Download to read offline
More Related Content
Similar to Approach-to-Lymphadenopathyyyyyyyyyy.ppt
![pt with inguinoscrotal swellings[1].pptx](https://cdn.slidesharecdn.com/ss_thumbnails/ptwithinguinoscrotalswellings1-250602050940-2dde0455-thumbnail.jpg?width=640&height=640&fit=bounds)
Approach-to-Lymphadenopathyyyyyyyyyy.ppt
- 1. Approach to Approach to Lymphadenopathy Lymphadenopathy Dr.FARYAL AZHAR Dr. FARYAL AZHAR
- 2. Case 1 Case 1 25 year old female 25 year old female 3 month history of B-symptoms, progressive 3 month history of B-symptoms, progressive anemia (normocytic), new adenopathy – not anemia (normocytic), new adenopathy – not painful but progressive over weeks, weight loss painful but progressive over weeks, weight loss Physical exam – diffuse adenopathy 2-3 cm in Physical exam – diffuse adenopathy 2-3 cm in size, oral ulceration - ?HSV, no organomegaly size, oral ulceration - ?HSV, no organomegaly Laboratory Investigations – Hemoglobin 60, Laboratory Investigations – Hemoglobin 60, MCV of 80, low WBC, normal platelet count, MCV of 80, low WBC, normal platelet count, normal biochemistry – high LDH normal biochemistry – high LDH
- 3. Case 2 Case 2 83 yo Female 83 yo Female Otherwise healthy Otherwise healthy 5 years ago presented with painful right submandicular 5 years ago presented with painful right submandicular node – 3X3 cm – given ABx and followed for a few node – 3X3 cm – given ABx and followed for a few months – slight decrease months – slight decrease FNA done – reactive FNA done – reactive Node persisted over months – excisional biopsy – Node persisted over months – excisional biopsy – reactive adenopathy reactive adenopathy 6 months ago – recurrent right submandicular node – 6 months ago – recurrent right submandicular node – matted, slowly increased in size – now 3X3cm matted, slowly increased in size – now 3X3cm
- 4. Objectives Objectives Approach toAdenopathy Approach to Adenopathy Who to investigate Who to investigate When to investigate When to investigate How to define risk for underlying malignancy How to define risk for underlying malignancy
- 6. Lymph Nodes Lymph Nodes Anatomy Anatomy Collection of lymphoid cells attached to both vascular and Collection of lymphoid cells attached to both vascular and lymphatic systems lymphatic systems Over 600 lymph nodes in the body Over 600 lymph nodes in the body Function Function To provide optimal sites for the concentration of free or cell- To provide optimal sites for the concentration of free or cell- associated antigens and recirculating lymphocytes – associated antigens and recirculating lymphocytes – “sensitization of the immune response” “sensitization of the immune response” To allow contact between B-cells, T-cells and macrophages To allow contact between B-cells, T-cells and macrophages Lymphadenopathy - node greater than 1cm in size Lymphadenopathy - node greater than 1cm in size
- 7. Why do lymphnodes enlarge? Why do lymph nodes enlarge? Increase in the number of benign lymphocytes Increase in the number of benign lymphocytes and macrophages in response to antigens and macrophages in response to antigens Infiltration of inflammatory cells in infection Infiltration of inflammatory cells in infection (lymphadenitis) (lymphadenitis) In situ proliferation of malignant lymphocytes or In situ proliferation of malignant lymphocytes or macrophages macrophages Infiltration by metastatic malignant cells Infiltration by metastatic malignant cells Infiltration of lymph nodes by metabolite laden Infiltration of lymph nodes by metabolite laden macrophages (lipid storage diseases) macrophages (lipid storage diseases)
- 8. Epidemiology Epidemiology 0.6% annualincidence of unexplained 0.6% annual incidence of unexplained adenopathy in the general population adenopathy in the general population 10% were referred to a subspecialist and 3.2 % 10% were referred to a subspecialist and 3.2 % required a biopsy and 1.1% had a malignancy required a biopsy and 1.1% had a malignancy
- 9. When to worry? Whento worry? Age Age Characteristics of the node Characteristics of the node Location of the node Location of the node Clinical setting associated with Clinical setting associated with lymphadenopathy lymphadenopathy
- 10. Age Age Children/young adults– more likely to respond Children/young adults – more likely to respond to minor stimuli with lymphoid hyperplasia to minor stimuli with lymphoid hyperplasia Lymph nodes in patients less than the age of 30 are Lymph nodes in patients less than the age of 30 are clinically benign in 80% of cases whereas in patients clinically benign in 80% of cases whereas in patients over the age of 50 only 40% are benign over the age of 50 only 40% are benign Biopsies done in patients less than 25 yrs have a Biopsies done in patients less than 25 yrs have a incidence of malignancy of <20% vs the over-50 age incidence of malignancy of <20% vs the over-50 age group has an incidence of malignancy of 55-80% group has an incidence of malignancy of 55-80%
- 11. Characteristics of thenode Characteristics of the node Nodes lasting less than 2 weeks or greater than Nodes lasting less than 2 weeks or greater than one year with no progression of size have a low one year with no progression of size have a low likelihood of being neoplastic – excludes low likelihood of being neoplastic – excludes low grade lymphoma grade lymphoma Cervical nodes – up to 56% of young adults Cervical nodes – up to 56% of young adults have adenopathy on clinical exam have adenopathy on clinical exam Inguinal adenopathy is common – up to 1-2 cm Inguinal adenopathy is common – up to 1-2 cm in size and often benign reactive nodes in size and often benign reactive nodes
- 12. Characteristics of thenode Characteristics of the node Consistency – Hard/Firm vs Soft/Shotty; Fluctuant Consistency – Hard/Firm vs Soft/Shotty; Fluctuant Mobile vs Fixed/Matted Mobile vs Fixed/Matted Tender vs Painless Tender vs Painless Clearly demarcated Clearly demarcated Size Size When to worry – 1.5-2cm in size When to worry – 1.5-2cm in size Epitroclear nodes over 0.5cm; Inguinal over 1.5cm Epitroclear nodes over 0.5cm; Inguinal over 1.5cm Duration and Rate of Growth Duration and Rate of Growth
- 13. Location of thenode Location of the node Supraclavicular lymphadenopathy Supraclavicular lymphadenopathy Highest risk of malignancy – estimated as 90% in Highest risk of malignancy – estimated as 90% in patients older than 40 years vs 25% in those younger patients older than 40 years vs 25% in those younger than 40 yrs than 40 yrs Right sided node – cancer in mediastinum, lungs, Right sided node – cancer in mediastinum, lungs, esophagus esophagus Left sided node (Virchow’s) – testes, ovaries, Left sided node (Virchow’s) – testes, ovaries, kidneys, pancreas, stomach, gallbladder or prostate kidneys, pancreas, stomach, gallbladder or prostate Paraumbilical node (Sister Joseph’s) Paraumbilical node (Sister Joseph’s) Abdominal or pelvic neoplasm Abdominal or pelvic neoplasm
- 14. Location of thenode Location of the node Epitroclear nodes Epitroclear nodes Unlikely to be reactive Unlikely to be reactive Isolated inguinal adenopathy Isolated inguinal adenopathy Less likely to be associated with malignancy Less likely to be associated with malignancy
- 15. Clinical Setting Clinical Setting B symptoms – fever, night sweats, weight loss B symptoms – fever, night sweats, weight loss Fatigue Fatigue Pruritis Pruritis Evidence of other medical conditions – Evidence of other medical conditions – connective tissue disease connective tissue disease Young patient – mononucleosis type of Young patient – mononucleosis type of syndrome syndrome
- 16. History History Identifiable causefor the lymphadenopathy? Identifiable cause for the lymphadenopathy? Localizing symptoms or signs to suggest Localizing symptoms or signs to suggest infection/neoplasm/trauma at a particular site infection/neoplasm/trauma at a particular site URTI, pharyngitis, periodontal disease, conjunctivitis, insect bites, URTI, pharyngitis, periodontal disease, conjunctivitis, insect bites, recent immunization etc recent immunization etc Constitutional symptoms Constitutional symptoms Epidemiological clues Epidemiological clues Occupational exposures, recent travel, high-risk behaviour Occupational exposures, recent travel, high-risk behaviour Medications – serum-sickness syndrome Medications – serum-sickness syndrome
- 17. Physical Exam Physical Exam Full nodal examination – nodal characteristics Full nodal examination – nodal characteristics Organomegaly Organomegaly Localized – examine area drained by the nodes Localized – examine area drained by the nodes for evidence of infection, skin lesions or for evidence of infection, skin lesions or tumours tumours
- 18. Approach to Lymphadenopathy Approachto Lymphadenopathy Localized – one area involved Localized – one area involved Generalized – two or more non-contiguous Generalized – two or more non-contiguous areas areas
- 23. Generalized Lymphadenopathy Generalized Lymphadenopathy Malignancy – lymphoma, leukemia, Kaposi’s sarcoma, Malignancy – lymphoma, leukemia, Kaposi’s sarcoma, metastases metastases Autoimmune – SLE, RA, Sjogren’s syndrome, Still’s Autoimmune – SLE, RA, Sjogren’s syndrome, Still’s disease, Dermatomyositis disease, Dermatomyositis Infectious – Brucellosis, Cat-scratch disease, CMV, Infectious – Brucellosis, Cat-scratch disease, CMV, HIV, EBV, Rubella, Tuberculosis, Tularemia, Typhoid HIV, EBV, Rubella, Tuberculosis, Tularemia, Typhoid Fever, Syphilis, viral hepatitis, Pharyngitis Fever, Syphilis, viral hepatitis, Pharyngitis Other – Kawasaki’s disease, sarcoidosis, amyloidosis, Other – Kawasaki’s disease, sarcoidosis, amyloidosis, lipid storage diseases, hyperthyroidism, necrotizing lipid storage diseases, hyperthyroidism, necrotizing lymphadenitis, histiocytosis X, Castlemen’s disease lymphadenitis, histiocytosis X, Castlemen’s disease
- 24. Drugs Drugs Allopurinol Allopurinol Atenolol Atenolol Captopril Captopril Carbamazepine Carbamazepine Gold Gold Hydralazine Hydralazine Penicillins Penicillins Phenytoin Phenytoin Primidone Primidone Pyrimethamine Pyrimethamine Quinidine Quinidine Trimethoprim/ Trimethoprim/ Sulfamethozole Sulfamethozole Suldinac Suldinac
- 25. Management Management Identify underlyingcause and treat as Identify underlying cause and treat as appropriate – confirmatory tests appropriate – confirmatory tests Generalized adenopathy – usually has Generalized adenopathy – usually has identifiable cause identifiable cause Localized adenopathy Localized adenopathy 3-4 week observation period for resolution if not 3-4 week observation period for resolution if not high clinical suspicion for malignancy high clinical suspicion for malignancy Biopsy if risk for malignancy - excisional Biopsy if risk for malignancy - excisional
- 26. Fine Needle Aspirate FineNeedle Aspirate Convenient, less invasive, quicker turn-around Convenient, less invasive, quicker turn-around time time Most patients with a benign diagnosis on FNA Most patients with a benign diagnosis on FNA biopsy do not undergo a surgical biopsy biopsy do not undergo a surgical biopsy
- 27. Conclusions Conclusions Lymphadenopathy –initial presenting symptom Lymphadenopathy – initial presenting symptom Reactive vs Malignant Reactive vs Malignant Probability Probability History History Physical Exam Physical Exam Biopsy if not resolved in 3-4 weeks for low risk Biopsy if not resolved in 3-4 weeks for low risk patients patients Biopsy all high risk patients – excisional biopsy Biopsy all high risk patients – excisional biopsy