MTE 4 - LYMPHADENOPATHY HOW CAN WE DIFFRENTIATE MALIGNANCY OR NON-MALIGNANCY.pdf

bagaiamana membendakan lymohadenopathy

2. MD,MaranathaChistianUniversityBandung(2010)
SpA,DiponegoroUniversity(2018)
PPDSSp-2HematologyOncology,Universityof
indonesia(August2024-present)
NationalCongressof
IndonesianPediatricSociety
SEMARANG-SOLCJ2024
°EnsuringEqualAccessofChildcaiaintheERAofSociety5.0“
StaffofHematologyOncologyivision,ChildHealth
Department/KariadiHospital—Diponegoro
University/2019-present

3. nesianPediatricSoc‹vt.,
SfMARANG-5‹2024
"‹
HedaMelinda,NadirahRasyidRidha
at:owcaweirentiate

4. •1982MediœlDoctor,FacultéofMedicine,
DepartmentofChildHealth,UniversitasPadjadjaran
•1993Pediatrician,FacultéofMedicine,Depanmentof
ChildHealth,UniversitasPadjadjaran
•1999PulmonologyFellowship,RadboudHospital
* -"'-
Nijmegen{AcademischZiekenhuis)TheNetherlands
•2003HealthMagiste•,FacultéofMedicine,Universi
Padjadjaran
•2003RespirologyConsultant,CollegiumofIndon
PediatricSociety
•2008Doctor,FacultyofMedicine,Universitas
Padjadjaran
•GeneralPediatric,HasanuddinUniversity(2008)
•Magister,HasanuddinUniversity(2008)
•Doctoral,HasanuddinUniversity(2013)
•PediatricHematologyOncologyConsultant,Univer
ofIndonesia(2015)
•HeadofPediatricHematologyOncologyDivision,
DepartmentofPediatrics,FacultyofMedicine
HasanuddinUniversity
•MemberofHematologyOncologyWorkingGroup
•HeadoftheMotherandChildInstallationDr.
WahidinSudirohusodoHospital(2022-2024)

5. enoatmean?
A.Theenlargementofalymphnode>1cmincervicalregionor>1cm
intheaxillary.
B.Theenlargementofalymphnode>0.5cmincervicalregionor>1
cmintheaxillary.
C.Theenlargementofalymphnode>0.5cmincervicalregionor>0.5
cmintheepitrochlearlymphnodes
D.Theenlargementofalymphnode>0.5cmintheaxillarylymph
nodeor>0.5cmtheepitrochlearlymphnodes
E.Theenlargementofalymphnode>0.5cminaxillarylymphnode
or>0,5cminsupraclavicularlymphnode.

6. 56
Theenlargementofalymphnode>1cmin
cervicalrepionor»1cmintheoxillary
Theenlargementofalymphnode»0.5cm
incervicalregionor>1cmintheaxillory
Theenlargementofalymphnode»0.5cm
incervicalregionor>0.5cminthe
epitrochleorlymph nodes
eo
Theenlargementofalymphnode>0.5cm
intheoxillorylymphnocleor>0.5cmthe
epitrochleorlymphnocles
Theenlargementofalymphnode>0.5cm
inoxillarylymph nodeor>0,cmin
supraclavicularlymphnode

8. ,g^«› t.
-”
,_,a«,-::!*
..,,”“"’.”.
.
Lympenopateniargeympnoes
",.
•Lymphadenopathyreferstolymphnodesthatareabnormalinsize
(e.g.,greaterthan1cm)orconsistency.Palpablesupraclavicular,
5popliteal,andiliacnodes,andepitrochlearnodesgreaterthan
mm,areconsideredabnormal.
AmFamPhysician.
2016;94(11):896-903
•Normallymphnodesintheaxillaryandcervicalregionsareupto1
cminsize,intheinguinalregionsupto1.5cminsize,andinthe
epitrochlearlocationupto0.5cminsize.
EvaluationandManagementofLymphadenopathyinChildrenAlisonM.FriedmannPediatricsinReview2008;29;53

9. enoatmean?
A.Theenlargementofalymphnode>1cmincervicalregionor>1cm
intheaxillary.
B.Theenlargementofalymphnode>0.5cmincervicalregionor>1
cmintheaxillary.
C.Theenlargementofalymphnode>0.5cmincervicalregionor>0.5
cmintheepitrochlearlymphnodes
D.Theenlargementofalymphnode>0.5cmintheaxillarylymph
nodeor>0.5cmtheepitrochlearlymphnodes
E.Theenlargementofalymphnode>0.5cminaxillarylymphnode
or>0,5cminsupraclavicularlymphnode.

11. ere loco
en y?
ÆOS
äMentimeter

12. Locations
Common
Regional
Cervical
Submanclibular
Suboccipita
Supaclavicuar
Ax4ary
anglican
Meseneric
MedBullSisliEtfalHosp2020;54(2):222-226
3(2)
131(98)
ioa
4
r«bleI:C“liiracteristicsotthisstflcJ;
TotalNumberofI.ymphNodeFNAA
No.ofFNACwithadequateaspirate
material
AgeGroupRange(Meanage)
male:Femaleratio
SitesofFNAC-
3
2
4
3
7
AnteriorCervical
PosteriorCervical
Preauricular
Subinandibular
Supraclavicular
Axillar)
Inguinal
948(,(I.1,")
«(revr";

13. e mostocation o
enopat
A.Cervical
B.
C.
Submandibular
Supraclavicular
D.Axillary
E.Inguinal
Cheek,sdeofnose,lower
lip ‹tongue
CausesofPcsiphcralLymphadenopathyinChildrcn.In:UpToDate,BasowDS(Ed).UpToDatc,Waltham,MA2013.Copyright'
›ToDatci inforWatiOD,vi5it
PediinRev2013,34(5)216-227

14. Takin
•Patient'sage
•Durationofneckmasses
•Associatedsymptoms
•Recentiddress
•Drughistory
•terminationstairs
•RecentTravelhistory Retraauricular
(mastoid)nodes
Sueñordeep
cer€calnodes
^p
cervicalnodes
cervicalnodes
2ndbranchial
claftcyst
i
M
ica
Epioermoidcyst
node
Submandibular
node
Submen+a
Cystichygroma
SupraclavicuJar
node
Inferiordeep
cervicalnodes
Anterior
cervicalnodes
gdEOMATE
COMMOM CAUSES
Toxoplasmosis
RARECAUSES
Chapasdisease
(congental)
Congenital
leukemia
Congenital
tuberculosis
Reticuloendothe-
liosis
Metabolicstorage
disease
Histiocytin
clisorders
Listeriasepsis
CHILD
NJonspecificviraI
infecttons
EBV
CMV
NAV
ToxopIasmosis
MeasIes
Serumsickness
SLE.USA
Leukemia/lymphoma
Tuberculosis(mlliary)
Sarcoidmsis
DRESS
Fangalimections
Pla‹gue
Leptospirosis
Brutcellosis
LanperhanseelI
histtocytosis
M a c r o p h ageactivation
syncJrome
H emophagocytic
lymphohistiocytosis
Castlemand isease (very
rareinthisagegroup)
Chronicgranulamatou s
disease
Sinushisttocytosis
(Rosai-Dorfman
disease)
Kikuchi-Fujimoto
disease
Autoimmu n e
lymphoprpliferative
oisease(ALP)
RickettsiaIinfection
AOOEESCGNT
ViraInfect
EBV
CMV
HIV
Measles
ions
Toxoplasmosis
S y p hilis
Serumsickness
SLE,USA
Leukemia/
Tuberculosis
DRESS
F r o gaIinfections
Plague
Leptospirosis
Brucelasis
Drugreaction
(immune)
C astleman‹isease
Rickettsial

15. I ite
ANTERIORAURICULAR
Conjunctivitisorothereyein(ections
Oculoglandulartularernia,cat-scratchdisease,EBV,adenovirus
CERVICAL
Orophayngealinfectïon(viral,groupAstreptococcal,staphylococcal,
orfusobacterial)
Sca!p infecttDn(tinea)
Mycobacteriallymphadenitis(tuberculousandnontuberculous
mycobacteria)
Viralinfection(EBV,CMV,HHV-6,measles)
Cat-scratchdisease
Kawasakidisease
MultisysteminflammatDrysyndromeinchildren(MIS-C)associatea
withCOVID19
Thyroid disease
Kimuradisease
Rosai-Dorfman(sinushistïocytosis)
Peiodicfever, aphthousstomatitis,pharyngitis,cervicaladenopathy
(PFAPA)syndrOme
KikuChi-Fujimotodisease
UnicentricCastlemandisease
AXILLRY
Cat-scratchdisease
Arminfection
Malignancyo(chestwall
Leukemia/lymphoma
Bucelosis
G.
ii
POSTERIORAURICULAR
Otitismedia
Viralin(ection(especiallyrubella,parvovirus)
SUPRAVICULAR
MalignancyorinfRCtioninthemediastinum(right)
Metastaticmalignancyfromabdomen{left)
Lymphoma
Tuberculosis
EPITROCHLEAR
Handin(ectiOn,arminfection•
Lymphoma
INGUINAL
Urinarytractinfection
Sexuallytransmittedinfection(especiallysyphilisoriymphogranuloma
venereum)
Lowerextremitysuppurativein(ection
Plague
HILAR(NOTPALPABLE,FOUNDONCHESTRADIOGRAPHOR
SEETABLE5391
ercuosis
Histoplasmosis'
Blastomycosis
Coccidioidomycosis”
Leukemia/lymphom-a
Hodgkindisease
Metastaticmaignancy'
Sarcoidosis”
Castlemandisease

16. “-+::t-" mica roac
Nonyphoidmasses:
•cervicalrib
•throossacyst
•branhiacleftcystofinfectedsinus
•cystichygroma
•gOiter
•thyroiditb
•sternoastoidmuscletumorofinfancy
•neuroibroa
4.Isthenodeenlared?
•Lymphnodesnotpalpableinthenewborn.
Withantigenicexposure,lymphoidtissue
increasesinvolume
Considerednormal
<1cmforcervicalandaxilarynodes
•<1.5cv
•<0.5cv
foringuinanodes
forepirochear
Otherlymphcodesnotpalpableor
visualisedwithplainradiographs.
Lymphadenopathy-0presenceofoneormorelymphnode,diameter>1cm
wi†horwi†hou†anabnormalityini†scharacter
QT eta£ sootofPediatrics22'
d
ed.24
Growth PatternsofVarious
Systems
180
100
20
LYMPHOID
BRAINAND
HEAD
GENERAL
0
Birth
REPRODUCTIVE
8 12 1620
Age(years)
4

17. HasanSadikinHospita’Patients
CDurtesyofHedaMelindaNataprawira
EtiologiesofPediatricCervical
L/mphadenopathy:ASystematic

18. )age-dependent
:odeatctice'
eaenot
Measurementofcervicallymphnodesinchildren
oncomputedtomography
SuzanneSpijkers’@•AnnemiekeS.L•ittooij
1
’
2
•RutgerA.J. NieveIstein
1
'
2
,z@xAtom+graé?,.PediatrRadlol2o1
§.editoF
!+2gg
FlthEd,Lippincottpress;2023.

19. Normalheadandnecklymphnodesinthe
paediatricpopulation
J.AlvesRosa"•',J.S.Calle-Toro',M.Kidd”,S.Andronikou"’'•
F 4S
long
SQL-.
axisratiosmdlymphnodemorphology(S,short

20. RE6EARCHARTICLE
Referenceintervalsofmesentericlymphnode
sizeaccordinglymphocytecountsin
asymptomaticchildren
BaohuanCal,Nu\udngYl*,WelZhang’•
1Departmentalpediotrica,Tm@Hospital,Tong|lMe‹âcalColkqje,HuazhongUnfrefaityoiSdenceand
Technology,WuhanCity,HubdPnMnce,China,2DepaitnmntofMedkmtUitiaaound,TannHospital,
TongjiMe‹AcalCdlege,HuazhongUniversityofScienceandTechnology,WuhanCity,HubelPnwlnoe, China
6-7 0.88I0.71 0.69 0J7 0.53 0.t6
EvaluationofMesentericLymphNodes
inaPediatricPopulationwithMesenteric
LymphadenitisUsingSuperbMicrovascular
Imaging
Ling-ungFeng
Lei2hang
Su-LiMa
Yl-ChengZhu
Thefindingsoftkepresentstudy,regaidingthesizeofabnormal!'
mesentericlymphnodes,aresupportedbythoseofprevlously
publlshedsNdiezBothtkegreatestdlameter(1.28y0.28mm)
aridleastdiameter(0.S8f0.ISmm)ofmesentericlymphnodes
inchildrenwith ‹nesente›icfyiziphadenitiswasgreaterthan
thatofmesentericlymphnodesinthehealthygroup(greatest
diameter,I.04t0.20mm;te4stdiameter,0.47z0.08mm)(Ix›th,
p‹0.001).However,KarmazynetaL[11]examinedmesenteric
lymphnodesin6\childrenwlthabdominalpainandfound
enlargedmesentericlymphnodesIn54Softhestudypopula-
tionsTheirysuredthatmesenterlclymphnodeswith
d,
thepresentstudythatneitherthegreatestdiameternorthe
least diameteraloneofthemesentericlymphnodeswassuf-
O
t:e5.t°kdiagnosticindicator,aresupportedbyprevi-
e,

21. !..,:...,.....
5.WhataretheCharacteristicsoftheNode*
Acutelyinfectedcodestender,erytheaandwarmth oftheoverlyingskin
abscessformation
matted
fire,fixed,non-mobye
•Fctuance
•ubercuous
•Malignancy
symptoms
toadjacentofunderlyingtissues),non-tender,with/withoutsystemic
Throwsortumor-involvednodes
(Never,weight loss,nightsneaks)
2weeksTotalextension(voicechange,dysphagia,otagia)ofsystemicsigns
6.IstheLymphadenopathyLocalizedorGeneralized?
Generalizeddenophy(enlargementof2non-contiguousnoderegions)4Systemicdisease
Regionaldenopahinfectiontocodeandoridsdrainageareaatypicalanatoicareas,aprolongedcourse,a
drainingsinus,lackofpriorpyogenicinfection

22. Agin,4years8monthsold
jugulogastriccode,diameter2mm,painless,•1enlargedlymphnode4
10days
•Weightfaltering
•Fever2eeks(-),Cough of2weeks(-
•HistoryofcontactedTB(herunclewasonpulmonaryTBtreatment)
.
PhysicalExamination
Weight:12kg
Height:100cm
Wt/A:-2.75SD,
Ht/A:-1.52SD
Ht:-.74SD
Neck
Lymphcodejuguogastriccodewaspalpable:solitarymodule,2cmin
diameter,mobile,tenderness(-),painless

23. are ï
Infection
ligncy
Autoine
istiocytosis

24. Infection
äMentimeter

25. are i
Infection
ligncy
Autoine
istiocytosis

26. ¿
•
yt
•.
;,
-
-.
.
,
‹
.
y/jg;
•
atIinitiatestwou suest
A.CBC,ESR,electrolyte,bloodandurineculture,chestX-Ray
B.ChestX-Ray,RapidMolecularTest,CultureM.tb,FNAC
C.CBC,electrolyte,bloodsugar,CSF,tuberculintest,chestX-Ray,
ThoracolumbalX-Ray
D.CBC,electrolyte,bloodsugar,CSF,ANA,antids-DNA,
tuberculinskintest
im?

27. .
i
CBC,ESR
electrolyte
bloooanaurine
cr›IturechestX-
Ray
Chest X-Ray,
RapidMolecular
Test.CultureM.
tb.FNAC
CBCelectrolyte,
blooosugar
CSF,tuberculin
test,chestX-Ray,
Tlaoracolumbal
X-Ray
CBC,electrolyte
bIooclsugar
CSF.ANAanti
ds-DNA,
tuberculinskin
test

28. ¿
•
yt
•.
;,
-
-.
.
,
‹
.
y/jg;
•
atIinitiatestwou suest
A.CBC,ESR,electrolyte,bloodandurineculture,chestX-Ray
B.ChestX-Ray,RapidMolecularTest,CultureM.tb,FNAC
C.CBC,electrolyte,bloodsugar,CSF,tuberculintest,chestX-Ray,
ThoracolumbalX-Ray
D.CBC,electrolyte,bloodsugar,CSF,ANA,antids-DNA,
tuberculinskintest
im?

29. Normalcardiacsize(CTR149.0%)
Sinusesanddiaphragm:withinnormallimits.
Langs:
-Hindiwithinnormallimits
-Normalbronhovascarpattern.
Alobulatedopaqueappearanceinthesbcarinal.
Conclusion:
SbcarinaLymphadenopathyduetoTB
! "

30. ITBFO REPORT
No.RegLab
HasilPemeriksaanTCMMTBRif(Xpert)
Tenggal JenisContoh
29/05/2024 FNAB
HasifUji
Keterangan.
Neg=MTBNotdetectRifSen=IVITBdetect.RitResNotdetect
RifRes=MTBdetect.RifResdetectRifIndet=MTRdetect,RifResindeterminate
INVALID=lnvalidERROR=ErrorNORESULT-No reultTDL=TidakDilakukan
ContohUji
fd0.RegLab
ASewaktu 3dú0
H a s l lPe m e r i k s a a nT C MM T BR i f( X p e r t )
Tangga\ JanisContoh
29/05/2024 Iahak
HasiTUji
Neg=MTBNntdetectRifSen—MTBdetect.RefRe'sNotclotect
RifRes=MTBdetect,RifResdetectRifIndet=MTBdetect.RifResindeterminate
INVALID=InaaieaERROR=Errc›rNORESULT=Ncires‹ItTDL=TiclakDitakukan
C a t a t a n
rc
No.MR:0002287024
Ket.Klinis:SUSPTB
TglNelesai:2024-05-5109:37:05
MIKROBIOLOGI
BTA2
.Spesimen
.PreparatBTA1
.TanggalPemeriksaan
Hasil
..Jamur
.PreparatBTA2
..TanggalPemeriksaan
Hasil
BilasLambung
28t05/2024
BTAtidakditemukan
i-iypnat+yvosim
nn/nwnnsa
BTAtidakditemukan
No.MR:0002287024
Ket.Klinis:ííUSPTB
TgI.Selesai:2024-09-1910:15:19
MIKROBIOLOGI
BiakanM.tbc
.Spesimen
.Hasíl
Pemeriksaan )Flag Hasil
,
i
I
BilasanLambung
Mycobacteriumtuberculosis(-)/NEGATIF

31. Dat¡aLa@hapsCell
.
..¿¿gt¿g
nterretation *""””"'*"
Microscopic:
TheaspiratebiopsyspecimenfromtheleftcheekconsistsofinflammatorycellsincludingPMN
(polymorphonuclearleukocytes),lymphocytes,andhistiocytes.Necrotictissueisobserved,along
withaproliferationofepithelioidcellsandthepresenceofLanghansgiantcells.Nomalignant

33. se
LimfadenitisTB
LymphodenitisTB
ien
ilI
Limfodenitistuberkulosis
TB
LymphodenopothyTB
LimfodenitisTB
Limfodenopoti
tuberculosis
LimfodenitisTB
.¥Mentimeter

34. se
lymphodenitisTB
Tblimfodenopoti
ien
ilI
Linfodenopotitb
Tuberculosis
TB
LimfodenitisTB
.¥Mentimeter
Lymphofenopothytb
LimfodenitisTB

35. se
Limfadenitistb
Tbonok
ien
ilI
Tuberculosis
LimfodenitisTB
LymphodenitisTB
Limfodenopotitb
Limfodenitistb
LymfodenitisTB
.¥Mentimeter

36. Tb
se
ien
ilI
Limfodenitistb Tbonok
AMentimeter

38. AFTER4monthstreatmentofAntiTuberculosisDrug
•Enlargedlymphnodediminishedwithminimalscar
•Gainingbodyweightupto3,8kg
Weight:15,8kg Wt/A:-0.94SD
Height:105cm Ht/0.855D
Wt/Ht:-0.66SD

39. 0RIGfNALARTICLE W1LEY
" Significanceofnon-granulomatous cytomorphologyonfine
needleaspirateinlymphadenitiscases classifiedastuberculous
byusingacompositereferencestandard
OleMagnusBjcrgaasHPMD’*^IWfaKanthaliMD’|NaishAkhtarMD*|
ManjuRajPurohitMD,PhD”*{TehmlnaMustafaMD,PhD’*
Bacl‹gzozmd:!Finer\eedIeaspàationcytok›gy{FNAC)is.establ'§f!edVsafìrstIipe
invesbgationfor.tubercuk›us’lymphadenitis.{TBWealmed:todescribetfievarious
i”feat‹xes.o’ftubercuIósis.(TB)ónENACànd theirconóibution’inthe
”diagnostic”desion:-md‹inginsuspectedTBLÀcases..
Methods:.PatientswithpresumphyeTBLAwere enrolkd(n—266)
.zx›zl›subjectedtoroutine:d›gr›osticw-u#f‹xTg,inct‹xlingFLACsan›pIès,andfol-
lowedui›tiItheend’oftreatu›enLPatientswe‹ccategodzedasTBórnon-TBes
basedon’acompositer¿ferencestandard.of’whichthevarious.c pat-
.... . . .....
.Conclu .Wefoundthataboutöne-thirdofTBLApatients’presentedwithout
granutomasonFMA,highlightingtheimp‹xtance.ofconsideringTBina.widespectrum
ofcytomorphologyin’ahigh.TBburdensettiOur.stüdysupgx:artsthe.useofFItAC
”a"first-Iê›eirïvestigationtoolfördiégnosingTBLA„in”s”low-réëöurceketting.duetö.
ksrelativesimplicityandgood..sensitivity.However,thelow’speüificity.öfFMAC,
. . .. ’..
emphaszzostheneedforasecond-tierconfirmatorytestwithimprcnzedspeczF«ztty.
‹.
léBI?112023.https://doI.org/10.1002/de.25167

40. UtilityandLimitationsofFine-NeedleAspirationCytologyin
theDiagnosisofLymphadenopathy
FNACofLym,phnodes

41. •A12years10monthsoldgirlwosodmittedtohospitolwithalumpinthe
therightneck,noticedsince2monthsbeforeadmittedtothehospital.
•Therewosohistoryoffrequentfeversince2monthsago,notcontinuous,
reducewithontipyreticdrugs
•Therewasahistoryofweightlosssince2monthsago.
•Physicalexamination:Therewaslymphadenopathyontherightcervical
withthesizewas7x4cm,hardconsistency,flatsurfaces,regularedges,
firmboundaries,didnotfollowbreathingmovements,mobile,painless.
Therewerenotpulsationandfluctuation.Thecolorandtemperaturewas
thesameasthesurroundings.

42. Patintsicture
AMentimeter

45. •Acutelym
•bautelym
•Chilym
at wee
weeks
pat weeks
BSUHClinicalPracticeGuideline—Lymphadenopathyand
Lyphadenitis

46. .....
•A12years10monthsoldgirlwasodmittedtohospitalwithalumpinthe
therightneck,noticedsince2monthsbeforeadmittedtothehospital.
•Therewasahistoryoffrequentfeversince2monthsago,notcontinuous,
reducewithontipyreticdrugs.
•Therewasohistoryofweightlosssince2monthsago.
•Physicalexamination.Therewaslymphadenopathyontherightcervical
withthesizewas6x4cm,hardconsistency,flatsurfaces,regularedges,
firmboundaries,didnotfollowbreathingmovements,mobile,painless.
Therewerenotpulsationandfluctuation.Thecolorandtemperaturewas
thesameasthesurroundings.

49. IC
23
stOryOf
jointpoino
swelling
I esisee
äMentimeter

50. 1storytai
iiii
»Agsomeinfectionshavuapredil+ctionforspecific
agugroups
»Characteristicsofthelymphadenopathy:
—Site?
—Duration?
—Timecourseofgrowth?
Overtyingskinchanges,forexample,discolouration,
induration'
Painfulorfluctuant?
Othernodesinvolved.generalisedorlocal7
>Recentinfections:
HistoryofrecentURTI7
Gumortoothinfection;mouthulcers7
Respiratorysymptoms:cough,shortnessofbreath,
orthopnoea7
Skininfections:cellulitisorimpetigo?
Sexuallytransmitteddisease(ifsexuallyactive)7
>Constitutionalsymptoms:
Fatigue7
Weightloss:howmuchoverwhattimeperiod7
Nightsweats?
Fever:constantorperiodic7
Bleedingoreasybruising?
Jointpainorswelling;whichjointsaffected?
Rash?
Historyofforeigntravel:countriesvisited?
Exposuretocots.otherpetsorwildanimals?
Exposuretotuberculosisviafamilycontactsorfrom
endemicarea?
Recentimmunisations?
Meclications?
ysicaTexaii
athy
•Generalobservation
—Isthechildwellorill?
Plotheightand weight
•Examinationoflymphadenopathy
Size
Location
Fixation
Consistency
Tenderness
Overlyingskinchanges,forexample,discolouration,
induration
Examinationofotherlymphnodes,forexample,
axillae/inguinalregions
»Headandneck
Scalpinfection,forexample,impetigo
Conjunctivitis,specifyifpurulentornon-purulent
Ear,noseandthroat—signsofinfection,mouth
ulcers.dentaldisease
•Skin
Rashes
—Localisedinfectionforexample,cellulitis/impetigo
Petechiae/eccyhmoses/purpura
Generalexamination
Cardiovascular
RespiratO@
Abdominalparticularlyforhepatosplenomegaly
King D,etal.ArchDisChildEducPractEd2014;

52. •A12yeors10monthsoldgirlwasodmittedtohospitalwithalumpinthe
therightneck,noticedsince2monthsbeforeadmittedtothehospital.
•Therewasahistoryoffrequentfeversince2monthsago,notcontinuous,
reducewithontipyreticdrugs.
•Therewasahistoryofweightlosssince2monthsago.
•Nohistoryof|ointpainorswelling
•Physicalexamination.Therewaslymphadenopathyontherightcervical
withthesizewas6x4cm,hardconsistency,flatsurfaces,regularedges,
firmboundaries,didnotfollowbreathingmovements,mobile,painless.
Therewerenotpulsationandfluctuation.Thecolorandtemperaturewas
thesameasthesurroundings.

53. ’"\,$-<"’”:-:‹“’:”‹ ,
•8..¥.,...,...I-,“*.,”;.”„”....,**.*{....
ie owingerentia
outenignwitmaignancy?
iagnosis
A.Malignant<2cm.Benign>2cm
B.Malignantsoftconsistency.Benignhard
C.Malignantduration<2weeks.Benign2-6weeks
D.Malignantmobile.Benignfixed
E.Malignantnontenderness.Benignusuallytender

54. IC Ilowi
enwimol
erenI
cy?
4 4
äMentimeter

55. Feature Malignant Benign
Size >2cm <2cm(<1cm)
ConsistencyHard,firmorrubbery Soft
Duration >2weeks <2weeks
Mobility Fixed Mobile
SurroundingsAttached(invasion) Notattached
Location Supraclavicular,epitrochlear,or
generalized
Inguinal,
submandibular
TendernessUsuallynon-tender Usuallytender
“ “•\”•
- ,”t”t‘ *
Table3:Clinicalfeaturestodifferentiatebenignfrommalignant
lymphadenopathy
......f...,..„.,...,
AnnalsofNigerianMedicine/Can-but012/Vol 6Iissue1

56. //łix::‹:‹
,”,x:,:.,t,:*,
,
śtż@Ó-
ic owingerentiaiagnosis
outenignwitmaignancy?
A.Malignant<2cm.Benign>2cm
B.Malignantsoftconsistency.Benignhard
C.Malignantduration<2weeks.Benign2-6weeks
D.Malignantmobile.Benignfixed
E.Malignantnontenderness.Benignusuallytender

57. •A12yeors10monthsoldgirlwasodmittedtohospitalwithalumpinthe
therightneck,noticedsince2monthsbeforeadmittedtothehospital.
•Therewasahistoryoffrequentfeversince2monthsago,notcontinuous,
reducewithontipyreticdrugs.
•Therewasahistoryofweightlosssince2monthsago.
•NohistoryoftOintpain orswelling
•Physicalexamination.Therewaslymphadenopathyontherightcervical
withthesizewas6x4cm,hardconsistency,flatsurfaces,regularedges,
firmboundaries,didnotfollowbreathingmovements,mobile,painless.
Therewerenotpulsationandfluctuation.Thecolorandtemperaturewas
thesameasthesurroundings.

58. i etiIgy
Tube
belosi
ycobacteri
ycobacte“
Kawaiisease
BacteriIinfecti
ligncy
losi

60. Casesofcervical
bautetochic
enpathy
set2-6weeks
Occurrin
Etiolojies
lnfetti0l1S(m0recoItIITI0n)Fre
•/J0n-tub9fcül0USlTlC0bacterium
uentlocurrin
*MCobacteriumtubercul0sÏs
80rt0fl«ÍÍ0t«fll«Í0«(Cüt-SCrütChdiS«S«)
FungalOrpr0tozoaninfecti0n(eg.t0X0§IüS10SÏS,
lmmun0l0$Ïc(IeSs¢0lTiN0hj
fytemiclUpuser\tnematsus
JuveniTeidi0§ütïicarthritis
Dermat0›Tl0Sitis
.XMentimeter
Assoriated‹Iinir»lfe»tures
,usuallymultiple,firmlymphn0des;tninandviolaceousoverlyingsLin.
Ma;deveTpflurtuancerrutanevssinvstrartt
Asb0V9
UOllatera0rbilateral,firrfh0h-tenderlymphh0d9f;fraydefixeJt0Jnder!\nj
tissuesandar0jrestt0b9C0ITl9lrlal8d,10\¥-gadefeverwiths;stemi‹s;mat0fTls
Catscratch0rbte
GeneraliseJF0n-ter/Jerl\mphó/J9h0§üt\y,fever,rash,arthalgia,arthritis,

61. Casescervical enpathy
Chinset>6weeks)
Imh0
Eti0l0çies
Ma1I§nanciei(m0rec0mm0n)
HoägÏhs&n0n-H0äg\in
Atuteleuîemia
Rt:bd0fM\0S8fC0M8
Neur0blüt0lTlü
IU0l0çic(tesstommon)
Commonvariableimmvnäefi‹ienc;
0| U0OUÂÏSg6Sg
r-i0I0äulinsand0
MIreII»ne0us(le5COlTIITIOh)
îarc0iä0|s
gt0füg9bÏS9âS9
A0ItdcIinic»Ifeatures
.XMentimeter
Firm,inJcrateJ,fi›eJ,matteJ,usually0-tenJerl;mpLOJ;
supratlavitular;s;stemitt;mpt0m;petechiae;pall0r;
hpt0tplenamejal/

62. RedFlags:
•LNsize>2cm
•SupraavicuarLN-generallyassociatedwithmalignancyinchildren.
•CFRchangessuggestiveofediasinaLymphadenopathyofinfra-abdominal LNs
Fixedtomuscularlayerswithnoinflammatorysides
•Associatedhepatoegawithnosignsofviralinfection.
Severepallor,jaundice,unexplainedbruising/beeding
•ProlongedNeverdaysand/orweightloss
•quickprogression
•Persistence>4-6weeks
•Presentationinthecontextofsepsis
•Bsymptoms fromhistoryclever,rightsweats,weightmossy

63. i etiIgy
Tube
belosi
ycobacteri
ycobacte“
Kawa iisease
BacteriIinfecti
licy
losi

64. •A12yeors10monthsoldgirlwosodmittedtohospitalwithalumpinthetheright
neck,noticedsince2monthsbeforeadmittedtothehospital.
•Therewasahistoryoffrequentfeversince2monthsago.
•Therewasahistoryofweightlosssince2monthsago.
•Therewosohistoryoffeverfor2weeks,notcontinuous,reducewithontipyretic
drugs.
•Nohistoryofjointpainorswelling
•Physicalexamination:Therewaslymphadenopathyontherightcervicalwith
thesizewas6x4cm,hardconsistency,flatsurfaces,regularedges,firm
boundaries,didnotfollowbreathingmovements,mobile,painless.Therewere
notpulsationandfluctuation.Thecolorandtemperaturewasthesameasthe
surroundings.

67. '*’’****
•afforaTéF-yexamination
?éf!é'”@
Thechoiceisdirectedbyclinicalsuspicion:
•Completeperipheralbloodcount+peripheralbloodsmear
•Erythrocytesedimentationrate&C-reactiveprotein
•Uricacid
•Lactatedehydrogenase(LDH)
PaediatricLymphadenopathy(andwhentosuspectmalignancy)Guideli nNQ,r y e s

69. ra
HEMATOLOG
RatikulcisltOtomatix+rematologlRutln
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AMentimeter

70. ra
XIMLADARAH
DS
FungsiGinjał
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108
ł7
Ú40
i6
140
LU1:3)P(•Œ])
35-50
mg.’’rtI
U’L
-5 UL
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IMUNOSEROLOGI
......................................... ......................
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10J
3.6
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13.DO-4?0.00
mmol'I
mmal'I
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AMentimeter

71. basedworkingiagnosis)
iograhyPA/LateI:edisti•Chest Iss/wii
geodes:ltrasou•infecti
• li
•CTsca
pectedbscess,cyst,
cypected:
witcont
•ET-sca

72. . t
. '”
1
.
/
-
J
.
T
.’.
S
.—’.
...„.....,...,..-..!..—
.
...........
•.’
Lymphadenopathycollidextra
EXAMINATIONRESULTS:
PAthoraxphotograph:
•Bronchovascularpatternwithinnormallimits
Novisibleinfiltratespotsandconsolidationofboth
lungs.
•Cor:normalwithCTR0.4,normalaorta
•Bothsinusanddiaphragmaregood
•Bonesareintact
irregulared9enon-calcificationinthecolliregion
Therewassofttissuedensitywithindistinctboundaries
biIaYeraIIy.
IMPRESSION:
Softtissuemassbilaterallyinthecolliregion
Normalcorandpulmo

74. •Heterogeneousmass(29-56HU)withfirmboundaries,irregularedges,lobulated,non-calcified,size+-4.44x3.74x7.42cmattheright
sidedcolliregio
•MultipleKGBenlargementoTcolliregiolevelII,IIIbilaterallyappeared
•The nasopharynx,parapharyngealspaceand larynxareaappearnormal.FossaofRossenmullerisgood
•Bothrecessuspiriformisappearnormal
•Scannedparanasalsinusesandmastoidairceilswithinnormallimits.
•Deviationoftheseptumofricetotheright
•Nodeviationoftheseptumnasiisseen
•Boththyroidlobeswithinnormallimits
•Scannedcerebralparenchymawithinnormallimits
•Bonesareintact
IMPRESSION:
•RightsidedHobliegiomasssspeceellymphadenopatyddlymphoma.
•Deviationoftheseptmofricetotheright
•a t h y r e g i o collilevelII,IIIbilaterally

77. 5814
5710
5601
5570
5561
5099
4980
4787
4720
4471
'g*catur
Ldr
Bell
Dora
\j/Maura
CarlGustav
’”’’"•Ribbit
Ambriel
Kathy
Wolfmeister
AMentimeter

78. Histopatogy-iopsy
Fineneedle
aspiration/FNA
Excisionbiopsy

79. Table4
'l”lzeresult.sof“fineneeclle.zspir.ztioncytologyinvariouspullished/›aecIiatricstudies.
Sonny N Sites Uns.ztisf.zctr›iyRenign Molign‹znt
.¥Mentimeter
FalsePcs FalseNeg .ten.sitivity(ñ) Specificity()
Conclusions:largeandsupracavicuarnodesshouldbebiopsied.UltrasoundislikelyNobeusefulbut furtherstudyis
required.FNACcannotberelieduponNoexcludemalignancyinchildren.ThediagnosticutilityofchestX-rapandFBCare
unclear.Workisrequiredofmultivariatepredictivemodels.
R.Lockeetat./InternationalJournalofPediatrictorhiolayngooy78(2014)393—401

80. •Minimallyinvasive
•Lowmorbidity
•Notasreliableinchildren
asinadultssoyoucanonly
trustFNAifitispositive
•Sensitivity49
0
aand
Specificity97%
•Falsenegativerate45
0
a•
83%ofthemwere
lymphomas
ExcisionalBiopsy
•Thegoldstandardfordiagnosis
•Biopsyofconcerningnodesthat
havenotdecreasedafter4-6
weeksorhavenotnormalizedin
-12weeks
•ConsiderifFNAisinconclusive
orifFNAisnegativebutyour
suspicionformalignancyishigh
•Excisethelargestandfirmest
nodethatpalpableandmust
removethenodewiththe
capsuleintact

81. •Thesmearconsistsofa
distributionofmatureandyoung
lymphocyteinflammatorycellson
abackgroundoferythrocytes
•Impression:
Chronicinflammatorylesions

82. ReferralAlgorith:Lymphadenopathy"PediatricPatient
Redflags
present
Yes
•RedFlagSymptoms:
•Fever>1week
(withoutsignsof
lympnadenitis)
•Nightsweats
•Unintentionalweignt
loss(›1O
O
H)
•Boneea‹n
•Easybruising/bleeding
•Shortnessofbrcai3or
orthopnca
•Splcnomcgalyor
ncpatomcgaty
•Jointpain/swellingor
rash
Firm,fixed,mattedlympnnodes
and/orsupraclavicularordiffuse
lymphadenopathyand/orlymph
nodes>2cmorrapidlygrowing+
UrgentreferraltoOncology,
considerconsulttooncall
oncologyatSeanleChildren's
(206-987-2000)to
discuss/expeditework-up.
Recommendedinitialwork-up:
Ultrasound.3viewCFR,labs
(CBCwithdifferentiaL
comprehensivemetabolicpanel.
phosphorus,uricacid, LDH,
ESR.CRP.EBVandCMVIgG &
IgM,considerHIVAAb)
No
Signsof
lymphadenitis
(rednesswarmth,
tender?
Treatwithantibiotics
(ensurestaphandsteep
coverage).Monitorfor
improvementover24-7Z
hOMrs.
!fnoimprovementand
highsuspicionfor
infection,considerconsum
toInfectiousDisease
NO
IRecentillnessor
infection?
ves
Likelyreactive
Continuetomonitor,anticipate resolution.
Avoidsteroids.Reassessin4-6weeks.
Ifnotresolving,considerotheretiologies
andinitialwork-up:Ultrasoundandlabs
(CBC+diff.basicmctabolicpanel,
phosphorus,uricacid, LDH,ESR.CRP,
EBVandCMVIgG&lgM,HIV Ag/Ab).
Localizedcervicalorisolated
axillaryoringuinallymphnode
Sizeoflymph
node?
Unexplained
lymphadenopathy?
Durationof
lymphadenopathy?
‹2cmor
unchangedin
sizesince
onset?
Lessthan4
w00kSOf
gfcatcfthan
1year*
2
Non-urgentreferraltoOncology
›dMentimeter

84. -+,.,
’ă‹
,
.^
.
•=
,
=
.
ąjp'”
.
.
.
ą
.
...........
istoat icaresu
•ClinicalDiagnosis:Lymphadenopaty
•Description:ClinicNotincluded
MacroscopiReceived1tissuewithasizeof1.5x0.8x0.5cm,blackish
browncolor,chewysolidconsistency,white-browncolorslicecrosssection.
Made1cassetteofallprints.
Microscopic:Tissuepreparationshavebeencompletelyprinted,showing
tumormassesarrangedsolidly,diffuselydistributed,withround,atypical,
relativelymonotonousnuclei,withnuclei>2timesthesizeofmature
lymphocytes.Mitoticactivitywas2-3/LPB.Erythrocyteextravasation
amongthetumorcellswasalsoseen.
Conclusion:NONHODGKIN'SMALIGNANTLYMPHOMA,
LARGECELLTYPE

85. Pagoda Avalokitesvara,Semarang
KlentengSamPooKong,Semarang
"£nsurinq£quat1c‹nsofChild‹arentheERAofSooety5.0-
29s•ptem•01
Narzts1Swiss-&a/inn5aripeto}eNotolSoloIPadmaHotelSaznarang
Lawangsewu,Semarang
KlentengSamPooKong,Semarang
KotaLama,Semarang