Role of Fine needle aspiration
cytology (FNAC) in patients presenting with cervicallymphadenopathy
referred to Gujarat Adani Institute of Medical Science, Bhuj, Kutch
Upadhyay J1, Shingala A2
1Dr. Jigna Upadhyay, Associate Professor, Department of Pathology,
Gujarat Adani Institute of Medical Science, Bhuj, Kutch, Gujarat,
India, 2Dr. Abhikumar Shingala, MPH candidate, Class of 2018, Tennessee
State University, USA
Address for
Correspondence: Dr. Jigna Upadhyay, Department of
Pathology, Gujarat Adani Institute of Medical Science, Bhuj, Kutch,
Gujarat. Email: researchguide86@gmail.com
Abstract
Background and Aim:
Fine Needle Aspiration Cytology (FNAC) is a simple, quick and
inexpensive method that is used to sample superficialmasses like
cervical lymph node found in the neck and is usually performed in the
outpatient clinic. Cervicallymphadenopathy is a common clinical
presentation across patients of all age group. The aetiology may range
from a benign nonspecificinflammation to lymphoproliferative disorders
and metastatic malignancy. The present study was undertaken to study
non neoplastic andneoplastic lesions of enlarged lymph nodes by Fine
needle aspiration cytology (FNAC) in patients presenting with cervical
lymphadenopathyreferred to pathology department from the Gujarat Adani
Institute of medical science, Bhuj, Kutch over a period of two years. Methods: Total of
850 patients were subjected to FNAC of cervical lymph nodes over two
years period. Since in 35 patients, the aspirate was inadequate the
remaining 815 cases were analyzed. Results:
Overall tuberculous lymphadenitis was the most common finding (42.45%),
followed by reactivehyperplasia (35.09%). Malignant pathology accounted
for 20.24% of cervical lymph node enlargement, most of which was due to
metastaticsquamous cell carcinoma (65.4%). Conclusion: This
study highlights the usefulness of FNAC as a reliable method for
diagnosis of cervical lymphadenopathy
Key words: Fine
Needle Aspiration Cytology,Lymphadenopathy, Neoplastic, Squamous cell
carcinoma
Manuscript received:
28th December 2017, Reviewed:
6th January 2018
Author Corrected:
14th January 2018, Accepted
for Publication: 18th January 2018
Introduction
Lymphadenopathy is an abnormal increase in size and alteredconsistency
of lymph nodes. It is a clinical manifestation of regional orsystemic
disease and serves as an excellent clue to the underlyingdisease.
Cervical lymphadenopathy is a common clinical presentationacross
patients of all age group. The aetiology may range from a
benignnonspecific inflammation to lymphoproliferative disorders
andmetastatic malignancy. FNAC is widely used as first line
investigation for the diagnosis of lymphadenopathy. This simple, easy
and quicktechnique can diagnose reactive, infective and malignant
conditions.Several studies in the past have documented the diagnostic
accuracy ofFNAC with reference to cervical lymphadenopathy among
patientspresenting to tertiary care institution to evaluate the
diagnostic efficacy ofFNAC [1-4].
Fine needle aspiration (FNA) cytology enables a simple and rapid
diagnostic approach of patients with lymph node enlargement. Several
studies in the past have documented the diagnostic efficacy of FNAC in
lymphadenopathyThe present study was undertaken to study non-neoplastic
andneoplastic lesions of enlarged lymph nodes by Fine needle
aspirationcytology (FNAC) in patients presenting with
cervicallymphadenopathy referred to cytopathology department from
theOPD/IPD of Department of Pathology, Gujarat Adani Institute of
Medical Science, Bhuj, Kutch, Gujarat over a period oftwo years.
Materials
and Methods
Study Design, Study
Population and Study Duration- This study was carried out
over a period of two years at a tertiary care institute Department of
Pathology, Gujarat Adani Institute of Medical Science, Bhuj, Kutch,
Gujarat, India.
Sampling Methods and
Sample collection- A total of850 patients with cervical
lymphadenopathy was subjected to FNACusing 23 G needle and a 10ml
disposable syringe. The slides were bothair dried and wet fixed in
alcohol for May-Grunwald Giemsa andPapanicolaou stain
respectively.Clinical records and details ofinformation like of age,
sex, site, size, duration, involvement of otherlymph nodes and other
investigations were done.
The cases were divided into following groups, viz.: (a)
Reactivehyperplasia: Smears were very cellular, showing a
polymorphouspopulation of lymphoid cells and histiocytes. (b)
Tuberculouslymphadenitis: showed epithelioid cell granulomas with or
withoutcaseous necrosis and giant cells. Smears showing only
caseousnecrotic material and lymphocytes were also grouped as
tuberculousinflammation. (c) Metastatic malignancy: revealed malignant
cells inclusters or scattered discretely along with other lymphoid
cells.
Metastatic carcinoma was subdivided (e.g. Squamous cell carcinoma,
adenocarcinoma, etc.) according to cytological features (d) Lymphoma:
cases with a mixed cell population and the characteristicReed-Sternberg
giant cell were categorized as Hodgkin's lymphoma.Non –
Hodgkin's lymphoma showed a monomorphous population of small lymphoid
cells or lymphoblast. (e)Miscellaneous group: showed features which
conform to none of the above mentionedgroups (e.g. RosaiDorfmann
disease).
Statistical Analysis-
Qualitative data will be expressed as percentages and proportions.
Quantitative data will be expressed as mean and standard deviation. The
differences between two groups with respect to continuous variables
will be analysed using t-test while categorical variables will be
analysed using chi-square test. All the statistical tests will be
performed in SPSS version 15 software.P value <0.05will be
considered as statistically significant while P value<0.01 will
be considered as statistically highly significant.
Results
In this study 850 patients were subjected to FNAC for
cervicallymphadenopathy. Among these patients, in 35 cases, the
aspirate wasinadequate despite repeated procedure. Hence these 35 cases
wereexcluded from study and we proceeded to analyse the
remaining815cases.The male: female ratio in this study was 1.36:1, the
mean age ofpresentation being 30.9 years and 26.8 years for male and
femalepatients respectively. The age at presentation ranged from 6
months to70 years. We received the maximum number of patients (23.68%)
inthe 21-30 years age group, and the least (2.94%) in the >60
years agecategory (Table 1).
Table-1: Age wise
distribution of cases
|
Age groups
|
Reactive Hyperplasia
|
TB
|
NHL
|
Hodkins
lymphoma
|
Metastasis
|
Others
|
Total
|
|
<10
|
58
|
11
|
1
|
0
|
0
|
4
|
74
|
|
11-20
|
101
|
35
|
0
|
2
|
1
|
2
|
141
|
|
21-30
|
43
|
137
|
1
|
0
|
8
|
4
|
193
|
|
31-40
|
29
|
70
|
2
|
1
|
11
|
7
|
120
|
|
41-50
|
27
|
52
|
5
|
4
|
39
|
1
|
128
|
|
51-60
|
22
|
34
|
9
|
1
|
60
|
1
|
127
|
|
>60
|
6
|
7
|
2
|
0
|
17
|
0
|
32
|
|
Total
|
286
|
346
|
20
|
8
|
136
|
19
|
815
|
Tubercular lymphadenitis (42.45%) was overall the most commoncause of
lymphadenopathy. Most of, the cases occurred between 21-30years.
Reactive lymphoid hyperplasia was the second most common finding
(35.09%) predominantly in the age group 0f 11-20 years. As expected,
the percentage of malignant cases rose steadily with age and
accountedfor 42.30% cases of cervical lymphadenopathy in patients more
than
50 years of age. Malignant pathology accounted 20.24% cases of
cervicallymphadenopathy (Table 1). Of these neoplastic lesion,
metastaticlymphadenopathy (82.42%) was most common. Rests of the
neoplastic cases were NHL 12.72% and Hodgkins lymphoma 4.84%.
Among the metastatic lesion, squamous cell carcinoma topped thechart
with 65.4%, as opposed to metastatic adenocarcinoma29.41%found in only
cases. Other than these, there were 2 cases of metastaticnasopharyngeal
carcinoma (1.47%), 4 undifferentiated carcinoma2.94% and a single case
of metastatic malignant melanoma. Besides the above mentioned causes of
lymph node affliction, wenoted three cases of Cat scratch disease, six
cases of Rosai Dorfmandisease (sinus histiocytosis with massive
lymphadenopathy). All 6patients were less than 15 years of age.
Malignant lesions were more inthe >50 years age group whereas in
all other age groups tuberculouslesions predominated.
Discussion
Cytology of cervical lymph node is the first investigation in diagnosis
of many diseases in tertiary care settings[5]. FNAC of cervical
lymphnodes helps to explore the various lesions that involve these In
thepresent study males were more commonly involved than females with
male:female ratio of 1.36:1 .Age of patients showed a wide
rangestarting from as early as 6 months to 70 years old, most of the
casesoccurring between 20-29 years of age group. Similar findings
wereobserved by Pandav AB et al. [5] and Shakera N Baji and
co-workers[6]. Since infections from oral cavity, ears, nose, and para
nasal sinusesdrain into cervical nodes, reactive lymphoid hyperplasia
is a common finding[7]. However, in our study tuberculous
lymphadenitisemerged as commonest (42%) cause of cervical
lymphadenopathy.
Lymphadenopathy presents an opportunity for a quick and efficient way
to reach an early diagnosis through fine needle aspiration cytology
(FNAC) of the involved lymph node. Lymph nodes react to a variety of
micro-organism and non specific stimuli by expansion of follicle
centers and / or intrafollicular tissue. Since infections from oral
cavity, ears, nose and paranasal sinuses drain into the nodes, reactive
lymphoid hyperplasia is a common finding. Germinal centres may be very
large in some cases of reactive follicular hyperplasia. If the aspirate
derives from such a large germinal centre, the proportion of large
cells (centroblasts, dendritic reticulum cells) and the number of
mitoses may be impressive enough to suggest malignant lymphoma.
However, the full range of lymphocyte transformation is still present,
including small lymphocytes and the various cell types occur in logical
proportions. Small lymphocytes are numerically predominant. A variable
number of plasma cells can usually be found. The presence of
macrophages with tingible bodies favors reactive hyperplasia.
Most of the cases occurred between 20-29 years of age. A decliningtrend
in cases has been observed after 30 years of age. Thiscorroborates with
other studies conducted by other studies [8]. The high incidence of
tuberculosismay be explained by the fact of low socioeconomic
condition,poorhygiene and lack of awareness in the region.
Reactive lymphoid hyperplasia was the second most commonlesion,commonly
in the younger age group. Males were affected morethan females. These
findings correlate with study by Shakera N Bajiandcoworker [8].The
incidence of reactive lymph node enlargementfell steadily the 5th
decade onwards and malignant lesions being most common.Among the
malignant lesion, metastatic lymphadenopathy (80%) wasthe most common
and predominant cause in patients ranging from 40years and above.Rest
of the cases were that of NHL (12.8%) andHodkins lymphoma (4.9-%).
These findings are similar to studies byK.BhuyanMedhi et al[9].Among
the metasticlesions,squamous cellcarcinoma (65%) was the commonest.
Metastatic squamous cellcarcinoma was found to be more common in males
and most of thecases occurred between 50-59 years of age. Similar
observation wasnoted in studies done by Nath s et al[10] Metastatic
adenocarcinomaand few cases of undifferentiated carcinoma constituted
the rest ofmalignant lesions. The high incidence of metastatic
lymphadenopathymay be due to high incidence of malignancy of Head and
neck region inthis geo-economic block.We noted 8 cases of Rosai Dorfman
syndrome. It is a benign condition andsome rare causes of cervical
lymphadenopathy[11]. It usually occurs inthe first decade of life and
manifest as massive enlargement of cervicallymph nodes.
Conclusion
The most frequent causes ofcervical lymphadenopathy are tuberculosis,
reactive lymphadenitis, and metastatic malignancies. In large number of
cases FNAC alone isenough for diagnosis in proper clinical setting and
surgical procedureslike biopsy can be avoided even in tertiary care
settings.
What this study addto existing knowledge?This study highlights the
usefulness of FNAC as a reliable method fordiagnosis of cervical
lymphadenopathy.Exactearlydiagnosis can save the patient from high
mortality and morbidity especially in malignant diseases.
Funding:
Nil, Conflict of interest:
None initiated
Permission from IRB: Yes
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How to cite this article?
Upadhyay J, Shingala A. Role of Fine needle aspiration cytology (FNAC)
in patients presenting with cervically mphadenopathy referred to
Gujarat Adani Institute of Medical Science, Bhuj, Kutch. Trop J Path
Micro 2018;4(1):113116. doi: 10.17511/jopm.2018.i1.20.