RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA, BANGALORE

ANNEXURE – II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

(to be submitted in duplicate)

1. Name of the Candidate & : Dr.PRADEEP KULAL.R.

Address (in block letters) # 10 “Sri Manjunatha Nilaya”,

5th cross, kalyan nagar, T.Dasarahalli, Bangalore-560057

2. Name of the Institution : Mysore Medical College & Research

Institute, Mysore

3. Course of Study & Subject : M.S. (General Surgery)

4. Date of Admission to Course : 16/6/2010

5. Title of the topic : “A CLINICO-PATHOLOGICAL

STUDY OF CERVICAL

LYMPHADENOPATHY”

6. BRIEF RESUME OF THE INTENDED WORK

6.1 Need for the Study

The Prime function of lymph node is to deal with antigen, whether this be in the form of organisms or other particulate material, or even soluble antigen. Lymph nodes are strategically placed along the drainage of tissue and body fluids, they are most numerous in those areas which are in direct contact with the exterior of the individual.

Neck consists of 300 Lymph nodes nearly 1/3 of total lymph nodes of the body. The enlargement of these nodes is significant because of many etiologic factors.

Lymphadenopathy is a very common clinical manifestation of many diseases. It is defined as an abnormality in the size or character of lymph nodes, caused by the invasion or propagation of either inflammatory cells or neoplastic cells into the node. It results from vast array of disease process whose brand categories are “MIAMI”, this represents malignancies, infections, autoimmune disorders, miscellaneous and iatrogenic causes.

Lymph Nodes may be the only site of disease. However most nodal disease is related to abnormalities in the organ associated with the abnormal node.

The analysis of lymph node enlargement in the neck is not an easy task and the diagnosis of the condition is a problem because most of the diseases resemble each other.

The swelling in the cervical region can be diagnostic challenge. The study intends to find out systematically the various pathological conditions presenting with enlarged lymph nodes in the neck, also the various modes of clinical presentation and behaviours of these conditions. It also intends to know the role of FNAC in diagnosing these conditions after correlating with a lymph node biopsy confirmation.

6.2. Review of Literatures

Bacterial cervical adenitis is most often caused by group A hemolytic Streptococci or S.aureus. Srofula is cervical adenitis secondary to tuberculosis1

The regional lymphatic drainage of the neck is divided into seven levels. These levels allow for a standardised format for radiologists, surgeons, pathologists, and radiation oncologists to communicate concerrning specific sites within the neck2

Lymphadanopathy is common in HIV infected patient. FNA Biopsies are generally performed in this population to rule out infection or a neoplasm such as malignant lymphoma of kaposis sarcoma. However persistent generalized lymphadenopathy is a part of the spectrum of HIV associated disease.3

Fine needle aspiration biopsy may be a means of diagnosing and straging Hodgkin’s disease. In one study, the accuracy for diagnosing Hodgkin’s disease was over 90%. Fine needle aspiration may be of greater use in the diagnosis of recurrence of Hodgkin’s disease, as Hodgkin cells are sometimes more easily identified in this instance4

Approximately 10% of patients with cancers of head and neck present with a clinically palpable metastatic lymph Node without any evidence of an obvious primary tumour. A systematic workup for these patients is essential to establish accurate tissue diagnosis and embark upon a systematic search for identifying the occult primary tumor, so as to facilitate therapeutic plan5

Peripheral lymph node involvement is the commonest form of extrapulmonary tuberculosis and the cervical region is the most frequently affected site. Peripheral and mediastinal lymph node tuberculosis is commonly seen in patients with HIV6

After all relevant investigations if Lymphoma is suspected, open biopsy should be done for confirmation and fresh tissue should be submitted to to the pathologist7

FNAC has an important role in the diagnosis of disease of enlarged cervical lymph nodes and good diagnostic yield. Procedure is easy, safe, simple, quick, inexpensive and reliable but biopsy of cervical lymph node is most important so far as diagnosis is concerned. However both the procedures are invasive8

The study done by Haque M.A.2003 concludes that before resorting to surgical intervention FNAC is a helpful procedure in the diagnosis of both the neoplastic and non neoplastic lesion of the lymph node. He reported sensitivity and specificity of 82.76% & 97.92% respectively for malignancy of lymph node9

Sonographically guided core biopsy is a safe and efficient tool for diagnosing the cause of cervical lymphadenopathy in patients without known malignancy and may prevent unnecessary excisional biopsy10

Appropriate patient management of cervical lymphadenopathy has to be timely, with the minimum morbidity, but must also be accurate. Current opinion would suggest that a neck lump clinic with a clinician and radiologist who can carry out ultrasound with FNAC and/or core biopsy is desirable11

Tubercular lymphadenitis is a common disease in cervical region. It is now rare in developed countries. It is more common in children and adolescent age group. Jugulodigastric nodes are more affected. It is not secondary to pulmonary tuberculosis. Females are affected more than males and non-vaccinated people suffer more12

3. OBJECTIVES OF STUDY

The objectives of the study are

1. To study about the various clinical presentations of cervical lympadenopathy.

2. To correlate pathological findings with the clinical diagnosis.

3. To study the role of FNAC by correlating with confirmed biopsy report.

4. To study the management, outcome and clinical behaviour of cervical lymph nodes on follow up.

7. MATERIALS AND METHODS

7.1. Source of Data

The material consists of inpatients in all surgical units and out patients of K.R. Hospital attached to MMC & RI. During the period of January 2011 to July 2012

2. Method of collection of Data

Total 40 cases clinically presenting as cervical lymph Node swelling during the period of January 2011 to July 2012 will be taken for study. Each case will be examined clinically and properly in systematic manner as per the proforma drafted for study of all patients presenting with cervical lymph node swelling.

Inclusion Criteria

1. Patient more than 12 years of age

2. Patients presenting with cervical lymph node enlargement

Exclusion Criteria

1. Patients less than 12 years of age

2. Patients where FNAC and / or biopsy of node could not be carried out were excluded.

7.3 Does the study require any investigation/intervention to be conducted on humans /animals? If so, please describe briefly.

Following investigastions will be undertaken:

a. Routine Investigations

Blood:

Hb% FBS

TC Blood Urea

DC Serum Creatinine

ESR

BT

CT

Urine:

❖ Albumin

❖ Sugar

❖ Microscopy

Radiological:

Chest X-Ray

b. Specific (Optional)

❖ X-ray: neck/skull/abdomen

❖ Sputum for AFB

❖ Mantoux test

❖ Peripheral smear cytology

❖ FNAC of swelling

❖ Lymph node HPE

❖ ENT surgeons opinion

❖ Barium swallow / meal

❖ Thyroid profile

❖ Ultrasound abdomen

❖ Endoscopy

7.4. Has ethical clearance been obtained from your Institution

Obtained (Copy enclosed)

List of References:

1. Lorenz.R.R., Netterville.J.L., Burkely.B.B., Sabiston Text book of surgery, 18th edition, Elsevier 2010, Chapter 33, Head & neck, P837.

2. Wein.R.O., Chandra.R.K., Weber.R.S., Schwartz’s principles of surgery, 9th edition, MC Graw hill 2009, Chapter 18, Disorders of the head and neck’ P503.

3. Silverberg.S, Delellis R A, Frable WJ. Principle and practice of surgical pathology and cytopathology: Lymph Nodes and spleen 3rd edition, London: Church hill living stone; 1997.

4. Dass D.K., Gupta.S K, Datta B M Et.al. Fine needle aspiration cytodiagnosis of Hodgkin’s disease and its subtypes: Scope and limitations Acta.Cytol.1989;34:329-36.

5. Shah.J.P., Patel.S.G., Jatin Shah Head & neck surgery and oncology, 3rd edition, Elsvier science publication 2003, Chapter 72, Cervical Lumph nodes; P360.

6. Kumar.A., “Tuberculosis” 1st Edition, J.P. Brothers Medical publishers Ltd., New Delhi 2001, Chapter 23, P273.

7. Roseman B F, Clark D.H., “ACS Surgery principles and Practice” 6th Ed. Web MD 2007 Chapter 74, Pg No.157.

8. Rahman.M.M., ASQM, Sadeque, Elizer Omar Et.al “Ultrasound differentiation of Benign and malignant cervical lymph nodes” Ibrahim Med.Coll.J.2009; 3(2):40,41.

9. Hagne MA, Talukder SI. Evaluation of Fine Needle aspiration cytology FNAC of lymph Node in mymensingh med.J.2003;12(1)33-5.

10. Kim.B.M., Kim.E.K., Kim.M.J. et.al Sonographically guided core needle biopsy of cervical lymphadenopathy in patients without known malignancy. J Ultrasound med 2007;26:585-591.

11. SAH Savage, HA watherspoon, EJ Fitzsimons et.al cervical lymphadenopathy resulting in a diagnosis of lymphoma. Scottish medical journal 2008;53(1):13.

12. Biswas.P.K, Begum.S.M.K., Tubercular cervical lymphadenopathy clinicopathological study of thirty cases. Teachers Association journal 2007; 20(1):36-38.

9. SIGNATURE OF THE :

CANDIDATE (Dr.PRADEEP KULAL.R.)

10.0. REMARKS OF THE GUIDE :

11.0 NAME & DESIGNATION OF :

(in block letters)

11.1. Guide Prof.Dr.B.K.Ramu

M.S.(General Surgery)

Professor

Department of Surgery

K.R.Hospital

M.M.C & R.I. Mysore.

11.2 Signature :

11.3 Co-Guide (If any) :

11.4 Signature :

11.5 Head of the Department : Dr.Avadhani.K.Geetha

M.S.(General Surgery)

Professor

Head of the Department of

Surgery

K.R.Hospital

M.M.C & R.I. Mysore.

11.6 Signature :

12.0. 12.1 Remarks of the Chairman

& Principal :

12.2 Signature :

ETHICAL COMMITTEE CLEARANCE

1. Title of Dissertation : “A CLINICO-PATHOLOGICAL

STUDY OF CERVICAL

LYMPHADENOPATHY”

2. Subject : M.S. GENERAL SURGERY

3. Name of the Candidate : DR.PRADEEP KULAL R

4. Name of the Guide : DR. B.K. RAMU

M.S. (General Surgery)

Professor,

Department of Surgery,

Mysore Medical College &

Research Institute, Mysore.

5. Approved / not approved

(If not approved, suggestions) :

MEMBERS OF THE ETHICAL CLEARANCE COMMITTEE

PROFESSOR & HOD PROFESSOR & HOD

DEPARTMENT OF SURGERY DEPARTMENT OF MEDICINE,

MYSORE MEDICAL COLLEGE & MYSORE MEDICAL COLLEGE &

RESEARCH INSTITUTE, RESEARCH INSTITUTE,

MYSORE MYSORE

MEDICAL SUPERINTENDENT MEDICAL SUPERINTENDENT

K. R. HOSPITAL CHELUVAMBA HOSPITAL

MYSORE MYSORE

MEDICAL SUPERINTENDENT LAW EXPERT

PKTB HOSPITAL

MYSORE

DEAN AND DIRECTOR PRINCIPAL

MYSORE MEDICAL COLLEGE MYSORE MEDICAL COLLEGE

& RESEARCH INSTITUTE & RESEARCH INSTITUTE

MYSORE MYSORE

From,

Dr.PRADEEP KULAL R.

Post-graduate in General Surgery

Department of General Surgery

Mysore Medical College & Research Institute

Mysore.

To,

Registrar (Evaluation)

Rajiv Gandhi University of Health Sciences

Bangalore.

Through proper channel.

Respected Sir,

Subject: Submission of Synopsis titled “A CLINICO-PATHOLOGICAL

STUDY OF CERVICAL LYMPHADENOPATHY”

I am hereby submitting the above titled synopsis (4 copies) as mentioned above, so kindly accept my application and do the needful.

Thanking you,

Yours faithfully,

(Dr.PRADEEP KULAL R.)

Forwarded to Dean and Director, MMC & RI, Mysore for further needful action

Professor and Head,

Date: Department of Surgery,

Place: MMC & RI, Mysore

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