04 Head Neck Lymph Node (2)

8/11/2019 04 Head Neck Lymph Node (2)

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PATHOLOGY OF LYMPH NODE. 1. Lymph node structure

Lymphoid tissue: -lymphoid system contain several focal concentrations of immune cells -lymph nodes, spleen, tonsils, GIT lymphoid tissue, etc

-major accumulations of immune competent cells occur at portals ofantigen entry - the tonsils (mouth and nose , the respiratory and GIT mucosa(for inhaled and ingested antigens , the lymph nodes (for lymph drainage of s!inand organs , the spleen (as the "lood filter

-central lymphoid tissue - thymus and "one marro#-these are central fordevelopment of the immune system-"ut do not participate in the immune

response in the adult-peripheral lymphoid tissue - remaining lymphoid organs- actively involvedin immune response

lymph node structure - capsule, sinuses, germ cell follicles, mantle $one,paracorte%, T and & cell regions

'. anifestations of diseases of the lymphoid system 1. Immune deficiency

-depletion of lymphocytes in the tissues or "lood (lymphopenia and

a"normalities relating to su"types of ly-ct -may "e associated #ith defectiveimmunity-lymphocyte depletion- occurs as a conse)uence of radiotherapy,

administration of cytoto%ic drugs, corticosteroids- general immunodeficiency-reversi"le

-selective atrophy of lymphoid tissues- in congenital deficiency syndromes

'. *erverted immune function -immune hypersensitivity and autoimmunity- manifestations of immune

responsemajor pathologic features are in the target organs of the a"normal immuneresponse, not in the lymphoid tissue+. Lymphadenopathy - enlarged lymph nodeslocali$ed to one lymph node ar group, or generali$ed

auses of lymphadenopathy: -reactive hyperplasia-due to immune response- nonspecific, usually a local

response to introduction of antigen, most commonly "acterial, only occasionally-generali$ed, as a response to viremia

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-reactive hyperplasia associated #ith specific infections- infectiousmononucleosis, granulomatous pattern in tu"erculosis and histoplasmosis andgranulomatous-purulent in cat scratch disease, lymphogranuloma venereum, etc,

-lymphadenopathy of uncertain cause- sarcoidosis, associated #ith

autoimmune diseases, such as rheumatoid arthritis, lupus erythematodes, etc,sinus histiocytosis #ith massive lymphadenopathy- orfman- osai disease,

astlemann disease, etc-primary neoplastic proliferations- lymphomas and /odg!in disease-secondary neoplasms- metastases- most commonly carcinomas and

melanomas0pper ervical L s - a of nasopharyn%, retrotonsilar region

idcervical L s - a of thyroid, upper aerodigestive tract, particularly pharyn%and laryn%.

supraclavicular L s - a of "reast, in left side -stomach, pancreas, prostatetestis, 2ircho#s Ln3%illary L s - ca of "reast, lungs, melanomaInguinal L s - e%ternal genital organs, melanomas of lo#er e%tremities, "ut onlyrarely ca from internal organs (ovary, cervi%, anal canal and even less the testis4.Lymphocytosis increase of the num"er of circulating lymphocytes in peripheral "lood- either asa function of the immune response or as a result of neoplastic proliferations(lymphocytic leu!emia, lymphoma5. onoclonal gammopathy neoplasms of & cell derivation- may sho# evidence of plasmacytoiddifferentiation-secret monoclonal IgG-that may "e detected in serum as 6component7 (malignant8. 9plenomegaly enlargment of the spleen (normal range of 1' -18 g , often result of the samefactors that cause lymphadenopathy-acute and chronic infections, inf.mononucleosis, leu!emia, lymphomas, etc

LYMPHADENOPATHY.lymphadenopathy -enlargement of the lymph node- the most importantmanifestation of lymph node disorders

eactive lymphoid hyperplasia reactive lymphoid hyperplasia #ithin lymphoid tissue represents a

manifestation of immune response and consists of three components- thiscondition may assume one of three major patters

-1. follicular hyperplasia - "ecause of an activation of & cell region-thispattern is often associated #ith chronic infections #ith &-cell amntigens

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-'. paracortical hyperplasia - represents a T cell response-this pattern ischaracteri$ed "y reactive changes #ithin the T-cell $one of the lymph nodes

-+. sinus histiocytosis -accounts for macrophage response-this reactivepattern is characteri$ed "y distention and prominence of lymphatic sinuses

-in most cases, immune response represents a com"ination of all three patterns,any one may predominate 1.-follicular hyperplasia:histological features: -large germinal centres- #ithin #hich "last transformationis prominent feature-prominent phagocytic activity in germinal centres- many apoptotic "odies

-often associated #ith chronic infections-caused "y organisms thatrepresent &-cell antigensdifferential diagnosis:

follicular hyperplasia of the lymph node may "e confused #ith follicular(nodular malignant lymphoma- "cl' oncoprotein

-preservation of lymph node architecture and variation in si$e and shapeof germinal centres- favors a diagnosis of hyperplasia in contrast to lymphoma

Lymphadenopathies associated #ith prominent follicular hyperplasia: -rheumatoid arthritis- systemic lupus erythematodes and other autoimmune diseases- o!oplas"osis:

relatively common ilness caused "y a proto$oon To%oplasma gondii ,- commonlyinfects cats, may "e transmitted to humans, danger of transplacental infectiona ac)uired to%oplasmosis - occurs in adults- acute fe"rile ilness #ith generali$edlymphadenopathy, or enlarged cervical lymph nodeshistological features:-e%tensive follicular hyperplasia, e%panded paracortical regions, numeroushistiocytes in clusters #ithin the paracorte% and reactive centers of follicles-may "e confused #ith lymphoma- "iopsy is necessary" congenital to%oplasmosis -more serious condition- infection is transmittedfrom mother to fetus-characteri$ed "y necrosis in the "rain, retinal involvement, may cause still"irth,hydrocephalus, microcephaly, congenital "lindness, other neurologic defectsdiagnosis- serologic techni)ues

-A#D$ - persis e% &e%erali'e( ly"pha(e%opa hy patients infected #ith /I2, #ith anti"odies against /I2- may present #ithpersistent enlargment of lymph nodes-7 persistent generali$edlymphadenopathy 7- component of 3I 9-related comple%histological features:

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-the lymph node sho#s folicular and parafollicular hyperplasia- very largefollicles in early stage, irregular loss or fragmentation of mantle $one (;the rimcomposed of small lymphocytes surrounding follicles , in later stage-progressive loss of all lymphocytes from the lymph node

H#)-associa e( *al(ayer ri%& ly"phoi( hyperplasia- /I2 infectedpatients have a high incidence of head and nec! manifestations, including

-opportunistic infections, neoplasms (


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+-$uppura i/e &ra%ulo"a ous ly"pha(e%i is -histologic appearances are much the same as for granulomatous

lymphadenopathy, "ut #ith addition of acute suppurative inflammation-neutrophils in the centres of granulomas

several different organisms may produce this form of lymphadenopathy-such as- a scra ch (isease -lymph nodes draining the site of the s!in scratch

G neg "acterium ( afipia felis , most patients are prepu"ertal patients,regression in t#o months

,-#%fec ious "o%o%ucleosis is caused "y >pstein-&arr virus

-characteri$ed "y fever, sore throat, peripheral "lood lymphocytosis,generali$ed lymphadenopathy and hepatosplenomegalymore common in children, more severe in young adults, is transmitted via the

upper respiratory tract- commonly through !issing (6!issing disease7morphology: lymph nodes sho# Tcell hyperplasia- follicles may "e totallyo"scured, T cells sho# activation- large num"ers of T immuno"lasts- possi"lemisdiagnosis of high grade lymphomain peripheral "lood- large transformed lymphocytes- o#ney cells- diagnosticfeature0- a2asa3i (isease - fe"rile disorder of un!no#n ethiology. ?ever and cervicallymphadenopathy, affecting children, pharyngeal and conjunctival inflammation,erythematous s!in rashes, arthritis. The L s sho# fi"rin throm"i and patchyinfarcts4 - i3uchi ly"pha(e%i is (necroti$ing histiocytic lymphadenitisuncommon "enign self-limited lesion of lymph nodes, characteri$ed "y presenceof large necroses, #ithout granuloma formation and #ithout suppurativeinflammation

LYMPHADENOPATH#E$ OF 5N NO*N PATHOGENE$#$.16 as le"a%%7s (isease (angiofollicular hyperplasia of lymph node-uncommon condition characteri$ed "y "enign non-progressive lymphadenopathyor "y slo#ly gro#ing massthere are t#o different variants of 1@ hyaline-vascular form -more common, occurs in all ages, slo#ly gro#ing mass -most commonly in themediastinum and the retroperitoneum, lymph nodes and soft tissues may "eaffected as #ell -"enign clinical outcomepathogenesis- un!no#n, recent studies suggest a role of a"normal developmentof germinal centres in the folicles "ecause of a"normal immune stimuli

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histology: lymph nodes sho# a"normal follicles #ithout germinal centres (folliclesvary in si$e and shape and hypervascular interfollicular areas, lymph nodesinuses are lac!ing, fi"rosis is common'@ plasma cell variant-systemic form, characteri$ed "y multiple foci of

infiltration and multiorgan involvement- severe prognosishistology:lymph node sho#s large follicles #ith numerous plasma cells in theinterfollicular regions- polyclonal- some cases may progress to lymphoma*A> 9 syndrome - polyneuropathy, organomegaly (spleen, lymp nodes, liver ,endocrinopathy (dia"etes mellitus, amenorrhea, gynecomastia , protein ands!in manifestation (hypertrichosis, hemangiomas,etc -may "e associated #ithmultiple myeloma+6 A%&ioi""u%o8las ic ly"pha(e%opa hy -relatively uncommon condition affecting older patients- #eight loss, fever, s!in

rashes, hepato-splenomegaly, generali$ed lymphadenopathycause is un!no#n, 5 B of patients die #ithin + years either of infection or"ecause of development of malignant lymphomahistology: lymph node sho#s progressive depletion of lymphoid cells #itho"literation of normal structure, loss of follicles and enlargement ofparacortical regions composed of numerous immuno"lasts, T lymphocytes,histiocytes, plasma cell and proliferation of "lood vessels,6 #""u%o8las ic ly"pha(e%opa hy represent a"normal immune response to various stimulihistology: lymph node structure may "e completely o"literated, proliferation ofimmature activated immuno"lasts, mar!ed T cell response #ith e%pansion ofparacortical regionsmay closely resem"le lymhomassome possi"le causes: -postvaccinal lymphadenopathy, lymphadenopathy inmeasles and other viral infections, drug hypersensitivity, etc.06 $i%us his iocy osis 2i h "assi/e ly"pha(e%opa hy- osai-Dorf"a%(isease -the cause is un!no#n, children are commonly affected- massive cervicallymphadenopathy, fever, mild anemia may "e presentmorphology:affected lymph node contains a"undant histiocytes that may fill the sinuses -histiocytes contain phagocytosed lymphocytes #ithin their cytoplasm-6emperipolesis 7-the phenomenon of ingestion living cells46 i"uras (isease it presents as a mass in the su"cutaneous tissue of the head and nec! region orin major salivary glands, often associated #ith locali$ed lymphadenopathy

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histology: lymph nodes sho# mar!ed hyperplasia of germinal centres, G s areoften vasculari$ed, infiltration "y mature eosinophils, hyalini$ed vessels inparacortical region

LYMPHOMA$.-lymphomas are primary neoplasms of lymphoid tissue derived from lymphocytes,their precursor and derivates- most lymphomas arise from the lymph nodes, the usual presentation is as alocali$ed or generali$ed lymphadenopathy- nodal lymphomas -less commonly (in a"out one third of cases lymphomas may "e primary ine%tranoda l lymphoid tissue , such as the tonsils, GI tract mucosa, spleen, etc-e%tranodal lymphomas

malignant lymphomas are classified in t#o major groups-non-/odg!in lymphomas - characteri$ed "y diffuse or nodularproliferation of neoplastic lymphoid cells

-/odg!in disease -malignant lymphoma, characteri$ed "y presenceof neoplastic diagnostic /odg!in and eed-9tern"erg cells #ithin a"undantreactive non-neoplastic infiltrate composed of lymphocytes, leu!ocytes, plasmacells, histiocytes,etc.

NON-HODG #N LYMPHOMA$

"a9or fea ures:-lymphomas are of monoclonal origin - can "e documented "y clonal generearrangements or monoclonal IgG production- monoclonality -vast majority ofneoplastic proliferations arise from one clone of lymphocytes- monoclonal, on theother hand reactive lymphoid proliferation as a part of immune response sho#spolyclonal proliferationmonoclonal nature can "e esta"lished "y:-the presence of monoclonal light and@or heavy chain of IgG-presence of a clonal chromosomal a"erration- for e%ample the C,14

translocation in &ur!itt lymphoma-clonal T receptor rearrangement (T- /Ls

-all forms of lymphoma have the potential to disseminate to the otherlymph nodes, "lood, "one marro#, spleen, etc. - neoplastic lymhocytes maycirculate in the "lood in /Ls and may "e #idely distri"uted throughout the#hole "ody

-if "one marro# involvement and neoplastic lymphoid cells circulating inperipheral "lood predominate, or if these constitute the first recogni$ed

manifestation of the disease- the process is called leu!emia

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-if the proliferation affects primarily lymph nodes or e%tranodal lymphoidtissue and presents as a mass in lymph node- the process is called lymphoma

Important features of /L-

-age dependency - /L is a group of tumors that encompasses a #idespectrum of disorders, differing in patients age at onset- incidence of su"typesof malignant lymphomas varies greatly #ith age, for e%ample lympho"lastic L-occurs in children and young adults and is rare in old patients, in contrastlymphocytic L occurs almost only in old age

- /Ls can derive of T or &-cells - T and & cell lymphomas- /Ls derivedfrom & cell are more common

- /Ls may sho# nodular(follicular or diffuse gro#th pattern,immunostaining #ith anti"odies to "cl-' oncogene helps in distinguishing

follicular hyperplasia (germinal centre are negative from nodular /L- positive LA$$#F# AT#ON OF NON-HODG #N LYMPHOMA$.-lymphomas sho# e%treme degree of variation in clinical "ehavior and responseto therapy-the aim of classification is to identify homogenous su"groups that "ehave in apredicta"le #aylo#-grade lymphomas -5-year survival rate ranges from 5 -D B clinicallyindolent, longer survival times, "ut rarely cured "y therapy

intermadiate grade - 5-year survival rate ranges from +5-45Bhigh-grade lymphomas- 5-year survival rate ranges from ' -+'B , aggressive"ehavior, "ut are responsive to therapy, "y current very effective treatmentprotocols potentially cura"le-each prognostic group contains several types of lymphoma

*HO classifica io% (pu"lished ' 1 - classification of tumors ofhematopoietic and lymhatic tissues is a result of several years ofdiscussions and consensus meetings, it is going to "e accepted

ELL LYMPHOMA$ -more common than T-cell /L, most of them are derived of the lymphoidcells of the lymph node follicles - follicular centre cell lymphomas &-cell neoplasms are divided into three major categories

a; Precursor -cell %eoplas"s 8; Ma ure -cell %eoplas"s c; -cell prolifera io%s of u%cer ai% "ali&%a% po e% ial

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A( a; P E 5 $O - ELL NEOPLA$M$ LYMPHO LA$T# LYMPHOMA


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- L comprises appro%imately +-1 B of lymphomas-it occurs mostly in middle age, slight male predominancesites of involvement- lymph nodes, spleen, "one marro#histologically: vagualy nodular diffuse infiltration, most cases- typical

cytogenetic a"normality #ith translocation t(11,14 ()1+,)+' resulting inovere%pression of cyclin 1prognosis: mantle cell lymphoma has median survival +-5 years, "ut most patientscannot "e cured

D#FF5$E LA GE - ELL LYMPHOMA-is a diffuse proliferation of large si$ed neoplastic &-cells, constitute a"out + -4 B of adult lymphomas in #estern countriesthe medium age is Dth decade, "ut age range is #ideclinically- patients typically present #ith a rapidly enlarging mass #ith lymph

node involvementhistologically: -al#ays diffuse gro#th pattern, composed of large immuno"lasts- large polymorphic cells #ith many mitoses, prominent nucleoli, in some cases-plasmacytoid differentiation- #ith monoclonal IgGprognosis: aggressive "ut potentially cura"le neoplasm, rapidly fatal ifuntreated, "ut usually favora"le response to chemotherapy-complete remissioncan "e achieved in 8 -C B of the patients, a"out 5 B remain disease-free forseveral years

FOLL# 5LA LYMPHOMA$ -is a neoplasm of follicle centre & cells (centrocytes and centro"lasts #hich hasat least partially follicular gro#th pattern- follicular lymphomas constitute a"out +5B of adult lymphomas in the 09, theincidence is lo#er in 3sia, #orld#ide E a"out ' Bclinically:-neoplasm affects predominantly adults, #ith median age of 8 years-most patients have #idespread disease at diagnosis, including lymphadenopathy-fre)uently generali$ed at onset-"one marro# is often involved (4 B at the time of diagnosishistologically: lymph node is infiltrated "y neoplastic &-cells #ith cleaved nuclei,scanty cytoplasm- nuclear chromatin is coarse, nuclei indistinct, mitosesinfre)uent (centrocytes and in addition to small cleaved lymphocytes- there arelarge cleaved and non-cleaved cells ( centro"lasts - more mitoses, larger nuclei,irregular contours of nuclei, distinctive nucleolicytogenetic a"normalities:-virtually in all cases, the tumor cells have cytogenetic a"normalities, mostly atranslocation t(14:1C - "rea!point on chromosome 1C- at the site of proto- oncogene "cl-' (present in D5 to F B of cases

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prognosis: in most cases lo# response to chemotherapy- impossi"le toeradicate completely neoplastic cells-in '5 to + B of patients- follicular lymphoma progress to high-grade large &-cell lymphoma

5 #TT LYMPHOMA-is highly aggressive lymhoma often presenting at e%tranodal sites

the neoplasm e%ists in t#o variants: endemic &L- this tumor #as descri"ed in 3frica, #here it is associated #ith>pstein-&arr viral infection-

-it represents one of most common malignant tumors of childhood in3frica, *apua, e# Guineasporadic &L- this variant is seen throughout the #orld mostly among young

adults and children- incidence is lo#, 1-'B of all lymphomas

histologically: "oth variants- tumor consists of small closely pac!ed lymphoidcells #ith regular round nuclei- many mitoses- many apoptotic "odies- starry s!y pattern --"oth african and related non-endemic cases- similar histological features,children and young adults are affected, in "oth form the tumor rarely arises#ithin lymph nodes-african cases- involvement of ja#s is the most common site, #hereas a"dominal

tumors are typical of non-african cases ( "o#el, ovaries, retroperitoneum prognosis: leu!emic transformation is not very common, the tumor responds toaggressive chemotherapy- long remissions are reported- in many cases relaps-long survival in a"out 5 B #ith appropriate treatment

T - ELL LYMPHOMA$ less common than & cell lymphomas

PE #PHE AL T- ELL LYMPHOMA- ost patients present #ith lymph node involvement, "ut any site may "e

affected-it is composed of polymorphic T-cell neoplastic elements-it accounts for a"out 5 B of T-cell derived lymphomasclinically: many patients present #ith advanced disease, it is among the mostaggressive lymphomas, prognosis is poor

MY O$#$ F5NGO#DE$ AND $E=A Y $YND OME - these are mature T-cell lymphomas presenting in the s!in #ithpatches@pla)ues and characteri$ed "y epidermal and dermal infiltrate composedof small to medium si$ed T-cells

mycosis fungoides is histologically characteri$ed "y cutaneous infiltrates composed of polymorphic small to medium-si$ed lymphoid neoplastic cells- in

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most patients slo# "ut permanent progression of the disease- #ith involvementof internal organsclinical course is slo#ly progressive "ut fatal in all cases, poor prognosisassociated #ith development of lymphadenopathy, sepsis is a fre)uent terminal

complication9e$ary syndrome -is characteri$ed clinically "y infiltrates in the s!in,lymphadenopathy and presence of 9e$ary cells (neoplastic in peripheral "lood *rognosis is related to stage- patients #ith limited s!in disease have goodprognosis, in more advanced stages #ith e%tracutaneous dissemination Eaggressive "ehaviour

E>T ANODAL N 6T- ELL LYMPHOMA? NA$AL TYPE -is predominantly e%tranodal lymphoma, characteri$ed "y prominent necrosis, it

is angiocentric-mostly composed of < cells ( 58 positive , the nasal cavity is most commonsiteclinically: the patients present #ith epista%is, e%tensive destructive lesion inmiddle part of face (so-called lethal midline granulomathe lymphoma can e%tend to paranasal sinuses, nasopharyn%, oral cavity, palate,etcprognosis is varia"le, some patients may respond #ell to therapy, the other dieof disseminated disease despite aggressive treatment

AD5LT T- ELL LE5 EM#A-LYMPHOMAhis is uncommon T-cell neoplasm, that is endemic in apan and ari"ean-caused "y /LT2-1 virus ,- this is oncogenic retrovirus- has strong tropism for

4 cells (similarly as /I2clinically: very aggressive disease #ith a median survival of a"out C month #iththerapy, present #ith lymphadenopathy, hepatospolenomegaly, s!in lesions, etc.

E>T ANODAL MAL#GNANT LYMPHOMA$

-lymphomas that arise at sites other than lymph nodes-can arise at any site in the "ody, "ut the commonest sites include - major lymphoid tissue sites, such as the spleen, =aldayer ring, salivary glands, GIT,s!in, testis, etcgreat majority are of &-cell origin -the commonest of them is gastric lymphoma- MALT ly"ho"a --malignant lymphomas arising in mucosa-associated lymphoid tissue ( 3LT

3LT lymphoma - lo#-grade &-cell lymphoma composed of medium-si$edlymphoid cells #ith pale cytoplasm, resem"ling centrocytes ( L cells , #ith

plasma cell differentiation- presence of lympho-epithelial lesions

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-tends to remain locali$ed for long periods, seldom disseminates to "onemarro#, responds favora"ly to local therapy-

ajor sites for developing of 3LT lymphoma-stomach, salivary glands1@ 3LT(&-cell gastric lymphoma-the most common of all e%tranodal

lymphomas-disease of the si%th and seventh decades, "ut !no#n also in younger

patients-clinical symptoms include dyspepsia, a"dominal pain, at endoscopy-

findings similar to those seen in chronic gastritis and peptic ulcersprognosis: -remains locali$ed to the stomach, in a minority of cases-gastriclymph nodes may "e involved later, L does not disseminate, prognosis is relatedto stage of the tumor- good result of surgery alone- the response of gastric

3LT lymphoma to eradication of /. pylori

overall prognosis is considera"ly "etter than that of nodal lymphoma of similarhistological grade'@ 3LT (&-cell salivary gland lymphoma in patients over 5 years, mar!ed female preponderance

-most cases arise in patients #ith lymphoepithelial sialadenitis L>93 and9jogren syndrom L>93 -salivary gland lesion consisting of infiltrates composed of polyclonal &cells and plasma cells, and epi-myoepithelial islands, inflammatory infiltrates mayreplace salivary gland tissue- acinar cell atrophy9jogren syndrome - autoimmune disease presenting #ith !eratoconjunctivitis,rheumatoid arthritis, %erostomia and enlargement of salivary glands (L>93 - "utnot all patients #ith L>93 have 99enlargement of salivary glands, later-involvement of intraparotideal and cervicallymph nodes, histologically-similar as gastric 3LT lymphomaprognosis: indolent "ehavior #ith long survival- surgery, no tendency to involve"one marro#

HODG #N D#$EA$E.- is a disorder involving primarily the lymphoid tissue-it arises almost al#ays in a single lymph node- commonly in cervical lymph node

-it is separated from non /odg!in lymphomas for characteristichistological features and systemic manifestations

-/ is characteri$ed morphologically "y the presence of distinctiveneoplastic cells called diagnostic eed-9tern"erg cells, admi%ed #ith a"undantreactive inflammatory "ac!ground infiltrate-

-the patients may present #ith systemic manifestations, such as fever,#eight loss, night s#eatscommon malignancy- accounts for + -4 B of all lymphomas

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*athologic features of / :-presence of diagnostic eed-9tern"erg cells- giant "inucleated ormultinucleated large cells #ith conspicuous large inclusion-li!e eosinophilicnucleoli #ith a clear halo around them, t#o halves of the cell often appear as a

mirror image of each other-diagnostic /odg!in cell - large mononuclear cell #ith large single often

multilo"ulted or polypoid nucleus- prominent 6o#l-eyed7 nucleoli surrounded "yclear halo

-lacunar cells - particular variant of the 9 cell, this cell is large and has asingle hyperlo"ated nucleus #ith multiple small nucleoli and an a"undant pale-staining cytoplasm #ith #ell-defined "orders- the cells appear such as lying inclear spaces ( lacunae - fi%ation artefact "ecause of shrin!age of the cytoplasm-neoplastic cells are typically dispersed #ithin an a"undant reactive infiltrate

composed of varia"le num"ers of lymphocytes, plasma cell, histiocytes,neutrophils, and eosinophils

-/ is one of the most common malignancies in young adults9tage of disease- means distri"ution of diseasethe staging of / is of great importance -very important prognostic factor in/ - stage is an e%pression of the e%tent of spread of the neoplams- the course,choice of therapy, and prognosis is related to the stage of disease

clinical stage -criteria for staging #ere esta"lished "ased on clinical

history and physical e%amination, radiologic studies, la"oratory testpathologic stage -"ased on histologic findings in tissue removed "y "iopsy

(lymph nodes, spleen, "one marro#, liver, etc. - pathologic staging is more e%act9tage I - involvement of a single L region or single e%tralymphoid site9tage II - involvement of ' or more L regions on the same side of diaphragm9tage III - Involvement of "oth sides of diaphragm, may include spleen and onlylimited e%tranodal sites.9tage I2 - ultiple or disseminated involvement of one or more e%tralymphaticorgans or tissues #ith or #ithout lymph node involvement

linically, the patients in all stages are further divided into ' prognostic groups-A 9 L399I?I 3TIA : - classification is "ased on relative proportion

of diagnostic neoplastic cells and inflammatory reactive "ac!ground infiltration:- 4 su"types of / - #ith prognostic and therapeutic implications

1@ / #ith lymphocyte predominance

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-this variant is characteri$ed "y the presence of numerous lymphocytes and fe#classic 9 cells- the "est prognosis, most often in cervical nodesit may occur in nodular and diffuse variant- typically present in stage I-progresses slo#ly

-affects young patients'@ / -nodular sclerosis

-this su"type has good prognosis, usually presents in early stage, more commonin females, typically presents in ' nd decade to early thirtiescervical lymph nodes are involved, or mediastinal masshistologically characteri$ed "y nodular gro#th pattern "ecause of the presenceof "road "ands of collagen that divide the lymphoid tissue into circumscri"ednodules - presence of lacunar cells -is a variant of 9 or / cells #ith a"undantpale-loo!ing cytoplasm

-classic 9 cells are infre)uent-prognosis is e%cellent, especially #hen seen in clinical stages I and II

+@ / -mi%ed cellularity -this form has intermediate prognosis- rapidly progressive, "ut good response totherapyhistologically-the involvement of the lymph node is diffuse, typical 9 cells areplentiful, there are fe#er lymphocytes then in type 1, prominent mi%ed infiltratecomposed of lymphocytes, plasma cells, neutrophils and eosinophils,-the disease may "e diagnosed at any stage, "ut if compared #ith type 1 and '/ , more patients have disseminated / at diagnosis- more often systemicmanifestation- #orse prognosis

4@ / - lymphocyte depleted this form has the #orst prognosis of all-typically presents in stage III or I2-lymph node are replaced "y destructive process- numerous neoplastic 9 cells,diffuse fi"rosis, lo#er num"ers of reactive cellsoften refractory to therapy-most patients are old- these have usuallyaggressive form of the disease

*ALDAYE #NG LYMPHOMA$

The palatine tonsils, nasopharyngeal and ligual lymphoid tissues constitute themajor parts of =

-lymphoid tissue of = "elongs to 3LT and is located at the gate#ay ofthe respiratory and GIT tract

appro%imately 5 to 1 B of patients #ith non-/odg!in lymphomas ( /Lhave = as the primary site of lymphoma

8 B affect tonsils, +5B nasopharyn%, follo#ed "y "ase of tongue (lessthan 1 B

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ost common types of = lymphomas-"y far the most common is L& L (diffuse large &-cell lymphoma - 4 B

is high grade lymphoma, clinically aggressive #ith fast dissemination-mantle cell lymphoma ( L - + B

-follicular lymphoma (?L - mar!ed predilection to tonsils- LL- 3LT lymphoma- indolent e%tranodal ly

$#NONA$AL LYMPHOMA$

- epresent a distinctive su"set of e%tranodal head and nec! lymphomasappearing in nose and paranasal sinuses

-sinonasal lymphomas are also one of the possi"le causes of lethal

midline granuloma- a clinical term for destructive and progressive lesionsaffecting the midline of the face

The sinonasal lymphomas are of &-cell or T@


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are most fre)uently tumors of mature plasma cellsost common sinonasal T@ < cell lymphomas:

-sinonasal

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04 Head Neck Lymph Node (2)