Cervical Lymphadenopathy Lecture PDF

A lecture on Cervical Lymphadenopathy for 4th year students By Dr. Ali Andaleeb Consultant Surgeon Lymph Nodes Anatomy They are encapsulated centres of lymphocyte differentiation and proliferation W...

A lecture on Cervical Lymphadenopathy for 4th year students By Dr. Ali Andaleeb Consultant Surgeon Lymph Nodes Anatomy They are encapsulated centres of lymphocyte differentiation and proliferation Which attached to both vascular and lymphatic systems (over 600 lymph nodes in the body) They are bean-shaped ,and each has fibrous capsule with a hilum at one side. It receives many afferent vessels & gives efferent vessel from its hilum. The lymph node is divided into an outer cortex and an inner medulla. Lymph fluid is similar in composition to blood plasma. Returning the fluid to the blood helps to maintain normal blood volume and pressure. Function Through filtering the lymph , they remove & destroy microorganisms and other foreign particles To allow contact between B-cells, T-cells and macrophages (sensitization of the immune response) It returns excess interstitial fluid to the blood to maintain blood volume and blood pressure. Git ‫الي موجودة بال‬ Lacteals (chyle). drian lymph of the git ‫و هاي تسوي‬ absorb fat and fat soluble vitamins milky appearance due to its high fat content ‫و تكون‬ chyle ‫ يسمو‬lacteals ‫و اللمف الي بداخل ال‬  CLASSIFICATION situated in the submental triangle, between the anterior bellies of the digastric muscle and the hyoid bone. 1. Upper horizontal chain lower jowbone (a) Submental between submandibular salivary glands (b) Submandibular found near the parotid gland (c) Parotid located posterior to the ear and lie on the insertion of the sternocleidomastoid muscle into the mastoid process (d) Postauricular in the back of the head at the lateral border of the trapezius muscle (e) Occipital surrounding the facial vessels on the external surface of the buccinator muscle. (f) Facial 2. Lateral cervical chain : They include nodes, superficial and deep to sternocleidomastoid muscle and in the posterior triangle. (a) Superficial external jugular group relations to Internal jugular vein (b) Deep group (i) Internal jugular chain (upper, middle and lower groups) relations to (ii) Spinal accessory chain relations to Spinal accessory nerve sternocleidomastiod muscle (iii) Transverse cervical chain relations to Transverse cervical artery 3. Anterior cervical chain: (a) Anterior jugular chain relations to anterior jugular vein (b) Juxtavisceral chain : (i) Prelaryngeal anterior to the larynx ‫أسم ثاني لل‬ trachea & larynx (ii) Pretracheal prelaryngeal anterior to the trachea LN delphian node ‫هو‬ (iii) Paratracheal AJCC(American Joint Committee on Cancer) classification Level 1 : submental + submandibular Level 2 : upper deep cervical nodes Internal jugular Level 3 : middle deep cervical nodes groups of LN Level 4 : lower deep cervical nodes Level 5 : spinal accessory + transverse lymph node in the posterior triangle cervical Level 6 : pretracheal, prelaryngeal, Anterior cervical chain paratacheal Level 7 : upper mediastinal nodes  What is lymphadenopathy Lymph nodes that are abnormal in size > 1cm, consistency or number. It may be localized (one area involved) or generalized ( two or more non-contiguous areas ) Why do lymph nodes enlarge (i.e, mechanisms of LAP) Hyperplasia with inflammatory cell infilteration in infection (lymphadenitis) In situ proliferation of malignant lymphocytes Infiltration by metastatic malignant cells Infiltration of lymph nodes by metabolite laden macrophages (lipid storage diseases) Infections: 1. Viral – Infectious Mononucleosis,EBV, Measles, HIV 2. Bacterial – T.B , cat scratch disease , Syphilis 3. Fungal – Histoplasmosis 4. Chlamydial – L. venereum 5. Parasitic – Toxoplasmosis 6. Ricketsial - Typhus Malignant Diseases 1. Haematologic ( Hodgkin’s , Non- Hodgkin’s , ALL , CLL , Sarcoma ) (Primary) 2. Metastatic : from a primary site (Secondary) Immunological diseases Other disorders Rhematoid arithritis Sarcoidosis Systemic lupus erythromatosis Castleman’s disease( Giant L.N hyperplasia) Dermatomyositis Histocytosis X Sjogren’s syndrome Kikuchi’s disease Drug hypersensitivity Causes of Generalized Lymphadenopathy ( CHICAGO ) C -- Cancer- HL/NHL/MM/Leukemia/ secondaries H -- hypersensitivity- drugs, serum sickness I -- infection – bacterial, viral C -- connective tissue disorders- SLE/RA A -- atypical – castlemans , wegeners dis G --Granulomatous dis- TB, Histoplasma, cryptococcus, silicosis O --OTHERS- Kikuchi (histiocytic necrotizing lymphadenitis) Management Plan Diagnosis LN ‫اول خطوة الزم تشوف كل ال‬ A) Clinical Examination localized ‫ لو‬general ‫حتى تعرف‬ General Full nodal examination (nodal characteristics) and organomegaly Localized – examine area drained by the nodes for evidence of infection, skin lesions or tumours  Age Children/young adults are more likely to respond to minor stimuli with lymphoid hyperplasia LAP in young patients ( > 30 ) are usually clinically. 80% of cervical LAP in the younger age group (‫ )اقل من أربعني سنه‬are benign  Site Cat-scratch disease typically causes cervical or axillary adenopathy, infectious mononucleosis causes cervical adenopathy Posterior cervical lymph node suppuration with absence of inflamatory signs usually point to tuberculosis  Supraclavicular LAP has highest risk of malignancy Rt sided node – cancer in mediastinum, lungs, esophagus , while Lt sided node (Virchow’s) – testes, ovaries, kidneys, pancreas, stomach, gallbladder or prostate Paraumbilical node (Sister mary Joseph’s) – Sister Mary Joseph nodule is an umbilical metastatic lesion typically originating from gastrointestinal or gynecologic malignancies.  Size less than 1cm LN ‫يسموها‬ Shotty LN is small LN Lymph nodes greater than 1 cm in diameter are considered to be abnormal. benign cause ‫و عادة تكون‬ recurrent infection in ‫تظهر مرات نتيجة‬ chelidren  Duration : Nodes lasting less than 2 weeks or greater than one year with no progression in size have usually a low malignant potential (exclude low grade lymphoma) fl  Pain/Tenderness Inflammatory process or suppuration Hemorrhage into the necrotic center of a malignant node However, the presence or absence of pain\ tenderness does not reliably differentiate benign ‫يعني مو قاعدة ثابته‬ from malignant nodes ‫بس بصورة عامة‬ pain ‫ يعني‬in ammatory  Consistency Stony-hard nodes are typically a sign of cancer, usually metastatic. primary ‫يعني مو‬ Very firm, rubbery nodes suggest lymphoma. Softer nodes are the result of infections or inflammatory conditions. Suppurant nodes may be fluctuant. “shotty” nodes  Matting A group of nodes that feels connected and seems to move as a unit is said to be “matted.” Benign (e.g., tuberculosis, sarcoidosis ) or malignant (e.g., metastatic carcinoma or lymphomas).  Examination of thyroid for palpable lesions mass in the lateral aspect of the neck LN ‫من نفحصها‬  Lateral abberant thyroid metastatic cancer of thyroid of occult thyroid cancer occult thyroid cancer ‫ نتيجة‬metastatic LN ‫يعني‬  Thorough ENT examination to rule out head and neck focus of infection or malignancy.  B) Investigatios : 1) Laboratory Investigations : complete hemogram and peripheral smear cannot be over- emphasized to diagnose clinical conditions like mononucleosis or hematological malignancies a. Complete blood count b. ESR , C- Reactive Protein( CRP) c. Serum lactate dehydrogenase d. serological test : to rule out infective etiology (EBV, toxoplasma, cytomegalovirus , RPR for syphilis ) e. Biochemical & immunologic tests (antinuclear antibody, dsDNA antibody, rheumatoid factor &complement level ) f. Kveim test for sarcoidosis g. Mantoux test ( TST for T.B ) 2) Imaging chest -x ray ‫يعني‬  CONVENTIONAL RADIOGRAPHY : for imaging calcifications in lymph nodes which have been chronically inflamed because of various diseases (usually granulomatous diseases as T.B) , and may show an enlargedmediastinal L.N or primary occult tumour of the lung.  Ultrasonography : Assessment of number, size, site, shape, margins. Color Doppler can evaluate vascularity pattern to help differentiate malignant from benign cervical lymph nodes.. Normal cervical nodes appears sonographically as somewhat flattened hypochoic structures with varying amounts of hilar fat and usually hypovascular.  Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) – CT & MRI are commonly used to evaluate the primary tumor & neck status. They characterize the cervical lymph node dependent on morphological criteria. They assess lymph nodes by relying on its anatomy. Most benign nodes have a central fatty hilum which is a distinctive feature on CT and MRI. MRI can clearly highlight soft tissue pathologies better than the C.T. Scan. CT SCAN is less accurate than M.R.I for the soft tissue examination, but is very useful to locate bony tumors and their dimensions and extensions.  Positron Emission Tomography ( PET- scan ) : It is a functional imaging that can detect metastasis lesion by pin pointing regions of high metabolism. It is better for assessing metastasis to lymph node that appear morphologically normal. Draw back of PET is poor anatomical resolution. Fused PET/CT is considerd most accurate for imaging nodal metastasis 3) Tissue dignosis : It is the gold standard in the evaluation of lymphedonopathy.  Fine Needle Aspiration Cytology (FNAC) : It is a safe, simple ,fast and cost-effective technique. Its findings are especially beneficial for verification of lymphoid origin of the enlarged growth and in differentiating between metastatic, infectious and reactive causes of LAP. Most patients who have a benign diagnosis on FNA do not require further evaluation. - The limitations of FNA remain in the lack of proper tissue sample to run special studies including cytogenetics, electronmicroscopy, and special stains.  Ultrasonography guided FNAC : It guides the needle to the most suspicious area of lymph nodes  Core needle biopsy:- - It provides more specimen from the tissue than does FNAC  Surgical excisional biopsy : It obtain a proper representative tissue for pathological diagnosis Ideally, the most accessible node is selected for biopsy.  young ‫يعني اجانا مريض‬ 2cm ‫ حجمها‬LN ‫عندة‬ When to obtain a tissue biopsy? ‫ مثال‬Stony-hard ‫ صايرة‬LN ‫يعني إذا شفت ال‬ treatment ‫انطينا‬ ‫ بعدها‬LN‫اجانا ورا أسبوعني ال‬ Clinically malignant lymph node. malignancy ‫فتشك انه‬ abnormal ‫ كلك هاي‬ultrasound ‫أو ابو ال‬ ENT‫دزينا ألبو ال‬ enlarged LN ‫ ك سبب لهاي ال‬lesion ‫ما شاف اكو‬ Suspected tuberculosis. biopsy ‫لهذا نفكر نسوي‬ Persistent lymphadenopathy in the absence of ent infection or abnormal chest radiograph and not responding to conservastive management. Presence of gross splenomegaly biopsy ‫ تسويلة‬spleen‫بدل ما تأخذ ال‬ LN palpable ‫ناخذ اي‬ tissue diagnosis ‫و تدزها‬ splenomegaly ‫حتى تعرف شنو سبب ال‬ Treatment Identify underlying cause and treat as appropriate – confirmatory tests  Generalized adenopathy – usually has identifiable cause  Localized adenopathy – 3-4 week observation period for resolution.If not with high clinical suspicion for malignancy – Biopsy Common differential diagnosis of cervical LAP Pre tracheal \ Laryngeal L.N