15 History Age Onset of symptoms Study from a tertiary centre: <30y >>> 79% benign vs 60% malignant if >50yProbably a bit different at primary level, but point takenOnset of symptomsDuration? 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
16 History Systemic symptoms (Guided by localization of LNs): Specific systems e.g. Respiratory, Genitourinary, GIT, musculoskeletalGeneral symptoms e.g. LOW, night sweats, fever, fatigue
17 History Previous medical history Previous surgical history Medication TB, HIV, Epilepsy, COPD, Previous malignancy & its treatmentPrevious surgical historyMedicationFamily historyMalignancy, TB contactSocialSmokingHigh risk behaviour (STI’s, HIV)TravelPets
20 Localization of nodes Supraclavicular (High likelihood for malignant) Right: Lung & breast Ca/implants, Lymphoma, TB, Esophageal CaLeft: Lung & breast Ca/implants, Lymphoma, TB, Intra-abdominal malignancyAxilliary (Drains arms, breasts & thorax)Skin infectionsMelanomaBreast CaLymphoma
21 Localization of nodes Epitrochlear Lymphoma Infectious mononucleosis Local upper extremity infectionsSarcoidosisSecondary syphilisHIV
22 Localization of nodesInguinal (Up to 2cm can be normal; lowest diagnostic yield)CellulitisVenereal diseaseLymphomaMetastatic melanomaSquamous cell carcinoma (metastatic from the penile or vulvar regions)
23 Localization of nodes Intra-abdominal Splenomegaly Suggestive of malignancy, chronic infection (especially if retroperitoneal)SplenomegalyInfectious mononucleosisVarious haematological malignancies (Lymphoma, CLL, ALL, AML)TuberculosisHIVCollagen vascular diseaseSarcoidosis
27 Systemic examinationAs guided by symptoms and LN drainage?HSM
28 Supportive tests Radiology Bloods CXR, Abd U/S, CT scanBloodsFBC&diff, smearLDH, Uric acid, LFT’sESRHIV & other virusses(e.g. Monospot test)RPR, ANF, s-ACESputum for TB (Zn, culture, GeneXpert)Throat culture
29 Impression after assessment Generalized LA with non-diagnostic initial assessmentLocalized LA with high suspicion of malignancyInvestigation of choice = Excision biopsy
30 Impression after assessment Localized LA with non-diagnostic work-up & low suspicion of malignancy= Observe for 3-4w & reassess!If persistent, excision biopsy.
31 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…
32 Advantages of FNA Quick, accessible Cheap Outpatient You can do it yourselfLess risk of tumour seedingNo scarQuick result/turnaround time….High yield in carcinoma & TB (in the HIV setting)
33 Disadvantages of FNA Operator dependent Often leads to delays if inconclusive resultsNot the procedure of choice if lymphoma suspected & patient will likely need a excisional biopsy anyway
34 To improve the yield of FNA Rapid on site evaluation (ROSE)U/S guided e.g. to try and avoid necrotic areasExperienced FNA clinicsCulturesFlow cytometryMolecular testsPreferences differ between institutions & health care levels
35 Most NB things to remember Excisional bx is diagnostic procedure of choice in >90% of literature for:Undiagnosed generalized LALocalized LA with suspicion of malignancyNon-resolving localized LAFNA has a potential role in:Pt’s with probable carcinoma or malignancy recurrenceHIV-negative patients with suspected TB
36 Most NB things to remember Sample the largest or most abnormal LNAvoid inguinal LNs if possible (lowest yield)FNA cytology result should be available within 24-48h, so follow-up result and reassessExcisional preferred above trucut/core needleExcisional biopsy resultsAtypical lymphoid hyperplasia: Considered non-diagnostic (not negative) >>> Close f/u and stronly consider repeat bxUnrevealing bx in a pt with high risk of malignancy should be considered non-diagnostic (not negative)
37 Most NB things to remember Avoid empiric antimicrobial therapy and corticosteroidsObscure accurate diagnosisPrognostic effectsTumor lysis syndromeTB lymphadenopathy is supposed to go away with TB treatment (This includes disseminated TB diagnosed by way of abdo U/S)
38 Most NB things to remember Keep in mind that a patient may occasionally have 2 diagnoses e.g.TB & Hodgkin’s lymphomaHIV & lymphoma, infections, carcinomaDermatomyositis & carcinoma etc.When in doubt, ask a colleague.
39 References BMJ best practice guidelines Up-to-date Some shared clinical experienceFine-needle aspiration biopsy of lymph nodes – CME 2012 Prof C WrightClinical approach to lymphadenopathy – JK-practitioner 2011, A Abdullah
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