1. What’s in a node ?! Dr Hannes Koornhof
Division of Clinical Haematology
Groote Schuur Hospital

2. Overview
Definition
Causes
Approach
Take home messages

3. Definition of lymphadenopathy (LA)
Lymph nodes (LNs) that are abnormal in size (>1cm), consistency or number.
Localized or generalized

4. Causes (CHICAGO) Cancer Hypersensitivity Infections
Collagen vascular diseases
Atypical lymphoproliferative disorders
Granulomatous disorders
Other

5. Cancer Haematological Solid tumors Lymphoma, CLL, ALL, AML
Head & neck, breast, lung, GIT, prostate, cervix, melanoma etc.

6. Hypersensitivity reaction
Drugs
Phenytoin
Allopurinol
Carbamazepine
Atenolol
Bactrim
Penicillins
Quinine
Serum sickness
GvHD

7. Infections
Viral
Infective mononucleosis, HIV, CMV, Hepatitis B&C, Adenovirus, HSV, HZV, MMR
Bacterial
Strep (pharyngitis), Staph, TB, Syphillis (1° or 2°), Chlamydia (LGV)
Cat scratch disease, Brucellosis, Leptospirosis
Fungal
Histoplasmosis, Cryptococcus
Rickettsia
Tick bite fever
Parasites
Toxoplasmosis

8. Connective tissue diseases
SLE (50%)
Rheumatoid arthritis
Dermatomyositis
Sjogren’s disease

9. Atypical lymphoproliferative disorders
Castleman’s disease
Rosai-Dorfman disease
Etc...

10. Granulomatous diseases
Sarcoidosis
Wegener’s granulomatosis
Crohn’s disease
Granulomatous infections
TB, fungi, Syphilis, Brucellosis

11. Other Hypothyroidism Addison’s Storage diseases
Gaucher’s disease, Niemann-Pick disease

12. So how on earth do I approach this??!
Back to 2nd year...
Often you just need common sense!

13. Which one is not supposed to look like this....??

14. History

15. History Age Onset of symptoms
Study from a tertiary centre: <30y >>> 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

16. 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

17. History Previous medical history Previous surgical history Medication
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

18. Physical examination

19. Localization of nodes Generalized Cervical/submandibular
Systemic disease
Cervical/submandibular
Viral (Infectious mononucleosis), Bacterial pharyngitis, Ear infections, TB
Malignancies of head, neck & oral cavity
Lymphoma
Melanoma

20. 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

21. Localization of nodes Epitrochlear Lymphoma Infectious mononucleosis
Local upper extremity infections
Sarcoidosis
Secondary syphilis
HIV

22. 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)

23. Localization of nodes Intra-abdominal Splenomegaly
Suggestive of malignancy, chronic infection (especially if retroperitoneal)
Splenomegaly
Infectious mononucleosis
Various haematological malignancies (Lymphoma, CLL, ALL, AML)
Tuberculosis
HIV
Collagen vascular disease
Sarcoidosis

24. Lymph node characteristics
Size
>1cm abnormal, especially >2cm
Consistency
Hard (Carcinoma)
Firm & rubbery (Lymphoma)
Matted (TB, Ca)
Fluctuant (TB)

25. Lymph node characteristics
Tender
Suggest recent, rapid enlargement (capsule stretch)
Usually inflammatory
Fixed
Ca, TB

26. JACCOLD Jaundice: Anaemia: Clubbing: Oedema
Hepatobiliary 1⁰ or 2⁰ malignancy, TB, Lymphoma, Viral hepatitis
Anaemia:
Chronic disease, BM infiltration, GIT bleeding, haemolysis
Clubbing:
Lung Ca
Oedema
Lymphoedema, Venous thrombosis, SVC obstruction, low albumin

27. Systemic examination
As guided by symptoms and LN drainage
?HSM

28. Supportive tests Radiology Bloods
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

29. Impression after assessment
Generalized LA with non-diagnostic initial assessment
Localized LA with high suspicion of malignancy
Investigation 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 yourself
Less risk of tumour seeding
No scar
Quick result/turnaround time….
High yield in carcinoma & TB (in the HIV setting)

33. 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

34. 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

35. 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

36. 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)

37. 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)

38. 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 & carcinoma etc.
When in doubt, ask a colleague.

39. 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

40. Thanks for trying to listen!