Approach to Lymphadenopathy

Question 1

What are the symptoms of lymphadenopthy?

Answer 1

Lump and other associated features = night sweats, weight loss, itch without rash, alcohol induced pain, fatigue

Question 2

What are the differentials of lymphadenopathy?

Answer 2

Reactive, bacterial infection (regional), viral infection (generalised), metastases, lymphoma

Question 3

What are the features of lymphadenopathy associated with infection?

Answer 3

Viral = tender, hard, smooth, no inflammation of skin, not tethered
Bacterial = tender, hard, smooth, inflamed skin, potentially tethered

Question 4

What are the features of lymphadenopathy associated with lymphoma and metastases?

Answer 4

Lymphoma = non-tender, rubbery/soft, smooth, no inflammation of skin, not tethered 
Metastases = non-tender, hard, irregular, no skin inflammation, tethered

Question 5

How are lymphomas investigated?

Answer 5

Can’t use CT

Biopsy done if lymphoma or other malignancy suspected = FNA or core biopsy often insufficient

Question 6

What is the purpose of lymph node biopsies?

Answer 6

Helps confirm cancer and exclude other causes

Question 7

Why is classification of lymphoma useful?

Answer 7

Guides treatment and predicts behaviour of lymphoma

Question 8

What are the different methods of assessing lymph node pathology?

Answer 8

Histology, immunohistochemistry of solid node, immunophenotyping of blood/marrow, genetic and molecular analysis

Question 9

What type of lymph node biopsy is best for diagnosing lymphoma?

Answer 9

Whole node biopsy = easier to histologically review sample than if CT guided biopsy was used

Question 10

What is the purpose of immunohistochemistry?

Answer 10

Confirms lymphoma and helps to subclassify = looks at pattern of proteins on surface of lymphoma cells plus CD numbers

Question 11

How is immunohistochemistry carried out?

Answer 11

Antibodies against proteins on cell surface are used and enzyme reaction occurs = brown colour is positive result

Question 12

What type of tissue is used for immunophenotyping?

Answer 12

Cells in the liquid phase rather than a block section of tissue = blood or bone marrow samples

Question 13

How is immunophenotyping carried out?

Answer 13

Cells are tagged with antibodies attached to a fluorochrome = emits a specific colour of light when a laser is shone on it

Question 14

What is the use of immunophenotyping?

Answer 14

Determines pattern of CD numbers = very useful in leukaemias and lymphomas involving marrow

Question 15

Why can lymphomas be cytogenetically analysed?

Answer 15

Certain lymphomas cause specific patterns of chromosome abnormality = can use FISH or G-banding to analyse

Question 16

What occurs in G-banding?

Answer 16

Aspirate node, grow cells in culture and look at spread of chromosomes

Question 17

How does FISH work?

Answer 17

Looks for specific abnormalities in chromosomes using probes that emit a specific light colour

Question 18

What occurs in molecular analysis?

Answer 18

Looks at patterns of gene expression = multiple analyses look at patterns of genes that are switched on or off

Question 19

What is the purpose of molecular analysis?

Answer 19

Helps to further classify lymphoma and identify subtypes suitable for specific treatment

Question 20

What does analysis of activated B cell type NHL show?

Answer 20

Overexpression of activation markers = responds well to ibrutinib (cell signalling pathway inhibitor)

Question 21

What lymphoma are Reed Sternberg cells associated with?

Answer 21

Hodgkin’s disease = very abnormal cells that have lost the normal proteins associated with B cells (e.g CD20)

Question 22

What are the types of non-Hodgkin’s lymphoma (NHL)?

Answer 22

T cell (10%) and B cell (90%)

Question 23

What are some types of B cell NHL?

Answer 23

Precursor B-ALL, B-ALL, lymphoblastic NHL, Burkitt’s, DLCL, mediastinal DLCL, primary effusion lymphoma, mantle cell lymphoma, follicular lymphoma, B-CLL, B-PLL, small lymphocytic lymphoma, lymphoplasmacytic lymphoma, marginal cell lymphoma, SLVL, MALToma

Question 24

What are some types of T cell NHL?

Answer 24

Precursor T-ALL, lymphoblastic lymphoma, T-PLL, T cell LGL, NK cell leukaemia/lymphoma, ATLL (HTLV-1+), CTCL (Sezary/Mycosis fungoides), hepatosplenic gamma/delta lymphoma, enteropathy type T cell NHL, ALCL, peripheral T cell lymphoma, angioimmunoblastic NHL