Lymphadenopathy

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Biopsy or Observation for Lymphadenopathy?

>40 years

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Biopsy

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Biopsy or Observation for Lymphadenopathy?

Location: cervical, inguinal, axillary

Back 2

Observation

Front 3

Biopsy or Observation for Lymphadenopathy?

Size >2 cm

Back 3

Biopsy

Front 4

Biopsy or Observation for Lymphadenopathy?

Tenderness present

Back 4

Observation

Front 5

Biopsy or Observation for Lymphadenopathy?

Rock hard, fixed

Back 5

Biopsy

Front 6

Biopsy or Observation for Lymphadenopathy?

Greater than 2 weeks

Back 6

Biopsy

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Back 7

Benign reactive lymph node

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Back 8

Diffuse D-cell Lymphoma

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Back 9

Follicular Lymphoma

CD10+

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CD5- and CD10-

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MALT lymphoma

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CD23+, CD5+, FMC7-

Back 11

CLL/SLL

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CD23-, FMC7+, CD5+

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Mantle cell lymphoma

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effect of increased Bcl-2

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decreased apoptosis; accumulation of mutations/transformation and proliferation

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Cyclin D1

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t(11;14) MCL

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BCL-2

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Follicular cell t(14;18)

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t(8;14)

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Burkitt's NHL

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NF-kB inhibitor

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t(11;19); CLL

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What are the two most common NHL

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Follicular and Diffuse Large B-Cell lymphoma

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Presenting symptoms of non-Hodgkin's lymphoma

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Painless enlargement of lymph nodes
Presence of B symptoms
Back pain
Severe fatigue
Swelling, epecially in ankles or legs
Severe fatigue

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Clinical features of NHL

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Lymphadenopathy
Splenomegaly-(early satiety, LUQ pain)
Hepatomegaly
Skin Infiltration
B symptoms
CBC abnormalities

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Stage one (Ann Arbor Staging)

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Localized disease
Single lymph node region
Single organ outside of the Lymph Nodes

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Stage 2 (Ann arbor)

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Two or more lymph node regions near to each other

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Stage 3 (Ann Arbor)

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2 or more lymph node regions in different parts of the body

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Stage 4 (Ann Arbor)

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Widespread disease
Multiple organs
With or without lymph node involvement

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Tx for Diffuse Large B-cell Lymphoma

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Chemo-immunotherapy
•Cyclophosphamide (Cytoxan)
•Doxorubicin (Adriamycin)
•Vincristine (Oncovin)
•Prednisone
•Rituximab (Rituxan)
Referred to as R-CHOP (or CHOP-R)
Administered every six weeks x 6 cycles

Front 26

Hemorrhagic cystitis side effect

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Cyclophosphamide

Acrolein is a highly reactive aldehyde--associated with sterile hemorrhagic cystitis

MESNA mops up the acrolein and prevents hemorrhagic cystitis

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Side effects of Vincristine

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Peripheral Neuropathy, neurotoxicity

Alopecia, constipation

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Side effects of Doxorubicin

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Cardiotoxicity

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Bind tubulin; block polymerization of microtubules

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Vincristine

Front 30

Mech of Doxorubicin

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Binds DNA/topoisomerase II
Causes lipid peroxidation and free radical damage
Intercalates in DNA, distorts DNA helix

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Monoclonal Ab that binds to CD20 on cell surface of B lymphocytes (>90% of non-Hodgkins lymphomas)

Bound antibody recruits immune cells-->cell lysis

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Rituximab

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lactate dehydrogenase

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Non specific marker; goes up when cells are proliferating; extra-nodal sites

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RICE chemo drugs

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Rituxan, Ifosfamide, Carboplatin, and Etoposide (RICE)

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Platinum coordination complex that causes DNA crosslinks

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Carboplatin

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Irreversibly binds/stabilizes DNA-topoisomerase II complexes

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Etoposide

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Side effects of ifosfamide

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Like cyclophosphamide (GI, alopecia, myelosuppression)
•Additional: nephrotoxicity, neurotoxicity (encephalopathy) - related to chloroacetaldehyde metabolite

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Lymphadenopathy in kids may be d/t generally

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cellular hyperplasia, cellular infiltration, or reactive tissue edema

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Enlarged nodes in neonates

Back 38

should prompt consideration of congenital infections such as toxoplasmosis or CMV

In general, newborns should not have palpable lymph nodes, though may have congenital lesions that could mimic a node

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will frequently have “shotty” nodes in the head and neck, axillary, or inguinal regions, even when otherwise healthy.

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Older infants and younger children

Pre-school and early school aged children are constantly bombarded with viruses!

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School-aged children and adolescents lymph node prevalence

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will less frequently have palpable nodes

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Inguinal Adenopathy

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STIs in teenages

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Size thresholds for locations

Inguinal
Head and Neck

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Inguinal-1.5 cm
Head and Neck-1 cm

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Left sided supraclavicular adenopathy

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from thoracic duct; probably some abdominal cancer

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Differential for generalized lympadenopathy Child

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Viral, EBV, EMV, HIV, Toxo

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Differential for generalized lympadenopathy: INfant

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syphillis, Toxoplasmosis, CMV, HIV

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Differential for generalized lympadenopathy: Adolescent

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Viral, EBV, CMV, HIV, Toxo, syphilis

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Tenderness of lymph node

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indication of infection and may be associated with overlying skin changes such as redness or swelling

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Hard nodes are indicative of

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Fibrosis secondary to cancer or previous infection

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Firm and rubbery nodes

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may indicate lymphomatous

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Fixing and matting nodes are signs of

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infiltrative changes

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Acute lymph node enlargements

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More likely to be infectious

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Acute cervical lymphadenitis

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recent upper respiratory tract infection with resolution, followed by new development of left-sided neck swelling, redness, and fevers. No new exposures from initial history.

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Post viral lymph node syndrome presents with

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Abdominal pain

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Strawberry tongue, extremitiy changes; 5 day history of fever, rashes

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Kawasaki disease

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Acute bilateral (reactive) lymphadenopathy

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lymphoid hyperplasia usually secondary to a head and neck infection. Typical pathogens include the following:
–RSV, adenovirus, influenza, other viral upper respiratory tract pathogens (also maybe EBV and CMV)

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frequently bacterial in nature, with either Staphylococcus aureus or group A streptococcal species being implicated

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Acute unilateral cervical lymphadenitis

Other important pathogens include oral flora, including anaerobes, from poor dentition
The presence of bacterial species in a lymph node incites a localized inflammatory reaction

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–Tuberculosis
–Atypical mycobacteria
–Bartonella henselae infection (cat scratch disease)

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Chronic cervical lymphadenopathy

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Non-Infectious etiologies of cervical lymphadenopathy

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Malignant
Immunologic
Endocrinologic

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First line drug options for Acute unilateral cervical lymphadenitis

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–Cephalexin, clindamycin, amoxicillin+clavulanate

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Tx for Cat-scratch disease

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Azithromycin: caution-get a PPD first
Ciprofloxacin, rifampin, TMP/SMX
Resistant to B-lactams

Bartonella henselae is bug

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Tx for Mycobacterium avium-intracellulare

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Clarithromycin, rifabutin