Other Hypothyroidism Addison’s Storage diseases Gaucher’s disease, Niemann-Pick disease
So how on earth do I approach this??! Back to 2nd year... Often you just need common sense!
Which one is not supposed to look like this....??
History Age Study from a tertiary centre: >> 79% benign vs 60% malignant if >50y Probably a bit different at primary level, but point taken Onset of symptoms Duration? Progressing? >4w or progressing: Chronic infections, malignancies, collagen vascular diseases <4w and not progressing (often localized): Most often infection e.g. Infectious mononucleosis, bacterial pharyngitis
History Systemic symptoms (Guided by localization of LNs): Specific systems e.g. Respiratory, Genitourinary, GIT, musculoskeletal General symptoms e.g. LOW, night sweats, fever, fatigue
History Previous medical history TB, HIV, Epilepsy, COPD, Previous malignancy & its treatment Previous surgical history Medication Family history Malignancy, TB contact Social Smoking High risk behaviour (STI’s, HIV) Travel Pets
Localization of nodes Supraclavicular (High likelihood for malignant) Right: Lung & breast Ca/implants, Lymphoma, TB, Esophageal Ca Left: Lung & breast Ca/implants, Lymphoma, TB, Intra-abdominal malignancy Axilliary (Drains arms, breasts & thorax) Skin infections Melanoma Breast Ca Lymphoma
Localization of nodes Epitrochlear Lymphoma Infectious mononucleosis Local upper extremity infections Sarcoidosis Secondary syphilis HIV
Localization of nodes Inguinal (Up to 2cm can be normal; lowest diagnostic yield) Cellulitis Venereal disease Lymphoma Metastatic melanoma Squamous cell carcinoma (metastatic from the penile or vulvar regions)
Localization of nodes Intra-abdominal Suggestive of malignancy, chronic infection (especially if retroperitoneal) Splenomegaly Infectious mononucleosis Various haematological malignancies (Lymphoma, CLL, ALL, AML) Tuberculosis HIV Collagen vascular disease Sarcoidosis
Systemic examination As guided by symptoms and LN drainage ?HSM
Supportive tests Radiology CXR, Abd U/S, CT scan Bloods FBC&diff, smear LDH, Uric acid, LFT’s ESR HIV & other virusses(e.g. Monospot test) RPR, ANF, s-ACE Sputum for TB (Zn, culture, GeneXpert) Throat culture
Impression after assessment Generalized LA with non-diagnostic initial assessment Localized LA with high suspicion of malignancy Investigation of choice = Excision biopsy
Impression after assessment Localized LA with non-diagnostic work-up & low suspicion of malignancy = Observe for 3-4w & reassess! If persistent, excision biopsy.
What about a fine needle aspiration? Haematologists generally want to ban the procedure… But it probably has a role… If done in the correct setting… In the correct way… With timeous follow-up of the result and subsequent lymph node excision in the likely event of a non-diagnostic FNA…
Advantages of FNA Quick, accessible Cheap Outpatient You can do it yourself Less risk of tumour seeding No scar Quick result/turnaround time…. High yield in carcinoma & TB (in the HIV setting)
Disadvantages of FNA Operator dependent Often leads to delays if inconclusive results Not the procedure of choice if lymphoma suspected & patient will likely need a excisional biopsy anyway
To improve the yield of FNA Rapid on site evaluation (ROSE) U/S guided e.g. to try and avoid necrotic areas Experienced FNA clinics Cultures Flow cytometry Molecular tests Preferences differ between institutions & health care levels
Most NB things to remember Excisional bx is diagnostic procedure of choice in >90% of literature for: Undiagnosed generalized LA Localized LA with suspicion of malignancy Non-resolving localized LA FNA has a potential role in: Pt’s with probable carcinoma or malignancy recurrence HIV-negative patients with suspected TB
Most NB things to remember Sample the largest or most abnormal LN Avoid inguinal LNs if possible (lowest yield) FNA cytology result should be available within 24-48h, so follow-up result and reassess Excisional preferred above trucut/core needle Excisional biopsy results Atypical lymphoid hyperplasia: Considered non-diagnostic (not negative) >>> Close f/u and stronly consider repeat bx Unrevealing bx in a pt with high risk of malignancy should be considered non-diagnostic (not negative)
Most NB things to remember Avoid empiric antimicrobial therapy and corticosteroids Obscure accurate diagnosis Prognostic effects Tumor lysis syndrome TB lymphadenopathy is supposed to go away with TB treatment (This includes disseminated TB diagnosed by way of abdo U/S)
Most NB things to remember Keep in mind that a patient may occasionally have 2 diagnoses e.g. TB & Hodgkin’s lymphoma HIV & lymphoma, infections, carcinoma Dermatomyositis & carcinomaetc. When in doubt, ask a colleague.
References BMJ best practice guidelines Up-to-date Some shared clinical experience Fine-needle aspiration biopsy of lymph nodes – CME 2012 Prof C Wright Clinical approach to lymphadenopathy – JK-practitioner 2011, A Abdullah