Transcript What`s in a Node

What’s in a node ?!
Dr Hannes Koornhof
Division of Clinical Haematology
Groote Schuur Hospital
Overview
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Definition
Causes
Approach
Take home messages
Definition of lymphadenopathy
(LA)
• Lymph nodes (LNs) that are abnormal in size (>1cm),
consistency or number.
• Localized or generalized
Causes (CHICAGO)
• Cancer
• Hypersensitivity
• Infections
• Collagen vascular diseases
• Atypical lymphoproliferative disorders
• Granulomatous disorders
• Other
Cancer
• Haematological
• Lymphoma, CLL, ALL, AML
• Solid tumors
• Head & neck, breast, lung, GIT, prostate, cervix, melanoma etc.
Hypersensitivity reaction
• Drugs
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Phenytoin
Allopurinol
Carbamazepine
Atenolol
Bactrim
Penicillins
Quinine
• Serum sickness
• GvHD
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
Connective tissue diseases
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SLE (50%)
Rheumatoid arthritis
Dermatomyositis
Sjogren’s disease
Atypical lymphoproliferative
disorders
• Castleman’s disease
• Rosai-Dorfman disease
• Etc...
Granulomatous diseases
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Sarcoidosis
Wegener’s granulomatosis
Crohn’s disease
Granulomatous infections
• TB, fungi, Syphilis, Brucellosis
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
History
• Age
• 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
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
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Smoking
High risk behaviour (STI’s, HIV)
Travel
Pets
PHYSICAL EXAMINATION
Localization of nodes
• Generalized
• Systemic disease
• Cervical/submandibular
• Viral (Infectious mononucleosis), Bacterial pharyngitis, Ear
infections, TB
• Malignancies of head, neck & oral cavity
• Lymphoma
• Melanoma
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)
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Skin infections
Melanoma
Breast Ca
Lymphoma
Localization of nodes
• Epitrochlear
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Lymphoma
Infectious mononucleosis
Local upper extremity infections
Sarcoidosis
Secondary syphilis
HIV
Localization of nodes
• Inguinal (Up to 2cm can be normal; lowest diagnostic yield)
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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
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Infectious mononucleosis
Various haematological malignancies (Lymphoma, CLL, ALL, AML)
Tuberculosis
HIV
Collagen vascular disease
Sarcoidosis
Lymph node characteristics
• Size
• >1cm abnormal, especially >2cm
• Consistency
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Hard (Carcinoma)
Firm & rubbery (Lymphoma)
Matted (TB, Ca)
Fluctuant (TB)
Lymph node characteristics
• Tender
• Suggest recent, rapid enlargement (capsule stretch)
• Usually inflammatory
• Fixed
• Ca, TB
JACCOLD
• Jaundice:
• 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
Systemic examination
• As guided by symptoms and LN drainage
• ?HSM
Supportive tests
• Radiology
• CXR, Abd U/S, CT scan
• Bloods
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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?
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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
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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
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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 & carcinoma
etc.
• When in doubt, ask a colleague.
References
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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
Thanks for trying to
listen!