Difference between revisions of "Lymph node pathology"

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Lymph node pathology (view source)

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*Neoplastic - lymphoma, carcinoma.
*Neoplastic - lymphoma, carcinoma.
*Endocrine - [[hyperthyroidism]].
*Endocrine - [[hyperthyroidism]].
*Trauma.
*Trauma.  
*Autoimmune - [[SLE]], [[RA]], [[dermatomyositis]].
*Autoimmune - [[SLE]], [[RA]], [[dermatomyositis]].
*Inflammatory - drugs (phenytoin).
*Inflammatory - drugs (phenytoin).
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| melanin-laden histiocytes
| melanin-laden histiocytes
| [[histiocytosis]]
| [[histiocytosis]]
| S100+ve (interdigitating dendritic cells), CD1a+ve (Langerhans cells)
| [[S-100]]+ve (interdigitating dendritic cells), CD1a+ve (Langerhans cells)
| [[cutaneous T-cell lymphoma]]
| [[cutaneous T-cell lymphoma]]
| [[Image:Dermatopathic_lymphadenopathy_-_intermed_mag.jpg |thumb|center|150px| DL - intermed. mag.]]  
| [[Image:Dermatopathic_lymphadenopathy_-_intermed_mag.jpg |thumb|center|150px| DL - intermed. mag.]]  
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| [[Kimura disease]]
| [[Kimura disease]]
| eosinophils
| eosinophils
| angiolymphoid proliferation (thick-walled blood vessels with hobnail endothelial cells)
| angiolymphoid proliferation (thick-walled blood vessels with [[hobnail]] endothelial cells)
| IHC ?
| IHC ?
| [[Langerhans cell histiocytosis]], drug reaction, [[angiolymphoid hyperplasia with eosinophilia]]
| [[Langerhans cell histiocytosis]], drug reaction, [[angiolymphoid hyperplasia with eosinophilia]]
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| abundant histiocytes with reniform nuclei
| abundant histiocytes with reniform nuclei
| often prominent eosinophilia
| often prominent eosinophilia
| S100+, CD1a+
| [[S-100]]+, CD1a+
| [[Kimura disease]] (eosinophilia), [[Rosai-Dorfman disease]]
| [[Kimura disease]] (eosinophilia), [[Rosai-Dorfman disease]]
| [[Image:Langerhans_cell_histiocytosis_-_very_high_mag.jpg|thumb|center|150px|LCH - very high mag.]]
| [[Image:Langerhans_cell_histiocytosis_-_very_high_mag.jpg|thumb|center|150px|LCH - very high mag.]]
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| sinus histiocytosis
| sinus histiocytosis
| emperipolesis (intact cell within a macrophage)
| emperipolesis (intact cell within a macrophage)
| S100+, CD1a-
| [[S-100]]+, CD1a-
| Langerhans cell histiocytosis
| Langerhans cell histiocytosis
| [[Image:Emperipolesis_-_very_high_mag.jpg |thumb|center|150px | RDD - very high mag.]]  
| [[Image:Emperipolesis_-_very_high_mag.jpg |thumb|center|150px | RDD - very high mag.]]  
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==Lymph node metastasis==
==Lymph node metastasis==
===General===
{{Main|Lymph node metastasis}}
*Determination of ''lymph node status'' is one of the most common indications for the examination of lymph nodes.
*It is a good idea to look at the tumour (if available) ...before looking at the LNs for mets.
*Lymph node metastasis, in the absence of other metastases, often up-stage a cancer from [[cancer staging|stage]] II to stage III.
 
===Gross===
*Outside:
**"Large" - size varies by site.
***Neck >10 mm.<ref name=pmid18337039>{{Cite journal  | last1 = Mack | first1 = MG. | last2 = Rieger | first2 = J. | last3 = Baghi | first3 = M. | last4 = Bisdas | first4 = S. | last5 = Vogl | first5 = TJ. | title = Cervical lymph nodes. | journal = Eur J Radiol | volume = 66 | issue = 3 | pages = 493-500 | month = Jun | year = 2008 | doi = 10.1016/j.ejrad.2008.01.019 | PMID = 18337039 }}</ref>
**Shape - round more suspicious than oval.
*Sectioned:
**White firm lesion with irregular border - classic appearance.
**Non-fatty hilum.<ref name=pmid18337039/>
 
===Microscopic===
Features:
*Foreign cell population - '''key feature'''.
**Classic location: subcapsular sinuses.
*+/-Cells with cytologic features of malignancy.
**Nuclear pleomorphism (variation in size, shape and staining).
**Nuclear atypia:
***Nuclear enlargement.
***Irregular nuclear membrane.
***Irregular chromatin pattern, esp. asymmetry.
***Large or irregular nucleolus.
**Abundant mitotic figures.
*+/-Cells in architectural arrangements seen in malignancy; highly variable - dependent on tumour type and differentiation.
**+/-Gland formation.
**+/-Single cells.
**+/-Small clusters of cells.
 
Notes:
#Cytologic features of malignancy may not be present; some tumours, e.g. gallbladder carcinoma, do not always have overt cytologic features of malignancy.
#*The diagnosis is based on the fact that they are foreign to the lymph node ''and'' architecturally consistent with a well-differentiated malignancy.
#[[Soft_tissue_lesions#Lymph_node_metastases_in_sarcomas|Lymph node metastases in sarcomas]] are uncommon; they are seen in <3% of cases.<ref name=pmid8424704>{{Cite journal  | last1 = Fong | first1 = Y. | last2 = Coit | first2 = DG. | last3 = Woodruff | first3 = JM. | last4 = Brennan | first4 = MF. | title = Lymph node metastasis from soft tissue sarcoma in adults. Analysis of data from a prospective database of 1772 sarcoma patients. | journal = Ann Surg | volume = 217 | issue = 1 | pages = 72-7 | month = Jan | year = 1993 | doi =  | PMID = 8424704 | PMC = 1242736}}</ref>
#Fatty lymph nodes (esp. fatty hilus<ref name=pmid18337039>{{Cite journal  | last1 = Mack | first1 = MG. | last2 = Rieger | first2 = J. | last3 = Baghi | first3 = M. | last4 = Bisdas | first4 = S. | last5 = Vogl | first5 = TJ. | title = Cervical lymph nodes. | journal = Eur J Radiol | volume = 66 | issue = 3 | pages = 493-500 | month = Jun | year = 2008 | doi = 10.1016/j.ejrad.2008.01.019 | PMID = 18337039 }}</ref>) are less likely to harbor metastases.<ref name=pmid21972135>{{Cite journal  | last1 = Korteweg | first1 = MA. | last2 = Veldhuis | first2 = WB. | last3 = Mali | first3 = WP. | last4 = Diepstraten | first4 = SC. | last5 = Luijten | first5 = PR. | last6 = van den Bosch | first6 = MA. | last7 = Eijkemans | first7 = RM. | last8 = van Diest | first8 = PJ. | last9 = Klomp | first9 = DW. | title = Investigation of lipid composition of dissected sentinel lymph nodes of breast cancer patients by 7T proton MR spectroscopy. | journal = J Magn Reson Imaging | volume = 35 | issue = 2 | pages = 387-92 | month = Feb | year = 2012 | doi = 10.1002/jmri.22820 | PMID = 21972135 }}</ref>
 
DDx - mimics of metastatic disease:
*[[Endometriosis]].
*Ectopic [[decidua]].<ref name=pmid15859655>{{Cite journal  | last1 = Wu | first1 = DC. | last2 = Hirschowitz | first2 = S. | last3 = Natarajan | first3 = S. | title = Ectopic decidua of pelvic lymph nodes: a potential diagnostic pitfall. | journal = Arch Pathol Lab Med | volume = 129 | issue = 5 | pages = e117-20 | month = May | year = 2005 | doi = 10.1043/1543-2165(2005)129e117:EDOPLN2.0.CO;2 | PMID = 15859655 }}</ref>
*[[Endosalpingiosis]].<ref name=pmid20631604>{{Cite journal  | last1 = Corben | first1 = AD. | last2 = Nehhozina | first2 = T. | last3 = Garg | first3 = K. | last4 = Vallejo | first4 = CE. | last5 = Brogi | first5 = E. | title = Endosalpingiosis in axillary lymph nodes: a possible pitfall in the staging of patients with breast carcinoma. | journal = Am J Surg Pathol | volume = 34 | issue = 8 | pages = 1211-6 | month = Aug | year = 2010 | doi = 10.1097/PAS.0b013e3181e5e03e | PMID = 20631604 }}</ref>
*Melanocytic nevus - intracapsular or within the trabeculae.<ref name=pmid12717252>{{Cite journal  | last1 = Biddle | first1 = DA. | last2 = Evans | first2 = HL. | last3 = Kemp | first3 = BL. | last4 = El-Naggar | first4 = AK. | last5 = Harvell | first5 = JD. | last6 = White | first6 = WL. | last7 = Iskandar | first7 = SS. | last8 = Prieto | first8 = VG. | title = Intraparenchymal nevus cell aggregates in lymph nodes: a possible diagnostic pitfall with malignant melanoma and carcinoma. | journal = Am J Surg Pathol | volume = 27 | issue = 5 | pages = 673-81 | month = May | year = 2003 | doi =  | PMID = 12717252 }}</ref>
*[[Dermatopathic lymphadenopathy]].{{fact}}
*[[Sinus histiocytosis]] - especially for the junior resident.
*[[Tumour deposit]] (discoutinuous extramural extension) - definition dependent on primary tumour (e.g. in the head & neck they are tumour replaced lymph nodes, in the colon they are considered separate and not counted as lymph nodes).
 
====Images====
<gallery>
Image:Breast_carcinoma_in_a_lymph_node.jpg | Breast carcinoma LN metastasis (WC)
Image:Lymph_node_with_papillary_thyroid_carcinoma.jpg | Thyroid carcinoma LN metastasis (WC)
Image:Crc_met_to_node1.jpg | Colorectal carcinoma LN metastasis (WC)
Image:Lymph_node_with_metastatic_melanoma_-_by_Gabriel_Caponetti,_MD.jpg | Melanoma in a lymph node. (WC)
</gallery>
=====Mimics=====
<gallery>
Image:Decidua_in_a_lymph_node_-_low_mag.jpg | Decidua in a LN - low mag. (WC)
Image:Decidua_in_a_lymph_node_-_high_mag.jpg | Decidua in a LN - high mag. (WC)
Image:Endometriosis_lymph_node_-_2_-_intermed_mag.jpg | Endometriosis in a LN - intermed. mag. (WC)
Image:Endosalpingiosis_in_lymph_node_-_intermed_mag.jpg | Endosalpingiosis in a LN - intermed. mag. (WC)
Image:Endosalpingiosis_in_lymph_node_-_very_high_mag.jpg | Endosalpingiosis in a LN - very high mag. (WC)
</gallery>


==Kaposi sarcoma==
==Kaposi sarcoma==
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==Reactive follicular hyperplasia==
==Reactive follicular hyperplasia==
===General===
{{Main|Reactive follicular hyperplasia}}
*Many causes - including: bacteria, viruses, chemicals, drugs, allergens.
**In only approximately 10% can definitive cause be identified.<ref name=Ref_ILNP174>{{Ref_ILNP|174}}</ref>
 
===Microscopic===
Features:<ref name=Ref_ILNP179>{{Ref_ILNP|179}}</ref>
*Enlarged follicles, follicle size variation - '''key feature''' with:
**Large germinal centers (pale on H&E).
***Mitoses common.
***Variable lymphocyte morphology.
***Tingible-body macrophage (large, pale cells with junk in the cytoplasm).
***Germinal centers (GCs) have a crisp/sharp edge.
***Normal dark/light variation of GCs; superficial aspect light, deeper aspect darker.
**Rim of small (inactive) lymphocytes.
 
DDx:
*[[Hodgkin lymphoma]] - with rare Reed-Sternberg cells.
*Non-Hodgkin [[lymphoma]].
**T-cell/histiocyte-rich large B cell lymphoma.
 
Image: [http://pleiad.umdnj.edu/hemepath/normal_node/normal_node.html Normal lymph node (umdnj.edu)].
 
===IHC===
Screening panel:
*CD3.
*CD5.
*CD10.
*CD20.
*CD30.
*CD15.
 
Others:
*BCL2 -ve.


==Diffuse paracortical hyperplasia==
==Diffuse paracortical hyperplasia==
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==Systemic lupus erythematosus lymphadenopathy==
==Systemic lupus erythematosus lymphadenopathy==
===General===
{{Main|Systemic lupus erythematosus lymphadenopathy}}
*Lymphadenopathy associated with [[systemic lupus erythematosus]] (SLE).
 
===Microscopic===
Features:<ref name=pmid9406250>{{Cite journal  | last1 = Kojima | first1 = M. | last2 = Nakamura | first2 = S. | last3 = Itoh | first3 = H. | last4 = Yoshida | first4 = K. | last5 = Asano | first5 = S. | last6 = Yamane | first6 = N. | last7 = Komatsumoto | first7 = S. | last8 = Ban | first8 = S. | last9 = Joshita | first9 = T. | title = Systemic lupus erythematosus (SLE) lymphadenopathy presenting with histopathologic features of Castleman' disease: a clinicopathologic study of five cases. | journal = Pathol Res Pract | volume = 193 | issue = 8 | pages = 565-71 | month =  | year = 1997 | doi =  | PMID = 9406250 }}</ref>
*Necrosis.
*Hematoxylin bodies (in necrotic foci).
**Dark blue irregular bodies on H&E.
 
DDx:
*[[Kikuchi disease]].
 
====Images====
<gallery>
Image:Systemic_lupus_erythematosus_lymphadenopathy_-_high_mag.jpg | SLE lymphadenopathy - high mag. (WC)
Image:Systemic_lupus_erythematosus_lymphadenopathy_-_very_high_mag.jpg | SLE lymphadenopathy - very high mag. (WC)
</gallery>


==Castleman disease==
==Castleman disease==
*[[AKA]] ''angiofollicular lymph node hyperplasia'', ''giant lymph node hyperplasia''.<ref>URL: [http://www.mayoclinic.com/health/castleman-disease/DS01000 http://www.mayoclinic.com/health/castleman-disease/DS01000]. Accessed on: 17 June 2010.</ref>
*[[AKA]] ''angiofollicular lymph node hyperplasia'', ''giant lymph node hyperplasia''.<ref>URL: [http://www.mayoclinic.com/health/castleman-disease/DS01000 http://www.mayoclinic.com/health/castleman-disease/DS01000]. Accessed on: 17 June 2010.</ref>
*Abbreviated '''CD'''.
*Abbreviated '''CD'''.
===General===
{{Main|Castleman disease}}
*Benign.
*Hyaline vascular variant - a pathology of the follicular dendritic cells.<ref>{{Cite journal  | last1 = Cokelaere | first1 = K. | last2 = Debiec-Rychter | first2 = M. | last3 = De Wolf-Peeters | first3 = C. | last4 = Hagemeijer | first4 = A. | last5 = Sciot | first5 = R. | title = Hyaline vascular Castleman's disease with HMGIC rearrangement in follicular dendritic cells: molecular evidence of mesenchymal tumorigenesis. | journal = Am J Surg Pathol | volume = 26 | issue = 5 | pages = 662-9 | month = May | year = 2002 | doi =  | PMID = 11979097 }}</ref>
 
===Classification===
CD is grouped by histologic appearance:<ref name=Ref_ILNP228>{{Ref ILNP|228}}</ref>
#Hyaline vascular (HV) variant (described by Castleman).
#*Usually unicentric.
#*Typically mediastinal or axial.
#*More common than plasma cell variant; represents 80-90% of CD cases.
#*May be associated with [[follicular dendritic cell neoplasia]].<ref name=Ref_WMSP_596>{{Ref WMSP|596}}</ref>
#Plasma cell (PC) variant.
#*Usually multicentric, may be unicentric.
#*Abundant plasma cells.
#*Associated with [[HHV-8]] infection (the same virus implicated in ''Kaposi's sarcoma'').
 
Notes:
*The subclassification of CD is in some flux. Some authors advocate splitting-out ''HHV-8'' and ''multicentric'' as separate subtypes.<ref name=pmid19546611>{{Cite journal  | last1 = Cronin | first1 = DM. | last2 = Warnke | first2 = RA. | title = Castleman disease: an update on classification and the spectrum of associated lesions. | journal = Adv Anat Pathol | volume = 16 | issue = 4 | pages = 236-46 | month = Jul | year = 2009 | doi = 10.1097/PAP.0b013e3181a9d4d3 | PMID = 19546611 }}</ref>
 
===Microscopic===
====Hyaline-vascular variant====
Features:<ref>URL: [http://www.ispub.com/journal/the_internet_journal_of_otorhinolaryngology/volume_9_number_2_11/article/a_rare_case_of_castleman_s_disease_presenting_as_cervical_neck_mass.html http://www.ispub.com/journal/the_internet_journal_of_otorhinolaryngology/volume_9_number_2_11/article/a_rare_case_of_castleman_s_disease_presenting_as_cervical_neck_mass.html]. Accessed on: 15 June 2010.</ref><ref name=Ref_ILNP236>{{Ref ILNP|236}}</ref>
*Pale concentric (expanded) mantle zone lymphocytes - '''key feature'''.
**"Regressed follicles" - germinal center (pale area) is small.
*"Lollipops":
**Germinal centers fed by prominent (radially penetrating sclerotic) vessels; lollipop-like appearance.
*Two germinal centers in one follicle.
*Hyaline material (pink acellular stuff on H&E) in germinal center.
*Sinuses effaced (lost).
*Mitoses absent.
 
====Images====
<gallery>
Image:Castleman_disease_-_high_mag.jpg | CD HVV - "lollipop" sign - high mag. (WC)
Image:Castleman_disease_-_intermed_mag.jpg | CD HVV - showing expanded mantle zone - intermed. mag. (WC)
</gallery>
www:
*[http://path.upmc.edu/cases/case115.html CD HVV - case 1 - several images (upmc.edu)].
*[http://path.upmc.edu/cases/case301.html CD HVV - case 2 - several images (upmc.edu)].
 
====Plasma cell variant====
Features:<ref name=Ref_ILNP236>{{Ref ILNP|236}}</ref>
*Interfollicular sheets of plasma cells - '''key feature'''.
*Active germinal centers - mitoses present.
*Sinus perserved.
 
===IHC===
Hyaline-vascular variant:
*Stains to exclude [[mantle cell lymphoma]]:
**Cyclin D1.
 
Plasma cell variant:
*HHV-8 +ve.


==Cat-scratch disease==
==Cat-scratch disease==
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*[[Amyloidosis]] - cotton candy-like appearance, usu. no calcifications.
*[[Amyloidosis]] - cotton candy-like appearance, usu. no calcifications.


Images:
====Images====
<gallery>
Image: Hyalinized lymph node -- intermed mag.jpg | Hyalinized LN - intermed. mag.
Image: Hyalinized lymph node - alt -- intermed mag.jpg | Hyalinized LN - intermed. mag.
Image: Hyalinized lymph node -- high mag.jpg | Hyalinized LN - high mag.
Image: Hyalinized lymph node -- very high mag.jpg | Hyalinized LN - very high mag.
</gallery>
www:
*[http://www.flickriver.com/photos/euthman/sets/72157594513987154/ Lymph node with amyloidosis - several images (flickriver.com)].
*[http://www.flickriver.com/photos/euthman/sets/72157594513987154/ Lymph node with amyloidosis - several images (flickriver.com)].
===Sign out===
*Not reported.


==See also==
==See also==
Michael
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