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Introduction: The primary morbidities of inguinal and axillary systematic nodal dissection are lymphatic fistulas and seromas. Intraoperative fluorescence imaging-guided sealing of lymph vessels may prevent these postoperative complications., Methods: Indocyanine dye was injected intracutaneously into the distal limb before the beginning of the lymphadenectomy. Systematic nodal dissection was performed according to standard protocols. Near-infrared imaging was applied throughout the procedure and real-time fluorescence-guided lymph vessel sealing was performed., Results: Fluorescence-guided lymph vessel sealing was implemented in three patients undergoing axillary systematic lymph node dissection. No adverse events occurred following fluorescence dye injection. All patients could be discharged free of wound complications., Conclusion: Fluorescence-guided lymph vessel sealing might be a promising new technique for preventing lymphatic fistulas and lymphocele after systematic lymphadenectomy., Competing Interests: Ioannis Karampinis hat keinen Interessenkonflikt zu erklären. Andreas Gerken hat keinen Interessenkonflikt zu erklären. Christoph Reissfelder hat keinen Interessenkonflikt zu erklären. Kai Nowak ist als Berater im Bereich der intraoperativen Fluoreszenztechnologie für Stryker und Novadaq tätig. Jens Jakob hat keinen Interessenkonflikt zu erklären., (Thieme. All rights reserved.)

Reactive and neoplastic thymic pathologies are the main considerations in the case of masses in the anterior and middle part of the mediastinum, while neurogenic tumors are predominant in the posterior mediastinum (which are not dealt with here). In neonates and infants, the commonest pathologies in the anterior mediastinum comprise germ cell tumors (mainly teratomas), congenital thymic cysts and true thymic hyperplasia (TTH). In toddlers, teratomas, yolk sac tumors and cysts predominate. In children over 5 years of age, lymphomas are the commonest mass lesions whereas thymomas and thymic carcinomas are rare. In addition, inflammation-linked hyperplasia in myasthenia gravis and rebound thymic hyperplasia after chemotherapy must be considered. Although rare at all ages, sarcomas must be considered in the differential diagnosis from birth onwards and throughout adolescence. Based on the report of a rare case of recurrent TTH, the differential diagnosis of this benign but potentially life-threatening condition is discussed.

Fine needle aspiration of peripheral lymph nodes is a minimal invasive procedure to extract material for cytological analyses. The method is safe, rapidly to apply, less expensive and almost painless for the patient. The puncture of low-lying lymph nodes shoud be performed via ultrasound navigation., (© Georg Thieme Verlag KG Stuttgart · New York.)

The lymph nodes are an essential part of the body's immune system and as such are affected in many infectious, autoimmune, metabolic and malignant diseases. The cervical lymph nodes are particularly important because they are the first drainage stations for key points of contact with the outside world (mouth/throat/nose/eyes/ears/respiratory system) - a critical aspect especially among children - and can represent an early clinical sign in their exposed position on a child's slim neck. Involvement of the lymph nodes in multiple conditions is accompanied by a correspondingly large number of available diagnostic procedures. In the interests of time, patient wellbeing and cost, a careful choice of these must be made to permit appropriate treatment. The basis of diagnostic decisions is a detailed anamnesis and clinical examination. Sonography also plays an important role in differential diagnosis of lymph node swelling in children and is useful in answering one of the critical diagnostic questions: is there a suspicion of malignancy? If so, full dissection of the most conspicuous lymph node may be necessary to obtain histological confirmation. Diagnosis and treatment of childhood cervical lymph node disorders present the attending pediatric and ENT physicians with some particular challenges. The spectrum of differential diagnoses and the varying degrees of clinical relevance - from banal infections to malignant diseases - demand a clear and considered approach to the child's individual clinical presentation. Such an approach is described in the following paper., (© Georg Thieme Verlag KG Stuttgart · New York.)

Recognition of the differential diagnosis between lymphadenitis and malignant lymphoma requires good knowledge of the basic forms of the disease as well in depth knowledge of the structure of the individual compartments. There are defined forms of lymphadenitis where the differential diagnosis to certain lymphoma entities is known. Other reactive structural alterations show indistinct limits so that a decision is only possible after using additional techniques, such as immunohistochemistry and molecular analyses. Finally, there are marginal areas which can only be clarified by including clinical data.

Background: According to recent clinical trials, EUS-FNA has a high diagnostic yield in case of mediastinal and abdominal lymphadenopathy. However, it is questionable, if the results of centers of excellence can be maintained in daily clinical practice., Methods: We retrospectively analyzed the results of 141 EUS-FNP in 121 patients (female 25, male 86; mean age 61,5 years, range 22-87) of 119 mediastinal and 22 abdominal lymph nodes, performed under routine conditions in daily clinical practice in a community hospital. Histopathological examination of operative specimens or clinical follow-up served as gold standard., Results: In 124/141 (80 %) of cases, adequate specimens could be obtained, irrespective of lymph node size. During follow-up, the rate of adequate specimens obtained increased from 77 % (2002-2006) to 98 % (2007-2010). Sensitivity and specifity for the diagnosis of malignancy was 77 and 100 % (diagnostic accuracy 92 %). During follow-up, a relevant learning curve could be observed with a significant increase in sensitivity (72 to 80 %)., Conclusion: In comparison to the results of centers of excellence, our diagnostic accuracy is slightly inferior. However, even in daily routine praxis, EUS-FNP is a safe and accurate method of sampling mediastinal and abdominal lymph nodes., (© Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: After ilioinguinal radical lymph node dissection (RLND), the therapy for lymph fistulas constitutes a challenge. Risk factors for the genesis of lymph fistulas have not been sufficiently evaluated. We investigated possible factors that could influence the development of lymph fistulas in patients suffering from malignant melanoma after iloinguinal RLND., Patient and Methods: The analysis was related to patients with intransit and lymphonodal metastasised malignant melanoma of the lower limb, who underwent RLND and isolated limb perfusion (ILP). Prospective data acquisition from patients undergoing ilioinguinal RLND and ILP in a one-step approach was performed. The association of lymph fistulas to risk factors was calculated using chi-squared, linear-by-linear test and ROC curves. As possible risk factors we investigated the presence of prior surgery and diabetes mellitus type II in the medical history, chemotherapeutics, patient age and the body mass index (BMI)., Results: Postoperative lymph fistula occurred in 11 of 108 patients (10.2%). A significant association to lymph fistulas was found in BMI (30.2± 7.0 kg/m (2), p<0.02). Other parameters, such as prior surgery (82% vs. 71%), diabetes mellitus type II (9% vs. 11.7%), chemotherapeutics and patient age (mean 67.8 vs. 62.4 years) showed no influence., Conclusion: Our results indicate that the incidence of lymph fistulas after RLND and ILP of malignant melanoma of the lower limb was associated with an increased BMI. Thus, for the prevention of lymph fistulae, an initially alternative wound-closure dressing like vacuum assisted closure (V.A.C.) dressing could be of clinical relevance for obese patients., (© Georg Thieme Verlag KG Stuttgart ˙ New York.)

We report the case of a 62 year old women with chronic idiopathic myelofibrosis who developed acute lymphadenopathy. At the same time diabetes insipidus, osteolytic bone lesions and exanthema of the skin were diagnosed. Suspected Langerhans cell histiocytosis could be proven by repeated biopsies of affected organs. Therapy was started in accordance with the recommendations of the Histiocyte Society.

History and Admission Findings: A 20-year-old female patient presented with painful axillary lymphadenopathy. She reported a tick bite five months ago in her right hand followed by fever, chills and regional lymphadenopathy. Empiric antibiotic treatment with doxycyclin and ciprofloxacin had led to defervescence but no change in painful lymph node swellings. Surgical removal of a cubital lymph node had already been performed three months after the tick bite., Investigations: Laboratory findings were normal except for moderate elevation of C-reactive protein. Serology confirmed the suspected clinical diagnosis of ulceroglandular tularemia. Retrospective real-time PCR (markers fopA and tul4) for Francisella tularensis from the previously removed lymph node (paraffin tissue blocks) was negative., Diagnosis, Treatment and Course: Clinical presentation and serological test results were consistent with a prolonged course of tick-borne ulceroglandular tularemia associated with reactive lymph node swelling. The patient requested surgical removal of the painful axillary lymph node. Histology showed reticulocytic, abscess forming lymphadenitis with pseudotuberculosis type of granulomatosis and negative acid-fast staining. Blood culture, capture ELISA and real-time PCR for Francisella tularensis performed on material from the lymph node preparations were negative. A complete recovery was achieved without renewed antibiotic treatment., Conclusions: According to recent seroprevalence studies, the emergence of tularemia as a rare zoonosis in Germany is clinically underestimated. This case report illustrates possible appearance of the disease in other than known risk groups (e.g. hunters, lumbermen). Ectoparasites like infected ticks have to be considered as vectors, even in non-endemic regions.

Percutaneous and endoscopic ultrasound are very useful complementary imaging tools in the detailed assessment of physiological as well as pathological lymph nodes in almost all anatomical regions of the human body. A comprehensive consideration of various features obtained by gray-scale and color Doppler sonography is the basis of the differentiation of benign from malignant lymphadenopathy. Sonographic elastography and contrast-enhanced sonography may provide further information. Nevertheless the sonographic differential diagnosis of enlarged and structurally altered lymph nodes has some limitations. (Endoscopic) ultrasound guided biopsy permits histological diagnosis of pathological lymph nodes with minimal risk, low cost, and high diagnostic accuracy. The sonographical evaluation of lymph nodes is an essential adjunct to the clinical investigation in staging of malignant tumors and lymphoma, in the case of palpable lymph nodes, and in various benign diseases.

Diagnostic lymph node pathology is primarily focused on identification, definition and classification of lymphoid neoplasms. Less attention is paid to reactive lymph node changes as their causes often cannot be elucidated. We outline several particular types of lymph node reactions that allow a delineation of potential causative agents. A thorough understanding of the morphology of reactive lymph node changes can also aid in the differential diagnosis between reactive and neoplastic lymph node changes.

We report a case of a 49-year-old woman from the Philippines, who has been living for many years in Switzerland, with chronic unilateral swelling of the cervical lymphnodes. After the serological exclusion of several microorganisms, a fine needle aspiration was performed without conclusive result. However, patient history and a strongly positive PPD skin test were highly suspicious for tuberculous lymphadenitis, which was finally confirmed by lymphnode biopsy on histopathological and cultural workup. Therefore tuberculostatic treatment was initiated for 6 months.

We report the case of a young woman, who presented a sus-clavicular adenopathy with fever and inflammatory syndrome. A cervico-thoracic scan reveals sus-clavicular and hilar adenopathies with central necrosis. Laboratory studies, including blood culture and viral serologies were negative, and excluded an infectious aetiology. Clinical features and anti-nuclear antibody tests were not compatible with an inflammatory autoimmune disease. Bone marrow examination and lymph node histology didn't show any malignant cell. Histology analysis of the lymph node showed a typical aspect of histiocytic necrotizing lymphadenitis. This is compatible with the diagnosis of Kikuchi's disease.

Malignant lymphomas are differentiated clinically, morphologically and molecular-biologically, into aggressive (formerly high-grade malignant) and indolent (formerly low-grade malignant) lymphomas. In the meantime, virtually all patients can be diagnosed and treated on an ambulatory basis. The introduction of the monoclonal antibody rituximab (R) in combination with chemotherapeutic agents, has led to the development of highly potent forms of chemoimmunotherapy. In the case of aggressive lymphomas, R-CHOP has been shown to be significantly superior to CHOP alone, both in elderly and younger patients. In stage III and IV indolent (follicular) lymphomas, rituximab/chemotherapy combinations achieve response rates in excess of 90%, and prolonged progression-free survival rates which, for the first time hold out hope of a cure. Monoclonal antibodies that can be coupled to radioisotopes open up new possibilities for potent radioimmunotherapy which look promising for effecting a cure or long-lasting palliation in additional proportion of the patients.

The capsular rupture and subsequent extranodal spread of lymph node metastases is of crucial and well established prognostic value in patients with squamous cell carcinomas of the upper aerodigestive tract. Besides the basic histologic definition of the extranodal spread (i.e. contact of the metastasis with perinodal fatty tissue), there is no agreement on the morphologic extent of transcapsular spread. As a measure of improvement, a histologic evaluation differentiating between seven gradual types of metastatic nodal affection was applied. The histologic scheme considers intranodal growth, infiltration of the capsule, the presence of desmoplasia and especially the rupture of the capsule and the subsequent extranodal spread of the metastasis. As extranodal spread is an easily reproducible and reliably significant prognostic criterion, it should be included in the current TNM classification, e.g., by an addition of the index R+ (lymph node metastasis with capsular rupture) or R- (lymph node metastasis without capsular rupture) to the N category.

Lymphadenopathy is a very common problem that affects patients of all ages. Differential diagnosis is extensive, in general lymph nodes that have been present for longer than 1 month and measure more than 1 x 1 cm should be considered for further examinations, including laboratory testing and biopsy for histological and microbiological examinations.

The aim of this study was to calculate the reliability of the examination of lymph node cytologies by individuals with little experience in the field of cytology. After an introduction comparable to the content of a cytology seminar, 11 students of veterinary medicine were asked to assess 20 slides with different lymphadenopathies (hyperplasia: n = 4, lymphadenitis: n = 4, malignant lymphoma: n = 4, different other neoplasias: n = 8). A correct classification according to these categories was achieved on the average (median value) in 18 of the 20 cases (minimum: 16, maximum: 20). The majority of the investigators also found a correct further differentiation for some slides, particularly with respect to the type of non-lymphatic neoplasia. The results of this study emphasize that the experience gained in a single cytology seminar enables only few individuals to reliably differentiate lymphadenopathies. The error rate, which was 10 to 20% for the majority of the investigators, however, has to be assessed critically due to the clinical consequences of misdiagnosis. This emphasizes the necessity of experience even for interpretation of lymph node cytology.

Monocytoid B-cells appear as a distinct B-cell population in a number of lymphadenopathies but above all in Piringer's lymphadenopathy. Up until now, their assignment to a recognised B-cell subpopulation has not been conclusively achieved. Immunohistological studies have shown characteristics in common with the tumour cells of hairy cell leukemia and also with so-called splenic marginal zone cells. In order to unequivocally clarify their B-cell differentiation stage we have isolated single monocytoid B-cells from immunostained frozen sections and have analysed their immunoglobulin chain gene rearrangements. In addition we have studied the Ig-expression of monocytoid B-cells at both the RNA and protein levels.

The article deals with the case of an inflammatory pseudotumour of the lung in conjunction with histoplasmosis of the hilar lymph glands in a 35-year-old immunocompetent woman in a non-endemic area. She had been suffering from headaches and painful swelling of the lower legs, reddening and hyperthermia for 1.5 years. In addition to the above-mentioned symptoms she also complained of a typical flush syndrome which had begun a year later. The main paraclinical finding was a round mass in the right lung in chest radiography. After considering various differential diagnostic possibilities, thoracotomy and resection of the upper lobe of the right lung were performed. The histological diagnosis of the material removed was that of an inflammatory pseudotumour of the lung, combined with histoplasmosis of the hilar lymph glands. Following a postoperative period without complications, antimycotic treatment was performed. The discussion includes whether the simultaneous occurrence of these two diseases is coincidental or whether there is a causal relation between the two. The authors also discuss various treatments with reference to the relevant literature.

Cervical lymphadenopathies are widespread diseases in otorhinolaryngology. There are many differential diagnoses which have to be considered when swelling persists. To gain further information it is advisable to perform sonographically controlled fine needle aspiration biopsy (FNP). If there is no reliable result, it is necessary to remove a lymph node. We report on the rare case of isolated histiocytosis X in lymph nodes. A 63-year-old male had noticed a swelling of the right side of the neck about 6 weeks previously. The preliminary examinations (FNP/blood examinations) revealed no pathological findings. Only the histological examination delivered the diagnosis of histiocytosis X. Systemic manifestation was excluded by staging examinations. No further therapy was necessary after lymph node extirpation. The report demonstrates how to diagnose and treat this rare disease.

The cytological preparation of a lymph node is a relatively simple technique. A fine needle aspirate is smeared as a blood sample and stained with a hematological method, Wright-stain or Diff-Quik. The microscopical examination can be completed in a few minutes. The cytology of a lymph node is a valuable diagnostical step for the classification of a lymphadenopathy. Reactive hyperplasia, forms of lymphadenitis, primary or metastatic neoplasias, microorganisms and parasites can be diagnosed.

Standard techniques for the detection of mycobacteria in granulomatous diseases can be inadequate. We analysed 71 formalin fixed and paraffin-embedded tissue blocks from 68 non-immunocompromised patients with caseating, non-caseating, scarred, and miliary granulomas of lung and lymph nodes. A reamplification PCR protocol was established to detect a 123 bp product of the repetitive insertion sequence IS986/IS6110. After exclusion of 6 PCR-negative cases with clinical sarcoidosis 97% of lung tissue blocks with more than 10% caseating and non-caseating granulomas contained mycobacterial DNA. By routine microbiology mycobacteria could be detected in 78% of the patients. Scarred granulomas were PCR-negative. All miliary granulomas were PCR-positive. Lymph nodes showed comparable results. We think that this method facilitates aetiologic analysis of granulomatous diseases especially when the suspicous tissue is fixed and microbiology is not available.

An attempt was made by means of microbiological and histomorphological methods for diagnostic elucidation of reactive lymphadenopathies in 52 patients. The serological findings differed from those recorded from clinically intact individuals, in that they included not only increased prevalence of antibodies but also increased antibody titres to cytomegalovirus, influenza virus, and toxoplasma gondii. The dynamic of antibody titres against antigens specific of herpesvirus, influenza virus, and toxoplasma gondii were followed up and enabled positive detection in 11 of 18 patients of active infections with the above pathogens involved. Histologically, the lymph nodes affected were characterised by alterations reminiscent to Piringer lymphadenitis. While, in the course of bacteriological investigations, various bacterial species were isolated from lymph node tissue of 35 patients, direct morphological identification from lymph node sections failed to work. Immature sinus histiocytosis and an increase in phagocytosis activity were among the typical tissue findings.

The disease is characterized by a painless tender and mainly worm-like lesion which partly or totally encircles the distal penis, proximal of the sulcus coronarius. Usually, there are no local or regional inflammatory signs of the glans, preputium, or the inguinal lymph nodes. The anatomic target is a lymphatic collecting vessel. The pathologic process is morphologically based on three major features: lymphostasis, coagulation thrombus formation, and vessel wall thickening. We therefore propose the term lymphangiofibrosis thrombotica occlusiva. Men 20-40 years of age are most commonly affected. A therapeutic measure is not necessary, unless there is no spontaneous regression which one can except in 90% of the patients within 2 months. Mechanical and unknown microbiologic insults are discussed as etiological factors. Furthermore, the topographical distribution of blood and lymphatic vessels of the distal penis region is delineated. Six patients are presented with the clinical data.

Histological examination of 187 tumours from 98 hens (laying hybrids of various lines, age 80-123 weeks) showed that highly-differentiated tubulo-alveolar adenocarcinoma was present in 95% of the birds; in 20% it had a scirrhus structure. Histological and ultrastructural features of these carcinomas and their tendency to form secretory granules pointed to an origin from the protein-secreting part of the oviduct (magnum). In the remaining 5% of birds there were non-specific adenocarcinomas (probably ovarian carcinoma) and mesotheliomas.

Four cases of acute mucocutaneous lymph node syndrome (Kawasaki-Syndrome) are presented This syndrome of yet unknown cause is quite frequent in Japan but lately it is being encountered with growing frequency in Europe, too. The significant clinical and diagnostical features of the disease are laid out and differentialdiagnostical and therapeutical questions are discussed. 1-2% of the children die suddenly or coronary thrombosis. Analogies with infantile polyarteritis nodosa which can be equally lethal and Kawasaki-Syndrome are examined.

Clinical, lymphographic and morphologic non tumor induced lymphnode lesions of 164 patients are described, and a roentgenographic morphological correlation is performed. Diffuse non specific inflammatory and reactivy lymphnode lesions are divided into three groups. These changes cannot be distinguished from lymphnodes with micrometastases. Typical cirteria for segmental lymphnode fibrosis and hyperplasia are described. Fatty lymphnode degeneration may be segmental or diffuse, their characteristics are presented as well.

A case of an unusual development of Wegener's granulomatosis is described. A long-term immunosuppressive therapy led to intermittent involution of the process, but finally a transformation to a new disease, for present qualified as "malignant histiocytosis" was the result. The cause of the transformation and the differentiation from other necrotising granulomas are discussed.