2 Outline Introducing Historical Clues Physical Examination Nodal Character and SizeDiagnosis and ManagementLymph Node Biopsy
3 Introducing Lymphadenopathy : an abnormality in the size or character of lymph nodesCategories of Lymphadenopathy : MIAMI Malignancies, Infections, Autoimmune disorders, Miscellaneous and unusual conditions, and Iatrogenic causesThe most concerning to the patient and physician : the possibility of underlying malignancyLow Rate of Malignancy in Primary Care :1.1 % of pt’s presenting to the office with unexplained lymphadenopathy
4 Age and Duration Exposures & History Associated Symptoms Historical CluesAge and DurationExposures & HistoryAssociated Symptoms
5 Historical Clues : Age and Duration Malignant rate increases with age.A majority of healthy children have palpable cervical, inguinal and axillary adenopathy. Most of them is infectious or benign in etiology.Lymphadenopathy that lasts less than 2 weeks or more than 1 year with no progressive size increase has a very low likelihood of being neoplastic.Rare Exception : low-grade Hodgkin’s/ non-Hodgkin’s lymphomas and, occasionally, chronic lymphocytic leukemia
6 Historical Clues : Exposures & History Animals, biting insects, infectious contacts, recurrent infections, chronic use of medications. Travel-related exposures and immunization status.Tobacco, alcohol, ultraviolet radiation : raise suspicion for metastatic carcinomaOccupational exposures to silicon or berylliumSexual history and orientation. AIDS pt’sFamily history
7 Medications That Can Cause Lymphadenopathy Allopurinol (Zyloprim)Atenolol (Tenormin)Captopril (Capoten)Carbamazepine (Tegretol)GoldHydralazine (Apresoline)PenicillinsPhenytoin (Dilantin)Primidone (Mysoline)Pyrimethamine (Daraprim)QuinidineTrimethoprim/sulfamethoxazole (Bactrim)Sulindac (Clinoril)
8 Historical Clues : Associated Symptoms Constitutional symptoms : fever, fatigue, malaise with atypical lymphocytosis → mononucleosis syndromesSignificant fever, night sweats, unexplained BW loss > 10% of normal BW → “B” symptoms of Hodgkin’s lymphomaArthralgias, muscle weakness, unusual rash → autoimmune diseases such as RA, SLE, dermatomyositis
9 Physical ExaminationHead and Neck LNAxillary LNInguinal LN
10 Lymph nodes of the head and neck, and the regions that they drain
11 Head and Neck Lymphadenopathy In one outpatient primary care study : cervical LNs are palpable in 51% of adult physicals, with the incidence declined with age.Infection is the most common causeMost cases resolve quickly; some entities can create persistent lymphadenopathy for months. (ex. Atypical mycobacteria, cat-scratch disease, toxoplasmosis, kikuchi’s lymphadenitis, sarcoidosis, Kawasaki’s syndrome.)Supraclavicular nodes are the most likely to be malignant and should always be investigated, even in children.
12 Axillary lymphatics and the structures that they drain
13 Axillary Lymphadenopathy Most of cases are nonspecific or reactive to local injury/infection in etiology.Persistent lymphadenopathy is less commonly found in the axillary nodes than in the inguinal chain.Breast adenocarcinoma often metastasis initially to the anterior and central axillary nodes, which may be palpable before discovery of the primary tumor.Antecubital or epitrochlear lymphadenopathy can suggest lymphoma or melanoma of the extremity.
14 Inguinal lymphatics and the structures that they drain
15 Inguinal Lymphadenopathy It is common, with nodes enlarged up to 1 to 2 cm in diameter in many healthy adults, but it is of low suspicion of malignancy.Benign reactive lymphadenopathy and infection are the most common etiologies.Although some tumors, such as Hodgkin’s lymphomas, penile/ vulvar SCC, melanoma in this area, may present with inguinal lymphadenopathy, it is typical presenting finding in neither case.
16 Generalized Lymphadenopathy Generalized lymphadenopathy : lymphadenopathy found in two or more distinct anatomic regionsMore likely to result from serious infections, autoimmune diseases, and disseminated malignancies.Specific testing is usually required.Generalized adenopathy infrequently occurs in pt’s with neoplasms, but it is occasionally seen in patients with leukemias and lymphomas, or advanced disseminated metastatic solid tumors.
17 Nodal Character and Size Hard and painless nodes have higher suspicion of malignancy or granulomatous disease.Viral infection typically produces hyperplastic nodes that are bilateral, mobile, nontender, and clearly demarcated.Palpable supraclavicular, iliac, or popliteal nodes of any size and epitrochlear nodes larger than 5mm are considered abnormal.Increasing size and persistence over time are of greater concern for malignancy than a specific level of nodal enlargement.
18 Algorithm for evaluation, diagnosis, and management.
20 Diagnosis and Management The first step : reviewing pts’ medications, considering unusual causes of lymphadenopathy, and reconsidering the risk factors for neoplasm. If a diagnosis is not suggested, and the patient is deemed low risk for neoplasm, the regional lymphadenopathy can be safely observed.It is suggested that non-inguinal lymphadenopathy lasting more than one month merits specific investigation or biopsy.
21 Lymph Node BiopsyOnce biopsy has been chosen, ideally the largest, most suspicious, and most accessible node is selected, taking into account differing diagnostic yields by site.Inguinal nodes offer the lowest yield, and supraclavicular nodes have the highest.Excisional biopsy remains the diagnostic procedure of choice.
22 Persistent Generalized Lymphadenopathy (PGL) Presenting Signs and SymptomsLymph nodes larger than 1.5 cm in diameter in 2 or more extrainguinal sites of 3 or more months durationNodes are non-tender, symmetrical, and often involve the posterior cervical, axillary, occipital, and epitrochlear nodes
23 Overview Swelling of lymph nodes is a frequently encountered symptom It is important to carry out a careful history and physical examThe cause often becomes obvious, but in more complicated cases, laboratory tests and lymph node biopsy may be necessary to establish a definitive diagnosis
24 DiagnosticsWhere possible, do a CBC (FBC) and chest x-ray before making a diagnosis of PGL Hilar or mediastinal lymphadenopathy on CXR
25 Management and Treatment No specific treatment for PGL
26 Unique features, Caveats Develops in up to 50% of HIV-infected individualsUp to one-third do not have any other symptom on presentation (WHO clinical stage 1)In HIV-positive patients, PGL is a clinical diagnosis. No further examinations are necessary, unless there are features of another disease PGL may slowly regress during the course of HIV infection and may disappear before the onset of AIDS
27 Tuberculosis lymphadenopathy Presenting Signs and SymptomsCervical nodes most commonly involvedUsual course of lymph node disease is as follows:Firm, discrete nodesfluctuant nodes matted togetherskin breakdown, abscesses, chronic sinuseshealing and scarring
28 Diagnostics Fine-needle aspiration of the involved lymph node Extra-thoracic lymph node aspirationPositive smears for acid-fast bacilli on fine-needle aspirates of the involved lymph nodes (high rate in HIV patients)In smear-negative pulmonary TB, it is worthwhile aspirating extra-thoracic lymph nodes to confirm diagnosis of TB (80% positive)
29 as part of immune reconstitution syndrome TB abscessas part of immune reconstitution syndrome
30 Management and Treatment Treatment should be started following the national TB Guidelines.For further details, see Part A Module 2, Session 3.
31 Unique features, Caveats One of the most common forms of extra-pulmonary TB in HIV patientsFluctuant cervical nodes that develop over weeks to months without significant inflammation or tenderness suggest infection with M. tuberculosis, atypical mycobacteria, or scratch disease (Bartonella henselae).In severe immunocompromised patients, tuberculosis lymphadenopathy may be acute and resemble acute pyogenic lymphadenitisMiliary TB is an important consideration in patients with generalized lymphadenopathy