Clinical Scenario:
A 10-year-old boy presents with bilateral cervical lymphadenopathy of 6 weeks’ duration. He was evaluated at a rural health centre and started empirically on anti-tuberculous therapy 2 weeks ago. There is no history of fever, night sweats or significant weight loss.
On examination, multiple cervical lymph nodes measuring 2–3 cm are palpable bilaterally. They are firm, non-tender and non-matted. A few axillary lymph nodes are also palpable. The liver is palpable 2 cm below the right costal margin, while the spleen is not palpable. The remainder of the examination is unremarkable.
His full blood count and platelet count are normal.
Which of the following is the most appropriate next step in establishing the diagnosis?
A. Continue anti-tuberculous therapy and reassess after 6 weeks
B. Excisional biopsy of a cervical lymph node
C. Fine-needle aspiration cytology of the largest lymph node
D. Bone marrow aspiration and trephine biopsy
E. Epstein–Barr virus serology
correct answer explanation:
Correct answer: B. Excisional biopsy of a cervical lymph node
Explanation
The child has persistent significant cervical lymphadenopathy with additional axillary lymphadenopathy and hepatomegaly. Although tuberculosis is an important differential diagnosis, the clinical picture should not automatically be attributed to TB, particularly when the nodes are firm, non-tender and persistent, and there is involvement of more than one lymph-node region.
Lymphoma must be actively excluded.
When lymphoma is suspected and an accessible lymph node is available, excisional lymph-node biopsy is the preferred diagnostic procedure. Histological assessment of the entire lymph-node architecture is important for establishing the diagnosis and classifying lymphoma, with immunohistochemistry and/or flow cytometry performed as required.
Why the other options are incorrect
A. Continue anti-tuberculous therapy — Incorrect
Empirical treatment should not delay tissue diagnosis when there are clinical features raising concern for malignancy. Lack of response after only 2 weeks would not itself prove treatment failure, but the initial diagnosis should be reassessed.
C. Fine-needle aspiration cytology — Incorrect
FNAC may demonstrate malignant cells or granulomatous inflammation, but it may not preserve the nodal architecture required for definitive lymphoma classification. An excisional biopsy is preferred when lymphoma is suspected.
D. Bone marrow aspiration and trephine biopsy — Incorrect
Bone marrow examination may be required for staging or when there are specific indications, but it is not the preferred initial diagnostic procedure when an accessible enlarged lymph node is available.
E. Epstein–Barr virus serology — Incorrect
EBV can cause cervical lymphadenopathy, but serology would not adequately exclude lymphoma in this clinical setting.
Reference
- Lanzkowsky P, Lipton JM, Fish JD. Lanzkowsky’s Manual of Pediatric Hematology and Oncology. 7th ed. London: Academic Press; 2022.
- Kliegman RM, St Geme JW, Blum NJ, Shah SS, Tasker RC, Wilson KM, editors. Nelson Textbook of Pediatrics. 22nd ed. Philadelphia: Elsevier; 2023.
