Persistent back pain due to malignant lymphadenopathy

SUMMARY Back pain is a common problem in rheumatology clinics and has a wide differential diagnosis. Ten young patients are described with the syndrome of persistent back pain, severe enough to prevent sleep, and characteristically eased by sitting forwards, which accompanies malignant retroperitoneal lymphadenopathy. Spinal movements and x rays are typically normal. Repeated thorough examinations are required to detect superficial adenopathy or testicular swellings. Ultrasound scanning usually reveals the nodes, which can also be demonstrated by computed tomographic (CT) scanning. These young patients have a variety of cancers, many of which can be cured, so increased awareness of this syndrome could save lives. Backache is a common problem: the general prac-titioner with an average list of 2500 patients can expect to see 50 cases each year, ' and many of these will later be seen in a rheumatology or orthopaedic clinic. Although most patients can be assessed in the clinic and will respond within two months to simple conservative treatment,2 severe, persistent back pain demands further investigation. Malignant causes are rare, but their early diagnosis is essential, particularly in young people who may have poten-tially curable cancers. We describe 10 such cases (eight seen in one year), in whom the characteristic syndrome of pain due to malignant retroperitoneal lymphadenopathy was initially overlooked. Case reports Table 1 gives details of all 10 cases. Three are further described below. CASE 1 A 44 year old woman (patient No 1) who worked as a hospital cleaner, when referred to the medical oncology department described a 10 month history of severe, intermittent back pain, gradually worsen-ing. It frequently awoke her from sleep and was only partially relieved by aspirin or ibuprofen. It wa