lymphadenopathy + lymphoma

Question 1

lymph nodes + spleen

Answer 1

forms of secondary lymphoid tissues

both provide a location for cells of immune system (lymphoid + acessary)

both are filters for circulatory fluids - lymph + blood

Question 2

lymphatics

Answer 2

blind ended vessels that permit passive unidirectional flow (valves) of lymphatic fluid
- different nodes drain particular territories

return fluid from EXTRAcellular connective tissues (lymph) to circulation
- prevent excessive accumulation in tissue - oedema
- important for fluid haemostasis

Question 3

what does the flow of lymph through lymphatic channels permit?

Answer 3

cell, microorganism + molecules within lymph can interact with immune system + illicit immune response -> protective fucntion

cell traffic + trapping
- immune + inflammatory
- malignant cells

Question 4

2 groups of nodes

Answer 4

superficial - cervical, axillary, inguinal -> can be palpated

internal - mediastinal, para-aortic -> viewed radiologically

virchows node/trosiers sign = left supraclavicular -> gastric/abdominal malignancy

Question 5

drainage through lymph nodes

Answer 5

afferent channels drain through the capsule to peripheral sinus, then filtered
- immune reaction can be triggered

efferent vessel leaves from hilum, drains to
- cisterna chyll/thoracic duct
- left jugular, subclavian

Question 6

sentinel lymph node

Answer 6

first lymph node to which cancer cells are most likely to spread, identified by dye or radioactive isotopes

if neg - tumour is localised
if pos - tumour has spread, further Ix

metastatic cells will be identified first in the subcapsular sinus

Question 7

cell populations in lymph nodes

Answer 7

lymphocytes
-B cells - assoc with follicles + germinal centres
— plasma cells - mainly in medulla
- T cells
—T helper cell, T cytotoxic cells
natural killer cells

mononuclear phagocytes - macrophages, antigen presenting cells + dendritic

endothelial cells

Question 8

how does a positive lymph node in lymphoma present compared to viral/bacterial infection + metastatic carcinoma?

Answer 8

rubbery/soft, compared to hard in others

viral/bacterial = tender
lymphoma/metastatic = NOT tender

lymphoma smooth surface, metastatic = irregular

Question 9

invesigating lymphadenopathy

Answer 9

if malignancy suspected ask surgeon to biopsy - fine needle aspiration is INSUFFICIENT
- need a big sample to assess architechture of lesion
- lymphoma not seen on CT

Question 10

assessing lymph node pathology

Answer 10

histology appearance
immunochemistry of solid node - surface proteins, brown = positive
immunophenotyping of blood/marrow - liquid phase

genetic analysis - FISH
molecular analysis - reed sternberg cells in Hodgkins

Question 11

what are the 3 main immune reaction in a lymph node + what causes these?

Answer 11

predominant B cell respones -> autoimmune, infections

predominant phagocytic response -> non-specific, draining a tumour site

predominant T-cell response -> viral infections, drugs (phenytoin), dematopathic

Question 12

caseating granulomas

Answer 12

infection until proved otherwise
-> likely microbacterial

Question 13

lymphomas

Answer 13

group of cancers that affect the lymphocytes inside the lymphatic system
-> these cancerous cells proliferate within nodes causing lymphadnopathy

malignant tumour derived from cells of immune system
many diff forms + varying course/prognosis

Question 14

hodgkins lymphoma

Answer 14

proliferation of lymphocytes
different types - classical + nodular lymphocyte predominant
also of B cell origin

bimodal age distribution with peaks aged 20 + 75yrs
usually v good prognosis

Question 15

hodgkins lymphoma risk factors

Answer 15

HIV
EPV
autoimmune conditions - rheumatoid arthritis, sarcoidosis
fam history

Question 16

hodgkins lymphoma presentation

Answer 16

lymphadenopathy - neck, axilla, inguinal
- non tender + rubbery
- *pain in lymph nodes when drink alcohol

fatigue, SOB
weight loss, fever, night sweats
itching
cough - medistinal mass
recurrent infections

Question 17

hodgkins lymphoma investigation findings

Answer 17

normocytic anaemia
eosinophilia
LDH raised (not specific)

lymph node biopsy
- Reed-Sternberg cell
– abnormally large B cells that have multiple nuclei that have nucleoli inside them - gives “owl” apearance (face with large eyes)

Question 18

staging of hodgkins lymphoma

Answer 18

Ann Arbor

I: single lymph node
II: 2 or more lymph nodes/regions on the same side of the diaphragm
III: nodes on both sides of the diaphragm
IV: spread beyond lymph nodes

Each stage may be subdivided into A or B
A = no systemic symptoms other than pruritus
B = weight loss > 10% in last 6 months, fever > 38c, night sweats (poor prognosis)

Question 19

hodgkins lymphoma Mx

Answer 19

chemo + radio

chemo - risk of leukaemia + infertility
radio - risk of cancer, damage to tissues + hypothyroidism

Question 20

non-hodgkins lymphomas examples

Answer 20

Burkitt lymphoma - assoc with EPV, malaria, HIV

MALT lymohoma - affect muscosa-assoc lymphoid tissue, usally stomach, assoc with H. Pylori

Diffuse large B cell lymphoma - rapidly growing painless mass in patients over 65yrs

Question 21

non-hodgkins lymphoma

Answer 21

diverse group of disease
B cell lymphoma - commonest NHL (90%), low + high grade forms
T cell lymphomas - less common, more complex classification

typically occurs in elderly

Question 22

Non-hodgkins risk factors

Answer 22

HIV, EPV
H.Pyloris - MALT lymphoma
hepatitis B or C infection
exposire to pesticides + trichlorethylene (used in industrial processes)
fam history

Question 23

differences between Hodgkins + non-Hodgkins presentation

Answer 23

• Alcohol induced pain in node -> Hodgkin’s
• Reed-Sternberg cells -> Hodgkins
• “B” symptoms occur earlier in Hodgkin’s
• Extra-nodal disease more common in Non-Hodgkin’s

Question 24

extra nodal features in non-hodgkins lymphoma

Answer 24

gastric - dyspepsia, dysphagia, abdo pain

bone marrow (pancytopenia, bone pain)
lungs, skin, central nervous system (nerve palsies)

Question 25

prognosis of lymphomas

Answer 25

Hodgkins – v treatable with chemo
High grade B cell NHL – aggressive but curable
Low grade B cell NHL – not curable but indolnent
Burkitts lymphoma – v aggressive B cell lymphoma, relapse v quickly
Mantle cell lymphoma
Marginal zone NHL – quick growing + curable