Lymphadenopathy may present as the first symptom of a patient's illness, as incidental findings, or simply as normal findings in people who are well.

Normal palpable lymph nodes are common in healthy young people, especially in the cervical and inguinal regions. They tend to be soft, flat, and usually less than 1 cm in diameter.

When lymph nodes are thought to be abnormal, a definitive diagnosis should be sought.

While most enlarged lymph nodes are inflammatory in origin, malignant disease, such as carcinoma or lymphoma, and specific infections, such as tuberculosis, toxoplasmosis, and HIV infection, are important causes that one has to rule out.

A careful medical history should include age, sex, occupation, exposure to pets, symptoms such as cough, sore throat, fever, weight loss, and night sweats, since these may point to the cause.

Physical examination of the entire haemopoietic system, including examination for the presence of hepatosplenomegaly, enables an assessment of the extent of the disease. Although local or regional lymphadenopathy imply a single anatomical area, generalised lymphadenopathy, as defined by three or more non-contiguous areas, can be due to many causes.

In the context of oncology, generalised lymphadenopathy tends to imply a lymphoproliferative disorder, the commonest being lymphoma. Although lymphadenopathy is localised to a defined region, a careful focus on the upstream lymphatic drainage region is necessary.

Lymphadenopathy high in the neck could be caused by cancers of the upper airway passages or scalp. Enlarged lymph nodes in the lower neck could be caused by cancers of the trunk or limbs. However, when the disease is more extensive, sequential involvement of the chain of lymph nodes makes this distinction less accurate.

Enlarged lymph nodes in the armpit areas are commonly due to cancers of the breast and occasionally of the upper limbs. Groin lymphadenopathy is commonly related to cancers of the lower limbs.

Cancerous involvement of the lymph nodes tends to give rise to lymph nodes that are firm and discrete. They may or may not be fixed or matted.

Enlarged lymph nodes within the trunk are not palpable. Instead, the enlarged glands compress surrounding structures and give rise to symptoms. Lymphadenopathy in the chest can cause shortness of breath from compression of the airway, hoarseness of voice from involvement of the recurrent laryngeal nerve, difficulty in swallowing from compression of the oesophagus, or swelling of the face from compression of the superior vena cava.

Confirmation of cancerous involvement requires the establishment of cancer cells in the lymph node or from the site of origin of the cancer.

In its simplest form, a needle aspiration of an accessible lymph node, done as a bedside, 2-3 minute procedure, may yield individual cells that can be confirmed after examination under the microscope. This form of investigation is ideal for metastatic carcinomas. Certain cancers, such as lymphoma, require more tissue assessment because their diagnosis requires full cytoarchitectural assessment. As such, a surgical biopsy may be necessary. This minor surgical procedure is commonly done under local anaesthesia, with the patient returning home several hours after the operation with some light pain killers.

The site of origin of the cancer cell also requires evaluation. Depending on the suspected tissue of origin, investigations can range from mammography or ultrasonography to computerised scans of the body to more invasive fibreoptic inspection of the airways or gastrointestinal tract.

Dr Koong Heng Nung
Senior Consultant
Surgical Oncology