LYMPHADENOPATHY &LYMPHADENOPATHY &SPLENOMEGALYSPLENOMEGALY

Martin H. Ellis MDMartin H. Ellis MDMeir HospitalMeir Hospital

CLINICAL ANATOMY OF CLINICAL ANATOMY OF THE LYMPH NODESTHE LYMPH NODES

Head & Neck – Head & Neck – occipital, postauricular, occipital, postauricular, preauricular, anterior cervical chain, preauricular, anterior cervical chain, posterior cervical chain, submandibular, posterior cervical chain, submandibular, submental, Waldeyer’s ringsubmental, Waldeyer’s ring

Clavicular – supra and infraClavicular – supra and infra Axillary – Axillary – lateral, medial, posterior, apicallateral, medial, posterior, apical EpitrochlearEpitrochlear InguinalInguinal FemoralFemoral

FemoralFemoralFemoral

RADIOLOGICAL ANATOMY RADIOLOGICAL ANATOMY OF LYMPH NODESOF LYMPH NODES MediastinalMediastinal PerihilarPerihilar RetroperitonealRetroperitoneal MesentericMesenteric IliacIliac

Hilar adenopathy (sarcoidosis)

Mediastinal adenopathy( lymphoma, sarcoma, teratoma)

DIAGNOSISDIAGNOSIS History & Physical diagnosisHistory & Physical diagnosis Laboratory testingLaboratory testing CT scanningCT scanning MRIMRI Isotope scanningIsotope scanning PET-CT scanningPET-CT scanning Histologic diagnosisHistologic diagnosis

APPROACH TO APPROACH TO DIAGNOSISDIAGNOSIS

Localized vs. generalized Localized vs. generalized (including splenomegaly)(including splenomegaly)

HistoryHistory Physical examPhysical exam Special investigationsSpecial investigations

CHARACTERISTICS OF CHARACTERISTICS OF ENLARGED NODESENLARGED NODES SizeSize

– < 1cm=normal< 1cm=normal Pain/TendernessPain/Tenderness

– inflammation/rapid growthinflammation/rapid growth ConsistencyConsistency

– stony, rubbery, firm, soft, fluctuantstony, rubbery, firm, soft, fluctuant MattingMatting

– a group of nodes that seem joineda group of nodes that seem joined MobilityMobility LocationLocation

DIFFERENTIAL DIFFERENTIAL DIAGNOSISDIAGNOSIS

CongenitalCongenital AcquiredAcquired

– Infectious – Infectious – bacterial,viral,fungal,parasitic,mycobacterialbacterial,viral,fungal,parasitic,mycobacterial

– Inflammatory – Inflammatory – autoimmune, allergic, vasculiticautoimmune, allergic, vasculitic– Neoplastic – Neoplastic – benign, malignant (primary,secondary)benign, malignant (primary,secondary)– Toxic & Metabolic – Toxic & Metabolic – storage diseases, hyperthyroidismstorage diseases, hyperthyroidism– DrugDrug – hydantoin, gold – hydantoin, gold– TraumaticTraumatic– Idiopathic – Idiopathic – sarcoidosis, Castleman diseasesarcoidosis, Castleman disease– Iatrogenic – Iatrogenic – silicone implantssilicone implants

SITE-DISEASE SITE-DISEASE ASSOCIATIONSASSOCIATIONS

Occipital – rubellaOccipital – rubella Supraclavicular – TB (scrofula), lung ca, Supraclavicular – TB (scrofula), lung ca,

gastric ca (Virchow node- Trousseau gastric ca (Virchow node- Trousseau sign)sign)

Axillary – breast caAxillary – breast ca Inguinal – STDsInguinal – STDs Umbilical – ovarian ca (Sister Joseph’s Umbilical – ovarian ca (Sister Joseph’s

node)node)

Hx / PE

DIAGNOSTICeg local infection,tumor

SUGGESTIVEeg mono,HIV,lymphoma

UNEXPLAINED

TREAT CONDITION

SPECIFIC TESTING

POSITIVE

LOCALIZEDGENERALIZED

Review epidemiologyReview medicationsPOSITIVE

DIAGNOSTIC

POSITIVE

No serious illness apparent

Observe 3-4 weeks

BiopsyResolved

Serious illnessapparent

Biopsy

MONONUCLEOSIS SEROLOGYPPD,HIV,HBV,CXR

NEGATIVE

BIOPSY ABNORMAL NODE

SPLENOMEGALY: SPLENOMEGALY: DIAGNOSISDIAGNOSIS

History & Physical diagnosisHistory & Physical diagnosis Laboratory testingLaboratory testing CT scanningCT scanning MRIMRI Isotope scanningIsotope scanning PET-CT scanningPET-CT scanning Histologic diagnosisHistologic diagnosis

DIFFERENTIAL DIFFERENTIAL DIAGNOSISDIAGNOSIS

CongenitalCongenital AcquiredAcquired

– Infectious – Infectious – bacterial,viral,fungal,parasitic,mycobacterialbacterial,viral,fungal,parasitic,mycobacterial

– Inflammatory – Inflammatory – autoimmune (SLE, Felty syndrome)autoimmune (SLE, Felty syndrome)– Neoplastic – Neoplastic – benign, malignant (primary,secondary)benign, malignant (primary,secondary)– Toxic & Metabolic - Toxic & Metabolic - (storage diseases eg Gaucher)(storage diseases eg Gaucher)– Congestive splenomegaly – Congestive splenomegaly – portal hypertensionportal hypertension– ““Work” hyperplasiaWork” hyperplasia- chronic hemolytic anemias- chronic hemolytic anemias

MASSIVE MASSIVE SPLENOMEGALYSPLENOMEGALY TumorsTumors

– Lymphoma, myeloproliferative Lymphoma, myeloproliferative disorders, Hairy cell leukemiadisorders, Hairy cell leukemia

InfectionsInfections– Kala-azar (trypanosomiasis)Kala-azar (trypanosomiasis)

Portal hypertensionPortal hypertension Gaucher diseaseGaucher disease

Approach to diagnosis-Approach to diagnosis-splenomegalysplenomegaly Known illnesses Known illnesses

– eg eg lymphoma, SLElymphoma, SLE Current clinical contextCurrent clinical context

– Fever, Fever, recentrecent travel, murmers travel, murmers Imaging studiesImaging studies

– SizeSize, focal , focal lesionslesions Histologic diagnosis Histologic diagnosis

– Splenectomy, ?splenic biopsySplenectomy, ?splenic biopsy