Diagnostic Biopsy of Lymph Nodes of the Neck, Axilla and Groin: Rhyme, Reason or Chance?

Abstract

INTRODUCTION Improving patient pathways of care is becoming increasingly important in the delivery of timely, appropriate surgical care. With this aim, we analysed the referral and management pathway of patients undergoing diagnostic superficial lymph node biopsy.PATIENTS AND METHODS A retrospective review of case notes of patients undergoing diagnostic superficial lymph node biopsy over 3 years, 1998-2000 at the Bradford Hospitals NHS Trust. Indication for surgical biopsy was based on clinical suspicion following assessment in the out-patient clinic for the majority, and arrangement of investigations as deemed appropriate. There were no clinical algorithms in use during the study period.RESULTS There was no evidence for the use of explicit protocols for referral or management. Biopsy was often delayed. Of 268 patients referred from primary care, referral was made to any of 14 hospital departments with 39% (105 of 268) attending more than one outpatient appointment, and 155 (41 of 268) attending more than one department. Eighteen percent (47 of 268) of patients were informed of their diagnosis within 6 weeks of referral and 42% (113 of 268) within 3 months of referral. Nine percent (24 of 268) underwent pre-operative fine needle aspiration cytology. Of patients with enlarged neck nodes, 29% (52/180) had examination of the upper aero-digestive tract.CONCLUSIONS The study supports the introduction of co-ordinated problem-based referral and management pathways for the management of patients with enlarged superficial lymph nodes supported by regular audits of practice.

Waiting Time to Lymph Node Biopsy is Dependent on Referral Method: Don't Write, Phone!

“…9,10 Wide-spread delays have been reported, both before biopsy and in informing patients of their diagnosis. 9 Of patients in this study, 43% had a diagnosis of neoplastic disease; it is imperative that these patients receive a rapid, accurate diagnosis and proceed quickly to treatment. Delay to diagnosis is a real concern: the time taken by a hospital team -after referral -to reach the diagnosis of lymphoma can outweigh the time spent in primary care.…”

“…Numerous complex patient pathways have been described in hospitals lacking a distinct referral pathway for patients with lymphadenopathy. 9,10,13 This results in unacceptable variation: patients referred to general surgery or ENT departments have longer times to diagnosis. 13 Standardised guidelines for lymphadenopathy assessment would facilitate the appropriate use of investigations other than lymph node biopsy, and a rapid diagnosis.…”

Lymphadenopathy : Histopathological evaluation of 90 Cases in Chittagong

“…Other causes are secondary metastasis, Non Hodgkin lymphoma, Hodgkin lymphoma and suppuration. In the study reactive hyperplasia was the predominant cause (51%) 7 . Other lesions reported were tuberculous lymphadenopathy (15%), metastasis (15%) and lymphoma (19%).…”

Lymph node enlargement and risk of haematological and solid cancer

“…That study, which focused on referral delay, reported that almost all diagnoses of malignancies were made within 2 months, although follow-up time was not specified (Chau et al, 2003). Other cross-sectional studies based on patients retrospectively identified in pathology registries have reported that 34-47% of patients who underwent surgical lymph node biopsies had malignancies (Sinclair et al, 1974;Lee et al, 1980;Moor et al, 2008). The prevalence of malignancies varied with the time period in which the biopsies were taken: 47% of biopsies indicated malignancy during 1966-67 (Sinclair et al, 1974), 40% of biopsies indicated malignancy during 1973-77 (Lee et al, 1980), and 34% during 1998-2000 (Moor et al, 2008).…”

“…While many diseases are associated with enlarged lymph nodes, most cases are due to infection, a rheumatologic/immune disorder, or a malignancy (Habermann & Steensma, 2000). Existing knowledge about causes of enlarged lymph nodes has been gleaned primarily from small case series of patients from general practice (Allhiser et al, 1981;Williamson, 1985), from patients referred to hospital clinics (Chau et al, 2003;Verbrugge et al, 2011), and from patients with a lymph node biopsy identified through pathology registries (Saltzstein, 1965;Sinclair et al, 1974;Lee et al, 1980;Mohan et al, 2007;Moor et al, 2008). In these cross-sectional studies, prevalence of malignancies varied widely, from 0-1% in general practice (Allhiser et al, 1981;Williamson, 1985) and up to 58% among patients at a tertiary referral center (Verbrugge et al, 2011).…”