16 terms
Lymphadenopathy/Hodgkins lymphoma
What percentage of lymphadenopathy presentations to a GP are due to malignancy?
1.1% - consider other causes!
Which is usually more sinister - anterior or posterior chain cervical lymphadenopathy?
Posterior - Lymphoma, TB, Kikuchi's disease, head and neck malignancy
Anterior - usually infection (local or systemic eg EBV/CMV/toxoplasmosis)
Anterior - usually infection (local or systemic eg EBV/CMV/toxoplasmosis)
Is supraclavicular lymphadenopathy a concern?
Yes - up to 50% of patients with supraclavicular lymphadenopathy have a malignancy.
Right-sided supraclavicular lymphadenopathy: mediastinum, lungs, oesophagus
Left-sided ("Virchow's node"): adbdominal malignancy
Right-sided supraclavicular lymphadenopathy: mediastinum, lungs, oesophagus
Left-sided ("Virchow's node"): adbdominal malignancy
Differentials for trochlear lymphadenopathy
Palpable lymph nodes are ALWAYS pathological.
- Local infections
- Lymphoma
- Rare causes (sarcoidosis, tularaemia, secondary syphilis)
- Local infections
- Lymphoma
- Rare causes (sarcoidosis, tularaemia, secondary syphilis)
Approach to history-taking in a patient presenting with lymphadenopathy
Time course
Malignancy screen (B symptoms, lumps/bumps, SOB/dysphagia, pain)
Infection screen (fevers, pharyngitis symptoms, other localising infective Sx, exposure history)
Autoimmune symptoms
Medications
Malignancy screen (B symptoms, lumps/bumps, SOB/dysphagia, pain)
Infection screen (fevers, pharyngitis symptoms, other localising infective Sx, exposure history)
Autoimmune symptoms
Medications
Top 5 differentials for generalised lymphadenopathy
HIV (non-tender)
TB (non-tender - can be fluctuant, matted)
EBV (triad of fever, lymphadenopathy, pharyngitis)
SLE (50% get lymphadenopathy - soft, non-tender)
Medications (typical= phenytoin)
TB (non-tender - can be fluctuant, matted)
EBV (triad of fever, lymphadenopathy, pharyngitis)
SLE (50% get lymphadenopathy - soft, non-tender)
Medications (typical= phenytoin)
Lymph node examination
Site, size, consistency, fixation, tenderness, fluctuance
Isolated lymphadenopathy, no other Sg/Sx - management plan?
Observe for 3-4 weeks - most will resolve
Hodgkin Lymphoma epidemiology - age? gender?
Bimodal age distribution - ~20yo, ~65yo
More common in males
More common in males
Types of Hodgkin Lymphoma
Classical types:
- Nodular sclerosis classical HL (NSHL)
- Mixed cellularity classical HL (MCHL)
- Lymphocyte rich classical HL (LRHL)
- Lymphocyte depleted classical HL (LDHL)
Non-classical:
- Nodular lymphocyte predominant HL (NLPHL)
- Nodular sclerosis classical HL (NSHL)
- Mixed cellularity classical HL (MCHL)
- Lymphocyte rich classical HL (LRHL)
- Lymphocyte depleted classical HL (LDHL)
Non-classical:
- Nodular lymphocyte predominant HL (NLPHL)
Utility of immunophenotyping?
Distinguishes classical HL from nodular lymphocyte predominant HL
- Classical subtypes express CD15 and CD30 but not pan-B or pan-T antigens
- NLPHL (usually CD30 and CD15 negative, but CD 20 positive)
- Classical subtypes express CD15 and CD30 but not pan-B or pan-T antigens
- NLPHL (usually CD30 and CD15 negative, but CD 20 positive)
What are "popcorn cells" or L&H (lymphocytic and histiocytic cells)
Atypical Reed-Sternberg cells found in nodular lymphocyte predominant Hodgkin Lymphoma (NLPHL)
Typical presentation of Hodgkin Lymphoma
Asymptomatic lymphadenopathy (70%)
Incidental finding of mediastinal mass
B symptoms
(less common: pruritis, pain, cholestatic liver disease, alcohol-induced pain, skin lesions, neurological syndromes, nephrotic syndrome)
Incidental finding of mediastinal mass
B symptoms
(less common: pruritis, pain, cholestatic liver disease, alcohol-induced pain, skin lesions, neurological syndromes, nephrotic syndrome)
Investigations: blood test abnormalities in Hodgkin Lymphoma?
# Hypercalcemia
- increased production of calcitriol or bony involvement
# Anemia
- normochromic and normocytic or Coombs' positive hemolytic anemia
# Eosinophilia
# In advanced disease....
Leukocytosis, thrombocytosis, lymphopenia, and hypoalbuminemia
- increased production of calcitriol or bony involvement
# Anemia
- normochromic and normocytic or Coombs' positive hemolytic anemia
# Eosinophilia
# In advanced disease....
Leukocytosis, thrombocytosis, lymphopenia, and hypoalbuminemia
Staging of Hodgkin Lymphoma
Stage I - Single lymph node region (IE - single extralymphatic organ without nodal involvement)
Stage II - 2+ lymph node regions same side of the diaphragm (or IIE, with involvement of limited, contiguous extralymphatic organ or tissue)
Stage III - Lymph node regions/ lymphoid structures on both sides of diaphragm.
Stage IV - Additional noncontiguous extralymphatic involvement +/- associated lymphatic involvement.
Stage II - 2+ lymph node regions same side of the diaphragm (or IIE, with involvement of limited, contiguous extralymphatic organ or tissue)
Stage III - Lymph node regions/ lymphoid structures on both sides of diaphragm.
Stage IV - Additional noncontiguous extralymphatic involvement +/- associated lymphatic involvement.
International Prognostic Score - what are the factors to consider?
Male gender
Age >45 years
Stage IV disease
Serum albumin <40
Hemoglobin <105
White blood cell count ≥15
Absolute lymphocyte count <0.6 and/or <8 percent of the total white blood cell count.
(none = 84% 5 year survival, all = 42% 5-year survival)
Age >45 years
Stage IV disease
Serum albumin <40
Hemoglobin <105
White blood cell count ≥15
Absolute lymphocyte count <0.6 and/or <8 percent of the total white blood cell count.
(none = 84% 5 year survival, all = 42% 5-year survival)