Lymphadenopathy Flashcards by Holly Wilson

What is lymphadenomegaly?

Lymph node enlargement

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What is lymphadenopathy?

Any abnormality of lymph nodes

size
shape
structure
cellular composition
necrosis

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What is lymphadenitis?

Inflammation of the lymph nodes

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

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

Inguinal lymph nodes in young or slim people

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

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

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

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

Ruler or US using mm

Long/short axis ratio:

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

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

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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What other presentation will accompany all enlarged LN?

Splenomegaly

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What causes lymph node enlargement?

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

Must NOT be treated (w/ Abx)

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

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

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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Which LNs can be predictors of malignancy?

Supraclavicular LNs= GI

LNs at multiple sites

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What are important parts of the patient history to explore?

previous cancer
immunodeficiencies
TB

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

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

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How can immunosuppressive agents effect the lymph nodes?

They can cause lymphoma-like growths or true lymphomas

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?

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

Unexplained generalised pruritus

Immunosuppression

Unexplained skin rash w/ oedema +/- arthralgias

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

Hodgkin’s lymphoma

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

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

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

cervical
occipital
preauricular

Cervical

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

Occipital

skin infection
eczema
toxoplasmosis

Preauricular

drain orbits
parotid
middle ear

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

Isolated unilateral cervical lymphadenitis (painless)

Asymptomatic

Biopsy

necrotic granulomas
histiocytes
caseous centre

What are possible causes of supraclavicular LN enlargement?

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

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?

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

What are causes of enlarged axillary LN?

``` Skin infection Breast cancer Melanoma Lymphoma Silicone leak Tattoo reaction Cat-scratch disease ```

What are causes of enlarged inguinal LN?

``` Cellulitis Venereal disease Lymphomas Melanoma SCC ```

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

Can get cavitation with coeliac disease | “Mesenteric LN cavitation syndrome”

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

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)

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

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

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

Infectious mononucleosis Kikuchi’s lymphadenitis - may present with lower neck LN - fever and malaise - painful LN (diff from lymphoma) SLE HIV/AIDs

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

``` 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 ```

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

FBC Flow cytometry of peripheral blood ``` Assocaited immunophenotype: -CD20+ CD3- CD5+ CD23+ ```

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

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

When is biopsy indicated?

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

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

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

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

Safer Cheaper Quicker Less accurate

Why is FNA not used for lymphadenomegaly of unknown origin?

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

What can FNA be used for?

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)

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

FISH Molecular studies Flow cytometry (with fresh sample) Touch imprints = quick!!

Why might histopathology report come back with no explicit diagnosis?

Inadequate material Appearance difficult to interpret Interpretable but the lymphoma is unclassifiable