EpistemisIsolated epitrochlear or supraclavicular lymphadenopathy
Specialty: Hematology.
Why it occurs
- Diffuse large B-cell or follicular non-Hodgkin lymphoma (clonal lymphoid neoplasms with a predilection for asymmetric lymph node involvement and unusual location such as the epitrochlear area of the antecubital fossa or the supraclavicular fossa)
- Hodgkin's lymphoma (nodular sclerosis variant, which frequently presents with left supraclavicular lymph node involvement, draining lymph from the thoracic duct, or right, draining the mediastinum)
- Chronic lymphocytic leukemia (asymmetric localized lymph node manifestation prior to the massive generalized lymphocytosis phase)
- Isolated extrapulmonary lymph node sarcoidosis (systemic granulomatous reaction)
- Specific local granulomatous infections such as cat scratch disease (Bartonella henselae) or tularemia (with a predilection for the epitrochlear ganglion after distal inoculation in the upper extremity).
Initial workup
Complete surgical excisional biopsy of the suspected lymph node (the diagnostic gold standard; fine needle puncture should be avoided given the impossibility of evaluating the complete nodal architecture and performing immunohistochemical subclassification of lymphomas); high-resolution computed tomography (CT) of the neck, chest, abdomen, and pelvis with contrast for generalized lymph node mapping; whole body positron emission tomography (PET-CT) for tumor metabolic staging; complete blood count with manual smear (search for atypical lymphocytes, Gumprecht shadows or blasts); erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and serum lactate dehydrogenase (LDH) levels.
red flags
Lymph node of stony or indurated consistency, fixed to the deep planes of the skin or underlying muscular fascia, painless on palpation and with a diameter greater than 2 centimeters of progressive evolution; coexistence of constitutional symptoms or "B symptoms" (fever, nocturnal diaphoresis and involuntary weight loss); presence of dyspnea due to airway compression or dysphagia due to esophageal compression if accompanied by mediastinal or retrosternal extension; Unilateral edema of the ipsilateral upper limb (lymphatic or deep venous obstruction syndrome due to the axillary/supraclavicular lymph node mass).
Standard management
- R-CHOP scheme — immunochemotherapy of choice that combines Rituximab, Cyclophosphamide, Doxorubicin, Vincristine and Prednisone; Standard curative regimen for diffuse large B-cell non-Hodgkin lymphoma
- ABVD Scheme — combined chemotherapy indicated in classical Hodgkin's Lymphoma
- Prednisone (immunosuppressive systemic corticosteroid useful to mitigate inflammatory lymph node growth in sarcoidosis or non-neoplastic reactive lymphadenopathy, and should be avoided empirically before biopsy so as not to delay or mask the diagnosis of an active lymphoma).
Educational guidance for study. It is NOT a prescription recommendation. The actual choice depends on the cause, the patient, and current guidelines.
- Area
- Hematology
- Listed causes
- 5
- Treatment options
- 3