1.Approach to Lymphadenopathy

8/10/2019 1.Approach to Lymphadenopathy

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Approach toLymphadenopathy


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Case

41 yo male school teacher presents to your office with right sidedcervical lymphadenopathy. His past medical history is significantfor hypertension and dyslipidemia. His medications include hctzand simvastatin. NKDA. He noticed the lump in his neck last week.He has not experienced any fevers, chills or weight loss. He denies

any sore throat, ear pain or dental problems. His vital signs arestable. On physical exam he has a 2cm anterior cervical lymphnode which is firm, non-tender and mobile. His HEENT exam isunremarkable. No skin lesions are evident. No otherlymphadenopathy is found. How should you proceed with thispatient?

A. Location and duration typical for viral etiology. Have your patient

follow up for annual physical next year.B. Proceed to fine needle aspiration.

C. Check a CXR and cbc.

D. Have patient follow up in 3-4 weeks.


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Learning Objectives

Provide an approach to the patient with

peripheral lymphadenopathy

Be able to differentiate between benign andserious illness

Knowledgeable of nodal distribution and

anatomic drainage

Present a substantial differential diagnosis

Indications for nodal biopsy


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Definition: Lymphadenopathy

Lymph nodes that are abnormal in

size, consistency or number

Generalized Localized


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Lymphatic System

Network that filters antigens from the interstitial fluid

Primary site of immune response from tissue

antigens

Lymphatic drainage in all organs of the body exceptbrain, eyes, marrow and cartilage

Flaccid thin walled channelsprogressive caliber

600 lymph nodes in body Slow flow, low pressure system returns interstitial

fluid to the blood system


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Secondary lymphoid tissue


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Lymph nodes

Capsular shell

Fibroblasts and reticulin

fibers

Macrophages

Dendritic cells

T cells

B cells


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Peripheral lymphadenopathy

Most cases benign, self limited illness

Primary or secondary manifestation of 100

illnesses

The CHALLENGE is to decide if it is

representative of a serious illness

P t t h l


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Parameters to help

distinguish between

benign and seriousillness

Age

Character

Location


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Malignancy much more

common in patientsgreater 50 yrs of age

Not exactly


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Epidemiology

Lee et al 1980 Referral centers 925underwent a lymph node biopsy.

Age 50 40% benign 16% lymphomatous

44% carcinomasAge 30-50 indeterminate values


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Dutch study Fijten 1988

0.6 annual incidence of generalized

lymphadenopathy

2,556 present with unexplained

lymphadenopathy

10% referred to subspecialist3.2% required

bx and of that 1.1% had a malignancy

40 yrs + 4% risk of cancer vs. 0.4% risk in pts

younger than 40


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Lymph node character

Size

Site

Consistency Pain with palpation


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Size

Greater than one centimeter generally

considered abnormal

Exception inguinal area, lymph nodes

commonly palpated (>1.5 cm)

Size does not indicate a specific disease

process

Obese and thin population


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Pain..

Indication of rapid increase in size: stretch of

capsular shell

NOT useful in determining benign vs

malignant state

Inflammation, suppuration, hemorrhage


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Consistency

Stone hard: typical of cancer usually

metastatic

Firm rubbery: can suggest lymphoma

Soft: infection or inflammation

Shotty buckshot under skin

Suppurated nodes: fluctuant Detect node from stroma

Matting


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Location, location, location


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Post cervical: scalp, neck skin of arms thorax cervical and axillary nodes (lymphoma, head/neck ca)


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Supraclavicular Nodes

Drain the mediastinum and abdomen

Breast, GI, Lung Malignancies Hodgkins/NHL

Chronic Fungal and mycobacterial


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Axillary Nodes

Drain arm, breast, thorax and neck

Hodgkin, NHL Melanoma (drains back of arm)

Staph/strep

Cat scratch Silicone prosthesis


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Inguinal lymphadenopathy

Drain the lower extremity, genitalia, buttocks,

abdominal wall

Normal

People who walk barefoot

Squamous cell carcinoma of penis or vulva Venereal disease
http://www.freefever.com/freeclipart/clipart/feet.gif


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Epitrochlear

Lymphoma/CLL

Mono

Historically associated with syphilis, rubella,leprosy

Studies to indicate an association with early

HIV disease in sub-Saharan Africa, areas

with high prevalence of disease


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Hilar, mediastinal, abdominal

>1 cm considered pathological

Pneumonia/inflammatory process can cause

unilateral hilar disease

Lymphadenopathy limited to abdomen likely

malignant


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Highest rate of malignancy

Right Supraclavicular

Mediastinum

Lungs

Upper 2/3 esophagus

Left Supraclavicular

Virchow node

Testes/ovaries

Kidneys

Pancreas

Prostate

StomachLower Esophagus


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Famous nodes

Virchows

Left supraclavicular (abdominal or thoracic ca)

Sister Joseph

Para-umbilical (gastric adenoca)

Delphian node

Prelaryngeal (thyroid or laryngeal ca)

Node of Cloquet (Rosenmuller node)Deep inguinal near femoral canal


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Presentation of

lymphadenopathy

Unexplained

lymphadenopathy

3/4 presents with

localized 1/4 present with

generalized


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Algorithm to evaluate

Lymphadenopathy

Attention to history and

physical exam

Confirmatory testing

Indication for biopsy
http://www.bradfitzpatrick.com/store/images/products/preview/pc017-cartoon-doctor-md.jpg


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History

Localizing symptoms or signs to suggest a

specific site

Constitutional symptoms: B symptoms

(fever, night sweats, >10%body wt >6months)

Epidemiologic clues: occupation, travel, high

risk behavior

Medications


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C


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Chicago

Cancer

Heme malignancies: Hodgkins, NHL, acute

and chronic leukemias, waldenstroms,

multiple myeloma (plastmocytomas)

Metastatic: solid tumor breast, lung, renal,

cell ovarian

H


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cHicago

Hypersensitivity syndromes

Serum sickness

Serum sickness like

illness

Drugs

Silicone

Vaccination

Graft vs Host


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Specific Medications

Cephalosporins

Atenolol

Captopril

Dilantin

Sulfonamides

Carbamazepine

Primodine

Gold

Allupurinol

i


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Chicago

Infections

Viral

Bacterial

Protozoan Mycotic

Rickettsial (typhus)

Helminthic (filariasis)


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VIRAL

EBVmono spot test

CMV.cmv titers, immunsuppresed,

transplant recipient, recent blood transfusion

HIVIV drug use, high risk sexual behavior

Hepatitis.IV drug use

Herpes Zoster.superficial cutaneous

nodules


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Bacterial

Staph/strep: cutaneous source, lymphadenitis

Cat scratch: bartonella hensalae, two weeks

after inoculation

Mycobacterium: TB and non-tb, host

characteristics (HIV, foreign born, low

socioeconomic status, homeless)


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Spirochete

Syphilis: Treponema pallidum Primary

localized inguinal lymph nodes and

secondary, non-treponemal, treponemal

Lyme disease


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Protozoan

Toxoplasmosis: ELISA assay, intracellular

protozoan toxoplasmosis gondii.bilateral,

symmetrical, non-tender cervical adenopathy

consider undercooked meat, reactivation in

immuncompromised host


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chicagoConnective Tissue Disease

Rheumatoid Arthritis

SLE

Dermatomyositis Mixed connective tissue disease

Sjogren

c c go


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Atypical lymphoproliferative

disorders

Castlemans disease

Wegeners

Angioimmuonplastic lymphadenopathy withdysproteinemia

G


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chicaGoGranulomatous

Histoplasmosis

Mycobacterial infections Cryptococcus

Silicosis: coal, foundry, ceramics, glass

Berylliosis: metal, alloys Cat Scratch


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My cat Pigeon


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OTHER.chicago

RARE

Kikuchi

Rosia Dorfman Kawasaki

Transformation of germinal centers


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Limited

Unexplained

Age Location History

Wait 3-4 weeks and reexamine

No indication for empiric antibiotics or steroids Glucorticoids can be harmful and delay diagnosis

can obscure diagnosis due to lympholytic affect

Unexplained Generalized


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Unexplained Generalized

lymphadenopathy

Always requires an evaluation

Start with CXR and CBC

Review Medications PPD, RPR, Hepatitis screen, ANA, HIV

No yield on above test: Biopsy most

abnormal node


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BIOPSY

Can be done by bedside, open surgery,

mediastinocopy or by needle aspiration*

FNA not recommended cannot distinguish

between lymphomas (nodal architecture

needs to be intact)

FNA reserved for established diagnosis and

to demonstrate recurrence


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Diagnostic Yield

Ideally axillary and inguinal nodes are

avoided as often demonstrate reactive

hyperplasia

Preferred supraclavicular, cervical, axillary,

epitrochlear, inguinal

Complications include vascular and nerve

injury


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Case

41 yo male school teacher presents to your office with right sidedcervical lymphadenopathy. His past medical history is significantfor hypertension and dyslipidemia. His medications include hctzand simvastatin. He has no known drug allergies. He believes henoticed the lump in his neck last week. He has not experiencedany fevers, chills or weight loss. He denies a sore throat, ear pain

or dental problems. His vital signs are stable. On physical exam hehas a 2cm anterior cervical lymph node which is firm, non-tenderand mobile. His HEENT exam is unremarkable. No skin lesions areevident. No other lymphadenopathy is found. How should youproceed with this patient?

A. Location and duration typical for viral etiology. Have your patient

follow up for annual physical next year.B. Proceed to fine needle aspiration

C. Check a CXR and cbc

D. Have patient follow up in 3-4 weeks.


54/54

References

Uptodate Fletcher 2008 Evaluation of Peripheral Lymphadenopathy

Aster 2008 Castlemans Disease

Glazer. G. Normal Mediastinal Nodes AJR 144:261-265 Feb 1985

Ghirardelli, M. Diagnositc approach to lymph node enlargement. Haematologica1999 84:242-247

Ferrer, R. Lymphadenopathy: Differential Diagnosis and Evaluation 1998

Haberman, T Lymphadenopathy Mayo Clinic Proc. 2000 75:723-732 Lee,Y. Lymph Node Biopsy for Diagnosis: A statistical study. Journal of Surgical

Oncology 14:53-60 1980

Skolnik, P Case 5-1999 37 yo male with fever and lymphadenopathy Volume340: 545-554

Lichtman et al. (2006) Williams Hematology New York. McGraw-Hill

Parslow et al. (2001) Medical Immunology new York. McGraw-Hill Malin, Ternouth (1994) Epitrochlear lymph nodes as a marker of HIV disease in

Subsaharan Africa BMJ 1994; 309 1550-1551

Bazemore and Smucker Lymphadenopathy and Malignancy AAFP 2002

1.Approach to Lymphadenopathy

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