Def.:Def.: It is an abnormal increase in size, It is an abnormal increase in size,

or altered consistency of L.N. & is a or altered consistency of L.N. & is a clinical manifestation of regional or clinical manifestation of regional or

systemic disease & serve as an systemic disease & serve as an excellent clue to the underlying excellent clue to the underlying

pathology and aetiology.pathology and aetiology.

1- L.N Draining a Septic Focus:1- L.N Draining a Septic Focus:** cervical : tonsilitis, scarlet fever, scalp infection. cervical : tonsilitis, scarlet fever, scalp infection.** periauricular: otitis media. periauricular: otitis media.** axillary : infections of fingers axillary : infections of fingers** inguinal : infections of lower extremities. inguinal : infections of lower extremities.** popliteal : infections of heel. popliteal : infections of heel.

Causes of Localised LymphadenopathyCauses of Localised Lymphadenopathy

2-Carcinomatous L.N. Draining a Malignant Tumour:2-Carcinomatous L.N. Draining a Malignant Tumour: ** hilar and scalene: bronchus. hilar and scalene: bronchus. ** virchow’s: stomach virchow’s: stomach ** cervical: thyroid, tongue, parotid. cervical: thyroid, tongue, parotid.

Causes of Localised Lymphadenopathy(2)Causes of Localised Lymphadenopathy(2)3- Systemic Infections3- Systemic Infections ** Viruses: Viruses: a-a- Viral hepatitis Rt. supraclavecular L.N Viral hepatitis Rt. supraclavecular L.N b- b- L.G.L.G.V. --V. --groin (ing LN)groin (ing LN) c-c- German measles (cervical LN) German measles (cervical LN)

** Bacteria: Bacteria: a- a- PlaguePlagueb-b- T.B T.B

** Spirochetes : (Iry $ draining chancer) Spirochetes : (Iry $ draining chancer) a-a- penis penis inguinal L.N. inguinal L.N. b-b- lips lips submandibular L.N. submandibular L.N.

c-c-nipplenipple axillary L.N. axillary L.N.

** Protozoa Protozoa a -a -Filarial infectious-----Filarial infectious----- inuguinal L.N.inuguinal L.N.

N.B Generalized N.B Generalized L.N. may start as localized L.N. as in Hodgkin’s diseaseL.N. may start as localized L.N. as in Hodgkin’s disease

Causes of Generalised LymphadenopathyCauses of Generalised Lymphadenopathy

I- InfectiousI- Infectious** Viruses: Viruses:

a-a-Infectious mononucleosis Infectious mononucleosis b-b-Cytomegalo virus (C.M.V.)Cytomegalo virus (C.M.V.)** Bacteria: Bacteria: a- a- brucellosisbrucellosis

b-b- T .B. T .B.**Spirochetes:Spirochetes:

(2ry $)(2ry $)** Protozoa Protozoa

a-a- kala azar kala azarb-b-toxoplasmosis.toxoplasmosis.

Causes of Generalised Lymphadenopathy(2)Causes of Generalised Lymphadenopathy(2)

2- Leukaemias:2- Leukaemias: especially chronic lymphocytic leukamia especially chronic lymphocytic leukamia (C.L.L.)(C.L.L.)

3- Lymphomas:3- Lymphomas: a-a- Hodgkin’s disease (H.D.) Hodgkin’s disease (H.D.) b-b-Non- Hodgkin’s lymphoma (N.H.L)Non- Hodgkin’s lymphoma (N.H.L)4- Collagenosis: 4- Collagenosis: a-a-rheumatoid artheritis.rheumatoid artheritis.

b-b- Felty’s syndrome. Felty’s syndrome. c-c-Still's disease.Still's disease. d-d- D.L.E. D.L.E.

5-Allergy5-Allergy: e.g.,: e.g., - Serum sickness. - Serum sickness.6- Sarcoidosis6- Sarcoidosis7- Lipoidosis7- Lipoidosis8-Miscellaneous8-Miscellaneous

Characters of L.N. Enlargement Characters of L.N. Enlargement inin Some Diseases Some Diseases

1- 1- Streptococcal infection of tonsils:Streptococcal infection of tonsils: ** Uni or Bilateral Uni or Bilateral * Tender & unmatted* Tender & unmatted **Usually submandibular but may extend to lower cervical Usually submandibular but may extend to lower cervical group.group.2- Scarlet Fever2- Scarlet Fever ** Sore throat. Sore throat. ** marked enlargement of marked enlargement of submandibular submandibular L.N.L.N. **Other cervical L.N. (bilateral, tender, discrete, suppuration Other cervical L.N. (bilateral, tender, discrete, suppuration is common).is common).3-Diphtheria3-Diphtheria **Enlarged Enlarged submandibular submandibular L.N. usually bilateral, tender, not L.N. usually bilateral, tender, not matted.matted.

4-German Measle4-German Measle::** OccipitaI OccipitaI L.N. enlargement are nearly always present, closely L.N. enlargement are nearly always present, closely resembles that of infectious mononucleosis.resembles that of infectious mononucleosis.

5-Infectious Mononucleosis:5-Infectious Mononucleosis: ** Sore throat, Fever, sometimes headache, myalgia. Sore throat, Fever, sometimes headache, myalgia. * * Bilateral L.N. enlargement, firm, discrete, mobile.Bilateral L.N. enlargement, firm, discrete, mobile. ** Appear first in posterior cervical area, adjacent to cervical Appear first in posterior cervical area, adjacent to cervical spines, few days later , submandibular L.N. will be enlargedspines, few days later , submandibular L.N. will be enlarged ** Palatal Palatal petechiae often, are presentpetechiae often, are present ** Mild splenomegally in Mild splenomegally in 50% 50% of casesof cases **Lymphocytosis in 75% of cases with some atypical Lymphocytosis in 75% of cases with some atypical lymphocytes.lymphocytes.

6- T.B6- T.B.:.: ** The chiefly affected group is upper cervical group, The chiefly affected group is upper cervical group, generalized L.N. enlargement is exceptional.generalized L.N. enlargement is exceptional. ** Unilateral or Bilateral. Unilateral or Bilateral. ** Often firm, matted, painful, may become adherent Often firm, matted, painful, may become adherent to skin or deep structures.to skin or deep structures. ** Cystic areas may occur due to caseation and later on Cystic areas may occur due to caseation and later on cold abscess formation.cold abscess formation. ** Overlying skin may break down giving T.B. ulcers Overlying skin may break down giving T.B. ulcers or sinuses.or sinuses.

7-Syphilis7-Syphilis:: ** Iry $:-Iry $:- L.N draining a chancreL.N draining a chancre-Rocky hard, -Rocky hard, uni Or bilateral, not tender.uni Or bilateral, not tender.** 2ry $:-2ry $:-

-Generalized L.N. enlargement especially -Generalized L.N. enlargement especially posterior triangle of the neck or epitrochlear gpposterior triangle of the neck or epitrochlear gp (slightly enlarged, shotty, discrete, painless).(slightly enlarged, shotty, discrete, painless).

8- LYMPHOMATOUS L. N:8- LYMPHOMATOUS L. N:**May be associated with constitutional symptoms.May be associated with constitutional symptoms.(anorexia, fever, weight loss, sweating, ….. etc).(anorexia, fever, weight loss, sweating, ….. etc).** Pel Ebstein fever: ma Pel Ebstein fever: may be y be observed in H.D., it is a observed in H.D., it is a period of fever lasting for period of fever lasting for few few days or weeks alternating days or weeks alternating with lonwith longer oger or shorter apyrexial periods .r shorter apyrexial periods .** L.N. usually discrete at start & not tender (but may L.N. usually discrete at start & not tender (but may become tender during febrile periods).become tender during febrile periods).* L.N. may increase in size during pyrexial periods and * L.N. may increase in size during pyrexial periods and decrease in size during apyrexial periodsdecrease in size during apyrexial periods

a-H.D.:a-H.D.:** may be confined to one group at first esp. lower cervical may be confined to one group at first esp. lower cervical group then later on generalized L.N. enlargement.group then later on generalized L.N. enlargement.•Glands are:Glands are:

a- a- moderately enlarged, not tender.moderately enlarged, not tender.b-b- Firm, rubbery in consistency. Firm, rubbery in consistency.c- c- Discrete, mobile however as a result of later Discrete, mobile however as a result of later

extension outside the capsule glands become matted or extension outside the capsule glands become matted or fixed fixed b-N.Hb-N.H .L.L::**Also the cervical Also the cervical group is group is firstly affectedfirstly affected**Rapid rate of growth results in large number of variable Rapid rate of growth results in large number of variable sized nodes which are hard in consistency, tend to become sized nodes which are hard in consistency, tend to become fused and fixed to deep structures & may give pressure fused and fixed to deep structures & may give pressure manifestations.manifestations.

9- LEUKAEMIC L. N:9- LEUKAEMIC L. N:**May be associated with general manifestations (fever, May be associated with general manifestations (fever, malaise, anorexia, headache, Hemorhagic tendency)malaise, anorexia, headache, Hemorhagic tendency)aa- Acute Leukaemia:- Acute Leukaemia:**Late, slightly or moderately enlargedLate, slightly or moderately enlarged**Soft, discrete esp. cervical L.N. due to oral sepsisSoft, discrete esp. cervical L.N. due to oral sepsis**May be tender bone.May be tender bone.b-C.L.L:b-C.L.L: ** May affect May affect cervica1 cervica1 L.N. but mostly all superficial L.N. L.N. but mostly all superficial L.N. are enlarged.are enlarged. **The glands usually are (firm, not tender, not matted, The glands usually are (firm, not tender, not matted, usually moderately enlarged, but in advanced stages may usually moderately enlarged, but in advanced stages may be markedly enlarged)be markedly enlarged)c-C.M.Lc-C.M.L.:.: **Rare to be manifested by L.N. enlargement.Rare to be manifested by L.N. enlargement.

10- CARCINOMATOUS L.N.:*Firm, but some times hard.*A stoney hard nodes fixed to underlying tissues are nearly always neoplastic in nature, however the reverse is not true.*Carcinomatous L.N. may be freely mobile

Presentation:Presentation: ** Swelling Swelling

** Constitutional symptoms (fever, sweating, loss of wt., pruritis) Constitutional symptoms (fever, sweating, loss of wt., pruritis) ** Pressure symptoms: Pressure symptoms:

-- Mediastinal syndrome Mediastinal syndrome -- Pressure on veins Pressure on veins →→ oedemaoedema -- Pressure on nerves Pressure on nerves →→ painpainAge:Age: ** T.B.: usually in children and young adults. T.B.: usually in children and young adults. ** H.D. : H.D. : any any age including childhood, but its highest incidence ( ) age including childhood, but its highest incidence ( ) (20-40 ys) (20-40 ys) ** N.H.L.: usually at middle age and late life. N.H.L.: usually at middle age and late life. ** Acute Leuk.: any age, but highest Acute Leuk.: any age, but highest in in first 6 years of life.first 6 years of life.

HistoryHistory:: * * of infections, drugs, or vaccinations.of infections, drugs, or vaccinations.DistributionDistribution:: ** Localized or generalized. Localized or generalized. ** Single or multiple groups affected. Single or multiple groups affected.CharactersCharacters mentioned before. mentioned before.Other Signs:Other Signs: *Fever:*Fever: Leuk., H.D., N.H.L., Pel Ebstein fever. Leuk., H.D., N.H.L., Pel Ebstein fever. *Jaundice :*Jaundice : H.D.,Chronic leuk. (due to hepatic H.D.,Chronic leuk. (due to hepatic infiltration infiltration →→ pressure on bile duct) pressure on bile duct) *Eye:*Eye: in leuk. (infections, sub conj. in leuk. (infections, sub conj. Hge., Hge., exophthalmos.)exophthalmos.) * * Mouth, Tonsils, Parotid, GumsMouth, Tonsils, Parotid, Gums..

* Skin:* Skin: -pruritis, esp. H.D., N.H.L., Leuk.-pruritis, esp. H.D., N.H.L., Leuk. - Rash in L.G.- Rash in L.G. - skin nodules in C.L.L., NHL.- skin nodules in C.L.L., NHL. - herpes zoster in H.D.- herpes zoster in H.D.* Genitalia:* Genitalia: chancre, chancroid, ulcer, gonorrhea chancre, chancroid, ulcer, gonorrhea** Mediastinum & Chest Mediastinum & Chest : mediastinal syndrome, pleural : mediastinal syndrome, pleural

effusion.effusion.* Tenderness of sternum :* Tenderness of sternum : in C.M.L. in C.M.L.** Bone tenderness. & Pathological fractures Bone tenderness. & Pathological fractures : in H.D. & N.H.L.: in H.D. & N.H.L.*Abdomen:*Abdomen: - ascitis and masses- ascitis and masses - liver: - liver:

i-i- acute leuk : late & slightly enlarged. acute leuk : late & slightly enlarged. ii-ii-C.M.L. : firm & smooth C.M.L. : firm & smooth iii-iii- C.L.L. : enlarged liver C.L.L. : enlarged liver

- spleen : huge in C.M.L. & may be friction rub- spleen : huge in C.M.L. & may be friction rub

** N.B.: in H.D.: N.B.: in H.D.: 2/3 moderately enlarged spleen.2/3 moderately enlarged spleen. I /3 moderately enlarged liver.I /3 moderately enlarged liver. in in Sarcoidosis :Sarcoidosis : hepatosplenomegaly in 1/3 of hepatosplenomegaly in 1/3 of cases cases** Limbs : bone aches, swelling, joint affection. Limbs : bone aches, swelling, joint affection.** C.N.S: C.N.S:

-- esp. M.D. & N.H.L. esp. M.D. & N.H.L.-- brain & spinal cord : Hge, meningeal infiltration, brain & spinal cord : Hge, meningeal infiltration,

pressure manifest.pressure manifest. -- peripheral nerves: pain, parathesia. peripheral nerves: pain, parathesia.

-- mediastinum : Horner's syndrome, or vocal mediastinum : Horner's syndrome, or vocal cordscords

** ForFor cases of genera1ised lymphadenopathy or local cases of genera1ised lymphadenopathy or local L.N. enlargement without local cases:L.N. enlargement without local cases:(1)(1) Complete clinical examinations. Complete clinical examinations.(2)(2) C.B.P. & E.S.R. C.B.P. & E.S.R.(3)(3) Serological tests for infections mononucleosis,T.B. Serological tests for infections mononucleosis,T.B. toxoplasmosis, $.toxoplasmosis, $.(4)(4) Plain chest X ray. Plain chest X ray.(5)(5) Biopsy. Biopsy.(6)(6) Bone marrow aspiration if leuk. is suspected from Bone marrow aspiration if leuk. is suspected from C.B.P.C.B.P.** Biopsy should be done for enlarged L.N. of more than Biopsy should be done for enlarged L.N. of more than one month duration and not responding to usual ttt.one month duration and not responding to usual ttt.

** According to L.N. biopsy ?: if:According to L.N. biopsy ?: if: -- +ve +ve →→ management. management. -- -ve (single reactive hyperplasia) -ve (single reactive hyperplasia) →→ follow follow

up & if persist repeat biopsy two months later.up & if persist repeat biopsy two months later.Isolated Mediastinal L.N. Enlargement occurs Isolated Mediastinal L.N. Enlargement occurs in:in:

-- H.D. & N.H.L. H.D. & N.H.L. -- T.B. & Sarcoidosis. T.B. & Sarcoidosis. -- Cancer lung or oesophagus. Cancer lung or oesophagus.Isolated Abdominal L.N. Enlargement occurs Isolated Abdominal L.N. Enlargement occurs in:in: -- H.D & N.H.L H.D & N.H.L -- Metastasis. Metastasis.

Staging of LymphomaStaging of LymphomaA-A- Clinical staging:Clinical staging:1-1-Detaild history esp. in systemic symptoms.Detaild history esp. in systemic symptoms.2-2-Clinical examination including the Waldeyer's ring & Clinical examination including the Waldeyer's ring & areas of bone metastasis.areas of bone metastasis.3-3- Adequate surgical biopsy Adequate surgical biopsy4-4- Routine lab. tests (C.B.P. & E.S.R & liver kidney Routine lab. tests (C.B.P. & E.S.R & liver kidney function tests & Serum Uric acid.)function tests & Serum Uric acid.)5-5- Plain chest X ray (P.A & Lat. view)Plain chest X ray (P.A & Lat. view)6-6- Bilateral lower extremities lymphangiography.Bilateral lower extremities lymphangiography.7-7- Radiological examinations (G.I.T., Gastroscopy if + Radiological examinations (G.I.T., Gastroscopy if + ve Waldeyer's ring)ve Waldeyer's ring)8-8- Abdominal Ultrasonography or C.T. Scan. Abdominal Ultrasonography or C.T. Scan.

B- PB- Pahological staging:ahological staging:

1- Bone narrow biopsy.1- Bone narrow biopsy. 2-2- Staging labarotomy. (Staging labarotomy. (only only indicated in indicated in H.D with clinical stage I & II, if theraputic H.D with clinical stage I & II, if theraputic decision will depend on the identification of decision will depend on the identification of occult abdominal involvement) .occult abdominal involvement) .

The Ann Arbor Staging Classification:-The Ann Arbor Staging Classification:-

Stage IStage I ** Involvement of single L.N. region (I) Involvement of single L.N. region (I)** Or single extra nodal organ or site (IE*) Or single extra nodal organ or site (IE*)

Stage IIStage II..**involvement of two or L.N region on the involvement of two or L.N region on the

same side of the diaphragm (II).same side of the diaphragm (II).**or. localised involvement of an extranodal or. localised involvement of an extranodal

organ or site will one or more L.N. regions on the same organ or site will one or more L.N. regions on the same side of the diaphragm (IIE*).side of the diaphragm (IIE*).

The Ann Arbor Staging Classification:-The Ann Arbor Staging Classification:-

Stage IIIStage IIIIII:III: involvement of L.N. regions on both sides of involvement of L.N. regions on both sides of

diaphragm.diaphragm.IIIs: IIIs: may be also accompanied by splenic may be also accompanied by splenic

enlargementenlargementIIIE* :IIIE* : or by localized involvement of an or by localized involvement of an

extranodal site.extranodal site.IIISE* :IIISE* : or both. or both.

Stage IVStage IV** Diffuse Diffuse or or disseminated involvement of one disseminated involvement of one or or

more more extranodal extranodal organs organs with or without associated L.N. with or without associated L.N. involvement.involvement.

NB.NB.** Any of them is further subdivided into: Any of them is further subdivided into:

A :A : without systemic symptoms. without systemic symptoms.B :B : with systemic symptoms with systemic symptoms

** (E) means very limited extra- lymphatic (E) means very limited extra- lymphatic disease (both in site & extent) subjected to define disease (both in site & extent) subjected to define ttt by radiotherapyttt by radiotherapy. e.g:. e.g:

i:i: L.N. + adjacent bone L.N. + adjacent boneii:ii: Ant. mediastinum + sternal invasion. Ant. mediastinum + sternal invasion.iii:iii: Mediastinal L.N. + adjacent lung Mediastinal L.N. + adjacent lung tissues.tissues.

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