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Most important things to know about enlarged Lymph glands (nodes) in adults.

Is it cancer?

Terms Lymph Gland and Lymph Node are used interchangeably here and refer to the same thing.

Enlargement of lymph glands is a common medical problem. Patients themselves can easily notice enlarged lymph glands. Enlargement of lymph glands may or may not indicate a serious illness. This pamphlet is intended to increase your knowledge about enlarged lymph nodes in adults and it dose not replace seeing a doctor or obtaining medical opinion from a qualified physician. You must see a doctor if you have any concerns about your health. This pamphlet does not address any issues in pediatric age group.

Our Website, www.tirgan.com. is a great resource to you for understanding of the technical terms that you may encounter here. Remember that you should discuss your medical problems with a physician and this pamphlet is not meant to substitute obtaining professional medical help from your doctor.

M. Hossein Tirgan, MD

Introduction:

Human body has numerous lymph nodes. Some are located under the skin and if enlarged, they can be easily noticed or palpated. Term Palpation means touching and feeling something with our fingers. We notice most of the enlarged nodes by palpation. Other lymph nodes are located inside chest, abdomen and pelvis and are very hard to palpate unless they are extremely large.

Most commonly, an enlarged lymph gland is noticed under the skin. The areas that contain lymph glands and are easily palpable are neck, the area behind the clavicles (collar bone), areas under the arms and groins. Enlarged lymph nodes can also be palpated in the area near the elbow as well.

Sometimes a lump may be palpated under the skin in other areas. Not every palpable lump is a lymph node. The location of lumps, their physical character and consistency and how hey feel under hands help in differentiating them from lymph nodes.

What are the other kinds of lumps that can be palpated under the skin?

There are a few other conditions that present themselves with lumps under the skin such as Lipomas and benign Cysts and nodules. Not every lump is a lymph node. Palpable lymph nodes are limited to the neck, under the arms, groins and rarely in the elbow region.

Lipomas are by far the most common form of lumps under the skin and are due to fatty tissue overgrowth. They are completely benign and cause no harm. They can be palpable everywhere in the body, mostly in the back, chest, abdominal area and arms and legs. They feel very soft, are mobile and may be even flat. Some people have more than one Lipoma and some may even have many Lipomas in various places. Lipomas grow extremely slowly and remain the same size as they have been in the past. They are painless and non-tender.

Cysts are small collection of fluids and may be seen in limited areas in the body. They can be of various sizes and most commonly are soft and can be compressed by the palpating fingers. Some cysts are located under the skin and some are within the thickness of skin itself. If the fluid in the cyst is under pressure, the cyst may feel tense and hard. Cysts are rather uncommon. They can be seen in the breasts or sometimes associated with a joint, referred to as synovial cyst and sometimes in the neck. Cysts can be emptied by inserting a needle inside them. Fluid and material that is removed should be sent for pathological evaluation. Some cysts completely disappear after this procedure.

Cancer Nodules are seen in patients who have advanced stages of cancer. Cancers can also spread to the skin or under the skin and look like a lump. Such lumps grow rather constantly and the overlying skin may be red. Such lumps are hard and may even involve the skin and be immobile. Depending on circumstances, such nodules may need to be biopsied or removed.

How can we determine if a lymph node is cancerous or not?

If the lump is determined to be a lymph node, the next step would be to find and establish the cause for its enlargement. Not every palpable lymph node is cancerous. The following is a clinical guideline that we use in evaluating enlarged lymph nodes. If the node is felt to be suspicious for a cancerous or other important illnesses, it must be further evaluated by performing blood tests, a needle biopsy or surgical removal.

Location of the enlarged node and preliminary assessment of its nature.

1- In women, any enlarged node under the arms is highly suspicious for presence of breast cancer and requires complete evaluation to rule out a cancerous process in breasts. Breast cancer at times can be very small so that it may not be palpable in the breasts, yet it may have already spread to the area under the arms. Any such node or lump should be biopsied or removed to establish an accurate diagnosis.

2- Any enlarged node in lower part of the neck and behind clavicles, both in men and women should be suspicious and requires complete evaluation to rule out a cancerous process. This area is referred to as Supraclavicular area. In otherwise healthy individuals, any enlarged lymph node or lump in this area should be biopsied or removed to establish an accurate diagnosis.

3- Small size nodes in groins are quite commonly seen in adults and most commonly they do not represent a cancerous process. (Small size refers to nodes smaller than 0.5 Cm or 1/4 of an inch in diameter) If such nodes are detected, the best approach is to follow them clinically, that is to examine them on a regular basis for their size and number. If the size or the number is increasing in a short period of time, they should then be evaluated more thoroughly. Large size Lymph nodes in groin area, larger than 1 cm or half an inch or larger need further evaluation, especially if they are new and have grown to the size gradually.

4- Small size nodes under the arms in men may be seen in adults and most commonly they do not represent a cancerous process. (Small size refers to nodes smaller than 0.5 Cm or 1/4 of an inch in diameter) If such nodes are detected, the best approach is to follow them clinically, that is to examine them on a regular basis for their size and number. If the size or the number is increasing in a short period of time, they should then be evaluated more thoroughly. Large size Lymph nodes in this area, larger than 1 cm or half an inch or larger need more evaluation, especially if they are new and have grown to the size gradually.

How quickly a Lymph node appears and enlarges is another important factor. Normally, benign lymph nodes grow and become enlarged in a short period of time, over a few days time frame. They normally do not get too big, unless there is a serious localized infection associated with the enlarged node. For example, such a problem can be seen when there is an ulcer in the foot and a few days later a node pops up in the groin in the same side.

In patients with dental abscess or oral infection, a node under the jaw can pop up and grow big in a few days. Such nodes are normally reacting to the infection in their nearby region and may disappear with treatment of the underlying infection. Such nodes can be painful and tender to touch.

Infections are common causes of lymph node enlargement. Even in the process of a viral illness, lymph nodes can be involved and become enlarged.

Cancerous lymph nodes grow slowly and continue to grow. This normally takes place over weeks to months. There is no limit as to how big they can get and this may be the only sign of a cancer. They normally are not painful and they may be mobile and can be pushed to move under the skin.

Is it one node or a cluster of nodes? Cluster of big nodes that have developed over a few weeks to months usually indicates a serious medical problem or a cancerous process. Infections can cause enlargement of more than one node, yet they happen quickly over a few days and they are tender to touch and do not last for more than a few weeks.

Is the enlarged node very hard and immobile? Most enlarged nodes are soft and mobile and not adherent to the surrounding tissue and feel rubbery. If the lymph node is very hard in its consistency and feels like a rock, it most likely is cancerous. Such hard nodes are usually stuck to the tissues surrounding them and are not mobile at all. Such a finding is mostly seen in cancerous nodes.

Is the enlargement of nodes generalized or limited to one region? Enlargement of nodes can be generalized with nodes being palpable in neck, under the arms and groins. This kind of presentation usually indicates a systemic illness (HIV infection, Rheumatoid Disease, Tuberculosis, etc) or a cancerous illness like lymphomas, leukemias, etc.

Is there an underlying disease present? In patients who have a known underlying disease, one has to consider that disease as a possible cause of enlarged lymph nodes.

1- Patients with known cancers.

In such a situation, when a patient is known to have a cancer and develops an enlarged lymph node, the node is most likely to be involved with the same cancer. In some cases, cancer may have already been treated in the past and an enlarged node may indicate a recurrence of the same disease.

2- Patients with known systemic illnesses.

Patient with diseases such as Rheumatoid Arthritis, Lupus, Sarcoidosis, etc., may develop an enlarged lymph node. Usually the disease has been present for some times and is already diagnosed before a lymph node enlargement is noticed.

3- Patients with known infections.

If there is a history of an infectious disease like Tuberculosis, Syphilis, HIV infection, Infectious Mono, etc., the enlarged node may be secondary to that infection.

Is there a new disease developing? This is the most important category of illnesses that one may face in evaluation of a patient with enlarged lymph nodes.

1- Infections. Sometimes an enlarged node may be the first sign of an infection. Some of the simple viral illnesses that involve throat can cause enlargement of nodes in the neck area. In such situations, patients have sign of another illness, like fever, chills, running nose, sore throat, etc.. HIV infection is a common cause of generalized enlargement of lymph nodes and may be associated with weight loss, fever and other systemic symptoms.

2- Cancers. In case of a cancer, the lymph node enlargement can be in any part of the body or it can be generalized. The enlarged node will continue to grow and become larger over time, usually over weeks and even months. Malignant nodes are usually not painful. They may be mobile under the skin or they can be adhering to the tissues and feel very hard like rock.

3- Other systemic illnesses such as immune system illness like Lupus, Rheumatoid Disease or Sarcoidosis and even reactions to certain drugs can cause enlargement of lymph nodes. Such a condition is normally associated with generalized enlargement of lymph nodes.

Are there any systemic symptoms associated with the enlarged lymph nodes? Certain symptoms may indicate an underlying disease that may indeed be the cause for the enlargement of the nodes. Symptoms may be:

Fever: is rather non-specific and may be seen in almost all illnesses that cause enlargement of lymph nodes. Fever usually lasts for weeks to months and may not respond to antibiotics or Aspirin or Tylenol.

Weight loss indicates a chronic and rather serious underlying illness such as cancer, HIV infection or advanced stages of Lupus or other non-cancerous conditions.

Nightly sweating if associated with enlarged lymph nodes may indicate a cancerous condition.

Itching if associated with enlarged lymph nodes may indicate a cancerous condition.

How do we evaluate enlarged lymph nodes? Once an enlarged lymph node is found, one has to take a systematic approach to its valuation. Such an approach should look into the characteristics that are mentioned above. The physician should obtain a detailed medical history from the patient and then examine the patient. Women shall have a breast examination as part of this work up. Examination should look into other areas like neck, under the arms and groins for possible enlarged nodes. The abdomen and chest need to be examined carefully and if indicated with CT scans, or MRIs.

If the size of the enlarge node is of concern and if there are no clues as to the nature of the node, and if the history and examination are both negative, the next step should be performing a needle aspiration biopsy of the node. This is a very simple procedure, which is done in the doctor’s office. A small needle is inserted into the node and minimal amount of sample tissue is obtained. This material is then sent to the laboratory and a pathologist for evaluation. If the result is not satisfactory and clinical circumstance is a suspicious one, the next step should be to remove the node for pathological study. This is called a surgical node biopsy, performed by a surgeon in a hospital or in an out patient surgical center.

If clinically indicated, further studies like blood tests, X rays and CT Scans, MRIs, etc. may be indicated.