Tuberculous lymphadenitis &

Lymphoma
Prof.Dr.S.P.Gayathre
Chief of general surgery
Madras medical college
Tuberculosis lymphadenitis
• Lateral or posterior neck swelling
• Causative organism – Mycobcterium tuberculosis
• H/o night sweats / evening rise of temperature
• H/o cough with expectoration
• H/o chest pain
• H/o hemoptysis
• H/o loss of weight /appetite
• Contact/family history of Tb
• H/o previous consumption of ATT

Tuberculous pus is highly infectious

Clinical examination
• Poorly nourished , muscle wasting ++
• Multiple lymph nodes
• Minimal signs of inflammation
• Not tender
• Firm in consistency
• Matted nodes , deep to the deep fascia plane
• Multiple discharging sinuses (in case of spontaneous rupture of abscess )
• Tuberculous stigmas – phlycten , lupus Vulgaris , scrofuloderma , erythema nodosum
Primary focus of cervical TB
• Jugulodigastric nodes —> tonsil is the primary focus
• Posterior cervical node —> adenoids
• Supraclavicular node —>apex of the lung is the primary focus
• Primary focus in lung to be always suspected and investigated

• Common nodes affected by tuberculosis

 Upper deep cervical
 Supraclavicular
 Mediastinal
 Axillary
 Inguinal
Stages of tuberculous lymphadenitis
( jones and Campbell classification)
Stage Finding
Stage 1 Lymph nodes are enlarged , discrete , no matting

Stage 2 Multiple enlarged lymph nodes with matting

(periadenitis)

Stage 3 Stage of caseation and cold abscess

Fluctuant , with no signs of inflammation

Stage 4 Collar stud abscess

- Deep fascia is eroded
- Pus beneath superficial fascia
Stage 5 - Stage of sinus and ulcers
- Pus burst through skin
Types of TB lymphadenitis
• Acute type – infants &children <5 years , inflammatory signs +
• Caseating type – matted nodes, cold abscess and sinuses
• Hyperplastic type – good resistance to TB , hence caseation is reduced
• Atrophic type – lymph node undergo natural involution , hence lymph nodes caseate
and burst early
Tuberculous ulcers
• Usually follow rupture of a cold abscess
• Multiple discharging sinuses
• Undermined edges (due to excessive destruction of subctaneous tissue in comparison to
the skin )
• Seropurulent discharge
• Pale granulation tissue
Investigation
• ESR will be raised
• X ray chest – evidence of pulmonary Tb
• Mantoux test : 1 unit PPD id in volar surface

Test is read after 48 hours

A induration of more than 12 mm is considered positive

But the test is losing its significance

• USG of the neck – to look for other lymph node status
• FNAC – epitheloid cells , langhans giant cell
• Biopsy of the lymph node – 2 in number – 1 in formalin sent for pathology

And another in saline and sent for microbiology

• Biopsy is superior than FNAC as pathological architecture can be studied
• Culture medium – lowenstein jensen medium
• Takes 6 weeks for a positive culture
• Selenite medium shorten the duration by 5 days
• Newer methods — > CBNAAT – in 2 hours /PCR results available in 24 hrs
• Line probe assay results available in 2 days
• The advantage of newer method is that diagnosis of drug resistance can also be made
simultaneously
• In biopsy — > area of caseation surrounded by Langhans giant cells , epithelialoid cells
and macrophages , lymphocytes and plasm cells
Mantoux test
Histopathology of a tuberculous
Granuloma
Treatment
• Anti tuberculous therapy is indicated
• Empirical initiation of ATT iS not followed now , pathological or microbiological
evidence of tuberculosis is required for ATT
• CATEGORY 1 – all newly diagnosed ATT
• CATEGORY 2 - all treated and recurrent ATT
• CATEGORY 4 – MDR TB
• CATEGORY 5 – XDR TB
Anti tuberculous therapy
• HRZE ( 2 months )+ HR (4 months )
• Dosage
• Isoniazid (H) – 5 mg/kg
• Rifampicin ( R) – 10 mg /kg
• Ethambutol (E )-15 mg/kg
• Pyrazinamide (z) –25 mg/kg
Indications for surgery
• Biopsy
• Excision of nodes if it is not responding to medical management
• Excision of lymph node in collar stud abscess
• Excision of abscess
• Persistent sinus
Cold abscess
• Aspiration
• In the non dependent part
• Using Z technique
• Incision and drainage is not done as it can lead to the formation of a fistula
Lymphomas
 Hodgkins lymphoma Non Hodgkin’s lymphoma

Age – bimodal peak – 20s and 60s 60- 80 years

Pattern- multi centric , clear centripetal disease Usually involve gastrointestinal , epitroclear
(axial ans spread to adjacent ) and waldeyers ring
Hepatosplenomegaly less common Hepatosplenomegaly more common

Extralymphoid tissue involvement uncommon Extralymphoidal tissue involvement more

common
Reed stern berg cells B and T cells

Associated with Epstein Barr virus infection Not commonly associated with viral infection.
Non Hodgkin’s lymphoma
NHL
• Neoplasms of the immune system usually resenting as disseminated and extranodal
disease of old age
• Multi centric
• Wide spread
• Showing malignant cells in the blood
• Leukaemia transformation in 10-15%
• Can present –
 Asypmptomatic
 Fever , night sweats , weight loss
 Enlarged lymph node
 Abdominal mass
 Gi symptoms – pain , vomiting and bleeding
Predisposing factors
• Immune suppression
• Autoimmune disorders
 Sjogrens disease
 Hashimoto’S thyroiditis

• Infection
 Epstein Barr – Burkitt lymphoma
 AIDS related
 HTLV
 HUMAN HERPES virus 8 – castlemanns disease
 HTLV 2 – T cell leukaemia and lymphoma
 H.pylori – gastric lymphoma .
 Prior chemotheraphy
 Prior radiotheraphy
Syndromes associated with NHL
• Ataxia telangiectasia
• Wiskott aldrichh syndrome
• Celiac disease
Extranodal sites with aggressive
• Gastrointestinal tract
• Nasopharynx
• Testes

Lymphomas for prediction for CNS mets

• Testes
• Paranasal sinuses
• AIDS related
Classification
• WHO classification
• B cell neoplasms
 Pre B cell
 Peripheral B cell neoplasms – Burkitt lymphoma

• T cell neoplasms
 Pre T cell neoplasms
 Peripheral T cell neoplasms – mycosis fungoides , intestinal T cell neoplasms

• FUNCTIONAL CLASSIFICATION
Indolent Aggressive

Smaller cells , well Larger cells ,

differentiated Less Differentiated

Progress to more aggressive

Highly aggressive
type

Very difficult to cure Better chance at cure

When to suspect transition ?
• Increased LDH
• Rapid enlargement of lymph node
• Constitutional symptoms
• Extranodal disease
Hodgkin’s lymphoma
Risk factors
• Sibling with Hodgkin disease
• HLA antigens
• Patients with immunodeficiency status
• Autoimmune disorder
• Epstein Barr infection
• Lymphotropic virus
Clinical presentation
• Painless progressive swelling
• H/ o weight loss
• H/o loss of appetite
• h/o pruritis /jaundice
• May present as Pyrexia of unknown origin
• H/o recurrent fever – Pel Ebsteins fever
• H/o venous congestion /dysphasia /dyspnea —> due to compressive symptoms
• O/e – non tender , size of the swelling , possible to define single nodes , smooth Ovoid ,
Indian rubber consistency , moved from side to side , fixity develops very late
• Hepatomegaly and splenomegaly
• Examine other draining areas
• Examine other lymph nodes
Reed stern berg cells
• Binucleate cells
• Have vesicular nuclei
• And prominent eosinophilic nucleoli
Antigens involved in Hodgkins
• Order of the nodes commonly involved
RS CELL CD 30+  Mediastinal -60%
 Pure infradiaphragmatic
NK CELL CD 56+  Extra nodal
 Spleenomegaly
CD 34+
Stem cell

Leukocyte antigen CD 45+

T cells CD 3,4,5,15,30 +

B cells CD 19,20,21,22+
Classification
Subtype Characteristics

Few RS CELLS , Diffuse lymphocytes

Lymphocyte rich
Excellent prognosis

Abundant RS cells
Lymphocyte depleted
Paucity of lymphocytes

Common type
Mixed cellularity
Presents with disseminated disease

Commonest , young women affected

Nodular sclerosis
Fibrosis + , RS CELLS and lymphocyte seen
Investigation
• Biopsy of the involved node ( proffered than FNAC )
• Complete blood count – hyperspleenism due to spleenomegaly
• ESR
• Liver function test – to look for alteration in liver enzymes
• Chest X-ray – pulmonary metastasis and mediastinal widening – d/t mediastinal lymph
node
• CT chest , abdomen and pelvis — > for staging
• Bone marrow biopsy
Ancillary procedures
• Bone pain —:> radio isotopic bone scan
• CT of head and neck in extranodal presentation
• MRI OF SPINE – suspected spinal involvement
• CSF cytology - >
 Stage 4
 Bone marrow involvement
 Testes involvement
 Parameningeal involvemet

• Bone marrow biopsy indicated in –

 B symptoms ( fever, night sweats , weight loss )
 Anemia
 Leukopenia
 Thrombocytopenia
Principles of biopsy
• Largest and most central node in group
• Nodes preferred- cervical >axillary>inguinal
• Intact node for biopsy
• Imprint cytology of freshly cut node
• Imprint cytology – node to be sent in a bottle containing saline
• Node that was manipulated by FNAC to be avoided
Staging
Ann –Arbor staging
Stage Description
I - Involvement of a single lymph node region
- Localized involvement of a single extra lymphatic
organ

II - 2 or more lymph node on the same side of diaphragm

- Extrnodal involvement along with regional lymph
node on same side

III - Lymph node regions on both sides of diaphragm +/-

extralymphatic extension

IV - Distant or disseminated disease

- Liver /bone marrow or nodular involvement of lung
• Depending on the B SYPMPTOMS – each stage divided into A or B
• DEPENDING ON PRESENCE OF EXTRANODAL EXTENSION – suffix E added to
staging
• B SYMPTOMS include
 Weight loss - >10% body weight in 6 months
 Fever – unexplained fever >38 degree
 Drenching night sweats that require change of clothes

• Extranodal sites include

 Bone marrow
 Gastrointestinal
 Skin
 Bone
 CNS
 GONADS
 Lungs
 Liver
 Kidneys and uterus
• Early stage of the disease includes – stage IA and IIA , non bulky disease
• Bulky disease includes –
 10 cm diameter mass or more
 Mediastinal disease with transverse diameter exceeding 1/3 rd the transthoracic
diameter
Treatment of Hodgkin’s lymphoma
• Radiotheraphy –
 Mantle
 Para aortic
 Pelvic – inverted Y

• Lungs , gonads , iliac crest , kidney , Heart and larynx protected by shields
• Dose – 40- 45Gy delivered at 10Gy per week

• Chemotheraphy
• ABVD REGIMEN
• MOPP regimen
Radiotheraphy
• Mainly given for stage I &II
• PRESENCE OF B SYMPTOMS —>.need for additional chemotheraphy
• Mantle cell radiation —:> cervical , axillary , mediastinal and hilar lymph nodes
• Subtotal lymphoid irradiation —:> mantle area + upper abdomen + spleenic bed + para
aortic nodes
• Total lymphoid irradiation —:> STLI + pelvis
Chemotheraphy
• For stage 3 and stage 4
• ABVD regimen
 6-8 cycles
 ADRIAMYCIN , BLEOMYCIN , VINBLASTIN , DACARBAZINE
 Better toxicity profile
 Better disease free survival

• MOPP regimen
 NITROGEN MUSTARD
 VINCRISTINE
 PROCARBAZINE
 PREDNISONE
Combination therapy

• Both chemo and radiotheraphy

• Done to prevent relapse
• Indication
 Unfavourable stage 3and 4
 Unfavourable histology ( mixed cellularity Nd lymphocyte depleted )
 Extensive spleenic involvement
 Children who can’t tolerate full dose radiotheraphy

• Radiation dose is reduced when given along with chemotheraphy

Radio immunotherapy
• Given in case of relapse
• I -131 labelled anti CD 30 monoclonal antibody is given
• Antibodies against CD 3 , CD28 and CD 25 are also available
Bad Prognostic factors of Hodgkins
• Bulky disease
• Anemia
• High ESR
• INFLAMMATORY SIGN
• INGUINAL NODE INVOLVEMENT
• TISSUE EOSINOPHILIA
• HIGH SERUM LDH
• PATHOLOGICAL GRADE
• Age >45
• Stage 4
• Serum albumin <4g/dl
• WBC >15000
Treatment of NHL
• Chemotheraphy is the primary modality of treatment in NHL
• LOCALISED disease radiotheraphy be useful
• Indolent –
 Localized – radiotheraphy
 Disseminated – rarely curative
 Palliation – watch and wait until they progress to aggressive type

• Aggressive
 Stage I and II – radiation alone
 Stage III and IV – CHOP regimen
 High dose chemotheraphy – with autologous marrow transplantation
Chemotheraphy in NHL
• CHOP regimen
 Cyclophosphamide
 Adriamycin
 Oncovin
 Prednisolone

• CHOP therapy has poor penetration to BBB

• HENCE FOR CNS METASTASIS – whole brain irradiation

- methotrexate – systemically and intrathecally

Role of surgery in NHL
• Establishing a diagnosis
• Resection of extranodal gastrointestinal lesions
• NHL Stomach or small bowel – Resection

because of risk of perforation / bleeding

Prognostic index for NHL
• Age >60 years
• Ann-Arbor stage 3 or 4
• Increased LDH
• REDUCED PERFORMANCE ECOG status 2
• Extranodal site – one or more
Thank you