PRESKAS 4 Virchowv Node

7/21/2019 PRESKAS 4 Virchowv Node

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CASE PRESENTATION

A. PATIENT IDENTITY

Name : Ms. FAge : 19 years oldSex : Female

Address : Lemah Tambah

Religion : MoslemMarital Status : Not married

B. ANAMNESIS

• Main Grievance

Lump on the let ne!"

• Historical of Present DiseaseThe patient !ame to the hospital Ar#a$inangun be!ause there $as a lump on her

ne!" sin!e % years ago. Sometimes she elt the pain on her lump and sometimes the lump

getting small but sometimes getting bigger. At irst& the lump as big as marble and sin!e

then the lump getting big by times.

There is no lump on the other parts o her body. 'atients not !omplaining e(er&

asthma& nausea or (omiting& and abdominal pain.

• Historical of Past Disease

)ipertension *+,-iabetes Melitus *+,

• Historical of Fail! Disease

)ipertension *+,

-iabetes Melitus *+,The patient said there $as no one o his amily member that ha(e a disease li"e him

MEDICA" E#AMINATION

• Present Stat$s

• eneral /ondition : Moderate

• A$areness : /omposmantis

• 0lood 'ressure : 12342

• 'ulse : 95 x3minute

• 0reathing : %6 x3minute

• Temperature : 7&5 8/

• General Stat$s

Hea%

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• Form : Normal& Simetri!al

• )air : 0la!" /olour& No hair all

• ye : Anemi! /on#ungti(al +3+

!teri! S!hlera +3+

Light Rele"s *;,

so!or pupil right < let

• ar : Normal orm& !erumen *+,& tympani membrane inta!

• Nose : Normal orm& No septum de(iation& epita!tion +3+

• Mulut : Normal

Nec&

• nlargement lymph nodes *+,

• Tra!hea in the middle

• Lump on the let ne!"

T'ora(

◦ "$n)s * +$lonar!

nspe!tion : The !hest shape is symmetri!al both olet and right

'alpation : Fremitus ta!tile and (o!al symmetri!al right and let&

!repitus *+,& tenderness *+,& rebound tenderness *+, 'er!ussion : Sound o resonant in both lung ields

Aus!ultation : Sound o (esi!ular and bron!hial the entire lung ield&

ron"hi +3+& $hee=ing +3+

◦

Heart nspe!tion : !tus !ordis is not (isible

'alpation : !tus !ordis palpable on the let mid!la(i!ula /S line 5

'er!ussion : >pper limit /S linea parasternalis sinistr

Right limit /S 6 linea sternalis dextr

Let limit /S 5 linea mid!la(i!ula sinistra Aus!ultation : )eart sound 1 ? % pure regular& murmur *+,& gallops *+,

A,%oen

• nspe!tion : lat abdomen shape& supple& not (isible s"in disorders

• 'alpation : tenderness *+,& rebound tenderness *+,• 'er!ussion : There $as a $hole ield tympani! abdomen

• Aus!ultation : 0o$el Sound *;, Normal

E&treitas

o Superior : >pper extremities $arm& dema +3+& /TR @ %

o nerior : Lo$er extremities $arm& dema +3+&

%



Genitalia : No abnormalities

IN-ESTIGATIONS

"a,orator! E(aination

Dara' "en)&a+• Leu"o!ytes : 11&122

• )b : 12 mg3dL

• 'latelets :2%.222

• ds : 112 mg3dL

• 0T : %B2BB

• /T : 6B2BB

E. DIAGNOSIS OF OR/

Cir!ho$Bs Nodule

F. DIAGNOSIS

0 *

G. MANAGEMENT P"AN

Non*e%ical1

D 0ed Rest

e%ical1

• nusion RL %2 TT 3 min

• Eeterola! x 1

• Ranitidine % x 1

• /ea=oline x 1

H Pro)nosis

uo ad (itam: Ad 0onam

uo ad un!tionam: Ad 0onam

uo ad sanationam: Ad 0onam



"ITERAT2RE RE-IE

A. -FNTGN

Nodule $as Cir!ho$Hs lymph node !ontained in the let supra!la(i!ular ossa *the area lo!ated

abo(e the let !la(i!ula,. ound an enlarged nodule $ith hard !onsisten!y *TroiserHs sign, isindi!ating the presen!e o a malignan!y in the abdominal area& espe!ially gastri! !an!er& $hi!h

metastasi=e to limogen.

0. )STGRI

Nodules Cir!ho$Hs immortali=ed his name is Rudol Cir!ho$ as the ounder& a erman

pathologist& $ho irst des!ribed the relationship $ith the enlargement o the gland malignan!y in

the stoma!h in 1464. xpert pathologi!al Fran!e& /harles mile Troiser& in 1449 suggested that

the malignan!y in the abdominal area !an also metastasi=e to lymph.

/. Anatomy and histology

Lymph nodes are round+shaped organ $ith a small si=e as an immune system are $idely

distributed throughout the body and lin"ed by lymphati! (essels. Lymph node !ells stored on 0

lympho!ytes& T& and other immune !ells. Lymph+node ser(es as a ilter. These nodes also ha(e

!lini!al signii!an!e& !an be!ome inlamed or enlarged in (arious !onditions *rom ine!tion to

malignan!y,. 0ased on !lini!al signs& !an be determined the degree o malignan!y !an be

determined so that the therapeuti! a!tion and disease prognosis.

Lymph node is surrounded by a ibrous !apsule and in the lymph node the ibrous !apsule

extends to orm trabe!ulae.Substan!e o the lymph nodes are di(ided into outer !ortex and inner medulla is surrounded by a !onstituent ex!ept the hilum area& $here the medulla asso!iated $ith

the sura!e.

Thin reti!ular ibers& elastin and reti!ular ibers orm a strong abri! "no$n as interla!ing

reti!ular in the node& $ith in $hi!h there are $hite blood !ells& parti!ularly lympho!ytes& in the

orm o solid olli!les in the !ortex. lse$here there are sometimes only $hite blood !ells

only. Not only strengthen the abri! o the reti!ular stru!ture but also pro(ides a sura!e or

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adhesion o dendriti! !ells& ma!rophages and lympho!ytes.nter$o(en enables the ex!hange o

material transported through the blood+(enule endothelial (enules and pro(ide gro$th a!tors

and regulators are reJuired or the a!ti(ation and maturation o immune !ells. The amount and

!omposition o the olli!les and !hange in parti!ular $hen dealing $ith the antigen and orm a

germinal !enter.

Lymph sinus is a !hannel $ith a !rease in it there is lymph node by the endothelial !ells $ith

ibroblast reti!ular !ells and allo$s the lymphati! lo$& embut through it. Sub!apsular sinus

sinuses are lo!ated inside the !apsule and endoteliumnya !ontinues into aerent lymphati!

(essels.This sinus is also !ontinuing $ith similar sinuses lan"ing the trabe!ulae to the !ortex in

it *!orti!al sinuses,. /orti!al sinuses lan"ing the trabe!ulae drain into the sinuses o the medulla&

$here the lo$ o lymphati! lo$ to eerent lymphati! (essels.

Multiple aerent lymphati! (essels bran!hed and extends inside the !apsule bring lymph to the

lymph nodes. Lymph node sub!apsular sinus is entered. The innermost layer o the aerent

lymphati! (essels !ontinued to ro$n !ells o lymphati! sinuses. Lymph is slo$ly ilteredthrough the substan!e o the lymph nodes and e(entually rea!h the medulla. Gn his $ay to see

the sap beninng lympho!ytes and their a!ti(ation may be initiated as part o the adapti(e immune

response. /on!a(e side o the lymph node is !alled the hilum. erent hilum by binding tightly

inter$o(en reti!ulum and !arry lymph out o the lymph nodes.

/ortexn the !ortex& the sub!apsular sinus lo$s into trabe!ular sinuses and lymph lo$ to the

sinuses o the medulla.The outer !ortex is !omposed mainly by 0 !ells arranged as olli!les&

$hi!h !an orm the germinal !enters as against the antigen& the deeper !ortex mainly !onsist o T

!ells This =one is "no$n as sub!orti!al =one $here T !ells primarily intera!t $ith dendriti! !ells

and in $hi!h the reti!ular densely inter$o(en.

MedullaThere are t$o stru!tures in the medulla name:o /orda medulla is !orda and lymphati!

tissues in!luding plasma !ells& ma!rophages and 0 !ellso medulla sinuses *or sinusoids, are

(essel spa!e that separates the medulla !orda. Lymph lo$ to the medulla o the sinus !orti!al

sinus and into the eerent lymphati! (essels. Sinus medulla !ontains histiiosit *mmobile

ma!rophages, and reti!ular !ells.

Lymphati! lo$Lymph lo$ to the lymph nodes (ia aerent lymphati! (essels and lymph lo$

into the spa!e under the !apsule !alled the sub!apsular sinus.Sub!apsular sinus lo$ into

trabe!ular sinuses and inally into a sinus medulla.Sinus !a(ity $as !rossed pseudopodama!rophages& $hi!h !ontribute to memperang"ap oreign parti!les and the ilter

lymphati!. Sinuses o the medulla met in spleen and let hilum and lymph nodes through eerent

lymphati! (essels and then lo$ into the sub!la(ian (ein& post"apiler (enules& !ross the $all

through the pro!ess o diapedesis.K 0 !ells migrate to the nodular !ortex and medulla.K T !ells

migrate into the inner !ortex *para"orte"s,.

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hen lympho!ytes re!ogni=e the antigen& 0 !ells are a!ti(ated and migrate to germinal

!enters. hen the antibody produ!ed by plasma !ells are ormed& they migrate to the spinal

!ord.Stimulation o lympho!ytes by antigen migration pro!ess is a!!elerated by 12 times aster

than normal& resulting in a !hara!teristi! s$elling o the lymph nodes. Spleen and tonsils adal

lymphoid organ that has the same un!tion as lymph nodes& spleen o blood through the ilter

more than through the lymph nodes.

-istribution Lymph nodes in head and ne!":

K !er(i!al lymph node anterior !er(i!al: glands here& either superi!ial or deep& ba!" in the

mus!le streno!leidomastoideus. They drain the !ontents into the throat and posterior pharynx&

tonsils and thyroid gland. 'osterior !er(i!al: These glands extending to the posterior

sterno"leidomastoideus but in ront o the trape=ius& rom the highest part o the mastoid

temporal bone to the !la(i!le. The gland is enlarged $hen there is ine!tion o the upper air$ay.

K Tonsil or submandibular: These glands are lo!ated belo$ the mandibular angle& along the bottom o the !hin. They lo$ into the tonsils and pharyngeal region& in!luding the basi!

stru!ture o the mouth and the maxillary anterior and molar 1 and %. They also lo$ to the

mandibular teeth ex!ept the in!isors.

K Retroaring: lim drainage rom mole palate and the third molar.

K Sub+mental: These glands are lo!ated #ust belo$ the !hin. They lo$ into the middle in!isors&

loor o the mouth and base o the tongue.

K supra!la(i!ular lymph nodes: these glands run along the !la(i!le& $here the lateral #oins the

sternum. They lo$ into the thora!i! !a(ity and abdomen.Cir!ho$Hs nodule in the supra!la(i!ular lymphati! glands are re!ei(ing rom all o(er the body limati"nya lo$ through the du!tus

thorasi"us and is a a(orite pla!e or metastati! malignan!ies



Thora!i! lymphati! glands

Lymphati! glands in the lungs: lim drained rom the lung tissue through the lymph

nodes subsegmental& segmental& lobar and inter lobar lymph nodes leading to hillus& $hi!h are

lo!ated around the hilum. The lo$ o lymphati! lo$ to the mediastinal lymph

nodes. Mediastinal lymph nodes: they !onsist o a se(eral lymph node groups limati"& espe!ially

along the tra!hea& along the esophagus and bet$een the lungs and diaphragm. n

the mediastinal lymph node glands rom lymphati! du!ts $hi!h drain into the sub!la(ian

(ein lim the let. Mediastinal lymph nodes along the esophagus programs so !losely

!onne!ted in the abdominal lymph nodes along the esophagus and stoma!h. This a!t a!ilitates

the spread o tumors (ia the lymphati! path$ays in !ases o malignan!y in the stoma!h and part

o the esophagus. Through the mediastinum& the primary lymphati! drainage through the

abdominal organs through the du!t thorasi"us& $here the main lo$ o the

abdomen is lim into the gland.

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-. /LN/AL RASGNN

Malignan!y& malignan!y o the internal organs !an rea!h an ad(an!ed stage beore

gi(ing symptoms. For example& gastri! !an!er !an be asymptomati! butalready metastasi=e. 'oint that it !an be seen $here the tumor is already metastati! at the

let supra!la(i!ular lymph nodes. Lymphati! nodules supra"la("ular let is the !lassi! Cir!ho$

nodules be!ause nodules are lo!ated on the let side o the ne!" $here almost allthe bodyHs

lymphati! drainage *rom thorasi"us du!t, into the let sub !la(ian

(ein "esir"ulasi through. Metastasis thorasi"us !log du!ts and !ause regurgitation into

the round nodules to nodules Cir!ho$ example. Another !on!ept is that one o the nodules

supra!la(i!ular nodes !orrespond to the end o the #ourney along the du!t and thereore ha(e an

enlarged thorasi"us.

. -ANGSS

-ierential diagnosis o nodular enlargement o Cir!ho$ $as lymphoma& malignant intra +

abdominal malignan!ies& breast !an!er and ine!tions *the arm,. Similarly& the enlargement o the

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lymphati! nodes tend to reer to the right supra!la(i!ular thora!i! malignan!iessu!h

as lung !an!er and esophageal!an!ers su!h as )odg"inHs lymphoma.

F.MANMNT

Gbtained $hen the si=e o lymph nodes1 !m then it is said to be abnormal& and a biopsy should

be perormed to determine the type o disorder. Lymph node biopsy in t$o $ays: by

simply ta"ing a portion oa lymph node or liting as $ell.

Gperation Te!hni!s

Made an in!ision in the s"in belo$ the sura!e o an enlarged lymph node and surrounding tissue

is !areully disse!ted a$ay rom the node. Should pay attention to the surrounding ner(e tissue&

espe!ially in the area around the ne!". To a!ilitate remo(al o the node& the asso!iation made

$ith yarn that is atta!hed to the !enter o the node& that node !an be remo(ed.

RFRN/S

1. Cir!ho$ R. OPur -iagnose der Erebse in >nterleibeO. Med. Reform. 1464Q 34: %64

%. Troisier /. OLHadnopathie sus+!la(i!ulaire dans les !an!ers de lHabdomenO. Arch. Gen.

de Med. 1449Q 5: 1%9?14 and %97?29

. Libman ). enerali=ed lyphadenopathy. en ntern Med 1947Q%:64+54

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6. Morlan 0. Lymphadenopathy. Ar!h -is /hild 1995Q 7: 67+9

5. 'angalis A& Cassila"opoulus T'& 0oussiotis CA& Fessas '. /lini!al approa!h to

lymphadenopathy. Semin Gn!ol 199Q %2Q 572+4%

. Mi=utani M& Na$ata S& )irai & Mura"ami & Eimura . Anat Sci Int %225Q 67 *6,: 19?4

7. http:33$$$.do"terbedahherryyudha.!om3%21%323diagnosis+and+management+(ir!ho$s+

node.html

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PRESKAS 4 Virchowv Node

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