Lymphadenopathy and Malignancy

1
Lymphadenopathy and Malignancy

2
Outline

• Introducing
• Historical Clues
• Physical Examination
• Nodal Character and Size
• Diagnosis and Management
• Lymph Node Biopsy

3
Introducing

• Lymphadenopathy
• an abnormality in the size or
• character of lymph nodes
• Categories of Lymphadenopathy MIAMI
  Malignancies, Infections, Autoimmune disorders,
  Miscellaneous and unusual conditions, and
  Iatrogenic causes
• The most concerning to the patient and physician
  the possibility of underlying malignancy
• Low Rate of Malignancy in Primary Care
• 1.1 of pts presenting to the office with
  unexplained lymphadenopathy

4
Historical Clues

• Age and Duration
• Exposures History
• Associated 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 Hodgkins/
  non-Hodgkins 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 carcinoma
• Occupational exposures to silicon or beryllium
• Sexual history and orientation. AIDS pts
• Family history

7
Medications That Can Cause Lymphadenopathy

• Allopurinol (Zyloprim)
• Atenolol (Tenormin)
• Captopril (Capoten)
• Carbamazepine (Tegretol)
• Gold
• Hydralazine (Apresoline)
• Penicillins
• Phenytoin (Dilantin)
• Primidone (Mysoline)
• Pyrimethamine (Daraprim)
• Quinidine
• Trimethoprim/sulfamethoxazole (Bactrim)
• Sulindac (Clinoril)

8
Historical Clues Associated Symptoms

• Constitutional symptoms fever, fatigue, malaise
  with atypical lymphocytosis ? mononucleosis
  syndromes
• Significant fever, night sweats, unexplained BW
  loss gt 10 of normal BW ? B symptoms of
  Hodgkins lymphoma
• Arthralgias, muscle weakness, unusual rash ?
  autoimmune diseases such as RA, SLE,
  dermatomyositis

9
Physical Examination

• Head and Neck LN
• Axillary LN
• Inguinal 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 cause
• Most cases resolve quickly some entities can
  create persistent lymphadenopathy for months.
  (ex. Atypical mycobacteria, cat-scratch disease,
  toxoplasmosis, kikuchis lymphadenitis,
  sarcoidosis, Kawasakis 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 Hodgkins
  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 regions
• More likely to result from serious infections,
  autoimmune diseases, and disseminated
  malignancies.
• Specific testing is usually required.
• Generalized adenopathy infrequently occurs in
  pts 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.
19
(No Transcript)
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 Biopsy

• Once 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 Symptoms

• Lymph nodes larger than 1.5 cm in diameter in 2
  or more extrainguinal sites of 3 or more months
  duration
• Nodes 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 exam
• The cause often becomes obvious, but in more
  complicated cases, laboratory tests and lymph
  node biopsy may be necessary to establish a
  definitive diagnosis

24
Diagnostics

• Where 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 individuals
  
• Up 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 Symptoms

• Cervical nodes most commonly involved
• Usual course of lymph node disease is as follows
• Firm, discrete nodes
• ?
• fluctuant nodes matted together
• ?
• skin breakdown, abscesses, chronic sinuses
• ?
• healing and scarring

28
Diagnostics

• Fine-needle aspiration of the involved lymph node
•  
• Extra-thoracic lymph node aspiration
•  
• Positive 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
TB abscess as 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 patients
• Fluctuant 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 lymphadenitis
• Miliary TB is an important consideration in
  patients with generalized lymphadenopathy