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LYMPHADENOPATHY. By. Prof. Dr. Sameh Shamaa. Def.: It is an abnormal increase in size, or altered consistency of L.N . & is a clinical manifestation of regional or systemic disease & serve as an excellent clue to the underlying pathology and aetiology .

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slide1

LYMPHADENOPATHY

By

Prof. Dr. Sameh Shamaa

slide2

Def.:

It is an abnormal increase in size, or altered consistency of L.N. & is a clinical manifestation of regional or systemic disease & serve as an excellent clue to the underlying pathology and aetiology.

slide3

Causes of Localised Lymphadenopathy

  • 1- L.N Draining a Septic Focus:
    • * cervical : tonsilitis, scarlet fever, scalp infection.
    • * periauricular: otitis media.
    • * axillary : infections of fingers
    • * inguinal : infections of lower extremities.
    • * popliteal : infections of heel.

2-Carcinomatous L.N. Draining a Malignant Tumour:

* hilar and scalene: bronchus.

* virchow’s: stomach

* cervical: thyroid, tongue, parotid.

slide4

Causes of LocalisedLymphadenopathy(2)

3- Systemic Infections

* Viruses: a- Viral hepatitis Rt. supraclavecular L.N

b- L.G.V. --groin (ing LN)

c- German measles (cervical LN)

* Bacteria: a- Plague

b- T.B

* Spirochetes : (Iry $ draining chancer)

a- penis inguinal L.N.

b- lips submandibular L.N.

c-nipple axillary L.N.

* Protozoa a -Filarial infectious-----inuguinal L.N.

N.B Generalized L.N. may start as localized L.N. as in Hodgkin’s disease

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Causes of Generalised Lymphadenopathy

I- Infectious

* Viruses:

a-Infectious mononucleosis b-Cytomegalo virus (C.M.V.)

* Bacteria: a- brucellosis

b- T .B.

*Spirochetes:

(2ry $)

*Protozoa

a-kalaazar

b-toxoplasmosis.

slide6

Causes of GeneralisedLymphadenopathy(2)

  • 2- Leukaemias: especially chronic lymphocytic leukamia (C.L.L.)
  • 3- Lymphomas:a- Hodgkin’s disease (H.D.)
  • b-Non- Hodgkin’s lymphoma (N.H.L)
  • 4- Collagenosis: a-rheumatoid artheritis.
          • b- Felty’s syndrome.
          • c-Still's disease.
          • d- D.L.E.
  • 5-Allergy: e.g., - Serum sickness.
  • 6- Sarcoidosis
  • 7- Lipoidosis
  • 8-Miscellaneous
slide7

Characters of L.N. Enlargement in Some Diseases

1- Streptococcal infection of tonsils:

*Uni or Bilateral * Tender & unmatted

*Usually submandibular but may extend to lower cervical group.

2- Scarlet Fever

* Sore throat.

* marked enlargement of submandibularL.N.

*Other cervical L.N. (bilateral, tender, discrete, suppuration is common).

3-Diphtheria

*Enlarged submandibularL.N. usually bilateral, tender, not matted.

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4-German Measle:

*OccipitaIL.N. enlargement are nearly always present, closely resembles that of infectious mononucleosis.

5-Infectious Mononucleosis:

* Sore throat, Fever, sometimes headache, myalgia.

* Bilateral L.N. enlargement, firm, discrete, mobile.

* Appear first in posterior cervical area, adjacent to cervical spines, few days later , submandibular L.N. will be enlarged

* Palatal petechiae often, are present

* Mild splenomegally in 50% of cases

*Lymphocytosisin 75% of cases with some atypical lymphocytes.

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6- T.B.:

* The chiefly affected group is upper cervical group, generalized L.N. enlargement is exceptional.

* Unilateral or Bilateral.

* Often firm, matted, painful, may become adherent to skin or deep structures.

* Cystic areas may occur due to caseation and later on cold abscess formation.

*Overlying skin may break down giving T.B. ulcers or sinuses.

slide10

7-Syphilis:

*Iry $:-

L.N draining a chancre

-Rocky hard, uni Or bilateral, not tender.

*2ry $:-

-Generalized L.N. enlargement especially posterior triangle of the neck or epitrochleargp

(slightly enlarged, shotty, discrete, painless).

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8- LYMPHOMATOUS L. N:

*May be associated with constitutional symptoms.(anorexia, fever, weight loss, sweating, ….. etc).

* Pel Ebstein fever: may be observed in H.D., it is a period of fever lasting for few days or weeks alternating with longer or shorter apyrexial periods .

* L.N. usually discrete at start & not tender (but may become tender during febrile periods).

* L.N. may increase in size during pyrexial periods and decrease in size during apyrexial periods

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a-H.D.:

  • * may be confined to one group at first esp. lower cervical group then later on generalized L.N. enlargement.
  • Glands are:
  • a- moderately enlarged, not tender.
  • b- Firm, rubbery in consistency.
  • c- Discrete, mobile however as a result of later extension outside the capsule glands become matted or fixed
  • b-N.H.L:
  • *Also the cervical group is firstly affected
  • *Rapid rate of growth results in large number of variable sized nodes which are hard in consistency, tend to become fused and fixed to deep structures & may give pressure manifestations.
slide13

9- LEUKAEMIC L. N:

*May be associated with general manifestations (fever, malaise, anorexia, headache, Hemorhagictendency)

a- Acute Leukaemia:

*Late, slightly or moderately enlarged

*Soft, discrete esp. cervical L.N. due to oral sepsis

*May be tender bone.

b-C.L.L:

* May affect cervica1 L.N. but mostly all superficial L.N. are enlarged.

*The glands usually are (firm, not tender, not matted, usually moderately enlarged, but in advanced stages may be markedly enlarged)

c-C.M.L.:

*Rare to be manifested by L.N. enlargement.

slide14

10- CARCINOMATOUS L.N.:

*Firm, but some times hard.

*A stoney hard nodes fixed to underlying tissues are nearly always neoplastic in nature, however the reverse is not true.

*Carcinomatous L.N. may be freely mobile

slide15

Clinical Approach

Presentation:

* Swelling

* Constitutional symptoms (fever, sweating, loss of wt., pruritis)

* Pressure symptoms:

-Mediastinal syndrome

- Pressure on veins →oedema

- Pressure on nerves → pain

Age:

* T.B.: usually in children and young adults.

* H.D. : any age including childhood, but its highest incidence ( ) (20-40 ys)

* N.H.L.: usually at middle age and late life.

* Acute Leuk.: any age, but highest in first 6 years of life.

slide16

History:

* of infections, drugs, or vaccinations.

Distribution:

* Localized or generalized.

* Single or multiple groups affected.

Characters mentioned before.

Other Signs:

*Fever:Leuk., H.D., N.H.L., PelEbsteinfever.

*Jaundice :H.D.,Chronicleuk. (due to hepatic infiltration → pressure on bile duct)

*Eye: in leuk. (infections, sub conj. Hge., exophthalmos.)

* Mouth, Tonsils, Parotid, Gums.

slide17

* Skin:

  • -pruritis, esp. H.D., N.H.L., Leuk.
  • - Rash in L.G.
  • - skin nodules in C.L.L., NHL.
  • - herpes zoster in H.D.
  • * Genitalia: chancre, chancroid, ulcer, gonorrhea
  • *Mediastinum & Chest : mediastinal syndrome, pleural effusion.
  • * Tenderness of sternum : in C.M.L.
  • *Bone tenderness. & Pathological fractures : in H.D. & N.H.L.
  • *Abdomen:
  • - ascitis and masses
  • - liver:
      • i- acute leuk : late & slightly enlarged.
      • ii-C.M.L. : firm & smooth
      • iii- C.L.L. : enlarged liver
  • - spleen : huge in C.M.L. & may be friction rub
slide18

* N.B.: in H.D.:

2/3 moderately enlarged spleen.

I /3 moderately enlarged liver.

in Sarcoidosis :hepatosplenomegaly in 1/3 of cases

* Limbs : bone aches, swelling, joint affection.

* C.N.S:

- esp. M.D. & N.H.L.

- brain & spinal cord : Hge, meningeal infiltration, pressure manifest.

- peripheral nerves: pain, parathesia.

-mediastinum : Horner's syndrome, or vocal cords

slide19

Investigations

*For cases of genera1ised lymphadenopathy or local L.N. enlargement without local cases:

(1) Complete clinical examinations.

(2) C.B.P. & E.S.R.

(3) Serological tests for infections mononucleosis,T.B. toxoplasmosis, $.

(4) Plain chest X ray.

(5) Biopsy.

(6) Bone marrow aspiration if leuk. is suspected from C.B.P.

* Biopsy should be done for enlarged L.N. of more than one month duration and not responding to usual ttt.

slide20

* According to L.N. biopsy ?: if:

- +ve→ management.

- -ve (single reactive hyperplasia) →follow up & if persist repeat biopsy two months later.

Isolated Mediastinal L.N. Enlargement occurs in:

- H.D. & N.H.L.

- T.B. & Sarcoidosis.

- Cancer lung or oesophagus.

Isolated Abdominal L.N. Enlargement occurs in:

- H.D & N.H.L

- Metastasis.

slide21

Staging of Lymphoma

A- Clinical staging:

1-Detaild history esp. in systemic symptoms.

2-Clinical examination including the Waldeyer's ring & areas of bone metastasis.

3-Adequate surgical biopsy

4- Routine lab. tests (C.B.P. & E.S.R & liver kidney function tests & Serum Uric acid.)

5- Plain chest X ray (P.A & Lat. view)

6- Bilateral lower extremities lymphangiography.

7- Radiological examinations (G.I.T., Gastroscopy if + veWaldeyer's ring)

8- Abdominal Ultrasonography or C.T. Scan.

slide22

B- Pahological staging:

1- Bone narrow biopsy.

2- Staging labarotomy. (only indicated in H.D with clinical stage I & II, if theraputic decision will depend on the identification of occult abdominal involvement) .

slide23

The Ann Arbor Staging Classification:-

Stage I* Involvement of single L.N. region (I)

* Or single extra nodal organ or site (IE*)

Stage II.

*involvement of two or L.N region on the same side of the diaphragm (II).

*or. localised involvement of an extranodal organ or site will one or more L.N. regions on the same side of the diaphragm (IIE*).

slide24

The Ann Arbor Staging Classification:-

Stage III

III: involvement of L.N. regions on both sides of diaphragm.

IIIs: may be also accompanied by splenic enlargement

IIIE* : or by localized involvement of an extranodal site.

IIISE* : or both.

Stage IV

* Diffuse or disseminated involvement of one or more extranodal organs with or without associated L.N. involvement.

slide25

NB.

  • * Any of them is further subdivided into:
  • A : without systemic symptoms.
  • B : with systemic symptoms
  • * (E) means very limited extra- lymphatic disease (both in site & extent) subjected to define ttt by radiotherapy. e.g:
        • i: L.N. + adjacent bone
        • ii: Ant. mediastinum + sternal invasion.
        • iii: Mediastinal L.N. + adjacent lung tissues.