Benjolan pada Trigonum Submental

Zaras Yudisthira

SagaDahlia

Septiawaty

Skenario

Laki-laki 65 tahun dengan keluhan benjolan dibawah dagu sudah 4-5 tahun, tidak pernah diperhatikan. Karena dinasehati teman-teman pasien, pasien datang ke dokter. Pada pemeriksaan status lokalis daerah trigonum submental terdapat benjolan kenyal.

Pertanyaan

1.Apa DD pasien ini?

2.Bagaimana menyingkirkan DD?

Anatomi

Menurut Sloan Kattering Memorial Cancer Center Classification, kelenjar getah bening leher dibagi atas 5 daerah penyebaran:

I. Kelenjar yang terletak di segitiga submentale dan submandibulae

II. Kelenjar yang terletak di 1/3 atas dan termasuk kelenjar getah bening jugularis superior, kelenjar digastrik dan kelenjar servikalis posterior.

III. Kelenjar getah bening jugularis di antara bifurkatio karotis dan persilangan Musculus omohioid dengan musculus sternokleidomastoideus dan batas posterior musculus sternokleidomastoideus.

IV. Grup kelenjar getah bening di daerah jugularis inferior dan supraklavikula

V. Kelenjar getah bening yang berada di segitiga posterior servikal.

Trigonum Submentale

• Letak : di bawah dagu• Batas : – Ventrokranial : mentum– lateral : venter anterior musculi

digastrici dextra dan sinistra– Kaudal : Corpus os. Hyoideum

• Dasar trigonum terbentuk dari mylohyoid• Atapnya tertutup kulit, fascia superficialis

yang mengandung platysma, fascia profunda leher.

• Vena : v. Jugularis interna• Struktur : nodus lymp.submental.

Pembuluh limfe eferen mencurahkan isinya ke dalam kelenjar limfe submandibularis dan cervicalis profundi

Anamnesis Tambahan

Age over 45 is most important predictor of

malignancy

Size and duration of neck mass

Habits with increased malignancy risk:

Tobacco abuse, Alcohol abuse

Miscellaneous symptoms fever, Weight loss, night sweats, neck pain, cough

Exposure history: Tuberculosis exposure,

Foreign travel, Occupation, Sexual

history, Head or neck trauma, insect bite,

expoosure to pets or farm animals

Age

• Children/young adults – more likely to respond to minor stimuli with lymphoid hyperplasia– Lymph nodes in patients less than the age of

30 are clinically benign in 80% of cases whereas in patients over the age of 50 only 40% are benign

– Biopsies done in patients less than 25 yrs have a incidence of malignancy of <20% vs the over-50 age group has an incidence of malignancy of 55-80%

Physical Exam• Full nodal

examination – nodal characteristics– Consistency –

Hard/Firm vs Soft/Shotty; Fluctuant

– Mobile vs Fixed/Matted

– Tender vs Painless– Clearly demarcated– Size

• When to worry – 1.5-2cm in size

• Epitroclear nodes over 0.5cm; Inguinal over 1.5cm

– Duration and Rate of Growth

• Organomegaly• Localized – examine

area drained by the nodes for evidence of infection, skin lesions or tumours

Differential Diagnosis: Benign Neck Masses in Adults

Lymphadenopathy or lymphadenitis

Specific InfectionsSoft tissue neck

abscessTuberculosis or Atypical Mycobacterial infection

Cat Scratch DiseaseInfectious

Mononucleosis

Vascular abnormalities:Hemangioma

Lymphangioma

Soft tissue masses:Paraganglioma

LipomaNeurofibroma

ThyroidGoiter or other Thyroid mass

Salivary Gland changes: Parotid cyst

ParotitisSialolithiasis or

SialadenitisSjogren's Syndrome

Congenital anomaly:Lateral neck: Brachial

cleft cyst Cystic Hygroma Dermoid

Medial Neck: Thyroglossal Duct Cyst

Miscellaneous Conditions: Sarcoidosis

Kimura's Disease, Ideopathic

subcutaneous inflammatio

Castleman's Disease, Benign

lymphoproliferative condition of

mediastinum Gout or Pseudogout

(rarely involves neck)

Differential Diagnosis: Malignant Adult Neck Masses

Metastatic Squamous Cell

Carcinoma

Thyroid Cancer

Lymphoma

Salivary Gland cancer

Sarcoma

Differential Diagnosis

Lymphadenopathy

Lymphoma

Lymphadenitis

Lipoma

Epidemiologic Clues to the Diagnosis of Lymphadenopathy

Exposure DiagnosisGeneral

Cat Cat-scratch disease, toxoplasmosis

Undercooked meat Toxoplasmosis

Tick bite Lyme disease, tularemia

Tuberculosis Tuberculous adenitis

Recent blood transfusion or transplant Cytomegalovirus, HIV

High-risk sexual behavior HIV, syphilis, herpes simplex virus, cytomegalovirus, hepatitis B infection

Intravenous drug use HIV, endocarditis, hepatitis B infection

Occupational

Hunters, trappers Tularemia

Fishermen, fishmongers, slaughterhouse workers Erysipeloid

Travel-related

Arizona, southern California, New Mexico, western Texas

Coccidioidomycosis

Southwestern United States Bubonic plague

Southeastern or central United States Histoplasmosis

Southeast Asia, India, northern Australia Scrub typhus

Central or west Africa African trypanosomiasis (sleeping sickness)

Central or South America American trypanosomiasis (Chagas' disease)

East Africa, Mediterranean, China, Latin America Kala-azar (leishmaniasis)

Mexico, Peru, Chile, India, Pakistan, Egypt, Indonesia Typhoid fever

Evaluation of Suspected Causes of Lymphadenopathy

Disorder Assosiated Findings Test

Mononucleosis-type syndromesFatigue, malaise, fever, atypical lymphocytosis

Epstein-Barr virus* Splenomegaly in 50% of patients Monospot, IgM EA or VCA

Toxoplasmosis*80 to 90% of patients are asymptomatic

IgM toxoplasma antibody

Cytomegalovirus*Often mild symptoms; patients may have hepatitis

IgM CMV antibody, viral culture of urine or blood

Initial stages of HIV infection* “Flu-like” illness, rash HIV antibody

Cat-scratch diseaseFever in one third of patients; cervical or axillary nodes

Usually clinical criteria; biopsy if necessary

Pharyngitis due to group A streptococcus, gonococcus

Fever, pharyngeal exudates, cervical nodes

Throat culture on appropriate medium

Tuberculosis lymphadenitis* Painless, matted cervical nodes PPD, biopsy

Secondary syphilis* Rash RPR

Hepatitis B* Fever, nausea, vomiting, icterus Liver function tests, HBsAg

Lymphogranuloma venereum Tender, matted inguinal nodes Serology

ChancroidPainful ulcer, painful inguinal nodes

Clinical criteria, culture

Lupus erythematosus*Arthritis, rash, serositis, renal, neurologic, hematologic disorders

Clinical criteria, antinuclear antibodies, complement levels

Rheumatoid arthritis* ArthritisClinical criteria, rheumatoid factor

Lymphoma*Fever, night sweats, weight loss in 20 to 30% of patients

Biopsy

Leukemia* Blood dyscrasias, bruising Blood smear, bone marrow

Serum sickness*Fever, malaise, arthralgia, urticaria; exposure to antisera or medications

Clinical criteria, complement assays

Sarcoidosis Hilar nodes, skin lesions, dyspnea Biopsy

Kawasaki disease*Fever, conjunctivitis, rash, mucous membrane lesions

Clinical criteria

Tinjauan Pustaka

Lymph Nodes

• Anatomy– Collection of lymphoid cells attached to both

vascular and lymphatic systems– Over 600 lymph nodes in the body

• Function– To provide optimal sites for the concentration

of free or cell-associated antigens and recirculating lymphocytes – “sensitization of the immune response”

– To allow contact between B-cells, T-cells and macrophages

• Lymphadenopathy - node greater than 1cm in size

History

• Identifiable cause for the lymphadenopathy?– Localizing symptoms or signs to suggest

infection/neoplasm/trauma at a particular site• URTI, pharyngitis, periodontal disease, conjunctivitis,

insect bites, recent immunization etc

• Constitutional symptoms• Epidemiological clues– Occupational exposures, recent travel, high-

risk behaviour

• Medications – serum-sickness syndrome

Epidemiology

• 0.6% annual incidence of unexplained adenopathy in the general population

• 10% were referred to a subspecialist and 3.2 % required a biopsy and 1.1% had a malignancy

Why do lymph nodes enlarge?

• Increase in the number of benign lymphocytes and macrophages in response to antigens

• Infiltration of inflammatory cells in infection (lymphadenitis)

• In situ proliferation of malignant lymphocytes or macrophages

• Infiltration by metastatic malignant cells• Infiltration of lymph nodes by metabolite

laden macrophages (lipid storage diseases)

Characteristics of the node

• Nodes lasting less than 2 weeks or greater than one year with no progression of size have a low likelihood of being neoplastic – excludes low grade lymphoma

• Cervical nodes – up to 56% of young adults have adenopathy on clinical exam

• Inguinal adenopathy is common – up to 1-2 cm in size and often benign reactive nodes

Characteristics of the node

• Consistency – Hard/Firm vs Soft/Shotty; Fluctuant

• Mobile vs Fixed/Matted• Tender vs Painless• Clearly demarcated• Size– When to worry – 1.5-2cm in size– Epitroclear nodes over 0.5cm; Inguinal over

1.5cm

• Duration and Rate of Growth

Location of the node

• Supraclavicular lymphadenopathy – Highest risk of malignancy – estimated as 90%

in patients older than 40 years vs 25% in those younger than 40 yrs

– Right sided node – cancer in mediastinum, lungs, esophagus

– Left sided node (Virchow’s) – testes, ovaries, kidneys, pancreas, stomach, gallbladder or prostate

• Paraumbilical node (Sister Joseph’s)– Abdominal or pelvic neoplasm

• Epitroclear nodes– Unlikely to be reactive

• Isolated inguinal adenopathy– Less likely to be associated with malignancy

Clinical Setting

• B symptoms – fever, night sweats, weight loss

• Fatigue• Pruritis• Evidence of other medical conditions –

connective tissue disease• Young patient – mononucleosis type of

syndrome

Physical Exam

• Full nodal examination – nodal characteristics

• Organomegaly• Localized – examine area drained

by the nodes for evidence of infection, skin lesions or tumours

Lymph node character

Size

Consistency

Site

Size

• Greater than one centimeter generally considered abnormal

• Exception inguinal area, lymph nodes commonly palpated (>1.5 cm)

• Size does not indicate a specific disease process

• Obese and thin population

Consistency

• Stone hard: typical of cancer usually metastatic

• Firm rubbery: can suggest lymphoma

• Soft: infection or inflammation

• Shotty “buckshot under skin”

• Suppurated nodes: fluctuant

• Detect node from stroma

• Matting

Pain• Indication of

rapid increase in size: stretch of capsular shell

• NOT useful in determining benign vs malignant state

• Inflammation, suppuration, hemorrhage

Drugs

• Allopurinol• Atenolol• Captopril• Carbamazepine• Gold• Hydralazine• Penicillins

• Phenytoin• Primidone• Pyrimethamine• Quinidine• Trimethoprim/

Sulfamethozole• Suldinac

Algorithm to evaluate Lymphadenopathy

Attention to history and physical exam

Confirmatory testing

Indication for biopsy

Management

• Identify underlying cause and treat as appropriate – confirmatory tests

• Generalized adenopathy – usually has identifiable cause

• Localized adenopathy– 3-4 week observation period for

resolution if not high clinical suspicion for malignancy

– Biopsy if risk for malignancy - excisional

• Wait 3-4 weeks and reexamine• No indication for empiric antibiotics

or steroids• Glucorticoids can be harmful and

delay diagnosis can obscure diagnosis due to lympholytic affect

BIOPSY

• Can be done by bedside, open surgery, mediastinocopy or by needle aspiration*

• FNA not recommended cannot distinguish between lymphomas (nodal architecture needs to be intact)

• FNA reserved for established diagnosis and to demonstrate recurrence

Fine Needle Aspirate

• Convenient, less invasive, quicker turn-around time

• Most patients with a benign diagnosis on FNA biopsy do not undergo a surgical biopsy

Conclusions

• Lymphadenopathy – initial presenting symptom

• Reactive vs Malignant– Probability– History– Physical Exam

• Biopsy if not resolved in 3-4 weeks for low risk patients

• Biopsy all high risk patients – excisional biopsy