Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 9  |  Issue : 1  |  Page : 43-50  

Cytomorphological study of lymph node lesions: A study of 187 cases


Department of Pathology, Dr. D. Y. Patil Medical College and Research Centre, Pimpri, Pune, Maharashtra, India

Date of Web Publication22-Dec-2015

Correspondence Address:
Shruti Vimal
D-1, 702, Nisarg Nirmati, Pimple Saudagar, Pune - 411 027, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.172428

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  Abstract 

Introduction: As components of peripheral or secondary lymphoid organs, lymph nodes are an important part of immune system. Their enlargement is noted in a wide spectrum of diseases, including infections and malignancy, they are a common finding in clinical practice. Therefore, peripheral lymphadenopathy is common in all age groups and management of cases depends on lymph node pathology, which can be studied by collecting material through fine-needle aspiration or excision biopsy. Objectives: The study was undertaken to assess the cytomorphological features and incidence of various lymph node diseases on fine-needle aspiration cytology (FNAC) and to analyze the utility and diagnostic importance of FNAC in lymph node diseases. Materials and Methods: In the study total of 187 patients were selected who had presented with lymph node enlargement at Department of Pathology in our Tertiary Care Centre. Results: Reactive lymphoid lesions comprised the majority (33.69%) followed by tubercular lymphadenitis, metastatic malignancies, acute suppurative lymphadenitis, and lymphomas, respectively. Conclusion: Reactive lymphoid and tubercular lesions were the most common among the lymph node swellings presentations. FNAC is a simple, safe, reliable, and inexpensive method in early detection of lymph node lesions, which has been proven once again in this study.

Keywords: Fine-needle aspiration cytology, lymph node, lymphadenitis


How to cite this article:
Vimal S, Dharwadkar A, Chandanwale SS, Vishwanathan V, Kumar H. Cytomorphological study of lymph node lesions: A study of 187 cases. Med J DY Patil Univ 2016;9:43-50

How to cite this URL:
Vimal S, Dharwadkar A, Chandanwale SS, Vishwanathan V, Kumar H. Cytomorphological study of lymph node lesions: A study of 187 cases. Med J DY Patil Univ [serial online] 2016 [cited 2020 Aug 10];9:43-50. Available from: http://www.mjdrdypu.org/text.asp?2016/9/1/43/172428


  Introduction Top


Lymph nodes are an integral component of the immune system and are a common presentation in the clinical practice. The lymphoid system grows rapidly in childhood and achieves twice the adult size in early adolescence. The same starts regressing during mid-adolescence, it does not reach its stable adult size until 20-25 years. Lymph nodes are a site for organized collections of lymphoreticular tissue and are pink gray bean shaped encapsulated organs. They are located at anatomically constant points along the course of lymphatic vessels. The common sites of distribution are cervical, axillary, mediastinal, retroperitoneal, iliac, and inguinal regions.

Dating back in history, Kun in 1847 had done the pioneering act of first time reporting the use of aspiration biopsy. Since then fine-needle aspiration cytology (FNAC) has been a simple, safe, reliable, and inexpensive method of establishing the diagnosis of lesions and masses in various sites and organs and is the most convenient bedside diagnostic aid. [1],[2],[3],[4],[5] As a minimally invasive technique, it also helps in early direction of appropriate investigations. Drawbacks of FNAC also exist like sampling error in form of improper technique, micrometastasis, benign epithelial inclusions, partial lymph node involvement by lesion and a very small lymph node where sampling is difficult, also a high incidence of false results, especially false negative in the case of lymphomas and the handicaps like assessment of lymph node architecture, which obviously cannot be done on cytological preparation. [5],[6],[7]


  Materials and Methods Top


This study was carried out in Department of Pathology at a Tertiary Care Centre to study the various cytomorphological features of neoplastic and nonneoplastic lesions of lymph nodes by FNAC in patients presenting with lymphadenopathy and to determine the incidence of various lymph node diseases among them. This was a prospective study conducted over a period of 2 years, and a total of 187 cases of lymphadenopathy of varied etiologies were considered.

All patients presenting with lymph node enlargement were included in the study, and they were divided according to the size of lymphadenopathy into following categories:

  1. <1 cm.
  2. 1-2 cm.
  3. >2 cm.
Study participants were subjected to standard FNA procedure after taking consent from the patient or guardian.

After studying all the clinical data, the smears were examined under the microscope. Based on the cellularity, the smears were categorized as of high, moderate, and low cellularity. The smears, which were hemorrhagic or with scanty cellularity to the extent that diagnosis could not be offered were labeled as inadequate for opinion.


  Results Top


A total of 187 aspirates were obtained out of which 102 were males and 85 females. The age of the patients varied from 1 year to 82 years with a mean age of 41.5 years. The maximum incidences of cases were seen in the age range of 20-30 years. A slight male preponderance with a male to female ratio of 1.17:1 was noted [Figure 1].
Figure 1: Age and sex wise distribution of cases

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Lymph nodes of varying sizes were subjected to FNAC. The smallest lymph node measured 0.5 cm and the largest measured 4 cm in maximum dimensions. Most of the lymph nodes (108) ranged in size between 1 and 2 cm [Figure 2].
Figure 2: Size of lymphadenopathy

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The most common group of lymph nodes aspirated were in a decreasing order cervical (50.80%), submandibular and supraclavicular (12.30%) each, axillary, and inguinal (10%) each and generalized which were (5%) and single case of abdominal lymphadenopathy was included in the study [Figure 3].
Figure 3: Site of lymphadenopathy

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A cytological diagnosis was made in 168 cases while no opinion was possible in 19 cases due to the inadequacy of the aspirates. Of the 168 cases, 63 cases (33.69%) were diagnosed as reactive hyperplasia, followed by 54 cases (28.88%) of tubercular lymphadenitis and 33 cases of metastatic malignancy i.e., 17.65%, 12 cases (6.42%) of acute suppurative lymphadenitis and total of four cases of nonHodgkin's lymphoma (NHL) (2.14%) and a single case of Hodgkin's lymphoma [Figure 4].
Figure 4: Distribution of cases

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The majority of cases recorded were those of reactive hyperplasia (33.69%) in which 58.7% were from the cervical group of lymph nodes. A brief clinical history and physical examination of the patient revealed invariably a septic or infective foci in the head and neck region like that of otitis media, tonsillitis, dental caries, and scalp lesions in most of the patients. The smears showed a high cell yield, the polymorphic population of lymphocytes and tingible body macrophages, which are the three important characteristic features of reactive follicular hyperplasia. The polymorphic population comprises of lymphocytes at different stages of maturation, monocytoid B cells and plasma cells. The lymphoid cells consisted of small mature lymphocytes, small and large cleaved cells and noncleaved cells and immunoblasts. The ratio is estimated to be 4: 1 for small to large cells [Figure 5].
Figure 5: Polymorphous population of lymphocytes in reactive hyperplasia (Leishman stain low power)

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Two cases of dermatopathic lymphadenitis were recorded in the study. The smears showed predominantly pale histiocytes like cells with typically folded nuclei among small lymphocytes and macrophages containing pigment. In both the cases, patients had clinically presented with psoriasis and generalized dermatitis.

A total of 54 cases (28.88%) of tuberculosis were recorded in the study. Of these 22 cases (40.74%) were positive for acid-fast bacilli (AFB). Necrosis was seen in 16 cases (29.62%). Granulomas were seen in a total of 23 cases (42.59%) [Table 1]. The background in these cases mainly comprised of a mixed population lymphoid cells. In the current study, the aspirates could not be subjected to culture [Figure 6] and [Figure 7].
Figure 6: Granulomatous lymphadenitis (tuberculosis)-collection of epithelioid histiocytes (Leishman-high power)

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Figure 7: Acid fast bacilli (Leishman-oil immersion)

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Table 1: Cytomorphological features of tubercular lymphadenitis

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The AFB positivity was graded according to the original grading of AFB for the sputum smears and there morphology was assessed broadly [Table 2] and [Table 3].
Table 2: Grading of AFB

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Table 3: Grading and morphology of AFB

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A total of 33 (19.65%) out of 168 cases were diagnosed as metastatic deposits in the study. A slight male preponderance was noted with a maximum number of cases recorded in the cervical group of lymph nodes followed by supraclavicular. Maximum cases of metastatic deposits in the study were those of squamous cell carcinoma (51%), followed by adenocarcinomas (30%), small cell carcinoma of lungs (3%), malignant melanoma (6%), anaplastic large cell carcinoma (6%), carcinoma deposits of breast and undifferentiated metastatic deposits (4%) [Figure 8] [Figure 9] [Figure 10].
Figure 8: Metastatic deposits of squamous cell carcinoma showing characteristic blue cytoplasmic staining indicating squamous differentiation (Leishman-high power)

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Figure 9: Metastatic adenocarcinoma showing prominent nucleoli (Leishman-high power)

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Figure 10: Metastatic deposits of malignant melanoma showing large nuclei with prominent nucleoli

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A total of 12 cases (6.41%) of acute suppurative lymphadenitis have been recorded in this study with maximum of them in the axillary group of lymph nodes. The smears showed both well-preserved and degenerated neutrophils and cell debris. In the initial phase if the lymph node is aspirated then a mixture of lymphocytes and neutrophils can be seen. With the treatment started the aspirates show a mixed population of cells comprising of polymorphs, lymphocytes, plasma cells and histiocytes along with cell debris. This pattern of organization of inflammatory exudates in suppurative lymphadenitis was seen in two cases in our study who had reported for FNAC after intake of the antibiotics [Figure 11].
Figure 11: Suppurative lymphadenitis showing numerous neutrophils and cell debris (high power-Leishman)

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There were a total of five cases (2.6%) of lymphomas, amongst which one case was of Hodgkin's lymphoma, and the rest of the four were NHL. The single case of Hodgkin's disease was an elderly male and showed Reed-Sternberg cells and Hodgkin cells against a background of reactive components such as eosinophils, plasma cells and benign histiocytes. Hence, the confidence of diagnosis was high, and the case was further sub typed as mixed cellularity type which was confirmed on histopathological examination. The four cases of NHL were all males and presented with inguinal, submandibular, and supraclavicular lymphadenopathy. All the cases were further confirmed on histopathology [Figure 12] and [Figure 13].
Figure 12: Hodgkin's lymphoma with Reed Sternberg cell

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Figure 13: NonHodgkin's lymphoma lymphoplasmacytic lymphoma showing small lymphocytes and few plasma blastic cells (Leishman-high power)

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Single case of fungal infection - Cryptococcus was recorded in the study in an HIV positive case. The smears were stained with periodic acid-Schiff (PAS) and mucicarmine to confirm the diagnosis. Lymph node aspirates showed the yeast with the thick pale capsule in histiocytes and multinucleated giant cells.


  Discussion Top


Inflammatory processes symptomatic or asymptomatic are the most common causes of peripheral lymphadenopathy. Although the surgical excision of a peripheral lymph node is relatively simple, but the procedure does require anesthesia, sterility and theater and the patient may be left with a scar.

FNAC is a simple, safe, reliable, rapid, and inexpensive method of establishing the diagnosis of lesions and masses in various sites and organs. [8-25] Lymph node aspiration is of great value in diagnosing lymphadenitis, lymphomas, and metastatic carcinoma. The value of FNAC also lies in the early direction of appropriate investigations, other than making the diagnosis. However, limitations and pitfalls of the procedure are there.

In developing countries like India tuberculosis, acute upper respiratory tract infections and suppurative lymphadenitis are some of the common causes of lymphadenopathy. It has been stated that any significant lymph node enlargement not subsiding or remaining static in size for more than 2 weeks after conventional antibiotics need to be thoroughly investigated.

In this study, reactive hyperplasia was the most common lesion, but in other studies the most common lesion recorded was tuberculosis. The next common lesion in the study was tuberculosis which was followed by metastatic malignancies in accordance with the study conducted by Malakar et al. [8] Furthermore, the study conducted by Annam et al. recorded a high percentage of metastatic malignancies next to reactive hyperplasia. [17] Lymphomas were less in our study and in accordance with Khajuria's study and Annam et al. study. [5],[17] Inadequate aspirates were less in the study conducted by Khajuria et al. and Annam et al. as compared to our study and Malakar et al. did not record any number of inadequate smears [Table 4]. [5],[8],[17]
Table 4: Comparison of the present study with the other studies

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As compared to other studies a slight male predominance was noted in the current study. These findings are comparable with studies conducted by Gupta et al. and Khajuria et al. [3],[5]

In the study conducted by Reddy et al. lymph nodes were studied according to their size and site of presentation and they had concluded that in cervical and axillary region lymph node size of 1 cms, more than 1.5 cms in the inguinal region and more than 0.5 cm at any other site are to be considered significant. [18] Although the lymph node lesions were considered according to size in the current study no significant conclusion could be made on the size and site of presentation of lymphadenopathy. In fact among the total cases majority of them were ranging in 1-2 cm size, followed by more than 2 cm with most of the cases presenting in the cervical area followed by other sites. This could be attributed to the rich lymphatic supply in the neck region the findings are comparable to the other studies. [3],[5],[8],[10],[11]

In the current study, majority of the cases recorded were those of reactive hyperplasia (33.69%) amongst which most of them were from the cervical group of lymph nodes. Reactive hyperplasia is a common nonspecific form of lymphadenopathy due to a variety of causes ranging from bacterial, viral or nonspecific etiology. The reactive pattern is variable, depending on the extent of stimulation, the number and size of the germinal center and whether the sample obtained is from a germinal center or from the interfollicular or paracortical tissue. The germinal center material is represented by poorly defined tissue fragments of poorly cohesive cells. The fragments include centroblast, centrocyte, "tingible body" macrophages, lymphogranular bodies and number of lymphocytes which adhere to the cytoplasm of dendritic retinaculum cells. Smears from interfollicular area consist mainly of lymphocytes, variable number of scattered immunoblasts, plasma cells, non-specific histiocytes and endothelial cell. [7] At times, a portion of a lymph node may be involved by the pathology and as FNA samples only a focal area, it may result in false negative results due to sampling error. These findings are in accordance with the studies conducted by Narang et al., Janardhan et al. and Khajuria et al. [5],[13],[14]

In dermatopathic lymphadenopathy numerous noncohesive, pale, histiocytes like cells (interdigitating cells) are present. Pigment containing, macrophages are also found. These have smaller and more consistently oval, nonfolded nuclei different from interdigitating cells and have a better defined cytoplasm. There may be a variable number of eosinophils. The background is predominantly comprised of lymphocytes which may appear slightly "atypical" with small pale central nucleoli and blast forms are less common. [7] These findings are in accordance with the other studies. [20]

Tuberculous lymphadenitis usually is the most common form of extra pulmonary tuberculosis and arises as a result of lymphatic spread from a primary focus. Most often it involves the cervical group of lymph nodes attributed to the rich lymphatic supply of the region and most commonly seen in second and third decades. [21] Tuberculosis, in all age groups, results in the continuous transmission of the disease in the population. Hence, the diagnosis of this by least intervention method helps in preventing and treating the disease. The cytomorphological pattern in tuberculosis is varied and can be divided into three patterns [Table 1].

Epithelioid granuloma without necrosis: In India, Mycobacterium tuberculosis infection is most common compared to other granulomatous diseases hence the presence of granulomas is highly suggestive of tuberculosis. A total of 23 cases (42.59%) had presented without necrosis but amongst these 2 (8.6%) of them were AFB positive. Most of these lesions were from the cervical and submandibular area. In epithelioid granuloma without necrosis, AFB positivity is usually very low and in cases negative for AFB other possibilities like sarcoidosis may be considered in the differential diagnosis. However, in under developed and developing countries where tuberculosis is very common, based on clinical history and clinical features cases of epithelioid granuloma without necrosis should be considered as tuberculous lesions unless proven otherwise.

Epithelioid granuloma with necrosis: Among the 54 cases 27.77% (15 cases) had presented as granulomatous lymphadenitis with necrosis. AFB positivity rate is particularly high in the presence of necrotic material in the background this is in accordance with the other studies. [13],[14],[15] In this study, a total of six cases (40%) showed AFB positivity in this category. This could be attributed to the compromised immune status or inadequacy of the cellular immune response. Cases showing epithelioid granuloma with necrosis in cytological specimen pose no diagnostic difficulty. Moreover, the frequency of AFB positivity is high in this group.

Necrotic material without granuloma: A total of 16 out of 54 cases (29.62%) had presented with necrosis only and showed clumps of amorphous acellular material. This has been described as degenerated granulomas which show a positive reaction for the tuberculous antigen. [24] Liquefied necrotic material with marked polymorphonuclear infiltration can be confused with suppurative lymphadenitis. A careful search for the presence of occasional epithelioid histiocytes should always be made in such cases. The neutrophilic infiltrate could also be due to the secondary immune host response to the necrotic infiltrate. Fortunately, AFB positivity is highest in this group. In the present study, AFB positivity recorded in this group is the highest that is 87.5%.

AFB positivity in aspiration smears of tuberculous lymphadenitis is variable between 40.6% and 56.4%. [19] The presence of caseous necrosis helps in diagnosing tuberculosis as it is more sensitive and specific to tuberculosis. Among the total of 54 cases, 22 cases (40.74%) demonstration of AFB was done by ZN stain. The background mainly comprised of a mixed population of lymphocytes, polymorphs, eosinophils and plasma cells. The neutrophils in the background may be due to the immune response of the host to the tubercle bacilli antigen.

It has been reported that the number of AFB in the smear indicate the immune status of the patient. There must be 10,000-100,000 organisms per milliliter of the sample in order to detect AFB in a cytological smear. [25]

The detection of AFB (87.5%) was more in the smears containing necrotic material alone than in those with granulomas. This has been found in other studies too. [8],[9] In this study, the AFB was also graded according to their morphology and number in accordance with the original grading of the AFB of the sputum smears.

The accessibility of the enlarged lymph nodes for palpation and puncture, the rich cellularity of the smear due to the high yield of the aspirated material and the ease with which the alien tumor cells can be differentiated from lymphocytes makes the technique of FNA very useful in investigation of metastatic lymphadenitis.

The pattern of metastatic deposits of squamous cell carcinoma, followed by adenocarcinomas and others are in accordance with other studies. [3],[4],[14],[16] Cytological features of squamous cell carcinoma vary depending on the degree of differentiation of neoplasm and the degenerated changes. In well-differentiated squamous cell carcinoma, the neoplastic cells may have a close resemblance to normal squamous cells and may create confusion with bronchiogenic cysts or epidermal inclusion cysts. Tumor cells in metastatic adenocarcinomas revealed certain patterns: Monolayer sheets, papillary formation and microacinar formation. Metastatic deposits of malignant melanoma show marked variation in their cytomorphology. In this study, two cases (6.06%) have been reported. The metastatic deposits of breast carcinoma mainly exhibited monolayer sheets of dispersed cells, with poor glandular differentiation. A single case small cell carcinoma of the lung showing secondaries in the supraclavicular lymph node was recorded. The smears showed closely packed cells with scanty cytoplasm, indistinct small nucleoli, and prominent nuclear molding.

The application of FNAC in the diagnosis of lymphoma is still controversial, particularly in cases of low-grade NHL. The study conducted by Narang et al. recorded a diagnostic accuracy of 88.8% in co-ordinance with other studies. [13] In this study, a total of five cases (2.67%) of lymphoma were diagnosed out of which four cases (2.14%) of NHL and one case (0.53%) of Hodgkin's lymphoma. The cytodiagnosis of NHL depends mainly on finding a relatively monomorphic population of lymphoid cells, whereas its differentiation or grading is predicted by cell size and shape, presence of nucleoli and mitotic activity. FNAC plays a greater role in the management of Hodgkin's disease as compared to NHL as it helps in the primary diagnosis, staging of the patient and monitoring the recurrence of the disease. Suboptimal cytologic preparations, variable pattern in one node, distinction from reactive lymph node and limitations of the FNAC procedure like aspirates can only be taken from the focal area in the lymph node are some of the shortcomings which make the diagnosis of NHL difficult. With the help of flow cytometry and immunohistochemistry in adjunct to FNAC the diagnosis of NHL can be made much easier. Although few cases of NHL can be attempted to diagnose as in high-grade lymphoma-like small noncleaved lymphoma, lymphoblastic lymphoma, immunoblastic lymphoma, myeloblastic, and diffuse large cell lymphoma as studied by Hemlatha et al. [22]


  Conclusion Top


FNAC has been yet again proved as an inexpensive and reliable diagnostic tool. It is ideal for the clinical set up in developing countries for the first line of investigation for lymphadenopathy at an approachable site. In the current study, reactive hyperplasia was recorded as the most common presentation of lymphadenopathy in the cervical region. Granulomatous lesions were next in which demonstration of AFB is must for the definite diagnosis of tuberculosis, but in our setup the presence of epithelioid granulomas, and the associated clinical symptoms together should be considered as conclusive of tuberculosis. FNAC helps in diagnosing neoplastic and metastatic lesions. It not only confirms the presence of metastatic diseases but also, in most cases, gives the clue regarding the origin of the primary tumor.

Financial support and sponsorship

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Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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