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Evaluating Adenopathy:
When to Worry and
What to Do
Kate Kolibaba, M.D.
Northwest Cancer Specialists
Vancouver, WA
[email protected]
Adenopathy: Objectives
Lymphatic system basics
Causes of lymphadenopathy
Evaluation
The Lymphatic
System
What is the Lymphatic System?
Network of organs, such as the tonsils, spleen, liver,
bone marrow and lymphatic vessels that connect
“glands”, the lymph nodes
Lymph nodes located throughout the body
Lymph nodes filter foreign particles out of the
lymphatic fluid
Contain B and T lymphocytes
Lymph Node - Normal Histology
afferent lymphatic vessel
capsule
C
follicle (mainly B-cells)
- germinal centre
- mantle zone
artery
efferent lymphatic vessel
vein
Lymphatic Tissue
Lymphocytes originate in bone marrow
Lymphocytes undergo proliferation and
differentiation in lymphoid tissue
• B-lymphocytes
-
tend to reside in lymph nodes & spleen
• T-lymphocytes
-
tend to circulate throughout the lymphatic system
Lymphocytes
20% of white blood cells are lymphocytes
Most lymphocytes are in lymph nodes, spleen,
bone marrow and lymphatic vessels
T cells, B cells, natural killer cells
• B cells produce antibodies
• T cells help B cells produce antibodies and fight
viruses
Lymphadenopathy
Enlargement or change in texture of a lymph
nodes
Adenopathy
• Benign vs. malignant
• Require treatment
Evaluation
Goals of Evaluation
Identify the infrequent but serious causes
of lymphadenopathy
• History, including exposures
• Age of patient
• Location
Differential Diagnosis
MIAMI
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•
•
•
•
Malignancy
Infection
Autoimmune
Miscellaneous-sarcoidosis, hyperthyroidism
Iatrogenic-serum sickness, medications
Infectious Causes of Adenopathy
Tuberculosis
Bacterial
• Brucellosis, cat-scratch, STDs
Viral
• HIV, hepatitis, CMV, EBV, rubella
Autoimmune Causes of Adenopathy
Lupus erythematosis
Rheumatoid arthritis
Dermatomyositis
Sjogren’s syndrome
Drugs Associated with Adenopathy
allopurinol
atenolol
captopril
carbamazepine
gold
hydralazine
penicillins
phenytoin
primidone
pyrimethamine
quinidine
Trimethoprim/sulfamethoxizole
sulindac
Likelihood of Malignancy
Series of patients having biopsy:
• 21% in patients under 30
• 41% in patients 31-50
• 61% in patients over 50
Lee et al; J Surg Oncol 1980; 14: 53 – 60
Likelihood of Malignancy
Lymphadenopathy that lasts
< 2 weeks or > one year
with no size increase
is unlikely to be neoplastic
Associated Symptoms
Fever, night sweats, weight loss
• “B” symptoms, lymphoma
Fatigue, malaise, fever
• Atypical lymphocytosis,
mononucleosis
Arthralgias, weakness, rash
• autoimmune
Physical Examination
Supraclavicular most likely to be malignant
• 54-85% neoplastic in biopsy series
Axillary and Inguinal Adenopathy
Drain extremities
Often nonspecific, reactive
Up to 2 cm can be normal
Nodal Character
There is no specific size threshold that
raises suspicion
Hard, painless
• Malignant (metastatic) or granulomatous
Rubbery
• Lymphoma
Evaluation of Adenopathy
Results of initial assessment
•
•
•
•
Benign or self-limited disease
Autoimmune or serious infectious
Malignancy
Unexplained
Bazemore and Smucker, Am Fam Physician 2002; 66:
2103-2110.
Evaluation of Adenopathy
Empiric treatment
• Often antibiotics and/or corticosteroids
are prescribed, but no data exists to
support this approach
Benign or Self-Limited Disease
Treatable
Yes
Treat
appropriately
No
Reassurance,
explain course
of disease
Offer follow-up for persistent or
changing adenopathy
Suspected Autoimmune or Serious
Infectious Disease
Specific Testing
Positive
Treat
appropriately
Negative
See
“Unexplained”
Suspected Malignancy
Biopsy
Positive
Treat
appropriately
Negative
See
“Unexplained”
Unexplained Adenopathy
Review risk factors for malignancy
If high risk, proceed with excisional
biopsy
Unexplained Adenopathy
Low Risk for Malignancy
Generalized
Regional
Referral or Follow-up
Unexplained Generalized
Adenopathy
Consider miscellaneous causes
•
•
•
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Sarcoidosis
Silicosis, berylliosis
Storage diseases: Gaucher, Fabry’s
Hyperthyroidism, hypertriglyceridemia
Kawasaki syndrome
Unexplained Generalized
Adenopathy
CBC, RPR, PPD, HIV, HBsAg, ANA
Positive
Negative
Biopsy most abnormal node
Treat
Positive
Negative
Follow-up
More About Biopsies
FNA
Core needle biopsy
Excisional biopsy
Fine Needle Aspiration
FNA - Fine Needle Aspiration
• Simple - 21-23 gauge needle,5-10 cc
syringe
• Relatively atraumatic
• Sensitivity of 73-99%
• Ideal for simple cyst aspiration
• Can’t distinguish in-situ vs invasive cancer
• Can confirm relapse of known cancer
Core Needle Biopsy
CNB - Core Needle Biopsy
•
•
•
•
14 - 20 gauge cutting needle
greater trauma
high sensitivity – 80-100%
distinguishes between invasive and
in-situ
• Diagnostic of many malignancies
• Non-diagnostic for lymphoma
• Avoid bone
Open Biopsy
Open Biopsy (incisional or excisional)
• any suspicious finding
• clinical or radiologic finding with negative FNA
or CNB
• atypia on FNA or CNB
- 20-50% malignancy on open biopsy
• recurring cyst, enlarging node
Adequate Biopsy is Critical
Open biopsy required to discern reactive
(benign) from malignant lymphoid
disorder
Open biopsy required for lymphoma
• Diagnosis must be biopsy-proven before
treatment is initiated
• Need enough tissue to assess architecture
• FNA is never adequate
Diagnosing Lymphoma
Nodular (follicular)
Diffuse
Indolent
Aggressive
small cell
large cell
Lymph node biopsy – Follicular NHL
Questions?
[email protected]
A practical way to think of lymphoma
Category
NonHodgkin
lymphoma
Hodgkin
lymphoma
Survival of
untreated
patients
Curability
To treat or
not to treat
Indolent
Years
Generally
not curable
Generally
defer Rx if
asymptomatic
Aggressive
Months
Curable in
some
Treat
Very
aggressive
Weeks
Curable in
some
Treat
All types
Variable –
months to
years
Curable in
most
Treat
Relative Frequencies of Lymphoma
Non-Hodgkin Lymphomas
85%
Diffuse large B-cell
Hodgkin
Lymphoma
15%
NHL
Follicular
Other NHL
~85% of NHL are B-lineage