Acute non specific lymphadenitis
It may be confined to local group of L.N draining focal infection , Or it may be generalized when there is bacterial or viral infection.X : L.N swollen tender the overlying skin is red with fluctuation if there is abscess.
Mic : large germinal center containing numerous mitotic figures, when the condition complicate pyogenic infection neutrophils seen around the follicles & in the sinuses . In sever bacterial infection center of the follicles undergo necrosis result in the formation of an abscess .
Chronic non specific lymphadeni tis :
It take 3 different forms :1- follicular hyperplasia : occur in inflammatory condition that activate B lymphocyte i.e it is due to non specific stimulation .
It may be seen in rheumatoid arthritis , toxoplasmosis & early stage of HIV infection & those should differentiate from follicular lymphoma by ;
1- preservation of L.N architecture with normal lymphoid tissue between the germinal center.
2- marked variation in shape & size of lymphoid follicles .
3-Mixed population of lymphocyte at different stage of differentiation .
4- prominent phagocytic & mitotic activity in germinal center.
Paracortical lymphoid hyperplasia-2
It characterized by reactive changes in T cell region of lymph node (paracortical ) . T cell undergo proliferation & transformation to immunoblast that may efface the germinal center,M:
1-Expansion of paracortical area with immunoblast .
2-hyperplasia of mononuclear phagocytic cell in the lymphatic sinuses .
3- enlargement of paracortical area that efface the lymphoid follicles.
3- Sinus histiocytosis :
Characterized by distension & prominence of the lymphoid sinusoid due to marked hypertrophy of lining endothelial cells & infiltration by histiocyte.
It is seen in L.N draining cancer as immunoresponse to the tumor or in L.N draining inflammatory lesion.
Mic :
Expansion of sinuses by proliferating large histiocyte containing phagocytic materials.
Malignant lymphoma :
1- Hodgkin's disease (HD) 25%2-Non Hodgkins lymphoma. 75%
Hodgkin's disease (HD)
It is primary disease of LN & may involve extra nodal site as secondary.Has bimodal peak incidence ( young adult 15-35)& in fifth decade .
Male more than female .
Characterized by presence of Reed Sternberg cell(RS).
X : LN enlarge discrete later become matted & cut section is homogenous .
Mic : microscopic diagnosis depend on presence of RS which is large cell with abundant eosinophilic cytoplasm . binucleated (mirror image) each nucleus has eosinophilic nucleolus surround by clear zone . INCLUDEPICTURE "E:\\JPEG5\\HEME045.JPG" \* MERGEFORMATINETRye classification: We have 4 types according to microscopic appearance
1- Lymphocytic predominance:LN contain mature lymphocyte mainly mix with histiocyte ,Rs are few , neutrophil plasma & esonophils are scanty .in addition to the presence of popcorn cell( cell with multilobed twisted nucleus similar to popcorn ). INCLUDEPICTURE "E:\\JPEG5\\HEME141.JPG" \* MERGEFORMATINET
2- nodular sclerosis
Characterized by the presence of collagen band that divide the LN into multiple lobules .in addition to the presence of lacunar cells ( large cell with multilobed nucleus containing many small nucleolus lying in clear space ) , surround by lymphocyte. INCLUDEPICTURE "E:\\JPEG5\\HEME110.JPG" \* MERGEFORMATINET .
3-Mixed cellularity:
Mix infiltration by lymphocyte ., plasma cell , eosinophils histiocyte & abundant RS cells.
4- lymphocytic depletion :of 2 subtypes;
a- fibrotic variant in which LN is replaced by fibrous tissue with some lymphocyte , Hodgkin cells & numerous RS cells .b-reticular variant : more cellular consist of atypical histiocyte , scanty lymphocyte & few RS cells.
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Clinical features:- Bimodal distribution seen in young & middle age - painless , movable , firm usually involve cervical & mediasstinal L.N.
-hepatosplenomegaly.
-constitutional symptom(type B symptom) as low grade fever , weight loss , sweating & pruritis.
Laboratory diagnosis :
1- CBP ;RBC : normochromic normocytic anaemia.
WBC: leukocytosis.
Platelets : normal.
2-ESR : high
Staging of HD:
Ann Arbor staging depend on clinical & pathological staging :
Stage 1 : involvement of L.N in single region on one side of diaphragm..
Stage 2: involvement of L.N in two region on one side of diaphragm .
Stage 3 : involvement of L.Ns i on both sides of diaphragm .
Stage 4 : multiple dissemination .
Each stage is subdivided into A (asymptomatic) & B ( has constitutional symptoms ).E (has extra nodal involvement ) .
Prognosis :
5 year survival for stage 1&2 is 100% .while for advance stage reach 50%.Non Hodgkins lymphoma (NHL) :
* malignant neoplasm of immune system of the body.* more common than HD.
* seen in 20-40 years .
* incidence increase due to increase in AIDS.
* majority arise from LN (65%) while in 35% has extra nodal origin .however all NHL has potential to spread to other LN , liver , B.M & spleen.
Etiopathogenesis :
NHL is clonal proliferation of immune cells & in 63% are of B cell origin 35% of T cell origin & 2% of histiocytic types . The following has association with NHL .1- viral association ; EB virus are involved in endemic Burkitts lymphoma while HTLV1 associated with T cell leukaemia .
2- genetic association in the form of translocation .
3- Immunodeficiency diseases various inherited or acquire Immunodeficiency disease as AIDS are associated with development of NHL .
4- immunosuppression by radiation or drug may associated with development of NHL .
5- Autoimmune diseases as sjogren syndrome , SLE , non tropical sprue may lead to NHL .
Classification of NHL :
There are different classification for NHL as Rappaport classification (19660 , Lukes-Collins (1974) Working formulation for clinical usagr (1982) ,& R.E.A.L.(1994) .
Clinical features:
1- superficial lymphadenopathy as painless asymptomatic enlargement of one or more group of peripheral L.N.2-Constitutional symptoms as fever , night sweating ,loss of body weight more than 10% .
3- Oropharyngeal involvement in 10% of cases .
4- Abdominal diseases as enlargement of liver , spleen or abdominal L.D
5- Other organ involvement as skin, CNS in certain type of NHL.
Laboratory Diagnosis of NHL:
In addition to clinical & histopathological features , other investigation may help in diagnosis (hematological findings):1- anemia of normochromic normocytic.
2-features of pancytopenia seen in late stages.
3-feature of leukemia seen in certain patients.
4-marrow involvement by NHL seen in 20% of cases .
5- hypercalcaemia & hyperuricaemia may seen .
Immunological abnormalities :
Majority of NHLs are of B-cell type associated with monoclonal excess of immunoglobulin of IgG or IgM.Staging;
Ann Arbor staging of Hodgkin disease is also used for NHL.