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Haematology > Lymphadenopathy > Flashcards

Lymphadenopathy Flashcards

1
Q

What is lymphadenomegaly?

A

Lymph node enlargement

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2
Q

What is lymphadenopathy?

A

Any abnormality of lymph nodes

  • size
  • shape
  • structure
  • cellular composition
  • necrosis
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3
Q

What is lymphadenitis?

A

Inflammation of the lymph nodes

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4
Q

What are the different ways to determine if a lymph node is enlarged?

A

It is visible

It is palpable

Measured size indicates it is enlarged

  • short axis >10 mm
  • long axis >15mm
  • cross-section area >2.25cmsqaured
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5
Q

Which lymph nodes might be palpable in the absence of pathology?

A

Inguinal lymph nodes in young or slim people

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6
Q

Which axis is most important to measure for lymph nodes? Which LN have naturally variation from the normal axis measurements?

A

Short axis>long axis

Sub-mental and submandibular = can be up to 15mm short axis

Obturator= up to 60mm long axis 
Inguinal= up to 20mm
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7
Q

Why do the obturator node have such a long long axis?

A

They are a continuous chain of lymphoid tissue with fatty ingrowths meaning it will be measured as a long chain

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8
Q

How are lymph node measured? What is important to calculate and how can this be used?

A

Ruler or US using mm

Long/short axis ratio:

  • 2:1 (oval)or ++= reactive LN
  • 1:1 (round)= malignant LN
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9
Q

What are the 3 classifications of lymphadenomegaly?How can this effect looking for causes?

A

Localised= one LN or one LN region

Regional= two or more contiguous regions

Generalised= two or more non-contiguous regions
I.e. Rt axillary and Rt inguinal

Localised and regional:
-look for problem in the drainage area of the LN

Generalised:

  • need to do haematological or serological tests for more info
  • more likely to be malignancy
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10
Q

What other presentation will accompany all enlarged LN?

A

Splenomegaly

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11
Q

What causes lymph node enlargement?

A

In-situ proliferation of leukocytes

Influx of lymphocytes from blood or lymph= leads to enlargement w/i a few hours

Infiltration by neoplastic cells

Accumulation of abnormal substances (foreign or endogenous) which have been phagocytose by histiocytes

Rarely:

  • swelling due to necrosis
  • suppuration
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12
Q

What is done when lymph node enlargement of unknown origin occurs?

A

Must NOT be treated (w/ Abx)

- can give steroids if the enlarge LN are obstructing an airway

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13
Q

What are important considerations when assessing if LN biopsy is needed? (Pros and cons)

A

Pros:
-LN excision biopsy provides information and can give definite diagnosis

Cons:

  • costly i.e. surgical procedure and lab costs
  • invasive procedure comes with risk (nerve damage/scar/infection/haematoma)
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14
Q

Which LNs can be predictors of malignancy?

A

Supraclavicular LNs= GI

LNs at multiple sites

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15
Q

What are important parts of the patient history to explore?

A

FH

  • previous cancer
  • immunodeficiencies
  • TB

SH

  • occupation= contact with animals
  • ethnic origin and travel (risk factors for TB, HTLV1)
  • Smoking

PMH

  • immunosuppression
  • current cancer
  • RhA
  • AI conditions

DH
-long list of drugs which can lead to LN enlargement (check patient drug history)

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16
Q

Give examples of a few drugs which can cause LN enlargement?

A 
Allopurinol 
Atenolol 
Carbamazepine 
Isoniazid
Penicillin 
Phenytoin
Quinidine 
All immunosuppressive agents (eg methotrexate)
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17
Q

How can immunosuppressive agents effect the lymph nodes?

A

They can cause lymphoma-like growths or true lymphomas

18
Q

If a patient has an enlarged lymph node, what red flag signs and symptoms should you be looking for to determine if there is a high risk of malignancy?

A

Fevers (>38)
Drenching night sweats
Unexplained weight loss (more than 10% of body weight)

Unexplained generalised pruritus

Immunosuppression

Unexplained skin rash w/ oedema +/- arthralgias

19
Q

What condition is indicated if there is LN pain after consuming alcohol?

A

Hodgkin’s lymphoma

20
Q

What features of enlarged LN increase the likelihood of them being malignant?

A

Located in lower neck or abdomen

Fixed

Form aggregates (packets)

Painless

Rock hard

Very large (>3-4cm)

No discernible fatty hilum on imaging

Necrosis on imaging

<4 weeks or >1 year history (not strictly relevant)

Patient >50 yo

21
Q

Enlarge LN can occur in different parts of the neck. What is the most likely cause of enlargement for following regions:

  • cervical
  • occipital
  • preauricular
A

Cervical

  • nasopharyngeal infection
  • pharyngitis
  • dental abscess
  • H+N cancer
  • thyroid ca
  • Tb
  • lymphoma

Occipital

  • skin infection
  • eczema
  • toxoplasmosis

Preauricular

  • drain orbits
  • parotid
  • middle ear
22
Q

How might a child with non-tuberculous mycobacterial infection present?

A

Isolated unilateral cervical lymphadenitis (painless)

Asymptomatic

Biopsy

  • necrotic granulomas
  • histiocytes
  • caseous centre
23
Q

What are possible causes of supraclavicular LN enlargement?

A 
Hodgins lymphoma 
NHL
Bronchial Ca
Breast Ca 
GIT malginancy (when left supraclavicular LN involved)
24
Q

What are causes of enlarged LN in the mediastinum? What is a serious complication of enlarged LN in this region and what would be the signs?

A

Cause:

  • sarcoidosis
  • lymphoma
  • TB
Superior vena canva syndrome 
S+S:
-headache
-upper thorax/arms congestion
-turgor of jugular veins 
-dilated superficial chest vein= garland shape (early sign)}
-dry cough 
-expiratory dyspnoea 
-hiccup
25
Q

What are causes of enlarged axillary LN?

A 
Skin infection 
Breast cancer 
Melanoma 
Lymphoma
Silicone leak 
Tattoo reaction 
Cat-scratch disease
26
Q

What are causes of enlarged inguinal LN?

A 
Cellulitis 
Venereal disease 
Lymphomas 
Melanoma 
SCC
27
Q

Abdominal LN enlargement is often malignant. However if there was cavitation present, what is more likely to be the cause?

A

Can get cavitation with coeliac disease

“Mesenteric LN cavitation syndrome”

28
Q

Where are the epitrochlear LN located? What are possible causes of enlargement?

A

Medial arm above medial epicondyle

  • Malignancy if there is no obvious pathology in the draining area
  • bilateral= sign of systemic inflammatory disease (infection mononucleosis/sarcoidosis)
29
Q

What non-neoplastic conditions can lead to very large LN?

A

Dermatopathic lymphadenopathy
-LN reaction due to cutaneous changes in draining area

Silicone reaction

Progressive transformation of germinal centres

  • abnormal immune reaction often linked to AI
  • self-limiting and no treatment needed

HIV lymphadenitis

TB

30
Q

What non-neoplastic conditions can have a lymphoma-like clinical presentation?

A

Infectious mononucleosis

Kikuchi’s lymphadenitis

  • may present with lower neck LN
  • fever and malaise
  • painful LN (diff from lymphoma)

SLE

HIV/AIDs

31
Q

What lab investigations would you request following HX and examination of LN?

A 
NOTE: only include as appropriate 
FBC and WBC differential- most important 
LDH= raised= suggestive of malginancy BUT can also be raised in haemolysis 
Throat culture 
Monospot test 
HIV test 
Infectious serology 
TB skin test
AI scan
32
Q

Chronic lymphocytic leukaemia can cause enlarged LN. How can it be diagnosed?

A

FBC
Flow cytometry of peripheral blood

Assocaited immunophenotype:
-CD20+ 
CD3-
CD5+
CD23+
33
Q

What imaging can be done to investigate enlarge LN and what are their uses?

A

CXR

US

  • precise measurement
  • contents= is hilum preserve or is necrosis present
  • margins
  • presence of other non-palpable nodes
  • visualises abdominal LN
  • method of choice for superficial LN

CT

  • generalised LN
  • Supraclavicular
  • any LN with splenomegaly
34
Q

When is biopsy indicated?

A

Localised/regional
-when there is a high risk of malignancy
(Otherwise= 3-4 week observation)

Generalised
-when no clues from FBC, infections serology or autoimmune scan

35
Q

What is the prefered method of biopsy and which LN should a biopsy be targeting?

A

Excision

Need to target the most abnormal LN (might not be the most accessible)

36
Q

What are the pros and cons of a core needle biopsy?

A

Safer
Cheaper
Quicker

Less accurate

37
Q

Why is FNA not used for lymphadenomegaly of unknown origin?

A

Fails to demonstrate tissue architecture
I.e. get smear rather than tissue section

Some lymphomas will be indistinguishable from reactive LN

Provides little material for special studies

Can miss focal lesions i.e. entire LN might not be neoplastic (aggressive lymphoma)

Fails to visual complex pathologies i.e. mixed pathology

Will need excision anyway if lymphoma indicated

May traumatise the best LN leading to biopsy induced necrosis and compromise further sampling

Delays final diagnosis

38
Q

What can FNA be used for?

A

Staging or re-staging of already diagnosed non-lymphoid cancer

Lesions in salivary glands, thyroid, breast, hepatic, pancreatic

LN when there is high index of suspicion for non-lymphoid cancer esp carcinoma (>90% accuracy)

39
Q

What are the different studies which can be carried out on a tissue biopsy?

A

FISH

Molecular studies

Flow cytometry (with fresh sample)

Touch imprints = quick!!

40
Q

Why might histopathology report come back with no explicit diagnosis?

A

Inadequate material

Appearance difficult to interpret

Interpretable but the lymphoma is unclassifiable

Haematology (17 decks)

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