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Swollen Lymph Nodes: When to Worry About Cancer vs. Benign Causes

Lymphadenopathy is common; malignancy is a minority cause. This guide differentiates concerning from reassuring features.

Common Benign Causes

  • Infections: viral (EBV, CMV, HIV), bacterial (strep, TB, cat‑scratch), fungal.
  • Reactive: post‑vaccination, dental/oral inflammation.
  • Autoimmune: SLE, RA, sarcoid, Kikuchi disease.
  • Medications: phenytoin, allopurinol, ACE inhibitors (serum sickness‑like).
  • Trauma / local irritation.

Features Suggesting Malignancy

Feature Benign / Reactive Suspicious for Malignancy
Consistency Soft, rubbery Hard, firm, matted
Tenderness Often tender Usually non‑tender
Mobility Mobile Fixed to skin/deep structures
Size <1–2 cm (often) >2 cm, increasing
Duration Resolves in 2–4 wks Persists >4–6 wks
Location Local to infection Supraclavicular, multiple regions
Systemic Symptoms Fever, sore throat Weight loss, night sweats, fatigue

Workup Algorithm

  1. History: onset, exposures, travel, medications, constitutional symptoms.
  2. Exam: full nodal basins, spleen, liver, skin.
  3. If localized, <2 cm, <2 wks, clear infectious trigger → observe 2–4 wks.
  4. If persistent, supraclavicular, >2 cm, hard/fixed, or constitutional symptoms → CBC, LFTs, LDH, ESR/CRP, CXR, HIV, TB testing ± ultrasound.
  5. Excisional biopsy (gold standard) for nodes with high‑risk features; FNA if lymphoma suspected (needs architecture).

Treatment of Malignant Adenopathy

Directed at primary malignancy: chemotherapy, immunotherapy, targeted therapy, radiation, or surgery per tumor type/stage.

Bottom Line

Most swollen nodes are reactive. Hard, fixed, non‑tender nodes >2 cm persisting >4 weeks—especially with B symptoms—mandate biopsy. Early diagnosis improves lymphoma/leukemia outcomes.

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