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ORIGINAL ARTICLE
Year : 2017  |  Volume : 10  |  Issue : 2  |  Page : 143-148  

Study of fine-needle aspiration cytology of lymph node in rural area of Bastar District, Chhattisgarh


1 Department of Pathology, Late Shree Baliram Kashyap Memorial Government Medical College, Jagdalpur, Chhattisgarh, India
2 Department of Anatomy, Late Shree Baliram Kashyap Memorial Government Medical College, Jagdalpur, Chhattisgarh, India

Date of Web Publication14-Mar-2017

Correspondence Address:
Sachin A Badge
Department of Pathology, Late Shree Baliram Kashyap Memorial Government Medical College, Jagdalpur-494 001, Chhattisgarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.202097

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  Abstract 

Aims and Objectives: Fine-needle aspiration cytology (FNAC) as the first line of investigation has assumed importance in diagnosing a variety of disease processes as it is rapid, simple, reliable, minimally invasive, and cost-effective procedure which can be used in outpatient setting. Lymphadenopathy is one of the most common clinical presentations of patients attending the outpatient department. This study was performed to find out the pattern of diseases in lymph node in the rural area of Bastar District of Chhattisgarh State. Materials and Methods: A prospective study of 310 cases of lymphadenopathy presenting to the Department of Pathology for 2 years from January 2014 to December 2015 was taken up for our study. FNAC was performed using a 22–24-gauge needle and 10 ml syringe. Two of the prepared smears were fixed in alcohol and stained with hematoxylin and eosin and Papanicolaou stain. Two smears were air-dried, one was stained with Leishman stain and the other kept unstained to be used for Ziehl–Neelsen staining whenever a cytological diagnosis of granulomatous disease was made and also in cases with abundant necrosis and suppuration. Results: Most common lesion found in our study was tubercular lymphadenitis, followed by granulomatous lymphadenitis and reactive hyperplasia. Conclusion: Our study highlighted the various cytomorphological patterns of lymphadenopathy and revealed a huge burden of tuberculous lymphadenitis in this region.

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


How to cite this article:
Badge SA, Ovhal AG, Azad K, Meshram AT. Study of fine-needle aspiration cytology of lymph node in rural area of Bastar District, Chhattisgarh. Med J DY Patil Univ 2017;10:143-8

How to cite this URL:
Badge SA, Ovhal AG, Azad K, Meshram AT. Study of fine-needle aspiration cytology of lymph node in rural area of Bastar District, Chhattisgarh. Med J DY Patil Univ [serial online] 2017 [cited 2017 Apr 30];10:143-8. Available from: http://www.mjdrdypu.org/text.asp?2017/10/2/143/202097


  Introduction Top


Lymphadenopathy is one of the most common clinical presentations of patients attending the outpatient department. The degree and pattern of morphological changes depend on the inciting stimulus and the intensity of the response. Thus, lymphadenopathy may be an incidental finding and/or primary or secondary manifestation of underlying diseases which may be neoplastic or non-neoplastic.[1] Fine-needle aspiration cytology (FNAC) as the first line of investigation has assumed importance in diagnosing a variety of disease processes as it is rapid, simple, reliable, minimally invasive, and cost-effective procedure which can be used in outpatient setting.[2] The etiology varies from an inflammatory process to a malignant condition. The knowledge of the pattern of lymphadenopathy in a given geographical region is essential for making a confident diagnosis or suspecting a disease.[3] Tuberculosis is the most common cause of lymphadenopathy in developing countries such as India and should be considered in every case of granulomatous lymphadenopathy unless proved otherwise. FNAC is a reliable, simple, safe, rapid, and inexpensive method of establishing the diagnosis of lesions and masses at various sites and organs.[4]

FNAC has an important role in the evaluation of peripheral lymphadenopathy, and it can be used as a safe alternative to excision biopsy.[5] FNAC has been used extensively for the diagnosis of primary and secondary lymphadenopathy. The present study was undertaken to determine the role of FNAC in the evaluation of cytomorphological features of various lymph node lesions. Our experience of the diagnostic utility of FNAC in the assessment of lymphadenopathy is presented. The study highlights the epidemiological patterns and cytomorphological spectrum of lymph node lesions in this rural region with emphasis on cytological spectrum in diagnosis of pattern of tuberculosis, also providing details about burden of disease in this region.


  Materials and Methods Top


A prospective study of 310 cases of lymphadenopathy presenting to the Department of Pathology for 2 years from January 2014 to December 2015 was taken up for our study. After obtaining the Ethical Committee Clearance from our institution and informed consent from the patients, FNAC was performed using a 22–24-gauge needle and 10 ml syringe. Two of the prepared smears were fixed in alcohol and stained with hematoxylin and eosin and Papanicolaou stain. Two smears were air-dried, one was stained with Leishman stain and the other kept unstained to be used for Ziehl–Neelsen (ZN) staining whenever a cytological diagnosis of granulomatous disease was made and also in cases with abundant necrosis and suppuration. In cases where fluid was aspirated, the fluid was centrifuged and smears were made from the sediment, followed by the above staining methods. The criteria for the lymph node aspirates to be diagnosed as tubercular lymphadenitis included the presence of epithelioid cell granuloma and caseous necrosis with or without Langhans giant cells or ZN positivity. Granulomatous lymphadenitis was diagnosed in the presence of epithelioid cell granuloma with or without giant cells and with the absence of necrosis.[6]


  Results Top


A total of 731 cases were obtained in the cytopathology section over a period of 2 years from January 2014 to December 2015; out of which, 310 (42.40%) cases were lymph node FNACs. Out of 310 cases, FNAC was inconclusive in 5 (1.61%) cases due to unsatisfactory smears. [Table 1] shows the cytological diagnosis in 310 patients with lymphadenopathy. Most common lesion found in our study was tubercular lymphadenitis [Figure 1] in 151 cases (48.70%), followed by granulomatous lymphadenitis [Figure 2] in 102 cases (32.90%), reactive hyperplasia in 25 cases (8.06%), metastatic carcinoma in 12 cases (3.87%), suppurative granulomatous in 7 cases (2.25%), acute suppurative lymphadenitis in 5 cases (1.61%), non-Hodgkin's lymphoma in 2 cases (0.64%), and Hodgkin's lymphoma in 1 case (0.32%). The age and sex distribution of the patients with lymphadenopathy are shown in [Table 2] and [Table 3]. Age of the patients ranged from 2.5 to 87 years. The youngest patient was diagnosed as tubercular lymphadenitis, and the oldest patient was diagnosed as having metastatic deposits in the lymph node from a squamous cell carcinoma. Majority (74.3%) of the patients were in the age group of 11–50 years, with a peak (105 patients) in the age group 21–30 years. Only 15 patients were aged <10 years and one aged above 80 years. Metastatic deposits were more common in the elderly age group (greater than the sixth decade). Tuberculous and granulomatous lymphadenopathies were more common in the third to fourth decade. There were 117 male and 193 female patients, with a male to female ratio of 1:1.64. [Table 4] shows the lymph node groups involved in various types of lymphadenopathy. It has been found that the most common lymph nodes involved in various types of lymphadenopathy were the cervical group. Out of 310 cases, 240 patients presented with cervical lymphadenopathy. Tubercular lymphadenitis was the most common finding in our study. ZN stain was done in all the cases and was positive in 43 cases (28.47%). We observed various cytomorphological patterns of tubercular lymphadenitis. (1) Granuloma with necrosis was seen in 132 cases (87.41%) with or without acid-fast Bacilli (AFB). Out of that, in 89 cases, numerous clusters of epithelioid cells were present, and in 43 cases, only a few clusters of epithelioid cells were present. (2) Necrosis alone was seen in 19 cases (12.58%) and all of these were positive for AFB on ZN stain. (3) Only clusters of epithelioid cells were found without necrosis (102 cases). Out of that, 73 cases had numerous clusters and 29 cases had very few clusters of epithelioid cells. We considered these cases as a separate entity of granulomatous lymphadenitis. However, in regions where tuberculosis is very common, this granulomatous lymphadenitis should be treated as due to tuberculosis if not otherwise specified. The distribution of the various subtypes of metastatic tumors on FNAC is indicated in [Table 5]. Majority (41.66%) were from a squamous cell carcinoma [Figure 3], followed by adenocarcinoma [Figure 4] and poorly differentiated carcinoma. Metastatic deposits are also common in the cervical group.
Table1: Distribution of fine-needle aspiration cytology diagnosis of 310cases of lymphadenopathy

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Figure 1: Tubercular lymphadenitis showing caseous necrosis

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Figure 2: Granulomatous lymphadenitis

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Table2: Age distribution of patients of lymphadenopathy

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Table3: Sex distribution of patients of lymphadenopathy

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Table4: Lymph node group involved in various types of lymphadenopathy

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Table5: Distribution of different types of metastatic tumors

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Figure 3: Metastatic squamous cell carcinoma

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Figure 4: Metastatic adenocarcinoma

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  Discussion Top


FNAC is a part of the initial management of patients presenting with any palpable mass as it is a simple, safe, cost-effective, and time-saving procedure. Aspiration of lymph nodes for diagnostic purposes was first done by Griey and Gray in 1904, in patients with sleeping sickness.[7] The experiment of fine-needle aspiration (FNA) developed gradually, until 1921, when Guthrie tried to correlate FNA results with various disease processes.[8] It was Dudgeon and Patrick in 1927, which first used FNAC in diagnosing tuberculous lymphadenitis.[9] In the present study, an attempt has been made to study the cytomorphological spectrum and epidemiological pattern of lymph node lesions. Adequate material was obtained in 98.38% which correlated with the study by Hemalatha et al. (98%) and Gupta et al. (85.2%).[10],[11] Aspirates were inconclusive in 1.61% cases due to unsatisfactory smears. The causes for unsatisfactory smears were scant cellular yield or obscuring blood. Aspirates were benign in 95.16% cases; metastatic deposits were found in 3.87% and lymphomas in 2.25%. Similar findings were obtained by other authors.[12],[13],[14] In our study, the majority of the patients were in the age group 21–30 years. This correlated with the study by Chandanwale et al., where maximum numbers of cases were seen in the age group of 21–40 years.[15] Cervical lymph nodes were the most common group of lymph nodes involved which was similar to that observed by Hirachand et al., Khajuria et al., and Chandanwale et al.[3],[6],[15] Tuberculous lymphadenitis was the most common lesion and was reported in 151 cases (48.70%). This correlated with the study by Khajuria et al. (52.3%).[3] In our study, it was seen more frequently in the second and third decades of life with a female preponderance (male: female = 1:1.55). Cervical lymph nodes were most commonly involved (77.41%), followed by axillary group (10%). Similar observations were made in the study by Khajuria et al.[3] ZN staining for AFB was positive in 28.47% cases in our study. Ng et al. reported positivity in 41.6% cases and Ahmed et al. in 46% cases.[16],[17] In our study, necrosis alone was seen in 19 cases and all of these (100%) were positive for AFB. Das et al. also observed that foci of necrosis were associated with marked proliferation of tubercle Bacilli and infiltration of polymorphs whereas lymphocytes, epithelioid cells, and multinucleated giant cells are likely to have some role in limiting the proliferation of AFB.[18],[19] When multiplication of Bacilli in a lymph node is not under control, the lymph node becomes necrotic and turns into an abscess. Therefore, it is expected that the FNA from a tubercular abscess contains more AFBs than early tuberculosis lymph nodes.[20] It appears that the chances of finding AFB are greater when pus or caseous material is aspirated while the aspiration of caseous material is almost always indicative of tuberculosis and merits an active search for AFB.[21] The characteristic necrotic background comprising eosinophilic granular material containing nuclear debris was described as “tubercular diathesis.” Those cases lacking the typical finding and showing scattered epithelioid cells with or without granuloma or only necrotic material with neutrophilic infiltration were diagnosed as tuberculous lymphadenitis when this tubercular diathesis was found cytologically even though AFB were absent in these smears.[22] The conventional diagnostic measure of excisional biopsy is potentially hazardous as it may spread the disease and give rise to sinus formation. In developing countries where mycobacterial infection is prevalent and resources for medical care are limited, FNAC provides a simple, efficient, and cost-effective alternative to diagnose tuberculous lymphadenopathy.[20] Granulomatous lymphadenitis was seen in 102 cases (32.90%). Majority of the patients were aged <40 years. Similar age distribution was found by Hemalatha et al. and Ng et al.[10],[16] Granulomatous lymphadenitis can be classified as noninfectious and infectious. Noninfectious causes include sarcoidosis and sarcoid-like reaction. Infectious causes can be classified as suppurative and nonsuppurative. Suppurative granulomatous disorders include tularemia, cat scratch disease, and Yersinia. Nonsuppurative granulomatous disorders include tuberculosis, Bacillus Calmette–Guérin, toxoplasma, lepra Bacilli, brucellosis, and syphilis.[15],[23] In a region where tuberculous infection is common and other granulomatous diseases are rare, the presence of a granulomatous feature in FNAC is highly suggestive of tuberculosis. The literature on the use of FNAC to diagnose tuberculous cervical lesions is mainly from the developing countries where mycobacterial infections are prevalent.[20] Reactive lymphadenopathy was in 25 (8.06%) cases. This is similar to the study by Khan et al. (28%) and Javed et al. (16.66%).[24],[25] Detailed clinical history and other relevant investigations were done to find the etiologies of reactive lymphadenitis. This is the third most common condition in our study probably because most of the patients presenting with lymphadenopathy were given a course of antibiotics, and if it still persisted, then FNAC was performed. Lymph node aspirates in 12 cases (3.87%) showed metastatic deposits. This is in correlation with the studies by Patel et al. and Ghartimagar et al. where metastatic deposits were seen in 27.06% and 18% cases.[26],[27] Most of the metastatic deposits (41.66%) were from squamous cell carcinoma and our findings correlated with the studies by Hemalatha et al. (60%) and Patel et al. (75.5%).[10],[26] The high incidence of squamous cell carcinomas in our study can be attributed to the high incidence of tobacco chewing and head and neck cancers in our region. Lymphomas constituted only 0.96% cases in our study. This was in accordance with the study by Khan et al. (2%).[24] Although their prevalence is low, they pose a great diagnostic challenge. Age of the patient and polymorphous population of cells and atypical cells should raise a suspicion of Hodgkin's lymphoma. Inadequate samples and fibrosed nodes in advanced disease may be the cause of lack of Reed–Sternberg cells.[3] Entities that can be diagnosed definitely on FNAC include high-grade lymphomas such as small noncleaved lymphoma, lymphoblastic lymphoma, immunoblastic lymphomas, Hodgkin's lymphoma, diffuse large B-cell lymphoma, and myeloblastic and lymphoblastic leukemia/lymphoma.[28]


  Conclusion Top


FNAC of lymph nodes is an excellent first-line investigation to determine the nature of lesion. It is quick, safe, minimally invasive, and reliable and is readily accepted by the patient. It is a useful tool in diagnosing both non-neoplastic and neoplastic lesions. ZN stain done in cases with granulomas, necrosis, or suppuration is highly valuable for routine diagnosing of tuberculosis. It is an economical and convenient alternative to open biopsy of lymph nodes. Our study highlighted the various cytomorphological patterns of lymphadenopathy and revealed a huge burden of tuberculous lymphadenitis in this region.

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Conflicts of interest

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  References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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