STUDY - Technical - New Dacian's Medicine
Lymphadenopathy
and Splenomegaly (1)
Translation Draft
Traditional medicine (alopathic) treats adenopathy (enlargement of the lymph nodes) and splenomegaly (enlargement of the spleen) together with haematological alterations.
Traditional medicine (alopathic) treats adenopathy (enlargement of the lymph nodes) and splenomegaly (enlargement of the spleen) together with haematological alterations.
I'm not going to
contradict them but, from my point of view (and the authors of
the "relationship" in the new medicine) the lymph has its
"problems", totally distinct and just as important with those of
blood, and the spleen, well, who am I to comment on?!? But let's
get to work!
Adenopathy may be a random discovery in patients examined for various reasons or may be a sign or symptom of the patient's disease. The doctor should decide whether adenopathy is normal in that context or requires closer examination until a biopsy is required. Soft, pleasant submandibular ganglia (less than 1 cm) are frequently palpable in healthy children and young adults, and healthy adults may have palpable inguinal ganglia of up to 2 cm, which are considered normal. Their in-depth assessment is not recommended. Instead, if the doctor thinks these ganglia are abnormal, a more accurate diagnosis is necessary.
From the point of view of the patient's approach, adenopathy can be the primary or secondary manifestation of many conditions: 1. infectious diseases (a. viral such as infectious mononucleosis syndromes - EBV, CMV, infectious hepatitis, herpes simplex, herpesvirus-6, varicella-zoster viruses, rubella, measles, adenoviruses, HIV, epidermal keratoconjunctivitis, vaccine; b. bacterial such as streptococci, staphylococci, cat claw disease , brucellosis, tularemia, plague, soft sancru, tuberculosis, atypical mycobacterial infection, primary and secondary syphilis, diphtheria, leprosy; c. fungal sortoplasmosis, coccidiomycosis and paracoccidiomycosis; d. chlamydia lupegranulomatosis and trahome; e. parasitic as toxoplasmosis, leishmaniosis, tripanosomiasis and filariasis; and f. richettsial as exantematic typhus and rickettsialpox), 2. immunological diseases (a. rheumatoid arthritis, juvenile rheumatoid arthritis, b. disease, mixed connective tissue, c. systemic lupus erythematosus, d. dermatomyositis, e. Sjogren's syndrome, f. serum disease, g. sensitivity to drugs such as diphenylhydrantoin, hydralazine, allopurinol, primidone, golden salts, carbamazepine, etc., h. angioimunoblastic lymphadenopathy, i. primitive biliary cirrhosis, j. host-contra-graft disease and k. associated with silicone) , 3. malignant diseases (a. haematological diseases such as Hodgkin's disease, acute or chronic lymphatic leukaemia, hairy cell leukemia, malignant histiocytosis, amyloidosis and metastatic b. - from numerous primary disorders), 4. lipid deposit disease (Gaucher, Niemann-Pick, Fabry, Tangier), 5. endocrine diseases (hyperthyroidism) and 6. other diseases (a. Castleman's disease or giant hyperplasia of the lymph nodes), sarcoidosis, dermatological lymphadenitis, lymphoid granulomatosis, necrotizing histocytic lymphadenitis or Kikuchi disease, sinus histiocytosis with massive lymphadenopathy or Rosai-Dorfman's disease, mucocutaneous lymph node syndrome or Kawasaki disease, histiocytosis X, familial Mediterranean fever, severe hypertriglycerides, vascular transformation of the sinuses and pseudoinflammatory mfatic).
Many of these diseases rarely cause adenopathy. Analysis of adenopathy in primary medical practice showed that more than two-thirds of patients had a nonspecific cause or upper respiratory tract disorders (viral or bacterial) and less than 1% had neoplasm. In one study, the researchers reported that more than 80% of patients sent to assess an adenopathy received a "benign" diagnosis. Others (less than 20%) had a neoplasm (lymphoma or metastatic adenocarcinoma). Then, more than 60% of patients with benign adenopathy had a nonspecific or reactive cause (no causative agent was found), and the others had a specific proven etiology, most commonly infectious mononucleosis, toxoplasmosis or tuberculosis. Thus, the majority of patients with adenopathy had a nonspecific etiology, which required only a few diagnostic tests.
In the clinical evaluation, the doctor will be helped in seeking an explanation of adenopathy by performing a careful anamnesis, physical examination, selected laboratory tests and perhaps excision and biopsy of the lymph node. The anamnesis must reveal the circumstances in which adenopathy occurred. Symptoms such as sore throat, cough, fever, night sweats, fatigue, weight loss or pain in the lumps should be sought. Other important elements of anamnesis are age, sex, profession, exposure to pets, the patient's sexual behavior and the use of drugs such as diphenylhydrantoin.
For example, children and young adults usually have benign (i.e. nonmalignant) conditions, such as upper respiratory tract infections, viral or bacterial infections, infectious mononucleosis, toxoplasmosis and, in some countries, tuberculosis, which explains the observed adenopathy. By contrast, after the age of 50, the incidence of malignancies increases and the incidence of benign conditions decreases. Physical examination may provide important information, such as the extension of adenopathy (localized or generalized), the size of the ganglia, the consistency, presence or absence of pain in their level, signs of inflammation around them, skin lesions and splenomegalia.
An examination of the neck, nose and ears (ORL) is indicated in adult patients with cervical adenopathy and smokers. Regional or localized adenopathy comprises a single anatomical area. Generalized adenopathy has been defined as the involvement of three or more areas with lymph nodes that do not border each other. Many of the above causes of adenopathy can cause localized or generalized adenopathy, so this distinction has limited utility in differential diagnosis. However, generalized adenopathy is commonly associated with non-malignant diseases such as infectious mononucleosis (Epstein-Barr virus - EBV or cytomegal virus - CMV), toxoplasmosis, AIDS, other infectious diseases, systemic lupus erythematosus (LES) and mixed connective tissue disease. Acute or chronic lymphocytic leukaemias and malignant lymphomas may also cause generalized adenopathy in adults. The localization of regional adenopathy may provide important clues in relation to etiology.
Occipital adenopathy usually occurs in scalp infections, and pre-uriculal adenopathy accompanies conjunctival infections and cat claw disease. The most common localization of regional adenopathy is the neck, and most causes are benign (upper respiratory tract infections, oral and dental lesions, infectious mononucleosis, other viral diseases). The most important malignant cause is the metastasis of primary neoplasms in the head and neck, breasts, lungs and thyroid. Enlargement of the sublavilal and scanial ganglia is always abnormal.
Because these lymph nodes drain the lymph from the lungs and retroperitoneal space, they may indicate the presence of lymphoma, another neoplasm or an infectious process in these areas. The Virchow ganglion is an enlarged left subclavicular ganglion, neoplastic infiltration, from a primary gastric cancer. Metastases in the sublavilal ganglia are also given by breast, lung and genital neoplasms. Tuberculosis, sarcoidosis and toxoplasmosis are other (non-malignant) causes of sub-secondary adenopathy. Axillary adenopathy is usually due to lesions or localized infections of the ipsilateral upper limb. Malignant causes include melanoma and lymphoma, and in women, breast cancer.
Inguinal adenopathy is usually secondary to infection or trauma of the lower limbs and can accompany sexually transmitted diseases, such as venereal lymphogranulomatosis, primary syphilis, genital herpes or sham. These adenopathies can also be caused by lymphomas or metastases of primary neoplasms located in the rectum, lower limbs (melanomas) or genital.
The size and consistency of lymph nodes and the presence of pain are useful parameters in the evaluation of patients with adenopathy. Ganglions with an area of less than 1 square cm are almost always secondary to benign reactive causes. In a retrospective analysis of young patients (between 9 and 25 years of age) who had the lymph nodes biopsied, the maximum diameter of more than 2 cm was used as a discriminative factor, indicating that the biopsy will reveal a malignant or granulomatous disease. Another study showed that the size of a ganglion greater than 2.25 square cm (1.5 x 1.5 cm) is the best discriminative limit to distinguish malignant or granulomatous adenopathy from other causes of adenopathy. Patients with ganglia less than one square centimeter should remain under observation after the exclusion of infectious mononucleosis/ toxoplasmosis, only if the signs and symptoms do not indicate a basic systemic disease.
The consistency of lymph nodes can be described as soft, firm, rubber-like, hard, heterogeneous, matte or lymph nodes can be sensitive, mobile or fixed. Sensitivity to palpation occurs when the capsule is stretched due to rapid volume growth, usually secondary to an inflammatory process. Some malignant diseases, such as acute leukemia, can cause sudden enlargement and pain in the lymph nodes. Ganglia interested in lymphoma are large, heterogeneous, symmetrical, rubber-like, firm, mobile and are not sensitive to palpation. Metastasis ganglia are usually hard, painless and immobile due to the fixation of surrounding tissues. The coexistence of splenomegaly in a patient with adenopathy involves a systemic disease such as infectious mononucleosis, lymphoma, acute or chronic leukemia, SLE, sarcoidosis, toxoplasmosis, cat claw disease or other less common haematological disorders.
Deep adenopathy (thoracic or abdominal) are usually detected due to an assessment dictated by symptomatology. Thoracic adenopathy can be detected by routine chest X-ray or during secondary evaluation of the discovery of superficial adenopathy. It can also be discovered because the patient complains of coughing and wheezing by compression of the airways, hoarseness in the case of involvement of the recurrent laryngeal nerve, dysphagia due to compression of the esophagus or edema of the face, neck or arms as a result of compression of the upper cave vein or subclavicular vein.
Differential diagnosis of mediastinal and hilarious adenopathy includes primary lung diseases and systemic diseases that are characteristically interested in mediastinal or hilarious nodules. In young people, mediastinal adenopathy is associated with infectious mononucleosis and sarcoidosis. In endemic areas, histoplasmosis may cause unilateral interest in the paratracheal lymph nodes that mimic lymphoma. And tuberculosis can cause unilateral adenopathy. In the elderly, differential diagnosis includes primary lung cancer (especially in smokers), lymphoma, metastatic carcinoma (usually lung), tuberculosis, fungal infections and sarcoidosis. Enlarged intraabdominal or retroperitoneal ganglia are usually malignant. Although tuberculosis can cause mesenteric adenopathy, these masses usually contain lymphomas or, in young men, metastatic tumor cells.
Laboratory investigations of patients with adenopathy should be conducted in such a way as to elucidate the suspected etiology after anamnesis and physical examination. In a study of young patients who presented with "enlarged, uninfected lymph nodes" or "adenopathy", 51% did not have laboratory tests (and this is not in Romania). In cases where laboratory investigations were carried out, the most common was a haemoleukogram (33%), a tracheal suction (16%), a chest X-ray (12%) or a serological test (10%). Only 3% underwent a ganglion biopsy and half of these were normal or reactive.
Hemoleucogram may provide useful data for the diagnosis of acute or chronic leukaemia, EVB or CMV mononucleosis, leucemic lymphoma, pyogenic infections or immune cytopenia from diseases such as SLE. Serological studies may cause specific antibodies to components of EVB or CMV, human immunodeficiency virus (HIV) and other viruses, Toxoplasma gondii, Brucella, etc. If SLE is suspected, determination of antinuclear or anti-DNA antibodies is indicated.
Chest X-ray is usually negative, but the presence of a pulmonary infiltration or mediastinal adenopathy suggests tuberculosis, sarcoidosis, lymphoma, primary pulmonary neoplasm or metastatic neoplasm and requires thorough investigation. Indications for biopsy of a lymph node are not well specified, but they are a useful diagnostic tool. The decision to perform the biopsy may be taken early after evaluation of a patient or delayed for a period (approximately 2 weeks), sufficient for observation.
Biopsy should be performed immediately if the patient's history and the data provided by the physical examination suggest malignancy (an example is hard, painless cervical adenopathy in an elderly, old smoker, supra-cnegative adenopathy and solitary or generalized adenopathy, which is firm, mobile and suggestive of lymphoma). If a primary neoplasm in the head or neck is suspected on the basis of the presence of a solitary, hard cervical ganglion, an ENT examination should be performed. Any lesion on the mucous membranes, the largest ganglion should be biopsied. Fine needle aspiration is not indicated as an initial diagnostic procedure.
Most diagnoses require more tissue than this procedure can provide, which can delay the definitive diagnosis. Fine needle aspiration should be reserved for thyroid nodules and for confirmation of recurrence in patients whose diagnosis is known. If the doctor is unsure about performing a biopsy, it may be useful to consult a hematologist or oncologist. In primary medical practice, less than 5% of adenopathies require biopsy. This percentage is considerably higher in specialized practice, i.e. haematological, oncological and otorinolaringological (ORL).
Two study groups reported algorithms that could more accurately identify patients with adenopathy that should be biopsied. Both studies were retrospective analyses of specialized practice. The first study included patients between the ages of 9 and 25 who had a ganglion biopsy. Three variables have been identified indicating those young patients with peripheral adenopathy to be biopsied (node size greater than 2 cm in diameter and abnormal chest X-ray are positive predictors, while recent ENT symptoms have a negative predictive value).
The second study in patients with adenopathy in a haematological clinic identifies five variables: the size of the lymph node, the location (over or non-clavicular), the age (greater or less than 40 years), the consistency (hard or not) and sensitivity to palpation. These were included in a mathematical formula to identify those patients who need biopsy. The positive predictive values found were more than 40 years of age, supralavicolal location, node size greater than 2.5 square cm, hard consistency and lack of pain or sensitivity to palpation. Negative predictive values are less than 40 years of age, node size less than 1 cm square, soft consistency and pain or sensitivity to palpation. 91% of those requiring biopsy were correctly classified by this formula.
Since both studies are retrospective analyses and one is limited to young patients, it is not known how useful these formulas are applied retrospectively in primary medical practice.
Most patients with adenopathy do not require biopsy and at least half do not need any laboratory investigations. If anamnesis and physical examination data indicate a benign cause of adenopathy, careful monitoring should be carried out for 2-4 weeks. Patients should be advised to return for reassessment if the lump increases in volume. Antibiotics are not indicated, unless there is clear evidence of a bacterial infection. Glucocorticoids should not be used to treat adenopathy, as their lympholytic effect may hide some diagnoses (lymphopenia, leukaemia, Castleman's disease) and contribute to delaying healing or triggering an infection. An exception to this rule is the obstruction of the pharynx by the growth of the lymphoid tissue of the Waldeyer ring, which sometimes occurs in infectious mononucleosis, which can threaten the patient's life.
Ready for today! In the next post we approach splenomegalia...
Adenopathy may be a random discovery in patients examined for various reasons or may be a sign or symptom of the patient's disease. The doctor should decide whether adenopathy is normal in that context or requires closer examination until a biopsy is required. Soft, pleasant submandibular ganglia (less than 1 cm) are frequently palpable in healthy children and young adults, and healthy adults may have palpable inguinal ganglia of up to 2 cm, which are considered normal. Their in-depth assessment is not recommended. Instead, if the doctor thinks these ganglia are abnormal, a more accurate diagnosis is necessary.
From the point of view of the patient's approach, adenopathy can be the primary or secondary manifestation of many conditions: 1. infectious diseases (a. viral such as infectious mononucleosis syndromes - EBV, CMV, infectious hepatitis, herpes simplex, herpesvirus-6, varicella-zoster viruses, rubella, measles, adenoviruses, HIV, epidermal keratoconjunctivitis, vaccine; b. bacterial such as streptococci, staphylococci, cat claw disease , brucellosis, tularemia, plague, soft sancru, tuberculosis, atypical mycobacterial infection, primary and secondary syphilis, diphtheria, leprosy; c. fungal sortoplasmosis, coccidiomycosis and paracoccidiomycosis; d. chlamydia lupegranulomatosis and trahome; e. parasitic as toxoplasmosis, leishmaniosis, tripanosomiasis and filariasis; and f. richettsial as exantematic typhus and rickettsialpox), 2. immunological diseases (a. rheumatoid arthritis, juvenile rheumatoid arthritis, b. disease, mixed connective tissue, c. systemic lupus erythematosus, d. dermatomyositis, e. Sjogren's syndrome, f. serum disease, g. sensitivity to drugs such as diphenylhydrantoin, hydralazine, allopurinol, primidone, golden salts, carbamazepine, etc., h. angioimunoblastic lymphadenopathy, i. primitive biliary cirrhosis, j. host-contra-graft disease and k. associated with silicone) , 3. malignant diseases (a. haematological diseases such as Hodgkin's disease, acute or chronic lymphatic leukaemia, hairy cell leukemia, malignant histiocytosis, amyloidosis and metastatic b. - from numerous primary disorders), 4. lipid deposit disease (Gaucher, Niemann-Pick, Fabry, Tangier), 5. endocrine diseases (hyperthyroidism) and 6. other diseases (a. Castleman's disease or giant hyperplasia of the lymph nodes), sarcoidosis, dermatological lymphadenitis, lymphoid granulomatosis, necrotizing histocytic lymphadenitis or Kikuchi disease, sinus histiocytosis with massive lymphadenopathy or Rosai-Dorfman's disease, mucocutaneous lymph node syndrome or Kawasaki disease, histiocytosis X, familial Mediterranean fever, severe hypertriglycerides, vascular transformation of the sinuses and pseudoinflammatory mfatic).
Many of these diseases rarely cause adenopathy. Analysis of adenopathy in primary medical practice showed that more than two-thirds of patients had a nonspecific cause or upper respiratory tract disorders (viral or bacterial) and less than 1% had neoplasm. In one study, the researchers reported that more than 80% of patients sent to assess an adenopathy received a "benign" diagnosis. Others (less than 20%) had a neoplasm (lymphoma or metastatic adenocarcinoma). Then, more than 60% of patients with benign adenopathy had a nonspecific or reactive cause (no causative agent was found), and the others had a specific proven etiology, most commonly infectious mononucleosis, toxoplasmosis or tuberculosis. Thus, the majority of patients with adenopathy had a nonspecific etiology, which required only a few diagnostic tests.
In the clinical evaluation, the doctor will be helped in seeking an explanation of adenopathy by performing a careful anamnesis, physical examination, selected laboratory tests and perhaps excision and biopsy of the lymph node. The anamnesis must reveal the circumstances in which adenopathy occurred. Symptoms such as sore throat, cough, fever, night sweats, fatigue, weight loss or pain in the lumps should be sought. Other important elements of anamnesis are age, sex, profession, exposure to pets, the patient's sexual behavior and the use of drugs such as diphenylhydrantoin.
For example, children and young adults usually have benign (i.e. nonmalignant) conditions, such as upper respiratory tract infections, viral or bacterial infections, infectious mononucleosis, toxoplasmosis and, in some countries, tuberculosis, which explains the observed adenopathy. By contrast, after the age of 50, the incidence of malignancies increases and the incidence of benign conditions decreases. Physical examination may provide important information, such as the extension of adenopathy (localized or generalized), the size of the ganglia, the consistency, presence or absence of pain in their level, signs of inflammation around them, skin lesions and splenomegalia.
An examination of the neck, nose and ears (ORL) is indicated in adult patients with cervical adenopathy and smokers. Regional or localized adenopathy comprises a single anatomical area. Generalized adenopathy has been defined as the involvement of three or more areas with lymph nodes that do not border each other. Many of the above causes of adenopathy can cause localized or generalized adenopathy, so this distinction has limited utility in differential diagnosis. However, generalized adenopathy is commonly associated with non-malignant diseases such as infectious mononucleosis (Epstein-Barr virus - EBV or cytomegal virus - CMV), toxoplasmosis, AIDS, other infectious diseases, systemic lupus erythematosus (LES) and mixed connective tissue disease. Acute or chronic lymphocytic leukaemias and malignant lymphomas may also cause generalized adenopathy in adults. The localization of regional adenopathy may provide important clues in relation to etiology.
Occipital adenopathy usually occurs in scalp infections, and pre-uriculal adenopathy accompanies conjunctival infections and cat claw disease. The most common localization of regional adenopathy is the neck, and most causes are benign (upper respiratory tract infections, oral and dental lesions, infectious mononucleosis, other viral diseases). The most important malignant cause is the metastasis of primary neoplasms in the head and neck, breasts, lungs and thyroid. Enlargement of the sublavilal and scanial ganglia is always abnormal.
Because these lymph nodes drain the lymph from the lungs and retroperitoneal space, they may indicate the presence of lymphoma, another neoplasm or an infectious process in these areas. The Virchow ganglion is an enlarged left subclavicular ganglion, neoplastic infiltration, from a primary gastric cancer. Metastases in the sublavilal ganglia are also given by breast, lung and genital neoplasms. Tuberculosis, sarcoidosis and toxoplasmosis are other (non-malignant) causes of sub-secondary adenopathy. Axillary adenopathy is usually due to lesions or localized infections of the ipsilateral upper limb. Malignant causes include melanoma and lymphoma, and in women, breast cancer.
Inguinal adenopathy is usually secondary to infection or trauma of the lower limbs and can accompany sexually transmitted diseases, such as venereal lymphogranulomatosis, primary syphilis, genital herpes or sham. These adenopathies can also be caused by lymphomas or metastases of primary neoplasms located in the rectum, lower limbs (melanomas) or genital.
The size and consistency of lymph nodes and the presence of pain are useful parameters in the evaluation of patients with adenopathy. Ganglions with an area of less than 1 square cm are almost always secondary to benign reactive causes. In a retrospective analysis of young patients (between 9 and 25 years of age) who had the lymph nodes biopsied, the maximum diameter of more than 2 cm was used as a discriminative factor, indicating that the biopsy will reveal a malignant or granulomatous disease. Another study showed that the size of a ganglion greater than 2.25 square cm (1.5 x 1.5 cm) is the best discriminative limit to distinguish malignant or granulomatous adenopathy from other causes of adenopathy. Patients with ganglia less than one square centimeter should remain under observation after the exclusion of infectious mononucleosis/ toxoplasmosis, only if the signs and symptoms do not indicate a basic systemic disease.
The consistency of lymph nodes can be described as soft, firm, rubber-like, hard, heterogeneous, matte or lymph nodes can be sensitive, mobile or fixed. Sensitivity to palpation occurs when the capsule is stretched due to rapid volume growth, usually secondary to an inflammatory process. Some malignant diseases, such as acute leukemia, can cause sudden enlargement and pain in the lymph nodes. Ganglia interested in lymphoma are large, heterogeneous, symmetrical, rubber-like, firm, mobile and are not sensitive to palpation. Metastasis ganglia are usually hard, painless and immobile due to the fixation of surrounding tissues. The coexistence of splenomegaly in a patient with adenopathy involves a systemic disease such as infectious mononucleosis, lymphoma, acute or chronic leukemia, SLE, sarcoidosis, toxoplasmosis, cat claw disease or other less common haematological disorders.
Deep adenopathy (thoracic or abdominal) are usually detected due to an assessment dictated by symptomatology. Thoracic adenopathy can be detected by routine chest X-ray or during secondary evaluation of the discovery of superficial adenopathy. It can also be discovered because the patient complains of coughing and wheezing by compression of the airways, hoarseness in the case of involvement of the recurrent laryngeal nerve, dysphagia due to compression of the esophagus or edema of the face, neck or arms as a result of compression of the upper cave vein or subclavicular vein.
Differential diagnosis of mediastinal and hilarious adenopathy includes primary lung diseases and systemic diseases that are characteristically interested in mediastinal or hilarious nodules. In young people, mediastinal adenopathy is associated with infectious mononucleosis and sarcoidosis. In endemic areas, histoplasmosis may cause unilateral interest in the paratracheal lymph nodes that mimic lymphoma. And tuberculosis can cause unilateral adenopathy. In the elderly, differential diagnosis includes primary lung cancer (especially in smokers), lymphoma, metastatic carcinoma (usually lung), tuberculosis, fungal infections and sarcoidosis. Enlarged intraabdominal or retroperitoneal ganglia are usually malignant. Although tuberculosis can cause mesenteric adenopathy, these masses usually contain lymphomas or, in young men, metastatic tumor cells.
Laboratory investigations of patients with adenopathy should be conducted in such a way as to elucidate the suspected etiology after anamnesis and physical examination. In a study of young patients who presented with "enlarged, uninfected lymph nodes" or "adenopathy", 51% did not have laboratory tests (and this is not in Romania). In cases where laboratory investigations were carried out, the most common was a haemoleukogram (33%), a tracheal suction (16%), a chest X-ray (12%) or a serological test (10%). Only 3% underwent a ganglion biopsy and half of these were normal or reactive.
Hemoleucogram may provide useful data for the diagnosis of acute or chronic leukaemia, EVB or CMV mononucleosis, leucemic lymphoma, pyogenic infections or immune cytopenia from diseases such as SLE. Serological studies may cause specific antibodies to components of EVB or CMV, human immunodeficiency virus (HIV) and other viruses, Toxoplasma gondii, Brucella, etc. If SLE is suspected, determination of antinuclear or anti-DNA antibodies is indicated.
Chest X-ray is usually negative, but the presence of a pulmonary infiltration or mediastinal adenopathy suggests tuberculosis, sarcoidosis, lymphoma, primary pulmonary neoplasm or metastatic neoplasm and requires thorough investigation. Indications for biopsy of a lymph node are not well specified, but they are a useful diagnostic tool. The decision to perform the biopsy may be taken early after evaluation of a patient or delayed for a period (approximately 2 weeks), sufficient for observation.
Biopsy should be performed immediately if the patient's history and the data provided by the physical examination suggest malignancy (an example is hard, painless cervical adenopathy in an elderly, old smoker, supra-cnegative adenopathy and solitary or generalized adenopathy, which is firm, mobile and suggestive of lymphoma). If a primary neoplasm in the head or neck is suspected on the basis of the presence of a solitary, hard cervical ganglion, an ENT examination should be performed. Any lesion on the mucous membranes, the largest ganglion should be biopsied. Fine needle aspiration is not indicated as an initial diagnostic procedure.
Most diagnoses require more tissue than this procedure can provide, which can delay the definitive diagnosis. Fine needle aspiration should be reserved for thyroid nodules and for confirmation of recurrence in patients whose diagnosis is known. If the doctor is unsure about performing a biopsy, it may be useful to consult a hematologist or oncologist. In primary medical practice, less than 5% of adenopathies require biopsy. This percentage is considerably higher in specialized practice, i.e. haematological, oncological and otorinolaringological (ORL).
Two study groups reported algorithms that could more accurately identify patients with adenopathy that should be biopsied. Both studies were retrospective analyses of specialized practice. The first study included patients between the ages of 9 and 25 who had a ganglion biopsy. Three variables have been identified indicating those young patients with peripheral adenopathy to be biopsied (node size greater than 2 cm in diameter and abnormal chest X-ray are positive predictors, while recent ENT symptoms have a negative predictive value).
The second study in patients with adenopathy in a haematological clinic identifies five variables: the size of the lymph node, the location (over or non-clavicular), the age (greater or less than 40 years), the consistency (hard or not) and sensitivity to palpation. These were included in a mathematical formula to identify those patients who need biopsy. The positive predictive values found were more than 40 years of age, supralavicolal location, node size greater than 2.5 square cm, hard consistency and lack of pain or sensitivity to palpation. Negative predictive values are less than 40 years of age, node size less than 1 cm square, soft consistency and pain or sensitivity to palpation. 91% of those requiring biopsy were correctly classified by this formula.
Since both studies are retrospective analyses and one is limited to young patients, it is not known how useful these formulas are applied retrospectively in primary medical practice.
Most patients with adenopathy do not require biopsy and at least half do not need any laboratory investigations. If anamnesis and physical examination data indicate a benign cause of adenopathy, careful monitoring should be carried out for 2-4 weeks. Patients should be advised to return for reassessment if the lump increases in volume. Antibiotics are not indicated, unless there is clear evidence of a bacterial infection. Glucocorticoids should not be used to treat adenopathy, as their lympholytic effect may hide some diagnoses (lymphopenia, leukaemia, Castleman's disease) and contribute to delaying healing or triggering an infection. An exception to this rule is the obstruction of the pharynx by the growth of the lymphoid tissue of the Waldeyer ring, which sometimes occurs in infectious mononucleosis, which can threaten the patient's life.
Ready for today! In the next post we approach splenomegalia...
Understanding, love and
gratitude!
Dorin, Merticaru