lymphadenopathy and malignancy andrew w.bazemore, m.d., and douglars r. smucker, m.d., m.p.h....
TRANSCRIPT
Lymphadenopathy and Malignancy
Andrew W.Bazemore, M.D., and Douglars R. Smucker, M.D., M.P.H.University of Cincinnati College of Medicine, Cincinnati, OhioAmerican Family Physician Dec. 1,2002 Vol.66 Num.11
Journal Reading, 萬芳醫院家庭醫學科Int. 蘇宏昌報告日期 Aug.4th, 2003實習日期 July 31th, 2003 – Aug. 8th, 2003
Outline
Introducing Historical Clues Physical Examination Nodal Character and Size Diagnosis and Management Lymph Node Biopsy
Introducing
Lymphadenopathy : an abnormality in the size or character of lymph nodes Categories of Lymphadenopathy : MIAMI Malignancies,
Infections, Autoimmune disorders, Miscellaneous and unusual conditions, and Iatrogenic causes
The most concerning to the patient and physician : the possibility of underlying malignancy
Low Rate of Malignancy in Primary Care : 1.1 % of pt’s presenting to the office with unexplained
lymphadenopathy
Historical Clues : Age and Duration
Malignant rate increases with age. A majority of healthy children have palpable c
ervical, inguinal and axillary adenopathy. Most of them is infectious or benign in etiology.
Lymphadenopathy that lasts less than 2 weeks or more than 1 year with no progressive size increase has a very low likelihood of being neoplastic.
Rare Exception : low-grade Hodgkin’s/ non-Hodgkin’s lymphomas and, occasionally, chronic lymphocytic leukemia
Historical Clues : Exposures & History
Animals, biting insects, infectious contacts, recurrent infections, chronic use of medications. Travel-related exposures and immunization status.
Tobacco, alcohol, ultraviolet radiation : raise suspicion for metastatic carcinoma
Occupational exposures to silicon or beryllium
Sexual history and orientation. AIDS pt’s Family history
Medications That Can Cause Lymphadenopathy
Allopurinol (Zyloprim) Atenolol (Tenormin) Captopril (Capoten) Carbamazepine (Tegretol) Gold Hydralazine (Apresoline) Penicillins Phenytoin (Dilantin) Primidone (Mysoline) Pyrimethamine (Daraprim) Quinidine Trimethoprim/sulfamethoxazole (Bactrim) Sulindac (Clinoril)
Historical Clues : Associated Symptoms
Constitutional symptoms : fever, fatigue, malaise with atypical lymphocytosis → mononucleosis syndromes
Significant fever, night sweats, unexplained BW loss > 10% of normal BW → “B” symptoms of Hodgkin’s lymphoma
Arthralgias, muscle weakness, unusual rash → autoimmune diseases such as RA, SLE, dermatomyositis
Head and Neck Lymphadenopathy
In one outpatient primary care study : cervical LNs are palpable in 51% of adult physicals, with the incidence declined with age.
Infection is the most common cause Most cases resolve quickly; some entities can
create persistent lymphadenopathy for months. (ex. Atypical mycobacteria, cat-scratch disease, toxoplasmosis, kikuchi’s lymphadenitis, sarcoidosis, Kawasaki’s syndrome.)
Supraclavicular nodes are the most likely to be malignant and should always be investigated, even in children.
Axillary Lymphadenopathy
Most of cases are nonspecific or reactive to local injury/infection in etiology.
Persistent lymphadenopathy is less commonly found in the axillary nodes than in the inguinal chain.
Breast adenocarcinoma often metastasis initially to the anterior and central axillary nodes, which may be palpable before discovery of the primary tumor.
Antecubital or epitrochlear lymphadenopathy can suggest lymphoma or melanoma of the extremity.
Inguinal Lymphadenopathy
It is common, with nodes enlarged up to 1 to 2 cm in diameter in many healthy adults, but it is of low suspicion of malignancy.
Benign reactive lymphadenopathy and infection are the most common etiologies.
Although some tumors, such as Hodgkin’s lymphomas, penile/ vulvar SCC, melanoma in this area, may present with inguinal lymphadenopathy, it is typical presenting finding in neither case.
Generalized Lymphadenopathy
Generalized lymphadenopathy : lymphadenopathy found in two or more distinct anatomic regions
More likely to result from serious infections, autoimmune diseases, and disseminated malignancies.
Specific testing is usually required. Generalized adenopathy infrequently occurs i
n pt’s with neoplasms, but it is occasionally seen in patients with leukemias and lymphomas, or advanced disseminated metastatic solid tumors.
Nodal Character and Size
Hard and painless nodes have higher suspicion of malignancy or granulomatous disease.
Viral infection typically produces hyperplastic nodes that are bilateral, mobile, nontender, and clearly demarcated.
Palpable supraclavicular, iliac, or popliteal nodes of any size and epitrochlear nodes larger than 5mm are considered abnormal.
Increasing size and persistence over time are of greater concern for malignancy than a specific level of nodal enlargement.
Diagnosis and Management
The first step : reviewing pts’ medications, considering unusual causes of lymphadenopathy, and reconsidering the risk factors for neoplasm. If a diagnosis is not suggested, and the patient is deemed low risk for neoplasm, the regional lymphadenopathy can be safely observed.
It is suggested that non-inguinal lymphadenopathy lasting more than one month merits specific investigation or biopsy.
Lymph Node Biopsy
Once biopsy has been chosen, ideally the largest, most suspicious, and most accessible node is selected, taking into account differing diagnostic yields by site.
Inguinal nodes offer the lowest yield, and supraclavicular nodes have the highest.
Excisional biopsy remains the diagnostic procedure of choice.