1. SPLENOMEGALY and LYMPHADENOPATHIES
Hasan Atilla Özkan, MD.

2. LYMPHADENOPATIES 1- Anatomy and Definitions
Lymph node regions in the body
- head and neck
- supraclavicular
- deltopectoral
- axillary
- epitroclear
- inguinal
- popliteal

5. Normal lymph nodes are usually less than 1 cm in diameter (tend to be larger in adolescence than later in life)
Lymph nodes are often palpable in the inguinal region in healthy people, may also be papable in the neck (particularly submandibular) ; because chronic trauma and infection is more common in these regions

6. 2. Diagnostic approach A – History B – Physical examination
C – Diagnostic tests

7. 1. History
Localizing signs or symptoms suggesting infection or malignancy
Exposures likely to be associated with infection (cat stratch disease, high risk behavior)
Constitutional symptoms such as fever, night sweets or weight loss
Use of medications that can cause lymphadenopathy
Foreign travel

10. 2. Physical examination
All lymph node groups should be examined with the following characteristics in mind:
Location
Localized or generalized
Size
Tenderness
Consistency
Fixation

16. Location - 1 Localized lymphadenopathy
- suggest local causes, search for pathology in the area of node drainage
- some systemic disease can also present with localized adenopathy
* tularemia
* aggressive lymphoma, etc

17. Location - 2 Cervical adenopathy - bacterial infections
- infectious mononucleosis
- toxoplasmosis
- tuberculosis
- lymphoma
- kikuchi’s disease
- head and neck malignancies

18. Location – 3 Supraclavicular lymphadenopathy
- is associated with high risk of malignancy
- right supra: mediastinum, lungs or esophagus
- left supra (Virchow’s node): abdominal malignancy

19. Location - 4
Axillary
- drainage from the arm, thoracic wall and breast
- infections are common causes
-in the absence of upper extremity lesions, cancer is often found (particularly breast cancer)

20. Location - 5 Epitrochlear - always pathologic
- infections of the forearm and hand, lymphoma, sarcoidosis, tularemia and secondary syphilis
Inguinal
- usually caused by lower extremity infection, sexually transmitted disease or cancer

21. Location - 6 Generalized lymphadenopathy
Usually a manifestation of systemic disease
* HIV infection
* mycobacterial infection
* infectious mononucleosis
* systemic lupus erythematosis
* medications
* lymphoma / leukemia

22. 3. Diagnostic tests Laboratory testing CBC Chest X-ray PPD HIV Ab ANA
Other spesific test in need

23. Lymph node biopsy;
(If an abnormal node has not resolved after 4 weeks or suspect of malignancy)
- Open biopsy: genarally is the best test
- Fine needle aspiration: useful when searching for reccurence of cancer
- Core needle biopsy: in situtition where the open lymph node biopsy can not be performed

24. Incision and drainage
Imaging
Observation over time

25. SPLENOMEGALY General Information
Hematopoietic organ capable of supporting elements of the erythroid, myeloid, megakaryositic, lymphoid and monocyte-macrophage systems
Participates in cellular and humoral immunity through its lymphoid elements
Removes senescent RBC, bacteria, and other particules from the circulation through monocyte-macrophage system (major function)

26. Splenectomized patients are suspectible to bacterial sepsis, especially with uncapsulated ones
Major lymphoid organ, containing ~ 25% of the total lymphoid mass of the body
About 1/3 of circulating plateletes are suspected in the spleen where they are in equilibrium with circulating plateletes

27. B. Size and Palpability Median weight is about 150 grams
Average estimated weight of palpable spleen is about 285 grams
Not usually palpable, but may be felt in children, adolescents and some adults, especially those of asthenic build
A palpable spleen usually means the presence of significant splenomegaly
Enlarged spleen on physical examination is more reliable than minimally enlarged on imaging

28. The clincal or diagnostic significance of a spleen that is minimally enlarged on scan but is not palpable (scanomegaly) is uncertain
Symptoms of an enlarged spleen may include;
- pain, a sense of fulness, or discomfprt in the left upper quadrant
- pain referred to the left shoulder
- early satiety, due to encrachment on the adjacent stomach

29. Criterias proposed to define the size of normal spleen;
* USG – length < 13 cm or thichness ≤ 5 cm
* CT scanning – length ≤ 10 cm

30. Causes of Splenomegaly
The causes of enlarged spleen are multiple: - most reflect the presence of hepatic or hematologic disease, infection or inflammation

31. Common causes
- liver disease : 33% (cirrhosis)
- hematologic malignancy : 27% (lymphoma)
- Infection : 23% (AIDS, endocarditis)
- congestion or inflammation : 8%
- primary splenic disease: 4% (splenic vein thrombosis)
- other or uncommon : 5%

33. Massive splenomegaly
- chronic myeloid leukemia
- myelofibrosis
- gaucher disease
- lymphoma
- Kala-azar (visceral leishmaniasis)
- malaria
- beta-thalassemia major
- AIDS with mycobacterium avium complex

36. D. Evaluation History: - chronic alcholism, hepatitis
- fatigue, fever, sore throat: inf. Mononucleosis
- post-bath pruritis: polycytemia vera
Imaging studies
CBC and pheripheral blood smear
Bone marrow asp. and biopsy

37. Diagnostic splenctomy
* most common pathologic diagnosis;
- leukemia / lymphoma 57%
- metastatic carcinoma 11%
- cyst / pseudocyst 9%
- beningn / malign vascular neoplasm 7%
- normal 5%
Splenic aspiration / biopsy
- is not widely practiced because of a concern for bleeding

38. General indications for splenectomy
- isolated thrombocytopenia, hemolytic anemia or neutropenia
- painfully enlarged spleen
- traumatic or atraumatic splenic rupture
- splenic artery aneurysm
- hypersplenism
- splenic vascular or parencymal lesion
- to allow diagnosis

39. Spesific conditions in which splenectomy may be considered;
İmmune thrombocytopenia
Autoimmune hemolytic anemia
Thalassemia major or intermedia
Hereditory spherocytosis
Primary myelofibrosis
Hairy cell leukemia, splenic marginal zone lymphoma
Splenic contusion or rupture
Splenic abscess or infection
Splenic vein thrombosis with bleeding varices
Felty’s syndrome