Lymphadenopathy

Lymphadenopathy
Other names: Adenopathy, swollen lymph nodes, lymphadenitis
A CT scan of axillary lymphadenopathy in a 57-year-old man with multiple myeloma.
SpecialtyInfectious disease, oncology
SymptomsEnlargement of lymph nodes[1]
CausesInfections, autoimmune diseases, cancers, lymphoproliferative disorders, unkown[1]
TreatmentBased on underlying cause[1]
FrequencyRelatively common, male = female[2]

Lymphadenopathy, also known as adenopathy, is the enlargement of lymph nodes.[1] This may occur in one part of the body or diffusely.[1] If the lymph node is tender there is a greater likelihood of an infectious cause and a lower likelihood of cancer.[1] Enlargement for more than 3 or 4 weeks is more concerning.[1][2]

Causes may include infections, autoimmune diseases, cancers, reactions to medications, and lymphoproliferative disorders.[1][2] Infections may be bacterial, fungal, viral, spirochetal, or protozoal.[1] Autoimmune diseases may include amyloidosis, lupus, and rheumatoid arthritis.[1] Cancers may include lymphoma, leukemia, and metastasis.[1] They cause may also remain unknown.[1] Generally in adults lymph nodes are smaller than 1 cm.[1] Diagnosis may be supported by a lymph node biopsy.[1]

Treatment depends on the underlying cause.[1] Most cases are non serious, especially in children.[1] Lymphadenopathy is relatively common.[2] Males and females are affected equally frequently.[2] Children are more commonly affected than adults.[2]

Terminology

Lymphadenopathy of an inflammatory type (the most common type) is also known as "lymphadenitis".[3] The distinction between lymphadenopathy and lymphadenitis is rarely made and the words are usually treated as synonymous. Inflammation of the lymphatic vessels is known as lymphangitis.[4] Infectious lymphadenitis due to tuberculosis affecting lymph nodes in the neck may be called a scrofula.

Causes

Retroperitoneal lymphadenopathies of testicular seminoma, embrace the aorta. Computed tomography image.

Lymph node enlargement is recognized as a common sign of infectious, autoimmune, or malignant disease. Examples may include:

Less common infectious causes of lymphadenopathy may include bacterial infections such as cat scratch disease, tularemia, brucellosis, or prevotella.

Benign (reactive) lymphadenopathy

Benign lymphadenopathy is a common biopsy finding, and may often be confused with malignant lymphoma. It may be separated into major morphologic patterns, each with its own differential diagnosis with certain types of lymphoma. Most cases of reactive follicular hyperplasia are easy to diagnose, but some cases may be confused with follicular lymphoma. There are seven distinct patterns of benign lymphadenopathy:[8]

  • Follicular hyperplasia: This is the most common type of reactive lymphadenopathy.[8]
  • Paracortical hyperplasia/Interfollicular hyperplasia: It is seen in viral infections, skin diseases, and nonspecific reactions.
  • Sinus histiocytosis: It is seen in lymph nodes draining limbs, inflammatory lesions, and malignancies.
  • Nodal extensive necrosis
  • Nodal granulomatous inflammation
  • Nodal extensive fibrosis (Connective tissue framework)
  • Nodal deposition of interstitial substance

These morphological patterns are never pure. Thus, reactive follicular hyperplasia can have a component of paracortical hyperplasia. However, this distinction is important for the differential diagnosis of the cause.

Diagnosis

Medical ultrasonography of a typical normal lymph node: smooth, gently lobulated oval with a hypoechoic cortex measuring less than 3 cm in thickness with a central echogenic hilum.[26]
Ultrasonography of a suspected malignant lymph node:
- Absence of the fatty hilum
- Increased focal cortical thickness greater than 3 cm
- Doppler ultrasonography that shows hyperaemic blood flow in the hilum and central cortex and/or abnormal (non-hilar cortical) blood flow.[26]

In cervical lymphadenopathy (of the neck), it is routine to perform a throat examination including the use of a mirror and an endoscope.[27]

On ultrasound, B-mode imaging depicts lymph node morphology, whilst power Doppler can assess the vascular pattern.[28] B-mode imaging features that can distinguish metastasis and lymphoma include size, shape, calcification, loss of hilar architecture, as well as intranodal necrosis.[28] Soft tissue edema and nodal matting on B-mode imaging suggests tuberculous cervical lymphadenitis or previous radiation therapy.[28] Serial monitoring of nodal size and vascularity are useful in assessing treatment response.[28]

Fine needle aspiration cytology (FNAC) has sensitivity and specificity percentages of 81% and 100%, respectively, in the histopathology of malignant cervical lymphadenopathy.[27] PET-CT has proven to be helpful in identifying occult primary carcinomas of the head and neck, especially when applied as a guiding tool prior to panendoscopy, and may induce treatment related clinical decisions in up to 60% of cases.[27]

Classification

Lymphadenopathy may be classified by:

Size

Micrograph of dermatopathic lymphadenopathy, a type of lymphadenopathy. H&E stain.
  • By size, where lymphadenopathy in adults is often defined as a short axis of one or more lymph nodes is greater than 10mm.[29][30] However, there is regional variation as detailed in this table:
Upper limit of lymph node sizes in adults
Generally10 mm[29][30]
Inguinal10[31] – 20 mm[32]
Pelvis10 mm for ovoid lymph nodes, 8 mm for rounded[31]
Neck
Generally (non-retropharyngeal)10 mm[31][33]
Jugulodigastric lymph nodes11mm[31] or 15 mm[33]
Retropharyngeal8 mm[33]
  • Lateral retropharyngeal: 5 mm[31]
Mediastinum
Mediastinum, generally10 mm[31]
Superior mediastinum and high paratracheal7mm[34]
Low paratracheal and subcarinal11 mm[34]
Upper abdominal
Retrocrural space6 mm[35]
Paracardiac8 mm[35]
Gastrohepatic ligament8 mm[35]
Upper paraaortic region9 mm[35]
Portacaval space10 mm[35]
Porta hepatis7 mm[35]
Lower paraaortic region11 mm[35]

Lymphadenopathy of the axillary lymph nodes can be defined as solid nodes measuring more than 15 mm without fatty hilum.[36] Axillary lymph nodes may be normal up to 30 mm if consisting largely of fat.[36]

In children, a short axis of 8 mm can be used.[37] However, inguinal lymph nodes of up to 15 mm and cervical lymph nodes of up to 20 mm are generally normal in children up to age 8–12.[38]

Lymphadenopathy of more than 1.5–2 cm increases the risk of cancer or granulomatous disease as the cause rather than only inflammation or infection. Still, an increasing size and persistence over time are more indicative of cancer.[39]

See also

References

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  4. "lymphangitis" at Dorland's Medical Dictionary
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