Slide Description: This is a section of a lymph node, showing metastasis. It is composed of glandular configurations exhibiting deeply hyperchromatic, anaplastic tumor cells.

IMDEPSAASIAC:

Identify: Lymph node

Morphology: Glandular looking, hyperchromatic, anaplastic tumor cells.

Disease: Metastasis of cancer

Etiology (main): Invasion of metastatic cell(s) through the lymph vessels with subsequent deposition in the lymph nodes. Follows routes of drainage.

Pathogenic mechanism: 2 phases of metastasis: 1) invasion of ECM 2) dissemination

Invasion of ECM occurs in 4 steps:

1) dettachment of tumor cells

2) attachment to matrix components

3) degradation of ECM proteins

4) movement through interstitial space

Structural changes (specific, gross, and micro): Microscopically we see the formation of anaplastic cells with a glandular morphology.

Are there any other sites of involvement in the body? Eventual hematogenous spread.

Are there any other diseases where similar changes can be seen?

Signs / Symptoms: Enlarged lymph nodes.

Investigations (confirmation / gauge extent): Palpation, Biopsy, Sentinal Node Biopsy

Are there any other diseases you have studied where such tests can be positive?

Course of disease progress (complications, monitoring, outcome): Metastasis beyond regional lymph nodes is a sign that the cancer has spread further.

Highlight 3 important points:

1. Lymph flow is unidirectional, therefore given a location of a primary tumor you can make an educated estimate of it's probable metastasis.

2. Metastasis via lymphatics is favored by carcinomas. Hematogenous spread is favored by sarcomas.

3. Virchow's lymph node is a possible sign of a primary carcinoma in the viscera. (See below)

Lab Questions:

1. Which neoplasms spread preferentially by lymphatic route?

Carcinomas

2. Which lymph nodes get involved in primary bronchogenic carcinoma?

Intrapulmonary lymph nodes --> left and right bronchopulmonary (hilar) lymph nodes --> carinal lymph (inferior tracheobronchial) nodes --> tracheobronchial lymph nodes --> paratracheal lymph nodes --> jugular trunk --> thoracic duct

An unusual feature of this anatomy is that carinal nodes, collect lymph from the left lower lobe but drain that fluid into the right tracheobronchial lymph nodes. This is significant because a suspicious-appearing lymph node in the right hilar region should prompt evaluation of the left lower lobe and the right lung.

3. What is Virchow's lymph node?

A firm, palpable, supraclavicular lymph node, usually on the left side, whose tumorous condition is usually secondary to primary carcinoma in one of the viscera. Also called jugular gland, signal node.

Vignette

A first generation 67 yo Japanese female patient comes in for the first time for a complete physical. Before this visit she has only been in to see a physician once for a laceration on her forearm she received while pruning her roses. There is no history of smoking, alcohol consumption. Her daily diet consists of smoked dried fish, pickled vegetables, and rice. On performing the physical you notice a swollen left supraclavicular lymph node. You're concerned that this may be a sign of asymptomatic gastric cancer given her ethnicity and diet. A xray with barium contrast and gastroscopy confirm his differential.