Case Answers:

Case answers will be presented after review of the HPI.

Answer 1
Students should be able to discuss the anatomy of the lymph node with its various cell populations (T & B cells). Superficial and deep lymphatic systems, intra abdominal and intrathoracic lymphatic systems and their final connection to the thoracic duct.

Answer 2
Discuss the most common cause of localized or generalized lymphadenopathy is from infection. Bacterial or viral causes predominate in the younger age group and malignancy predominates in age group above 40 years.

Answer 3
The concept to thoroughly examine the primary area of drainage must be emphasized.

• Entire lower extremity.
• Perianal region below the pectineal line.
• External genitalia in both sexes.
• Lower third of the vagina in the female.

Answer 4
Discuss. Size indicates time element. Quickly enlarging and tender node indicates either an acute inflammatory process or a neoplastic process with short doubling time. Eg.: Burkitt’s lymphoma. Discrete nodes indicate this process is limited to the capsule. Fixity and confluence of nodes indicate the process has gone beyond the capsule and has invaded the surrounding structures or nodes. Eg. Malignancy. Suppurative processes can also cause this, but usually, the signs of diffuse inflammation are obvious clinically.

Answer 5

• Most common causes are viral in origin, eg. Rubella, Mononucleosis, AIDS
• Autoimmune disorders, eg. Lupus or Rheumatoid arthritis
• Granulomatous diseases, eg. Sarcoid
• Drug induced, eg. Dilantin, INH, Gold
• B-Cell Lymphomas, eg. C.L.L., Non-Hodgkins lymphoma

Answer 6
A sentinel node is the first enlarged node in any given situation that alerts the physician of the existence of an underlying malignancy. This is a metastatic node. Eg. Supraclavicular node enlargement in gastric or testicular cancer. CABANAS described this in penile cancer which identified the drainage pathway. This principle is made use of today in staging of breast cancer and cutaneous melanoma.

Answer 7
Explain the process of FNA.

One can obtain specific and non-specific information.

Polymorphous cell population
- Reactive node

Monomorphous cell population
- Lymphoma, Leukemia, Myeloma

Granulomatous Cytology
- T.B., Sarcoid

Malignant Cytology
- Metastasis

Pus
- Gram stains, Cultures for bacteria & fungi

Other Studies:

Cell block with immunostaining.
Flow cytometry and immunophenotyping.
P.C.R. analysis.

Answer 8
Large, fixed, confluent and rapidly enlarging nodes with or without systemic symptoms should alert the clinician. Nodes in which FNA has not been helpful.

Answer 9
Do a step-by-step evaluation. Thorough history and physical examination. CBC and DIF. (infectious process). Serologic studies (VDRL, MONO, CMV, TOX., etc.) X-ray chest to exclude mediastinal adenopathy (sarcoid, lymphoma). Skin tests (TB, Anergy). If all these and FNA is inconclusive and after a waiting period of 2-3 weeks, one should do an excisional biopsy of lymph node.

Answer 10
There are instances when usual investigation and FNA may be negative or inconclusive. In these instances, the patient must be closely followed till resolution. In 20% to 30% of atypical lymphoid hyperplasia can go on to lymphoma. Delay in diagnosis can be a cause for malpractice. Discuss all possibilities when you decide a conservative course and document it.