Lymph Node Examination and Organomegaly — DCE Clinical Case

Clinical Case — Station 3 Lymph Node and Abdominal Examination

Patient brief (for the candidate)

Mr David K is a 34-year-old man. He is known to the haematology service. The examiner asks you to examine his lymph nodes. [1]

The examination (candidate performs the head-to-toe routine)

The candidate introduces themselves, positions the patient sitting upright at 45 degrees for the head and neck and then supine for the remaining regions, and performs the systematic routine: [1]

End of bed. The patient is pale but not cachectic or jaundiced. He is comfortable at rest. [1]

Head and neck nodes. Bilateral, rubbery, mobile, non-tender nodes in the anterior and posterior cervical chains, the largest 2 by 2 centimetres. The submental, submandibular, pre-auricular, post-auricular, and occipital nodes are unremarkable. The tonsillar nodes are enlarged bilaterally. In the left supraclavicular fossa, examined from behind with the neck flexed and shoulders relaxed, there is a rubbery (not hard) node of 1.5 cm — rubbery rather than stony, favouring lymphoma over a Virchow node from carcinoma. The right supraclavicular fossa has a similar smaller node. [1]

Axillary nodes. In both axillae, matted, firm, mobile masses up to 3 centimetres in the central and anterior groups. The posterior and lateral groups are also involved. [1]

Epitrochlear nodes. Palpable bilaterally, rubbery, 1 cm. [1]

Inguinal nodes. Small, mobile, shotty nodes up to 1 cm bilaterally in both the horizontal and vertical groups — consistent with reactive change. [1]

Popliteal nodes. Not palpable. [1]

Abdomen for organomegaly. The spleen is palpable 6 cm below the left costal margin, smooth, with a notch on its medial border. The candidate confirms this is the spleen: cannot get above it, dull to percussion, has a notch. This is moderate splenomegaly. The liver is not enlarged, with a percussion span of 13 cm in the midclavicular line and a smooth, non-tender edge. The kidneys are not ballotable. There is no ascites and no other mass. [1]

The presentation

"I examined Mr David's lymph nodes. At the end of the bed, he is pale but not cachectic or jaundiced. There is generalised lymphadenopathy. In the neck, there are bilateral, rubbery, mobile, non-tender nodes in the anterior and posterior cervical chains, the largest 2 by 2 centimetres, with a rubbery node in the left supraclavicular fossa — rubbery rather than hard, favouring lymphoma over a Virchow node from carcinoma. In both axillae, there are matted, firm, mobile masses up to 3 centimetres. The epitrochlear nodes are palpable bilaterally. The inguinal nodes are small, mobile, and shotty — reactive. The popliteal nodes are not palpable. In the abdomen, the spleen is moderately enlarged, 6 centimetres below the left costal margin, smooth, with a notch — I cannot get above it and it is dull to percussion, confirming it is the spleen. The liver is not enlarged, with a percussion span of 13 centimetres. My findings are of generalised lymphadenopathy with moderate splenomegaly. The most likely diagnosis is lymphoma — the rubbery consistency, the generalised distribution, the epitrochlear involvement, and the splenomegaly all support this. I would also consider chronic lymphocytic leukaemia, HIV-related lymphadenopathy, and infectious mononucleosis. I would investigate with a full blood count and film, a lactate dehydrogenase, an HIV test, EBV serology, and an excisional biopsy of the most abnormal node for histology, flow cytometry, and immunohistochemistry, followed by a staging CT and a PET scan." [1]

Probing questions

Q: Why lymphoma specifically, and why Hodgkin rather than non-Hodgkin? [1]

The rubbery consistency, the generalised distribution, the contiguous spread (the cervical nodes leading to the supraclavicular and then the axillary), the epitrochlear involvement, the moderate splenomegaly, and the age of the patient (Hodgkin lymphoma has a bimodal age distribution with peaks in young adults and in the over-50s) all favour Hodgkin lymphoma. Non-Hodgkin lymphoma more often produces firm rather than rubbery nodes, may be extranodal, and is more common in older patients. The distinction is made histologically — the Reed-Sternberg cell is the hallmark of classical Hodgkin lymphoma. The B symptoms (if present — I would ask about fever, night sweats, and weight loss) further support lymphoma. I would confirm the histological subtype on the excisional biopsy. [1]

Q: Why excisional biopsy rather than fine needle aspiration? [1]

Excisional biopsy removes the entire intact node, preserving the architectural pattern essential for lymphoma subtyping, and providing sufficient tissue for flow cytometry, immunohistochemistry, and molecular studies. Fine needle aspiration destroys architecture and provides insufficient material for immunophenotyping, so it is inadequate for the diagnosis and classification of lymphoma. The clinical reviews by Ferrer and by Habermann and Steensma both recommend excisional biopsy of the most abnormal node when lymphoma is suspected [3][4].

Q: How do you confirm the mass is the spleen and not the kidney? [1]

Three features. First, I cannot get above the spleen — its upper border is continuous with the diaphragm. Second, the spleen is dull to percussion. Third, the spleen has a notch. The spleen also moves with respiration and cannot be ballotted; the kidney enlarges downward, is resonant, and can be ballotted. The Grover systematic review found these manoeuvres have moderate sensitivity [1].

Second short-case scenario — massive splenomegaly

Examiner: "Please examine this patient's abdomen for organomegaly. He is 62." [1]

End of bed. The patient appears pale but not cachectic or jaundiced, and not in distress. The palms and conjunctivae are pale. [1]

Hands and face. Pallor of the palmar creases and conjunctivae. No clubbing, no stigmata of chronic liver disease, no splinter haemorrhages. [1]

Lymph nodes. No generalised lymphadenopathy — the cervical, axillary, epitrochlear, and inguinal nodes are unremarkable. [1]

Abdomen. A large mass in the left upper quadrant extending from the left costal margin to the level of the umbilicus and crossing the midline toward the right iliac fossa. It has a smooth surface, a firm consistency, and a palpable notch on its medial border. The candidate cannot get above it. It is dull to percussion. This is massive splenomegaly. There is no hepatomegaly, no ascites, and no other mass. [1]

Presentation and discussion: [1]

"My findings are of massive splenomegaly — the spleen is palpable to the umbilicus and crosses the midline, with a smooth surface and a notch. I cannot get above it, confirming it is the spleen. The most likely cause of splenomegaly of this magnitude is a myeloproliferative neoplasm — chronic myeloid leukaemia or myelofibrosis. The pallor supports a marrow-infiltrative process. I would also consider chronic malaria, visceral leishmaniasis or kala-azar, and a storage disorder such as Gaucher disease. I would investigate with a full blood count and peripheral blood film, a lactate dehydrogenase, a bone marrow biopsy with cytogenetics for the BCR-ABL translocation of CML and the JAK2 mutation of myelofibrosis, and an abdominal CT." [1]

The Grover systematic review found that clinical assessment of splenomegaly has imperfect sensitivity but that when the spleen is massively enlarged and palpable with a notch, the clinical diagnosis is reliable [1]. The key skills are to differentiate the spleen from the kidney, to grade the splenomegaly as massive, and to generate the narrow differential of CML, myelofibrosis, chronic malaria, kala-azar, and Gaucher disease.