PERIPHERAL LYMPHADENOPATHY IN BASRAH . A HISTOPATHOLOGICAL STUDY OF 1167 CASES DURING ( 1980-1997 ) PERIODS

A review of the histopathological examination reports of 1167 cases of peripheral lymphadenopathy (LAP) received in the Department of Pathology in Basrah Saddam Teaching Hospital (1980-1997) and from Al-Wiswasy Private Laboratory (1984-1997) in two different periods (1980-1989) and (1990-1997) was done. Tuberculous lymphadenitis was the commonest pathological lesion in both periods. It was responsible for 36.9% and 46.3% of the total cases respectively, with an 80% rise of cases per year in the 2 nd period. Neoplastic LAP was responsible for 32.9% and 37.2% of the total cases in the two periods respectively, with 61% rise in the average number of cases per year in the 2 nd period. In both periods, primary lymphoid tumours were more frequent than metastatic malignancy, with 106/74 cases in the 1 st period and 141/90 cases in the 2 nd period respectively with a ratio of 1.5:1 for both. Nonspecific reactive hyperplasia and other inflammatory lesions account for 30.2% and 16.5% of peripheral LAP in the two periods respectively, with a 23% decrease in the average number of cases per year. The mean age, sex and site distribution of different pathological lesions were demonstrated. In all these varieties of peripheral LAP, males were affected more than females except in tuberculosis. Cervical lymph nodes were most frequently involved in both periods. A comparison of the results were made with similar studies.


Introduction
eripheral lymphadenopathy (LAP) is a common problem encountered in clinical practice, it could be a sign of inflammation, non-specific reactive hyperplasia and other inflammatory lesions, lymphomas or metastatic malig-nancy 1,2 .
Enlarged peripheral lymph nodes requiring investigations are defined as one or more nodes equal to or greater than 1 cm in diameter, newly recongnized and not known to arise from a previously recognized cause.Multiple smaller nodes may also require investigations 2,3 .
Lymph node biopsy is an essential step in evaluating the nature of the patho-logical process responsible for LAP as there is no single clinical feature that, by its presence or absence, can predict the histological diagnosis at biopsy examination 4,5 .
In Iraq, primary tumour of lymphoid tissue is relatively common.It accounts for 9.3% of total cancer cases, ranking the 3 rd most common cancer (Iraqi Cancer Registry 1995-1997) 6 , and the 2 nd commonest cancer in Basrah forming (11.6%) in 1999 (7) .Therefore, the major indication for lymph node biopsy is to exclude malignancy.
This work was undertaken in order to assess the relative frequency of various pathological lesions diagnosed by histopathological examination of enlarged peripheral lymph nodes.

Materials and Methods
The histopathological reports of patients with peripheral LAP diagnosed in the Pathology Department of Basrah Saddam Teaching Hospital (1980-1997)  and AL-Wiswasy Private Laboratory (1984-1997) during two different periods (1980-1989) and (1990-1997) were reviewed.
The age and sex of the patients and the sites of the examined lymph nodes were recorded.The histopathological examination reports of peripheral LAP from a previously known cancer cases were excluded from this study, i.e. the study include only first time diagnosed cancer cases of peripheral LAP, whether primary or metastastic.The study excludes regional lymph nodes that were attached to surgical specimens of resected malignant tumours.

Results
The results are summarized in Table (I-V) and Figure (1-2).There were a total of 1167 cases of peripheral LAP in 18 years period (1980-1997).In the 1 st 10 years period (1980-1989), there were a total of 547 cases with an average number of 54.7 cases per year, of these 202 cases (36.9%) were tuberculosis (average number of 20.2 cases per year), 180 cases (32.9%) were neoplasms (average number 18 cases per year) and 165 (30.2%) were non-specific reactive hyperplasia and other inflammatory lesions (average number 16.5 cases per year), Table I The relative frequency and the mean age of patients with different neoplastic lymphadenopathies were shown in Table III.In both periods, primary lymphoid tumours (non-Hodgkins lymphoma and Hodgkins disease) were more frequent than metastatic malignancies.In the 1 st period primary lymphoid tumours were106 cases out of total 180 cases (58.8%), and it constitutes 141 cases out of total 231 cases (61%) in the second period, metastatic malignancies were detected in 74 cases out of the total 180 cases of neoplastic lesions (41.1%), and 90 cases out of total 231 cases of neoplastic lesions (38.9%) in both periods respectively.
Non-Hodgkin's lymphoma was the commonest primary tumour in the 1st period (34.4%), while Hodgkin's disease exceeded it in the 2nd period (32.5%).Diffuse large cell lymphoma was the commonest subtype of Non-Hodgkin's lymphoma in both periods (75.8% and 65.1%) respectively, and mixed cellularity Hodgkin's disease was the commonest subtype (65.9% and 69.3%) in both periods respectively.Adenocarcinoma was found to be the commonest metastatic carcinoma (52%), Table IV.
Table V

Discussion
Enlarged peripheral lymph nodes occur in many conditions, either as a reaction to a local inflammatory process or associated with systemic diseases whose central focus is not in the lymphoreticular system, or due to neoplastic diseases 1,8.In this study, tuberculous lymphadenitis was the commonest cause of peripheral LAP in both periods, followed by neoplasms and non-specific reactive hyperplasia and other inflammatory lesions.Tuberculous lymphadenitis was responsible for 36.9% and 46.3% of the total cases in the 1 st and 2 nd periods respectively.Tuberculosis is the most common cause of peripheral LAP in Basrah, and its incidence is rising from an average of 20.2 cases per year in the 1 st period to 35.8 cases per year in the 2 nd period, i.e. an increase of 80%.In an analysis of 759 cases of histopathologically diagnosed extrapulmonary tuberculosis in Basrah during the period (1985-1999), Al-Wiswasy found that the lymph nodes were the commonest site of involvement by extrapulmonary tuberculosis accounting for 72% of all cases 9.
Further studies confirm and pinpointed inadequate chemotherapy and BCG immunization as a major cause of the deterioration in the epidemiological situation of the disease.The economic embargo on Iraq with associated nutritional problems and poor housing condition created further circumstances for the disease re-emergence 10.
The present study, like other previous studies, showed a high prevalence of tuberculous lymphadenitis, in Baghdad 12 and Mosul 11 , reported a relative frequency of 26.1% and 36.8% was respectively reported.Similarly Abdullah, et al. 13 in Saudi-Arabia found a relative frequency of 37.9%.Also tuberculosis is common and forms a major health problem in other parts of the world 14 .
Neoplasm was the 2 nd most common group of the diseases accounting for 32.9% and 37.2% of the total cases in the two periods respectively, with an increase from 18 cases per year in the 1 st period to 28.8% cases in the 2 nd period (i.e.61% rise).In Al-Wiswasy study of the total new cancer cases in Basrah (excluding leukaemia) for the year 1999, a rise of 41% was found compared with the year 1990 with 263% rise of

Inguinal nodes total
Site of LAP lymphomas only 7 .This may be due to the effect of economic embargo and radiation effect of depleted uranium (DU) missile used in the 1991war by USA and UK military forces against Iraq.The primary lymphoid tumours (Hodgkin's disease and Non-Hodgkin's lymphoma), were more frequent than metastatic malignancy with a ratio of 1.5:1 in both periods.In Baghdad 12 and in Mosul 11 , a ratio of 1.08:1 and 1:1.1 was reported respectively.While in Saudi Arabia 13 a reported ratio was 5:10.Non Hodgkin's lymphoma was the commonest primary tumour in the 1 st period, while Hodgkin's disease was the commonest in the 2 nd period with 113% rise from an average of 4.4 cases per year in the 1 st period to 9.4 cases per year in the 2 nd period, Table III, nearly equal incidence of non-Hodgkin's lymphoma and Hodgkin's disease (10.9% and 11.1%) respectively was found in Baghdad 12 and (8.7% and 8.1%) respectively in Mosul 11 , similarly reported in Saudi Arabia 13 (17.4% and 15.5%) respectively.Diffuse large cell lymphoma was the commonest type of non-Hodgkin's lymphoma in both periods (75.8% and 65.1%) respectively, while mixed cellularity was the commonest subtype of Hodgkin's disease forming (65.9% and 69.3%) in both periods respectively.This is in agreement with other studies 11,2,17 .
The lymph nodes are one of the most common sites of metastatic malignancy & sometimes constitute the first clinical manifestation of the disease 18 .In this study, adenocarcinoma was the commonest metastatic carcinoma 52% followed by squamous cell carcinoma 31% & undifferentiated carcinoma, Table IV.This is in consistent with other studies [11][12][13][14][15] .
Non specific reactive hyperplasia and other inflammatory lesions was the third cause of peripheral LAP.In this study accounting for 30.2% and 16.5% in the two periods respectively, with a decrease from 16.5 cases per year in the first period to 12.75 cases per year in the 2 nd period, a decrease of 23%.This is due to the increase in the relative frequency of tuberculosis from 36.9% to 46.3% and neoplasms from 32.9% to 37.2% in the two periods respectively.Similarly reported by other studies in Baghdad 12 and Mosul 11 (31.6% and 25.9%) respectively.In Saudi Arabia 13 , the relative frequency of non-specific reactive hyperplasia and other inflammatory lesions accounting for 16.2% of the total cases.
Table II.The mean age of patients with tuberculosis was (28.8 years, 32.8 years), neoplasms (48.4 years, 47.3 years) and non-specific reactive hyperplasia and other inflammatory lesions (23.4 years, 25.7 years), in the 1 st and 2 nd period respectively.This is in agreement with other studies in Iraq, Alash, et al 12 , found the mean age for tuberculosis, neoplasms and non-specific reactive hyperplasia (27.1 years, 40.2 years and 26.6 years) respectively and Al-Dewachi, et al 11 in Mosul, reported the mean age of tuberculosis (29.5 years), neoplasms (42.5 years) and non-specific reactive hyperplasia and other inflammatory lesions (26.6 years) and also similarly reported by other studies 13 .
In the three types of peripheral LAP, males were more affected than females except in tuberculosis which show female preponderance (M:F ratio, 1:1.5).
In Baghdad 12 , Mosul 11 and Saudi Arabia 13 , reported M: F ratio for tuberculosis 0.5:1, 1:2.7 and 2:1 respectively, and also these results is consistent with what has been reported by other studies 15,19,20 .
Regarding the site distribution, cervical lymph nodes were the most frequently involved than other sites in both periods, followed by axillary, supracalvicular and inguinal nodes.Such findings were reported by other studies 9, [11][12][13]15,20 and fig 2, show the site distribution of peripheral LAP.Cervical lymph nodes were the commonest site of involvement in 581 (49.8%), followed by axillary nodes 284 (24.3%), supra-clavicular nodes 194 (16.6%) and inguinal nodes in 108 (9.3%).

Table V . The site distribution of peripheral LAP in the 1st and 2nd period
12This reflects the greater proportion of lymph nodes situated in the neck.It has also suggested that lymphoid tissue of the tonsils and adenoid provide an easy entry for the mycobacteria; easily recognized and palpable lymph node in the neck, and cervical lymph node receive lymphatic drainage from areas regarded as common sites of infections and malignancy12.