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CLINICAL WORK UP OF A PATIENT WITH LYM


Dr.Anil Haripriya


      The lymph nodes are major components of the lymphatic s...
It is estimated that 500 to 600 lymph nodes exist in humans. These nodes are lo
vessels, whose contents pass through the r...
SUPERFICIAL LYMPH NODE                DEEP LYMPH NODE GROUPS
 GROUPS
 1.Superficial Cervical lymph          1. Deep Cervic...
side wall of the Pharynx. The deeper nodes drain (a) the nasopharynx (b) the back
      from (a) the eyelids, (b) front of...
(c)    The pre tracheal nodes: These lie in relation to the inferior thyroid veins in
            trachea.

Efferents of t...
There are a few small nodes of deep cervical group which lie in the groove between the
nerve. They are called paratracheal...
internal jugular vein. On the left side the trunk enters the thoracic duct.




Level of Nodes in Neck Dissection:

      ...
surrounding the spinal accessory nerve from the jugular foramen to the posterior borde
the (lymph nodes in the upper poste...
The major and primary route of drainage of lymphatics from the breast is by axilla
axilla namely the anterior, posterior, ...
first intercostal space, behind by the axillary vein, infront by the costocoracoid membran
by pushing the fingers of one h...
groin and are subdivided into proximal set just below and parallel to the inguinal ligame
along the upper end of long saph...
new multiple or single smaller lymph nodes may warrant investigation. While taking his
following points are particularly n...
lymphogranuloma venereum and syphilis are associated with unilateral inguinal ade
     enlargement without obvious infecti...
is best accomplished by paplation of epitrochlear node area in an anterior to poster

             Enlarged abdominal lymp...
C.        IMMUNOLOGICAL DISEASES

     a)     Rheumatoid arthritis

     b)     Systemic lypus erythematosis

     c)     ...
INVESTIGATION

      The investigation of lymphadenopathy can be organised according to where nod
   lymphadenopathy patie...
suggested inactive disease. Low attenuation areas within the nodes had pathologic co
may be a reliable indicator for disea...
studies. The histopathological criteria used for diagnosis for tuberculosis is presence o
and presence of necrotic materia...
Technique of lymph node biopsy:

      It may be easy enough to remove a normal lymph node, but it often requires grea
nod...
LYMPHANGIOGRAPHY:

       Bilateral lower limb lymphangiography is an excellent method for defining abnorm
area lymph node...
presented in an extra nodal site such as the gut or skin, of which only four percent were
always be considered in a patien...
histological setting.

Rye histological classification of Hodgkin’s disease:



Subgroup             Major Histological fe...
Mixed lymphocytic and histiocytic

      Histiocytic

Diffuse sub types

      Lymphocytic well differentiated

      Lymp...
Stage III Involvement of lymph nodes on both sides of the diaphragm (III). There may
            of extra lymphatic organ ...
6. Suen J.Y., Goeptent H: Editorial standerization of neck dissection nomenclature., Head Neck Surg 1

7. Shah J.P., Stron...
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Clinical Work Up Of A Patient With Lymph adenopathy

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Clinical Work Up Of A Patient With Lymph adenopathy

  1. 1. CLINICAL WORK UP OF A PATIENT WITH LYM Dr.Anil Haripriya The lymph nodes are major components of the lymphatic system placed in small drain the lymphatic vessels of various anatomic regions. They are composed of dense node is ovoid, round or bean shaped and vary in size from 2 mm to 20mm in longitudin nodes in the mammalian body is relatively constant receiving lymph from a specific reg on its convex border. The efferent lymphatic vessels along with blood vessels are situa The drainage of lymph involves not only the mechanical filtration of the foreign P lymph but also the recognition and processing of antigens. The lymph nodes exhibit a populations are arranged in distinct interfacing compartments. This provides a favorab components can process antigens, interact, and generate the immune response. Affer and antigens, enters the lymph node via the subcapsular space and drains through par that converge to form efferent lymphatic vessels through which lymph exits. B cells fro lymph nodes from the circulation by binding to specific receptors on cells of post capilla antigen and clonal expansion, sensitized T and B cells and antibody secreting plasma c peripheral blood circulation via the thoracic duct. Removal of macro molecules and excessive fluid from the interstitium also takes escape into the tissue fluid have considerable difficulty in re-entering the vascular comp fibrinogen that enter the interstitial fluid are usually returned to the plasma through the where the foreign bodies are removed. LYMPH NODE GROUPS:
  2. 2. It is estimated that 500 to 600 lymph nodes exist in humans. These nodes are lo vessels, whose contents pass through the regional nodes to the main drainage system good health lymph nodes are usually not palpable. It is important to understand the basic functional anatomy of the lymphatic system enlargement. Major lymph node groups of the body may be classified into superficial a which are within the reach of an examiner without assistance of investigative radiograp involvement of which is easy to diagnose and manage. It is the deep group which pose Fig. 1 : Functional architecture of the lymph node MAJOR LYMPH NODE GROUPS:
  3. 3. SUPERFICIAL LYMPH NODE DEEP LYMPH NODE GROUPS GROUPS 1.Superficial Cervical lymph 1. Deep Cervical lymph nodes nodes: 2. Supra clavicular lymph nodes 2. Intra thoracic lymph nodes (Mediastinal) 3. Extra thoracic lymph nodes 3. Para-aortic Lymph node (axillary group) 4. Inguinal lymph nodes 4. Peri portal lymph nodes 5. Epitrochlear lymph nodes 5. Iliac lymph nodes 6. Mesenteric group of nodes. (Lymph nodes along the named vessels. eg. Superior and inferior mesenteric) Other unnamed lymph nodes LYMPH NODES OF THE HEAD AND NECK Approximately 75 nodes are present on each side of the neck, most of which ar chains. Cervical group of lymph nodes are divided into superficial and deep group. Superficial group of lymph nodes are arranged in circular chain and consist of (a) Occipital - one or two nodes situated midway between the mastoid process and back of the scalp. (b) Post auricular nodes: Situated on the mastoid process behind the pinna. They dr pinna, and external auditory meatus. (c) Pre-auricular nodes: Situated immediately in front of the tragus, the situation is s tragus cannot arise from this node. The node lies superficial to the parotid fascia. scalp. (d) Parotid nodes: These nodes are situated both in the substance of the parotid sal
  4. 4. side wall of the Pharynx. The deeper nodes drain (a) the nasopharynx (b) the back from (a) the eyelids, (b) front of the scalp. (c) external auditary meatus (d) lymparic (e) Submental nodes receives drainage from the skin of the chin, the midportion of t cavity, and the nasal vestibule. (f) Submandibular: nodes receive drainage from the submental area, the lower na anterior oral cavity, and the skin of the midface. The submandibular nodes drain in (g) Facial nodes: consists of superficial and deep groups. Superficial group consists of (a) Infraorbital: just below the orbit (b) Buccinator: on the muscle of this name lateral to the angle of the mouth. (c) Supramandibular: on the mandible in front of the masseter around the facial These nodes receive lymph from conjunctiva and eyelids, nose and the neck. Deep Group: These lie around the maxillary vessels in relation to the external ptery infratemporal fossa (c) back of the nose (d) pharynx. (h) Superficial Cervical nodes: These lie on the outer surface of the sternomastoid ar parotid region and lower part of the ear. (i) Anterior cervical nodes: These lie near the middle line of the neck in front of the l deep set of nodes. Superficial Set: Lie in relation to the anterior Jugular vein and drain the skin of the Deep Set consists of: (a) The infra hyoid nodes: These lie on the thyrohyoid membrane and drain th (b) The prelaryngeal nodes: These lie on the cricothyroid ligament and drain th foramen in the middle of the cricothyroid ligament. These nodes are often the larynx. These nodes assist in the drainage of the thyroid.
  5. 5. (c) The pre tracheal nodes: These lie in relation to the inferior thyroid veins in trachea. Efferents of the circular chain: The deep cervical chain receives ultimately all the node directly from all these node groups except the facial and sub mental. The efferents from nodes. CERVICAL LYMPH NODES. Vertical chain of the deep cervical nodes: This consists of a number of large nodes lying in relation to the carotid sheath. A position behind the pharynx and are called the retropharyngeal nodes. They drain the The vertical chain of deep cervical nodes, lies alongside the pharynx, trachea, an the root of the neck. They are arbitrarily divided into superior deep cervical and inferior the common carotid (or, alternatively, by the Omohyoid). The nodes of both groups are vein. Some of the nodes of the inferior group project beyond the posterior border of the neck (Supraclavicular). The Spinal accessory nodes are located along the spinal acces and occipital regions of the scalp and the nape of the neck and from the upper retropha nasopharynx, oropharynx and paranasal sinuses. The upper spinal accessory nodes d spinal accessory nodes, which in turn drain into the supraclavicular nodes.
  6. 6. There are a few small nodes of deep cervical group which lie in the groove between the nerve. They are called paratracheal nodes and assist in the drainage of the thyroid. Two of the deep cervical group are named Jugulodigastric, which is the main nod angle of mandible in the angle between the internal jugular and common fascial vein. J common carotid just above the point where the anterior belly of the Omohyoid crosses lymph drainage of the tongue, receiving some vessels from the apex which take a circu (Virchow’s) nodes received drainage from the thoracic duct and are located at the junct vein. They usually are the site of metastasis from Infraclavicular primary cancers. The spinal accessory nodes and from infraclavicular primary cancers. The deep cervical nodes receive the lymph from the entire head and neck either chain. The lymph from the deep cervical chain i.e. all the lymph from that half of the he lymph trunk, which leaves the inferior deep cervical nodes. On the right side this trunk
  7. 7. internal jugular vein. On the left side the trunk enters the thoracic duct. Level of Nodes in Neck Dissection: The terminology for the classification for neck dissections has been very confusin results of treatment of neck disease because there are so many variations of neck diss uniform. Suen and Goepert in 1987 proposed a classification of neck dissections base recommended terminology for the nodal group was based on a modification of the Mem This classification assigns five level of distribution to the different nodal groups. Level I is subdivided into Level I-A (submental triangle nodes) and Level I-B (submandi Level II includes two subgroups, Level II-A (Jugular nodes including the subdigastric ar
  8. 8. surrounding the spinal accessory nerve from the jugular foramen to the posterior borde the (lymph nodes in the upper posterior cervical triangle above the entrance of the spin Leve bifurcation and the level of the carotid sheath where the omohyoid muscle crosses this muscle. Level IV includes sub group IV-A (Jugular nodes between the omohyoid muscle and th the sterno cleidomastoid muscle) Level IV-B (the lymph nodes in the supra clavicular s muscle and candal to the omohyoid muscle. Level V includes the nodes in the posterior cervical triangle created by the posterior ed the entrance of the spinal accessory nerve, the trapezius muscle, and the posterior bell AXILLARY LYMPH NODES:
  9. 9. The major and primary route of drainage of lymphatics from the breast is by axilla axilla namely the anterior, posterior, lateral, central and apical set. There are about 35 Anterior set situated along the lateral thoracic veins under the anterior axillary fold. Th Spence is in actual contact with those nodes and therefore cancer involving this proces Posterior set lie along the posterior axillary fold in relationship to the subscapular vesse Lateral Set: lie along the upper part of the humerus in relation to the axillary vein. Cent axilla. The intercostobrachial nerve passes outwards amongst these nodes. Enlargeme by pressure on the nerve, cause pain in the distribution of the nerve along the inner bor is involved in carcinoma stomach via Perigastric and para oesophageal to mediastinal as Irish node. Apical Set: These are also called the infraclavicular nodes. They are very important an
  10. 10. first intercostal space, behind by the axillary vein, infront by the costocoracoid membran by pushing the fingers of one hand into the axillary apex from below, and the fingers of They are of great importance because they receive one vessel directly from the u lymph from the breast. A single trunk leaves the apical group on each side of the subc subclavian vein, or may join the thoracic duct on the left. These nodes can conveniently be subdivided into three main groups according to nodes at level 1 lie below the muscle, level 2 lymph glands lie behind it, and those of le muscle. The majority of lymph drains from nodes at level 1 sequentially to those at leve INGUINAL LYMPH NODES: The lymph nodes of the lower limb are divided into superficial and deep group. The su
  11. 11. groin and are subdivided into proximal set just below and parallel to the inguinal ligame along the upper end of long saphenous vein (vertical chain). Deep inguinal lymph node of the femoral vein. One of these deep inguinal node lies in femoral canal called node LYMPH NODE ENLARGEMENT: Lymph node enlargement may occur because of proliferation of cells of the lymp in response to antigenic stimulus or infiltration by inflammatory cells in infections involv of malignant lymphocytes or macrophages, infiltration of nodes by metastatic malignan laden macrophages in lipid storage diseases. In normal immune responses, antigen stimulation of macrophages and lymphocy lymphocytic traffic. One of the earliest effects of the antigen is to increase the blood flow 25 times of normal levels. Lymphocytes accumulate in antigen stimulated nodes by inc of lymphocyte from antigen stimulated nodes, and proliferation of responding T and B normal size 5 to 10 days after antigen stimulation. DISEASES ASSOCIATED WITH LYMPHADENOPATHY: In childhood, the lymphoid system grows rapidly. Possibly as a result of antigeni parts of the body is an almost universal finding. Thus nearly all children under 12 years nodes. In adults inguinal node enlargement is commonplace, presumably secondary to generated by multiple minor injuries to the lower extremity. Enlargement of other super the same reason, such as repeated hand injuries in manual labourers. History and Examination: Enlargement of lymph nodes require investigation when there are one or more n diameter, and not known to arise from a previously recognised cause. However, this is
  12. 12. new multiple or single smaller lymph nodes may warrant investigation. While taking his following points are particularly noted: 1. Age : Hodgkin’s disease, tuberculosis, syphilisare disease of the young, wher old age 2. Duration: In acute lymphadenitis is short, whereas it is long in chronic lymphad 3. Which group was first affected? In case of generalised involvement of the lym was first affected as it may give some clue to the diagnosis for example cervical Hodgkin’s lymphoma. 4. Pain: lymph nodes are painful in both acute and chronic lymphadenitis but are carcinoma etc. 5. Fever: evening rise in temperature is a characteristic feature of tuberculosis. In disease intermittent bouts of recurrent fever is quite peculiar. So called Pel-Ebsta 6. Primary focus: whenever the lymph nodes are enlarged, it is usual practice to lymph nodes for the reason of lymph node enlargement. On examination : The following Important factors should be considered in assessing th 1. The Node location: The location of enlarged lymph nodes may suggest important clu nodes are frequently present in scalp infections, Toxoplasmosis, and rubella, where the eyelids and conjunctiva, Lymphomas commonly involve cervical lymph nodes an occipital nodes as well. Enlarged suppurative cervical nodes are seen in mycobacte lymph node enlargement suggests lymphoma or non lymphoid head and neck malig enlargement is always significant and frequently results from metastasis from intrath lymphoma. Virchow’s node is an enlarged left supraclavicular lymph node infiltrated gastrointestinal tract. Unilateral axillary adenopathy can be seen with breast carcino disease. Unilateral epitrochlear node enlargement is usually due to hand infections, Sarcoidosis and secondary Syphillis. Bilateral inguinal adenopathy can be seen in v
  13. 13. lymphogranuloma venereum and syphilis are associated with unilateral inguinal ade enlargement without obvious infection suggests malignant disease. Femoral node e Pasteurella Pestis infection and lymphomas. Enlargement of deeply situated lymph nodes may present by indirect evidence. or mediastinal node enlargement. These patients may present with cough or wheez nerve compression with hoarseness, paralysis of diaphragm, dysphagia with oesoph arm due to superior vena cava or subclavian vein compression. Enlarged retroperit limbs. Intra abdominal lymph nodes may sometimes be palpable in thin subjects. 2. The physical characteristics of the peripheral lymph nodes are important. Nodes o discrete but occasionally they are matted. Tuberculous lymph node are matted and are usually hard and may be fixed to underlying tissue. In acute infections, nodes a and the overlying skin may be erythematous. 3. The clinical setting is also important in assessing lymphadenopathy. In a young c node enlargement, infectious mono nucleosis syndromes are important to consider. drug abusers with systemic lymphadenopathy, the acquired immunodeficiency synd lymphadenopathy Liver and Spleen should be palpated for enlargement and nodula Good physical examination techniques for palpation and assessment of lymph node which diagnostic and therapeutic decisions can be based. For serial evaluation of n size, location, consistency soft and mobility at each examination is critical. For cerv of the seated patient to palpate the the neck and to examine in sequence the sites o Central axillary nodes are located near the middle of the thoracic wall of the axilla part of the humerus along the axillary vein and are best felt by having the patients a the anterior edge of the latissmus dorsi muscle and pectoral nodes are beneath the muscle. Infraclavicular nodes can be felt under the distal end of clavicle and may re Epitrochlear nodes are located approximately 3 cm proximal to the medial h
  14. 14. is best accomplished by paplation of epitrochlear node area in an anterior to poster Enlarged abdominal lymph nodes can be difficult to palpate and may be fe nodes are best evaluated with deep palpation of the lower abdomen by rolling the ex CAUSES OF LYMPH NODE ENLARGEMENT: Infection: Bacterial: Streptococci, staphylococci, anthrax, brucellosis, Pasteurella, Salmonella, H infections: Tuberculosis, leprosy Viral: Infectious mononucleosis syndrome (cytomegalovirus, EB Virus), Human Immuno zoster. Fungal: Coccidioidomycosis, histoplasmosis Chlamydial infections: Lymphogranuloma veneram, trachoma. Parasitic injections:Microfilariasis, trypanosomiasis. Spirochetal-diseases: Syphillis, yaws, leptospirosis, toxoplasmosis NEOPLASTIC A. HEMATOLOGIC – Hodgkin’s disease, lymphomas, malignant histiocytosis & leu B. METASTATIC TUMORS OF LYMPH NODES: Breast, Melanoma, Seminoma, tumo gastrointestinal tract, Kapsoi’s sarcoma Neuroblastoma.
  15. 15. C. IMMUNOLOGICAL DISEASES a) Rheumatoid arthritis b) Systemic lypus erythematosis c) Dermatomyositis d) Serum Sickness e) Drug reactions: Phenytoin, hydralazine, Allopurinol. f) Angio immunoblastic lymphadenopathy. D. ENDOCRINE DISEASE: hyperthyroidism E. LIPID STORAGE DISEASE: Gaucher’s and Niemann-Pick diseases F. MISCELLANEOUS a) Giant follicular lymph node hyperplasia b) Sinus histiocytosis c) Dermatopathic lymphadenitis d) Sarcoidosis e) Amyloidosis f) Muco cutaneous lymph node syndrome.
  16. 16. INVESTIGATION The investigation of lymphadenopathy can be organised according to where nod lymphadenopathy patients do not require a biopsy and atleast half require no labora findings point to a benign cause for lymphadenopathy, then careful follow up at 2 to should be instructed to return for re-evaluation if the node(s) increase in size. Routine investigations should include a full blood count, erythrocyte sedimentatio may be diagnostic in Leukemia, or point to a viral cause such as glandular fever. Ad radiograph, biochemical profile, and antibody screening for an infective cause togeth Chest Radiograph: Useful in assessment of the amount of medistinal disease, hilar mediastinal gland enlargement is seen in Tuberculosis, sarcoidosis, lymphomas, me histoplasmosis. ULTRASONOGRAPHY: Is useful in screening patients suspected of abdominal lymph or secondary to some malignancy. Its resolution is not as good as that obtained with C response, but even then it is highly operator dependent. COLOUR DOPPLER SONOGRAPHY : Colour Doppler Sonography is proving useful in lymphadenopathy. On colour doppler the patterns of hilar vascularity, central nodal vas assessed. The highest resistive index and pulsatility index are measured from special disease 98% nodes with malignant disease and 100% of tuberculous nodes show abno for the resistive and pulsatility indexes were highly specific for malignant lymphadenopa CONTRAST ENHANCED CT (CECT): In recent year CT has become the main radiolo enlargement in the mediastinum, abdomen and pelvis. It is non invasive and has the a revealing enlargement of and can also detect enlarged nodes in the mediastinum that m radiograph. It may also detect large deposits in the liver and spleen. In mediastinal tub central low attenuation and peripheral rim enhancement suggests active disease, and f
  17. 17. suggested inactive disease. Low attenuation areas within the nodes had pathologic co may be a reliable indicator for disease activity. In abdominal tuberculous lymphadenop peripheral rim enhancement and of multilocular appearance. The enlarged lymph node diameter. Lymphadenopathy caused by hematogenous dissemination often accompan density foci in the spleen. The predominant sites of lymphadenopathy of disseminated hepatogastric ligamentous, mesenteric and both upper and lower portions of the retrop Tuberculosis all the above lymph nodes excluding the lower retroperitoneal lymph node lymph nodes nor distinguish infiltration from reactive hymperplasia. In lymphomas it is retroperitoneal, iliac and mesenteric lymph node groups and can also detect enlarged n apparent on the plain chest radiograph. M.R. EVALUATION : Magnetic resonance imaging (MRI) can help in distinguishing lym Tuberculosis, Hodgkin’s lymphoma and metastatic lymph node enlargement Tuberculo and T2W1, on contrast injectionmultiple hypointense foci can be seen. The metastatic hypointense foci in T2W1, whereas the lymphomatous lymph nodes revealed heteroge revealed mild to moderate type of enhancement, the metastatic nodes revealed dense non contrast images. FINE NEEDLE ASPIRATION CYTOLOGY/BIOPSY (FNAC/B): This is a simple proced involved. However aspiration of deep central lymph nodes require the assistance of ra endoscopy. Central lymph nodes are localized and aspirated under fluoroscopic, ultras guidance. Fiberoptic bronchoscopy, thoracoscopy and medistianoscopy can aid in asp to visualize abdominal lymph nodes and aspirate them by laproscopic procedures. However the accuracy of FNAC deplends on the experience of the clinician taking th reasonably competent cytologist certain diagnoses are relatively easy. Well differentiat problems, nor does the confirmation of highly malignant cells. Malignant lymphoma ca lymph node. Malignant lymphocytes in a neck node with a normal blood film confirm th granulomatous lymph node enlargement Fine needle aspirations could be a valuable m
  18. 18. studies. The histopathological criteria used for diagnosis for tuberculosis is presence o and presence of necrotic material with or without epitheloid cells. The entire smear is s AFB under oil immersion and part of aspirated material should be cultured on a pair of 37 C for 8 weeks. The growth once evident is examined by Z-N staining for acid fast ba Gaining experience in Fine needle aspiration cytology has considerably reduced the a diagnosis in clinical enlargement of lymph nodes. When tissue is required by patholo Needle biopsy may prove to be useful. LYMPH NODE BIOPSY: There are five main reasons for performing a lymph node biopsy. They are: 1. To make a diagnosis in a case of persistent unexplained lymph node enlarge How long should one abserve an unexplained enlarged lymph node before generally applicable answer to this question. So, much will depend on the circu demands immediate exploration regardless of the length of history. Conversely, children, should seldom be removed at all unless there are other indications. 2. To confirm a diagnosis suspected on other grounds. The clinical history or fin suggestive of malignant disease, but even where the primary tumor is obvious, r for example, to discover the histological type of a bronchial carcinoma, as a nec the presence of multiple nodes in different groups may suggest a malignant lymp confirm and elaborate on this diagnosis. 3. To make a diagnosis or assist in the investigation of a patient who has unexp accompanied by lymphadenopathy. 4. To assess the extent of spread of known malignant disease. 5. To monitor the progress of disease in patients with malignant lymphoma. Tw nodes persisting after therapy which would normally be effective in that particula appear in a patient previously in remission after effective therapy.
  19. 19. Technique of lymph node biopsy: It may be easy enough to remove a normal lymph node, but it often requires grea node. For the interpretation of a difficult lymph node biopsy it is important not only that should be subjected to the minimum of trauma in the process of removal. A badly traum Choice of node for biopsy is also important. If there is only a single enlarged no other hand, there is widespread lymphadenopathy, then other considerations apply. In adults, because they so ofen show scarring or other evidence of past lymphadenitis wh infrequently show fatty involution of their centres, so that from the histopathologist’s poi preferred. The most accessible node is not always the best one to remove and, generally, s pathologist is the largest one available. All too often the surgeon is tempted to remove representative and the diagnosis may consequently be missed. If there are multiple en easily achieved and may give more information than can be obtained from a single nod alike. However, there are occasions when it is necessary to obtain material from thorac biopsied on mediastinoscopy, but it is often difficult to get a satisfactory (i.e. untraumati to resort to open operation to make a diagnosis. Scalane node biopsy often provides u disease eg. Sarcoidosis or Carcinoma. Abdominal nodes are commonly removed in sites of removal of such nodes may be indicated by small metal clips to enable subsequ preoperative/pretreatment lymphangiogram. On receipts, the fresh node should be cleanly sliced in half with a new scalpel bla suggest infection, one half of the node should be immediately placed in a dry sterile con investigations. The other half of the node may then be placed in fixative. An excised l where a diagnosis of HIV infection seems likely, and gloves should always be worn wh Imprints are useful, not only for showing the appearance of the cells in a cytologi Romamowsky method, for comparision with blood or bone marrow smears, but also fo
  20. 20. LYMPHANGIOGRAPHY: Bilateral lower limb lymphangiography is an excellent method for defining abnorm area lymph nodes, and is reportedly accurate in detecting abnormalities in these areas technique does not help in defining abdominal nodes above the level of the kidneys or 10 to 25 percent of equivocal or false negative results. False positive results are quite lymph nodes for some time, and can be used to follow the progress of disease during th disordered architecture in normal sized lymph nodes. The use of lymphangiography has declined significantly after introduction of CT s complimentary, with similar individual sensivities and specificities. Lymphangiography performed. CT Lymphangiography Mesentric and high para-aortic Internal node structu Advantages lymphnodes can be delineated. Images persist for mo Of little value for dia Needs fat for resolution thus not good in in normal size nodes thin patients Disadvantages Does not image node Cannot determine internal node structure and spleen or in mese reaction to contrast d LYMPHOMAS: The lymphomas are malignant neoplastic proliferations of cells of the immune sy involved and progressive lymphadenopathy is the most common presentation. Historically the lymphomas have been separated on histological grounds into Ho distinction is being partially eroded with better understanding of the biology of these con lymphomas (of any histological sub type) are of B cell origin, with about 10 to 20 percen Non-Hodgkin lymphoma accounts for more than three quarters of the cases of ly
  21. 21. presented in an extra nodal site such as the gut or skin, of which only four percent were always be considered in a patient presenting with signs or symptoms affecting multiple malaise, or unexpected weight loss. The most common manifestation of lymphoma is lymphadenopathy. Most clinica nodes in the neck or axillae, although involvement of internal lymph nodes (principally m by further investigation. Involvement of lymphoid tissue in other sites (extranodal involv lymphoma than in Hodgkin’s disease. Indeed, primary extra nodal lymphomas are virtu sites most commonly involved are the submucosal tissues of the intestinal tract (includ bone marrow, liver and bronchial mucosa, no site is immune. Hodgkin’s disease appears to spread from node to contiguous mode via the lymp widespread. Non-Hodgkin’s lymphoma spread via the blood stream, and often involve so after malignant transformation, they are thus best considered as systemic disorder. In general the incidence of lymphomas increase with age, and most patients that principal exception is Hodgkin’s disease, which has in addition, a peak incidence early The diagnosis of lymphoma is often strongly suggested by the history and clinica affected tissue is required to establish the diagnosis and to distinguish between Hodgk Surgical lymph node biopsy remains the ‘gold standard’ for determining the histo aspiration of enlarged lymph nodes can be useful in distinguishing reactive from patho frequently difficult to interpret and every effort should be made to obtain an adequate sa knowledge can be obtained about the origin of the lymphoma from immuno-chemistry, tissue. Biopsy samples should not, therefore, be placed automatically into formalin or o before the biopsy is done to ensure prompt and correct handling. PATHOLOGY: Pathological diagnosis of Hodgkin’s disease is the presence of characteristic gia
  22. 22. histological setting. Rye histological classification of Hodgkin’s disease: Subgroup Major Histological features Approximate Frequency Lymphocyte Abundant normal appearing lymphocytes 2-10% Predominance with or without benign histiocytes, rare RS.Cells Nodular Sclerosis Nodules of lymphoid infiltrate of varying size, separated by bands of collagen and containing 40-80% numerous “lacunar cell” variants of R-S cells Mixed cellularity Pleomorphic infiltrate of eosinophils, Plasma cells, histiocytes and lymphocytes 20-40% With numerous R-S cells Lymphocytic Paucity of lymphocytes with numerous R-S cells Depletion often bizarre in appearance, may have diffuse fibrosis 2-15% or reticular fibres NON-HODGKIN’S LYMPHOMA: It has been said that nowhere in the field of pathology has there been more confu classification of the Non-Hodgkin’s lymphoma. The most widely used classification is th Modified Rappaport classification of Non-Hodgkin’s Lymphoma Nodular Sub types Lymphocytic poorly differentiated
  23. 23. Mixed lymphocytic and histiocytic Histiocytic Diffuse sub types Lymphocytic well differentiated Lymphocytic poorly differentiated Mixed, lymphocytic and histiocytic Lymphoblastic Lymphoma Histiocytic Undifferentiated (Burkitt’s or non-Burkitt’s types) STAGING It is important to determine as accurately as possible the full extent of involvemen bearing on Prognosis and selection of treatment. Truly localized disease can be effecti of cure. Chemotherapy is appropriate for more widespread disease. The staging class Widespread use. Ann Arbor staging classification Stage I Involvement of a single lymph node region (I) or of a single extralymphatic orga Sage II Involvement of two or more lymph node regions on the same side of diaphrag or site and of one or more lymph node regions on the same side of the diaph
  24. 24. Stage III Involvement of lymph nodes on both sides of the diaphragm (III). There may of extra lymphatic organ or site (IIIE). Stage IV Involvement of extranodal sites, other than by direct invasion from an affecte For each stage, qualifier ‘A’ or ‘B’ is used. ‘A’ denotes the absence and ‘B’ presence sweats. Staging Laparotomy: The use of staging laparotomy has markedly declined in recent (a) advent of CECT, which is non invasive and delinerates the intra abdo infiltrates. (b) absence of clear survival advantage for groups of patients who have b (c) success of chemotherapeutic regimens in controlling the disease and stage of disease. (d) Splenectomy carries a small but significant morbidity, risk of overwhel Staging laparotomy should include detailed inspection of the abdomen. The rem disease is identified in spleen total number of nodules should be enumerated. Ex right lobe, three needle biopsies of the right and left lobes and a biopsy of any gr palpation of the nodal groups, a biopsy should be taken from the right and left pa removed from splenic hilar, porta, hepatic and mesenteric regions. Iliac bone ma operation. BIBLIOGRAPHY 1. LYMPH NODE PATHOLOGY, Second Edition, Harry L. loachim. J.B. Olippincott Company, Philadelph 2. Slevens A, Lowe J. Histology. London: Gower Medical Publishing 1992 3. Ehrich, W.E.: The role of the lymphocyte in the circulation of lymph . Ann. NY Acad Sci, 46:823, 1946 4. Arno J 91980) Atlas of lymph node Pathology M.T.P. Press, Lancaster. 5. GAG Decker, D.J. Dee Plessis: Lee Mc Gregor’s Synopsis of SURGICAL ANATOMY 12th Ed. (1986)
  25. 25. 6. Suen J.Y., Goeptent H: Editorial standerization of neck dissection nomenclature., Head Neck Surg 1 7. Shah J.P., Strong E, Spiro RH, Vikram B: Neck dissection: current status and future possibilities. Cl 8. Turner – warwick RT. The lymphatics of the breast Br J Surg. 1959, 46: 574-82 9. Butcher E., Weissman I, Lymphoid tissues and organs in WE Paul (ed). New York, Raven 1984 pp 109 10. Na DG, Lim HG, Byun HS, Kim HD, K.YH: Differential diagnosis of cervical lymphadenopathy. Usefuln Mar, 170(3): 715-718 11. Yang 2, Sone S, Min P, etal. Distribution of contrast enhanced CT appearance of abdominal tuberculo 12. Bergsagel. D.E. etal (1982) Results of treating Hodgkin’s disease without a policy of laparotomy stag 13. Carbone P.B., Kaplan H.S. Musshof K. Smithers D.W. and Tubiana M. (1921). Report on the committe 31, 1860-1

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