Lymphadenectomy Notes

Lymphatics Lymph Vessels And Lymphoma

Lymphatics and lymph vessels play the role of draining the waste fluid from the body. Hence, they are vulnerable to various infections. The lymphatics drain into the veins and they are connected to a group of lymph nodes. Hence, infections of the lymphatics give rise to enlargement of lymph nodes.

Read And Learn More: Clinical Medicine And Surgery Notes

In this chapter, significant surgical diseases affecting the lymphatics and lymph nodes are discussed.

Lymphangiography

Lymphangiography is an investigation wherein a dye is injected into the lymphatics and the entire draining lymphatics and lymph nodes are visualized.

Indications for Lymphangiography

1. Lymphoedema, if surgery is planned.
2. In cases of lymphoma, to detect pelvic nodes, para-aortic nodes, etc.

Lymphangiography Procedure

• Commonly, pedal lymphangiograms are done.
• 5–10 ml of methylene blue (patent blue) is injected into the web spaces intradermally between the toes. This delineates the lymphatics of the dorsum of the foot which are identified. Then, oily dye such as “ultra fluid lipoidol” is injected (10–15 ml).
• It may take 12–24 hours to delineate inguinal nodes and para-aortic nodes.
• Isotope lymphangiography refers to the injection of albumin labeled with technetium 99 colloid or I131.

Lymphangiography Results

1. Metastases appear as irregular filling defects in the lymph nodes.
2. It may demonstrate hypoplasia or hyperplasia as in primary lymphoedema.
3. If there is obstruction, the dye may return back (dermal backflow).

Complications Of Lymphangiography

1. Lymphangitis and toxemia
   • It is not being done routinely these days, because of the availability of ultrasound, CT scan, and other noninvasive investigations.
2. Too rapid an infusion of the dye is to be avoided for the fear of lipid pulmonary embolus.

Lymphoscintigraphy

• It has a sensitivity and specificity of 92% and 100% respectively.
• It has replaced lymphangiography
• Radiolabelled (technetium 99m) colloid is injected into a web space between the 2nd and 3rd toes or fingers. A limb is exercised periodically and images are taken.
• Abnormal accumulation of tracer with collaterals is considered a sign of lymphoedema.
• MRI and CT scan are the latest investigations in addition to lymphangiography for the evaluation of gross swelling of the limb.

Lymphoedema Of Leg

Accumulation of lymph in the subcutaneous tissues results in enlargement of the limb. Fluid collects in the extracellular, extravascular compartment.

Common Sites Of Lymphoedema

1. Lower limbs are the most common sites.
2. Upper limbs
3. Scrotum: Elephantiasis of the scrotum is caused by filarial organisms (Wuchereria bancrofti).
4. Elephantiasis of the penis caused by filarial organisms produces Ram’s horn penis.

Causes Of Lower Limb Elephantiasis

1. Primary

1. Lymphatic aplasia: The number of lymphatic channels and nodes is grossly reduced.
2. Lymphatic hypoplasia: In this variety, the lymphatic channels are of small caliber.
3. Milroy’s disease is a type of lymphoedema congenita which runs in families.
4. Depending upon the time at which the lymphoedema appears, it can be classified as follows:

Birth         – Lymphoedema congenital

Puberty    – Lymphoedema praecox

Later life   – Lymphoedema tarda

2. Acquired (Secondary lymphoedema)

1. Filarial elephantiasis is caused by Wuchereria bancrofti, transmitted by the mosquito (Culex fatigans). The disease is caused by adult worms which have an affinity towards lymphatic vessels and lymph nodes. Microfilariae do not produce any lesions.

• Initially, it causes lymphangitis which clinically presents with high-grade fever with chills and rigors, red streaks in the limb, with tenderness and swelling of the spermatic cord and scrotum.
• The lymph nodes are swollen and tender. Retroperitoneal lymphangitis produces acute abdominal pain.
• Due to such repeated infections, fibrosis occurs resulting in lymphatic obstruction. This later gives rise to lymphatic dilatation. Lower limb lymphatics are dilated and tortuous (lymphangiectasis).
• To start with, lymphoedema is pitting in nature and after some time becomes non-pitting in nature. Lymph (protein) provides good nourishment for fibroblasts.
• After repeated infections, the skin over the limb becomes dry, thickened, and thrown into folds and even nodules which break open and result in ulcers, hence called “elephant leg”. Lack of nutrition and infection precipitate lymphoedema. Oedema is also due to reflux of lymph from para-aortic vessels into the smaller lymphatics draining the lower limb. Subcutaneous tissue is grossly thickened. The presence of deep fascia prevents the involvement of deep muscles of the lower limb.

2. After inguinal block dissection for secondaries in lymph nodes (Upper limb lymphoedema following axillary block dissection).

3. Following radiotherapy to lymph nodes

4. Advanced malignancies

5. Repeated infections due to bare-foot walking

Grades Of Filarial Lymphoedema

• Grade 1 Oedema—pitting—Completely relieved on rest and elevation. No skin changes.
• Grade 2 Oedema—pitting—Partially relieved on rest and elevation. No skin changes.
• Grade 3 Oedema—Non-pitting—Skin involvement, subcutaneous thickening present.
• Grade 4 Oedema — Non-pitting—Not relieved, warty projections, elephantiasis, lymphorrhoea present.

Filarial lymphangitis
↓
Lymphatic obstruction
↓
Lymph stasis
↓
Recurrent lymphangitis
↓
Transudation of albumin
↓
Lymphoedema (pitting)
↓
Coagulation of fluid
↓
Repeated infection
↓
Lymphoedema (non-pitting)

Differential Diagnosis Of Unilateral Elephantiasis Of The Leg

1. Filariasis is the most common cause of elephantiasis of the leg in endemic areas such as coastal Karnataka, coastal Andhra Pradesh, Tamilnadu, etc.
2. Congenital A-V Fistula can present with unilateral gigantism of the leg. Dilated veins, continuous murmur, gigantism, and non-healing ulcer in the leg in a young boy give the clue to the diagnosis.
3. Elephantiasis neuromatosa of the leg can cause diffuse enlargement of the leg. The leg is tender on palpation with soft to firm diffuse swelling.
4. Extensive lipomatosis of the leg.

Treatment Of Filarial Lymphoedema

1. Conservative line of management

• Combination of physical therapies (CPT): This includes gentle massage of limbs, physical exercises, elastic compression bandage, rest, and elevation of the limb.
• Skincare and good hygiene is an important part of the treatment. To avoid injury and not to apply any irritants to the skin.
• Drugs

1. 1. Diuretics: 20 mg of furosemide every day/alternate days, helps in early cases of lymphoedema.
   2. Antifilarial treatment: Diethyl carbs-amazing citrate (DEC) 100 mg 3 times/ day for 21 days with every attack of lymphangitis and once in 6 months.
   3. Warfarin has been used in reducing lymphoedema due to filariasis. It acts by enhancing macrophage activity and extra lymphatic absorption of interstitial fluid.
   4. Antibiotics are used in cases of cellulitis and lymphangitis. Cephalosporins are being used against Staphylococci and Streptococci.

2. Surgery

Aim: To reduce the limb size.

1. Swiss roll Operation (Thompson’s): In this, a skin flap contains the dermis and it is buried into the deep tissues (close to the vascular bundle). This is a dermal flap prepared by denuding the epidermis.
2. Charle’s excision operation: It is indicated in primary lymphoedema. It is performed for extensive swelling and skin changes.
   • In this operation, thickened, diseased skin and subcutaneous tissue are excised till the healthy underlying structures are seen followed by split skin grafting.
   • The skin has dermal lymphatics which are never involved in filariasis. Thus, the subcutaneous lymph may flow via dermal lymphatics.
3. Nodovenous shunt: Dilated, enlarged lymph node in the inguinal region is anastomosed to a vein nearby, e.g. long saphenous vein or femoral vein, etc.

Thus, these are the 3 types of surgery commonly done for the filarial leg. There are many other surgeries which are of historical interest. However, the results of the surgery for the filarial leg are disappointing. Many patients develop intractable ulcers, and wetting of the limb due to loss of protein. The wound gets secondarily infected resulting in sepsis, recurrent lymphangitis, etc. As a last resort, many patients beg for amputation, to get rid of the “useless limb”. After amputation, the limb can be fitted with a prosthesis.

Hodgkin’s Lymphoma (Disease) Definition

This is a malignant neoplasm of the lymphoreticular system. Thus, it can involve the lymph nodes, spleen, liver, etc.

Hodgkin’s Lymphoma Pathology

• The disease starts usually in one of the lymph nodes as a painless swelling.
• Commonly, it involves the left supraclavicular region. The nodes are enlarged without matting. It spreads to other nodes in downstream lymphatic drainage. The cut surface of lymph nodes is smooth and homogenous.
• The axial lymphatic system is almost always affected in Hodgkin’s disease.
• Microscopy: “Cellular pleomorphism” lymphocytes, histiocytes, eosinophils, and fibrous tissue with REED Sternberg Cells —a giant cell containing mirror image nucleus.

Hodgkin’s Lymphoma Classification (Rye’s Classification Is No Longer Used).

Real (1994)—Revised European American Lymphoma

1. Lymphocyte Predominance, nodular (both Hodgkin’s Lymphoma and low-grade B Cell lymphomas)
2. Classic Hodgkin’s Lymphoma (HL)
   • Nodular Sclerosis
   • Lymphocyte Rich
   • Lymphocyte Depletion
   • Mixed Cellularity

Hodgkin’s Lymphoma Classification Clinical Features

1. Age: Bimodal distribution. In children and middle age (30–50 years).
2. Sex: Increased incidence is found in males.
3. It presents as generalized lymphadenopathy. Generalized lymphadenopathy means when more than one group of lymph nodes are enlarged and are significant. Significant lymphadenopathy means:

• Lymph node > 2 cm in size
• Node is hard to consistency
• Palpable left supraclavicular node

The disease starts in the left posterior triangle as a group of lymph nodes with a ‘bunch of grapes’ appearance. This is seen in about 80% of cases. By means of contiguous and centripetal spread, other lymph nodes in the neck, axillary, mediastinal, para-aortic, and inguinal lymph nodes get enlarged.

The nodes are firm (India rubber consistency) without matting. In advanced cases and in poorly differentiated variety, matting can occur.

4. Abdominal pain can occur due to hepato-splenomegaly, which is smooth and firm with round borders.

5. Para-aortic nodes are felt in the umbilical region, more so on the left side. Its clinical features are:

• Nodular
• Firm to hard mass
• Fixed mass
• Does not move with respiration
• Being retroperitoneal, the mass does not fall forward on the knee-elbow position.

Para-Aortic Node Enlargement Common Causes

• Lymphoma
• Testicular tumors
• Malignant melanoma
• Gastrointestinal malignancy

6. There may be ascites.

7. Intermittent fever (irregular) is sometimes seen. Skin rashes1 are rare in Hodgkin’s lymphoma.

8. Multiple bony pains can occur due to secondary deposits, especially in the lumbar vertebrae. The secondary deposits are usually osteoblastic giving rise to ivory vertebrae.

9. Superior vena cava obstruction indicates enlarged mediastinal nodes. This is tested by asking the patient to raise the hand above the head. Engorgement of the veins indicates obstruction and the test is said to be positive (Pemberton’s test)

Clinical Staging Of Lymphoma

Stage 1: Lymph node involvement in one anatomical region or involvement of a single extra lymphatic organ or site (IE), for example. palpable left supraclavicular nodes.

Stage 2: Involvement of two or more anatomical groups of lymph nodes confined to the same side of the diaphragm.

Examples are:

• Left supraclavicular and left axillary node
• Left supraclavicular, left axillary and right supraclavicular

Stage 3: Involvement of the lymph nodes on both sides of the diaphragm, with or without spleen. Examples are:

• Left supraclavicular and left inguinal lymph nodes
• Left supraclavicular lymph nodes with splenomegaly (III. S)

Stage 4: Diffuse involvement of one or more extra-lymphoid organs with or without lymph node involvement Liver (H), marrow (M), pleura (P), bones (O), etc.

Each stage is further divided into group A which means absence of symptoms and group B means presence of symptoms.

The symptoms are:

• Fever, above 38° C or night sweats
• Pruritis may be the presenting feature of nodular sclerosis
• Weight loss of more than 10% of body weight in the last 6 months
• Bony pains
• Anaemia.

Clinical Staging Of Lymphoma Investigations

1. Complete blood picture (CBP): Peripheral smear to rule out leukemia. Anaemia indicates
2. widespread metastases.
3. Elevated creatinine and blood urea nitrogen (BUN) indicate ureteral obstruction due to the direct involvement of kidneys. (Increased uric acid levels indicate aggressive non-Hodgkin’s lymphoma.)
4. Chest X-ray is taken to rule out mediastinal lymph nodes, mediastinal widening, pleural effusion.
5. Abdominal USG

• • To look for para-aortic nodes
  • To look for splenomegaly
  • To rule out secondaries in the liver
  • However, a CT scan of the abdomen is better to define para-aortic nodes when there is minimal enlargement (0.5 cm).

5. Intravenous pyelography (IVP) is done to look for hydronephrosis as a result of backpressure caused by para-aortic node mass pressing on the ureter (left side) and to assess the function of the kidney.

6. Lymph node biopsy: An incision biopsy is done and a neck node is usually removed. Fine needle aspiration cytology (FNAC) may give the diagnosis, but the definite histological pattern cannot be made out by FNAC. A trust biopsy also can give the diagnosis.

7. Mediastinoscopy (Chamberlain procedure) is done if peripheral nodes are not available.

¹Mycosis fungoides: It is not a fungal infection but is caused by non-Hodgkin’s lymphoma with infiltration of the skin with malignant lymphocytes. Dermatitis and papular rashes are common which progress to the tumor formation. It is a variety of cutaneous T-cell lymphoma.

7. Bipedal lymphangiography can be done in doubtful cases. A foamy appearance is characteristic of lymphoma (rarely done nowadays).

Clinical Staging Of Lymphoma Treatment

• Stage 1, and 2 are treated by RADIOTHERAPY considering that the disease is still curable, not spread to the bloodstream and the five-year survival rate is as high as 80%.
• Dose of radiotherapy: 3500–4500 Centigray (cGy) units.
  1. When the disease is confined to one group of lymph nodes, local regional radiotherapy is given.
  2. When both sides of neck nodes are involved —The mantle field of therapy is given.
  3. Neck nodes with the mediastinal nodes are given—Extended mantle field of therapy.
  4. When para-aortic nodes and bilateral inguinal nodes are enlarged—an inverted Y-field radiotherapy is given.
• Stage 3A, 3B, and 4 are treated by chemotherapy because it is considered a systemic disease. The following drugs are used in combination. Hence, it is called combination chemotherapy. There are various chemotherapy regimes available. These drugs have to be used judiciously and carefully, depending upon the merits of the case. The age and weight of the patient, systemic illness, and other factors also decide the chemotherapy. One example of a chemotherapy regime is given below.

MOPP regime

• Mechlorethamine 6 mg/m2 body area on 1st day and 8th day.
• Oncovin (Vincristine) 1.4 mg/m2 I.V. on 1st day and 8th day.
• Procarbazine 100 mg orally 1 to 10 days.
• Prednisolone 15 mg 8th hourly orally 1 to 10 days.

A minimum of 6 cycles or at least 2 extra cycles after attaining complete remission should be given. In spite of stage III and stage IV disease, survival of 10 years with disease-free interval is about 80%.

Side effects of MOPP therapy

• Infertility both in men and women
• Development of acute myeloid leukemia
• Hematosuppression (bone marrow suppression)

Another alternative regimen that is as good as MOPP is ABVD (Adriamycin, Bleomycin, Vinblastine, and dacarbazine): less incidence of leukemia and infertility.

Staging Laparotomy For Lymphomas

• It is not done routinely these days because of sophisticated investigations such as USG, CT scan, MRI scan (Magnetic Resonance Imaging) which can detect lesions as small as 1–2 cm.
• Staging laparotomy is indicated in stage 1 and 2 early cases, especially supradiaphragmatic cases. The following procedures are done in a staging laparotomy
  1. Splenectomy and biopsy and removal of splenic hilar lymph nodes
  2. Liver biopsy-wedge and needle biopsies of both lobes
  3. Para-aortic node biopsy
  4. Iliac node biopsy and coeliac node biopsy
  5. Iliac crest bone biopsy
  6. In females, strapping the ovaries behind the uterus prevents radiation effects on the ovaries (Oophoropexy).

Staging Laparotomy for Lymphomas Advantages of staging laparotomy

It avoids irradiation to the spleen. Thus, irradiation damage to the lower lobe of the left lung and kidney is prevented.

Staging Laparotomy for Lymphomas Disadvantages

It is an invasive procedure and may result in pneumonia, embolism, pancreatitis, etc.

Causes Of Death In Lymphoma

1. Recurrent respiratory tract infections both, bacterial and fungal because they are immunocompromised patients.

2. Disseminated disease—involvement of the liver, hepatocellular failure, etc.

3. Multiple bony metastases, pathological fractures, paraplegia, etc. with spine involvement.

Non-Hodgkin’s Lymphoma (NHL) Aetiology

1. Age and sex
   • Small lymphocytic lymphoma—elderly patients
   • Lymphoblastic lymphoma—male adolescents and young adults
   • Follicular lymphoma —mid-adult age group
   • Burkitt’s lymphoma —children, young adults
2. Viruses
   • RNA viruses: Human immunodeficiency virus (HIV) produces AIDS. These patients can develop high-grade B cell lymphoma.
   • DNA viruses: Epstein-Barr viruses (EBV) can produce Burkitt’s lymphoma.
3. Bacteria
   • H.pylori—Gastric extranodal marginal zone B-cell lymphomas of MALT type
4. Immunodeficiency states
   • AIDS
   • Organ transplantation.

Classification Of Non-L-Lodgl(In’S Lymphoma

Working formulation of NHL

1. Low grade
   • Small lymphocytic
   • Follicular, predominantly small cleaved cell
2. Intermediate grade
   • Follicular, predominantly large cell
   • Diffuse, small cleaved cell
   • Diffuse mixed small and large cell
   • Diffuse large cell
3. High grade
   • Large cell immunoblastic
   • Lymphoblastic
   • Burkitt’s or non-Burkitt’s lymphoma

Pathological classification

B cell NHL: Small lymphocytic lymphoma, follicular lymphoma, Burkitt’s lymphoma.

T cell NHL: Cutaneous T cell lymphoma-Mycosis fungoides and sezary syndrome, lymphoblastic lymphoma, etc.

Treatment Of Non-Hodgkin’s Lymphoma

It depends on the following factors:

• Grade of tumour
• Stage of disease

Stage 1 and 2—Low grade: Radiotherapy

Stage 1 and 2—Intermediate and high grade: Chemotherapy

Stage I3 and 4—Chemotherapy.

Combination Chemotherapy

• CHOP regime, cyclophosphamide, adriamycin, vincristine, prednisolone.
• Combination chemotherapy has its side effects. Hence, has to be administered carefully.
• Cyclophosphamide can cause hemorrhagic cystitis, adriamycin can cause cardiac toxicity. Epirubicin has lesser cardiac toxicity.
• Vincristine can give rise to bone marrow depression.

Burkitt’s Lymphoma (Small Noncleaved Lymphoma)

• It is a type of high-grade non-Hodgkin’s lymphoma first described by Burkitt affecting jaw bone (maxilla, mandible).
• It is rare everywhere except in a few places where malarial infestation is heavy.
• It is caused by Epstein-Barr Virus (EBV) which multiplies in the presence of a heavy malarial infestation.

Burkitt’s Lymphoma Types

Endemic: Parts of Africa and other tropical locations. It is associated with EBV. Affects the jaw and orbit. It has a good prognosis.

Sporadic: Throughout the world. It is not associated with EBV. It affects the abdomen and GI tract rather than bones and has a poor prognosis.

Diagnosis

The biopsy will reveal a typical ‘starry sky’ appearance with primitive lymphoid cells and large clear histiocytes.

Burkitt’s Lymphoma Treatment

• Endemic cases respond well to cyclophosphamide.
• Sporadic cases need to be treated with combination chemotherapy.

Sezary’S Syndrome

It is also a type of cutaneous T-cell lymphoma. Here, skin involvement is manifested clinically as a generalized exfoliative erythroderma along with associated leukemia of sezary cells.

These cells are characterized by the cerebriform nuclei. These are indolent tumors that have good survival time.

Clinical Examination Of The Lymphatic System History

1. Age of the patient
   • In young children, the common cause of lymph node enlargement is due to viral etiology. Tuberculosis can also occur. Acute leukemia can present with lymph node swelling and fever.
   • Adults: TB lymphadenitis is common in this age group. Typically jugulo-digastric cervical nodes are enlarged.
   • Middle age: Hodgkin’s lymphoma
   • Old age: Metastasis from known and unknown primary
2. Duration of the swelling
   • Short: In cases of pyogenic infections, for example. in acute tonsillitis, enlargement of tonsillar node—jugulodigastric node may be seen.
   • Long: In tuberculosis and metastasis (secondaries), the duration is long—maybe a few months.
3. Other such similar swellings
   • Often lymph node swellings can be in multiple sites. In such cases find out which one started first, for example. in Hodgkin’s lymphoma, the patient may say that swelling in the neck started first and was followed later by axillary swelling (lymph nodes).
   • The patient may show multiple sites wherein swellings have appeared simultaneously, for example. submental, submandibular, preauricular, etc. which suggests it could be a case of non-Hodgkin’s lymphoma.
4. Speed of growth
   • Short duration and rapid growth usually suggest metastasis in lymph nodes.
   • Slow growth suggests tuberculosis or even lymphomas.
5. Fever
   • Mild fever with evening rise, sometimes with chills suggests tuberculosis.
   • Remittent bouts of intermittent fever suggest lymphoma Metastasis in the lymph nodes usually does not give rise to fever unless secondarily infected (rare).
   • Often leukemia and lymphomas can present as fever with or without lymph nodes.
   • Fever with multiple nodes and pain may be a feature of infectious mononucleosis. A sore throat gives a clue to the diagnosis.
6. Weight loss
   • Fever with weight loss suggests chronic diseases, such as tuberculosis or metastasis.
7. Pain
   • Pain indicates inflammation as in pyogenic lymphadenitis. Pain can be very severe as in axillary lymphadenitis due to hand infections or sometimes so severe to mimic acute appendicitis as in external iliac lymphadenitis due to foot trauma more so in children.
8. Find out the primary focus
   • History of dysphagia in patients with cervical lymph nodes suggests it can be metastasis and primary may be in the posterior third of the tongue or pyriform fossa, etc.
   • History of change in voice or breathing difficulty can be due to carcinoma larynx.
9. History suggestive of chronic disease in the past or present should be asked
   • TB: Evening rise in temperature, weight loss, cough with or without hemoptysis.
   • Exposure to sexually transmitted diseases, such as HIV or syphilis (rare nowadays). HIV is more significant today. It decreases the immunity and predisposes to tuberculosis as well as lymphoma.
10. Recurrent chills and rigors and groin swelling—such attacks are common in our country and the most possible cause is filarial lymphangitis and lymphadenitis of lymph nodes in the groin. They are very tender.

General Physical Examination

It should be done from head to toe. Only relevant points or examination findings in cases of lymph node swellings are given below.

1. Pallor: It suggests, chronic disease such as tuberculosis or malignancy.
2. Jaundice: It can be seen in late cases of lymphoma with involvement of the liver.
3. Skin rashes: Coppery red skin rashes with lymphadenopathy may be an indication of secondary syphilis (rare nowadays).
4. Dilated veins over the chest and congestion of the face suggest superior vena cava obstruction – may be caused by mediastinal lymph nodes, suspect lymphoma.
5. Bony pains with lymph nodes in the neck may be due to leukemia or lymphoma or due to disseminated malignancy.
6. Unilateral pedal edema can be caused by enlarged iliac nodes—may be malignant or lymphoma.

Local Examination

Inspection

• Swelling: First describe the exact location, e.g. anterior triangle or posterior triangle. If anterior triangle, is it in the upper part-upper deep cervical (jugulo digastric) or lower part (jugulo omohyoid)? If it is in the posterior triangle is it in the upper part-posterior upper deep cervical nodes or is it in the lower part—Supraclavicular group? Is it an inguinal—a vertical chain of lymph nodes or horizontal? Please remember common things are common.

1. 1. Tuberculosis: Upper deep cervical
   2. Hodgkin’s lymphoma: Supraclavicular/ posterior triangle lymph nodes
   3. Bronchogenic carcinoma: Supraclavicular lymph nodes
   4. Filariasis: Inguinal lymph nodes
   5. Secondary syphilis: Epitrochlear or occipital
   6. Non-Hodgkin’s lymphoma: Waldeyer’s ring. However, atypical presentations should be kept in mind.

• When lymph nodes are situated in more than 2 anatomical sites, it is called generalized lymphadenopathy. Please mention all the anatomical sites of lymph node enlargement.
• Describe their number. When more than 1 node is present just say multiple nodes are seen
• Size: When the size is variable describe the largest and smallest one and mention where they vary from, for example. 3 cm to 1 cm.
• Surface: Like any other swelling described them, e.g. smooth, isolated enlargement of lymph node or cold abscess (tubercular), nodular in lymphoma or secondaries, or may be uneven as in secondaries.
• The skin over the swelling

1. 1. Red: Inflammatory—lymphadenitis
   2. Yellowish: Inflammatory with the formation of pus. Please note both these signs are absent in clod abscess due to tuberculosis, hence the name cold abscess.
   3. Sinus: This is due to tuberculosis. Describe the discharge also in such cases. Sinus in the groin can be also due to lymphogranuloma inguinal.
   4. Tethering of skin or dimpling or peau d’ orange means the skin is infiltrated by the underlying disease and it is most likely secondaries or metastasis.
   5. Sometimes a fold of prominent skin is seen in the neck in advanced cases of secondaries in the neck. It is due to the infiltration of skin including platysma by the underlying secondaries. It is called a platysma sign.
   6. Fungating ulcer over a lymph node mass is typical of late cases of secondaries
   7. Dilated veins over the skin reflect increased vascularity, usually seen in secondaries.

Palpation

• Palpation of the neck lymph nodes should be done from standing behind the patient, with slight bending of the neck to relax strap muscles and deep cervical fascia.
• Have a checklist with you and examine all the groups of lymph nodes in the neck first.

1. 1. Cervical
   2. Axillary
   3. Abdominal: Para-aortic, iliac nodes (bilateral)
   4. Inguinal: both horizontal and vertical
   5. In specific situations: For example Popliteal group of lymph nodes in foot lesions such as malignant melanoma and squamous cell carcinoma epitrochlear node in Non Hodgkin’s lymphoma.

• Since lymph nodes form a swelling, description should be like an examination of swelling in the form of the site, size, shape, surface, borders, consistency, mobility, etc. A few typical examples are given below.

1. Consistency

Soft in acute lymphadenitis and nodes are usually tender. It may be soft also when the tubercular nodes undergo caseation necrosis which is called a cold abscess (no signs of inflammation). Even malignant lymph nodes undergo degeneration and may feel soft. It is due to a lack of blood supply especially in the center. This is an ideal situation to do Paget’s test  You will find hard lymph nodes underneath or indurated areas underneath in cases of malignancy.

• Firm nodes are seen in chronic infection classically tuberculous or even filarial nodes in the groin.
• Rubbery is a word used only in lymphomas (Hodgkin’s lymphoma).
• Hard nodes are characteristic of malignancies. It is also mentioned that chronic tuberculous lymph nodes sometimes may feel hard due to calcification but that situation is very rare.

2. Matting

This refers to adherence of one lymph node to the other so that they cannot move independently of each other. Classically described for tuberculous nodes in stage 2 wherein there is periadenitis which is responsible for matting. In malignancies, lymph nodes get adhered together due to infiltration (better not to use the word matting in malignancies). Matting is sometimes seen in acute infections other than tuberculous.

3. Mobility and fixity

• Mobile nodes are seen in chronic infections, such as tuberculous and filarial nodes in the groin. In the early stages of secondaries in the lymph nodes, nodes may be mobile. However, once infiltration starts, mobility gets restricted and later they become immobile. In this situation, it is called fixed. It should be remembered that in cases of acute enlargement of nodes, mobility may be restricted due to inflammatory reaction. Such nodes are tender also.
• If the nodes are fixed mention to what structures they are fixed. For example: Lift the skin (Lifting is a better word than pinching). If it is not possible to lift the skin, it is fixed to the skin.
  • Classically happens in secondaries in the neck. The skin may not be liftable in a cold abscess or pyogenic abscess (pyogenic lymphadenitis if they involve the skin.
  • Contract the muscle in relation to the nodes and see for movement. Restricted mobility indicates infiltration into the muscles as in secondaries. In cases of cervical nodes (jugulodigastric and jugulo-omohyoid nodes, contract sternomastoid

Lymph Nodes And Suppuration

• Tuberculosis
• Granuloma inguinale
• Cat scratch disease
• Pyogenic lymphadenitis.

Infiltration into the nerves: Large neck node mass due to secondaries can infiltrate the hypoglossal nerve and cause paralysis of the intrinsic muscles of the tongue. In such cases, the tongue deviates to the same side of the lesion.

A few examples of primary malignant tumors and lymph nodes involving the various nerves are given.

Relevant Tests For Nerve Paralysis

1. Hypoglossal nerve: Ask the patient to protrude the tongue and see for any deviation. The tongue will point out the side of the lesion because of the contraction of the opposite side muscle.
2. Recurrent laryngeal nerve paralysis: Dypsnoea on exertion.

Malignancies And Nerve Paralysis

• Carcinoma parotid: Facial nerve paralysis
• Carcinoma thyroid: Recurrent laryngeal nerve paralysis
• Metastatic nodes in the neck: Hypoglossal nerve paralysis
• Sarcoma of the arm: Radial nerve paralysis
• Maxillary antral carcinoma: Infra orbital nerve paralysis
• Osteosarcoma fibula: Lateral popliteal nerve paralysis

Examination Of Lymphatic System

• All groups of lymph nodes — cervical, axillary, inguinal, iliac, para-aortic lymph nodes
• Oral cavity
• Drainage areas
• Liver and spleen
• Bony tenderness
• Lymphatics—in the upper limb and lower limb

3. Facial nerve paralysis: Ask the patient to clench the teeth and see for any deviation of the angle of the mouth.

4. Infraorbital nerve paralysis: Anaesthesia over the prominence of the cheek.

5. Lateral popliteal nerve paralysis: Foot drop.

Epitrochlear Node Enlargement

Osier noted that epitrochlear nodes were a prominent clinical feature of secondary syphilis. Today especially in African countries, HIV infection has to be considered as the first diagnosis instead of syphilis.

In most instances, any lymph node up to 1 cm can still be considered normal. The two exceptions to this rule include the epitrochlear node in which up to 0.5 cm is allowed and the inguinal nodes in which up to 1.5 cm is allowed.

Look For Evidence Of The Primary

• This is especially applicable when you suspect metastasis or secondaries. Why is this lymph node enlarged is the question you have to ask yourself.
• Hence, when neck nodes are enlarged, a thorough examination of the oral cavity should be done. Examine buccal mucosa, anterior and posterior third of the tongue, retromolar trigone, etc. Look into the tonsils also.
• Think which is the area drained by this lymph node and what pathology may be present. A few examples are given below.

1. 1. A young female 30 years old with firm mobile multiple nodes in the upper part of the neck —oral cavity examination revealed enlargement of the tonsils. This is a case of non-Hodgkin’s lymphoma.
   2. 50-year 50-year-old male smoker and pan chewer presents with hard lymph nodes in the lower deep cervical region (juguloomohyoid). The diagnosis is metastasis. Where is the primary? Inspection and palpation of the anterior third of the tongue is normal. However, on palpation of the posterior one-third of the tongue, it revealed a hard indurated lesion in the posterior third of the tongue. The diagnosis is carcinoma posterior third of the tongue.
   3. A young girl of 20 years comes with palpable juguloomohyoid nodes and nodes in the posterior triangle. One should carefully examine the thyroid gland. She had a nodule in one of the lobes. The diagnosis is papillary carcinoma thyroid.

Causes Of Epitrochlear Node Enlargement

• Cat scratch disease: Irritation
• Non-Hodgkin’s lymphoma
• Glandular fever: Infectious mononucleosis
• Secondary syphilis
• Hand infections
• Rheumatoid arthritis—when active joint disease is present in the joints: Inflammation

Examination Of Abdomen

• In cases of cervical lymphadenopathy, the abdomen should be examined for evidence of spleen, liver, para-aortic nodes, and external iliac nodes.
• Various interpretations of the abdominal signs with lymph node enlargement findings are given below.
  1. Cervical group of lymph nodes on the left side with palpable spleen: Most likely it is Hodgkin’s lymphoma.
  2. Cervical nodes with para-aortic and iliac nodes: Hodgkin’s lymphoma.
  3. Hepatosplenomegaly with lymph nodes: Lymphoma, chronic lymphatic leukemia, autoimmune disorders.

From the examination point: Once the clinical examination is done and diagnosis is given, a few questions will be asked such as what is the anatomical diagnosis, why do you say it is liver, spleen, or lymph node, etc.? A few answers are given as follows.

Clinical Features Of Enlarged Liver

• It is in the right hypochondrium, epigastrium, and left hypochondrium.
• It moves with respiration
• It is dull to percuss and dullness continues over the mass below.
• Finger insinuation between the liver mass and costal margin is not possible.
• It has no intrinsic mobility because it is covered by ribs.

Clinical Features Of Enlarged Spleen

• It is located in the left hypochondrium and enlarges towards the right iliac fossa.
• It moves with respiration.
• It is also dull on percussion.
• Fingers cannot be insinuated between splenic mass and costal margin.
• Splenic notch if felt is characteristic of the spleen—it is felt in the anterior border.

Clinical Features Of Para-Aortic Lymph Node Mass

• Located in the epigastrium and umbilical region.
• Typically nodular firm to a hard mass.
• Does not move with respiration.
• Aortic pulsations may be felt over the swelling-transmitted pulsations.
• It does not fall forward on the knee-elbow position because they are retroperitoneal.

Please Note: BDS students need not know the methods of abdominal palpation in detail, but palpation of the liver and spleen should be learned which are very helpful in the diagnosis of many conditions associated with lymph node enlargement in the neck.

Examination Of Lymphatic Vessels

• Examine the leg and upper limb for any red streaks or lines which is one of the features of filarial lymphangitis.
• Examine the limbs distally—For example:

1. 1. When there are axillary groups of lymph node enlargement, the upper limb may be swollen —it is due to lymphatic obstruction called—lymphoedema.
   2. When there are multiple inguinal lymph node enlargements, there may be lymphoedema of the leg.
   3. In cases of malignant melanoma, multiple cutaneous nodules may be found between the primary lesion and secondaries (groin nodes). These are called as in-transit deposits. This occurs due to the spread of malignant cells through lymphatics.