymphoma and non-Hodgkin lymphoma. Non-Hodgkin lymphoma may develop in lymph nodes anywhere in the body, whereas Hodgkin lymphoma tends to develop in the neck, chest, or armpits.
A person who experiences any of these symptoms in addition to enlarged lymph nodes should see their doctor. Hodgkin lymphoma is highly treatable if a person receives a diagnosis and starts undergoing treatment in the early stages.
Non-Hodgkin lymphoma is less treatable , but this is because doctors may not be able to diagnose it until it has reached an advanced stage. HIV is a common cause of swollen lymph nodes. Further spread is to the common iliac and paraaortic nodes.
Another example where knowledge of the pathway of dissemination aids in diagnosis is in patients with testicular cancer. Lymphatic spread occurs along lymphatic channels that accompany the spermatic cord. These lymphatic vessels drain into the nodes within the retroperitoneum.
Typically, right-sided testicular tumours disseminate to the retroperitoneal nodes on the right precaval, paracaval, aortocaval and retrocaval nodes and left-sided tumours disseminate to the left-sided pre-aortic and para-aortic nodes. The incidence of nodal disease increases with the stage of the primary tumour in most abdominal and pelvic tumours. The grade and other histologic characteristics of tumours have a bearing on the likelihood of nodal metastases; e.
Other biologic indices can help to alert the radiologist to the likelihood of nodal metastases. For example, in patients with prostate cancer, a high prostate-specific antigen PSA level or high Gleeson score on biopsy have a higher likelihood of nodal involvement and extracapsular prostatic disease and nodal disease. Knowledge of previous therapy is vital as it modifies the pattern of nodal disease.
For example, in patients with prostate cancer, nodal relapse after radiotherapy or radical prostatectomy is usually outside the pelvis [ 28 ]. Following total mesorectal excision surgery for rectal cancer, nodal recurrence can occur within the obturator chain along the pelvic sidewall or more cranially within the retroperitoneum. The diagnostic accuracy of CT and MR imaging for nodal staging of cancers in the abdomen and pelvis varies widely in the literature. For pelvic malignancies, the accuracy of CT and MR imaging is similar [ 29—31 ].
Conventional CT and MR imaging are limited by their ability to detect metastases in normal or minimally enlarged lymph nodes. In lymphoma patients PET-CT has been found to be superior to 67 Ga imaging, and equal or superior to CT for the detection of nodal and extranodal lymphoma at initial staging [ 34 ]. For partial response, stable disease and progressive disease, the actual short axis measurement of the nodes is included in the sum of target lesions.
MR lymphography is an imaging technique that helps to distinguish malignant and benign nodes based on the pattern and degree of contrast enhancement independent of nodal size or morphology.
MR lymphography is performed after the administration of a lymphotrophic MR contrast agent, of which ultrasmall iron oxide particles USPIO have been most widely applied. Following the administration of USPIO, the particles escape into the interstitial spaces and are transported by lymphatics into the lymph nodes.
Prior to contrast administration, blood vessels and lymph nodes have relatively high signal intensity. Note signal darkening of the normal nodes after contrast, thus facilitating their detection. The main potential advantage of the imaging technique is the ability to detect partially replaced non-enlarged malignant lymph nodes [ 36 ]. The image contrast on diffusion-weighted imaging is based on differences in the mobility of water protons between tissues, and reflects tissue cellularity and the integrity of cellular membranes.
Tumour tissues are generally more cellular compared with the native tissues from which they originate, and thus they show high signal restricted diffusion on diffusion-weighted MR imaging. Diffusion-weighted MR imaging has been shown to improve the detection of lymph nodes.
Fusion images created by the addition of DW-MRI to a conventional T1- or T2-weighted image can improve the detection of small nodes throughout the body. Early reports using diffusion-weighted imaging to identify malignant nodes in patients with head and neck and cervical cancers have been encouraging. The accurate identification of malignant lymph nodes is a major challenge in diagnostic radiology. CT and MRI are limited in their ability to detect metastases in normal or minimally enlarged lymph nodes.
By using the combination of size, shape, characteristics and site of lymph nodes identified on imaging, the radiologist can better indicate if a lymph node is likely to be metastatic. Functional imaging with PET-CT adds to the sensitivity and specificity of nodal evaluation in many tumours but has important limitations. Novel imaging techniques such as USPIO and diffusion-weighted imaging, alone or in combination, may further improve the diagnostic accuracy of nodal staging.
National Center for Biotechnology Information , U. Journal List Cancer Imaging v. Cancer Imaging. Published online Dec Skandadas Ganeshalingam and Dow-Mu Koh.
Author information Article notes Copyright and License information Disclaimer. Corresponding author. Email: ku. Accepted Nov This article has been cited by other articles in PMC.
Abstract Lymph node metastases are a poor prognostic indicator in many tumours and therefore accurate identification during staging is important prior to commencing treatment. Keywords: Lymph node, computed tomography, magnetic resonance imaging. Introduction Nodal disease is most frequently staged using the TNM staging system.
Imaging lymph nodes in oncology Historically, contrast lymphography was used to assess lymph nodes but this has been superseded by ultrasound, CT and magnetic resonance imaging MRI. Ultrasound Superficial lymph nodes, particularly in the head and neck, axilla and inguinal regions are amenable to ultrasound US evaluation. Open in a separate window. Figure 1. Nodal shapes Benign nodes are more likely to be ovoid and they become more rounded as a result of malignant infiltration.
Nodal appearance The sonographic features that are encountered in malignancy include loss of echogenic nodal hilum, irregular nodal contour and internal nodal heterogeneity.
Vascularity on Doppler ultrasound Normal and benign nodes tend to show central hilar vascularity and central symmetric vascularity. Figure 2. Size Currently, the only widely accepted method for discriminating between normal and pathologic nodes is by size. Shape and contour The usefulness of nodal shape on CT or MR imaging is less certain compared with reports in the ultrasound literature.
Figure 3. Figure 4. Figure 5. Potential pitfalls in nodal assessment on CT Using multi-planar reformats makes errors in interpretation less likely. Figure 6. Optimisation of nodal assessment by imaging Metastases are frequently found in nodes that are not enlarged by conventional criteria [ 25 ]. Patterns of tumour spread An understanding of the pathway of tumour spread allows close scrutiny of the most likely sites of nodal involvement. Clinical and pathologic features The incidence of nodal disease increases with the stage of the primary tumour in most abdominal and pelvic tumours.
Details of previous treatment Knowledge of previous therapy is vital as it modifies the pattern of nodal disease. Diagnostic accuracy of nodal staging The diagnostic accuracy of CT and MR imaging for nodal staging of cancers in the abdomen and pelvis varies widely in the literature.
Advances in nodal staging MR lymphography MR lymphography is an imaging technique that helps to distinguish malignant and benign nodes based on the pattern and degree of contrast enhancement independent of nodal size or morphology. Figure 7. Diffusion-weighted MR imaging The image contrast on diffusion-weighted imaging is based on differences in the mobility of water protons between tissues, and reflects tissue cellularity and the integrity of cellular membranes.
Conclusion The accurate identification of malignant lymph nodes is a major challenge in diagnostic radiology.
References 1. Cervical lymphadenopathy: ratio of long to short-axis diameter as a predictor of malignancy. Br J Radiol. Some medications are known to specifically cause lymphadenopathy e. Clinical approach to lymphadenopathy. Semin Oncol ; — When lymphadenopathy is localized, the clinician should examine the region drained by the nodes for evidence of infection, skin lesions or tumors Table 3.
Other nodal sites should also be carefully examined to exclude the possibility of generalized rather than localized lymphadenopathy. This is an important aspect of the examination, as a study of primary care physicians found that generalized lymphadenopathy was identified in only 17 percent of the patients in whom it was present. Scalp and neck, skin of arms and pectorals, thorax, cervical and axillary nodes. Infections, cat-scratch disease, lymphoma, breast cancer, silicone implants, brucellosis, melanoma.
Penis, scrotum, vulva, vagina, perineum, gluteal region, lower abdominal wall, lower anal canal. Infections of the leg or foot, STDs e. Nodes are generally considered to be normal if they are up to 1 cm in diameter; however, some authors suggest that epitrochlear nodes larger than 0. In children, lymph nodes larger than 2 cm in diameter along with an abnormal chest radiograph and the absence of ear, nose and throat symptoms were predictive of granulomatous diseases i.
When a lymph node rapidly increases in size, its capsule stretches and causes pain. Pain is usually the result of an inflammatory process or suppuration, but pain may also result from hemorrhage into the necrotic center of a malignant node. The presence or absence of tenderness does not reliably differentiate benign from malignant nodes.
Stony-hard nodes are typically a sign of cancer, usually metastatic. Very firm, rubbery nodes suggest lymphoma. Softer nodes are the result of infections or inflammatory conditions. Suppurant nodes may be fluctuant. The anatomic location of localized adenopathy will sometimes be helpful in narrowing the differential diagnosis. For example, cat-scratch disease typically causes cervical or axillary adenopathy, infectious mononucleosis causes cervical adenopathy and a number of sexually transmitted diseases are associated with inguinal adenopathy Table 4.
Supraclavicular lymphadenopathy has the highest risk of malignancy, estimated as 90 percent in patients older than 40 years and 25 percent in those younger than age Lymphadenopathy of the right supraclavicular node is associated with cancer in the mediastinum, lungs or esophagus. The left supraclavicular Virchow's node receives lymphatic flow from the thorax and abdomen, and may signal pathology in the testes, ovaries, kidneys, pancreas, prostate, stomach or gallbladder. Although rarely present, a paraumbilical Sister Joseph's node may be a sign of an abdominal or pelvic neoplasm.
In patients with generalized lymphadenopathy, the physical examination should focus on searching for signs of systemic illness. The most helpful findings are rash, mucous membrane lesions, hepatomegaly, splenomegaly or arthritis Table 4.
Splenomegaly and lymphadenopathy occur concurrently in many conditions, including mononucleosis-type syndromes, lymphocytic leukemia, lymphoma and sarcoidosis. Laboratory tests that may be useful in confirming the cause of lymphadenopathy are listed in Table 4. The presence of certain characteristic clinical syndromes may help the physician determine a suspected cause of lymphadenopathy. Patients with these syndromes present with lymphadenopathy, fatigue, malaise, fever and an increased atypical lymphocyte count.
Mononucleosis is most commonly due to Epstein-Barr virus infection. The presence of the typical syndrome and positive results on a heterophilic antibody test Monospot test confirms the diagnosis.
The most common cause of heterophil-negative mononucleosis is early Epstein-Barr virus infection. False-negative results on heterophilic antibody tests are especially common in patients younger than four years of age.
Epstein-Barr virus infection may be confirmed by repeating the Monospot test in seven to 10 days. Rarely is it necessary to confirm the diagnosis with IgM viral capsid antigen or early antigen antibody titers. If Epstein-Barr virus antibodies are absent, other causes of the mononucleosis syndrome should be considered. These include toxoplasmosis, cytomegalovirus infection, streptococcal pharyngitis, hepatitis B infection and acute human immunodeficiency virus HIV infection.
Acute infections with cytomegalovirus and Toxoplasma may be identified with IgM serology for those organisms. This syndrome is defined by the presence of a skin lesion with associated regional lymphadenopathy. The classic cause is tularemia, acquired by contact with an infected rabbit or tick; more common causes include streptococcal infection e.
This syndrome involves the combination of conjunctivitis and associated preauricular nodes. Common causes include viral kerato-conjunctivitis and cat-scratch disease resulting from an ocular lesion. Enlargement of the lymph nodes that persists for at least three months in at least two extrainguinal sites is defined as persistent generalized lymphadenopathy and is common in patients in the early stages of HIV infection. Other causes of generalized lymphadenopathy in HIV-infected patients include Kaposi's sarcoma, cytomegalovirus infection, toxoplasmosis, tuberculosis, cryptococcosis, syphilis and lymphoma.
The decision will depend primarily on the clinical setting as determined by the patient's age, the duration of the lymphadenopathy and the characteristics and location of the nodes. Because generalized lymphadenopathy almost always indicates that a significant systemic disease is present, the clinician should consider the diseases listed in Table 4 and proceed with specific testing as indicated.
If a diagnosis cannot be made, the clinician should obtain a biopsy of the node. The diagnostic yield of the biopsy can be maximized by obtaining an excisional biopsy of the largest and most abnormal node which is not necessarily the most accessible node. If possible, the physician should not select inguinal and axillary nodes for biopsy, since they frequently show only reactive hyperplasia. If the lymphadenopathy is localized, the decision about when to biopsy is more difficult.
Patients with a benign clinical history, an unremarkable physical examination and no constitutional symptoms should be reexamined in three to four weeks to see if the lymph nodes have regressed or disappeared. Patients with unexplained localized lymphadenopathy who have constitutional symptoms or signs, risk factors for malignancy or lymphadenopathy that persists for three to four weeks should undergo a biopsy.
Biopsy should be avoided in patients with probable viral illness because lymph node pathology in these patients may sometimes simulate lymphoma and lead to a false-positive diagnosis of malignancy. Many patients worry about the cause of their abnormal lymph nodes. To adequately address their fears, the physician should ask the patient about his or her concerns and respond to questions about specific diagnoses.
When biopsy is deferred, the physician should explain to the patient the rationale for waiting. Patients should be cautioned to remain alert for the reappearance of the nodes because lymphomatous nodes have been known to temporarily regress.
In most patients, lymphadenopathy has a readily diagnosable infectious cause. A diagnosis of less obvious causes can often be made after considering the patient's age, the duration of the lymphadenopathy and whether localizing signs or symptoms, constitutional signs or epidemiologic clues are present.
When the cause of the lymphadenopathy remains unexplained, a three- to four-week observation period is appropriate when the clinical setting indicates a high probability of benign disease. Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. Address correspondence to Robert Ferrer, M. Reprints are not available from the author. Lymphadenopathy in a family practice. Lymphadenopathy in a family practice: a descriptive study of cases.
J Fam Pract ;— Primary care medicine: office evaluation and management of the adult patient. Philadelphia: Lippincott, J Fam Pract. Williamson HA Jr. Unexplained lymphadenopathy in family practice.
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