A 47-year-old woman who recently completed adjuvant chemotherapy for colon cancer has painless cervical lymphadenopathy of 1 to 2 cm. She has no fever, sore throat, cough, or unexplained weight loss, and she denies exposure to ill persons or animals.
Adenocarcinoma of the sigmoid colon was detected during a workup for anemia. A preoperative carcinoembryonic antigen (CEA) level was normal. The patient underwent surgery with curative intent; she received no blood transfusions during the procedure. The operation was followed by 12 weekly treatments with 5-fluorouracil and leucovorin (administered according to the Roswell Park regimen) to reduce her risk of disease recurrence. She has no other significant medical history.
Other than the cervical lymphadenopathy, physical findings are unremarkable. No supraclavicular, axillary, or inguinal lymphadenopathy is detected. There is no hepatosplenomegaly. The patient's surgical wound is completely healed and nontender.
LABORATORY AND IMAGING RESULTS
Her total white blood cell count is 4200/µL, with 51.9% neutrophils and 34.4% lymphocytes. She has mild anemia but without evidence of iron deficiency; no thrombocytopenia is detected. Her CEA level remains normal. Results of a chemistry panel and biochemical profile are also normal.
CT scans, with and without contrast, reveal diffuse adenopathy throughout. No liver or lung lesions are identified. A screening mammogram reveals bilateral axillary lymphadenopathy.
What is the most appropriate next step in the evaluation of this patient?
A. Inform her that metastatic colon cancer has probably developed,
and initiate a more aggressive chemotherapy regimen that includes
B. Order a biopsy of a cervical lymph node to evaluate the adenopathy.
C. Order a bone marrow biopsy to evaluate her anemia.
D. Order serological tests for inflammatory and infectious conditions
such as HIV infection.
(Answer on next page.)
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