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Management of Lymphadenopathy
1. Approach to
Lymphadenopathy
Professor Panna Lal SahaProfessor Panna Lal Saha
Professor of Surgery & HeadProfessor of Surgery & Head
Department of SurgeryDepartment of Surgery
BGC Trust Medical CollegeBGC Trust Medical College
ChittagongChittagong
3. 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
except brain, eyes, marrow and cartilage
Flaccid thin walled channels progressive caliber
800 lymph nodes in body
Slow flow, low pressure system returns interstitial
fluid to the blood system
4. 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…
5. Parameters to help distinguish
between benign and serious
illness
AGE
CHARACTER
LOCATION
8. 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
9. Pain…..
Indication of rapid increase in
size: stretch of capsular shell
NOT useful in determining benign
vs malignant state
Inflammation, suppuration,
hemorrhage
10. Consistency
Stone hard: typical of cancer usually
metastatic
Firm rubbery: can suggest lymphoma
Soft: infection or inflammation
Suppurated nodes: fluctuant
Detect node from stroma
Matting
11.
12. Post cervical: scalp, neck skin of arms t horax cervical and axillary nodes (lymphoma, head/neck ca)
13. Supraclavicular Nodes
Drain the mediastinum and
abdomen
Breast, GI, Lung Malignancies
Hodgkin's/NHL
Chronic Fungal and mycobacterial
14. Axillary Nodes
Drain arm, breast, thorax and neck
Hodgkin, NHL
Melanoma (drains back of arm)
Staph/strep
Cat scratch
Silicone prosthesis
15. Inguinal lymphadenopathy
Drain the lower extremity, genitalia,
buttocks, abdominal wall
Normal
People who walk barefoot
Squamous cell carcinoma of penis or
vulva
Venereal disease
16. 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
17.
18. Hilar, mediastinal,
abdominal
>1 cm considered
pathological
Pneumonia/inflammatory
process can cause unilateral
hilar disease
Lymph adenopathy limited to
abdomen likely malignant.
19. Highest rate of malignancy
Right Supraclavicular
Mediastinum
Lungs
Upper 2/3 esophagus
Left Supraclavicular
Virchow node
Testes/ovaries
Kidneys
Pancreas
Prostate
Stomach
Lower Esophagus
20. Famous nodes
Virchows
Left supraclavicular (abdominal or thoracic ca)
Sister Joseph
Para-umbilical (gastric adeno ca)
Delphian node
Prelaryngeal (thyroid or laryngeal ca)
Node of Cloquet (Rosenmuller node)
Deep inguinal near femoral canal
23. 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
40. 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
41. Unexplained Generalized
lymph adenopathy
Always requires an evaluation
Start with CXR and CBC
Review Medications
PPD (purified protein derivatives), RPR
(rapid plasma regain for syphylis),
Hepatitis screen, ANA (antinuclear
antibody), HIV
No yield on above test: Biopsy most
abnormal node
42. 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
43. 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
Primary site of immune response from tissue antigens
Invasion by malignant cells or propagation of a inflammatory process
Picture of lymph node sites
Surgeon William J Mayo’s Scrub nurse predict the findings when scrubbing abdomen preoperatively
Serum sickness TYPE III immune complex mediated antibody antigen and complement cascade (horse serum to treat diptheria) humoral response to foreign protein
Believed to be caused by a different mechanism which is NOT classical serum sickness…delayed reaction to above
Cat scratch (bite, scratch or flea bite): two weeks after inoculation
Half of tb (Mexico, Philippines, Vietnam, India, china)
Lt cat scratch
Rt lympahdenitis with suppuration
Felines protozoan completes reproductive cycle: oocytes in feces, ingested by humans other animals : predominately undercooked meat, invade gi epithelium and lie dormant in neural and muscular tissue, 10% adults are seropositive
Arthralgias, skin manifestations
Lymphoprolifertative disorder (associatin with HIV and HHV-8) localized no systemic symptoms and systemic fevers night sweats Multicentric form
Young woman painless lymphadenopathy unilateral in cervical region resolves in 3 months unknown etiology: histiocytic necrotiziing lympadenitis
RD: greatly exaggerated lymph node reaction children bl cervical lymph node
