Sandbox:Javaria

The algorathmn illustrates the approach to management of lymphadenopathy. Borrowed from:

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History ❑Patient age (specific demographic characteristics (age) of certain malignancies) ❑ Duration of lymphadenopathy (<2 weeks or >1 year without an increase in size has low malignant potential) ❑ Past medical history of underlying disease, suggestive of immunodeficiency, or recurrent infections ❑ Sexual history suggestive of infection transmission ❑ Family history of certain malignant disorders (breast cancer, or melanoma) ❑ Exposure to communicable infectious diseases/ travel to high-risk areas ❑ Environmental exposure such as UV (skin cancer risk)/ animals/ occupational exposure ❑ Social history such as tobacco use, alcohol use (head and neck cancers risk) ❑ Associated symptoms such as pain, fever, weight loss, anorexia, cough, or recurrent UTIs

Physical exam Appearance of the patient Cachexia or surgical scar marks demonstrating previous malignancy treatment ❑ Vital signs ❑ Temperature: High-grade / low-grade fever may demonstrate infection. ❑ Heart rate: Tachycardia with regular pulse may demonstrate infection. ❑ Respiratory rate: Tachypnea may demonstrate respiratory system involvement (infection\ metastasis). ❑ Blood pressure: Chronic hypertension or hypotension (may indicate sepsis as a complication). ❑ Oxygen saturation: may be low if the respiratory system is affected. ❑ HEENT ❑ Cardiovascular examination ❑ Respiratory examination ❑ Gastrointestinal system exam includes oral examination, abdominal examination, and digital rectal exam. ❑ Splenomegaly) may demonstrate IM, hodgkin's/ non-Hodgkin's lymphoma, and sarcoidosis ❑ Extremities exam ❑ Skin exam: Evaluate for the lesions that indicate malignancy such as melanoma/ potential inoculation sites for germ such as traumatic lesions.

Palpable lymph node ❑ Location: (Localized vs generalized) ❑ For nodes involving several groups of nodes; suspect malignancy. ❑ An enlarged node in a lymphatic rich region; suspect local disease. ❑ Associated red streaking, suspect lymphangitis. ❑ Left supraclavicular L.N (Virchow's nodes); suspect gastric carcinoma ❑ Right supraclavicular L.N, suspect intra-thoracic carcinoma ❑ Dimensions The aforementioned dimensions are abnormal for a palpable lymph node but do not lead to the suspicion of a neoplasm. ❑ supraclavicular, iliac, epitrochlear, and popliteal lymph nodes >0.5cm ❑ Inguinal nodes > 1.5 cm ❑ Other area lymph nodes >1 cm ❑ Tenderness or pain: ❑ Suspect infection. ❑ A neoplastic node may also demonstrate pain due to hemorrhage associated with central necrosis or a brisk growing tumor. ❑ Consistency ❑ Hard on palpation; suspect chronic inflammation ❑ consistent- acute inflammation ❑ Stony-hard and painless nodes-metastatic cancer/ granuloma ❑ Firm and rubbery nodes- lymphoma ❑ Matted L.N suspect mycobacterium / sarcoidosis/ lymphoma / metastatic carcinoma) ❑ Mobility ❑ Freely movable; suspect infections and collagen vascular disease ❑ Fixed L.N to surrounding tissue; suspect malignancy

Labs ❑ CBC with differential ❑ ESR ❑ CMP ❑ Peripheral smaer ❑ LFTs Labs may be required at a later stage pf diagnosis

Diagnostic of self-limiting or benign disease Pharyngitis, URTI, conjunctivitis, cat-scratch disease, etc

Suggests infection/ serious infection

Unexplained

Suggests malignancy

May require specific tests ❑ Throat swab ❑ Sputum exam

Perform specific tests ❑ IM: Heterophile Antibody and monospot test ❑ Syphilis: VDRL, RPR ❑ HIV: HIV antibody test ❑ CMV: Anti CMV IgM ❑ Autoimmune disorders: ANA, Rheumatoid factor, etc ❑ Tuberculosis: PPD ❑ Cat scratch disease: IgM, IgG

Risk factors for malignancy Family history, age, exposure, etc

Perform specific tests

Excisional biopsy

Positive

Negative

Negative

Positive

❑ Treat with antibiotics if required and/ or symptomatic treatment ❑ For an untreatable or disease with residual symptoms counsel the patient ❑ Follow up for advancing or persistent LAD

Treat ❑ IM treatment ❑ Syphilis treatment ❑ HIV treatment ❑ CMV treatment ❑ Treatment of autoimmune disorders ❑ Tuberculosis treatment ❑ cat scratch disease treatment

Staging

Treat Surgical resection/ chemotherapy/ radiotherapy

Low risk

High risk

Specific tests/ biopsy

Localized

Generalized

Review history and clues suggesting malignancy

Review history and clues suggesting malignancy

Observe 3-4 weeks

Specific tests such as CXR, ultrasound, CT, lab workup, biopsy The US findings that help differentiate benign lAD from malignant include: ❑ Benign: An isoechoic oviod shaped lesion with variable borders. High long axis/short axis ratio(L/S) of >2. A hilum is present with blood flow. Pulsatility index id <1.5. ❑ Malignant: A hypoechoic round lesion with sharp borders. Low L/S ratio of <2. Hilum is absent with peripheral blood flow distribution.

Undiagnostic

Diagnostic

Progress/persists

Regress

No follow-up

Biopsy

Treatment

Positive

Negative

Staging

Follow-up

Biopsy

Treatment

Negative

Positive

Staging

Treatment