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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”
6.0 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.
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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
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
6
tuberculosis is commonly seen in patients with HIV
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
4
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
6.3. 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.
7.0. 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
7.2. 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.
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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
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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)
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List of References:
1. Lorenz.R.R., Netterville.J.L., Burkely.B.B., Sabiston Text book of surgery, 18 th 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.
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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 :
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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) :
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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
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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
