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The enlargement of a lymph node, due to primary disease or secondary cause, is of concern to both patients and clinicians, particularly, if the underlying pathology is a malignant disease. Lymph node aspiration pubmed journal list pdf biopsy for histopathological evaluation may not reveal the diagnosis due to several factors. However, a methodological approach to LAP can disclose the accurate diagnosis with minimal discomfort to the patient and in a short time.

In this review article, we provide evidence-based clinical evaluation of LAP, guided by the probability of the underlying disease to assist clinicians in establishing the proper cause and hence offer appropriate management. Medknow Publications and Media Pvt. The body has approximately 600 LNs, and their locations are scattered around ports of entry as well as major vessels. The peripheral groups are those readily palpable by clinical examination, and routinely looked for, but only those in the submandibular, axillary or inguinal regions may normally be palpable in healthy individuals. Lymphadenopathy can be defined as LNs that are abnormal in size, consistency or number. Fortunately, the majority of patients presenting with peripheral LAP have easily identifiable causes that are benign or self-limiting. Lymphadenopathy is considered to be localized if only one group of LN is involved, limited if 2-3 groups of LN are involved and generalized if more than three noncontiguous groups are involved.

Localized LAP is more common and it has been reported to affect nearly 75 percent of patients presenting with LAP, whereas 25 percent of those patients had generalized LAP. In our study of 258 adults who presented with LAP as a presenting feature, localized LAP occurred in 54. Distinguishing between the extensions of LAP is important in formulating a differential diagnosis. Generalized LAP is almost always due to a significant systemic illness.

The cause of LAP is essentially due to either an immune response to infective agents, or inflammatory cells in infections involving the LN. Moreover, it may be due to infiltration of neoplastic cells carried to the node by lymphatic or blood circulation. Alternatively, primary neoplastic proliferation of lymphocytes may be the underlying pathology of LAP. It is not exhaustive but considering the causes as classified may be helpful in arriving at a diagnosis in a timely manner. Furthermore, the epidemiological pattern in a particular locality may also determine which causes to put uppermost in the differential diagnosis.

The prevalence of malignancy, the most serious of the causes of LAP, is quite low among the general population with LAP being as low as 1. 1 percent or even lower. Lyimphatic metastasis of tumor cells represents a series of extremely complex and sequential processes that include dissemination and invasion into surrounding stromal tissues from primary tumors, penetration into lymphatic walls and implantation in regional LNs. Recent developments in lymphatic biology and research, especially the application of unique molecular markers specific for lymphatic endothelial cells have provided exciting new insights into the tumor microenvironment. Generalized LAP is more likely to occur in patients with malignancy.

It is frequently seen in patients with leukemias and lymphomas, or metastatic solid tumors. Lymphomas and most metastatic carcinomas characteristically progress through nodes in anatomic sequence. LAP, including early infection with HIV, activated TB, cryptococcosis, cytomegalovirus, toxoplasmosis, and Kaposi’s sarcoma, which can present with LAP before visible skin lesions appear. Reaching an accurate diagnosis for a patient presenting with LAP may not be an easy task for clinicians with the background of massive number of differential diagnosis. A methodological approach guided by educated evidence-based evaluation is therefore necessary from the outset. LAP that may aid in the process of reaching a correct diagnosis.

Most patients can be diagnosed on the basis of a careful history and physical examination. Thorough history and meticulous physical examination will identify a readily diagnosable cause of the LAP, such as upper respiratory tract infection, pharyngitis, periodontal disease, conjunctivitis, insect bites, recent immunization, cat-scratch disease or dermatitis. Where the cause and course of LAP is obvious, no further assessment is necessary. Furthermore, getting a clear history of exposure to certain risk factors may suggest the cause of LAP, such as history of animal contact or raw milk ingestion may suggest brucellosis, or intravenous drug abuse and high risk sexual practices may suggest HIV. Environmental exposures such as tobacco, alcohol, and ultraviolet radiation as well as occupational exposures to silicon or beryllium may raise suspicion for metastatic carcinoma of the internal organs, the head and neck, and skin. Family history may raise suspicion for certain neoplastic causes of LAP, such as carcinomas of the breast or familial dysplastic nevus syndrome and melanoma. Lymphadenopathy that lasts less than two weeks or more than one year with no progressive size increase has a very low likelihood of being neoplastic.

The precise timing of the onset of LAP is however elusive as most patients are unable to say with certainty as to when the enlargement started. Normal nodes are generally less than 1 cm in diameter. In one series, no patient with a LN smaller than 1 cm had cancer, compared with 8 and 38 percent of those with nodes 1 to 2. 25 cm and greater than 2. Some authors have however suggested that epitrochlear nodes of size 0.

5 cm or more and inguinal nodes of size 1. 5 cm or more should be considered abnormal. It has been shown that benign or self-limited causes were found in 79 percent of patients younger than 30 years of age, versus 59 percent in patients 31 to 50 years of age and 39 percent in those older than 50 years. In primary care settings, patients 40 years of age and older with unexplained LAP have about a4 percent risk of cancer versus a 0. 4 percent risk in patients younger than age 40.

In our study of 258 adults who presented with LAP, multivariate logistic regression model revealed that age over 40 years, male gender, generalized LAP, presence of other physical signs, abnormal liver function tests and negative Mantoux test to be statistically significantly associated with nodal malignancy. Other studies have also demonstrated that an increased likelihood of malignancy was associated with age over 40 years, male gender, white ethnicity, supraclavicular and epitrochlear locations, fixed nodal character, duration of greater than two weeks, and larger size. When LAP is localized, the clinician should examine the region drained by the nodes for evidence of infection, skin lesions or tumors. LAP may be secondary to infectious mononucleosis, axillary LAP are seen in patients with cat-scratch disease, whereas inguinal LAP may point towards sexually transmitted diseases.

Supraclavicular LAP has the highest risk of malignancy, estimated as90 percent in patients older than 40 years and25 percent in those younger than age 40. Having the patient perform a Valsalva’s maneuver during palpation of the supraclavicular fossae increases the chance of detecting a node. LAP according to region involved and drugs known to cause LAP, respectively. Another clinical feature that is of diagnostic importance is the consistency. Fluctuant nodes usually indicate suppuration while rubbery, firm nodes suggest lymphoma. Metastatic nodes are usually stony hard while softer nodes indicate inflammatory or infective conditions. Small shotty nodes are felt in childhood viral infections.