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

2. Definition: Lymphadenopathy
 Lymph nodes that are abnormal
in size, consistency or number
 Generalized
 Localized

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

6. “Malignancy much common
in patients more 50 yrs of
age”
NOT EXACTLY

7. Lymph node character
Size
Site
Consistency
Pain with palpation

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

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

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

21. Presentation of lymphadenopathy
 Unexplained
lymphadenopathy
 3/4 presents with
localized
 1/4 present with
generalized

22. Algorithm to evaluate
Lymphadenopathy
Attention to history and physical exam
Confirmatory testing
Indication for biopsy

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

25. Creating a Differential
CHICAGO

26. Chicago
Cancer
Malignancies: Hodgkins, NHL,
acute and chronic leukemias,
waldenstroms, multiple myeloma
(plastmocytomas)
Metastatic: solid tumor breast,
lung, renal, cell ovarian

27. cHicago
Hypersensitivity syndromes
 Drugs
 Silicone
 Vaccination
 Graft vs Host
 Serum sickness

28. Specific Medications
 Dilantin
 Sulfonamides
 Carbamazepine
 Primodine
 Gold
 Allupurinol
 Cephalosporins
 Atenolol
 Captopril

29. Chicago
Infections
Viral
Bacterial
Protozoan
Mycotic
Rickettsial (typhus)
Helminthic (filariasis)

30. VIRAL
 EBV…mono spot test
 CMV….cmv titers, immunsuppresed,
transplant recipient, recent blood
transfusion
 HIV…IV drug use, high risk sexual behavior
 Hepatitis….IV drug use
 Herpes Zoster….superficial cutaneous
nodules

31. 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)

32. 



33. Spirochete
Syphilis: Treponema
pallidum Primary localized
inguinal lymph nodes and
secondary, non-
treponemal, treponemal
Lyme disease

34. Protozoan
 Toxoplasmosis: ELISA assay,
intracellular protozoan
toxoplasmosis gondii….bilateral,
symmetrical, non-tender cervical
adenopathy
…consider undercooked meat,
reactivation in immuncompromised
host

35. chicago
Connective Tissue Disease
Rheumatoid Arthritis
SLE
Dermatomyositis
Mixed connective tissue
disease
Sjogren

36. chicago
Atypical lymphoproliferative disorders
Castleman’s disease
Wegeners
Angioimmuonplastic
lymphadenopathy with
dysproteinemia

37. chicaGo
Granulomatous
 Histoplasmosis
 Mycobacterial infections
 Cryptococcus
 Silicosis: coal, foundry, ceramics, glass
 Berylliosis: metal, alloys
 Cat Scratch

38. OTHER…….chicago
 RARE
 Kikuchi
 Rosia Dorfman
 Kawasaki
 Transformation of germinal centers

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

44. THANK YOU