Rajiv Gandhi University of Health Sciences s166

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. Name of the candidate: Dr. Bincy Merin Zacharia

2. Name of the institution: St. John’s Medical College Hospital,

Johnnagar, Bangalore- 560034

3. Course of the study and subject: M.S. General Surgery

4. Date of admission to the course: 18th March, 2009

5. Title of the synopsis

CLINICAL SIGNIFICANCE OF LYMPHADENOPATHY BASED ON ANATOMIC LOCATION AND HISTOPATHOLOGIC SPECTRUM

6. BRIEF RESUME OF THE INTENDED WORK

6.1 NEED FOR THE STUDY Lymph nodes are considered to be the fortresses that aid immunologic defense. A common problem that is faced when a patient presents with an enlarged lymph node is the challenge to distinguish between benign and malignant lymphadenopathy and to do so in a timely andcost effective manner. Organizing the possible causes of lymphadenopathy by anatomic location and origin aids in evaluation.

Lymph nodes are arranged in groups that drain specific regions of the body. This knowledge guides to inspect, image and investigate particular areas of anatomy when lymphadenopathy occurs.

In this study an attempt is made to determine the etiology of the lymph node disorder based on site and reaction pattern, and various disorders that may be considered when treating a patient with lymphadenopathy.

Lymph Node Groups: Location, Lymphatic Drainage and Selected Differential Diagnosis

Location Lymphatic drainage Causes

Submandibular Tongue, submaxillary gland, Infections of head, neck, sinuses,

Lips, mouth, conjunctivae ears, eyes, scalp, pharynx

Submental Lower lip, floor of mouth, Mononucleosis syndromes, Epstein

Tip of tongue, skin of cheek Barr virus, Cytomegalo virus,

Toxoplasmosis

Jugular Tongue, tonsil, pinna, parotid Pharyngitis organisms, Rubella

Posterior cervical Scalp, neck, skin of arms, Tuberculosis, lymphoma, head &

& pectorals, thorax, cervical neck malignancy & axillary nodes

Suboccipital Scalp, head Local infection

Post auricular External auditory meatus, Local infection

Pinna, scalp

Preauricular Eyelids, conjunctivae, External auditory canal

Temporal region, pinna

Right supraclavicular Mediastinum, lungs Lung, retroperitoneum,

node Esophagus GI cancer

Left supraclavicular Thorax, abdomen Lymphoma, thoracic,

node Via thoracic duct retroperitoneal cancer,

Bacterial or fungal infection

Axillary Arm, thoracic wall, Infections, Cat Scratch disease,

Breast Lymphoma, breast cancer

Silicon implants, Burcellosis, melanoma

Epitrochlear Ulnar aspect of Infections, lymphoma, sarcoidosis, Forearm & hand Tularemia. Secondary syphilis

Inguinal Penis, scrotum, vulva Infections of leg or foot

Vagina, perineum STDs(HSV, gonococcal infection,

Gluteal region, Lower Syphilis, chancroid,

Abdominal wall, Lower lymphogranuloma venereum)

Anal canal Lyhoma, pelvic malignancy, bubonic

plague

6.2 REVIEW OF LITERATURE

1. Micrometastasis or isolated tumor cells and outcome of breast cancer Maaike de Boer, Carolien HM, van Deurzen, Jos AAM et al

New England Journal of Medicine. 2009 August 13; 361(7): 653-63

Isolated tumor cells or micrometastasis in regional lymph nodes were associated with a reduced 5 years rate of disease free survival among women with favourable early stage breast cancer who did not receive adjuvant therapy.

2. Number of lymph nodes involved with metastatic disease does not affect outcome in Melanoma patients as long as all disease is confined to the sentinel lymph node

James W, Jakub, Marianne Huebner, Steve Shivon et al

Annals of Surgical Oncology. 2009 August; 16(8): 2245-51

The number of regional nodes involved with metastatic disease does not affect disease free survival and overall survival in melanoma patients if disease is confined to the sentinel lymph nodes.

3. Metastasis to the sigmoid or sigmoid mesenteric lymph nodes from rectal cancer

Park, In Ja Choi, Gyn Seong et al

Annals of Surgery. 2009 June; 249(6):960-4

Sigmoid mesenteric or sigmoid lymph node metastases developed in 23.2% of patients studied. There were no differences in the cancer specific survival, overall and local disease recurrence rates in the patients with sigmoid mesenteric or sigmoid lymph node metastases.

4. Place of surgery in Cervical Tuberculous Lymphadenitis

Najh bemansour, Abdellah, Oudidi, Mohamed Noureddine et al

Journal of Otolaryngology, Head & Neck Surgery. 2009 February; 38(1): 23-8

Surgery keeps a place impossible to circumvent in the presence of a cold abscess, an inexhaustible fistula, lymphadenitis with atypical mycobacteria, and a large and calcified lymphnode mass for which medical treatment will not be sufficient, or in secondary surgery in the event of failure or progress under medical treatment or in case of residual adenopathy at the en of an appropriate medical treatment.

The above mentioned reports suggest the importance of the anatomic pattern of involvement in lymph nodes, their histopathologic reaction. They also give an idea about how surgical intervention may impact outcome and survival in various diseases, based on lymph node involvement. 6.3 OBJECTIVES OF THE STUDY

To characterize lymphadenopathies by their patterns of reaction

To determine an etiology from the site of involvement and pattern of reaction

To determine the spectrum of reaction patterns that can be observed in lymph nodes at the same anatomical location

To determine the use of lymphadenopathy and lymph node biopsy in cancer staging and its effect on survival based on type and number of lymph nodes dissected

7. MATERIALS AND METHODS

7.1 SOURCE OF DATA

About 100 adult patients undergoing lymph node biopsy, in the Department of Surgery, St. John’s Medical College Hospital, from September 2009 to march 2011. The procedure will be a fine needle aspiration cytology, excision biopsy or biopsy taken during resection of tumours. The biopsy may be taken from any lymph node site.

7.2 STUDY DESIGN

A descriptive study to be conducted in a prospective manner.

7.3 INCLUSION CRITERIA

Patients should be undergoing an excision biopsy for diagnosis, staging, prognostication, treatment.

Patients who’ve given a formal written and informed consent.

7.4 EXCLUSION CRITERIA

Children upto the age of 15 years.

7.5 PROCEDURE FOR COLLECTING DATA All relevant data concerning patients’ history, routine laboratory investigation, chest radiograph, operative procedure, treatment and histopathology report of lymph node biopsy will be procured from the hospital records.

7.6 SAMPLE SIZE

100 patients undergoing lymph node biopsy of any anatomical location.

7.7 Does the study require any investigation or intervention to be conducted on patients or other humans or animals?

7.8 Has the ethical clearance been obtained for your study?

8. LIST OF REFERENCES

1. Micrometastasis or Isolated tumor cells and outcome of breast cancer

Maaike de Boer, Carolien HM, van Deurzen, Jos AAM et al

New England Journal of Medicine. 2009 August 13; 361(7): 653-63

2. Number of lymph nodes involved with metastatic disease does not affect outcome in Melanoma patients as long as all disease is confined to the sentinel lymph node

James W, Jakub, Marianne Huebner, Steve Shivon et al

Annals of Surgical Oncology. 2009 August; 16(8): 2245-51

3. Metastasis to the sigmoid or sigmoid mesenteric lymph nodes from rectal cancer

Park, In Ja Choi, Gyn Seong et al

Annals of Surgery. 2009 June; 249(6):960-4

4. Place of surgery in Cervical Tuberculous Lymphadenitis

Najh Bbemansour, Abdellah, Oudidi, Mohamed Noureddine et al

Journal of Otolaryngology, Head & Neck Surgery. 2009 February; 38(1): 23-8

9. SIGNATURE OF THE CANDIDATE 10. REMARKS OF THE GUIDE:

11. GUIDE: Dr. Lakshmikanth T. K.

Professor, Department of General Surgery,

St. John‘s Medical College Hospital,

Bangalore- 560034.

11.1 SIGNATURE:

11.2 HEAD OF THE DEPARTMENT: Dr. Arun B. Kilpadi

Professor & Head, Department of General Surgery,

St. John’s Medical College Hospital,

Bangalore- 560034.

11.3 SIGNATURE:

12. CHAIRMAN AND PRINCIPAL:

12.1 REMARKS:

12.2 SIGNATURE: