|Year : 2014 | Volume
| Issue : 2 | Page : 86-91
Evaluation of peripheral lymphadenopathy by fine needle aspiration cytology: A three year study at tertiary center
Atul Shrivastav1, Harsh A Shah2, Neeru M Agarwal2, Pravina M Santwani2, Geetika Srivastava3
1 Department of Pathology, C. U. Shah Medical College, Surendranagar, Gujarat, India
2 Department of Pathology, M. P. Shah Medical College, Jamnagar, Gujarat, India
3 Department of Opthalmology, ICARE Hospital, Noida, Uttar Pradesh, India
|Date of Web Publication||20-Jun-2014|
Department of Pathology, C. U. Shah Medical College, Dudhrej Road, Surendranagar - 363 001, Gujarat
Source of Support: None, Conflict of Interest: None
Background: Lymphadenopathy is a common presenting symptom in various diseases.
Objective: The present study was undertaken to evaluate the usefulness of fine-needle aspiration cytology (FNAC) as a diagnostic tool in cases of lymphadenopathy, to find the frequency and cause of lymph node enlargement in patients of different age groups and analyze the different cytomorphological patterns associated with various lymphadenopathies.
Materials and Methods: The present study was conducted in the department of pathology, Shri M.P. Shah Medical College, Jamnagar from June 2008 to July 2011. FNAC of the enlarged lymph nodes was performed with informed consent of the patient. Totally 1022 patients of lymphadenopathy who underwent FNAC were divided into three groups: Group I (0-20 years), Group II (21-50 years) and Group III (>51 years).
Results: Maximum number of patients with lymphadenopathy was in Group II: 502 (49.11%), followed by Group I: 378 (36.98%) and in Group III there were 142 (13.90%) cases. Most common causes of lymphadenopathy in different groups were found to be: In Group I: Reactive hyperplasia 198 cases (52.38%), Group II: Tubercular lymphadenitis 232 cases (46.21%) and Group III: Metastatic carcinoma 80 cases (56.33%).
Conclusion: It was concluded that different etiological factors play a role in causation of lymphadenopathy in different age groups and that aspiration cytology provided a reliable, safe, rapid and economical method of screening these patients with accuracy.
Keywords: Fine-needle aspiration cytology, lymphadenopathy, reactive hyperplasia, tubercular lymphadenitis
|How to cite this article:|
Shrivastav A, Shah HA, Agarwal NM, Santwani PM, Srivastava G. Evaluation of peripheral lymphadenopathy by fine needle aspiration cytology: A three year study at tertiary center. J NTR Univ Health Sci 2014;3:86-91
|How to cite this URL:|
Shrivastav A, Shah HA, Agarwal NM, Santwani PM, Srivastava G. Evaluation of peripheral lymphadenopathy by fine needle aspiration cytology: A three year study at tertiary center. J NTR Univ Health Sci [serial online] 2014 [cited 2020 Jan 28];3:86-91. Available from: http://www.jdrntruhs.org/text.asp?2014/3/2/86/134834
| Introduction|| |
Lymphadenopathy is one of the most common clinical presentations of patients, attending the outdoor department. The etiology varies from an inflammatory process to a malignant condition.  Fine-needle aspiration cytology (FNAC) is a clinical technique used to obtain cells, tissues and/or fluid through a thin needle attached with disposable syringe for the purpose of diagnosis of masses.  De May has summarized the advantages of FNAC with the acronym SAFE means Simple, Accurate, Fast and Economical.  It can easily differentiate between non-neoplastic and neoplastic lesions and is very useful in deep seated masses of head and neck. , It is a simple and rapid diagnostic technique and because of early availability of results, simplicity, minimal trauma and absence of complications, the aspiration cytology is now considered a valuable diagnostic aid. The cytomorphological features collaborates with histopathology and has qualities of a micro-biopsy. , The diagnostic yield of FNAC can be improved if it is accompanied by radiological guidance like ultrasonography and computed tomography scan.  The outcome of FNAC can be improved by proper clinical assessment of lesion, careful procedure and adequate smear preparation. 
The aims of this study are:
- To evaluate the role of FNAC in patients presenting with lymph node enlargement.
- To find out the frequency of lymphadenopathy in different age groups.
- To find out the etiological factors causing lymphadenopathy in different age groups.
- To study the different cytomorphological patterns associated with various lymphadenopathies.
| Materials and Methods|| |
The present study was conducted in the Department of Pathology, Shri M.P. Shah Medical College, Jamnagar from June 2008 to July 2011 (1022 cases) FNAC of the enlarged lymph nodes was performed with informed consent of the patient. Detailed clinical history was noted. Palpable nodes were aspirated in the cytology department while in cases of deep seated nodes, radiological assistance is taken. Smears were stained with Giemsa, hematoxylin and eosin (H and E) and Pap stains depending upon the clinical presentation of the patient. In elderly patients more smears (at least 50%) were fixed in alcohol and stained with Pap and H and E stains. One slide was kept unstained in each case and Ziehl-Neelsen staining was performed where a cytological diagnosis of granulomatous disease was made. The cytological results were compared with histological findings, whenever possible.
Prior approval is taken for this study from ethical committee of our institute.
| Results|| |
During this period, a total 1022 FNAC's from lymph nodes were performed. These cases were divided into three groups depending on their age: Group I (0-20 years), Group II including adolescent and middle-aged patients (21-50 years) and Group III with elderly patients (>51 years). In Group I, there were 378 (36.98%) patients with male:female ratio of 1.22:1; in Group II total 502 (49.11%) cases and male:female ratio was 0.92:1; in Group III there were 142 (13.90%) cases with male:female ratio of 2.55:1.
Among the various sites of lymph node involvements, cervical lymph nodes were the most common 877 (85.82%) cases followed by, supraclavicular 43 (4.22%), inguinal nodes 36 (3.48%), axillary 28 (2.73%) and in 38 (3.73%) of cases more than 1 site was involved.
It was observed that in each of the three groups, the most common cause of lymphadenopathy was different. In Group I, the most frequent cause of lymphadenopathy was found to be reactive lymphoid hyperplasia with 198 cases (52.38%) followed by tubercular lymphadenitis in 149 cases (39.41%). In Group II, the most common etiology of lymphadenopathy was found to be tubercular with 232 cases (46.21%) followed by reactive lymphoid hyperplasia with 141 cases (28.08%). Metastasis was observed as the most frequent causative agent of lymphadenopathy with 80 cases (56.33%) in Group III, followed by tubercular lymphadenitis in 21 cases (16.30%) [Table 1].
|Table 1: Result of FNAC showing frequency distribution of various pathological conditions in each group|
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Out of total 118 cases of metastatic carcinoma, 19 patients who had breast lump along with axillary lymphadenopathy were not included in the study. In remaining 99 cases, squamous cell variety was predominant 64 (65%) cases followed by adenocarcinoma 23 (23%) cases, 2 (2%) cases having small cell carcinoma and 10 (10%) cases having undifferentiated carcinoma.
The cytological diagnosis of reactive hyperplasia was established by the presence of high cell density, polymorphic cell population and a considerable number of tingible body macrophages [Figure 1].
|Figure 1: Aspirates from reactive lymphadenitis, showing polymorphous population of lymphoid cells (H and E, ×200)|
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The diagnosis of tubercular lymphadenitis was made in the presence of typical cytological features like epithelioid cell granuloma with or without caseous necrosis [Figure 2], positive Ziehl-Neelsen stained smears [Figure 3] and these were correlated with clinical features and other lab findings like chest X-ray and sputum examination. In cases where Ziehl-Neelsen stain was negative and no other supportive findings were present, diagnosis of granulomatous lymphadenitis was given.
|Figure 3: Smear showing many pink colored acid fast bacilli, lying singly and in clusters (Ziehl-Neelsen, ×1000)|
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In differentiated squamous carcinomas, tight clusters or loosely scattered single cells showing various degrees of keratinization were seen [Figure 4]. Most of the aspirated cells were mature, but a careful search for hyperchromatic irregular nuclei showed more malignant features, which were important for confident diagnosis. This is because on rare occasions, the branchial or epidermal cyst aspirate with its content of mature squamous cells may closely mimic a differentiated metastatic carcinoma.  The less differentiated squamous carcinomas are more difficult to diagnose, but cells with abundant dense opaque cytoplasm, arranged in mosaic sheets with occasional keratin pearl formation and giant cell reaction to keratin are useful diagnostic clues.
In metastatic adenocarcinomas, the individual cells were large cuboidal to columnar with abundant lacy cytoplasm, many a times forming papillary architecture [Figure 5] and often with a pale blue extra cellular mucinous fluid background. Some cells even exhibited vacuoles with definite signet ring cell morphology. The nuclei were round to oval with irregularly thickened nuclear membranes and prominent nucleoli, sometimes making it difficult to rule out a poorly differentiated squamous carcinoma. 
|Figure 4: Clusters of malignant squamous cells (H and E stain, ×400) and inset shows Pap positivity in slide (Pap, ×200)|
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|Figure 5: Clusters of adenocarcinoma cells arranged in papillary clusters (H and E, ×200)|
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Metastatic small cell carcinoma was seen in two cases where the patient had suspicious mass lesion in the lung. Ten cases having features, which were not fitting into any differentiated type were labeled as undifferentiated metastatic carcinoma [Figure 6].
Non-Hodgkin's lymphoma (NHL) smears showed a monomorphic cell pattern, consisting of lymphoblasts or lymphocytes, the cells being singly scattered. Hodgkin's lymphoma showed a mixed cell population with characteristic Reed-Sternberg cells.
Histopathological examination was advised in 37 cases comprising of lymphoma, histiocytosis and immunoblastic lymphadenopathy, of which correlation was possible in only 28 cases. All these cases (including 16 cases of lymphomas) showed exact histological correlation.
| Discussion|| |
Lymphadenopathy is one of the common clinical presentations of various ongoing disease processes inside the body. FNAC is a simple and rapid diagnostic technique for evaluation of lymphadenopathy. This study was carried out to find out the relative frequencies of various pathologies presenting as lymph node enlargement in different age groups. The lesions arising in the lymph node can be found in patients ranging from early to advanced age. In our study, the youngest patient was 6 months old and oldest was 85 years of age. These figures come in close comparison to other studies. ,
FNAC was performed in 1022 cases of lymphadenopathy, both superficial and deep. The overall male preponderance seen in our study correlates well with studies done by Ahmad et al. 
As observed by Khajuria et al.  and Ahmad et al.,  in our study also the most common group of lymph nodes involved was cervical group (85.82%) followed by supraclavicular, axillary and inguinal group of lymph nodes.
Various causes have been found to be responsible for lymphadenopathy and their frequency varies according to the age of the patient. It was observed that in pediatric and adolescents' age group the most common cause of lymphadenopathy was reactive hyperplasia 198 cases out of total 378 cases (52.38%), while tubercular lymphadenitis outnumbered other causes of lymph node enlargement in young adults and middle-aged patients 232 cases out of total 502 cases (46.21%). Males showed a preponderance of reactive hyperplasia, lymphoma and metastatic carcinoma, while tuberculous lymphadenitis showed a slight female preponderance this was noted in concordance with other studies done by Khajuria et al.  We do not have microbiological correlation (like culture, gram staining etc.) for infective etiologies so we are not able to name them specifically, in our study they may be reactive, suppurative or granulomatous type of lymphadenitis.
Metastatic carcinoma constituted as a major cause of lymphadenopathy in patients above 50 years of age 80 cases out of total 142 cases (56.33%).
The most common tumor metastasizing to the neck nodes was the squamous carcinoma (65% of all metastatic lymph nodes) arising commonly in the tongue, alveolus, buccal mucosa, palate and from lung followed by adenocarcinoma (23%), undifferentiated carcinoma (10%) and small cell carcinoma of lung (2%). This high percentage of squamous cell carcinoma has possible explanation that in our region (Saurashtra region) of Gujarat very high number of people have a bad habit of tobacco chewing. 
Aspirates with papillary branching, three-dimensional groups of cells may originate from thyroid, salivary glands, breast, lung, kidney, prostate, and gonads. All these sites were encountered as the primary tumor sites in one or many cases in the present study. Aspirates with papillary branching, three-dimensional groups of cells and psammoma bodies have been in thyroid, lung, pancreas and ovarian metastasis. 
In aspirate of metastatic small cell carcinoma cells have scant cytoplasm with nuclei 2-3 times larger than small lymphocytes. Nuclei usually demonstrate the classical "salt and pepper" chromatin with indistinct nucleoli and frequent molding. Streaking artifact along with karyorrhectic debris are seen in the background. , Sometimes, these background findings may make it difficult to differentiate from lymphoma where clinical findings (more generalized lymphadenopathy) may be helpful to differentiate. 
Many metastatic nodes undergo liquefaction necrosis with central cavitations. FNA smears of these nodes reveal abundant neutrophils, histiocytes, necrotic debris and stray individually scattered keratinized cells. The differential diagnosis includes an acute suppurative pathology, a Warthin's tumor, infected branchial cleft cyst, epidermoid cyst and necrotizing squamous carcinoma. A re-aspiration from the edge of the mass rather than from the center is more contributory. , Cystic change in metastatic nodes was noted in about 9% (nine cases) of our cases. The tumor cells of non-keratinizing variant of squamous carcinoma appear in sheets and have round to oval nuclei with coarse granular chromatin and prominent nucleoli. Sometimes differentiation from poorly differentiated adenocarcinoma becomes difficult or even impossible. A mucin stain may be helpful in select cases. When cells are singly scattered and much undifferentiated the possibility of NHL has also to be considered. 
Out of total 1022 patients, the most common etiological factor in lymphadenopathy was tubercular with 402 (39.33%) cases followed by Reactive with 357 (34.93%) cases which are comparable with studies done by Khajuria et al. 
Comparison of this study with other study is listed in [Table 2]. Hirachand et al.  noted that the most common type of metastatic carcinoma to lymph node was of squamous cell variety followed by adenocarcinoma. Lymphoma (both NHL and Hodgkin's) was found in 2% cases which is lower than the result reported in other studies, we also found low incidence of 2.25%.
Out of 37 cases of lymphoma, histiocytic and immunoblastic lymphadenopathy and Castleman's disease 28 were confirmed histopathologically. Of the 23 lymphoma cases histological correlation was possible in 16 cases. Diagnostic accuracy was observed to be 100% in these cases. Khajuria et al.,  Gupta et al.  and Tripathi et al.  reported it as 84%, 82% and 80% respectively in their study of lymphoma cases.
| Conclusion|| |
We conclude that there were different etiological factors playing a role in causation of lymphadenopathy in different age groups. Most common causes of lymphadenopathy in 0-20 years age group was reactive hyperplasia, in 21-50 years tubercular lymphadenitis and metastatic carcinoma in patients >50 years of age. Considering these statistical data it can be suggested that while doing lymph node FNAC in patients >50 years of age, a precaution should be taken to make wet fixed smears more and also should keep unstained smears for special histochemical stains, e.g., for mucin, etc. Though the diagnostic accuracy of FNAC is low when compared to histological examination, it is a valuable and reliable screening tool in outpatient clinics. Following the cytodiagnosis, decision regarding the requirement of histological examination can be made and patient can be managed with a curative or palliative approach.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2]