Approach to a Patient with Lymphadenopathy

Lymphadenopathy

• Enlargement of the lymph nodes.• Can be considered normal: 1) soft, flat,

submandibular nodes (<1cm) in healthy children and young adults; 2) palpabale inguinal lymph nodes of up to 2cm in diameter in healthy adults.

• May be a primary or secondary manifestation of numerous disorders, both benign and malignant.

Clinical Assessment

• Medical History• Physical Examination• Laboratory Tests• Excisional LN Biopsy

Medical History

• Reveals the setting in which lymphadenopathy is occuring.

• General information, accompanying symptoms, personal and social history.

• Ex.: viral/bacterial URTI, toxoplasmosis, TB benign disorders in children and young adults; if>50 y/o increase incidence of malignant disorder.

Physical Examination

• Extent of lymphadenopathy ( localized or generalized), size, texture, presence/ absence of tenderness, signs of inflammation over the node, skin lesions, and splenomegaly.

• ENT exam indicated in an adult patient with cervical lymphanedopathy with history of tobacco use.

Extent of Lymphadenopathy

• Localized/regional- involvement of a single anatomic site.

• Generalized- involvement of 3 or more non-contiguous lymph node areas; usually indicates non- malignant disorder (except for ALL, CLL, and malignant lymphomas.)

Site of Localized Adenopathy

• Occipital• Preauricular• Neck• Supraclavicular and scalene• Virchow’s nodes• Axillary• Inguinal

Size of the Node

• <1.0 cm2 –benign; non-specific causes.• >2.0 cm/ >2.25cm2 -malignant or

granulomatous disease.

Texture and Presence of Pain

• Acute leukemia- pain in nodes due to rapid enlargement.

• Lymphoma- large, discrete, symmetric, rubbery, firm, and non-tender.

• Metastatic cancer- hard, non-tender, and non moveable.

• W/ splenomegaly- systemic illness (IM, lymphoma, acute or chronic leukemia, etc.)

Thoracic Adenopathy

• Detected by CXR or work-up for superficial adenopathy.

• May cause coughing/wheezing, hoarseness, dysphagia, and/or swelling of the face and neck.

• Due to a primary lung disorder or systemic illness.

Abdominal and Retroperitoneal Adenopathy

• Usually malignant.• TB mesenteric lymphadenitis; lymphoma;

GCT in young men.

Laboratory Investigation

• CBC• Serology• CXR• CT and MRI• Ultrasound

Lymph Node Biopsy

• Done if PE findings suggest malignancy.• Biopsy evident primary lesion first.• FNAB- not to be used as primary diagnostic

procedure; for thyroid nodules or confirmation of relapse in patient whose primary diagnosis is known.

• Guidelines: Older patients (>40y/o), large LN (>2.25cm2 ), hard and non-tender

Follow-up and Treatment

• Follow-up at 2-4 weeks interval for benign causes.

• Antibiotics are given only if there is strong evidence of bacterial infection.

• DO NOT USE GLUCOCORTICOIDS-might obscure diagnosis or delay healing in cases of infection (EXCEPTION: life-threatening pharyngeal obstruction by enlarged lymph tissue in Waldeyer’s ring caused by IM.)