APPROACH TO THE PATIENT WITH LYMPHADENOPATHY AND SPLENOMEGALY

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APPROACH TO THE PATIENT WITH LYMPHADENOPATHY
AND SPLENOMEGALY
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APPROACH TO THE PATIENT WITH LYMPHADENOPATHY AND
SPLENOMEGALY

• PHYSIOLOGY AND ANATOMY
• Lymph nodes are populated predominantly by
• macrophages,
• dendritic cells,
• B lymphocytes, and
• T lymphocytes.
• B lymphocytes are located primarily in the
  follicles and perifollicular areas,
• T lymphocytes are found primarily in the
  interfollicular or paracortical areas of the
  lymph node.

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APPROACH TO THE PATIENT WITH LYMPHADENOPATHY AND
SPLENOMEGALY
PHYSIOLOGY AND ANATOMY In young childrenpalpable
lymphadenopathy is the rule. who are
continuously undergoing exposure to new antigens,
In fact, the absence of palpable
lymphadenopathy would be considered abnormal In
adults, lymph nodes larger than 1 to 2 cm in
diameter are generally considered abnormal.
However, lymph nodes 1 to 2 cm in diameter in
the groin are sufficiently frequent to often be
considered "normal.
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APPROACH TO THE PATIENT WITH LYMPHADENOPATHY AND
SPLENOMEGALY
Generalized immune proliferation and
lymphadenopathy can occur with a systemic
disorder of the immune system, disseminated
infection, or disseminated neoplasia.
Malignancies of the immune system might be
manifested as localized or disseminated
lymphadenopathy.
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APPROACH TO THE PATIENT WITH LYMPHADENOPATHY AND
SPLENOMEGALY
more than two-thirds of patients with LAP have
nonspecific causes or upper respiratory
illnesses (viral or bacterial), fewer than 1
have a malignancy in another study 16 had a
malignancy (lymphoma or metastatic
adenocarcinoma) Thus, the vast majority of
patients with lymphadenopathy will have a
nonspecific etiology requiring few diagnostic
tests.
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APPROACH TO THE PATIENT WITH LYMPHADENOPATHY AND
SPLENOMEGALY
Differential diagnosis of lymphadenopathy TABLE
1781. CAUSES OF LYMPHADENOPATHY
Infection Bacterial (e.g., all pyogenic
bacteria, cat-scratch disease, syphilis, tularemia
) Mycobacterial (e.g., tuberculosis,
leprosy) Fungal (e.g., histoplasmosis,
coccidioidomycosis) Chlamydial (e.g.,
lymphogranuloma venereum) Parasitic (e.g.,
toxoplasmosis, trypanosomiasis, filariasis) Viral
(e.g., Epstein-Barr virus, cytomegalovirus,
rubella, hepatitis, HIV) Benign disorders of the
immune system (e.g., rheumatoid arthritis,
systemic
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APPROACH TO THE PATIENT WITH LYMPHADENOPATHY AND
SPLENOMEGALY
TABLE 1781. CAUSES OF LYMPHADENOPATHY lupus
erythematosus, serum sickness, drug reactions
such as to phenytoin, Castleman's disease, sinus
histiocytosis with massive lymphadenopathy,
Langerhans'cell histiocytosis, Kawasaki syndrome,
Kimura's disease) Malignant disorders of the
immune system (e.g., chronic and acute myeloid
and lymphoid leukemia, non-Hodgkin's lymphoma,
Hodgkin's disease, angioimmunoblastic-like T-cell
lymphoma, Waldenström's macroglobulinemia,
multiple myeloma with amyloidosis, malignant
histiocytosis) Other malignancies (e.g., breast
carcinoma, lung carcinoma, melanoma, head
and neck cancer, gastrointestinal malignancies,
germ cell tumors, Kaposi's sarcoma) Storage
diseases (e.g., Gaucher's disease, Niemann-Pick
disease) Endocrinopathies (e.g., hyperthyroidism,
adrenal insufficiency, thyroiditis) Miscellaneous
(e.g., sarcoidosis, amyloidosis, dermatopathic
lymphadenitis)
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APPROACH TO THE PATIENT WITH LYMPHADENOPATHY AND
SPLENOMEGALY
TABLE 1782. MOST FREQUENT CAUSES OF
LYMPHADENOPATHY IN ADULTS IN AMERICA
Unexplained Infection In drainage area of
infection (e.g., cervical adenopathy with
pharyngitis) Disseminated (e.g., mononucleosis,
HIV infection) Immune disorders (e.g., rheumatoid
arthritis) Neoplasms Immune system malignancies
(e.g., leukemia and lymphomas) Metastatic
carcinoma or sarcoma
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APPROACH TO THE PATIENT WITH LYMPHADENOPATHY AND
SPLENOMEGALY

• FACTORS TO CONSIDER IN THE DIAGNOSIS OF
  LYMPHADENOPATHY
• Associated systemic symptoms
• Patient age
• History of infection, trauma, medications, travel
  experience, previousmalignancy, etc.
• Location cervical, supraclavicular,
  epitrochlear, axillary, intrathoracic(hilar
  versus mediastinal), intra-abdominal
  (retroperitoneal versus mesentericversus other),
  iliac, inguinal, femoral
• Localized versus disseminated
• Tenderness/inflammationSizeConsistency

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APPROACH TO THE PATIENT WITH LYMPHADENOPATHY AND
SPLENOMEGALY

• LYMPH NODE EVALUATION.
• a careful history
• a thorough physical examination
• laboratory tests
• imaging studies to determine the extent and
  character of the
• lymphadenopathy
• age of the patient
• The occurrence of fever, sweats, or weight
  loss
• of a site of infection, a particular medication,
  a travel history, or a previous malignancy.

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APPROACH TO THE PATIENT WITH LYMPHADENOPATHY AND
SPLENOMEGALY

• physical examination
• localized or generalized
• size of nodes
• Texture
• presence or absence of nodal tenderness
• signs of inflammation over the node
• skin lesions
• splenomegaly.

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APPROACH TO THE PATIENT WITH LYMPHADENOPATHY AND
SPLENOMEGALY

• Generalized adenopathy has been defined as
• involvement of three or more
  noncontiguous lymph node areas.
• generalized lymphadenopathy is
  frequently associated with
  nonmalignant disorders

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APPROACH TO THE PATIENT WITH LYMPHADENOPATHY AND
SPLENOMEGALY
physical examination (localized or
generalized), size of nodes, texture, presence or
absence of nodal tenderness, signs of
inflammation over the node, skin lesions, and
splenomegaly. Generalized adenopathy has been
defined as involvement of three or more
noncontiguous lymph node areas. generalized
lymphadenopathy is frequently associated with
nonmalignant disorders The site of localized or
regional adenopathy Nodes lt1.0 cm2 in area (1.0
1.0 cm or less) are almost always secondary to
benign, nonspecific reactive causes. Patients
with node(s) lt1.0 cm2 should be observed after
excluding infectious mononucleosis and/or
toxoplasmosis unless there are symptoms and signs
of an underlying systemic illness.
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APPROACH TO THE PATIENT WITH LYMPHADENOPATHY AND
SPLENOMEGALY

• METHODS OF LYMPH NODE EVALUATION
• Physical examination
• Imaging
• Chest radiography
• Lymphangiography
• Ultrasonography
• Computed tomography
• Magnetic resonance imaging
• Gallium scanning
• Positron emission tomography
• Sampling
• Needle aspiration
• Cutting needle biopsy
• Excisional biopsy

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APPROACH TO THE PATIENT WITH LYMPHADENOPATHY AND
SPLENOMEGALY
lymph nodes that are tender are more likely to be
due to an infectious process, whereas painless
adenopathy raises the concern of malignancy.
Lymph node consistency lymph nodes containing
metastatic carcinoma are rock hard, lymph nodes
containing lymphoma are firm and rubbery, lymph
nodes enlarged in response to an infectious
process are soft. The larger the lymph node, the
more likely a serious underlying cause exists,
and lymph nodes greater than 3 to 4 cm in
diameter in an adult are very concerning
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APPROACH TO THE PATIENT WITH LYMPHADENOPATHY AND
SPLENOMEGALY
Chest radiographs provide the most economical and
easiest method to assess mediastinal and hilar
lymphadenopathy but are not as accurate as CT of
the chest. lymphangiography provides an
extremely accurate assessment of the lower
abdominal lymph nodes and, because of retained
contrast material, allows repeat examinations and
assessment of the response to therapy. CT and
ultrasound provide the most useful ways to assess
abdominal and retroperitoneal lymphadenopathy
ultrasound has the advantage of being less
expensive and not requiring radiation exposure.
MRI and gallium scanning are not first-line
studies for the assessment of lymphadenopathy
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APPROACH TO THE PATIENT WITH LYMPHADENOPATHY AND
SPLENOMEGALY
Gallium scans presence of active lymphoma in
patients with lymphadenopathy and a proven
diagnosis Fine-needle aspiration currently
popular and is often an accurate way to diagnose
infection or carcinoma it is inappropriate as an
initial diagnostic maneuver for lymphoma.
Cutting needle biopsies will occasionally
provide sufficient material for an unequivocal
diagnosis and subtyping of the lymphom
excisional biopsy, which is most likely to
provide the pathologist with adequate material to
perform histologic, immunologic, and genetic
studies, is the most appropriate approach.
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APPROACH TO THE PATIENT WITH LYMPHADENOPATHY AND
SPLENOMEGALY
AN APPROACH TO THE PATIENT WITH LYMPHADENOPATHY

• AN APPROACH TO THE PATIENT WITH LYMPHADENOPATHY
• Does the patient have a known illness that causes
  lymphadenopathy?Treat and monitor for resolution.
• 2. Is there an obvious infection to explain the
  lymphadenopathy (e.g., infectious
  mononucleosis)?Treat and monitor for resolution.
• 3. Are the nodes very large and/or very firm and
  thus suggestive of malignancy?Perform a biopsy.
• 4. Is the patient very concerned about malignancy
  and unable to be reassured thatmalignancy is
  unlikely? Perform a biopsy.
• 5. If none of the preceding are true, perform a
  complete blood count and if it isunrevealing,
  monitor for a pre-determined period (usually 2 to
  6 weeks).If the nodes do not regress or if they
  increase in size, perform a biopsy.

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APPROACH TO THE PATIENT WITH LYMPHADENOPATHY AND
SPLENOMEGALY
AN APPROACH TO THE PATIENT WITH LYMPHADENOPATHY
come to medical attention in several ways felt a
lymph node in the neck, axilla, or groin an
unexpected finding on routine physical
examination or as part of the evaluation of
another complaint. Finally, patients might be
found to have unexpected lymphadenopathy on
imaging studies of the chest or abdomen. The
approach to a patient complaining of newly
discovered lymphadenopathy in the neck, axilla,
or groin will depend on the size, consistency,
and number of enlarged lymph nodes and the
patient's general health a biopsy might be done
more quickly in a patient who is very anxious
about malignancy or who needs a definitive
diagnosis expeditiously.
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APPROACH TO THE PATIENT WITH LYMPHADENOPATHY AND
SPLENOMEGALY
AN APPROACH TO THE PATIENT WITH LYMPHADENOPATHY
Biopsy might be done more quickly in a patient
who is very anxious about malignancy or who needs
a definitive diagnosis expeditiously.
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GENERAL ASPECTS OF LYMPHOID MALIGNANCIES ETIOLOGY
AND EPIDEMIOLOGY
Hodgkin's disease The cell of origin of
suggests that most are of B cell origin.
Hodgkin's disease is more common in whites than
in blacks more common in males than in females
A bimodal distribution of age at diagnosis has
been observed, with one peak incidence occurring
in patients in their 20s and the other in those
in their 80s younger age groups diagnosed in the
United States largely have the nodular sclerosing
subtype Elderly patients, patients infected with
HIV, and patients in third world countries more
commonly have mixed-cellularity Hodgkin's disease
or lymphocyte-depleted Hodgkin's disease
Infection by HIV is a risk factor for developing
Hodgkin's disease. In addition, an association
between infection by EBV and Hodgkin's disease
has been demonstrated
Dr.Mokarian
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GENERAL ASPECTS OF LYMPHOID MALIGNANCIES ETIOLOGY
AND EPIDEMIOLOGY
non-Hodgkin's lymphomas have increased in
frequency in the United States at the rate of 4
per year since 1950. more frequent in the
elderly and more frequent in men Patients with
both primary and secondary immunodeficiency
states are predisposed to developing
non-Hodgkin's lymphomas. HIV infection
patients who have undergone organ
transplantation patients with inherited immune
deficiencies, the sicca syndrome rheumatoid
arthritis
Dr.Mokarian
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GENERAL ASPECTS OF LYMPHOID MALIGNANCIES ETIOLOGY
AND EPIDEMIOLOGY
non-Hodgkin's lymphomas various subtypes differ
geographically T cell lymphomas are more common
in Asia follicular lymphoma are more common in
western countries. angiocentric nasal T/natural
killer (NK) cell lymphoma has a striking
geographic occurrence, being most frequent in
Southern Asia and parts of Latin America. human
T cell lymphotropic virus (HTLV) I is seen
particularly in southern Japan and the Caribbean.
Dr.Mokarian
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GENERAL ASPECTS OF LYMPHOID MALIGNANCIES ETIOLOGY
AND EPIDEMIOLOGY
non-Hodgkin's lymphomas environmental factors
infectious agents, chemical exposures medical
treatments Patients treated for Hodgkin's
disease can develop non-Hodgkin's lymphoma
agricultural chemicals
Dr.Mokarian
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GENERAL ASPECTS OF LYMPHOID MALIGNANCIES ETIOLOGY
AND EPIDEMIOLOGY
non-Hodgkin's lymphomas HTLV-I infects T cells
directly to the development of adult T cell
lymphoma (ATL) in a small percentage of infected
patients. cumulative lifetime risk of developing
lymphoma in an infected patient is 2.5.
transmitted by infected lymphocytes ingested by
nursing babies of infected mothers, blood-borne
transmission, or sexually The median age of
patients with ATL is about 56 years, emphasizing
the long latency.
Dr.Mokarian
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GENERAL ASPECTS OF LYMPHOID MALIGNANCIES ETIOLOGY
AND EPIDEMIOLOGY
non-Hodgkin's lymphomas EBV Burkitt's lymphoma
in Central Africa and the occurrence of
aggressive non-Hodgkin's lymphomas in
immunosuppressed patients in western countries
EBV infection is strongly associated with the
occurrence of extranodal nasal T/NK cell
lymphomas in Asia and South America.
Dr.Mokarian
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GENERAL ASPECTS OF LYMPHOID MALIGNANCIES ETIOLOGY
AND EPIDEMIOLOGY
non-Hodgkin's lymphomas HIV predisposes to the
development of aggressive, B cell non-Hodgkin's
lymphoma overexpression of interleukin 6 by
infected macrophages Helicobacter pylori
Infection of the stomach by the bacterium
induces the development of gastric MALT
(mucosa-associated lymphoid tissue) lymphomas.
The bacterium does not transform lymphocytes to
produce the lymphoma instead, a vigorous immune
response is made to the bacterium and the chronic
antigenic stimulation leads to the neoplasia.
Dr.Mokarian
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GENERAL ASPECTS OF LYMPHOID MALIGNANCIES ETIOLOGY
AND EPIDEMIOLOGY
non-Hodgkin's lymphomas Chronic hepatitis C virus
lymphoplasmacytic lymphoma Human herpesvirus 8
is associated with primary effusion lymphoma in
HIV-infected persons and multicentric Castleman's
disease, a diffuse lymphadenopathy associated
with systemic symptoms of fever, malaise, and
weight loss.
Dr.Mokarian
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TABLE 1792. COMPARISON OF THE WORKING FORMULATION AND THE WORLD HEALTH ORGANIZATION CLASSIFICATION OF LYMPHOID NEOPLASMS TABLE 1792. COMPARISON OF THE WORKING FORMULATION AND THE WORLD HEALTH ORGANIZATION CLASSIFICATION OF LYMPHOID NEOPLASMS TABLE 1792. COMPARISON OF THE WORKING FORMULATION AND THE WORLD HEALTH ORGANIZATION CLASSIFICATION OF LYMPHOID NEOPLASMS
WORKING FORMULATION WHO CLASSIFICATION WHO CLASSIFICATION
WORKING FORMULATION B-Cell Neoplasms T-Cell Neoplasms
Low Grade     
A. Small lymphocytic consistent with CLL B-cell CLL/SLL  
B. Follicular, predominantly small cleaved cell Follicular lymphoma, grade I  
C. Follicular, mixed small cleaved and large cell Follicular lymphoma, grade II  
Intermediate Grade     
D. Follicular, large cell Follicular lymphoma, grade III  
E. Diffuse, small cleaved cell Mantle cell lymphoma  
F. Diffuse, mixed small and large cell Large B-cell lymphoma (rich in T cells) Peripheral T cell, unspecified
G. Diffuse, large cell Diffuse large B-cell lymphoma Peripheral T cell, unspecified
High Grade     
H. Large cell immunoblastic Diffuse large B-cell lymphoma Peripheral T cell, unspecified
I. Lymphoblastic Precursor B lymphoblastic Precursor T lymphoblastic
J. Small non-cleaved cell  Burkitt's  Non-Burkitt's Burkitt's lymphoma  
  CLL chronic lymphocytic leukemia SLL small lymphocytic lymphoma.   CLL chronic lymphocytic leukemia SLL small lymphocytic lymphoma.   CLL chronic lymphocytic leukemia SLL small lymphocytic lymphoma.
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TABLE 1791. WORLD HEALTH ORGANIZATION CLASSIFICATION OF NEOPLASTIC DISEASES OF THE HEMATOPOIETIC AND LYMPHOID TISSUES LYMPHOID NEOPLASMS
B-Cell Neoplasms Precursor B-cell lymphoblastic leukemia/lymphoma Mature B-cell neoplasms B-cell chronic lymphocytic leukemia/small lymphocytic lymphoma B-cell prolymphocytic leukemia Lymphoplasmacytic lymphoma Splenic marginal zone B-cell lymphoma Hairy cell leukemia Extranodal marginal zone B-cell lymphoma of the mucosa-associated lymphoid tissue type Mantle cell lymphoma Follicular lymphoma Nodal marginal zone lymphoma with or without monocytoid B cells Diffuse large B-cell lymphoma Burkitt's lymphoma Plasmacytoma Plasma cell myeloma T-Cell Neoplasms Precursor T-cell lymphoblastic lymphoma/leukemia Mature T-cell and NK cell neoplasms T-cell prolymphocytic leukemia T-cell large granular lymphocytic leukemia NK cell leukemia Extranodal NK/T-cell lymphoma, nasal and nasal type Mycosis fungoides/Sézary syndrome Primary cutaneous anaplastic large cell lymphoma Subcutaneous panniculitis-like T-cell lymphoma Enteropathy-type intestinal T-cell lymphoma Hepatosplenic g/d T-cell lymphoma Angioimmunoblastic T-cell lymphoma Peripheral T-cell lymphoma (unspecified) Anaplastic large cell lymphoma, primary systemic type Adult T-cell lymphoma/leukemia (HTLVI)
  NK natural killer HTLV human T-cell leukemia virus.   The most common B- and T-cell malignancies are in bold.   Modified from Jaffe E, Bernard C, Harris N, et al Proposed World Health Organization classification of neoplastic diseases of hematopoietic and lymphoid tissues. Am J Surg Pathol 21114, 1997.
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TABLE 1794. ANN ARBOR STAGING SYSTEM TABLE 1794. ANN ARBOR STAGING SYSTEM
Stage I Involvement of a single lymph node region (I) or a single extralymphatic organ or site (IE)
Stage II Involvement of two or more lymph node regions on the same side of the diaphragm (II) or localized involvement of an extralymphatic organ or site (IIE)
Stage III Involvement of lymph node regions on both sides of the diaphragm (III) or localized involvement of an extralymphatic organ or site (IIIE), the spleen (IIIS), or both (IIISE)
Stage IV Diffuse or disseminated involvement of one or more extralymphatic organs with or without associated lymph node involvement
  Identification of the presence or absence of symptoms should be noted with each stage designation. A asymptomatic B fever, sweats, or weight loss greater than 10 of body weight.   Identification of the presence or absence of symptoms should be noted with each stage designation. A asymptomatic B fever, sweats, or weight loss greater than 10 of body weight.
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HODGKIN'S DISEASE Nodular Lymphocyte-Predominant
Hodgkin's Disease CLASSIC HD LP NST MCT LD
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APPROACH TO THE PATIENT SPLENOMEGALY
PHYSIOLOGY AND ANATOMY.
the largest lymphatic organ function the primary
immune response filter for the blood removing
from the circulation senescent red cells,
Removing blood cells and other cells coated with
immunoglobulins Red pulp occupies more than half
the volume of the spleen is the site where
senescent red cells are identified and destroyed
and red cell inclusions are removed by a process
known as pitting In the absence of splenic
function, inclusions known as Howell-Jolly bodies
are seen in circulating red blood cells White
pulp of the spleen contains macrophages, B
lymphocytes, and T lymphocytes, participates in
the recognition of microorganisms and foreign
proteins, and is involved in the primary immune
response
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APPROACH TO THE PATIENT SPLENOMEGALY
PHYSIOLOGY AND ANATOMY.
TABLE 1786. CAUSES OF SPLENOMEGALY
Infection Bacterial (e.g., endocarditis,
brucellosis, syphilis, typhoid, pyogenic
abscess) Mycobacterial (e.g., tuberculosis) Fungal
(e.g., histoplasmosis, toxoplasmosis) Parasitic
(e.g., malaria, leishmaniasis) Rickettsial (e.g.,
Rocky Mountain spotted fever) Viral (e.g.,
Epstein-Barr virus, cytomegalovirus, HIV,
hepatitis) Benign disorders of the immune system
(e.g., rheumatoid arthritis with Felty's
syndrome, systemic lupus erythematosus, drug
reactions such as to phenytoin, Langerhans' cell
histiocytosis, serum sickness)
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APPROACH TO THE PATIENT SPLENOMEGALY
PHYSIOLOGY AND ANATOMY.
TABLE 1786. CAUSES OF SPLENOMEGALY Malignant
disorders of the immune system (e.g., acute or
chronic myeloid or lymphoid leukemia,
non-Hodgkin's lymphoma, Hodgkin's
disease, Waldenström's macroglobulinemia,
angioimmunoblastic-like T-cell lymphoma,
malignant histiocytosis) Other malignancies
(e.g., melanoma, sarcoma) Congestive splenomegaly
(e.g., portal hypertension secondary to liver
disease, splenic or portal vein
thrombosis) Hematologic disorders (e.g.,
autoimmune hemolytic anemia, hereditary spherocyto
sis, thalassemia major, hemoglobinopathies,
elliptocytosis, megaloblastic anemia,
extramedullary hematopoiesis) Storage diseases
(e.g., Gaucher's disease) Endocrinopathies (e.g.,
hyperthyroidism) Miscellaneous (e.g.,
sarcoidosis, amyloidosis, tropical splenomegaly,
cysts)
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APPROACH TO THE PATIENT SPLENOMEGALY
PHYSIOLOGY AND ANATOMY.
EVALUATION OF SPLENIC SIZE AND FUNCTION. TABLE
1787. METHODS FOR EVALUATION OF THE
SPLEEN Physical examination Imaging Ultrasonograph
y Computed tomography Liver-spleen
scanningGallium scanning Positron emission
tomography BiopsyNeedle aspiration Splenectomy Lap
arotomy (total or partial splenectomy) Laparoscopy
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APPROACH TO THE PATIENT SPLENOMEGALY
PHYSIOLOGY AND ANATOMY.
an important skill, but it is not easily learned
the existence of a splenic rub on inspiration
can lead to the diagnosis of splenic infarct. In
general, a splenic "biopsy" involves splenectomy,
which can be performed at laparotomy or with
laparoscopy a splenectomy done via laparoscopy
leads to maceration of the organ and reduces the
diagnostic information.
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APPROACH TO THE PATIENT SPLENOMEGALY
PHYSIOLOGY AND ANATOMY.

• AN APPROACH TO THE PATIENT WITH SPLENOMEGALY
• Does the patient have a known illness that causes
  splenomegaly(e.g., infectious mononucleosis)?
  Treat and monitor for resolution.
• 2. Search for an occult infection (e.g.,
  infectious endocarditis), hematologicdisorder
  (e.g., hereditary spherocytosis), occult liver
  disease (e.g., cryptogeniccirrhosis), autoimmune
  disease (e.g., systemic lupus erythematosus),or
  storage disease (e.g., Gaucher's disease). If
  found, manage appropriately.
• 3. If systemic symptoms are present and suggest
  malignancy and/or focal replacement of the spleen
  is seen on imaging studies and no other site is
  available for biopsy,splenectomy is indicated.
• 4. If none of the above are true, monitor closely
  and repeat studies until thesplenomegaly resolves
  or a diagnosis becomes apparent.

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APPROACH TO THE PATIENT WITH LYMPHADENOPATHY AND
SPLENOMEGALY
AN APPROACH TO THE PATIENT WITH
SPLENOMEGALY presentation left upper quadrant
pain or fullness or of early satiety
catastrophic symptoms of splenic rupture
unexplained cytopenias incidentally on physical
examination The presence of a palpable spleen on
physical examination is almost always abnormal.
The one exception to this rule is a palpable
spleen tip in a slender, young woman In
general, the presence of a palpable spleen should
be considered a serious finding and an
explanation should be sought.
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APPROACH TO THE PATIENT WITH LYMPHADENOPATHY AND
SPLENOMEGALY