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PERIPHERAL LYMPHADENOPATHY :

APPROACH & DIAGNOSTIC TOOLS


PERIPHERAL LYMPHADENOPATHY (LAP)
Lymphadenopathy : conditions in which lymph nodes become abnormal in size,
consistency & number
LAP located deep in the subcutaneous tissue, can be palpated if enlarge
LAP :
75% localized, 50% in head & neck area
Cervical lymph node infection >>>, supraclavicular malignancy
FNA / excisional biopsy Gold standard for etiology of LAP
Size (N) : < 1 cm (diameter)
< 1.5 cm (inguinal lymph node)
< 0.5 cm2 (epitrochlear nodes)
< 2 cm (age 2 -10 yo) > 2 cm malignancy (lymphoma) or
granulomatous disease (TB)
PHYSICAL EXAMINATION
Location : Localized vs generalized
Local disease : LAP in lymphatic-rich region / red lymphangitic streaking
Malignancy : several gruops of nodes, supraclavicular (90% > 40 yo; 25% < 40 yo)
Virchow node in left supraclavicular area intraabdominal malignancy
-Drain the gastrointestinal tract & genitourinary tract
Right side intra-thoracic malignancy
-Drain the mediastinum, lungs, esophagus
Size
Supraclavicular, iliac, popliteal, epitrochlear : > 0.5 cm
Inguinal node : > 1.5 cm
Other area : > 1 cm
Consistency
Acute inflammation : more consistent with concomitant pain tension on the caps
Chronic inflammation : hard in palpation fibrotic changes
Metastasis / Granulomatous : Stony-hard & painless
Lymphoma : Firm & rubbery node
Matted lymph node benign (M. TB & sarcoidosis) or malignant (lymphoma &
metastatic)
PHYSICAL EXAMINATION
Mobility
Freely mobile in subcutaneous : infection & cllagen vascular disease
Rubbery mobile node : Lymphoma
Fixed to the skin / surrounding tissue : Malignancy
With organomegaly (ex splenomegaly) : mononucleosis, acte lymphoma, Hodgkins
disease, non-Hodgkins lymphoma, sarcoidosis
Check the skin for malignancy (melanoma) or traumatic region
Pain & Tenderness
Non-spesific
Infection >>>>
Hemorrhage into necrotic center of a neoplastic area
Rapid tumor expansion or immunologic stimulation of pain receptor
DIFFERENTIAL DIAGNOSIS MNEMONIC
C : Cancers (HL & NHL, Leukemia, metastatic (breast, lung, kidney, others))
H : Hypersensitivity syndrome (Serum sickness, drugs)
I : Infection : viral (EBV, cytomegalovirus, HIV), bacterial (TB), fungal, protozoa, rickettsial
(typus), helminthes
C : Connective tissue disorders : SLE, RA, deratomyositis
A : Atypical lymphoproliferative disorders : Castlemans disease, Wegener
G : Granulomatous : Histoplasmosis, Mycobacterium infection, Cryptococcus, Berrylliosis,
Cat scratch disease, silicosis
O : Others
ULTRASOUND
B-mode : Assesment of number, size, site, shape, margin, internal structure
Color Doppler : vascular pattern, displacement of vascularity, vascular resistence, PI,
distinguish old LAP and recent active LAP
Criteria :
Lymph node cortical thickness & uniformity
N : Reniform shape, hypoechoic cortex with max. Thickness 3 mm, smooth
margin, central fatty hilum
TISSUE DIAGNOSIS
Increased risk of malignancy
Oliver S Soldes et al.
> 8 yo, node size diameter > 1 cm, multiple adenopathy, supraclavicular lymph
nodes, fixed nodes, abnormal CXR
NHMRC
Lymph node biopsy : age > 40 years, supraclavicular lymph node, nodal
diameter > 2.25 cm, firm-hard texture, lack of pain
HISTOPATHOLOGY
5 distinct pattern of benign LAP
Follicular hyperplasia : increase in the size & number of B-cell in the germinal center
Infection, autoimmune disorders, non-spesific reaction
Paracortical hyperplasia : extension of the T-cells in the paracortical region
Sinus hyperplasia : expansion of histiocyte cell in the medullary & cortical sinuses
Inflammation & malignancy
Granulomatous inflammation : formation of histiocytic granuloma
TB, sarcoidosis
Acute lymphadenitis : follicular hyperplasia & infiltration PMN cells
Bacterial infection
HODGKINS LYMPHOMA (WHO)
Nodular sclerosis (80%) : young adult
Lymphocyte-rich
Mixed cellularity
Lymphocyte-depleted
Nodular lymphocyte-predominant

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