Diagnostic uncertainties can lead to unnecessary surgery. It is important to recognise the clinical, radiological and histological indicators of an inflammatory pseudotumour to enable a timely diagnosis and arrange appropriate treatment. In patients with co-morbidities causing immunocompromise, the potential diagnosis of an inflammatory pseudotumour should be considered. This is especially the case in human immunodeficiency virus patients, as inflammatory pseudotumours have been associated with immune reconstitution inflammatory syndrome, which can manifest up to several years after the initiation of, or change in, antiretroviral therapies.

We conclude that patients presenting with level 5 lymphadenopathy should be investigated with heightened clinical vigilance. Our results suggest that up to 80 % will harbour clinically significant pathology requiring further medical treatment, three quarters of which will be malignancy. We report an observational study of histological outcomes of level 5 lymph node biopsies from a regional histopathology department across 5 years. 184 subjects were identified as having a biopsy of a lymph node from the level 5 region within the study period. One hundred and fifty six cases (84.8 %) had clinically significant pathology on final histology requiring further medical treatment. Lymphoma accounted for the highest number of cases (n = 72, 39.1 %), followed by metastatic carcinoma (n = 65, 35.3 %) and granulomatous change (n = 17, 9.2 %). Gender and laterality were not shown to be independent predictors of pathology significance (p [ 0.05).

Dear Sir, We read with great interest the article by Yeo et al 1 regarding their experience of non-head and neck primaries presenting to their neck lump clinic.Our head and neck 'lump-and-bump' clinic is well established, having started in 1995. We recently conducted a similar review and will summarise our findings, which are comparable with minor interesting differences. MethodA retrospective casenote review of patients who underwent cervical lymph node excision biopsy between January 2007 and June 2013 at our centre was undertaken. ResultsTwo hundred and twelve cervical lymph node biopsies were performed. The median age of presentation was 44 years (range 2-88). Haematological malignancy, predominantly lymphoma, was diagnosed in 95 patients (41.5%). 'Benign' pathology was found in 90 patients (39.3%), which included 39 cases of granulomatous lymphadenitis (17%), 50 simple reactive nodes (21.8%) and 1 case of amyloid infiltration (0.4%).Metastatic carcinoma was diagnosed in 27 patients (11.8%). Primary source data were unavailable for two cases. Eighteen were of non-head and neck origin. The top three primary sources in our series in descending order of frequency were lung (n = 5), unknown primary source (n = 5) and genitourinary (prostate, testicular and renal) (n = 3).Data regarding referral sources were retrieved for 193 cases (90.6%): 49 were referred by haematology (23%), 94 from primary care (45%) and 15 each from paediatricians and respiratory physicians (7%). The remaining 20 cases (9%) were referred from various other allied specialties. DiscussionWe find it interesting that despite our centres being at opposite ends of the country, we report similar figures with regard to both haematological and lung malignancies presenting primarily with cervical lymphadenopathy.Primary head and neck lesions should be diagnosed with clinical examination and formal biopsy plus fineneedle aspiration of associated lymphadenopathy instead of excision biopsy. This explains the small proportion of metastatic head and neck tumours in this series (n = 7).In contrast, our rate of 'benign' pathology may simply reflect a different patient group, as excision biopsy is only performed if initial cytology is inconclusive. Where granulomatous inflammation was found histologically, nineteen cases were Nepalese patients who were later diagnosed with tuberculosis, reflecting the large Ghurkha population in our region. 2 In conclusion, our data show broadly similar rates and types of pathology in a similar neck lump clinic. This information might support departments and individuals aspiring to develop a business case and service strategy, to run similar clinics in other regions of the UK. Conflict of interestThere are no conflict of interests to declare.

Most processes involving the scrotum are infectious or inflammatory in nature. Testicular tumors are relatively uncommon, making up about 1% of all cancers in men. Lymphoma is the most common scrotal tumor found in men over 60 years old. The testicle is the usual site of involvement with spread beyond the tunica albuginea into the extratesticular compartment noted in only 10% of cases.l In this report we describe the sonographic findings of a predominantly extra testicular intrascrotal mass arising in an HIVpositive patient mimicking a scrotal abscess in both clinical symptoms and ultrasonographic appearance but proved to be a non-Hodgkin's lymphoma. CASE REPORTA 68 year old HlV-positive black man was admitted for evaluation of jaundice. The history revealed anorexia, nau· sea, vomiting, and weight loss. On physical examination the patient was found to be afebrile and icteric. The liver was mildly enlarged and a few small lymph nodes were palpable in the axilla. The scrotum and prostate were ABBREVIATIONS HIV, Human immunodeficiency virus; CT, Computed tomography; AIDS, Acquired immunodeficiency syndrome

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