Enlarged Chest and Neck Lymph Nodes in Children: A Medical-Legal Guide for Attorneys

The Scenario (De-identified)

A 10-year-old girl in a city where tuberculosis (TB) is common was seen as an outpatient for a swelling at the base of the left side of her neck, just above the collarbone (the supraclavicular area). The skin over it looked normal. Over two days she had a chest X-ray and blood tests.

Chest X-ray (PA view):

• The mediastinum (the central part of the chest between the lungs, which holds the heart, windpipe and lymph nodes) was markedly widened, with a lumpy (lobulated) outline on both sides.
• The left hilum (the "root" of the lung, where airways, vessels and lymph nodes enter) was enlarged and dense.
• There was streaky (reticular) shadowing around both hila, worse on the left.
• There was no pneumonia-type consolidation, no fluid around the lungs and no collapsed lung.
• The radiologist's impression was enlarged lymph nodes in the mediastinum and hila plus possible lung inflammation. The radiologist recommended a contrast CT scan of the chest and evaluation for TB ("Koch's") or a lymphoproliferative disorder (such as lymphoma).

Blood tests:

At this stage there was no tissue diagnosis. The findings were suspicious but not conclusive.

What the Findings Mean in Plain Terms

A child with bulky lymph nodes in the chest, an enlarged node above the collarbone, and blood tests showing systemic inflammation has a short list of serious possibilities. Physicians must work through these quickly.

1. Hodgkin lymphoma. A cancer of the lymphatic system that often first appears as a painless neck or collarbone lump with chest nodes. It is highly curable when diagnosed and staged correctly. The high white count, high platelets, low lymphocytes and high ESR fit this pattern.
2. Lymphoblastic (non-Hodgkin) lymphoma. A faster-growing lymphoma, and one of the most common causes of a chest mass in children. It is more likely to compress the windpipe or major veins.
3. Tuberculosis of the lymph nodes. In TB-endemic regions this is a genuine competing diagnosis. TB and lymphoma can look almost identical on X-ray and blood tests, and occasionally both are present together.
4. Less common causes. These include germ cell tumours, fungal infections, sarcoidosis and Castleman disease.

Why the collarbone lump matters: In children, an enlarged node in the supraclavicular (above the collarbone) region is one of the strongest warning signs of a blood cancer. It is also an easy place to take a biopsy without operating inside the chest (Viard et al., European Journal of Pediatrics, 2026).

The Expected Standard of Diagnostic Work-up

Pediatric oncology and anesthesia literature describe a broadly consistent approach. Practice varies by setting, but the core elements are:

1. Prompt cross-sectional imaging. A contrast CT of the neck and chest (often abdomen and pelvis too) defines the mass and shows whether the airway or major vessels are compressed. CT can also suggest TB (nodes with a dark, dead centre and an enhancing rim) versus lymphoma (uniformly enhancing nodes), but it cannot replace tissue diagnosis (Tang et al., Clinical Radiology, 2012).
2. Tissue diagnosis by biopsy. The National Comprehensive Cancer Network (NCCN) pediatric Hodgkin lymphoma guideline calls for an excisional or incisional biopsy with immunohistochemistry. It states that fine-needle aspiration (FNA) is not an appropriate diagnostic test for this disease; core needle biopsy may be acceptable only if it is diagnostic (National Comprehensive Cancer Network, Pediatric Hodgkin Lymphoma, 2026).
3. Splitting the biopsy specimen. In a TB-endemic setting, good practice is to send part of the node for pathology (to look for lymphoma) and part for TB testing (acid-fast stain, molecular testing such as GeneXpert, and culture). This allows either diagnosis, or both, to be confirmed from one procedure.
4. Supporting tests. These include LDH, uric acid and electrolytes (to assess tumour burden and the risk of tumour lysis), tumour markers (AFP, β-hCG), TB skin or blood testing, and HIV testing.
5. Staging once lymphoma is confirmed. This means PET-CT, echocardiogram and related tests before chemotherapy (National Comprehensive Cancer Network, Pediatric Hodgkin Lymphoma, 2026).

Key Medicolegal Risk Points

A. Diagnostic delay

• Delayed diagnosis is one of the most common allegations in pediatric oncology litigation. A review of 81 lawsuits alleging delayed diagnosis of childhood cancer included Hodgkin and non-Hodgkin lymphoma cases. The median age was 10 years and the median time to diagnosis was 6 months (Brasme et al., The Lancet Oncology, 2012).
• The same review found that court-appointed expert opinions on whether the delay changed the outcome matched the published medical literature in only about one-third of cases. In 30% of cases experts said the delay had no consequence, and in 38% they said it had negative consequences, in some instances contrary to or unsupported by the evidence (Brasme et al., The Lancet Oncology, 2012). Causation opinions should therefore be tested against the literature.
• The relationship between delay and outcome differs by tumour type. For Hodgkin lymphoma, a single-centre study from Pakistan found that a delay of more than one year before starting treatment was an independent adverse factor for survival (Ghafoor, Leukemia & Lymphoma, 2020).

B. Treating for TB without tissue confirmation

• In high-TB-burden regions, childhood cancers are often misdiagnosed and treated as TB first. In a South African registry, 5% of children with cancer had started anti-TB treatment before the cancer was diagnosed. The median added delay was 25 days, and this group had higher mortality (odds ratio 2.6) (van Heerden et al., Pediatric Infectious Disease Journal, 2021).
• The Pakistani Hodgkin lymphoma series also found that prior anti-TB therapy was associated with worse overall survival in univariate analysis (Ghafoor, Leukemia & Lymphoma, 2020).
• TB and Hodgkin lymphoma can coexist in the same lymph node. A positive TB result does not automatically exclude lymphoma (Obando et al., Pediatric Blood & Cancer, 2020).
• Records to look for: whether a biopsy was obtained before anti-TB drugs were started, and whether the patient was reassessed when the child did not respond.

C. Steroids given before biopsy

• Corticosteroids (for example prednisolone or dexamethasone) can rapidly shrink lymphoma and distort the biopsy tissue so that the diagnosis cannot be made. In one pediatric series, prebiopsy steroids impaired the diagnosis in 22% of mediastinal lymphoma cases (Borenstein et al., Journal of Pediatric Surgery, 2000).
• Pre-biopsy steroids may be justified when the airway is critically compromised. That decision should be documented and made with oncology input.

D. Sedation and anesthesia risk

• A large chest mass can compress the windpipe, heart or major vessels. General anesthesia can cause sudden airway or circulatory collapse, even in a child without symptoms (Hammer, Pediatric Anesthesia, 2004; Sola et al., Pediatric Anesthesia, 2014).
• Retrospective studies report cardiorespiratory complications in about 5–18% of these children under general anesthesia (Sola et al., Pediatric Anesthesia, 2014). One series reported a 15% complication rate, including one tracheostomy and two deaths (Latham and Greenberg, Pediatric Anesthesia, 2010).
• Recognised warning signs include difficulty breathing when lying flat, noisy breathing (stridor), wheeze, swelling of the face or upper body, and compression of the airway or vessels on CT (Tan and Nolan, Pediatric Anesthesia, 2022; Latham and Greenberg, Pediatric Anesthesia, 2010).
• The expected approach is a multidisciplinary decision involving senior anesthesia, surgery, radiology and oncology. Biopsy of an accessible node (such as the neck node here) should be done under local anesthesia or light sedation with the child breathing on their own whenever possible, with rescue equipment such as rigid bronchoscopy immediately available (Tan and Nolan, Pediatric Anesthesia, 2022; Ross et al., Gregory's Pediatric Anesthesia, 2020).
• Records to look for: pre-procedure airway assessment, CT airway measurements, echocardiogram, documented team discussion, and the choice of anesthetic technique.

E. Inadequate biopsy technique

• Relying on FNA alone to diagnose or exclude Hodgkin lymphoma is inconsistent with NCCN guidance (National Comprehensive Cancer Network, Pediatric Hodgkin Lymphoma, 2026). A "reactive" or "inconclusive" FNA result in this setting should prompt a surgical biopsy.

Record-Review Checklist

Attorneys reviewing a similar case may wish to confirm:

• Timeline: dates of first symptom, first medical visit, chest X-ray, CT, biopsy, diagnosis and start of treatment.
• Response to the radiologist's recommendation: whether the recommended CT and evaluation for TB or lymphoma were acted on, and how quickly.
• Biopsy: type (excisional, core or FNA), and whether tissue was sent for both pathology and TB studies.
• Medications before diagnosis: steroids, anti-TB drugs or repeated antibiotic courses.
• Airway safety documentation: symptoms when lying flat, CT airway findings, echocardiogram, anesthesia plan and multidisciplinary notes.
• Referral: when the child was referred to a pediatric oncology centre.
• Communication: what the family was told about the differential diagnosis and the urgency.

Glossary

• Mediastinum: The central chest compartment between the lungs.
• Hilum (hilar): The point where airways, vessels and lymph nodes enter each lung.
• Lymphadenopathy: Enlarged lymph nodes.
• ESR: Erythrocyte sedimentation rate, a non-specific blood marker of inflammation.
• Koch's: A common term in South Asia for tuberculosis.
• Lymphoproliferative disorder: A broad term for abnormal growth of lymphatic cells, including lymphoma.
• Excisional biopsy: Surgical removal of a whole lymph node for analysis.
• FNA (fine-needle aspiration): A thin-needle sample of cells. Useful for some conditions but inadequate for diagnosing Hodgkin lymphoma.
• GeneXpert: A rapid molecular test for TB and rifampicin resistance.

References

• Viard et al., European Journal of Pediatrics, 2026.
• Tang et al., Clinical Radiology, 2012.
• National Comprehensive Cancer Network, Pediatric Hodgkin Lymphoma, 2026.
• Brasme et al., The Lancet Oncology, 2012.
• Ghafoor, Leukemia & Lymphoma, 2020.
• van Heerden et al., Pediatric Infectious Disease Journal, 2021.
• Obando et al., Pediatric Blood & Cancer, 2020.
• Borenstein et al., Journal of Pediatric Surgery, 2000.
• Hammer, Pediatric Anesthesia, 2004.
• Sola et al., Pediatric Anesthesia, 2014.
• Latham and Greenberg, Pediatric Anesthesia, 2010.
• Tan and Nolan, Pediatric Anesthesia, 2022.
• Ross et al., Gregory's Pediatric Anesthesia, 2020.