1. LYMPHADENOPATHY & SPLENOMEGALY Martin H. Ellis MD Meir Hospital

2. CLINICAL ANATOMY OF THE LYMPH NODES Head & Neck – occipital, postauricular, preauricular, anterior cervical chain, posterior cervical chain, submandibular, submental, Waldeyer ’ s ring Head & Neck – occipital, postauricular, preauricular, anterior cervical chain, posterior cervical chain, submandibular, submental, Waldeyer ’ s ring Clavicular – supra and infra Clavicular – supra and infra Axillary – lateral, medial, posterior, apical Axillary – lateral, medial, posterior, apical Epitrochlear Epitrochlear Inguinal Inguinal Femoral Femoral

4. Femoral

5. RADIOLOGICAL ANATOMY OF LYMPH NODES Mediastinal Mediastinal Perihilar Perihilar Retroperitoneal Retroperitoneal Mesenteric Mesenteric Iliac Iliac

6. Hilar adenopathy (sarcoidosis) Mediastinal adenopathy (lymphoma, sarcoma, teratoma)

7. DIAGNOSIS History & Physical diagnosis History & Physical diagnosis Laboratory testing Laboratory testing CT scanning CT scanning MRI MRI Isotope scanning Isotope scanning PET-CT scanning PET-CT scanning Histologic diagnosis Histologic diagnosis

8. APPROACH TO DIAGNOSIS Localized vs. generalized (including splenomegaly) Localized vs. generalized (including splenomegaly) History History Physical exam Physical exam Special investigations Special investigations

9. CHARACTERISTICS OF ENLARGED NODES Size Size –< 1cm=normal Pain/Tenderness Pain/Tenderness –inflammation/rapid growth Consistency Consistency –stony, rubbery, firm, soft, fluctuant Matting Matting –a group of nodes that seem joined Mobility Mobility Location Location

10. DIFFERENTIAL DIAGNOSIS Congenital Congenital Acquired Acquired –Infectious – bacterial,viral,fungal,parasitic,mycobacterial –Inflammatory – autoimmune, allergic, vasculitic –Neoplastic – benign, malignant (primary,secondary) –Toxic & Metabolic – storage diseases, hyperthyroidism –Drug – hydantoin, gold –Traumatic –Idiopathic – sarcoidosis, Castleman disease –Iatrogenic – silicone implants

11. SITE-DISEASE ASSOCIATIONS SITE-DISEASE ASSOCIATIONS Occipital – rubella Occipital – rubella Supraclavicular – TB (scrofula), lung ca, gastric ca (Virchow node- Trousseau sign) Supraclavicular – TB (scrofula), lung ca, gastric ca (Virchow node- Trousseau sign) Axillary – breast ca Axillary – breast ca Inguinal – STDs Inguinal – STDs Umbilical – ovarian ca (Sister Joseph ’ s node) Umbilical – ovarian ca (Sister Joseph ’ s node)

12. Hx / PE DIAGNOSTIC eg local infection,tumor SUGGESTIVE eg mono,HIV,lymphoma UNEXPLAINED TREAT CONDITION SPECIFIC TESTING POSITIVE LOCALIZED GENERALIZED Review epidemiology Review medications POSITIVE DIAGNOSTIC POSITIVE No serious illness apparent Observe 3-4 weeks BiopsyResolved Serious illness apparent Biopsy MONONUCLEOSIS SEROLOGY PPD,HIV,HBV,CXR NEGATIVE BIOPSY ABNORMAL NODE

13. SPLENOMEGALY: DIAGNOSIS History & Physical diagnosis History & Physical diagnosis Laboratory testing Laboratory testing CT scanning CT scanning MRI MRI Isotope scanning Isotope scanning PET-CT scanning PET-CT scanning Histologic diagnosis Histologic diagnosis

14. DIFFERENTIAL DIAGNOSIS Congenital Congenital Acquired Acquired –Infectious – bacterial,viral,fungal,parasitic,mycobacterial –Inflammatory – autoimmune (SLE, Felty syndrome) –Neoplastic – benign, malignant (primary,secondary) –Toxic & Metabolic - (storage diseases eg Gaucher) –Congestive splenomegaly – portal hypertension –“ Work ” hyperplasia- chronic hemolytic anemias

15. MASSIVE SPLENOMEGALY Tumors Tumors –Lymphoma, myeloproliferative disorders, Hairy cell leukemia Infections Infections –Kala-azar (trypanosomiasis) Portal hypertension Portal hypertension Gaucher disease Gaucher disease

17. Approach to diagnosis- splenomegaly Known illnesses Known illnesses –eg lymphoma, SLE Current clinical context Current clinical context –Fever, recent travel, murmers Imaging studies Imaging studies –Size, focal lesions Histologic diagnosis Histologic diagnosis –Splenectomy, ?splenic biopsy