|Year : 2022 | Volume
| Issue : 2 | Page : 132-136
Cytomorphological study of lymph node lesions at a tertiary care center
Summi Ganguli, Mayurika Subodh Kumar Tyagi, Malay Bajpai, Swati Singh, Prem Kumar Garg, Abhishek Pathre
Department of Pathology, Santosh Medical College, Santosh Deemed to be University, Ghaziabad, Uttar Pradesh, India
|Date of Submission||19-Apr-2022|
|Date of Acceptance||24-Nov-2022|
|Date of Web Publication||11-Jan-2023|
Mayurika Subodh Kumar Tyagi
Department of Pathology, Santosh Medical College, Santosh Deemed to be University, Ghaziabad - 201 009, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Lymphadenopathy is one of the most common clinical presentations of patients attending the outpatient department. The degree and pattern of morphological changes depend on inciting stimulus and the intensity of the response. Fine-needle aspiration cytology (FNAC) is an important procedure in establishing the diagnosis of various lymph node lesions. It is a widely accepted, accurate, sensitive, and specific test used in an outpatient setting.
Methodology: An observational study was carried out at the department of pathology of a tertiary care hospital in North India from July 2019 to February 2020. A total of 100 lymphadenopathy cases were taken. Smears were stained with Giemsa and categorized according to the cytomorphological pattern. Ziehl - Neelsen (ZN) stain was done in clinically suspicious cases of tuberculosis (TB). Data regarding brief history, site, age, and cytomorphologic features were collected and analyzed.
Results: Out of 100 cases of lymph node aspirations, 70 cases showed features of tubercular lymphadenitis followed by reactive lymphadenitis, 29 cases while 1 malignancy. TB was prevalent in all age groups.
Conclusion: Lymph node FNAC is a simple, cost-effective investigation with great importance in view of high prevalence of TB in our country, where an atypical presentation of TB can be screened. Purulent aspirate smears which do not show typical features of TB can be dismissed as acute suppurative lymphadenitis in the absence of ZN staining. Acid-fast bacillus positivity in such cases confirms the diagnosis and helps in better patient management.
Keywords: Fine needle aspiration cytology, lymphadenopathy, tuberculosis
|How to cite this article:|
Ganguli S, Kumar Tyagi MS, Bajpai M, Singh S, Garg PK, Pathre A. Cytomorphological study of lymph node lesions at a tertiary care center. Santosh Univ J Health Sci 2022;8:132-6
|How to cite this URL:|
Ganguli S, Kumar Tyagi MS, Bajpai M, Singh S, Garg PK, Pathre A. Cytomorphological study of lymph node lesions at a tertiary care center. Santosh Univ J Health Sci [serial online] 2022 [cited 2023 Feb 1];8:132-6. Available from: http://www.sujhs.org/text.asp?2022/8/2/132/367559
| Introduction|| |
Lymphadenopathy is one of the prevalent clinical presentations of patients attending the outpatient department (OPD). The degree and pattern of morphological changes depend on the inciting stimulus and the intensity of the response. Fine needle aspiration cytology (FNAC) is an important procedure nowadays in establishing the diagnosis of various disease conditions of lymph nodes and other organs. It is a rapid, simple, reliable, minimally invasive, and cost-effective procedure used in the outpatient settings. The use of FNAC with other ancillary tests (microbiological, radiological, immune-histochemical, biochemical, and special staining techniques) is worthwhile for obtaining a definitive diagnosis in the setting of granulomatous disorders. Lymphadenopathy often denotes the spectrum of other serious illnesses such as lymphoma, metastatic cancer, or acquired immunodeficiency syndrome. Ease of access to enlarged cervical lymph nodes for FNAC makes this procedure of immense importance in diagnosing lymph node disorders. Cell morphology reflects the biological behavior of the tissue and host as well as the genetic and molecular biology of cells themselves. General biological activity is reflected best in the cellular structures of the nucleus. Functional activity is reflected mainly in the morphology of the cytoplasm. For the purpose of diagnostic cytopathology, cells can be categorized into different morphological groups. The degree of cellularity is a crucial criterion in the differential diagnosis of a benign or malignant tumor.
There are several parameters for the assessment of the individual cells, such as cell size, shape, N/C ratio, nuclear size, shape and distribution of chromatin, and nucleolar number, shape, and size. In conjunction with immunophenotyping and molecular studies, FNAC has gained acceptance in many centers as an initial diagnostic tool. The simplicity and timeliness of the procedure make it most appropriate and convenient for use in peripheral hospitals and dispensaries in an outpatient setting.
Cytological findings of a normal lymph node: Aspirates from a normal lymph node are dominated by a mixed population of lymphocytes, plasma cells, macrophages, and granulocytes. Mature lymphocytes measure around 8 μm in air-dried smears. They have a dense nucleus with coarse chromatin and a pale blue rim of cytoplasm. Plasma cells are characterized by their eccentrically placed nucleus with chromatin arranged in a chart wheel-like pattern. The abundant cytoplasm often shows a less intense basophilic staining in the paranuclear area. Centrocytes are B-cells measuring around 10 μm and have sparse weekly stained basophilic cytoplasm. The nucleus has a fine chromatin pattern in irregular shape and may be cleaved. Centro blasts are larger than centrocytes and have characteristic round nuclei, usually with several marginal nucleoli. Immunoblasts are the largest of the lymphoid cells and measure 20–30 μm. They have a round nucleus. Often eccentrically placed with 1–3 prominent strongly basophilic nucleoli. Macrophages may measure up to 45 μm with a round-to-oval nuclei with evenly distributed chromatin and inconspicuous nucleoli.
Aims and objectives
- To study the different cytomorphological patterns of FNAC associated with lymph nodes
- To study the etiological factors of lymphadenopathy
- To analyze the diagnostic importance and utility of FNAC in lymph node diseases.
| Methodology|| |
This observational study was conducted at a tertiary care hospital in Ghaziabad, Uttar Pradesh. This study was done from July 2019 to February 2020 after taking ethical clearance from the institution. The study was conducted on the cases from OPD and admitted patients requiring FNAC. Study participants were subjected to standard FNAC procedure.
A total of 100 patients presented for lymph node FNAC in the hospital. FNAC of the lymph node was performed with full aseptic precautions after taking consent. The procedure was performed using a 22 or 23G needle with an average of two passes, and a minimum of 4–5 slides were prepared. Slides were stained by Giemsa stain, and one slide was reserved for Ziehl Neelsen (ZN) stain or any special stain if required [Figure 1]. The aspiration smears were examined to reach a probable diagnosis. ZN staining was done to look for acid-fast bacilli in all cases where granulomatous disease or necrosis was observed in the cytology. A detailed history, clinical examination, and investigation faculty were documented as per pro forma. Data were recorded in Microsoft Excel, and appropriate statistical methods were applied.
Persons giving consent for FNAC.
Persons not giving consent for FNAC.
| Results|| |
In this study, the most common age group was between 17 and 31 years (45%), followed by 1–16 years (34%), with the mean age being 23.12 years and median age being 20 years, as shown in [Table 1]. Fifty-nine percent of the cases were female and 41% were male with female-to-male ratio being 1.44:1.
The cytological findings included reactive lymphadenitis [Figure 2], granulomatous lymphadenitis [Figure 3], necrotizing lymphadenitis, suppurative lymphadenitis, granulomatous necrotizing lymphadenitis, and metastatic squamous cell carcinoma [Table 2]. The most common finding was granulomatous lymphadenitis (36%), followed by reactive lymphadenitis (27%).
|Figure 2: Reactive lymphadenitis showing polymorphous population of lymphoid series, lymphoglandular bodies and tingible body macrophages Giemsa ×40|
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|Figure 3: Formation of granuloma in a lymph node aspirate. Inset: Langhans type of giant cell with horse shoe arrangement of nuclei Giemsa ×100|
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|Table 2: Cytological diagnosis of the Lymph node fine needle aspiration cytology|
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The most common site from where aspiration was done was the right cervical lymph node (38%), followed by the left cervical lymph node (32%). The most common size of lymph nodes aspirated ranged from approximately 3 cm to 4 cm. In this study, most cases were from the surgery department (40%), followed by pediatrics (17%).
Acid-fast bacillus (AFB) staining [Figure 4] was done in 72 suspected cases, out of which 26 (36.11%) of the cases were found to be positive for acid-fast bacilli, while 46 (63.89%) of the cases were reported as negative for the acid-fast bacilli [Table 3]. [Figure 5] shows a pie chart representing AFB positivity of the total cases. While AFB staining was not done in 28 cases as they were either reactive lymphadenitis or metastatic lymphadenitis.
|Figure 4: ZN Staining done for AFB (oil immersion). AFB Positive- Grade 4+. ZN: Ziehl Neelsen, AFB: Acid-fast bacillus|
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|Figure 5: Pie chart representing AFB positivity of the total cases. AFB: Acid-fast bacillus|
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Granulomatous necrotizing lymphadenitis showed the highest AFB positivity with 41.67%, followed by granulomatous lymphadenitis with 38.89% and necrotizing lymphadenitis with 38.46%, as shown in [Table 4].
|Table 4: Percentage of acid-fast bacilli positivity in all suspicious cases|
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| Discussion|| |
FNAC offers a rapid preliminary diagnosis of various disease conditions of lymph nodes and other organs. This is also an excellent teaching tool, which is becoming broader with advances in technology such as ultrasonography, magnetic resonance imaging, and computed tomography. With the help of either imaging techniques or palpation, virtually any organ can be sampled. It has reduced the number of excisional biopsies of nodes. The cytomorphological studies of smears obtained from aspirates can be offered as an alternative, easy, well-tolerated accurate, and less time-consuming, that can be done on a patient basis. It is a unique path that might lead to the identification of the underlying condition. Lymphadenopathy can arise from benign or malignant causes. However, proper aspiration technique and slide preparation are required, along with good knowledge of surgical pathology is required for reliable results. FNAC and other ancillary tests (microbiological, immunohistochemical, radiological, biochemical, and special staining techniques) are useful for obtaining a definitive diagnosis. The principal indication for FNAC is persistent lymphadenopathy to establish the causes of lymphadenopathy, which could not be reliably diagnosed on clinical grounds. Although metastatic cancer is the most common target of lymph node aspiration, frequently the majority of benign disorders have been accurately identified using FNAC as a tool. The applications of immunocytochemistry allow the identification of a broad spectrum of lymphomas.
FNAC, combined with the clinical experience, makes it a valuable method of high significance, especially in developing countries with limited financial and health care resources. In the present study, the cervical region was the most frequent site of lymphadenopathy (86%), followed by axillary (10%) and inguinal (3%). The cervical region was also seen as the most common site of involvement in other studies. Reddy et al. studied the lymph nodes according to their size and presentation site. They had concluded that the size of more than 1.5 cm in the inguinal region, 1 cm in the cervical and axillary region lymph node, and more than 0.5 cm at any other site should be considered significant. Although no substantial conclusion could be made according to the size and site of presentation of lymphadenopathy in the current study.
Granulomatous necrotizing lymphadenitis showed the highest AFB positivity with 41.67%, followed by granulomatous lymphadenitis with 38.89%.
In 1927, Dudgeon and Patrick first used the fine-needle aspiration technique in diagnosing tubercular lymphadenitis, followed by Tempka, Kubiczek, and Rosa. In our clinical setting, tubercular lymphadenitis constituted 70.0% of all the lymph node aspirates and was the most frequent cause of lymphadenopathy. This may be due to the prevalence of tuberculosis (TB) in India, along with the low socio-economic status of the population being studied. This study was in concordance with the previous Indian studies. The percentage was higher than in western studies, which might be due to the extremely low prevalence of tuberculous infections in developed countries.
Rajashekaran et al. have shown that no group was exempted from tubercular lymphadenitis. This may be attributed to the development of cell-mediated immunity against tubercle antigens in elderly patients not suffering from any comorbid diseases such as diabetes mellitus or malnutrition. Our study reiterated these findings.
Granulomatous lymphadenitis can be seen in TB, atypical mycobacterium, brucellosis, fungal infection, sarcoidosis, lymphoma, foreign-body reactions, and tumor metastasis. Over the last decade, the number of new TB cases has seen an increasing trend, primarily due to increased HIV infection. The incidence of TB is more in young children, elderly adults, and in immunocompromised states such as HIV infection.
Three patterns of tubercular lymphadenitis have been described by Das, depending on the cellular components as they present as a spectrum in natural history and progression of tubercular lymphadenitis.
- Epithelioid granuloma without necrosis with a considerable number of lymphocytes
- Epithelioid granuloma with necrosis with appreciable giant cells
- Necrosis without epithelioid granuloma with neutrophilic infiltrate and high AFB load.
| Conclusion|| |
Cytomorphological study of lymph nodes has become a highly utilized diagnostic tool due to the quick availability of results with minimally invasive technique and has few complications. It is cost-effective and accurate as the first-line investigation for diagnosis of lymphadenopathy, especially in peripheral centers. As a clinical manifestation, lymph node enlargement gives a clue that may lead to the diagnosis of the underlying disease, which can be either benign or malignant. The findings of this study included reactive conditions, granulomatous changes, necrotizing lesions, suppurative lesions, and malignancy. In the present study, granulomatous lymphadenitis was the most common lesion, while reactive lymphadenitis was the second most common cause of lymphadenopathy. ZN staining was done in all the suspected cases. The highest AFB positivity rate was seen in granulomatous necrotizing lymphadenitis.
The cervical group of lymph nodes was the most frequently affected lymph nodes in most of the lesions, followed by the axillary group of lymph nodes. In the present study, supraclavicular lymph nodes are the least affected group of lymph nodes. This technique helps in the diagnosis of benign and malignant lesions. It helps in confirming whether the metastatic diseases are present or not and also tells about the point of origin of primaries in most of the cases.
FNAC and clinical correlation might be used as a 1st line diagnostic tool in examining lymph node diseases. This simple, cost-effective procedure can suitably guide the next step in the treatment based on the etiology.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4]