Oncology (General Cancer)/swollen axillary lymph nodes

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QUESTION: Doc: my husband's biopsy came out today diagnosed as reactive hyperplasia after doing the immunohistochemical stain, such a relief that its not lymphoma but we still have to find the underlying cause, he has no symptoms and cbc is normal so seems like  theres no infection going on,  surgeon suggested that it might be a past infection but even he was puzzled because the node that underwent biopsy is very big 4.1 cm, my question is is it possible that this is a precancerous node that may turn into lymphoma one day? or should we get a second opinion for pathology? but if its infection what kind could it be for lymph nodes to be enlarged to a size like this?

please advise thanks

ANSWER: Reactive hyperplasia is only a description of the tissue under the microscope.  Many years ago it was called "reactive" because people figured that if it wasn't cancer, it was probably reacting to something.  I think most of us still think this way, but in truth, there isn't a way to tell what caused the reaction in patients with no other problems.  We see this feature in patients with rheumatoid arthritis, lupus, etc; along with AIDS, Castleman's disease, TB and fungal infection, viral infections -- the fact that the nodes "reacted" generally means that they destroyed whatever caused them to swell.  So I don't think you can really find the underlying cause.  As for the size of the nodes, this is a fairly large node, but not terribly abnormal for reactive hyperplasia.  
From your description I suspect that this is a reaction to a viral infection.  
I don't think this is "pre-cancerous".  Generally lymphomas start out that way, marked with BCL-2 in most cases.  I don't know what immunochemical studies were done, but I suspect the common ones would have ruled out T cell and B cell types of lymphomas, which make up the vast majority.  Reactive hyperplasia in addition to lacking markers for lymphoma, generally under the microscope shows lymph cells of varying maturity, unlike a real lymphoma.  At this point I'd watch.  A second opinion is always worth getting, though.  Generally you can ask your surgeon to send the tissue to a lymphoma expert; you don't need another biopsy.  Hope this helps.

---------- FOLLOW-UP ----------

QUESTION: Hi Doc: the immunohistochemical stain results as follow:
CD3 - positive around follicles
CD20 positive in germinal centers
CD5 - positive around and within germinal centers
CD10 - positive in germinal centers
Bcl 2 -  positive around germinal centers
Ki - 67 - present mostly in germinal centers
remarks: the immunohistochemical stain results support the diagnosis of reactive hyperplasia.

today we went back to the surgeon for follow up , he also said it should be some kind of viral infection, and told my husband to go back after a month to check if the nodes have gone down, as of now the remaining enlarged lymph nodes are still the same, but didnt increase in size according to the surgeon, and he agreed to send the tissue to an expert.

doc why are the stain results all positive in reactive hyperplasia? if its lymphoma are the stain results   negative? thanks again

Answer
The stains test for certain proteins that are common to lymphocytes as well as lymphomas.  It is the pattern of the stain that tells the pathologist what is going on.  We would expect the stain pattern you have in normal lymphocytes, where the germinal centers are where the young lymphocytes grow.  In a lymphoma we would see the bcl-3w and some of these all through the lymph node.  

Oncology (General Cancer)

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Donald Higby, M.D.

Expertise

I can answer almost all questions related to the treatment and natural course of most kinds of cancer, especially cancers of prostate, colon, lung and breast.

Experience

I have been a practicing medical oncologist for 36 years, and have been chief of service at a major medical center for 25 years. I've also done research in cancer treatments.

Organizations
American Society of Clinical Oncology

Publications
New England Journal of Medicine American Journal of Medicine Journal of the American Society of Clinical Oncology Hematology Transfusion Medicine

Education/Credentials
MD, Stanford University Internal Medicine residency, St. Louis University School of Medicine, St. Louis, MO Medical Oncology Fellowship, Roswell Park Cancer Institute, Buffalo, NY

Awards and Honors
America's Best Physicians, last 14 years

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