Difference between revisions of "Lymph node pathology"

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This article deals with non-haematologic malignant and non-malignant '''lymph node pathology'''.  An introduction to the lymph node is in the ''[[lymph nodes]]'' article.
This article deals with non-haematologic malignant, i.e. metastases, and non-malignant '''lymph node pathology'''.  An introduction to the lymph node is in the ''[[lymph nodes]]'' article.


Haematologic malignancies (in lymph nodes) are dealt with in other articles - see ''[[haematopathology]]''.
Haematologic malignancies (in lymph nodes) are dealt with in other articles - see ''[[haematopathology]]'' and ''[[lymphoma]]''.
 
==Overview==
Clinical:
*Lymphadenopathy.
 
Differential diagnosis:<ref>URL: [http://path.upmc.edu/cases/case289.html http://path.upmc.edu/cases/case289.html]. Accessed on: 14 January 2012.</ref>
*Infectious - fungal, mycobacterial, viral, protozoal (Toxoplasma), bacterial (Chlamydia, Rickettsia, Bartonella)).
*Neoplastic - lymphoma, carcinoma.
*Endocrine - [[hyperthyroidism]].
*Trauma.
*Autoimmune - [[SLE]], [[RA]], [[dermatomyositis]].
*Inflammatory - drugs (phenytoin).
*Idiopathic - [[sarcoidosis]].


==Overview in a table==
==Overview in a table==
{| class="wikitable"
{| class="wikitable sortable"
! Entity
! Entity
! Key feature
! Key feature
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| large spaced cortical follicles
| large spaced cortical follicles
| tingible body macrophages, normal dark/light GC pattern
| tingible body macrophages, normal dark/light GC pattern
| BCL-2 -ve
| BCL2 -ve
| infection (Toxoplasmosis, HIV/AIDS), [[Hodgkin's lymphoma]]
| infection ([[Toxoplasmosis]], [[HIV]]/AIDS), [[Hodgkin's lymphoma]]
| image ?  
| image ?  
|-
|-
| Toxoplasmosis
| [[Lymph node metastasis]]
| foreign cell population, usu. in subcapsular sinuses 
| +/-nuclear atypia, +/-malignant architecture
| dependent on tumour type (see ''[[IHC]]'')
| dependent on morphology, [[endometriosis]] (mimics adenocarcinoma), ectopic decidua (mimics [[SCC]])
| [[Image:Crc_met_to_node1.jpg|thumb|center|125px| CRC metastasis]] [[Image:Breast_carcinoma_in_a_lymph_node.jpg|thumb|center|125px | Breast metastasis]]
|-
| [[Progressive transformation of germinal centers]]
| large (atypical) germinal centers
| poorly demarcated germinal center (GC)/mantle zone interfaces, expanded mantle zone
| IHC to r/o ''nodular lymphocyte predominant [[Hodgkin lymphoma]]'' (NLPHL)
| NLPHL, follicular hyperplasia
| [[Image:Progressive transformation_of_germinal_centres_-1-_very_low_mag.jpg|thumb|center|150px | PTGC - very low mag.]]
|-
| [[Toxoplasmosis]]
| large follicles; epithelioid cells perifollicular & intrafollicular
| large follicles; epithelioid cells perifollicular & intrafollicular
| reactive GCs, monocytoid cell clusters, epithelioid cells
| reactive GCs, monocytoid cell clusters, epithelioid cells
| IHC ?
| IHC for toxoplasma
| NSRFH, HIV/AIDS, Hodgkin's lymphoma
| NSRFH, HIV/AIDS, [[Hodgkin's lymphoma]]
| image ?
| [[Image:Toxoplasmosis_lymphadenopathy_-_low_mag.jpg|thumb|center|150px | TL - low mag.]]
|-
|-
| Kikuchi disease (histiocystic necrotizing lymphadenitis)
| [[Kikuchi disease]] (histiocystic necrotizing lymphadenitis)
| No PMNs
| No PMNs
| histiocytes, necrosis
| histiocytes, [[necrosis]]
| IHC neg. for malignancy
| IHC for large cell lymphoma (CD30 + others)
| SLE (has (blue) hematoxylin bodies in necrotic areas)
| [[SLE]] (has (blue) hematoxylin bodies in necrotic areas), large cell lymphomas
| [http://commons.wikimedia.org/w/index.php?title=File:Histiocytic_necrotizing_lymphadenitis_-_very_high_mag.jpg]
| [[Image:Histiocytic_necrotizing_lymphadenitis_-_very_high_mag.jpg |thumb|center|150px| HNL - very high mag.]]
|-
|-
| Cat-scratch disease  
| [[Cat-scratch disease]]
| PMNs in necrotic area
| PMNs in necrotic area
| "stellate" (or serpentine) shaped microabscesses, granulomas  
| "stellate" (or serpentine) shaped microabscesses, granulomas  
| B. henselae, Dieterle stain
| B. henselae, [[Dieterle stain]]
| HIV/AIDS, NSRFH
| [[HIV]]/AIDS, NSRFH
| image ?
| [[Image:Cat_scratch_disease_-_very_low_mag.jpg|thumb|center|150px|Cat scratch - very low mag.]]
|-
|-
| Dermatopathic lymphadenopathy  
| [[Dermatopathic lymphadenopathy]]
| 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)
| DDx ?
| [[cutaneous T-cell lymphoma]]
| image ?
| [[Image:Dermatopathic_lymphadenopathy_-_intermed_mag.jpg |thumb|center|150px| DL - intermed. mag.]]
|-
|-
| Kimura disease
| [[Kimura disease]]
| eosinophils
| eosinophils
| angiolymphoid proliferation
| angiolymphoid proliferation (thick-walled blood vessels with [[hobnail]] endothelial cells)
| IHC ?
| IHC ?
| eosinophilic granuloma
| [[Langerhans cell histiocytosis]], drug reaction, [[angiolymphoid hyperplasia with eosinophilia]]
| [[Image:Kimura_disease_-_very_high_mag.jpg|thumb|center|150px|Kimura disease - very high mag.]]
|-
| [[Langerhans cell histiocytosis]]
| abundant histiocytes with reniform nuclei
| often prominent eosinophilia
| [[S-100]]+, CD1a+
| [[Kimura disease]] (eosinophilia), [[Rosai-Dorfman disease]]
| [[Image:Langerhans_cell_histiocytosis_-_very_high_mag.jpg|thumb|center|150px|LCH - very high mag.]]
|-
| [[Rosai-Dorfman disease]]
| sinus histiocytosis
| emperipolesis (intact cell within a macrophage)
| [[S-100]]+, CD1a-
| Langerhans cell histiocytosis
| [[Image:Emperipolesis_-_very_high_mag.jpg |thumb|center|150px | RDD - very high mag.]]
|-
| [[Systemic lupus erythematosus]] lymphadenopathy
| (blue) hematoxylin bodies
| necrosis, no PMNs
| IHC for large cell lymphoma (CD30 + others)
| [[Kikuchi disease]], large cell [[lymphoma]]s
| [[Image:Systemic_lupus_erythematosus_lymphadenopathy_-_high_mag.jpg|thumb|center|150px | SLEL - high mag.]]
|-
| [[Castleman disease]], hyaline vascular variant
| thick mantle cell layer with laminar appearance ("onion skin" layering)
| hyaline (pink crap), lollipops (large vessels into GC), no mitoses in GC
| IHC - to r/o [[mantle cell lymphoma]]
| mantle cell lymphoma, [[HIV]]/AIDS
| [[Image:Castleman_disease_-_intermed_mag.jpg|thumb|center|150px | CD - intermed. mag.]]
|-
| Castleman disease, plasma cell variant
| thick mantle cell layer
| sinus perserved, interfollicular plasma cells, mitoses in GC
| [[HHV-8]]
| HIV/AIDS
| image ?
| image ?
|-
|-
| entity  
| [[Intranodal palisaded myofibroblastoma]]
| spindle cells with nuclear palisading
| [[RBC extravasation]], fibrillary bodies with a central vessel "amianthoid fibers"
| SMA+, cyclin D1+
| [[schwannoma]]
| [[Image:Intranodal_palisaded_myofibroblastoma_-_very_high_mag.jpg|thumb|center|150px|IPM - very high mag.]]
|-
<!-- | entity  
| key feature
| key feature
| other features
| other features
| IHC
| IHC
| DDx
| DDx
| image  
| image -->
|}
|}


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|-
|-
| Germinal center density
| Germinal center density
| well spaced
| well spaced, sinuses open
| crowded
| crowded, sinuses effaced/<br>compressed to nothingness
|-
|-
| Tingible body <br>macrophages
| Tingible body <br>macrophages
Line 89: Line 158:
| abnormal
| abnormal
|}
|}
==Lymph node metastasis==
{{Main|Lymph node metastasis}}
==Kaposi sarcoma==
{{Main|Kaposi sarcoma}}
*One of the few non-lymphoid primary lymph node tumours.<ref name=pmid1918406>{{Cite journal  | last1 = Bigotti | first1 = G. | last2 = Coli | first2 = A. | last3 = Mottolese | first3 = M. | last4 = Di Filippo | first4 = F. | title = Selective location of palisaded myofibroblastoma with amianthoid fibres. | journal = J Clin Pathol | volume = 44 | issue = 9 | pages = 761-4 | month = Sep | year = 1991 | doi =  | PMID = 1918406 | PMC = 496726 }}</ref>
==Melanocytic nevi==
{{Main|Melanocytic lesions}}
:See: ''[[Dermatopathic lymphadenopathy]]''.
*Benign melanocytic nevi can be found in lymph nodes.<ref name=pmid1918406>{{Cite journal  | last1 = Bigotti | first1 = G. | last2 = Coli | first2 = A. | last3 = Mottolese | first3 = M. | last4 = Di Filippo | first4 = F. | title = Selective location of palisaded myofibroblastoma with amianthoid fibres. | journal = J Clin Pathol | volume = 44 | issue = 9 | pages = 761-4 | month = Sep | year = 1991 | doi =  | PMID = 1918406 | PMC = 496726 }}</ref>


==Progressive transformation of germinal centers==
==Progressive transformation of germinal centers==
===General===
{{Main|Progressive transformation of germinal centers}}
*Abbreviated as ''PTGC''.
*Abbreviated as ''PTGC''.
*Benign.
*Classically in younger patients.
*Associated with [[Hodgkin's lymphoma]] - non-classic type (nodular lymphocyte predominant Hodgkin's lymphoma).
===Microscopic===
Features:
*'''Focally''' large germinal centers with:
**Expanded mantle zone.
**Poorly demarcated germinal centre (due to infiltration by mantle zone lymphocytes) -- '''key feature'''.


==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.
 
IHC:
*BCL-2 -ve.
 
Image: [http://pleiad.umdnj.edu/hemepath/normal_node/normal_node.html Normal lymph node (umdnj.edu)].


==Diffuse paracortical hyperplasia==
==Diffuse paracortical hyperplasia==
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==Sinus histiocytosis==
==Sinus histiocytosis==
===General===
:Should '''not''' be confused with ''[[sinus histiocytosis with massive lymphadenopathy]]'', also known as Rosai-Dorfman disease.
*Benign.
{{Main|Sinus histiocytosis}}
 
===Microscopic===
Features:<ref name=Ref_ILNP179>{{Ref_ILNP|179}}</ref>
*Sinuses distended with histiocytes - '''key feature'''.
*Plasma cells increased.


==Kikuchi disease==
==Kikuchi disease==
===General===
*[[AKA]] ''histiocytic necrotising lymphadenitis'' (HNL).<ref name="pmid15570824">{{cite journal |author=Kaushik V, Malik TH, Bishop PW, Jones PH |title=Histiocytic necrotising lymphadenitis (Kikuchi's disease): a rare cause of cervical lymphadenopathy |journal=Surgeon |volume=2 |issue=3 |pages=179–82 |year=2004 |month=June |pmid=15570824 |doi= |url=}}</ref>
*AKA ''histiocytic necrotising lymphadenitis'' (HNL),<ref name="pmid15570824">{{cite journal |author=Kaushik V, Malik TH, Bishop PW, Jones PH |title=Histiocytic necrotising lymphadenitis (Kikuchi's disease): a rare cause of cervical lymphadenopathy |journal=Surgeon |volume=2 |issue=3 |pages=179–82 |year=2004 |month=June |pmid=15570824 |doi= |url=}}</ref> and ''Kikuchi-Fujimoto disease''.
*[[AKA]] ''Kikuchi-Fujimoto disease''.
*Rare disease that may mimic cancer, esp. lymphoma.
{{Main|Kikuchi disease}}
**May cause fever & systemic symptoms.<ref name=pmid20121621>{{cite journal |author=Hutchinson CB, Wang E |title=Kikuchi-Fujimoto disease |journal=Arch. Pathol. Lab. Med. |volume=134 |issue=2 |pages=289–93 |year=2010 |month=February |pmid=20121621 |doi= |url=}}</ref>
 
Epidemiology:<ref name=pmid20121621/>
*Usually <40 years old.
*Asian.
*Female:Male = 3:1.<ref>URL: [http://emedicine.medscape.com/article/210752-overview http://emedicine.medscape.com/article/210752-overview]. Accessed on: 3 June 2010.</ref>
 
Treatment:
*Usually self-limited.<ref name=pmid20121621/>
*Oral corticosteroids.
 
DDx:
*Non-Hodgkin lymphoma.
*Systemic lupus erythematosus.
**Hematoxyphil bodies in necrotic foci.
***Dark blue irregular bodies on H&E.
 
===Micrograph===
Features (the three main features - just as the name suggests):<ref>URL: [http://www.ispub.com/journal/the_internet_journal_of_head_and_neck_surgery/volume_1_number_1_30/article_printable/kikuchi_s_lymphadenitis_in_a_young_male.html http://www.ispub.com/journal/the_internet_journal_of_head_and_neck_surgery/volume_1_number_1_30/article_printable/kikuchi_s_lymphadenitis_in_a_young_male.html]. Accessed on: 1 June 2010.</ref>
*Histiocytes.
**May be crescentic.
*Necrosis (due to apoptosis) - paracortical areas.<ref name=pmid20121621/>
**Necrosis without neutrophils - '''key feature'''.
*Lymphocytes (CD8 +ve).
*Plasmacytoid dendritic cells.
 
 
Notes:
*Dendritic cell - vaguely resembles a macrophage:<ref>URL: [http://www.healthsystem.virginia.edu/internet/hematology/hessedd/benignhematologicdisorders/normal-hematopoietic-cells/dendritic-cell.cfm?drid=214 http://www.healthsystem.virginia.edu/internet/hematology/hessedd/benignhematologicdisorders/normal-hematopoietic-cells/dendritic-cell.cfm?drid=214]. Accessed on: 3 June 2010.</ref>
**Long membrane projections - '''key feature'''.
**Abundant blue-grey cytoplasm, +/- ground-glass appearance.
**Nucleus: small, ovoid, usu. single nucleolous.
 
Images:
*[http://www.surgicalpathologyatlas.com/glfusion/mediagallery/media.php?s=20080802171644281 Kikuchi disease (surgicalpathologyatlas.com)].
*[http://www.healthsystem.virginia.edu/internet/hematology/hessedd/benignhematologicdisorders/normal-hematopoietic-cells/dendritic-cell.cfm?drid=214 Dendritic cell (virginia.edu)].


===IHC===
==Systemic lupus erythematosus lymphadenopathy==
*CD68 +ve.
{{Main|Systemic lupus erythematosus lymphadenopathy}}
*CD8 +ve.
*CD4, CD20, CD3, and CD30 - mixed.
**Done to excluded lymphoma; should show a mixed population of lymphocytes.


==Castleman disease==
==Castleman disease==
===General===
*[[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>
*Benign.
*Abbreviated '''CD'''.
*Abbreviated '''CD'''.
 
{{Main|Castleman disease}}
===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.
#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'').
 
Discussed here: <ref name=pmid19546611>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.
 
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.


==Cat-scratch disease==
==Cat-scratch disease==
===General===
*[[AKA]] ''cat scratch fever''.
*[[AKA]] ''Cat-scratch fever''.
{{Main|Cat scratch disease}}
*Infection caused ''Bartonella henselae'',<ref name=pmid19332922>{{Cite journal  | last1 = Jerris | first1 = RC. | last2 = Regnery | first2 = RL. | title = Will the real agent of cat-scratch disease please stand up? | journal = Annu Rev Microbiol | volume = 50 | issue =  | pages = 707-25 | month =  | year = 1996 | doi = 10.1146/annurev.micro.50.1.707 | PMID = 8905096 }}</ref> a gram-negative bacilla (0.3-1.0 x 0.6-3.0 micrometers) in chains, clumps, or singular.<ref name=Ref_ILNP110>{{Ref ILNP|110}}</ref>
*Treatment: antibiotics.
 
===Clinical===
Features:<ref name=Ref_ILNP113>{{Ref ILNP|113}}</ref>
*Usually unilateral.
**May be disseminated in individuals with immune dysfunction.
*Contact with cats.
 
===Micrograph===
Features:<ref name=Ref_ILNP113>{{Ref ILNP|113}}</ref>
*Necrotizing granulomas with:
**Neutrophils present in microabscess (necrotic debris) - '''key feature'''.
***Microabscesses often described as "stellate" (star-shaped).
*+/-Multinucleated giant cells.
 
Notes:
*May involve capsule or perinodal tissue.
 
Stains:
*Warthin-Starry stain +ve.
*B. henselae IHC stain +ve.
 
Image(s):
*[http://www.webpathology.com/image.asp?case=386&n=1 Cat-scratch disease (webpathology.com)].
*[http://www.webpathology.com/image.asp?n=2&Case=386 Cat-scratch disease - high mag. (webpathology.com)]


==Toxoplasma lymphadenitis==
==Toxoplasma lymphadenitis==
{{Main|Toxoplasma}}
===General===
===General===
*Caused by protozoan ''Toxoplasma gondii''.
*Caused by protozoan ''Toxoplasma gondii''.
Line 274: Line 229:
***Well-defined cell border - '''important'''.
***Well-defined cell border - '''important'''.
***Singular nucleus.  
***Singular nucleus.  
**Cell clusters usually have interspersed neutrophils.
Images:
*[http://commons.wikimedia.org/wiki/File:Toxoplasmosis_lymphadenopathy_-_low_mag.jpg Toxoplasmosis - low mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Toxoplasmosis_lymphadenopathy_-_high_mag.jpg Toxoplasmosis - high mag. (WC)].


Notes:  
Notes:  
*Monocytoid cells CD68 -ve.
*Monocytoid cells CD68 -ve.
===IHC===
*IHC for toxoplasmosis.


==Dermatopathic lymphadenopathy==
==Dermatopathic lymphadenopathy==
===General===
{{Main|Dermatopathic lymphadenopathy}}
*Lymphadenopathy associated with a skin lesion - '''key feature'''.
*May be benign or malignant (e.g. T-cell lymphoma).


===Microscopic===
==Kimura lymphadenopathy==
Features:<ref name=ILNP226>{{Ref ILNP|226}}</ref>
{{Main|Kimura disease}}
*Abundant histiocytes & special histiocytes - in loose irregular clusters '''key feature''':
**Do ''not'' form granuloma; may be similar to ''toxoplasma''.
*Plasma cells (medulla).
*Eosinophils.


Histiocytes & special histiocytes:
==Rosai-Dorfman disease==
*Histiocytes:
*Abbreviated ''RDD''.
**+/-Melanin pigment '''key feature''' (if present).
*[[AKA]] ''sinus histiocytosis with massive lymphadenopathy'', abbreviated ''SHML''.
**Lipid-laden macrophages.
{{Main|Rosai-Dorfman disease}}
*Interdigitating dendritic cells:
**Need IHC to identify definitively.
*Langerhans cells:
**Classically have a kidney bean nuclei.
**Need IHC to identify definitively.


IHC:
==Langerhans cell histiocytosis==
*Interdigitating dendritic cells: S100 +ve, CD1a -ve.
{{Main|Langerhans cell histiocytosis}}
*Langerhans cells: S100 +ve, CD1a +ve.


==Kimura lymphadenopathy==
==Lymph node hyalinization==
*[[AKA]] ''hyalinized lymph node''.
===General===
===General===
*[[AKA]] ''eosinophilic lymphogranuloma'', ''Kimura disease''.
*Benign.
*Chronic inflammatory disorder - suspected to be infectious.
*Associated with aging.<ref name=pmid12973685>{{Cite journal  | last1 = Taniguchi | first1 = I. | last2 = Murakami | first2 = G. | last3 = Sato | first3 = A. | last4 = Fujiwara | first4 = D. | last5 = Ichikawa | first5 = H. | last6 = Yajima | first6 = T. | last7 = Kohama | first7 = G. | title = Lymph node hyalinization in elderly Japanese. | journal = Histol Histopathol | volume = 18 | issue = 4 | pages = 1169-80 | month = Oct | year = 2003 | doi =  | PMID = 12973685 }}</ref>
 
Clinical:
*Usually neck, periauricular.
*Peripheral blood eosinophilia.
*Increased blood IgE.
 
===Epidemiology===
*Males > females.
*Young.
*Asian.


===Microscopic===
===Microscopic===
Features:<ref name=Ref_ILNP190>{{Ref ILNP|190}}</ref>
Features:
*Angiolymphoid proliferation.
*Hyaline material (acellular pink stuff on H&E) within a [[lymph node]].
*Eosinophils - abundant - '''key feature'''.


Notes:
Subdivided into:<ref name=pmid12973685/>
*Abundant eosinophils: consider Langerhans histiocytosis.
*Mediastinal-type.
**Usually in medullary sinus.
**Onion peel-like appearance.
*Pelvic-type hyalinization.
**Discrete round, eosinophilic, glassy appearance at low power, whirled/fibrous at high power.
**+/-Calcification.  


==Rosai-Dorfman disease==
DDx:
===General===
*[[Amyloidosis]] - cotton candy-like appearance, usu. no calcifications.
*[[AKA]] ''sinus histiocytosis with massive lymphadenopathy'', abbreviated ''SHML''.<ref name=pmid17183839>{{cite journal |author=Agarwal A, Pathak S, Gujral S |title=Sinus histiocytosis with massive lymphadenopathy--a review of seven cases |journal=Indian J Pathol Microbiol |volume=49 |issue=4 |pages=509–15 |year=2006 |month=October |pmid=17183839 |doi= |url=}}</ref>
*Super rare.
*Prognosis - good.


===Microscopic===
====Images====
Features:
<gallery>
*Sinus histiocytosis:
Image: Hyalinized lymph node -- intermed mag.jpg | Hyalinized LN - intermed. mag.
**Histiocytes - abundant.
Image: Hyalinized lymph node - alt -- intermed mag.jpg | Hyalinized LN - intermed. mag.
***Small round nuclei.
Image: Hyalinized lymph node -- high mag.jpg | Hyalinized LN - high mag.
***Abundant cytoplasm.
Image: Hyalinized lymph node -- very high mag.jpg | Hyalinized LN - very high mag.
*Emperipolesis.
</gallery>
**Histiocytes "eat" other cells: neutrophils, lymphocytes, plasma cells.
www:
*[http://www.flickriver.com/photos/euthman/sets/72157594513987154/ Lymph node with amyloidosis - several images (flickriver.com)].


IHC:
===Sign out===
*CD68 +ve.
*Not reported.
*S100 +ve.
**Useful for seeing emperipolesis.
*CD1a -ve.
**CD1a positive in Langerhans cell histiocytosis.
 
Images:
*[http://commons.wikimedia.org/wiki/File:Emperipolesis_-_very_high_mag.jpg Emperipolesis in SHML (WC)].
*[http://commons.wikimedia.org/wiki/File:Rosai-Dorfman_disease_-_very_high_mag.jpg Rosai-Dorfman disease (WC)].


==See also==
==See also==
Line 360: Line 296:


[[Category:Haematopathology]]
[[Category:Haematopathology]]
[[Category:Lymph node pathology|Lymph node pathology]]

Latest revision as of 15:16, 16 February 2021

This article deals with non-haematologic malignant, i.e. metastases, and non-malignant lymph node pathology. An introduction to the lymph node is in the lymph nodes article.

Haematologic malignancies (in lymph nodes) are dealt with in other articles - see haematopathology and lymphoma.

Overview

Clinical:

  • Lymphadenopathy.

Differential diagnosis:[1]

  • Infectious - fungal, mycobacterial, viral, protozoal (Toxoplasma), bacterial (Chlamydia, Rickettsia, Bartonella)).
  • Neoplastic - lymphoma, carcinoma.
  • Endocrine - hyperthyroidism.
  • Trauma.
  • Autoimmune - SLE, RA, dermatomyositis.
  • Inflammatory - drugs (phenytoin).
  • Idiopathic - sarcoidosis.

Overview in a table

Entity Key feature Other findings IHC DDx Image
Non-specific reactive follicular hyperplasia (NSRFH) large spaced cortical follicles tingible body macrophages, normal dark/light GC pattern BCL2 -ve infection (Toxoplasmosis, HIV/AIDS), Hodgkin's lymphoma image ?
Lymph node metastasis foreign cell population, usu. in subcapsular sinuses +/-nuclear atypia, +/-malignant architecture dependent on tumour type (see IHC) dependent on morphology, endometriosis (mimics adenocarcinoma), ectopic decidua (mimics SCC)
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CRC metastasis
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Breast metastasis
Progressive transformation of germinal centers large (atypical) germinal centers poorly demarcated germinal center (GC)/mantle zone interfaces, expanded mantle zone IHC to r/o nodular lymphocyte predominant Hodgkin lymphoma (NLPHL) NLPHL, follicular hyperplasia
File:Progressive transformation of germinal centres -1- very low mag.jpg
PTGC - very low mag.
Toxoplasmosis large follicles; epithelioid cells perifollicular & intrafollicular reactive GCs, monocytoid cell clusters, epithelioid cells IHC for toxoplasma NSRFH, HIV/AIDS, Hodgkin's lymphoma
File:Toxoplasmosis lymphadenopathy - low mag.jpg
TL - low mag.
Kikuchi disease (histiocystic necrotizing lymphadenitis) No PMNs histiocytes, necrosis IHC for large cell lymphoma (CD30 + others) SLE (has (blue) hematoxylin bodies in necrotic areas), large cell lymphomas
HNL - very high mag.
Cat-scratch disease PMNs in necrotic area "stellate" (or serpentine) shaped microabscesses, granulomas B. henselae, Dieterle stain HIV/AIDS, NSRFH
File:Cat scratch disease - very low mag.jpg
Cat scratch - very low mag.
Dermatopathic lymphadenopathy melanin-laden histiocytes histiocytosis S-100+ve (interdigitating dendritic cells), CD1a+ve (Langerhans cells) cutaneous T-cell lymphoma
File:Dermatopathic lymphadenopathy - intermed mag.jpg
DL - intermed. mag.
Kimura disease eosinophils angiolymphoid proliferation (thick-walled blood vessels with hobnail endothelial cells) IHC ? Langerhans cell histiocytosis, drug reaction, angiolymphoid hyperplasia with eosinophilia
Kimura disease - very high mag.
Langerhans cell histiocytosis abundant histiocytes with reniform nuclei often prominent eosinophilia S-100+, CD1a+ Kimura disease (eosinophilia), Rosai-Dorfman disease
File:Langerhans cell histiocytosis - very high mag.jpg
LCH - very high mag.
Rosai-Dorfman disease sinus histiocytosis emperipolesis (intact cell within a macrophage) S-100+, CD1a- Langerhans cell histiocytosis
File:Emperipolesis - very high mag.jpg
RDD - very high mag.
Systemic lupus erythematosus lymphadenopathy (blue) hematoxylin bodies necrosis, no PMNs IHC for large cell lymphoma (CD30 + others) Kikuchi disease, large cell lymphomas
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SLEL - high mag.
Castleman disease, hyaline vascular variant thick mantle cell layer with laminar appearance ("onion skin" layering) hyaline (pink crap), lollipops (large vessels into GC), no mitoses in GC IHC - to r/o mantle cell lymphoma mantle cell lymphoma, HIV/AIDS
File:Castleman disease - intermed mag.jpg
CD - intermed. mag.
Castleman disease, plasma cell variant thick mantle cell layer sinus perserved, interfollicular plasma cells, mitoses in GC HHV-8 HIV/AIDS image ?
Intranodal palisaded myofibroblastoma spindle cells with nuclear palisading RBC extravasation, fibrillary bodies with a central vessel "amianthoid fibers" SMA+, cyclin D1+ schwannoma
File:Intranodal palisaded myofibroblastoma - very high mag.jpg
IPM - very high mag.

Follicular lymphoma vs. reactive follicular hyperplasia

Factors to consider:[2]

Reactive follicular
hyperplasia 		Follicular lymphoma
Follicle location cortex cortex and medulla
Germinal center edge sharp/well-demarcated poorly demarcated
Germinal center density well spaced, sinuses open crowded, sinuses effaced/
compressed to nothingness
Tingible body
macrophages 		common uncommon
Germinal center
light/dark pattern 		normal abnormal

Lymph node metastasis

Main article: Lymph node metastasis

Kaposi sarcoma

Main article: Kaposi sarcoma
  • One of the few non-lymphoid primary lymph node tumours.[3]

Melanocytic nevi

Main article: Melanocytic lesions
See: Dermatopathic lymphadenopathy.
  • Benign melanocytic nevi can be found in lymph nodes.[3]

Progressive transformation of germinal centers

Main article: Progressive transformation of germinal centers
  • Abbreviated as PTGC.

Reactive follicular hyperplasia

Main article: Reactive follicular hyperplasia

Diffuse paracortical hyperplasia

General

  • Benign.

Microscopic

Features:[4]

  • Interfollicular areas enlarged - key feature.
    • T cell population increased.
    • Plasma cells.
    • Macrophages.
    • Large Reed-Sternberg-like cells.

Sinus histiocytosis

Should not be confused with sinus histiocytosis with massive lymphadenopathy, also known as Rosai-Dorfman disease.
Main article: Sinus histiocytosis

Kikuchi disease

  • AKA histiocytic necrotising lymphadenitis (HNL).[5]
  • AKA Kikuchi-Fujimoto disease.
Main article: Kikuchi disease

Systemic lupus erythematosus lymphadenopathy

Main article: Systemic lupus erythematosus lymphadenopathy

Castleman disease

  • AKA angiofollicular lymph node hyperplasia, giant lymph node hyperplasia.[6]
  • Abbreviated CD.
Main article: Castleman disease

Cat-scratch disease

  • AKA cat scratch fever.
Main article: Cat scratch disease

Toxoplasma lymphadenitis

Main article: Toxoplasma

General

  • Caused by protozoan Toxoplasma gondii.

Microscopic

Features:[7]

  • Reactive germinal centers (pale areas - larger than usual).
    • Often poorly demarcated - due to loose epithelioid cell clusters at germinal center edge - key feature.
  • Epithelioid cells - perifollicular & intrafollicular.
    • Loose aggregates of histiocytes (do not form round granulomas):
      • Abundant pale cytoplasm.
      • Nucleoli.
  • Monocytoid cells (monocyte-like cells) - in cortex & paracortex.
    • Large cells in islands/sheets key feature with:
      • Abundant pale cytoplasm - important.
      • Well-defined cell border - important.
      • Singular nucleus.
    • Cell clusters usually have interspersed neutrophils.

Images:

Notes:

  • Monocytoid cells CD68 -ve.

IHC

  • IHC for toxoplasmosis.

Dermatopathic lymphadenopathy

Main article: Dermatopathic lymphadenopathy

Kimura lymphadenopathy

Main article: Kimura disease

Rosai-Dorfman disease

  • Abbreviated RDD.
  • AKA sinus histiocytosis with massive lymphadenopathy, abbreviated SHML.
Main article: Rosai-Dorfman disease

Langerhans cell histiocytosis

Main article: Langerhans cell histiocytosis

Lymph node hyalinization

  • AKA hyalinized lymph node.

General

  • Benign.
  • Associated with aging.[8]

Microscopic

Features:

  • Hyaline material (acellular pink stuff on H&E) within a lymph node.

Subdivided into:[8]

  • Mediastinal-type.
    • Usually in medullary sinus.
    • Onion peel-like appearance.
  • Pelvic-type hyalinization.
    • Discrete round, eosinophilic, glassy appearance at low power, whirled/fibrous at high power.
    • +/-Calcification.

DDx:

  • Amyloidosis - cotton candy-like appearance, usu. no calcifications.

Images

  • Hyalinized LN - intermed. mag.

  • Hyalinized lymph node - alt -- intermed mag.jpg

    Hyalinized LN - intermed. mag.

  • Hyalinized lymph node -- high mag.jpg

    Hyalinized LN - high mag.

  • Hyalinized LN - very high mag.

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  • Not reported.

See also

References

  1. ↑ URL: http://path.upmc.edu/cases/case289.html. Accessed on: 14 January 2012.
  2. ↑ DB. 4 August 2010.
  3. ↑ 3.0 3.1 Bigotti, G.; Coli, A.; Mottolese, M.; Di Filippo, F. (Sep 1991). "Selective location of palisaded myofibroblastoma with amianthoid fibres.". J Clin Pathol 44 (9): 761-4. PMC 496726. PMID 1918406. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC496726/.
  4. ↑ Ioachim, Harry L; Medeiros, L. Jeffrey (2008). Ioachim's Lymph Node Pathology (4th ed.). Lippincott Williams & Wilkins. pp. 179. ISBN 978-0781775960.
  5. ↑ Kaushik V, Malik TH, Bishop PW, Jones PH (June 2004). "Histiocytic necrotising lymphadenitis (Kikuchi's disease): a rare cause of cervical lymphadenopathy". Surgeon 2 (3): 179–82. PMID 15570824.
  6. ↑ URL: http://www.mayoclinic.com/health/castleman-disease/DS01000. Accessed on: 17 June 2010.
  7. ↑ Ioachim, Harry L; Medeiros, L. Jeffrey (2008). Ioachim's Lymph Node Pathology (4th ed.). Lippincott Williams & Wilkins. pp. 113. ISBN 978-0781775960.
  8. ↑ 8.0 8.1 Taniguchi, I.; Murakami, G.; Sato, A.; Fujiwara, D.; Ichikawa, H.; Yajima, T.; Kohama, G. (Oct 2003). "Lymph node hyalinization in elderly Japanese.". Histol Histopathol 18 (4): 1169-80. PMID 12973685.
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