|Year : 2021 | Volume
| Issue : 1 | Page : 102-107
Utility of fine-needle aspiration cytology in diagnosis of lymphadenopathy: Experience from a tertiary care centre from South India
Panduranga Chikkannaiah, Channaigaramaiah Guruprasad, Srinivasamurthy Venkataramanappa
Department of Pathology, Employees' State Insurance Corporation Medical College and PGIMSR, Bengaluru, Karnataka, India
|Date of Submission||15-Sep-2019|
|Date of Acceptance||16-Jan-2020|
|Date of Web Publication||29-Jul-2021|
Dr. Panduranga Chikkannaiah
Department of Pathology, Employees' State Insurance Corporation Medical College and PGIMSR, Rajajinagar, Bengaluru - 560 010, Karnataka
Source of Support: None, Conflict of Interest: None
Introduction: Abnormal shape, size, and consistency of the lymph node constitute lymphadenopathy. The etiology of lymphadenopathy varies from reactive to malignancy. It is the significant manifestation of local and systemic ailments specially an occult malignancy. Fine-needle aspiration cytology (FNAC) is a simple, reliable initial diagnostic modality. Materials and Methods: This is a retrospective study from January 2005 to December 2017. The lesions were classified into reactive lymphadenopathy, granulomatous lymphadenitis, necrotizing lymphadenitis, suppurative lymphadenitis, lymphoma, and metastatic lesions. Primary organ was identified in available cases of metastatic lesions. Cytological and histopathological correlation was done in available cases. Results: A total of 3676 cases were retrieved constituting 16% of total FNAC performed during the study, females outnumbered the male. Most of the cases were observed in the age of 21–30 years. Cervical lymph nodes were the common site of involvement (88.8%). Among the benign lesions, granulomatous (40%) was most common followed by reactive (39%). Metastatic lymphadenopathy (13%) was the most common malignant lesion. Squamous cell carcinoma was the most common metastatic tumor followed by adenocarcinoma. The lung was the most common primary organ. FNAC is having high sensitivity and specificity for malignant lesions than the benign. Conclusion: FNAC is a rapid, initial diagnostic tool for lymphadenopathy. It is an effective tool to differentiate inflammatory, benign, and malignant lesions.
Keywords: Fine-needle aspiration cytology, lymphadenopathy, metastatic squamous cell carcinoma, reactive lymphadenopathy, tuberculosis
|How to cite this article:|
Chikkannaiah P, Guruprasad C, Venkataramanappa S. Utility of fine-needle aspiration cytology in diagnosis of lymphadenopathy: Experience from a tertiary care centre from South India. J Datta Meghe Inst Med Sci Univ 2021;16:102-7
|How to cite this URL:|
Chikkannaiah P, Guruprasad C, Venkataramanappa S. Utility of fine-needle aspiration cytology in diagnosis of lymphadenopathy: Experience from a tertiary care centre from South India. J Datta Meghe Inst Med Sci Univ [serial online] 2021 [cited 2021 Sep 16];16:102-7. Available from: http://www.journaldmims.com/text.asp?2021/16/1/102/322596
| Introduction|| |
Lymphadenopathy is one of the common clinical presentations in all the age groups. It varies in etiology from benign lesion such as reactive condition to malignancy. In developing countries like India tuberculosis is still the common cause of lymphadenopathy. RNTCP in the latest guidelines emphasize that lymph node enlargement more than 1 cm needs to be investigated to rule out tuberculosis. Lymph node tuberculosis is having a prevalence of 35%. Metastatic deposits are the most common malignant lesions with an incidence ranging from 65.7% to 80.4%, while lymphomas constitute 2%–15.3%.
The diagnosis of lymphadenopathy is challenging, the available modalities are fine-needle aspiration cytology (FNAC), core biopsy, and open biopsy. FNAC is a simple, reliable, outpatient procedure with minimal complications and can differentiate benign from malignant lesions. It is better accepted by patient and clinicians.,,
Few authors have documented the usefulness of FNAC as a diagnostic tool for lymphadenopathy across India.,,,, Similar studies are sparse from south India., Hence, this study was carried out to document utility of FNAC in the diagnosis of lymphadenopathy and to study the prevalence of various neoplastic and nonneoplastic diseases of lymphadenopathy with cytology and histopathology correlation.
| Materials and Methods|| |
This is a retrospective study conducted in the Department of Pathology at a Medical College and Teaching Hospital for 13 years from January 2005 to December 2017. All the cases of lymphadenopathy which had undergone FNAC have been included in the study. With aseptic precautions, FNAC had been done with 10 cc syringe. Half of the smears had been air dried and half had been fixed in alcohol for 30 min. Air-dried smears were stained by Ziehl–Neelsen stain and Giemsa. Alcohol fixed smears were stained with hematoxylin and eosin (H and E) and Papanicolaou stain. The demographic details of the patients were retrieved from cytology request form. The lesions were classified into reactive lymphadenopathy, granulomatous lymphadenitis, necrotizing lymphadenitis, suppurative lymphadenitis, lymphoma and metastatic lesions. For metastatic lesions in available cases, primary organ was identified.
Cytology and histopathological correlation was done from January 2013 to December 2017. The available histopathological slides were retrieved, if the slides were not available paraffin blocks were retrieved, and 3–5 μm sections were cut and stained by H and E. The slides were screened and lesions were confirmed.
Descriptive statistics were done percentage and frequency was calculated. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated using Chi-square test. Results were tabulated.
| Results|| |
A total of 23,341 FNAC were performed during the study, out of which 3676 were of lymph node constituting 16%. Females outnumbered the male M:F:0.8:1. Our cases were distributed in all the age groups, minimum age was 6 months and maximum was 89 years. Maximum number of cases were in the age group of 21–30 years (24.7%), and least number of cases were below 6 months (0.1%) [Table 1]. Cervical lymph nodes were most commonly involved (88.8%) followed by axillary (75%) and inguinal (3%). Granulomatous lymphadenitis was the most common lesion (40%) followed by reactive lymphadenopathy (39%), suppurative lymphadenitis and necrotizing lymphadenitis constituted 2.5% and 1.3%, respectively. Among the malignant lesions, metastatic lesions were commonly followed by lymphoma (non-Hodgkin lymphoma [NHL] - 2.3%, HL 0.3%). The criteria used for diagnosis of GL were the presence of epithelioid cells in singles or clusters with or without giant cells or caseous necrosis [Figure 1]a and [Figure 1]b. They are the most common lesions observed in the present study. GL cases were distributed in all the age groups from 6 months to 80 years. The disease is common in the age group of 21–30 years (36.5%) followed by 31–40 years (25.5%). Cervical lymph nodes were commonly involved in 93.5% of cases. Of 1472 cases, 279 (19%) were positive for acid-fast bacilli.
|Figure 1: (a) Cytological smear from a case of granulomatous lymphadenitis, showing clusters of epithelioid cells forming granulomas (red arrow) (Leishman, ×10), (b) higher magnification of the same showing epithelioid cells (black arrow head) (Leishman, ×40), (c) microphotograph of cytological smear from a case of reactive lymphadenopathy, showing polymorphous population of lymphoid series cells (Leishman, ×10), (d) higher magnification of the same (Leishman, ×40)|
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The cytological criteria used for diagnosis was the presence of polymorphous population of lymphoid series cells along with tingible body macrophages [Figure 1]c and [Figure 1]d. They are the second-most common lesions observed in the study (39%). Cervical lymph node was commonly involved in 94.5% of cases. With respect to age distribution, reinforcement learning was observed in a younger age i.e., 1–10 years (24%) followed by 21–30 years. Suppurative lymphadenitis is diagnosed based on the observation of dense neutrophils [Figure 2]a. The criteria for diagnosis of NL are the presence of necrosis other than caseous necrosis [Figure 2]b. Cervical lymph nodes were involved in 94% and 89%, respectively. Both the lesions were common in 21–30 years, followed by 31–40 years.
|Figure 2: (a) Smear of suppurative lymphadenitis, showing neutrophilic debris in a necrotic back ground (Leishman, ×10), (b) Smear showing necrotic material in a case of necrotizing lymphadenitis, (c) smear showing polymorphous population of lymphoid series cell admixed with Reed–Sternberg cells (red arrow head), (d) smear showing monomorphic population to dimorphic population of lymphoid series cells (Leishman, ×40), (e) microphotograph showing clusters of squamous cells with malignant nature in a case of metastatic squamous cell carcinoma (red arrow) (Leishman, ×40), (f) microphotograph showing clusters of glandular cells with malignant nature in a case of metastatic adenocarcinoma (black arrow) (Leishman, ×40)|
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HL is diagnosed on observation of Reed–Sternberg cells in the background of eosinophils, neutrophils, and plasma cells [Figure 2]c. Cervical lymph node was commonly involved in addition abdominal (2 cases) and mediastinal (3 cases) lymph nodes were also involved. NHL constituted 2.3% while HL was 0.3%. Both the lesions were common in the age group of 41–60 years. NHL was diagnosed based on the presence of monomorphic malignant looking lymphoid series cells [Figure 2]d.
The criteria used for the diagnosis of metastatic lymphadenopathy were the presence of extra lymphoid population of tumor cells. They are the most common neoplastic lesions observed in the present study, constituting 13%. Cervical lymph nodes were commonly involved in 82%. The lesion was commonly observed in elderly population between 51 and 70 years (59%). Microscopically, squamous cell type [Figure 2]e is most common followed by adenocarcinoma [Figure 2]f.
In 383 cases (January 2011–December 2017), the primary organ for metastatic lymph node was attempted. Of 383 cases, in 79 cases, the primary organ was not traceable. For the cervical lymph node (309 cases), the primary organs in the decreasing order were lung, pharynx, larynx, oral cavity, gastrointestinal tract, and thyroid. For all the cases of axillary lymph node (62 cases) breast was the only primary organ. Four cases of breast carcinoma in addition involved the cervical lymph node. Inguinal lymph node was involved in five cases, four from carcinoma of penis, and one from carcinoma of testis [Table 2].
Cytology and histological correlation were available in 106 cases. FNAC is having high sensitivity, specificity, PPV, NPV, and accuracy for malignant lesion in comparison to inflammatory lesions [Table 3]. Twenty-two cases were associated with human immunodeficiency viruses, 17 were in cervical, 3 axillary, and 2 inguinal region. Among 22 cases, 13 were granulomatous, 7 reactive and in 2 cases no opinion was possible.
|Table 3: The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of fine.needle aspiration cytology for various lesions|
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| Discussion|| |
Human body consists of around 600 lymph nodes. Lymph nodes are the easily accessible component of the lymphoid system. Abnormal shape, size, and consistency of the lymph node constitute lymphadenopathy. The factors affecting lymphadenopathy are the age, sex, geographic location, and socioeconomic status. Enlargement of lymph nodes occurs due to either local cause or systemic causes. In few cases, it is the first sign of systemic malignancy. Even though biopsy is considered gold standard, FNAC is a quick, reliable initial diagnostic modality for lymphadenopathy and the technique is well accepted by patient, cytopathologist, and clinicians.,,,
In the present study, lymphadenopathy seeking FNAC constituted 16% and in a study by Qadri et al. indication for FNAC was 21%. The age of the patient in the present study ranged from 6 months to 89 years and our findings are in consistent with literature.,,,,,
Females outnumbered the male with M:F:0.8:1 and our observation is in consistence with Nidhi et al. In contrast Pathy et al. Hirachand et al. observed male predominance. The female predominance in our study is because our hospital is an insurance organization which caters patient mainly from the garments and small scale industries where female are the predominant workers.
Cervical region was the most common site of involvement (88.8%) and our findings are in consistent with literature.,,,,,,,,,,, Ojo et al. observed axillary lymph node as the most common site. The reason for cervical lymph node being common may be due to anatomy of the lymph node as it drains most part of the body like head and neck, thorax, and part of abdomen where infections and malignancy are common. Another reason is due to our sample are derived from low social economic groups where infection of respiratory track, scalp, and tuberculosis are common.
In the present study, the prevalence of granulomatous and reactive lymphadenopathy was 40% and 39%, respectively, the results are of less difference. On reviewing the literature from Indian and other Asian countries, few authors such as Dhingra et al., Khajuria et al. and Batni et al. observed reactive lymphadenopathy as the most common cause for lymph node enlargement. However, a study by Fatima et al., from Pakistan, observed granulomatous lymphadenitis as the most common cause of lymphadenopathy. Among the malignant lesions, metastatic lesions were most common followed by lymphomas. In the present study, metastatic lymphadenopathy constituted 13% while lymphomas constituted 6% and our findings are in sync with literature.,,,,,,,,,,,
Few authors such as Pathy et al., from India, Qadri et al., from Pakistan and Darnal et al., from Malaysia observed malignant lesions as the common cause of lymphadenopathy in comparison to benign lesions, this may be due to all these studies were carried out at a tertiary care and cancer centers which caters only referred cases [Table 4].
Among the metastatic tumors, squamous cell carcinoma was most common followed by adenocarcinoma and breast carcinoma. Our findings are in consistent with Pathy et al., Qadri et al., Khajuria et al., Hirachand et al., Wilkinson et al., while Ghartimagar et al., Darnal et al., observed adenocarcinoma has the most common tumor. The observation of squamous cell carcinoma as the most common metastatic tumor is due the high prevalence of cancer of oral cavity, lung, and larynx in India. In the present study primary organ for squamous cell carcinoma is lung followed by pharynx, larynx and oral cavity. Wilkinson et al. in their study observed oral cavity as the most common primary organ followed by larynx and pharynx. Mitra et al. observed lungs, breast, stomach, and esophagus as the most common primary organs.
FNAC is having high specificity and sensitivity especially for malignant lesions than benign. In the present study, we observed overall sensitivity of 81%, specificity of 94.4%, PPV of 81.2%, NPV of 94.4%, and accuracy of 98.89%. Our observations are in accordance with Dhingra et al. Pathy et al. and Hirachand et al. In the present study, we have observed an accuracy of 97.16% for metastatic lesions, 93.29% for lymphoma, and 87.73% for granulomatous and reactive lymphadenopathy and our findings are comparable to literature. Less accuracy of FNAC for benign lesions may be due to natural course of the disease as most of them including tuberculosis begin as reactive lymphadenopathy.
| Conclusion|| |
FNAC is a primary, cost-effective diagnostic modality for lymphadenopathy. Etiology of lymphadenopathy varies with the age. Cervical lymph nodes were the common site of involvement. Among the benign lesions, granulomatous and reactive were common. Metastatic lymphadenopathy was the most common malignant lesion. Squamous cell carcinoma was the most common metastatic tumor and lung was the most common primary organ. FNAC is having high sensitivity and specificity for malignant lesions than the benign.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]