Lymphadenopathy approach

LYMPHADENOPATHY -
APPROACH
By : dr. / SAHAR H. MOSTAFA
CONSULTANT OF INTERNAL MEDICINE
EL-MATARIA TEACHING HOSPITAL - CAIRO
OCTOBER, 2016

INTENDED LEARNING OUTCOME
Define Lymphadenopathy..
Differentiate between Generalized and Localized
Lymphadenopathy and Recognize their main
Causes..
Understand the role of Internist in Mapping of
the condition for a better symptom-directed
diagnostic workup..
Management and/or Referral to the Oncologist
at the proper time..

Introduction
 The lymphatic system is the part of the immune system
comprising a network of conduits called lymphatic vessels that
carry a clear fluid called lymph (from Latin lympha "water") in a
unidirectional pathway.
 The widely and extensively dispersed vessel system collects
tissue fluids from all regions of the body to eventually convey
them towards the heart.
 The components of the lymphatic system are :-
I. Lymph, the recovered fluid
II. Lymphatic vessels, which transport the lymph
III. Lymphatic tissue, composed of aggregates of lymphocytes and
macrophages that populate many organs of the body; and
IV. Lymphatic organs, in which these cells are especially concentrated
and which are set off from surrounding organs by connective tissue
capsules

DEFINITION
Lymphadenopathy: refers to lymph nodes that are abnormal in:
 Size
 Number
 Consistency
Whether as a result of normal reactive process or pathology
(Abnormalities may be localized or generalized)
-------------------------------------------------------------------------------------
 Generalized lymphadenopathy is defined as: -
enlargement of ≥ 2 non-contiguous lymph node groups
 Regional lymphadenopathy If :
 It involves enlargement of a single node or multiple
contiguous nodal regions

Clinical understanding
 LAD may be an incidental finding in patients being
examined for various reasons, or it may be a presenting
sign or symptom of the patient's illness
 Commonly palpable and accessible lymph nodes are the
cervical, axillary, and inguinal
 Lymph nodes are common sites of metastatic cancer
because cancer cells from almost any organ can break
loose, enter the lymphatic capillaries, and lodge in the
nodes
 Soft, flat, submandibular nodes (<1 cm) are often
palpable in healthy children
 Healthy adults may have palpable inguinal nodes of up
to 2 cm

The Lymph
 Lymph is usually a clear, colorless fluid, similar to
blood plasma but low in protein. Its composition varies
substantially from place to place
 Origin: Lymph originates in microscopic vessels called
lymphatic capillaries. The gaps between lymphatic
endothelial cells are so large that bacteria and other
cells can enter along with the fluid.
 The overlapping edges of the endothelial cells act as
valve-like flaps that can open and close. When tissue
fluid pressure is high, it pushes the flaps inward (open)
and fluid flows into the lymphatic capillary. When
pressure is higher in the lymphatic capillary than in the
tissue fluid, the flaps are pressed outward (closed)

Lymphatic cells and Tissues
 T lymphocytes (T cells):
These are so-named because they develop for a time in the thymus and
later depend on thymic hormones. There are several subclasses of T
cells
 B lymphocytes (B cells):
These are named after an organ in birds (the bursa of Fabricius) in which
they were first discovered. When activated, B cells differentiate into
plasma cells, they produce circulating antibodies.
 Macrophages:
These cells, derived from blood monocytes, perform phagocytosis to
foreign matter (antigens) and display the fragments to certain T cells,
thus alerting the immune system to the presence of an enemy.
Macrophages and other cells that do this are collectively called antigen-
presenting cells (APCs)
 Dendritic cells:
These are APCs found in the epidermis, mucous membranes, and lymphatic
organs. (In the skin, they are often called Langerhans cells)

Lymphatic Organs
 Primary Lymphatic Organs :-
 The red bone marrow
 The thymus gland
(Lymphocytes originate and mature in these organs)
Secondary Lymphatic Organs:-
 The spleen
 The lymph nodes
 Other organs, such as: the tonsils, Payer's
patches, and the appendix, ..
(All the secondary organs are the places where lymphocytes encounter
and bind with antigens, after which they proliferate and become
actively engaged cells)

Primary Lymphoid Organs
Red bone marrow
 It is the site of stem cells that are ever capable of dividing and
producing blood cells
 In a child, most bones have red bone marrow
 In an adult, it is limited to the sternum, vertebrae, ribs, part of the
pelvic girdle, and the proximal heads of the humerus and femur
The thymus
 It is a member of both the lymphatic and endocrine systems
 It houses developing lymphocytes and secretes hormones that
regulate their activity
 It is located between the sternum and aortic arch in the superior
mediastinum
 It is very large in the fetus and grows slightly during childhood, when
it is most active. After age 14, however, it begins to undergo
involution (shrinkage) so that it is quite small in adults

Secondary Lymphoid Organs
 All the secondary organs are the places where
lymphocytes encounter and bind with antigens,
after which they proliferate and become actively
engaged cells
 The secondary lymphatic organs are:
 The spleen
The lymph nodes
Other organs, such as:
 The tonsils
 Peyer’s patches
 The appendix

The spleen
 It is the body’s largest lymphatic organ
 Its parenchyma exhibits two types of tissues named for their
appearance in fresh specimens (not in stained sections):
 The red pulp, which consists of sinuses gorged with concentrated
erythrocytes, and
 The white pulp, which consists of lymphocytes and macrophages aggregated
like sleeves along small branches of the splenic artery
N.B.= A person can live without a spleen, but is somewhat more
vulnerable to infections
 Functions:
 It produces blood cells in the fetus and may resume this role in
adults in the event of extreme anemia
 It monitors the blood for foreign antigens: Lymphocytes and
macrophages of the white pulp are quick to detect foreign antigens
in the blood and activate immune reactions
 It also compensates for excessive blood volume by transferring
plasma from the bloodstream into the lymphatic system

The lymph nodes
 Lymph nodes are bean-shaped organs found in clusters along the
distribution of lymph channels of the body
 Every tissue supplied by blood vessels is supplied by lymphatic's
except placenta and brain
 There are over 800 lymph nodes in the body and around 300 are located
in the head and neck
 The superficial nodes are located in the subcutaneous connective
tissue, and the deeper nodes lie beneath the fascia & muscles and
within various body cavities
 The superficial nodes are the gateways for assessing the health of the
entire lymphatic system
 The lymph node is a bottleneck that slows down lymph flow and allows
time for cleansing it of foreign matter
 On its way to the bloodstream, lymph flows through one lymph node
after another and thus becomes quite thoroughly cleansed of most
impurities

Structural anatomy of a lymph node
 A lymph node is usually < 3 cm long, often with a hilum on one side
 It is enclosed in a fibrous capsule with extensions (trabeculae) that
incompletely divide the interior of the node into compartments.
 The interior consists of a stroma of reticular C.T. and a parenchyma of
lymphocytes and antigen-presenting cells(APCs)
 The parenchyma is divided into an outer cortex and an inner
medulla(near the hilum)
 The cortex consists mainly of lymphatic nodules which when fighting a
pathogen, they acquire light-staining germinal centers where B cells
multiply and differentiate into plasma cells
 The medulla consists largely of .cords composed of lymphocytes,
plasma cells, macrophages, reticular cells, and reticular fibers
♥♥ The macrophages and reticular cells of the sinuses remove
about 99% of the impurities before the lymph leaves the node

Common causes of generalized lymphadenopathy
• EBV/CMV
• AIDS /AIDS related
complex
• Toxoplasmosis
• Secondary syphilis
Infectious
• ALL / CLL
• Lymphoma
Neoplasia
• Serum Sickness
• Drugs (Phenytoin)
• SLE
• Rheumatoid Arthritis
Hyper-
sensitivity
• Hyperthyroidism
• Lipid storage
disease
Metabolic

Common Causes of localized lymphadenopathy
(Site Predilection)
• Viral Conjunctivitis
• Trachoma
• Cat-scratch disease
• Tularemia
• Sarcoidosis
Pre-auricular
• Rubella
• Scalp infection
Post-auricular/
Occipital
• Pharyngitis
• EBV
• Toxoplasmosis
• Sarcoidosis
Cervical
• Pharyngitis/buccal cavity
tumor
• Nasopharyngeal tumor
• Thyroid malignancy
Submandibular

(Site Predilection)
• Pulmonary / Mediastinal /
Esophageal Malignancy
• T.B.
• Sarcoidosis
• Toxoplasmosis
Right supraclavicular
• Intra-abdominal malignancy
• RCC
• Ovarian/Testicular /Prostate
malignancy
Left supraclavicular
(Virchow’s)
• Cancer Breast / Breast infection
• Melanoma
• Lymphoma
• Ipsilateral upper limb infection /
Reaction to immunization
• Juvenile RA
Axillary
• Syphilis(bilateral)
• Sarcoidosis
• Infection(unilateral)
• Leprosy
• IMN
• CLL/Lymphoma
Epitrochlear

(Site Predilection)
•Syphilis
•Genital herpes
• Lymphogranuloma venereum
• Chancroid
• Lower extremity/local infection
• Lymphoma
• Metastatic carcinoma from: rectum,
genitalia or lower limb(melanoma)
Inguinal
• Lymphoma
• Bronchogenic Carcinoma
• T.B.
• Sarcoidosis
• Histiocytosis
• Coccidiomycosis
Hilar
• Gut Adenocarcinoma
• Hodgkin’s disease
• T.B.
• Lymphoma
• Bladder carcinoma
Abdominal
• Lymphomas
• Leukemias
• Cat-Scratch disease
• Metastasis
• Sarcoidosis
• Granulomas
Any region

Localized lymphadenopathy
Submandibular Cervical

Castleman disease: Pre- and Post- Auricular LAD
 Rare, Idiopathic
 Localized/multicentric
 Mimic lymphoma/HIV
 Systemic symptoms,
increased risk of infection

Cat-Scratch LAD Kikuchi’s Disease(Histiocytic
necrotizing lymphadenitis)

Right Supraclavicular Left Supraclavicular

Axillary Inguinal

Clinical assessment and applied aspects
I. History: Detailed personal/present/past- history
II. General Examination: Review of ALL body systems
III. Local (Physical) Examination: Inspection and Palpation
IV. Investigations: Laboratory and Radiological
V. Treatment

Historical Preview
and
Thorough Review of other body systems
 The vast majority of cases of lymphadenopathy in children
have infectious etiology.
 Lymphadenopathy that has been present for < 2 weeks has
a very low chance of representing a malignant condition
 Lymphadenopathy that has been present for > 1 year and
has been stable in size over the year, has a very low chance
of being malignant (with exception of indolent NHL and
low-grade Hodgkin lymphomas)
 Presence of fever points toward a broad differential, mainly
consisting of infection or lymphoma
(Evening raise or Pel-Ebstein fever)

Historical Preview
and
 The Exposure history as well as the Travel history may be
considered as epidemiologic clues to diagnosis:
 Exposure to Animals/Pets and biting insects:
 Cat-scratch disease
 Exposure to infectious contacts
 Consuming Undercooked meat for possible Toxoplasmosis
 Environmental exposure such as tobacco, alcohol, and
ultraviolet radiation may raise suspicion for metastatic
carcinoma of the internal organs, cancers of the head and
neck, and skin malignancies
 Occupational exposure to silicon or beryllium

Historical Preview
and
 Sexual history is also important in determining potential
sexually transmitted causes of inguinal and cervical
lymphadenopathy; as: HIV, Syphilis, HBV, HSV, CMV
 Blood Transfusion or recent transplant history: for possible
infections as CMV and HIV
 History of recent immunization
 IV- Drug Users: for possible HIV, HBV, or endocarditis
 Drug history:
 Medications that may cause lymphadenopathy(such as phenytoin)
 Others(such as cephalosporins, penicillins or sulfonamides) are more
likely to cause a serum sickness-like syndrome with fever, arthralgia
and rash in addition to lymphadenopathy
 Immunosuppressive agents

Historical Preview
and
 Constitutional symptoms such as: fever, malaise, fatigue, cachexia,
unexplained loss of weight(>10% of body eight) and loss of appetite
 Presence of petechiae in palate of a young, may preclude IMN
 Presence of non-pitting edema with inguinal LAD may suggest
filariasis
 Arthralgia, muscle weakness, unusual rashes may indicate
possibility of autoimmune diseases
 Hemiparesis of the tongue can occur if the hypoglossal nerve is
involved by affection of upper deep cervical L.N. group due to
carcinoma(The tongue will deviate towards the side of the lesion when
asked to protrude out)
 Cases are not uncommon when patient may complain of
compression symptoms as dyspnea & dysphagia due to pressure
on trachea or esophagus by the enlarged lymph nodes
 Patients with retroperitoneal node enlargement, may present with
LL edema

Historical Preview
and
 Coexistence of splenomegaly implies a systemic disorders or a
hematological disorder as:
(IMN, Lymphoma, acute or chronic leukemia, SLE, Sarcoidosis,
Toxoplasmosis, or cat-scratch disease)
 Symptoms associated with lymphadenopathy that should be
considered red flag symptoms for malignancy include:
 Fever, night sweats, and unexplained weight loss
 A supraclavicular node
 Hard and tender L.N. with a significant size or draining an area with a
significant pathology
 Matted or Fixed node(s)
 Non-recessive node after 3 weeks period or after disappearance of fever

RED FLAGS IN LYMPHADENOPATHY
1. Fever, night sweats, and unexplained weight loss
2. A supraclavicular node
3. Hard and tender L.N. with a significant size or draining an area with a significant pathology
4. Matted or Fixed node(s)
5. Non-recessive node after 3 weeks period or after disappearance of fever

Clinical Considerations
The normally palpable L.Ns. Are:
 Submandibular
 Axillary
 Inguinal

Clinical Considerations
 Is the palpable mass a L.N. ?
 Acute or Chronic ?
 Epidemiological clues ?
 Site ? {Localized or Generalized}
 Number ?
 Size ?
 Character ? {surface and consistency}
 Discrete or Matted ?
 Tenderness ?
 Mobility ?
 Attachment ? And Relation to adjacent muscle ?
 Associated Systemic and/or Localizing symptoms or
signs?

Local Examination
Mapping Examination
 The physical examination
should be regionally directed
by knowledge of the lymphatic
drainage patterns
 All the normal anatomic sites
should be inspected for any
obvious enlargements.
 When lymphadenopathy is
localized, the clinician should
examine the region drained by
the nodes for evidence of
infection, lesions or tumors

Node Palpation
*** Confirm that the palpable mass is indeed a L.N..
{ NOT something else as: Thyroglossal cyst, Abscess, Branchial cyst,
Enlarged parotid, ..}
 Exposure of the patient:
 Cervical: all head and neck to clavicles
 Axillary: stripped to the waist
 Inguinal: umbilicus to knee
 Before performing palpation, ask the patient to identify painful
areas so that you can examine those areas last
 During the procedure, pay attention to their facial expression to
assess for sign of discomfort
 Technique: Use the pads of the index and middle finger to
move the skin in circular motions over the underlying tissues in
each area
 For Serial Evaluation, documentation of “all” of the L.N.
criteria is critical !!

Axillary Node Palpation
 The central group: near the middle of the thoracic wall of the axilla
 The lateral group: near the upper part of the humerus and is best
demonstrated by having the patient’s arm elevated so that you can feel
along the axillary vein.
 With the patient’s arm still elevated, feel along beneath the lateral edge of
the pectoralis major muscle for the pectoral group

Epitrochlear node palpation: Approximately 3 cm
proximal to the medial humeral epicondyle, in the groove between
the biceps and triceps brachii. Best approached in an anterior to
posterior direction

Inguinal node palpation
horizontal group: along the inguinal ligament(both above and over)
vertical group: beside great saphenous vein in the proximal thigh
iliac nodes: above and deep to inguinal ligament

Local examination
You Have To Answer The Previous Questions of Clinical
Considerations ..
►►► Note for:
Number: (single or multiple), (localized or generalized)
Site: Anatomic location can narrow the D.D.
 T.B. and Hodgkin’s ----- > cervical (earlier stages)
 Cat-scratch disease ----- > cervical and axillary
 IMN --- > cervical
 Sexually-transmitted diseases ----- > Inguinal
 Supraclavicular ----- > Highest risk of malignancy(90% in old
patients)
 Paraumbilical (Sister Mary Joseph's)----- > Abdominal or pelvic
neoplasm
Size (up to 1 cm is considered normal).. Except epitrochlear
:if >0.5cm
N.B.=The size is usually of little importance in adding information to establish
diagnosis; however increase in size on serial examination may be of value..

Local examination
 Surface and Consistency (Soft, hard, firm, rubbery, fluctuant, shotty, or
variable)
 Stony-hard nodes are typically a sign of cancer, usually metastatic
 Firm, rubbery nodes suggest lymphoma
 Softer nodes are the result of infections or inflammatory conditions
 Suppurant nodes may be fluctuant
 The term “shotty” refers to small nodes that feel like buckshot under
the skin, as found in the cervical nodes of children with viral illnesses
 Discrete or Matted(nodes that feel connected and seem to move as a unit)
N.B.=Nodes that are matted can be either benign (T.B., Sarcoidosis,
lymphogranuloma venereum), or malignant (metastatic carcinoma or
lymphomas).
 Painless or Painful(when a lymph node increases in size its capsule stretches
and causes pain, or when there is hemorrhage into the necrotic center of a
malignant node)
N.B.=The presence or absence of tenderness does not necessarily differentiate benign from
malignant nodes..

Local examination
 Fixed or not to the underlying skin, deep fascia or muscles
The patient is asked to contract the muscles against resistance:
 If the swelling becomes MORE apparent it is SUPERFICIAL to
muscles
 If the swelling becomes LESS apparent it is DEEP to muscles
 If the swelling is NOT affected it is IN the muscle
 The overlying skin has to be noted:
 Skin redness, edema and brawny induration denote acute
lymphadenitis
 Skin over tuberculous lymphadenitis becomes red and glossy
when they reach the point of bursting
 Scar often indicates previous bursting of abscess or operation
 Skin may appear tense and stretched with dilated subcutaneous
veins when overlying a rapidly growing lymphoma
 In secondary carcinoma, the skin may become fixed

Investigations
 The investigation of lymphadenopathy can be organized according
to where nodes occur and type of clinical symptoms present
 Most lymphadenopathy patients do not require a biopsy and at
least half require no laboratory study
********************************************************************

Investigations
It includes:
I - Laboratory
II - Radiological
III - Others (as: Bronchoscopy, Mediastinoscopy or
Bone Marrow Biopsy)
IV - Node Biopsy

Investigations
I - Laboratory:
The laboratory investigation of patients with lymphadenopathy must be tailored to
elucidate the etiology suspected from the patient's history and physical findings
 CBC with differential count : provides useful data for the diagnosis of:
 Acute or Chronic leukemia's
 EBV or CMV mononucleosis(atypical lymphocytosis)
 Pyogenic infections
 Lymphoma with a leukemic component
 Immune cytopenias (in illnesses such as SLE)
 ESR
 Serology: may demonstrate:
 Antibodies specific to: components of EBV(viral Capsid Ag), CMV,
HIV, Toxoplasma, Brucella, etc
 PCR-for: CMV-DNA, T.B.
 ANA/Anti-ds DNA antibody (SLE)
 Others: In cases of hilar LAD, do:
 Serum ACE
 Tuberculin T.

Investigations
II - Radiological:
They include:
1. Chest X-Ray (CXR)
2. Node Ultrasonography (U/S) / Color Doppler U/S
3. Abdominal: U/S and CT
4. Throat culture/urethral or cervical swab for regional
affection
5. Magnetic Resonance Imaging scans(MRI)
6. Positron Emission Tomography scans(PET)

Investigations
1 – CXR:
 To assess for mediastinal disease, Hilar nodes, or for
Parenchymal lung disease (Pulmonary infiltrate)
 Mediastinal LAD would suggest:
 T.B.
 Histoplasmosis,
 Sarcoidosis
 Lymphoma
 Primary/metastatic lung cancer

Investigations
2 – Nodal U / S and Color Doppler U/S:
 A lymph node measuring ≥ 10 mm in the short axis is defined as
malignant
 A lymph node with a L/S ratio of ≥ 3.5 is considered reactive or
benign
 A lymph node with a L/S ratio of ≤ 1.6 is considered metastatic
 A lymph node which can not be fitted to the previous categories is
considered to be “questionable”
 Malignant infiltration alters the U/S features of the lymph nodes,
resulting in enlarged nodes that are usually rounded, with definite
“internal echoes” and showing peripheral and mixed vascularity
♥♥♥Using these features, U/S has been shown to have an
accuracy of 89%– 94% in differentiating malignant from
benign cervical L.Ns.

Normal cervical nodes appear sonographically as somewhat
flattened, cigar-shape, hypo-echoic structures with varying
amounts of Hilar fat

Ultrasonography Differentiation
Benign
(No definite internal echoes)
Malignant
(Definite internal echoes)

Investigations
3 – Contrast Enhanced CT(CECT):
For the reveal of: mediastinal, retroperitoneal, iliac or
mesenteric nodal affection
4 – MRI:
 T1-weighted images depict lymph nodes as being of
intermediate signal intensity (similar to muscle)
 T2-weighted images show them as hyper-intense signal

MRI – Sagittal scan of a large pathological
deep cervical L.N.
T1 - Weighted T2 - Weighted

Investigations
4 - PET:
 Most head and neck PET imaging is performed with the radio-
labeled glucose analogue FDG Fluoro-Deoxy-Glucose which
has increased uptake in viable malignant tumor due to
enhanced glycolysis
 The result can be expressed as a standardized uptake value
(SUV), with those values > 2 being considered abnormal
 PET scanning provides functional rather than anatomical
imaging

Investigations
III – Node Biopsy:
Node Excision Biopsy:
 It is a valuable diagnostic tool
 It could be performed directly or via radiological
interventional methods or via surgery or
endoscopy
 Its accuracy not only on the experience of the
clinician, but also on the cytologist who reports it
 Node should be subjected to the minimal of trauma
during removal, or it may be difficult for
interpretation

Investigations
 Proper choice of node:
Choose the LARGEST node
Avoid axillary(which can show fatty involution) and
inguinal nodes(which can show scaring due to
repeated infections)
Supraclavicular nodes have the highest diagnostic
yield

Investigations
 The decision to biopsy may be made:
 Early in a patient's evaluation, or
 Delayed for up to 2 weeks
N.B.-- PROMPT biopsy should be performed if the
patient's history and physical findings suggest a
MALIGNANCY:
 If a solitary, hard, non-tender cervical node is found in an
older patient who is a chronic user of tobacco, or
 If a supraclavicular adenopathy is present, or
 If there is generalized adenopathy that is firm, movable,
and suggestive of lymphoma

FNAC/B: should not be
performed as the first
diagnostic procedure
As most diagnoses
require more tissue,
thus it often delays a
definitive diagnosis..
FNAC/B: Cannot give
information about gland
architecture..
FNAC/B: should be
reserved for thyroid
nodules and for
confirmation of relapse
in patients whose
primary diagnosis is
known..
FINE NEEDLE ASPIRATION

Investigations
 Imprints are useful, not only for showing the appearance
of the cells in a cytological preparation but when stained
by a Romamowsky method, for comparison with blood
or bone marrow smears, but also for cytochemical or
immunochemical studies
 Scalene node biopsy often provides useful information
about the nature of underlying lung disease
 Abdominal nodes are commonly removed in the course of
staging laparotomy operations and the sites of removal of
such nodes may be indicated by small metal clips to enable
subsequent abdominal X-ray films to be compared with
preoperative / pre-treatment lymphangiogram

• Look at aspirated material
• Smear for AFB
• Smear for cytologyFNAC / B
• Look at cut-surface
• Fresh node for T.B. cuture
• Fresh node for immuno
phenotyping/cytochemistry
• Smear for AFB
• Node in formalin for histology
Excision
Biopsy

Treatment and Follow-up
 Patients with unexplained localized
lymphadenopathy and a reassuring clinical picture
-------------> 2 – 4 week period of observation is
appropriate before biopsy, for re-evaluation of
node(s)-increase in size
 Patients with localized lymphadenopathy and a
worrisome clinical picture or patients with
generalized lymphadenopathy
-----------> further diagnostic evaluation that often
includes Biopsy

Treatment and Follow-up
 Antibiotics are given only if there is strong
evidence of bacterial infection
 DO NOT USE GLUCOCORTICOIDS, which might
obscure some diagnosis (because of their lympholytic
effect) or might delay healing/activate underlying
infection.. (Except in life-threatening pharyngeal
obstruction by enlarged lymph tissue in Waldeyer’s ring
caused by EBV)

Self – Assessment Clinical Cases

ONE
Question
A 66-y-old man presents with poor appetite and general malaise.
Physical examination reveals palpable L.N.s.
The finding of L/N. in which of the following areas is most likely
to be suggestive of malignancy?
A. Cervical
B. Supraclavicular
C. Epitrochlear
D. Axillary
E. Inguinal

ONE
ANSWER
A 66-y-old man presents with poor appetite and general malaise.
Physical examination reveals palpable L.N.s.
The finding of L/N. in which of the following areas is most likely
to be suggestive of malignancy?
A. Cervical
B. Supraclavicular
C. Epitrochlear
D. Axillary
E. Inguinal

TWO
QUESTION
A 66-y-old man is referred for further investigation of an enlarged
supraclavicular L.N.
Which one of the following is the diagnostic technique of choice
for evaluating LAD, if neoplasm is suspected?
A. CT scan
B. MRI
C. Open biopsy
D. FNA
E. Incisional wedge biopsy

TWO
ANSWER
A 66-y-old man is referred for further investigation of an enlarged
supraclavicular L.N.
Which one of the following is the diagnostic technique of choice
for evaluating LAD, if neoplasm is suspected?
A. CT scan
B. MRI
C. Open biopsy
D. FNA
E. Incisional wedge biopsy

THREE
QUESTION
A 12-y-old girl presents with painful epitrochlear LAD associated
with low grade fever and malaise. The pt. has a cat and she
also gave a history of a papillary lesion in her left forearm
about 1 Wk. – 10 Ds ago.
The most likely etiologic agent in this situation is:
A. Bartonella henselae
B. Staph. aureus
C. EBV
D. Sporothrix schenkii
E. Yersinia pestis

THREE
ANSWER
A 12-y-old girl presents with painful epitrochlear LAD associated
with low grade fever and malaise. The pt. has a cat and she
also gave a history of a papillary lesion in her left forearm
about 1 Wk. – 10 Ds ago.
The most likely etiologic agent in this situation is:
A. Bartonella henselae
B. Staph. aureus
C. EBV
D. Sporothrix schenkii
E. Yersinia pestis

FOUR
QUESTION
A 59-y-old woman who has had Sjogren’s syndrome for 10 Ys,
presents with enlarged Cervical L.Ns.
Which one of the following is the most likely neoplasm
responsible for this presentation?
A. Gastric carcinoma
B. Lymphoma
C. Bronchial carcinoma
D. CLL
E. Pancreatic carcinoma

FOUR
ANSWER
A 59-y-old woman who has had Sjogren’s syndrome for 10 Ys,
presents with enlarged Cervical L.Ns.
Which one of the following is the most likely neoplasm
responsible for this presentation?
A. Gastric carcinoma
B. Lymphoma
C. Bronchial carcinoma
D. CLL
E. Pancreatic carcinoma

FIVE
QUESTION
A 69-y-old lifelong non-smoker is referred because of his
abnormal blood tests: Hb=11.2, WBCs=86.400 (with 98%
lymphocytes), PLTs=180.000.
O/E: his R.R. is 16 breaths/min, with widespread non-tender LAD
and 5 cm-hepatomegaly and a palapable spleen. Pulmonary
function tests show a FVC of 80% of predicted value and FEV 1
of 84%.
What is the most likely explanation for the abnormal pulmonary
function tests?
A. CHF
B. Diffuse pulmonary lymphoma
C. Lung fibrosis
D. Pneumonia
E. Sarcoidosis

FIVE
ANSWER
A 69-y-old lifelong non-smoker is referred because of his
abnormal blood tests: Hb=11.2, WBCs=86.400 (with 98%
lymphocytes), PLTs=180.000.
O/E: his R.R. is 16 breaths/min, with widespread non-tender LAD
and 5 cm-hepatomegaly and a palapable spleen. Pulmonary
function tests show a FVC of 80% of predicted value and FEV 1
of 84%.
What is the most likely explanation for the abnormal pulmonary
function tests?
A. CHF
B. Diffuse pulmonary lymphoma
C. Lung fibrosis
D. Pneumonia
E. Sarcoidosis

SIX
QUESTION
A 25-y-old woman presents with widespread LAD. She is taking
no regular medications and past medical history is irrelevant.
Investigations show: Hb=8, WBCs=42 000, lymphoblasts=64%,
PLTs=210 000.
Which of the following is the most likely underlying diagnosis?
A. AML
B. ALL
C. Glandular fever
D. Hodgkin’s disease
E. Toxic shock syndrome

SIX
ANSWER
A 25-y-old woman presents with widespread LAD. She is taking
no regular medications and past medical history is irrelevant.
Investigations show: Hb=8, WBCs=42 000, lymphoblasts=64%,
PLTs=210 000.
Which of the following is the most likely underlying diagnosis?
A. AML
B. ALL
C. Glandular fever
D. Hodgkin’s disease
E. Toxic shock syndrome

SEVEN
QUESTION
A 24-y-old man has noted for the last 2 Ms that his face is
swollen in the morning. He has lost 10-Kg in weight over 6-Ms.
He has no other complaints.
O/E: The ext. jugular veins are dilated. CXR: shows a mediastinal
mass.
Which one of the following is the most likely diagnosis of his
SVC obstruction?
A. Adenocarcinoma of the lung
B. Hodgkin’s disease
C. Sarcoidosis
D. Seminoma
E. Tuberculosis

SEVEN
ANSWER
A 24-y-old man has noted for the last 2 Ms that his face is
swollen in the morning. He has lost 10-Kg in weight over 6-Ms.
He has no other complaints.
O/E: The ext. jugular veins are dilated. CXR: shows a mediastinal
mass.
Which one of the following is the most likely diagnosis of his
SVC obstruction?
A. Adenocarcinoma of the lung
B. Hodgkin’s disease
C. Sarcoidosis
D. Seminoma
E. Tuberculosis

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