Finding Suspicious Lymph Nodes – How Scary It Must Be

 

Perhaps more worrisome for a physician to experience personally, but it must be such a scary feeling to find a lymph node on your body that doesn’t belong. I’m certain many doctors in the years since Hippocrates have found ominous lumps on their body. As a patient you feel helpless and find yourself at the mercy of the clinician, hoping that they won’t merely dismiss something that may be serious. As a clinician on the receiving end you perhaps wish you had the oblivion of a patient.

A lymph node has such scary connotations yet we see so many patients with suddenly notable lymph nodes that we know are benign. We assure them, we explain it to them and we watch their fears melt away. What an awesome power to possess. 

What do we do as clinicians with the same fears? We perhaps consult a colleague who may downplay what we have, yet order all the proper tests and put in the right referrals just in case. It’s an impressive state of mind, one that’s hard to explain to anyone else… at least to someone who hasn’t experienced it.

virchoe's node, left subclavian lymph node

You wake up thinking about it, you can’t help but touch it over and over. You look up all the different diagnoses and you play out all the different scenarios. No, you’re not gonna be that hapless soul clinging to the promises of oncotherapy. You will go out with dignity, you will face it as bravely as you’ve instructed your patients to do.

More importantly, you are suddenly awoken from this life you’ve been living. You thought you were alive all this time, living, reacting, breathing, excitement, sadness, anxiety and frustration. But now you are feeling alive for the first time in a long time. Time to make all those promises that you will uphold ‘if this is benign’. 

Update – 7/31/2015 10:25am

Deciding on the next step wasn’t easy. I asked a colleague who really didn’t have any input. I consulted my best friend who recommended I just make an appointment. I made an appointment and saw a PA who said the node felt around 1cm and he would recommend a course of doxycycline for 7 days. He did recommend an US which I had already ordered for myself.

It took several phone calls to finally connect with the radiology department but I was able to schedule the US which was to take place the following day. I met the nicest US tech who showed me what a normal lymph node looked like and what this one looked like.

1cm left subclavian neck mass.
1cm left subclavian neck mass.

So here it is, now I wait.

Update – 8/3/2015 12:10pm

Few more days have gone by and I finally got the US report. Since then I probably have found a few lymph nodes on my body that are unwanted. The mind tends to get very creative though so I’m not putting too much faith in my assessment. After all, I thought the first node was over 2.5cm and ended up being only 1.1cm. So, here is the report:

FINDINGS:  
There is an 11 x 9 x 11 mm heterogeneous rounded hypoechoic mass within the inferior lateral left neck inferiorly at level 5B corresponding to the purported palpable concern. This demonstrates a 6 x 8 x 7 mm central area of greater decreased echogenicity suggesting some central necrosis. There
is mild circumferential peripheral flow.
No additional masses/nodules are seen.
IMPRESSION:  
11 mm hypoechoic nodule corresponding to the purported palpable concern in the inferior lateral neck with evidence suggesting some central necrosis. Findings are nonspecific but could reflect a pathologic lymph node. Other masses are not excluded.
So if this was a patient of mine I would weigh their risks and decide what to do next based on that information. Still, even with the US report there isn’t much I could tell this patient. In my case I contacted the NP that saw me and he said he would refer me to ENT which he did. He said it might be 2 weeks until I see them. As a doc I realize 2 weeks really wouldn’t make much of a difference. As a patient I’m freaking out. Just last night I was feeling around the area and felt 2 more small nodes adjacent to the main node.

Update – 8/13/2015 12:10pm

I stopped thinking about it for a while.. a good 5 days almost. Then I felt another node pop up next to the first one and all the negative thoughts came back in. Surprisingly, I didn’t do a lot of research online, I only concluded that most likely this would be a lymphoma. So today at work, just now actually, I decided to corner one of our ENT docs. Coincidentally it’s the same doc that I had an appointment with on 8/20/2015. She seemed confident and very, very sincere.

My personal opinion about curbsiding a colleague is to lay everything out off the bat:

  • “I’m sorry to take your time, I need a very unofficial clinical opinion about my…”
  • “I realize this is not an official clinic visit and I just need to ask a few questions to guide me in the right direction.”
  • “I won’t take more than 5 minutes of your time.”

I purchased a gift card for her ahead of the visit because no matter what I think it’s very thoughtful for one doc to allow another doc to come to them for something personal.

So… the juicy details: She said I didn’t have anything to worry about, the nodes didn’t feel suspicious. She said she wouldn’t image them, wouldn’t get any blood work and certainly wouldn’t take any abx. She said likely reactive nodes. Naturally she said I should keep an eye on it and if it changes in any way to let her know.

In my panic/anxiety/excitement of being in the room I totally forgot to tell her that I already had an US done but I’m not worried about the US. I feel very confident with her assessment.

Finally

I think I can put this episode to rest. However, I don’t want to forget about it. There have been some intense moments and it helped me realize how patients must feel. I’ve thought about some other things as well… I’ll write about them for sure in the future.

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