Investigation of lymphadenopathy

Question 1

What are some causes of lymphadenopathy?

Answer 1

• Lymphoma Infection - viral, bacterial
• Metastatic cancer
• Connective tissue disease - sarcoidosis, SLE

Question 2

What are some symptoms associated with lymphadenopathy?

Answer 2

• Night sweats - lymphoma, infection, menopause
• Weight loss - lymphoma, other malignancy, infection Itch without rash, alcohol induced pain, fatigue

Question 3

What causes glandular fever and what is another name for it?

Answer 3

• Epstein-Barr virus
• Infectious mononucleosis

Question 4

Describe the expected examination findings for lymphadenopathy due to viral infection

Answer 4

Tender, hard, smooth

Question 5

Describe the expected examination findings for lymphadenopathy due to bacterial infection

Answer 5

Tender, hard, smooth, inflamed skin and possibly tethered skin

Question 6

Describe the expected examination findings for lymphadenopathy due to lymphoma

Answer 6

Non-tender, rubbery/soft, smooth

Question 7

Describe the expected examination findings for lymphadenopathy due to metastatic carcinoma

Answer 7

Non-tender, hard, irregular, tethered skin

Question 8

What is the next step if lymphoma or other malignancy is suspected?

Answer 8

• Ask a surgeon to biopsy
• FNA or core biopsy is often insufficient - need a big sample to assess architecture of lesion

Question 9

How is lymph node pathology assessed?

Answer 9

• Histology-microscopic appearance
• Immunohistochemistry solid node
• Immunophenotyping blood/marrow
• Genetic analysis
• Molecular analysis

Question 10

Some diagnoses can be made just on histology. What does this histology sample show?

Answer 10

Nodular sclerosing Hodgkin’s disease

Question 11

Some diagnoses can be made just on histology. What do these low power and high power histology samples show?

Answer 11

Low grade follicular lymphoma (non-Hodgkin’s)

Question 12

Some diagnoses can be made just on histology. What does this histology sample show?

Answer 12

High grade diffuse large B cell lymphoma (non-Hodgkin’s)

Question 13

Why is immunohistochemistry of a lymph node used and how does it work?

Answer 13

• Confirming a lymphoma and helping to subclassify
• Looks at pattern of proteins on the surface of lymphoma cells
• Use antibodes against these, and enzyme reaction
• Brown = positive
• CD numbers - cluster of designation

Question 14

How does immunophenotyping work?

Answer 14

• Use cells in a liquid phase rather than block section of tissue - blood or bone marrow
• Cells are tagged with antibodies attached to a fluorochrome - emits a specific colour of light when a laser is shone on it
• Determine pattern of CD numbers

Question 15

When is immunophenotyping useful?

Answer 15

Very useful in leukaemias and in lymphomas involving marrow e.g. Burkitt’s lymhpoma

Question 16

How does cytogenic analysis work and why is it useful?

Answer 16

• Identifies specific patterns of chromosome abnormality in certain lymphomas
• G banding. Aspirate node, grow cells in culture and look at spread of chromosomes
• FISH - look for specific abnormalities in chromosomes using probes that emit a specific light colour

Question 17

How does molecular analysis work and why is it useful?

Answer 17

• Patterns of gene expression
• Multiple analyses looking at patterns of genes that are switched both on and off
• Helping to further classify lymphoma and identify subtypes suitable for specific treatment

Question 18

What does activated diffuse large B cell NHL respond well to?

Answer 18

Ibrutinib - inhibitor of cell signalling pathway