Suspicious Lymphadenopathy — ORE Part 1 MCQ

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ModerateOral MedicineSuspicious LymphadenopathyORE Part 1

A 55-year-old patient presents with an enlarged submandibular lymph node that is firm, fixed to underlying structures, and has been enlarging over 3 months. There is no apparent dental cause for the lymphadenopathy. What is the most important differential diagnosis to exclude?

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Reveal the answer and explanation

Correct answer: E — Lymph node metastasis or lymphoma

Explanation lettering: B = shown as A · C = shown as B · D = shown as C · E = shown as D · A = shown as E

The clinical presentation is highly suspicious for malignant lymph node disease (metastatic carcinoma or lymphoma). The key discriminating features are: (1) fixed position—indicates invasion into underlying structures, not typical of benign reactive nodes which are mobile; (2) firm consistency—malignant nodes are characteristically firm or hard, whereas reactive nodes are soft; (3) 3-month progressive duration—reactive lymphadenitis resolves within 2–4 weeks; persistent enlargement is a red flag; (4) age 55 and submandibular location—common sites and age for oral cancer metastasis; (5) no dental cause—excludes reactive lymphadenitis from dental infection. NICE NG12 and NHS Scotland guidelines classify unexplained neck lumps with change over 3–6 weeks as red-flag symptoms requiring urgent suspected cancer referral. Distractors B–E are implausible: reactive lymphadenitis would be mobile, soft, tender and transient; sialadenitis and salivary stones cause gland-centred symptoms with salivary obstruction; lipoma is a soft tissue tumour, not a lymph node. Malignancy must be excluded.

Reference: NICE NG12 (2015, updated May 2025): Suspected cancer: recognition and referral, recommendations for non-Hodgkin lymphoma and head and neck cancer. https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer