Difference between revisions of "Lymph nodes"

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In samples with '''tumors''', slice through all included fat while palpating and looking for lymph nodes, and submit all that are found.
 
In samples with '''tumors''', slice through all included fat while palpating and looking for lymph nodes, and submit all that are found.
 +
 +
===Definition of an enlarged lymph node===
 +
[[File:Long and short axis.png|120px|right]]
 +
*By size, where lymphadenopathy in adults is often defined as a short axis of one or more lymph nodes is greater than 10mm.<ref name="GaneshalingamKoh2009"/><ref name="Schmidt JúniorRodrigues2007"/> However, there is regional variation as detailed in this table:
 +
{|class="wikitable"
 +
|+Upper limit of lymph node sizes in adults
 +
|-
 +
| Generally || 10&nbsp;mm<ref name="GaneshalingamKoh2009">{{cite journal|last1=Ganeshalingam|first1=Skandadas|last2=Koh|first2=Dow-Mu|title=Nodal staging|journal=Cancer Imaging|volume=9|issue=1|pages=104–111|year=2009|issn=1470-7330|doi=10.1102/1470-7330.2009.0017|pmid=20080453|pmc=2821588}}</ref><ref name="Schmidt JúniorRodrigues2007">{{cite journal|last1=Schmidt Júnior|first1=Aurelino Fernandes|last2=Rodrigues|first2=Olavo Ribeiro|last3=Matheus|first3=Roberto Storte|last4=Kim|first4=Jorge Du Ub|last5=Jatene|first5=Fábio Biscegli|title=Distribuição, tamanho e número dos linfonodos mediastinais: definições por meio de estudo anatômico|journal=Jornal Brasileiro de Pneumologia|volume=33|issue=2|year=2007|pages=134–140|issn=1806-3713|doi=10.1590/S1806-37132007000200006|pmid=17724531|doi-access=free}}</ref>
 +
|-
 +
| Inguinal || 10<ref name=Torabi2004>{{cite journal | vauthors = Torabi M, Aquino SL, Harisinghani MG | title = Current concepts in lymph node imaging | journal = Journal of Nuclear Medicine | volume = 45 | issue = 9 | pages = 1509–18 | date = September 2004 | pmid = 15347718 }}</ref> – 20&nbsp;mm<ref>{{cite web|url=http://bestpractice.bmj.com/best-practice/monograph/838/diagnosis/step-by-step.html|title=Assessment of lymphadenopathy|website=[[BMJ Best Practice]]|accessdate=2017-03-04}} Last updated: Last updated: Feb 16, 2017</ref>
 +
|-
 +
| Pelvis || 10&nbsp;mm for ovoid lymph nodes, 8&nbsp;mm for rounded<ref name=Torabi2004/>
 +
|-
 +
!colspan=2|Neck
 +
|-
 +
| Generally (non-retropharyngeal) || 10&nbsp;mm<ref name=Torabi2004/><ref name=Saba2016>[https://books.google.com/books?id=q7v1CwAAQBAJ&pg=PA432 Page 432] in: {{cite book|title=Image Principles, Neck, and the Brain|author=Luca Saba|publisher=CRC Press|year=2016|isbn=9781482216202}}</ref>
 +
|-
 +
| Jugulodigastric lymph nodes || 11mm<ref name=Torabi2004/> or 15&nbsp;mm<ref name=Saba2016/>
 +
|-
 +
| Retropharyngeal || 8&nbsp;mm<ref name=Saba2016/>
 +
*Lateral retropharyngeal: 5&nbsp;mm<ref name=Torabi2004/>
 +
|-
 +
!colspan=2|Mediastinum
 +
|-
 +
| [[Mediastinum]], generally || 10&nbsp;mm<ref name=Torabi2004/>
 +
|-
 +
| Superior mediastinum and high paratracheal || 7mm<ref name="SharmaFidias2004"/>
 +
|-
 +
| Low paratracheal and subcarinal || 11&nbsp;mm<ref name="SharmaFidias2004">{{cite journal|last1=Sharma|first1=Amita|last2=Fidias|first2=Panos|last3=Hayman|first3=L. Anne|last4=Loomis|first4=Susanne L.|last5=Taber|first5=Katherine H.|last6=Aquino|first6=Suzanne L.|title=Patterns of Lymphadenopathy in Thoracic Malignancies|journal=RadioGraphics|volume=24|issue=2|year=2004|pages=419–434|issn=0271-5333|doi=10.1148/rg.242035075|pmid=15026591|url=https://semanticscholar.org/paper/145256a2605c552c77534f2a509227902440bf7b}}</ref>
 +
|-
 +
!colspan=2| Upper abdominal
 +
|-
 +
| Retrocrural space || 6&nbsp;mm<ref name="DorfmanAlpern1991">{{cite journal|last1=Dorfman|first1=R E|last2=Alpern|first2=M B|last3=Gross|first3=B H|last4=Sandler|first4=M A|title=Upper abdominal lymph nodes: criteria for normal size determined with CT.|journal=Radiology|volume=180|issue=2|year=1991|pages=319–322|issn=0033-8419|doi=10.1148/radiology.180.2.2068292|pmid=2068292}}</ref>
 +
|-
 +
| Paracardiac || 8&nbsp;mm<ref name="DorfmanAlpern1991"/>
 +
|-
 +
| Gastrohepatic ligament || 8&nbsp;mm<ref name="DorfmanAlpern1991"/>
 +
|-
 +
| Upper paraaortic region || 9&nbsp;mm<ref name="DorfmanAlpern1991"/>
 +
|-
 +
| Portacaval space || 10&nbsp;mm<ref name="DorfmanAlpern1991"/>
 +
|-
 +
| Porta hepatis || 7&nbsp;mm<ref name="DorfmanAlpern1991"/>
 +
|-
 +
| Lower paraaortic region || 11&nbsp;mm<ref name="DorfmanAlpern1991"/>
 +
|}
 +
 +
Lymphadenopathy of the '''axillary''' lymph nodes can be defined as solid nodes measuring more than 15&nbsp;mm without fatty hilum.<ref name=dahnert2011>[https://books.google.com/books?id=uYREa2bKNW8C&pg=PA559 Page 559] in: {{cite book|title=Radiology Review Manual|author=Wolfgang Dähnert|publisher=Lippincott Williams & Wilkins|year=2011|isbn=9781609139438}}</ref> Axillary lymph nodes may be normal up to 30&nbsp;mm if consisting largely of fat.<ref name=dahnert2011/>
 +
 +
In '''children''', a short axis of 8&nbsp;mm can be used.<ref>[https://books.google.com/books?id=nmpI1bLGCV4C&pg=PA942 Page 942] in: {{cite book|title=High Yield Imaging Gastrointestinal HIGH YIELD in Radiology|author=Richard M. Gore, Marc S. Levine|publisher=Elsevier Health Sciences|year=2010|isbn=9781455711444}}</ref> 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.<ref>{{cite web|website=[[Patient UK]]|url=http://patient.info/doctor/generalised-lymphadenopathy|title=Generalised Lymphadenopathy|author=Laurence Knott|accessdate=2017-03-04}} Last checked: 24 March 2014</ref>
 +
 +
Lymphadenopathy of more than 1.5&nbsp;cm - 2&nbsp;cm increases the risk of cancer or granulomatous disease as the cause rather than only inflammation or infection.<ref name="pmid12484692">{{cite journal | vauthors = Bazemore AW, Smucker DR | title = Lymphadenopathy and malignancy | journal = American Family Physician | volume = 66 | issue = 11 | pages = 2103–10 | date = December 2002 | pmid = 12484692  }}</ref>
  
 
==Microscopic examination==
 
==Microscopic examination==
Look for whatever pathology is indicated by the referral, or findings in other submitted specimens. The main target conditions are:
+
Look for:
 +
*Whatever pathology is '''indicated''' by the referral, or findings in other submitted specimens.
 +
*General '''screening''':
 
[[File:Lymph node metastasis from neuroendocrine tumor.jpg|thumb|Lymph node metastasis from a [[neuroendocrine tumor of the midgut]].]]
 
[[File:Lymph node metastasis from neuroendocrine tumor.jpg|thumb|Lymph node metastasis from a [[neuroendocrine tumor of the midgut]].]]
*'''Metastasis''', which usually looks similar to the primary tumor (neuroendocrine tumor in picture at right).
+
:*Any '''metastasis''', which usually looks similar to the primary tumor (neuroendocrine tumor in picture at right).
*'''Reactive''' lymphadenopathy, by inflammation in an adjacent area, or systemic.
+
:*'''Enlargement''', as preferably measured during grossing, but can possibly be made on the microscopy slide. If present, see section below:
  
===Reactive lymphadenopathy===
+
===Microscopy of enlarged lymph nodes===
Main patterns:
+
*Look at the overall '''architecture''':
*'''Follicular hyperplasia''' is the most common pattern of reactive lymphadenopathy.<ref name="WeissO'Malley2013">{{cite journal|last1=Weiss|first1=Lawrence M|last2=O'Malley|first2=Dennis|title=Benign lymphadenopathies|journal=Modern Pathology|volume=26|issue=S1|year=2013|pages=S88–S96|issn=0893-3952|doi=10.1038/modpathol.2012.176}}</ref> It is usually associated with varying degrees of paracortical and/or sinus hyperplasia.
+
:*'''Follicular hyperplasia''': {{Further|Follicular lymphoma versus reactive follicular hyperplasia|linebreak=no}}
 +
:*'''Paracortical hyperplasia''': Reactive paracortical hyperplasia shows expansion of paracortical areas by a mixed infiltrate, often having a mottled appearance, and it usually has a concomitant reactive follicular hyperplasia.<ref name="WeissO'Malley2013"/> A [[T-cell lymphoma]] should be suspected if there is obliteration or marked diminution of the B-cell cortical region, or highly irregular or hyperchromatic nuclei.<ref name="WeissO'Malley2013"/>
 +
:*'''Unspecific hyperplasia''': An unspecific pattern of lymph node enlargement, without atypical cells, next to an inflamed area, may simply be diagnosed as "benign reactive lymph node".
 
<gallery mode=packed heights=220>
 
<gallery mode=packed heights=220>
 
File:Histopathology of reactive follicular hyperplasia.jpg|thumb|Histopathology of reactive follicular hyperplasia
 
File:Histopathology of reactive follicular hyperplasia.jpg|thumb|Histopathology of reactive follicular hyperplasia
 
</gallery>
 
</gallery>
It usually has varying amount of paracortical and/or sinus hyperplasia.<ref name="WeissO'Malley2013"/> Older age, increased follicular density (especially back-to-back arrangement) and areas of diffuse nodal effacement leads to a suspicion of '''[[follicular lymphoma]]'''.<ref name="WeissO'Malley2013"/> {{Further|Follicular lymphoma versus reactive follicular hyperplasia}}
 
*'''Reactive paracortical hyperplasia''', with expansion of paracortical areas by a mixed infiltrate, often having a mottled appearance. It usually has a concomitant reactive follicular hyperplasia.<ref name="WeissO'Malley2013"/> A [[T-cell lymphoma]] should be suspected if there is obliteration or marked diminution of the B-cell cortical region, or highly irregular or hyperchromatic nuclei.<ref name="WeissO'Malley2013"/>
 
*An unspecific pattern of lymph node enlargement next to an inflamed area may simply be diagnosed as "benign reactive lymph node".
 
 
{{Bottom}}
 
{{Bottom}}

Revision as of 11:58, 17 August 2020

Author: Mikael Häggström [note 1]

Gross processing

If suspected lymphoma, before putting tissue in formalin, ensure that tissue is preserved in appropriate media for any special tests.

In samples with tumors, slice through all included fat while palpating and looking for lymph nodes, and submit all that are found.

Definition of an enlarged lymph node

Long and short axis.png
  • By size, where lymphadenopathy in adults is often defined as a short axis of one or more lymph nodes is greater than 10mm.[1][2] However, there is regional variation as detailed in this table:
Upper limit of lymph node sizes in adults
Generally 10 mm[1][2]
Inguinal 10[3] – 20 mm[4]
Pelvis 10 mm for ovoid lymph nodes, 8 mm for rounded[3]
Neck
Generally (non-retropharyngeal) 10 mm[3][5]
Jugulodigastric lymph nodes 11mm[3] or 15 mm[5]
Retropharyngeal 8 mm[5]
  • Lateral retropharyngeal: 5 mm[3]
Mediastinum
Mediastinum, generally 10 mm[3]
Superior mediastinum and high paratracheal 7mm[6]
Low paratracheal and subcarinal 11 mm[6]
Upper abdominal
Retrocrural space 6 mm[7]
Paracardiac 8 mm[7]
Gastrohepatic ligament 8 mm[7]
Upper paraaortic region 9 mm[7]
Portacaval space 10 mm[7]
Porta hepatis 7 mm[7]
Lower paraaortic region 11 mm[7]

Lymphadenopathy of the axillary lymph nodes can be defined as solid nodes measuring more than 15 mm without fatty hilum.[8] Axillary lymph nodes may be normal up to 30 mm if consisting largely of fat.[8]

In children, a short axis of 8 mm can be used.[9] 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.[10]

Lymphadenopathy of more than 1.5 cm - 2 cm increases the risk of cancer or granulomatous disease as the cause rather than only inflammation or infection.[11]

Microscopic examination

Look for:

  • Whatever pathology is indicated by the referral, or findings in other submitted specimens.
  • General screening:
Lymph node metastasis from a neuroendocrine tumor of the midgut.
  • Any metastasis, which usually looks similar to the primary tumor (neuroendocrine tumor in picture at right).
  • Enlargement, as preferably measured during grossing, but can possibly be made on the microscopy slide. If present, see section below:

Microscopy of enlarged lymph nodes

  • Look at the overall architecture:
  • Follicular hyperplasia: Further information: Follicular lymphoma versus reactive follicular hyperplasia
  • Paracortical hyperplasia: Reactive paracortical hyperplasia shows expansion of paracortical areas by a mixed infiltrate, often having a mottled appearance, and it usually has a concomitant reactive follicular hyperplasia.[12] A T-cell lymphoma should be suspected if there is obliteration or marked diminution of the B-cell cortical region, or highly irregular or hyperchromatic nuclei.[12]
  • Unspecific hyperplasia: An unspecific pattern of lymph node enlargement, without atypical cells, next to an inflamed area, may simply be diagnosed as "benign reactive lymph node".

Notes

  1. For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.

Main page

References

  1. 1.0 1.1 Ganeshalingam, Skandadas; Koh, Dow-Mu (2009). "Nodal staging ". Cancer Imaging 9 (1): 104–111. doi:10.1102/1470-7330.2009.0017. ISSN 1470-7330. PMID 20080453. 
  2. 2.0 2.1 Schmidt Júnior, Aurelino Fernandes; Rodrigues, Olavo Ribeiro; Matheus, Roberto Storte; Kim, Jorge Du Ub; Jatene, Fábio Biscegli (2007). "Distribuição, tamanho e número dos linfonodos mediastinais: definições por meio de estudo anatômico ". Jornal Brasileiro de Pneumologia 33 (2): 134–140. doi:10.1590/S1806-37132007000200006. ISSN 1806-3713. PMID 17724531. 
  3. 3.0 3.1 3.2 3.3 3.4 3.5 "Current concepts in lymph node imaging ". Journal of Nuclear Medicine 45 (9): 1509–18. September 2004. PMID 15347718. 
  4. . Assessment of lymphadenopathy. BMJ Best Practice. Retrieved on 2017-03-04. Last updated: Last updated: Feb 16, 2017
  5. 5.0 5.1 5.2 Page 432 in: Luca Saba (2016). Image Principles, Neck, and the Brain . CRC Press. ISBN 9781482216202. 
  6. 6.0 6.1 Sharma, Amita; Fidias, Panos; Hayman, L. Anne; Loomis, Susanne L.; Taber, Katherine H.; Aquino, Suzanne L. (2004). "Patterns of Lymphadenopathy in Thoracic Malignancies ". RadioGraphics 24 (2): 419–434. doi:10.1148/rg.242035075. ISSN 0271-5333. PMID 15026591. Archived from the original. . 
  7. 7.0 7.1 7.2 7.3 7.4 7.5 7.6 Dorfman, R E; Alpern, M B; Gross, B H; Sandler, M A (1991). "Upper abdominal lymph nodes: criteria for normal size determined with CT. ". Radiology 180 (2): 319–322. doi:10.1148/radiology.180.2.2068292. ISSN 0033-8419. PMID 2068292. 
  8. 8.0 8.1 Page 559 in: Wolfgang Dähnert (2011). Radiology Review Manual . Lippincott Williams & Wilkins. ISBN 9781609139438. 
  9. Page 942 in: Richard M. Gore, Marc S. Levine (2010). High Yield Imaging Gastrointestinal HIGH YIELD in Radiology . Elsevier Health Sciences. ISBN 9781455711444. 
  10. Laurence Knott. Generalised Lymphadenopathy. Patient UK. Retrieved on 2017-03-04. Last checked: 24 March 2014
  11. "Lymphadenopathy and malignancy ". American Family Physician 66 (11): 2103–10. December 2002. PMID 12484692. 
  12. 12.0 12.1 Cite error: Invalid <ref> tag; no text was provided for refs named WeissO'Malley2013

Image sources