Patients are normally referred from secondary referral hospitals after a diagnosis of cancer has been made. Royal Marsden Hospital (RMH) is a tertiary referral comprehensive cancer centre. In some cases, this could lead to delays in diagnosis, resulting in increased anxiety among patients and further postponement in commencing definitive treatment. Some patients may be referred to general surgeons for biopsy, some to haematologists for evaluation and others to various specialties depending on sites of LA and associated clinical features. In addition, immune-induced injury disorders such as systemic lupus erythematosus, sarcoidosis and rheumatoid arthritis will also require specialist care.Įven after the general practitioner (GP) has decided to refer a patient with lymphadenopathy for definitive diagnostic assessment, the referral pattern to specialists varies at the present time. This would include infections such as tuberculosis (TB) and human immunodeficiency virus (HIV), both of which pose an important public health problem. The current guideline recommends all patients with lymphadenopathy of more than 1 cm in size persisting for 6 weeks to be referred urgently for further evaluation ( Department of Health, 2000a).Īpart from cancer, there are also other medical conditions presenting with LA that will require urgent medical attention. To address this problem, the British government proposed, in September 2000, the National Health Service (NHS) Cancer Plan to provide a comprehensive strategy for bringing together prevention, screening, diagnosis, treatment and care for cancer to improve survival ( Department of Health, 2000b). Despite the incidences of many cancers being broadly similar in England compared with other European countries and the USA, the corresponding survival rates are poorer ( Table 1) ( Office for National Statistics, 1999 Ries et al, 2001). Prompt referral for definitive investigations and treatment cannot be overstated, as cancer is perhaps the disease people fear most. The possibility of malignancy raises the most concern among patients and health care professionals. When physicians are faced with these patients, the critical tasks are to differentiate benign from malignant lymph nodes, to identify serious medical conditions that require specialist care, and to reassure patients with benign reactive lymphadenopathy or self-limiting diseases. Patients with lymphadenopathy present to a wide range of medical specialties. An annual incidence of 0.6–0.7% has been estimated for the general population ( Allhiser et al, 1981 Fijten and Blijham, 1988). Lymphadenopathy (LA) is common and affects patients of all ages. In conclusion, a multidisciplinary lymph node diagnostic clinic enables a rapid, concerted approach to a common medical problem and patients with malignant diseases were diagnosed in a timely fashion. An accuracy of 97 and 84% was found, respectively. Ultrasound and fine-needle aspiration cytology of palpable lymph nodes were performed in 154 and 289 patients, respectively. Multivariate logistic regression analysis identified five significant predictors for malignant nodes: male gender (risk ratio (RR)=2.72 95% confidence interval (CI): 1.63–4.56), increasing age (RR=1.05 95% CI: 1.04–1.07), white ethnicity (RR=3.01 95% CI: 1.19–7.6) and sites of lymph nodes: supraclavicular region (RR=3.72 95% CI: 1.52–9.12) and ⩾2 regions of lymph nodes (RR=6.41 95% CI: 2.82–14.58). Of 95 patients diagnosed to have malignant diseases, the median time from the first clinic visit to reaching malignant diagnosis was 15 days. The median time between initial referral and the first clinic visit was 6 days. The median age was 40 years (range 14–90). Between December 1996 and July 2001, 550 patients were referred (M: 203 F:347). Details of clinical presentation and investigations were recorded prospectively. Our institution set up a lymph node diagnostic clinic (LNDC) accepting direct referrals from primary care physicians. The current referral pattern for investigating patients with lymphadenopathy varies widely with no universally practised pathway. Lymphadenopathy is common, affecting patients of all ages.
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