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ORIGINAL ARTICLE
Year : 2013  |  Volume : 6  |  Issue : 4  |  Page : 400-404  

Role of fine needle aspiration cytology in assessment of cervical lymphadenopathy


Department of Pathology, Padmashree Dr D Y Patil Medical College, Hospital and Research Centre, Dr D Y Patil Vidyapeeth, Pimpri, Pune, India

Date of Web Publication17-Sep-2013

Correspondence Address:
Harsh Kumar
132, Brighton Court, Clover Village, Wanowrie, Pune - 411 040
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.118287

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  Abstract 

Background: Cervical lymphadenopathy is a common clinical problem that confronts us in daily clinical practice. The causes vary from simple treatable infections to malignancies that require highly specialized institutional management. It therefore needs to be speedily investigated. Fine needle aspiration cytology (FNAC) is simple, quick, inexpensive and minimally invasive technique that can be used as an outpatient procedure to diagnose them. Aims and Objectives: To assess the various causes of cervical lymphadenopathy through FNAC, and to see the distribution of lesions with respect to age and gender . Material and Methods: A retrospective study was conducted over a period of 10 months in a major laboratory. The cyto-morphologic features seen in the aspirates were critically analyzed and correlated with their aetiology. Results: In this study, 214 cases of cervical lymphadenopathy were analyzed. The age of the patients ranged from 9 months to 84 years of which 59% were males and 41% were females. Maximum incidence of cervical lymphadenopathy was observed in the age group of 21 to 40 years. The maximum numbers of patients (47.67%) were diagnosed as tuberculous lymphadenitis, followed by reactive lymphadenitis (44.39%), lymphomas (4.2%) malignant metastatic deposits (2.8%), and granulomatous lymphadenitis (0.94%). Conclusion: Our study concluded that FNAC is simple, quick, minimally invasive, and inexpensive technique to diagnose cervical lymphadenopathy. It can differentiate a neoplastic from a non-neoplastic process and therefore influence patient management preventing patient from being subjected to unnecessary surgery.

Keywords: Cervical lymphadenopathy, fine needle aspiration cytology, granulomatous lymphadenitis


How to cite this article:
Kumar H, Chandanwale SS, Gore CR, Buch AC, Satav VH, Pagaro PM. Role of fine needle aspiration cytology in assessment of cervical lymphadenopathy. Med J DY Patil Univ 2013;6:400-4

How to cite this URL:
Kumar H, Chandanwale SS, Gore CR, Buch AC, Satav VH, Pagaro PM. Role of fine needle aspiration cytology in assessment of cervical lymphadenopathy. Med J DY Patil Univ [serial online] 2013 [cited 2021 Sep 17];6:400-4. Available from: https://www.mjdrdypu.org/text.asp?2013/6/4/400/118287


  Introduction Top


Cervical lymphadenopathy is very commonly encountered in clinical practice in our country. The cause of lymphadenopathy can range from an innocuous reactive lesion to tuberculosis to malignancy. The management of these various lesions is very different and hence the determination of the etiology is of paramount importance. A quick, inexpensive, and reliable investigative tool is therefore required. For many decades, pathologists have employed needles to obtain cell and tissue fragments to diagnose an underlying pathology. FNAC has emerged as a sensitive, specific, and cost-effective tool to diagnose cervical lymphadenitis. [1] It is a reliable and an inexpensive method, suitable for developing countries like India for the investigation of any accessible superficial swelling, especially lymphadenopathies. The method is easily applicable to lesions that are easily palpable e.g. breast, thyroid, salivary glands, subcutaneous swellings, and superficial lymph nodes. New radiological techniques for internal imaging of visceral organs have opened vast opportunities for performing guided FNAC of deep-seated lesions. The role of FNAC in the investigation of lymphadenopathy has previously been established by a number of studies. [2],[3],[4],[5],[6] Due to the simplicity of the technique and speedy results, FNAC needs to be promoted in third world conditions. The most common cause of peripheral lymphadenopathy in our setting is an inflammatory reaction to a microbial challenge, followed by lymphomas and malignant metastatic deposits. The etiological factors for these lesions make a large list. Broadly speaking, they tend to be considered as reactive, tuberculous, or malignant metastases. Overall, infective conditions (reactive and tuberculous) are responsible for the majority of lesions. M. tuberculosis is the most common cause of granulomatous lymphadenitis in India. [7],[8],[9] Lymph nodes clinically suspected of lymphomas or malignant metastasis are one of the most common indications for FNAC in the elderly.

The biopsy of the cervical lymph node is always the gold standard. However, it is more resource intensive than FNAC, requires anaesthesia, strict asepsis, theatre time and often leaves a scar. In contrast, FNAC of the cervical node is relatively simpler and offers quick reliable results. There is no evidence that the tumour spreads through the skin track created by the fine hypodermic needle used in this technique. [10]


  Materials and Methods Top


A retrospective study was carried out for over a period of 10 months in a large laboratory. Patients with significant cervical lymphadenopathy irrespective of age and gender were included in this study. A total of 214 patients with cervical lymphadenopathy were evaluated. The detailed clinical findings were recorded before performing FNAC. Other relevant radiological findings were also noted for correlation. FNAC was done on the representative lymph nodes observing strict aseptic precautions. Multiple aspirations were done in patients with generalized lymphadenopathy. An informed consent from the patient was taken before performing the procedure. The palpable lymph node was fixed with one hand and the overlying skin was scrupulously cleaned prior to performing FNAC. A size 22 gauge needle, attached to a 10 ml syringe was inserted into the swelling and full suction pressure was applied. The tip of the needle was briskly moved up and down and sideways a few times till a spot of material showed in the stem of the needle. The negative pressure in the syringe was then released and the needle was withdrawn. The aspirated material was then blown on a clean glass slides using the same syringe. Smears were prepared on glass slides, fixed in alcohol, and stained with Leishman's and Hematoxylin and Eosin stain. Necrotic aspirates were also submitted for Ziehl-Neelsen (ZN) staining for Acid Fast Bacilli (AFB) and their culture. Microscopic analysis was carried out after staining. For diagnosing tuberculous lymphadenitis on FNAC the following criteria were observed:

  1. Characteristic cytologic features of tuberculosis such as epithelioid granulomas, caseous necrosis with or without AFB.
  2. Epitheloid granulomas without necrosis with AFB (on ZN stain or culture)
  3. Extensive necrosis with AFB (on ZN stain or culture)


If epitheloid granulomas were detected, but no caseation necrosis or AFB were seen, a diagnosis of granulomatous lymphadenitis was offered.

A lymph node biopsy was done in all cases diagnosed as lymphoma by FNAC.


  Results Top


This study analyzed 214 cases of cervical lymphadenopathy. The age of patients ranged from 9 months to 84 years in which 59% were males and 41% were females [Table 1]. The maximum incidence of cervical lymphadenopathy was observed in the age group of 21 to 40 years (n = 139). Tuberculous lymphadenitis (n = 102) was found to be the most common pathologic lesion in our study, accounting for 47.67% of cases followed by reactive (non-specific) lymphadenitis (n = 95) constituting 44.39% of cases [Table 2]. In these 102 cases, epitheloid cell granulomas [Figure 1] with either caseation necrosis or AFB were seen, thereby confirming the diagnosis of tubercular lymphadenitis. These patients with tuberculous lymphadenitis were mainly in the third decade of life. Most patients of tuberculosis showed caseous material (n = 94) on smear. The Ziehl Neelsen stain for AFB was positive in 37 out of the total of 104 cases showing epitheloid cell granulomas. AFB were cultured in 42 out of the 102 cases diagnosed as tubercular lymphadenitis. In four patients, numerous were AFB seen on the smear. They were subsequently diagnosed to be HIV positive. In all, epitheloid cell granulomas were observed in all cases of tuberculosis with or without caseation and/or AFB. Two cases of granulomatous lymphadenitis remained. They did not show caseation and were negative for AFB on smear and culture. Both of these cases did not grow AFB on culture. Non caseating granulomas were confirmed in both these cases on biopsy. They were further investigated, followed up, and subsequently diagnosed as Cat scratch disease and toxoplasmosis respectively.
Figure 1: FNAC smear showing epithelioid granuloma (Leishman, X400)

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Table 1: Age and gender distribution of 214 cases of cervical lymphadenopathy


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Table 2: 214 cases of various cervical lymph node lesions


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Lymphomas constituted nine cases (4.2%) followed by metastatic carcinoma found in six (2.8%) of our cases. The distribution of various lesions is shown in [Table 2].

Reactive lymphadenitis was seen in 95 patients. Their aspirate showed the various stages of maturing lymphocytes, as seen in a reactive lymphoid follicle. In this group, six patients showed features of viral infection as prominence of immunoblasts and plasma cells. The background of lymphocytes was however polymorphous. The peripheral blood smear in these six cases showed antigenically stimulated lymphocytes. In a follow up of these cases over a period of 6 months, the clinical and peripheral blood findings totally regressed. There were nine patients of lymphoma. The aspirate in these cases was highly cellular and showed an almost monotonous population of round cells with scanty cytoplasm which were larger than lymphocytes [Figure 2]. In two cases, the background population of lymphoid cells was polymorphous, but they showed few large cells, reminiscent of  Reed-Sternberg cells More Details. All the nine patients of lymphoma were confirmed through lymph node biopsy. Five cases were follicular lymphoma, two were small lymphocytic lymphoma and two were of Hodgkins disease (mixed cellularity). The classical Reed-Sternberg cells were unequivocally identified on biopsy.
Figure 2: FNAC smear shows monomorphic lymphoma cells (Leishman, X400)

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Malignant metastases were demonstrated in six elderly patients. These patients were in the 5 th and 6 th decade of life. The smears from these patients showed a polymorphous background of lymphoid cells with small to large clumps of anaplastic cells having pleomorphic nuclei with irregular chromatin and prominent nucleoli. The metastatic cells in four of these cases showed features of keratinization and on work up these turned out to be metastatic deposits of squamous cell carcinoma [Figure 3] from oral carcinoma (n=2), carcinoma lung (n=1), and larynx (n=1). The remaining two patients showed adenocarcinoma of colon on biopsy.
Figure 3: FNAC smear showing metastatic squamous cell carcinoma (Leishman, X400)

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  Discussion Top


Enlarged cervical lymph nodes are always accessible for FNAC and therefore, this procedure is of great importance in the diagnosis of these disorders. It plays a significant role in developing countries like India, as it is relatively a cheap procedure, simple to perform and practically has almost no complications. [11],[12],[13] The diagnosis offered on FNAC has been shown to correlate very well with histopathological diagnosis after biopsy. [2],[3],[4],[5] Many times, an aspirate may be the only tissue available for offering a diagnosis, as sometimes a surgical biopsy may not be possible for various reasons. FNAC may often be the only tool for diagnosis for management of the patients in some cases of disseminated metastatic malignancy. In our study, the maximum number of cases were observed in the age group of 21-40 years, as also observed by Chandanwale et al. [14] There was a slight male preponderance in our cases. Similar observations have been made by Gadre et al, and others. [15],[16] Some authors have reported a slight female preponderance. [17],[18] Tuberculosis once thought to be under control has undergone a dramatic resurgence in the number of cases due to complacency and growing number of drug resistant strains. In our study, FNAC of the nodes, in these cases invariably revealed epitheloid cell granulomas. Most of the patients with tuberculosis showed caseous material (94/102 patients). The AFB were detected in 37/102 patients. The frequency of AFB positivity in FNAC smears in various study ranges from 10% to 70%. [19],[20],[21],[22] Overall, only two cases remained labeled as granulomatous lymphadenitis, and both cases were negative for M. tuberculosis on smear and culture. These cases were subsequently diagnosed as cat scratch disease and toxoplasmosis, respectively. Some authors believe in regions where tuberculosis is very common, morphologic findings of granulomatous inflammation are consistent with tuberculosis. [21],[22] Culture for AFB is advised in such cases, however, it is wise to mention that several weeks are needed to obtain the culture result. This may delay the initiation of treatment. Cultures have been found to be positive in 10-69% of cases with tuberculosis. [23],[24],[25] In our study, 42/102 cases of tubercular lymphadenitis were positive for AFB culture. Patients with a concurrent HIV infection revealed a heavy load of AFB, which is well documented in the literature. [17] The reactive lymph nodes (n = 95) formed the second major group. These patients were informed that they did not warrant any treatment.

Malignancies in lymph nodes are predominantly seen in the elderly. We had nine cases of lymphoma and six cases of malignant metastases. All the cases of lymphoma were confirmed by a lymph node biopsy. The overall incidence of malignancy in this study was 7%. Studies published in literature peg the incidence of malignancies in lymph nodes varying from 5.8% [11] to 25.03%. [12] The total number of malignancies in this study is small to draw any conclusion regarding their incidence.

Aspiration cytology is a valuable tool for tracing occult primaries and sometimes surprises the clinicians when they have not suspected any malignancy.

A histopathological examination of lymph nodes has always been considered to be the gold standard for tissue diagnosis for lymphomas. A well processed FNAC sample helps us to diagnose lymphomas; however, proper evaluation of lymphomas is best done on a lymph node biopsy. [2],[3],[4],[5],[26] In our study, all cases of lymphomas diagnosed by FNAC were subjected to lymph node biopsy for a detailed evaluation before they were managed by the onco-physician.


  Conclusions Top


FNAC of lymph nodes is a very useful and simple tool in the diagnosis of cervical lymphadenopathies. It is easy, maybe performed in OPDs, and serves as a rapid modality for the diagnosis of one of the common curable causes of cervical lymphadenopathy as tuberculosis. A cytological follow-up of the lesions is also easily possible by FNAC study. Tuberculosis stands out to be the most common cause of cervical lymphadenopathy in India. Patients with a heavy acid-fast bacilli load in the aspirate should be screened for HIV infection. FNAC may be the only tool available for the diagnosis of metastatic malignant lesions in lymph nodes in disseminated cancer and malignancies with an occult primary. For the diagnosis of lymphomas, FNAC can strongly suggest a preliminary diagnosis, which can be followed up by biopsy for histopathology and immunohistochemistry for confirmation and final classification.

 
  References Top

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    Figures

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

  [Table 1], [Table 2]


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