Palpable cervical lymphadenopathy is a very common referral cause in children. It is mostly of an inflammatory/benign etiology. The clinician should be suspicious but he/she should also remain safe and use timely and cost-effective methods in lymphadenopathy evaluation. Open cervical lymph node biopsy will enable the establishment of an accurate histopathological diagnosis when other means are inconclusive.
17 Cervical Lymph Node Biopsy in Children
Palpable cervical lymphadenopathy is very common in children; therefore, much thought must be given to the justification of carrying out a surgical biopsy with its associated risks of complications and comorbidities. There are currently no evidence-based guidelines for conducting such biopsies in the evaluation of pediatric neck lumps. 1 , 2
The lymphatic system is a major component of the immune system. It consists of lymphatic fluid, lymphatic vessels, lymph nodes, spleen, tonsils, adenoid, Peyer patches, and the thymus. Along these channels reside approximately 600 lymph nodes, with about 300 of them located in the neck (▶ Fig. 17.1). Exposure to immune challenge mediates a proliferation process leading to lymph node activation and enlargement. 3 , 4
Lymphadenopathy is defined as a disease of the lymph nodes in which they are abnormal in size, number, or consistency. Lymph node enlargement is due to either proliferation of normal cells or infiltration by abnormal cells. There are five broad etiologic categories of lymph node enlargement:
Immune response to infective agents (e.g., bacteria, viruses, fungi).
Inflammatory cells in infections involving a lymph node(s).
Localized neoplastic proliferation of lymphocytes or macrophages (e.g., leukemia, lymphoma).
Infiltration of neoplastic cells carried to the node by lymphatic or blood circulation (metastasis).
A lump is most often randomly discovered by a parent, a caregiver, or a pediatrician. The major challenge is to differentiate between a benign and a pathologic process. The differential diagnosis of pediatric neck lumps is detailed in ▶ Table 17.1. There are differences in therapeutic approaches to pediatric lymph adenopathy from that of adult lymph adenopathy since the former is such a common cause for referral and made mostly on the basis of a benign/inflammatory etiology. The clinician should relieve the parent’s and child’s fear of malignancy while being suspicious enough but still being safe, timely, and cost-effective. Open cervical lymph node biopsy will enable the establishment of an accurate histopathological diagnosis when other means are inconclusive. 8 – 10
17.2 Preoperative and Anesthesia Considerations
A thorough stepwise approach that includes in-depth history acquisition, physical examination, laboratory examinations, and preoperative imaging studies is mandatory for planning treatment, for contributing to the establishment of a likely etiology, and in order to avoid carrying out unnecessary tests. However, an excisional biopsy is unavoidable when the diagnosis is uncertain or there is need for further characterization, especially when there is suspicion of a potential malignancy.
The medical history should focus upon the duration of symptoms, the presence and nature of any systemic signs (e.g., fever, malaise, weight loss, night sweats), recent infections, local or adjacent pain, local trauma, exposure to animals, immunosuppression, and sexual behavior (adolescents). Previous antibiotic treatment should be reviewed for reason and type. 11 , 12
17.2.2 Physical Examination
The physical examination should be thorough and focus upon the enlarged lymph nodes. Benign nodes are differentiated from malignant nodes by their being soft, mobile, tender, and smaller than 1 cm. Malignant nodes tend to be non-tender, firm, and fixed. Other features of note are signs of inflammation, skin involvement, and trauma. The location of the lymph nodes is also significant. Localized lymphadenopathy usually results from a localized abnormality that had originated in its drainage pathway, and might be inflamed, infected, or misleading congenital neck mass. The most worrisome regional lymph adenopathy in terms of malignancy is in the supraclavicular area. Generalized lymphadenopathy is more suggestive of a systemic disease (viral infections, malignancies, tuberculosis, autoimmune diseases, and drug exposure). 7 , 13
17.2.3 Laboratory Studies
A complete blood count with differential, blood chemistry (including serum lactate dehydrogenase levels), and selected serologic tests (e.g., Epstein-Barr virus, cytomegalovirus, Bartonella bacteria) further contribute to establishing the diagnosis. 14 , 15
17.2.4 Imaging Studies
Chest radiography may be helpful in identifying sources of infection, in defining hilar and mediastinal adenopathy, and, in some cases, in providing preoperative assessment relevant to the anesthesiologist. Ultrasonography (US) is a widely available, noninvasive, quickly performed radiographic test with no exposure to radiation. It is very useful in defining the nature and architecture of a lymph node for establishing its etiology. US is also useful in the operating room for identifying and marking the exact location of the lymph node for the purpose of determining the site for the incision. Computed tomography (CT) is helpful in defining deep lymph nodes, as well as in characterizing their nature and likelihood of malignancy. Due to the high level of radiation exposure, CT is usually not performed routinely for pediatric patients but rather reserved for specific cases. 18F-fluorodeoxyglucose positron emission tomography ( 18 FFDG-PET) or integrated PET-CTs are applied for staging Hodgkin’s and non-Hodgkin’s lymphomas. The high rate of false-positive results for inflammatory processes as well as the high level of radiation exposure precludes its use before a histopathological diagnosis has been made. 16 – 19