Friday, June 03, 2005

Follow up: enlarged hilar lymph nodes

See original post, to which this followup refers.
Based upon a paper by Winterbauer et al. Ann Intern Med 1979; 78:65 where he examined 5000+ pateints with sarcoidosis, lymphoma, TB, and metastatic ca, I decided to watch.

Of those 5000+, 100 had isolated bilateral hilar adenopathy (no other abnormalities on CXR). 30 of the 100 with bilateral hilar adenopathy were asymptomatic, and all 30 of those had sarcoidosis. This is the basis of the concept of not requiring a biopsy for asymptomatic bilateral hilar adenopathy.

Joe Lynch frequently quoted this paper in clinic, so he was not an advocate for
As someone mentioned in the comments, pelvic lymph nodes occur in sarcoid frequently enough so that we did not go after enlarged lymph nodes in asymptomatic patients.

My big worry is her reduced pulmonary function; however, this could have occurred 4 years ago and I would not have known it.

So my plan: watch her for 3 months and repeat a chest CT (to look at the lymph nodes) and repeat the PFT's. If she has larger LAD or worsening PFT's, she buys a bronch with multiple biopsies to make a diagnosis.

Let me know what you think.

4 comments - CLICK HERE to read & add your own!:

Jeff H said...

I never read that paper. Sure, pelvic nodes are common, but I don't know how common upper-abdominal nodes are. In either case, as I previously mentioned, as long as her abdominal symptoms resolved I think observation is fine. If a lymphoma or infection was causing the abdominal pain and was associated with the LAD, I would not expect it to resolve spontaneously.

DKeena said...

I think monitoring her is a resonable way to proceed.
Did the patients in that study have PFT abnormalities? Could they do a DLCO in 79?

She would be technically stage 1 sarcoid with the normal CXR, but the nodules on chest CT, abdominal involvement, and reduced DLCO are concerning. I've been calling these folks stage II and offering therapy vs monitoring. I would probably take a more agressive route, bronch her, get a Dx, and then decide on therapy based on her preferences.

Baleeiro said...

The choice on 3 months for waiting time seems reasonable. Furthermore, if she has another pathology (e.g. lymphoma) she has had very slow progression and already has disease on both sides of the diaphragm so therapy options won't change much in those 3 months.

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