Emad Raddaoui, MD, FCAP, FASC King Khalid University Hospital,
College Of Medicine, King Saud University FNA of Lymph Nodes
Slide 2
Objectives: At the end of the course, participants should be
able to: Recognize and differentiate the cytopathology of various
lymphoid neoplasms and non-neoplastic lesions of lymph nodes.
Identify cytopathologic imitators of malignant lymphoma and various
non-lymphoid lesions, metastatic to lymph nodes. Define the
application of immunophenotyping to the cytopathologic diagnosis of
malignant lymphoma. Discuss the limitations of aspiration
cytopathology as applied to lymph nodes and lymphoid
malignancies.
Slide 3
FNA Of Lymph Nodes Introduction Three debatable areas in the
field of FNA cytology that General Pathologists (specially those
who have no interest in cytology) and some clinicians dislike, and
these are: - Lymph node, - Salivary glands, - and the breast.
Slide 4
FNA Of Lymph Nodes Introduction Rationale for sampling an
enlarged lymph node with a thin gauge needle is in general used to
determine the cause of lymphadenopathy. Previously, the Diagnosis
and classification of lymphoma was achieved by histological
examination of excised lymph nodes or tissues. Now, the pathologist
is pressured to diagnose/classify lymphoma from tiny needle
biopsies or fine needle aspirates (FNA).
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FNA Of Lymph Nodes Introduction Can we accurately diagnose and
classify lymphoma using such limited material? The answer is: yes
and no There are then two schools : 1- The yes school, saying that
FNA is a great tool, and we have 97% sensitivity and 100%
specificity. 2- Skeptical school, we always need tissue.
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FNA Of Lymph Nodes Remember To achieve a high quality Lymph
node FNA practice, that gives us a very sensitive and specific
results, you need the support of ancillary studies, namely Flow
Cytometry, IHC, PCR, Cytogenetic, and Molecular studies.
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LYMPH NODE FNA - LIMIT ATIONS - Sampling error secondary to:
Improper/poor technique. Lymph node fibrosis, excessive necrosis,
inflammation, or blood. Partial involvement of lymph node by the
lesion. Small or deep seated lymph node. Lymph node/mass too large.
Failure to obtain cells for ancillary studies, e:g.
immunophenotyping, culture, molecular techniques. - Inability to
evaluate Architecture/Vascular pattern Examples: Progressive
Transformation of Germinal Centers, Vascular transformation of
lymph node sinuses, etc. Sub-typing of some lymphoid disorders not
possible - Interpretation error: Limited experience/expertise.
Attempting to make specific diagnoses on limited or poorly
preserved material.
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FNA of Lymph Nodes Where should we stand You, the wise, will
stand at the mid distance and focus on the advantages,
disadvantages of the procedure, and take it from there. Understand
to utilize it wisely, make sure you know the limitations of any FNA
Generally, I would stand with the Triage school, and view FNA of
lymphoid lesions as a screening tool for deciding whether or not a
biopsy has to be obtained. In some and certain circumstances we are
forced to make a final diagnosis by FNA and treat the patient
depending solely on such a diagnosis.
Slide 9
Practical Benefits of LN FNAs 1- Triage of Patient with
Lymphadenopathy Confirms that the mass is lymphoid tissue. Can
preselect those patients without a prior medical history of cancer
that would require surgery ( e.g. Hodgkins lymphoma) from those
where it can be avoided (reactive hyperplasia, some non-Hodgkin
lymphomas, many infectious conditions, metastatic tumor). May help
to focus laboratory testing for clinician thus resulting in a more
informed and economical workup (e.g. granulomatous disease). May
suggest a primary site if metastatic tumor is found.
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Practical Benefits of LN FNAs 2- Effective Diagnostic Tool
Rapid turnaround time (minutes for a preliminary interpretation).
High diagnostic sensitivity and specificity for experienced
observers. Ability to sample multiple nodes if necessary. Minimal
trauma, rare complications, Low cost. Capable of obtaining cells
for immunophenotyping, and other ancillary tests.
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Practical Benefits of LN FNAs 3- Efficacious in the Cancer
Patient Documents metastasis in a known cancer patient. Can confirm
recurrence or transformation to a higher grade lymphoma in a
patient with known malignant lymphoma. Helps in staging of
tumor.
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Systematic Evaluation of Aspirate Smears In each aspirate we
should evaluate five parameters: Smear cellularity. Cell
arrangement/architecture. Cell composition. Cell morphology. Smear
background.
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a.) cell distribution predominantly as non-clustered,
individual cells (single cell pattern), b.) the presence of
isolated globular or flake-like cytoplasmic fragments; LGBs
[lymphoglandular bodies] in background. Two basics are used in
recognizing cells as lymphoid on a smear[ regardless of whether
they are benign or malignant] :
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A 32 y/o woman presents with an enlarged 2.0 cm. slightly firm
right cervical lymph node CASE 1
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A 12 y/o girl is seen in the clinic with a 1.5 cm. right
axillary node witch was noted by her mother 3 weeks earlier. The
mass has increased slightly despite antibiotic therapy. Case 2
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A 25 y/o female presented to clinic with a 4 cm. non-tender
left neck mass. The mass has been present for 3 weeks according to
her mother CASE 3
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A 44 y/o woman presents with enlarged cervical, axillary and
inguinal lymph nodes which she states appeared about four months
ago CASE 4
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A 69 y/o man presents with a 2.0 cm. left posterior cervical
lymph node Case 5
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65 y/o woman underwent FNA of a left neck 3cm lymph node Case
6
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A 15 y/o male presented to the emergency room with wheezing and
difficulty breathing. Physical examination revealed a 4 cm. midline
neck mass. Case 7
Slide 21
One year old Saudi girl presented with paraspinal/spinal mass
lesion with multiple rnlarged cervical and right supraclavicular
lymph nodes. Case 8
Slide 22
A 47 y/o man complained of a lump in his neck which has been
present for about 2 weeks. Physical examination reveals a 2 x 3 cm.
firm, left upper cervical lymph node. Case 9
Slide 23
34 year old Saudi female, right cervical lymph node 34 year old
Saudi female, right cervical lymph node Case 10
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7 year old, Saudi boy with 4cm neck mass, No other clinical
complaints Case 11
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31 year old,Saudi Male, Anterior neck, probably Lymph Node, 3
cm in size Case 12
Slide 26
Conclusion : FNA of Lymph Nodes Where should we stand You, the
wise, will stand at the mid distance and focus on the advantages,
disadvantages of the procedure, and take it from there. Understand
to utilize it wisely, make sure you know the limitations of any FNA
Generally, I would stand with the Triage school, and view FNA of
lymphoid lesions as a screening tool for deciding whether or not a
biopsy has to be obtained.
Slide 27
Conclusion : FNA of Lymph Nodes In some and certain
circumstances we are forced to make a final diagnosis by FNA and
treat the patient depending solely on such a diagnosis.