Dr Abhay A. Bhave, MD, FRCPA Haematologist …...Uptodate Fletcher 2008 Evaluation of Peripheral...

Dr Abhay A. Bhave, MD, FRCPA

Haematologist

Lilavati , GLOBAL Hospitals

Empire Haematology Oncology Day care centre, Bandra (W), MUMBAI

1 PUNE HAEMATOLOGY CONFERENCE 2013

PUNE HAEMATOLOGY CONFERENCE 2013 2

Size

Site

Consistency

Pain with palpation


tendertender are more likely to be due to an infectious process,

painlesspainless adenopathy raises the concern of malignancy.

consistencyconsistency

lymph nodes containing metastatic carcinoma are rock hard,

lymph nodes containing lymphoma are firm and rubbery,

lymph nodes enlarged in response to an infectious process are soft.

largerlarger the lymph node more likely to be malignant esp if > 3 to 4 cm


Right Supraclavicular

Mediastinum

Lungs

Upper 2/3 esophagus

Left Supraclavicular

Virchow node

Testes/ovaries

Kidneys

Pancreas

Prostate

Stomach

Lower Esophagus

Virchows

Left supraclavicular (abdominal or thoracic ca)

Sister Joseph

Para-umbilical (gastric adenoca)

Delphian node

Prelaryngeal (thyroid or laryngeal ca)

Node of Cloquet (Rosenmuller node)

Deep inguinal near femoral canal


CANCER

HYPERSENSITIVITY

I NFECTIONS

C ONNECTIVE TISSUE

ATYPICAL LPDS

GRANULOMATOUS

OTHERS



Investigations

History

LN biopsy

AVOID FNAC


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CHRONIC LYMPHOPROLIFERATIVE DISORDER

CLL

NHL IN LEUKAEMIC PHASE

MANTLE CELL LYMPHOMA

HAIRY CELL LEUKAEMIA

IMMUNOPHENOTYPING

CD 5+ , 19 + , 20+ , 23+, SmIG NEG

CD 5+ , 19 + , 20+ , 23 neg, SmIG NEG

CD 5+ , 19 + , 20+ , 23+, SmIG positive

CD 5+ , 19 + , 20+ , 25+, CD 103 + FMC 7 +

IMMUNOPHENOTYPING

CD 5+ , 19 + , 20+ , 23+, SmIG NEG CLL

CD 5+ , 19 + , 20+ , 23 neg, SmIG NEG

CD 5+ , 19 + , 20+ , 23+, SmIG positive

CD 5+ , 19 + , 20+ , 25+, CD 103 + FMC 7 +

IMMUNOPHENOTYPING

CD 5+ , 19 + , 20+ , 23+, SmIG NEG

CD 5+ , 19 + , 20+ , 23 neg, SmIG NEG MCL

CD 5+ , 19 + , 20+ , 23+, SmIG positive

CD 5+ , 19 + , 20+ , 25+, CD 103 + FMC 7 +

IMMUNOPHENOTYPING

CD 5+ , 19 + , 20+ , 23+, SmIG NEG

CD 5+ , 19 + , 20+ , 23 neg, SmIG NEG

CD 5+ , 19 + , 20+ , 23+, SmIG POS SLL

CD 5+ , 19 + , 20+ , 25+, CD 103 + FMC 7 +

IMMUNOPHENOTYPING

CD 5+ , 19 + , 20+ , 23+, SmIG NEG

CD 5+ , 19 + , 20+ , 23 neg, SmIG NEG

CD 5+ , 19 + , 20+ , 23+, SmIG positive

CD 5+ , 19 + , 20+ , 25+, CD 103 + FMC 7 + HAIRY CELL

Physical examination

Imaging

Chest radiography

Lymphangiography

Ultrasonography

Computed tomography

Magnetic resonance imaging

Gallium scanning

Positron emission tomography

Sampling

Needle aspiration

Cutting needle biopsy

Excisional biopsy


Can be done by bedside, open surgery, mediastinocopy or laparoscopy

FNA not recommended cannot distinguish between lymphomas (nodal architecture needs to be intact)

excisionalexcisional biopsybiopsy,

Provides the pathologist with adequate material to perform histologic,

immunologic, and genetic studies, is the most appropriate approach

FNA reserved for

established diagnosis and to demonstrate recurrence

Culture


67 year old male Left sided cervical lymphadenopathy Presented 3 years ago with swelling No history of fever or type B symptoms No other lymphadenopathy is found.

LNBiopsy done

Pressure to treat


Similar in architecture to normal

geminal centers.

Can Resemble Reactive Follicular

Hyperplasia

Low proliferation rate in

comparison to RFH

Bcl-2 staining absent in RFH

Residual benign mantle zones not

seen

Dendritic cells are present and

stains can highlight diffuse areas

FLIPI AND FLIPI 2

PARATRABECULAR AGGREGATES OF LYMPHOID CELLS

HOW DO I TREAT SUCH PATIENTS?

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13 year old female Right sided cervical lymphadenopathy persistent

2 months No history of fever or type B symptoms No sore throat, ear pain or dental problems. Vital signs are stable. O/E 3cm anterior cervical lymph node which is

firm, non-tender and mobile. Others NAD No other lymphadenopathy is found.

CT scan – no other LN group

LN biopsy done


Castleman’s Disease Hyaline Vascular


Castleman’s Disease – Plasma cell


58 year old female, obese Difficulty in vision Retinal haemorrhages CBC showed anaemia with raised ESR Right sided cervical lymphadenopathy No history of fever or type B symptoms PET CT scan Multiple LN on PET CT LN biopsy done


Plasmacytoma


IgG Kappa Myeloma ISS III

26 year old male PUO for 2 months, multiple antibiotics Right sided cervical lymphadenopathy Axillary Lnpathy Bicytopenia- low WBC and PLTS

Bone marrow done- suspect T Lymphoblastic leukaemia


Lymphoblastic Lymphoma


TdT Positive

52 year old female History of fever and weight loss over 2-4 weeks Right sided cervical lymphadenopathy CXR – mediastinal LN pathy Easy bruisability (plts 1000) No drugs No organomegaly Bone marrow done


Granuloma


63 MALE

PAIN/ SWELLING ON LEFT LOWER LIMB

TREATED WITH PAIN KILLERS

NO RESPONSE

CT SCAN OF CHEST ABD AND PELVIS

MULTIPLE LNS IN THE ILIAC AND INGUINAL GROUPS

FNAC NON-DIAGNOSTIC

TREATED WITH AKT ON SPECULATION

NO RESPONSE AT 4 WEEKS

DVT

RETROSPECTIVELY WEIGHT LOSS

FEVER

LN BIOPSY

HODGKINS LYMPHOMA

ADVANTAGE OF EARLY DETECTION


RS cell


21 year old male PUO for 3 months Right sided cervical lymphadenopathy, axillary and

inguinal LNs bulky Mediastinal LNs LN biopsy done and assessed at one centre-

? NLPHL ?HD

LN biopsy reviewed at another centre –


Classical HD –negated

(LCA - +ve,CD15,CD30 –ve)

??TCRBCL

PET – CT EXTENSIVE STAGE IV DISEASE

MARROW UNINVOLVED

HD –negated

(LCA - +ve,CD15,CD30 –ve)

??TCRBCL

Large CD20+ve cells in a nodular small l’cyte background

?NLPHL

Single NLPHL nodule

Strong diffuse CD57 +ve

>>>TCRBCL like NLPHL

because

Background is T cells

Loss of dendritic network

HOW DO I TREAT THIS PATIENT ?

Uptodate Fletcher 2008 Evaluation of Peripheral Lymphadenopathy Aster 2008 Castleman’s Disease Glazer. G. Normal Mediastinal Nodes AJR 144:261-265 Feb 1985 Ghirardelli, M. Diagnositc approach to lymph node enlargement. Haematologica 1999 84:242-247 Ferrer, R. Lymphadenopathy: Differential Diagnosis and Evaluation 1998 Haberman, T Lymphadenopathy Mayo Clinic Proc. 2000 75:723-732 Lee,Y. Lymph Node Biopsy for Diagnosis: A statistical study. Journal of Surgical Oncology 14:53-60

1980 Skolnik, P Case 5-1999 37 yo male with fever and lymphadenopathy Volume 340: 545-554 Lichtman et al. (2006) Williams Hematology New York. McGraw-Hill Parslow et al. (2001) Medical Immunology new York. McGraw-Hill Malin, Ternouth (1994) Epitrochlear lymph nodes as a marker of HIV disease in Subsaharan Africa

BMJ 1994; 309 1550-1551 Bazemore and Smucker Lymphadenopathy and Malignancy AAFP 2002 Ashley Rosko, MD presentation

ACKNOWLEDGEMENT: Dr Minal Hastak, hematopathologist, Lilavati Hospital and research

centre Dr Chandalekha Tampi hematopathologist, Lilavati Hospital and

research centre


Dr Abhay A. Bhave, MD, FRCPA Haematologist …...Uptodate Fletcher 2008 Evaluation of Peripheral...

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