Evaluation of Unexplained Peripheral Lymphadenopathy and Suspected Malignancy Using a Distinct Quick Diagnostic Delivery Model

Abstract

Although rapid diagnostic testing is essential in suspicious peripheral lymphadenopathy, delays in accessing them can be considerable. We investigated the usefulness of an internist-led outpatient quick diagnosis unit (QDU) in assessing patients with unexplained peripheral lymphadenopathy, focusing on the characteristics, diagnostic, and treatment waiting times of those with malignancy. Patients aged ≥18 years, consecutively referred from 12 primary health care centers (PHCs) or the emergency department (ED) for unexplained peripheral lymphadenopathy, were prospectively evaluated during 7 years. Diagnostic investigations were done using a predefined study protocol. Three experienced cytopathologists performed a fine-needle aspiration cytology (FNAC) systematic approach of clinically suspicious lymphadenopathy with cytomorphology and immunophenotyping analyses. We evaluated 372 patients with a mean age (SD) of 45.3 (13.8) years; 56% were women. Malignancy was diagnosed in 120 (32%) patients, including 81 lymphomas and 39 metastatic tumors. Metastatic lymphadenopathy was diagnosed by FNAC in all 39 patients and the primary tumor site was identified in 82% of them when cytomorphology and immunocytochemistry were combined. A correct diagnosis of lymphoma was reached by FNAC in 73% of patients. When accepting “suspicious of” as correct diagnosis, the FNAC diagnosis rate of lymphoma increased to 94%. Among patients with malignancy, FNAC yielded 1.3% of false negatives and no false positives. All patients with an FNAC report of correct or suspicious lymphoma underwent a surgical biopsy, as it is a mandatory requirement of the hematology department. Mean times from first QDU visit to FNAC diagnosis of malignancy were 5.4 days in metastatic lymphadenopathy and 7.5 days in lymphoma. Mean times from receiving the initial referral report to first treatment were 29.2 days in metastatic lymphadenopathy and 40 days in lymphoma. In conclusion, a distinct internal medicine QDU allows an expeditious, agile, and prearranged system to diagnose malignant peripheral lymphadenopathy. Because of the close collaboration with the cytopathology unit and the FNAC methodical approach, diagnostic and treatment waiting times of patients with malignancy fulfilled national and international time frame standards. This particular diagnostic delivery unit could help overcome the difficulties facing PHC, ED, and other physicians when trying to provide rapid access to investigations to patients with troublesome lymphadenopathy.

Perception of quality of care of patients with potentially severe diseases evaluated at a distinct quick diagnostic delivery model: a cross-sectional study

“…Although we identified one aspect of the QDU care process that was worse than expected, patient opinion of it remained high. In particular, compared with other Spanish studies on QDUs [ 2 , 15 , 21 , 22 ], the mean time to diagnosis was too long, reflecting delays in diagnostic tests as a consequence of variations in the organization of healthcare services in the hospital related to the Spanish financial crisis. Yet nearly 70 % of patients scored time to diagnosis as short or very short, and, on regression analysis, an age older than 65 years was close to statistical significance ( B coefficient = 0.16; P = 0.07) (Table 5 ).…”

“…In the clinical management of patients attended in QDUs, where the likelihood of having a severe disease, particularly cancer, is often high and causes worry and anxiety to both patients and relatives (malignancy is the most common diagnosis in Spanish QDUs [ 14 , 15 , 24 ]), evaluating quality of care through the measurement of patient perception of physician supportiveness, empathy, and information giving is essential. Details as simple as knowing the physician name (97 % of our respondents knew it) are important because, as reported, patient receptiveness and satisfaction is higher when the physician introduces himself or herself at the time of the first encounter [ 31 , 32 , 37 ].…”

“…In Spain, QDUs have become a paradigm of publicly financed hospital-based outpatient units that help overcome diagnostic and referral delays and the overall difficulties faced by physicians at PCCs and EDs in ensuring quick access to investigations. Indeed, the poor coordination between primary and hospital care in Spain is reflected by the fact that, in practice, only hospitalized patients are firstly selected for prompt diagnostic examinations [ 12 , 15 , 16 ].…”

“…These shortcomings have led to the design of alternatives to conventional hospitalization for medical disorders, more recently hospital-based outpatients quick diagnosis units (QDUs). Although still little known today, this type of units, run by internists, nurses, and secretarial staff, have been established in Europe, and they have been principally studied in Spain [ 1 , 2 , 4 , 12 – 15 , 17 , 18 , 20 – 24 ]. The advantages over conventional hospitalization are numerous: in addition to ensuring an early diagnosis, QDUs avoid hospital-related morbidity, decrease ED referrals from PCCs and decongestion overcrowded ED, and help decrease unnecessary health costs of traditional hospitalization without lowering the quality of diagnostic practice and patient care [ 2 , 12 , 14 , 17 , 18 , 21 – 24 ].…”

Peripheral Lymphadenopathy: A Descriptive Study from a Tertiary Care Centre in Lubumbashi (D.R.C)

“…This demonstrates predominance of male patients in our sampling which seems to be confirmed by a numerous literature [9] [12]- [21] and in proportions ranging from 1.2 to 1.7. Nevertheless, some authors seem to report female predominance [22]- [24].…”