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What’s in a node ?! Dr Hannes Koornhof Division of Clinical Haematology Groote Schuur Hospital Overview • • • • 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 • • • • • • • 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 • • • • SLE (50%) Rheumatoid arthritis Dermatomyositis Sjogren’s disease Atypical lymphoproliferative disorders • Castleman’s disease • Rosai-Dorfman disease • Etc... Granulomatous diseases • • • • 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 • • • • 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) • • • • Skin infections Melanoma Breast Ca Lymphoma Localization of nodes • Epitrochlear • • • • • • Lymphoma Infectious mononucleosis Local upper extremity infections Sarcoidosis Secondary syphilis HIV 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) Localization of nodes • Intra-abdominal • Suggestive of malignancy, chronic infection (especially if retroperitoneal) • Splenomegaly • • • • • • Infectious mononucleosis Various haematological malignancies (Lymphoma, CLL, ALL, AML) Tuberculosis HIV Collagen vascular disease Sarcoidosis Lymph node characteristics • Size • >1cm abnormal, especially >2cm • Consistency • • • • 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 • • • • • 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? • • • • • 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 • • • • • • • • 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 • • • • • • 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 • • • • 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!
