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Yr 3 - January lectures 19 > Lymphadenopathy > Flashcards

Lymphadenopathy Flashcards

1
Q

Define: lymphadenomegaly

A

lymph node enlargement

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2
Q

Define: lymphadenopathy

A

any abnormality of lymph node(s)

- size, shape, structure, cellular composition, necrosis

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3
Q

Define: lymphadenitis

A

inflammation of lymph nodes

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4
Q

What factors indicate an enlarged and/or pathological lymph node?

A 
see it 
easily palpate it 
measurable size is increased, short axis more important 
- short axis >10mm
- long axis >15mm 
- cross-section area >2.25cm^2
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5
Q

How should you measure a lymph node?

A

measure with a rule or use US
express results in mm or cm
long axis/short axis ratio is important
- reactive node: usually about 2:1 or higher
- closer to 1:1 (round node) - more likely malignant (sobiaiti index)
(submandibular, parotid and mesenteric lymph nodes may be normally round)

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6
Q

What are the different types of lymphadenomegaly?

A

localised: one LN / one LN region
regional: 2 or more contiguous regions

Generalised: 2 or more non-contiguous regions
- about 25% lymphadenopathies

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7
Q

What causes lymph node enlargement?

A

1) in situ proliferation of leukocytes (mostly lymphocytes, but also histiocytes and rarely, dendritic cells)
2) influx of lymphocytes from blood and lymph
3) infiltration by neoplastic cells
4) accumulation of abnormal substances of foreign or endogenous origin, usually phagocytosed by histiocytes

rarely:

  • swelling due to necrosis or dilatation of sinuses
  • suppuration
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8
Q

Can new LNs arise?

A

it has been suggested that they can originate “de novo” from clusters of lymphocytes in many sites

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9
Q

What should you do after noting an enlarged lymph node?

A

enlargement of unknown origin should NOT be treated it MUST be diagnosed
- the exception to this is if it is life threatening obstruction of upper airways by pharyngeal nodes

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10
Q

Should a biopsy of an enlarged LN be performed?

A

simple algorithmic approach is NOT possible
need to weight up pros and cons
- LN excision biopsy provides plenty info and often definite diagnosis - surgical procedure is costly and although simple it has risks (scar, nerve damage, infection, haemotoma)

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11
Q

What are the chances of an enlarged LN being malignant?

A

annual incidence of lympahdenopathy in gen pop - 0.6%

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12
Q

What to ask in the history?

A

history:

  • Fam = previous cancers, immunodeficiencies, other cancer RF, TB
  • Occupational = contact with animals and animal products, healthcare workers
  • Ethnic origin and travel - TB, HTLV1, kikuchi lymphdenitis
  • Lifestyle risks= smoking
  • Co-morbidities = immunosuppression, current cancer, other autoimmunedisease, RA)
  • drugs = anticonvulsants (phenytoin, captopril, mephenytoin)
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13
Q

What can all immunosuppresive agents cause?

A

e.g. methotrexate administered for RA

may cause lymphoma like growths and true lymphomas

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14
Q

What are the definitions of localised/region LNs and generalised?

A

localised- focus on drainage area

generalised = serological / haematological tests may give more useful info
- much higher risk of malignancy

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15
Q

What are some non-malignant conditions in which there is generalised LN enlargement?

A 
HIV/AIDs
Infectious mononucleosis
SLE
TB 
Sarcoidosis
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16
Q

What are the associated symptoms that increase risk of malignancy?

A

B symptoms
- fever >38
- drenching night sweats
- unexplained weight loss of more than 10% body weight
unexplained generalised pruritus
immunosuppression
unexplained skin rash, particularly when accompanied by oedema, fluid accumulation in body cavities or arthralgias

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17
Q

What is LN pain following alcohol consumption characteristic of?

A

hodgkin’s lymphoma - rare

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18
Q

What are some worrisome features of enlarged LNs?

A

likely malignant if:

  • lower neck nodes
  • abdominal nodes
  • fixed to surrounding tissue
  • forming aggregates
  • painless
  • rock hard
  • very large 3-4cm
  • on imaging:-round, fatty hilum not discernible. necrosis
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19
Q

What is a poor predictor of malignancy and what is a good one?

A

poor- time
- some say <4 weeks and greater than 1 yr likely to be benign however indolent lymphomas are frequently >1 yr

Age
<30 mostly benign
>50 much more likely to be malignant

20
Q

What is non-TB mycobacterial infection in children?

A 
1 in 100,000 children per year
80% <5 yrs 
previously healthy no immunodeficiency 
isolated unilateral cervical lymphadenitis
painless
asymptomatic 
no dissemination 
IGRA test usually negative

No consensus on treatment (excision, drugs, watch and wait)
RF largely unknown
no human to human transmission

21
Q

What is the lymph node that drains the thorax, GIT and GU tract and what happens if its enlarged?

A

supraclavicular
- normally not palpable
over 50% are malignant
- hodgkin’s lymphoma, NHL, bronchial cancer, breast cancer

22
Q

What is virchow’s node?

A

left supraclavicular - more frequently malignant than the right, frequently signifies an inoperable malignancy of the git

23
Q

What is likely if the infraclavicular node is enlarged?

A

very rare, highly suspicious of hodgkin’s lymphoma

24
Q

What are some potential diagnoses if the mediastinal LN is enlarged and what can it lead to?

A

sarcoidosis (rarely massive)
lymphoma (usually massive)]
TB
Can result in superior vena cava syndrome

25
Q

What are the symptoms of vena cava syndrome?

A 
headache
upper thorax /arm congestion 
turgor of jugular veins 
dilated superficial chest vein 
also
- dry cough, predominantly expiratory dyspnoea, hiccup
26
Q

What are the potential causes of enlarged axillary node?

A 
skin infection 
breast cancer 
cat-scratch disease 
melanoma
lymphoma 
silicone leak 
tattoo reaction - persistent painless anxillary LN
27
Q

What does the inguinal LN drain and what are the potential diagnoses if its enlarged?

A

drains penis, scrotum, vulva, anus, perineum, inner thigh, lower abdominal wall (doesnt drain testes)

cellulitis
venereal diseases 
lymphomas 
melanoma 
SCC
28
Q

What are you worried about if you have enlarged abdominal LN?

A

always highly suspicious of malignancy

even if 1-1.5cm

29
Q

What does the epitrochlear LN drain and what are you worried about if its enlarged?

A

medial arm, above medial epicondyle of the humerus often forgotten on physical examination
always pathological regardless of size
frequently malignant if no obvious pathology in the draining area

bilateral enlargement may signify a systemic inflammatory disease - infectious mononucleosis, sarcoidosis, syphilis, tularamia, exotic infections

30
Q

What are some examples of non-neoplastic conditions in which the LN may be very large?

A 
dermatopathic lymphadenopathy 
silicone reaction 
progressive transformation of germinal centres
HIV lympahdenitis
TB

Also typically painless and therefore makes you think lymphoma

31
Q

What is dermatopathic lymphadenitis?

A

LN reaction to any cutaneous changes in the draining area may be disproportional to intensity of skin changes

32
Q

What is progressive transformation of germinal centres?

A

abnormal immune reaction, cause unknown but linked to autoimmune phenomena/disorders in 1/4 of patients
self limiting, no treatment needed, may recur

33
Q

What are some examples of non-neoplastic diseases with lymphoma like clinical presentation?

A

infectious mononucleosis
kikuchi’s lymphadenitis
SLE
HIV/AIDs

34
Q

What is kikuchi’s lymphadenitis?

A

kikuchi-fujimoto disease, necrotising histiocytic lymphadenitis
self-limiting (1-5 months) inflammatory disorder of unknown aetiology
LN are often painful unlike in lymphoma

commonly mis-diagnosed as lymphoma

35
Q

What do most T cell lymphomas express?

A

CD4 not CD8

36
Q

What laboratory investigations are most important with an enlarged LN?

A 
FBC with WBC differential 
check LDH - if raised strongly suggestive of malignancy 
throat culture
monospot test (infectiousmononucleosis\)
HIV test
TB skin test
autoimmune scan 
serum total proteins and protein electrophoresis 
serum markers of germ cell neoplasia
37
Q

What radiological examinations are helpful?

A

US

  • precise measurements (short axis)
  • relationship to contiguous structures
  • margins
  • presence of other non-palpable nodes in vicinity
  • method of choice of superficial LNs

CXR

CT

  • generalised LN
  • supraclavicular
  • any LN with splenomegaly
38
Q

What should you do if you have localised/regional LN enlarged with high risk of malignancy?

A

biopsy

39
Q

What should you do if you have localised/regional LN enlarged with low risk of malignancy?

A

3-4 week observations

40
Q

What should you do if you have generalised LN enlarged ?

A

if still no clear clue from FBC, infectious serology and autoimmune scan then BIOPSY

41
Q

What are the different types of biopsy?

A

excision biopsy- best
if not possible then
core needle biopsy or incision biopsy
always target most abnormal/largest node not most easily accessible

42
Q

Why is the core needle biopsy becoming increasingly popular?

A

safer
cheaper
quicker
but less accurate

43
Q

Why is fine needle biopsy not used?

A

not robust method for diagnosis of lymphadenopathy
cant demonstrate tissue architecture
very little material for special studies
some very good samples can allow flow cytometry, genetics and immunicytochemistry

44
Q

What is FNA good for?

A

staging or re-stagin of already diagnosed non-lymphoid cancer
salivary , thyroid, breast, hepatic and pancreatic lesion
LN in cases with high index suspicion for non-lymphoid cancer particularly carcinomas

45
Q

What can you do with a tissue biopsy?

A

FISH
Molecular studies
Flow cytometry
touch imprints - quick cytology

Yr 3 - January lectures 19 (30 decks)

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