Prof. DR. Ambar Mudigdo, Sp.PA(K) dr. Erna Sulistyowati, M.

Kes

Lymph Node

Lymph Node

1. AFF LYMPH. VES. 2. CAPSULE 3. PERI PHER SINUS 4. PARA FOLICULAR CORTEX/ T CELL ZONE

5. LYMPHOID FOLICLE/ B CELL ZONE

6. EFF LYMPH VES

7. ARTERI & VEIN

8. MEDULLA 9. MEDULLARY SINUSES

White cell Disorders

Defisiensi (leukopenia) Proliferatif

reaktif

infeksi neoplasma

Reactive leukocytosis

Peningkatan leukosit Penyebab mikrobial non mikrobial

Reactive leukocytosis
Causes of leucocytosis Neutrophilic acut bacterial infections Eosinophilic allergic Basophilic jarang,myeloproliferative disease Monocytosis chronic infections(TB),bact endocarditis, rickettsiosis,malaria Lymphocytosis accompanies with monocytosis in chronic immunologic stimulation (TB,brucellosis); viral (hep A, CMV,EBV); Bordetella pertusis.

Infectious Mononucleosis

Acute Self-limited disease Adolescent and young adult Kissing disease Caused by B lymphocytotropic EBV (member herpesvirus family) Gx:
fever,sore

throat and generalized lymphadenitis Increased lymphocytes in blood (atypical) Humoral antibody response to EBV

Polyclonal activation and proliferation of B cells

Infectious Mononucleosis

Morphology Lymphocytosis (12.000-18.000/L) Atypical lymphocytes (abundant cytoplasm,multiple nuclear vacuolation, oval, folded nucleus) Lymph nodes: typically discrete,enlarged,post cervical,axillary and groin regions) Spleen: enlarged Liver: impaired, atypical lymphocytes in the portal areas and sinusoids

Infectious Mononucleosis

Atypical lymphocytes

Reactive Lymphadenitis

Infections and nonmicrobial inflammatory stimuli cause leucocytosis but also involve lymph nodes (defensive barriers) Acute nonspecific lymphadenitis Chronic nonspecific lymphadenitis Chronic specific lymphadenitis

ACUTE NON SP LYMPHADENITIS

REACTIVE CHANGES : Micro organism Cell debris Foreign material

cervical axillaries inguinal

Macros : Enlarged, swollen, grey-red, pain. Micros : Lymphoid foll prominent, large germinal center,histiosit, neutrophil.

ACUTE NON SP LYMPHADENITIS

Reactive changes Cervical, axillaries, inguinal, mesenteric Morphology : enlarged, swollen, grey-red, distended caps tender. Histopathology : Lymph. Follicles >>, Large germ C with mitotic activity, neutrophil infiltration. Sinuses cell hyper trophi / plasia.

CHRONIC NON SP LYMPHADENITIS

Inguinal, axillaries, not tender. Histopathology: follicular hyperplasia-B cell dark zone, light zone, plasma cell, histiosit, PMN, eosinophyl. Three patterns: Follicular hyperplasia Paracortical lymphoid hyperplasia Sinus histiocytosis

CHRONIC NON SP LYMPHADENITIS

I. II. Follicular hyperplasia activated B cell, larged, round germinal center. Paracortical lymphoid hyperplasia Reactive chages T cell Viral Infection. Sinus histiocytosis. Distention-prominent sinusoid Lymph node draining cancer

III.

CHRONIC SPECIFIC LYMPHADENITIS

TUBERCULOSA

MACROS : bergerombol, packed, central caseous. MICROS

tubercle, cheese, necrotic, langhans cell,epitheloid cell.

CHRONIC SPECIFIC LYMPHADENITIS

Morphology : besar, multiple, bergerombol, tdk nyeri, livide, fistel Histopatology: tuberc, epiteloid, caseosa, langhans. Lokasi: Leher, Supraclav, axilla

NEOPLASTIC PROLIFERATIONS OF WHITE CELLS

Divided into 3 categories:

Lymphoid

neoplasms (HL,NHL,lyphocytics leukemias, plasma cells dyscrasias) Myeloid neoplasms (acute myelogenous leukemia, chronic myeloproliferative disorder,myelodisplastic syndr) Hystiocytic neoplasms proliferations of hystiocytes

LYMPHOID NEOPLASMA

LYMPHOMA

HODGKINS LIMPHOMA

NON HODGKINS LYMPHOMA

Hodgkin Disease

Chain nodes-spread characteristic Giant cells, Reed-Stenberg cell induced

Rx lymph, histiocyt, granulocyt. Nodular sclerosis mixed cellularity lymph predominant lymphocyte-depleted

Hodgkin Disease

Hodgkin Disease

Hodgkin disease

100% kel limfe Tunggal menyebar 20-40 th(30-35 th) Jenis

Nodular

sclerosis Mixed cellularity Limfositik predominan Limfositik depletion

: 65% : 25% :10%

Clinical staging of HD

HD & NHL
HD
Local lymph .CERME.ST-P.A CONTIQUITY

NHL
MULTIPHERIPHERAL NO

EXTRA NODAL UNCOMMON WALDEYER & MESENTERIC INVOLVED RARE

COMMON
COMMON

NODULAR SCLEROSIS

Most common 65-75%, , Young

Prognosa BAIK, Kel limfe Leher Supraclavicular, Mediastinum.

Nodular, Variant Reed Stenberg, Lacunar cell, collagen band, divide lymphositis-nodule.

Reed-Stenberg cell
Microskopis : Reed-stenberg cell: besar, binukleus, berhadap-kaca, kadangkadang multi nuc, single lob, sekitar halo area Lacunar cell : nodular sel

HD; mixed cell type

25%,, older, prognosa baik Diffuse heterogen cell infiltrat, classic RS cell, some mononucleus v

HD; lymphocytes predominant

6%, , <35 th, prognosa exelent Lymph leher, axilla Nodular inf by lymph small round,RS cell jarang, popcorn cell, << necrosis, fibrosis

Non Hodgkin Lymphomas

B-cell lymphoma

Chronic lymphocitic lymphoma Folicular lymphoma Diffus large B cell lymphoma Burkitt lymphoma Plasma cell neoplasm, etc.

MULTIPLE MYELOMA

PLASMA CELL bone, > , Immunoglobulin > , prot Bence Jones (urine), Midle age (50). Clinic :
Multiple bone destruct: bone pain; Vert, Ribs, Skull, pelvis, femur, R bulat oval, batas fract. Patol. Micros : plasma cell >> pleomorphic, exentric nucleus plasma blast spleen, liver, kidney, lungs Recurrent inf St.aureus, Str.pneumoniae Renal insuff; prot Bence Jones

Folicular lymphoma

NHL : paling sering(45%) ~; dewasa Micros : nodular struktur, small cell irreg. inti lebih besar, cell chrom >>, nucleoli > Clinical : painless limfadenopati, general, extra nodal rare, median survival 7-9 th Tx : Chemoteraphy, radiasi, palliative Tx

Diffuse Large B-cell Lymphoma

20% NHL <, 60 th Micros :

Diffus patern Large cell : 4-5x limf kecil Nuclei : bulat-oval, cleaved-lobulasi Anak inti : 2-3 atau 1 di tengah

Clinic :
pembesaran kel. limf., kadang-kadang extra nodal : Git, bone, brain, skin. Prog : Jelek Tx : Intensive mix chemo Tx complete remission 60-80%, 50% for several years.

T cell lymphoma & natural killer cell N

1. 2. 3. 4.

Peri T cell L UNSP Adult T cell Lymphoma Mycosis fungoides Hodgkin disease

Precursor B Cell & T cell N

Acut Lymphoblastic L
Klasifikasi bervariasi mnrt : Asal :sel B,sel T. Struktur : FOL,DIF. Vol.sel : LARGE,SM. DIFERENSIASI : WORKING FROM.,REAL CLAS.,RAPPAPORT.

ACUT LIMFOBLASTIC LIMFOMA/LEUKEMIA

di AS : 2500 KASUS BARU/TH < 15 th, kulit putih 2X > atau = , balita, < 15 th. Mic : Str Norm kel lif rusak, sel limfoblas dominan : Besar. Inti Lobulated, Mitosis >> Clinn : Anemia, Lemah, Panas acut. Infeksi, Bone pain, Spleen & liver enlargement, General limfadenopati, dll

Chronic lymphocitic / small cell limfoma

Sering pada dewasa Small B cell pd sirkulasi (leukemia) Micros : str NL rusak, Small limfosit predominan, inti kecil, kombinasi dgan sel > besar (prolimfositic) Clin :
> 50 tahun < atau = , sering asimptom, BB, lemah, anoreksi, Lekosit >>, Limfadenopatia, spleen+ Liver

Burkitt limfoma

Endemic-sporadic-agresif (Afrika). Mic : invasi intermed size sel limfosit, inti oval-bulat, nucleoli>1 kromatin kasar, mitosis>> starry sky patern (macrophages, ingest nuc debris) Clinic :
extra

nodal manifes, mandibula, organ intra Abdomen. Children, muda.

SPLEEN

SPLEEN

150 GR : 12 x 7 X 3 CM MACROS : KAPSUL TIPIS, ABU-ABU TRABEKULA PD. PARENKIM MERAH DGN BERCAK PUTIH-WHITE PULP. RED PULP. SINUSSOID DGN KAPILER DD TIPIS

FUNGSI
1.

2. 3. 4.

Pembentukan sel darah (diluar sumsum tulang). Proses hemolisis Reservoir darah, mobilisasi bila perlu Reaksi pertahanan-kekebalan tubuh, produksi limfosit dan zat anti

Gangguan sirkulasi
1.

2.
3.

4.

Bendungan akut Bendungan menahun Sindroma banti : splenomegali kongestif >>, lekopeni, anemi. Infark : Obstr. Emboli cor single/ multipleBaji.
Gamna-Gandy bodies : bercak abu2-coklat (fibrosis+ endapan pigmen) pd Banti sindrom

Splenomegali
1. 2. 3. 4. 5. 6.

Infeksi : Typ. TBC, Mal syph Congestiv : Cirh, decomp, portalthrom Limfo-hematogen dis. Immunogenic Storage dis : gaucher, niemann-Pick Lain : amyloid, neopl
Neoplasm : Jarang Benign : Hemangioma, Limfangioma, fibroma