i

PROSPECTIVE STUDY OF FINE NEEDLE ASPIRATION

CYTOLOGY OF LYMPH NODES OF THE HEAD AND

NECK REGION OVER A 2 YEAR PERIOD WITH

HISTOPATHOLOGICAL CORRELATION

by

Dr. Satish Arakeri

Dissertation Submitted to the Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka,

In partial fulfilment of the requirements for the degree of

DOCTOR OF MEDICINE

IN

PATHOLOGY

Under the guidance of

Dr. N Gandhi

Professor of Pathology

DEPARTMENT OF PATHOLOGY

M.V.J MEDICAL COLLEGE AND RESEARCH HOSPITAL, HOSKOTE

BANGALORE

2013

ii

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCE

KARNATAKA

DECLARATION BY CANDIDATE

I hereby declare that this dissertation entitled “Prospective study of fine needle

aspiration cytology of lymph nodes of the Head and Neck region over a 2 year period

with histopathological correlation” is a bonafide and genuine research work carried

out by me under the guidance of Dr. N. Gandhi, Professor of Pathology M.V.J

Medical College and Research Hospital, Bangalore.

This dissertation has not formed the basis for the award of any degree to me

previously by any other university.

Date: 15-11-2012 Dr. Satish Arakeri,

Postgraduate student,

Place: Bangalore Department of Pathology,

M.V.J Medical College and Research

Hospital, Hoskote, Bangalore

iii

CERTIFICATE BY THE GUIDE

This is to certify that dissertation entitled “Prospective study of fine needle aspiration

cytology of lymph nodes of the Head and Neck region over a 2 year period with

histopathological correlation” is a bonafide research work done by Dr. Satish Arakeri,

Postgraduate student, Department of Pathology, M.V.J Medical College and Research

Hospital, Hoskote, Bangalore. It was done under my guidance in partial fulfillment of

the requirement for the M.D in Pathology degree examination of Rajiv Gandhi

University of Health Science to be held in 2013.

Date: 15-11-2012 Dr. N. Gandhi,

Professor of Pathology,

Place: Bangalore M.V.J Medical College and

Research Hospital, Hoskote,

Bangalore

iv

ENDORSEMENT BY THE HOD / DEAN CUM DIRECTOR / HEAD OF THE

INSTITUTION

This is to certify that dissertation entitled “Prospective study of fine needle aspiration

cytology of lymph nodes of the Head and Neck region over a 2 year period with

histopathological correlation” is a bonafide research work done by Dr. Satish Arakeri,

Postgraduate student, Department of Pathology, M.V.J Medical College and Research

Hospital, Hoskote, Bangalore under the guidance and supervision of Dr. N.Gandhi,

Professor of Pathology, M.V.J Medical College and Research Hospital, Hoskote,

Bangalore in the partial fulfillment of the regulations for the M.D in Pathology degree

examination of Rajiv Gandhi University of Health Science to be held in 2013.

Air Vice Marshal (Retd)

Dr. T.S. Raghuraman

Principal,

M.V.J. Medical College

And Research Hospital

Hoskote, Bangalore.

Date: 15-11-2012

Place: Bangalore

Dr. Padmini

Jeychandran

Professor and Head,

Department of Pathology,

M.V.J. Medical College

And Research Hospital

Hoskote, Bangalore.

Date: 15-11-2012

Place: Bangalore

v

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA, BANGALORE.

COPY RIGHT

DECLARATION BY THE CANDIDATE

I hereby declare that the Rajiv Gandhi University of Health Sciences, Karnataka, shall

have the rights to preserve, use and disseminate this dissertation in print or electronic

format for academic /research purpose.

Date: 15-11-2012 Dr. Satish Arakeri

Place: Bangalore

© Rajiv Gandhi University of Health Sciences, Karnataka

vi

ACKNOWLEDGEMENT

I bow my head in gratitude to Almighty god, without whose blessings, I could not

have reached so far in my life.

It gives me immense pleasure to express my sincere and heartfelt gratitude to my

respected guide Dr. N. Gandhi, Professor of Pathology, M.V.J.Medical College and

Research Hospital, Hoskote, Bangalore for his expertise supervision, continous

enthusiasm, valuable advice and extensive knowledge. He has taken pain to go

through the project starting from the selection of topic till the end and make necessary

corrections as and when needed. He has been an inspiration to me ever I have joined

the course and his encouragement has been crucial for me in the completion of this

dissertation.

I would like to express my deepest gratitude and respect to our Principal, Dr.

Raghuraman, for his constructive guidance, generous support and inspired

suggestions which has greatly helped to improve my work.

I am very much grateful to my beloved HOD Dr. Padmini Jeychandran, Department

of Pathology, M.V.J Medical College and Research Hospital, Bangalore for her

co-operation, timely help, motivation and effective advices throughout my course. My

special thanks to her for the enormous amount of time given in the department during

the preparation of dissertation.

I express my thanks to the management for their encouragement for providing the

necessary facilities during my study without which this task could not accomplished.

It gives me immense pleasure to express my sincere and heartfelt gratitude to

Dr. Shameem Shariff, Professor of Pathology, Department of Pathology, M.V.J

Medical College and Research Hospital, Hoskote, Bangalore for her guidance and

timely support.

I am heartily thankful to Dr. Madhusmitha Jena, Dr. Raja Parthiban and Dr. Roopa,

Associate Professors of Pathology, whose encouragement, supervision and support

from preliminary to concluding level enabled me to complete the project with ease.

vii

My sincere thanks to Dr. Umabai, Dr. Revadi, Dr. Suma, Dr. Leena, Dr. Vidya,

Assistant Professors of Pathology, for their never ending support, guidance,

motivation and valuable advices during my study.

My deepest gratitude to my parents, my brother Vishwanath , my sister Suvarna , my

Uncle Gururaj Sankad for being the biggest motivation in my life and putting in me

the strength to reach so far.

I thank my seniors Dr. Shilpa, Dr. Shashikala, my colleagues, Dr. Priyadarshini,

Dr. Sabina and Junior Dr. Shilpa, Dr. Shalini & Dr. Shantha for all their help in

completing the dissertation work.

My sincere thanks to the technical staff of Department of Pathology, M.V.J Medical

College and Research Hospital, Hoskote, Bangalore.

I express my sincere thanks to all patients without whom this work would not have

been possible.

I thank Laxmi computers for their technical expertise and patience.

Date:15-11-2012

Place: Bangalore Dr.Satish Arakeri

viii

LIST OF ABBREVATIONS

Yrs Years

Sl.No Serial number

% Percentage

NO. Number

MGG May Grunwald Giemsa

LPD Lymphoproliferative disorder

FNAC Fine Needle Aspiration Cytology

RS cell Reed Sternberg cell

OPD Out Patient Department

IHC Immunohistochemistry

H&E Haematoxylene-Eosin

PAP Papanicolaou

ix

ABSTRACT

Title: Prospective study of fine needle aspiration cytology of lymph nodes of the

Head and Neck region over a 2 year period with histopathological correlation.

Background: Fine needle aspiration cytology is a simple, quick and inexpensive

method that is used to sample lymph nodes found in the head and neck region and is

usually performed in the outpatient clinic. Because of early availability of results,

simplicity, minimal trauma and complication, the aspiration cytology is now

considered as a valuable diagnostic aid and is gaining popularity. Fine needle

aspiration cytology thus would be a valuable diagnostic procedure in our rural set up

providing the clinician a quick diagnosis to initiate treatment. However it should be

stressed that aspiration is not a substitute for histopathological study, which is always

a gold standard one.

Aims: 1) To study the different cytomorphological patterns of FNAC associated with

lymph nodes in the head and neck region. 2) To correlate the fine needle aspiration

findings with histopathology. 3) To evaluate the sensitivity and specificity using

histopathology as the gold standard.

Material and methods: Minimum 100 cases of lymph node swellings of head and

neck region of all age group of either sex from the department of Medicine, Chest

Medicine and Tuberculosis, Surgery, ENT & Pediatric will be included in the present

study.

Method: Fine needle aspiration has been done from the enlarged lymph nodes using

23 gauge syringe. Slides are prepared and examined under microscope.

Inclusion criteria: All superficial lymph node swellings of the head and neck region.

Exclusion criteria: 1) All non-lymphoid aspirates from the head and neck region.

2) Inadequate aspirate.

x

Observation:. The present study was undertaken to know the spectrum of lesions

found in the enlarged lymph nodes of Head and Neck region in 100 patients. 20 cases

have histopathological correlation. Cervical group of lymph nodes are most

commonly involved in both benign and malignant condition. Non-specific reactive

lymphadenitis is the most common benign pathology associated with enlarged lymph

nodes whereas metastasis is the most common malignant condition. In the present

study, over all accuracy and sensitivity was 90% and 100% respectively. The highest

diagnostic accuracy with FNAC was observed in metastatic carcinoma, followed by

tuberculous lymphadenitis, reactive hyperplasia and lymphoma, where as in some

cases, the differentiation between Hodgkin’s lymphoma and Non-Hodgkin’s

lymphoma in case of absence of Reed – Sternberg cells proved difficult to diagnose

on cytology.

Conclusion: FNAC is a very useful and accurate approach in diagnosing various

benign and malignant lymphadenopathies, as it has the diagnostic value of the first

step in the workup of patients with nodal enlargement.

Keywords: FNAC, Lymphadenopathy, Reed-Sternberg cell.

xi

CONTENTS

Sl.No. Title Page

No.

1.

INTRODUCTION

1-3

2.

AIMS AND OBJECTIVES

4

3.

REVIEW OF LITERATURE

5-12

4.

CYTOLOGICAL FEATURES

13-35

5.

MATERIALS AND METHODS

36-39

6.

OBSERVATIONS AND RESULTS

40-79

7.

DISCUSSION

80-87

8.

SUMMARY AND CONCLUSION

88-89

9.

BIBLIOGRAPHY

90-96

10.

ANNEXURE

PROFORMA

KEY TO MASTER CHART

MASTER CHART

97-104

xii

LIST OF TABLES

Table No. TITLE Page No.

TABLE.1 Most common site of Primary tumor draining to

regional lymph node 32

TABLE. 2 Year wise distribution of all lymph node lesions

aspirated.

40

TABLE.3 Year wise distribution of the lymph node biopsy.

41

TABLE.4 Age wise distribution of the lymph node lesions

aspirated. 42

TABLE.5 Gender wise distribution of the lymph node lesions

aspirated. 43

TABLE.6 Age and Gender wise distribution of the lymph node

lesions aspirated. 44

TABLE.7 Site wise distribution of the lymph node lesions

aspirated. 45

TABLE.8 Incidence of benign and malignant lesions of FNAC

of the lymph node. 46

TABLE.9 Incidence of primary and secondary malignant lesions

of FNAC of lymph node. 47

TABLE.10 Site wise distribution of FNAC on benign lesions of

lymph node. 48

TABLE.11 Site wise distribution of FNAC on malignant lesions

of lymph node. 49

TABLE.12 Site wise distribution of FNAC of primary 50

xiii

malignancy of lymph node.

TABLE.13 Site wise distribution of FNAC on metastatic lesions

of lymph node. 51

TABLE.14 Age wise distribution of FNAC on benign lesions of

lymph node. 52

TABLE.15 Age wise distribution of FNAC of primary

malignancy of lymph node. 53

TABLE.16 Age wise distribution of FNAC on metastatic lesion

of lymph node. 54

TABLE.17 Gender wise distribution of FNAC on benign lesions

of lymph node. 55

TABLE.18 Gender wise distribution of FNAC of primary

malignancy of lymph node. 56

TABLE.19 Gender wise distribution of FNAC on metastatic

lesions of lymph node. 57

TABLE.20 Cytopathological diagnosis of FNAC of lymph nodes. 58

TABLE.21 Incidence of benign lesions of lymph node on FNAC. 59

TABLE.22 Incidence of malignant lesions of lymph node on

FNAC. 60

TABLE.23 Site wise distribution of FNAC on benign lesions of

lymph node. 62

TABLE.24 Site wise distribution of FNAC on malignant leions of

lymph node. 64

TABLE.25 Table demonstrating FNAC diagnosis with

histopathological diagnosis. 64

TABLE.26 Correlation between cytological and histopathological 65

xiv

diagnosis of lymph node.

TABLE.27 Statistical analysis of the malignant and benign

diagnosis from the data available for correlation 80

TABLE.28 Comparison of FNACs’ which have histopathological

correlation with various other studies 80

TABLE.29 Comparison of age range of all the cases with various

other studies. 80

TABLE.30

Comparison of most common age group of

lymphadenopathy of Head and Neck region with

various other studies.

81

TABLE.31

Comparison of most common age group of benign

and malignant lymphadenopathies with various other

studies.

81

TABLE.32

Comparison of sex ratio of the FNACs’ of lymph

nodes of Head and Neck region with various other

studies

82

TABLE.33

Comparison of FNACs’ of Benign and Malignant

lymphadenopathies of Head and Neck region with

various other studies

83

TABLE.34

Comparison of various benign lesions of

lymphadenopathies of Head and Neck region with

other studies.

84

TABLE.35 Comparison of malignant lesions of lymph node of

Head and Neck region with various other studies 86

TABLE.36

Comparison of Sensitivity, Specificity and Accuracy

of FNACs’ of lymph node of Head and Neck region

with various other studies.

87

xv

LIST OF GRAPHS

GRAPH No. TITLE Page No

GRAPH 1 Year wise distribution of all lymph node lesions

aspirated 40

GRAPH 2 Year wise distribution of the lymph node biopsy 41

GRAPH 3 Age wise distribution of the lymph node lesions

aspirated 42

GRAPH 4 Gender wise distribution of the lymph nodes aspirated. 43

GRAPH 5 Age and Gender wise distribution of the lymph node

lesions aspirated. 44

GRAPH 6 Site wise distribution of the lymph node lesions apirated. 45

GRAPH 7 Incidence of benign and malignant lesions of FNAC of

the lymph node lesions aspirated 46

GRAPH 8 Incidence of primary malignant and metastatic lesions of

FNAC of lymph node 47

GRAPH 9 Site wise distribution of FNAC on benign lesions of

lymph nodes 48

GRAPH 10 Site wise distribution of FNAC on malignant lesions of

of lymph nodes 49

GRAPH 11 Site wise distribution of FNAC of primary malignancy

of lymph node. 50

GRAPH 12 Site wise distribution of FNAC on metastatic lesions in

the lymph node. 51

GRAPH 13 Age wise distribution of FNAC on benign lesions of

lymph node. 52

xvi

GRAPH 14 Age wise distribution of FNAC on primary malignany of

lymph node. 53

GRAPH 15 Age wise distribution of FNAC on metastatic lesion of

lymph node. 54

GRAPH 16 Gender wise distribution of FNAC on benign lesions of

lymph node. 55

GRAPH 17 Gender wise distribution of FNAC on primary

malignancy of lymph node. 56

GRAPH 18 Gender wise distribution of FNAC on metastatic lesion

of lymph node. 57

GRAPH 19 Cytopathological diagnosis of FNAC of lymph nodes. 58

GRAPH 20 Incidence of benign lesions of lymph nodes by FNAC. 59

GRAPH 21 Incidence of malignant lesions of lymph node by FNAC. 60

GRAPH 22 Site wise distribution of FNAC on non-specific reactive

lymphadenitis of lymph node. 61

GRAPH 23 Site wise distribution of FNAC on granulomatous

lymphadenitis of lymph node. 61

GRAPH 24 Site wise distribution of FNAC on tubercular

lymphadenitis of lymph node. 62

GRAPH 25 Site wise distribution of FNAC on Hodgkin’s lymphoma

of lymph node. 63

GRAPH 26 Site wise distribution of FNAC on metastatic lesions of

lymph node. 64

xvii

LIST OF IMAGES

IMAGE No. TITLE PAGE NO

IMAGE 1 Gross anatomy of lymph node 13

IMAGE 2

Materials used for Fine needle aspiration (Sterile

Gloves, Glass slide, Syringe, Cameco syringe holder,

cotton swab, spirit, 90% ethyl alcohol as fixative)

38

IMAGE 3

Method of doing fine needle aspiration of left cervical

group of lymph node using 5ml syringe under a septic

precaution.

38

IMAGE 4 FNAC smear of reactive lymphadenitis of lymph node

showing mixed population of reactive lymphoid cells. 67

IMAGE 5 FNAC smear of reactive lymphadenitis of lymph node

showing tingible body macrophage ingesting debris 67

IMAGE 6

Histopathological section of reactive lymphadenitis of

lymph node showing mixed population of reactive

lymphoid cells

68

IMAGE 7

FNAC smear of tubercular lymph node showing

granuloma consists of epitheloid cells, fibroblast,

lymphocyte and necrosis

68

IMAGE 8 FNAC smear of tubercular lymph node showing caseous

necrotic material 69

IMAGE 9 FNAC smear of tubercular lymph node showing tubercle

bacilli (Acid fast bacilli) in the background of necrosis 69

IMAGE 10

Histopathological section of tubercular lymph node

showing multiple granuloma consists of epitheloid cells,

Langhan’s giant cell, fibroblast, lymphocyte and

necrosis

70

xviii

IMAGE 11

Histopathological section of tubercular lymph node

showing granuloma consists of epitheloid cells,

Langhan’s giant cell , fibroblast, lymphocyte and

necrosis

70

IMAGE 12

FNAC smear of metastatic lymph node showing tumor

cells of squamoid type in a background of lymphoid

cells.

71

IMAGE 13 FNAC smear of metastatic lymph node showing tumor

necrosis 71

IMAGE 14

Histopathological section of metastatic lymph node

showing metastasis of tumor cells (right) of squamoid

type with lymphoid parenchyma (left)

72

IMAGE 15

Histopathogical section of metastatic lymph node

showing metastasis of tumor cells (right ) of squamoid

type with lymphoid parenchyma( left).

72

IMAGE 16

Histopathogical section of metastatic lymph node

showing keratin (center) with tumor cells (right) and

lymphoid parenchyma (left).

73

IMAGE 17 FNAC smear of lymph node of Hodgkin’s lymphoma

showing monomorphic tumor cells. 73

IMAGE 18 FNAC smear of lymph node of Hodgkin’s lymphoma

showing Classical Reed-Sternberg cell 74

IMAGE 19

Histopathological section of lymph node of Hodgkin’s

lymphoma showing diffuse effacement of architecture

with replacement of normal parenchyma by

monomorphic tumor cells.

74

IMAGE 20 Histopathological section of lymph node of Hodgkin’s

lymphoma showing monomorphic tumor cells with few

75

xix

mitosis

IMAGE 21 Histopathological section of lymph node of Hodgkin’s

lymphoma showing classical Reed Sternberg cell 75

IMAGE 22

Immunohistochemistry showing positivity for CD15

marker in Hodgkin’s lymphoma on histopathological

section

76

IMAGE 23

Immunohistochemistry showing positivity for CD30

marker in Hodgkin’s lymphoma on histopathological

section

76

IMAGE 24

Immunohistochemistry showing positivity for CD19

marker in Hodgkin’s lymphoma on histopathological

section

77

IMAGE 25

Immunohistochemistry showing positivity for CD20

marker in Hodgkin’s lymphoma on histopathological

section

77

IMAGE 26

FNAC smear of lymph node of Non-Hodgkin’s

lymphoma showing monomorphic tumor cells of high

grade

78

IMAGE 27

FNAC smear of lymph node of Rosai-Dorfmann disease

showing polymorphous population of lymphoid cells

consisting of histiocytes, lymphocytes, plasma cells

78

IMAGE 28 FNAC smear of lymph node of Rosia-Dorfmann disease

showing histiocyte ingested lymphocyte (emperipolesis). 79

IMAGE 29 FNAC smear of lymph node of Rosia-Dorfmann disease

showing histiocyte ingested lymphocyte (emperipolesis). 79

1

1. INTRODUCTION

Lymphadenopathy is one of the commonest clinical presentations of all age groups

attending Out Patient Departments. The etiology can vary from an inflammatory

process to a malignant condition.39

Most common tool used in the present day is Fine

needle aspiration cytology.

Fine needle aspiration cytology:

Fine needle aspiration cytology (FNAC) is the study of cells and other tissue

components obtained by sampling of a palpable superficial lesion or radiologically

localized deep seated lesion through a small gauge needle.

FNAC is used routinely as a first line of investigation in the evaluation of patients

with lymphadenopathy. Enlarged lymph nodes are one of the oldest indications for

FNAC. This diagnostic modality has gained considerable importance in the

management of patients with lymphadenopathy over several years.

Advantages of FNAC over biopsy: 4, 5, 6

1. It is a safe ,almost atraumatic technique usually performed as an OPD

procedure

2. It is relatively painless, cost effective modality of investigation.

3. It is a speedy procedure and result will be available within 2-3hrs.

4. It avoids the surgical expertise, anesthesia, operation theatre sterility,

hospitalization, nursing care and histopathological processing.

5. It has low risk of complications compared to biopsy.

6. It does not leave any scar.

7. It is highly reliable in its diagnostic accuracy and hence considered as a micro-

biopsy with high degree of correlation with histopathology.

8. It can be readily repeated with wide patient acceptance.

9. It can be performed in debilitated patients in cases where biopsy is

contraindicated.

10. Aspirates can be taken from multiple sites at the same time, thus increasing the

diagnostic yield.

2

11. Radiologic image guided FNAC, can be applied for deep seated lesions not

easily accessible to surgical biopsy.

Limitations and disadvantages of FNAC: 4, 5, 6

1. Minimal or severe hemorrhage can occur following FNAC of lesions in close

proximity to large blood vessels, in vascular lesions, in lesions of vascular

organs and in patients having bleeding diathesis.

2. Intrathoracic FNACs carry possible dangers of pneumothorax, and rarely

pneumomediastinum, air embolism, hemothorax and cardiac tamponade.

3. There is a minor possibility of tumor implantation in the needle tract. Multiple

passes, larger gauge needles and absence of normal parenchyma covering the

lesion appear to increasing the risk.

4. Preoperative FNAC may cause local tissue changes such as, hematoma,

infarction, capsular pesudoinvasion and pseudomalignant reparative changes,

which could render subsequent histological diagnosis difficult.

5. Due to relative absence of tissue architecture patterns in FNAC, smears and

the small amount of tissue material, specific diagnostic conclusions cannot

always be reached.

Fine needle aspiration of lymph nodes

Lymphadenopathy is one of the oldest indications for the FNAC. The etiologies can

vary from an inflammatory to malignant conditions. Peripheral lymph nodes are easily

accessible and amenable to FNAC. It has increased success rate of getting

representative material with high accuracy of diagnosis.

Advantages of FNAC in Lymphadenopathy: 7

1. Easy diagnosis of reactive lymphadenopathy and recognition of some specific

conditions.

2. Diagnosis of tuberculosis, a disease having high burden in our country.

3. Diagnosis of metastatic malignancy and indication of the possible primary

site.

4. Initial diagnosis of lymphomas, followed by biopsy for confirmation.

5. For staging and monitoring for relapse or the effects of treatment

3

Thus, FNAC offers a simple and inexpensive test for the diagnosis of reactive

hyperplasia, infections, metastatic diseases etc.

In cases of reactive lymphadenopathy, FNAC can significantly reduce the number of

open biopsies. In case of specific infectious etiology, not only the cause of

lymphadenopathy is determined, but also the causative organism can be identified

which help in planning the treatment.

Fine needle aspiration cytology is a well established tool for the diagnosis of

metastatic malignancies in lymph nodes. FNAC not only confirms the presence of

metastatic disease but also gives clues regarding the nature and origin of the primary

tumor.17

Although the role of FNAC is initial diagnosis, subclassification and management of

patients with lymphomas may be controversial; it helps in detection of residual

disease, recurrences and progression of low-grade lymphoma, and helps in staging the

disease.18

As we know FNAC is not a replacement for open biopsy, in each and every case of

lymphadenopathy it can help to establish a workable diagnosis and reduce the number

of total biopsies.

In the present study, we have tried to make a scientific contribution by studying the

incidence, nature and types of lymphadenopathies in the patients of MVJ Medical

College and Research Hospital, Hoskote by FNAC in relation to age, sex and site-

wise distribution and correlating them with histopathological diagnosis wherever

possible.

In cases of Tuberculosis, special stains e.g. Zeihl Neelsen stain has been used to

identify the mycobacterium. In cases of lymphomas, immunohistochemistry (IHC) is

used to confirm the diagnosis.

Our study is the prospective study of FNAC of lymph node of Head and Neck region

over a period of 2 years from June 2010 to May 2012 in the Department of Pathology,

MVJ Medical College and Research Hospital, Hoskote, Bangalore.

4

2. AIMS AND OBJECTIVES

1. To study the different cytomorphological patterns of FNAC associated with

lymph nodes in the head and neck region.

2. To correlate the fine needle aspiration findings with histopathology.

3. To evaluate the sensitivity and specificity using histopathology as the gold

standard.

5

3. REVIEW OF LITERATURE

First time in 1833, Baron Dupuytren published an article about the usage of fine

needle aspiration technique and diagnosis of echinococcus cyst by FNAC.19

In the same year, Stanley also described about using needle aspiration for diagnostic

purpose.19

In 1847, Kun of Strasbourg described fine needle aspiration as a new tool for the

diagnosis of tumors. It is followed by sporadic reports of this technique. 20

In 1851, Skey strongly favored breast aspiration for cystic lesions but, did not

encourage microscopy of the contents.

In 1853, Sir James Paget and Erichsen from London, favored the use of aspiration

biopsy especially for the breast lesions.21

Leyden for the time used transthoracic aspiration biopsy to obtain cells to isolate

pneumonic organisms. Menetrier used the technique to diagnose pulmonary

carcinomas.20

The major problems for the microscopists at that time were the absence of tissue

stains. The decade 1870-1880 witnessed a dramatic change. Tissue stains were

discovered and mechanical microtomes so improved that thin, well stained sections of

tissue could be made. These were easier to read than scrape or puncture smears so, by

1890, there was an eclipse of early tissue cytology.22

In 1905, Greig and Gray published a study about the aspiration of lymph nodes for

the identification of motile trypanosomes in the British Journal Memorandum. 21, 22

In 1907, Proscher used the fine needle aspiration technique to diagnose syphilis

identifying spirochetes in lymph node aspirate. 19

6

In 1909, Horder used the fine needle aspiration technique for diagnostic purposes in

lung disease. 19

In 1912, Hans Hirschfield, a German hematologist, described the needle aspiration

biopsy technique in great detail while reporting its use in diagnosis of cutaneous

lymphomas and other tumors. 19

In 1914, Ward studied in detail about aspiration technique for the diagnosis of

lymphoma. Chatard and Guthrie, from the Hopkins Hospital , New York, in the

same year, employed needle aspiration to diagnose trypanosomes in lymph node

material. 19.

In 1921, Guthrie reported systematic study of smears from lymph node puncture

using 21-gauge needle and syringe successfully diagnosed cases of syphilis,

tuberculosis, malignant lymphomas, leukemia and metastatic carcinoma. 19, 21

In 1927, Dudgeon and Patrick proposed needle aspiration of tumors as a means of

rapid microscopic diagnosis. They reported 200 cases with a diagnostic accuracy of

98.6%. 21

In 1933, Stewart described elaborately fine needle aspiration features of not less than

2500 tumors done over a period of 3 years. 21, 23

Despite encouraging results, limited interest was shown by other cancer center in the

United States and the popularity of the technique waned to such an extent that the

technique was obsolete at the Memorial Hospital itself. 20.21

In mid 1950s, Europeans like Soderstrom and Franzen in Sweden, Lopes- Cardozo

in Holland, and Zajdela in France have published various articles on fine needle

aspiration features using thin size needle (22 gauge). 20, 21

Joseph Zajicek at the Radiumhemmet of the Karolinska Hospital in Sweden applied

the requisite scientific rigour to define precise diagnostic criteria in a variety of

conditions. He emphasized the simplicity, safety, rapidity and diagnostic accuracy of

7

the technique by presenting their findings with full clinical, histological and follow-up

data. They operated a direct referral clinic-based service ran by specialists in

cytopathology who performed the aspiration, prepared the slides and provided a

diagnosis, creating a model FNAC services for the rest of the world. 20, 21

In the early 1970s, Dr.M.S.Sukuraman from Chennai and Dr. Subhash kumari

Gupta from Postgraduate Institute of Medical Education and Research Center,

Chandigarh, first time introduced the fine needle aspiration technique in India. 24

Thereafter lots of studies were conducted to study the fine needle aspiration cytology

of the various lymphadenopathies.

Thomas et al, reported that the accuracy of interpretation of aspirates of lymph nodes

improved over the 3 year period. This was probably due to the increasing experience

and expertise acquired and improvement achieved in specimen handling and

processing during this period. Similarly, the number of unsatisfactory smears

decreased when performance of aspirations was limited to pathologists. 27

Nausti et al (2001) and Gupta et al (2003) in their studies on lymph node FNACs,

tried on-spot evaluation by Diff-Quik or any other rapid staining technique and

concluded that it is extremely valuable in providing an accurate, on the spot

interpretation in a large majority of cases but in addition, also helps triage specimens

for ancillary studies. They emphasized the utility of ancillary techniques such as

special histochemical stains, cell block preparations, immunohistochemistry and flow

cytometry in the interpretation of lymph node FNACs.28, 29, 30, 31

Bezabih M and Mariam DW have done study on determination of etiology of

superficial enlarged lymph nodes using fine needle aspiration cytology and found that

the cervical region was the most frequent site for the enlarged lymph node disorders

accounting for more than three fourth of all the cases.43

Lee J, conducted study on usefulness and limitations of fine needle aspiration

cytology in adult cervical lymph node enlargement patients involving 342 cases. He

found that 51.5% cases were reactive hyperplasia, Kikuchi’s disease and acute

8

suppuration, 25.7% cases were tubercular lymphadenitis, 19.3% cases were metastasis

and 3.5% cases were lymphoma. The overall diagnostic sensitivity of FNAC was

88%. The sensitivity was 88.6% in benign nature lesion, 77.3% in tuberculosis, 90.1%

in metastasis and 58.3 % in lymphoma. The diagnosis of tuberculosis was made by

FNAC in 68 (77.3%) among 88 cases.44

Jayaram et al (2000), Sakia et al (2001), Nayak et al (2003) and Vanisri et al

(2008), in their studies on FNAC of lymphadenopathy in HIV positive patients

concluded that FNAC is the primary and safe investigative modality for lesions of

lymph nodes in HIV patients. Most opportunistic infections (bacterial and fungal) in

these patients can be correctly identified and high grade lymphomas can be diagnosed

and phenotyped. It can obviate the need for surgical excision of the node and enables

immediate treatment of specific infections. 34,35,36,37

Shamshad Ahmad et al conducted the study of fine needle aspiration cytology in

lymphadenopathy with special reference to acid fast staining in cases of tuberculosis.

They found that 53.6% cases were benign reactive nature, 32.8% were tubercular

etiology, and 13.6% were malignant lymphadenopathy. Out of 328 cases of tubercular

lymphadenopathy, Z-N positivity for acid fast bacilli was found in 152 cases (46.4%).

Overall sensitivity and specificity was 91.6% and 99% respectively.46

Al-Muhim et al had done study on the role of fine needle aspiration cytology in

cervical lymphadenopathy. They found that overall accuracy of fine needle aspiration

was 93%. It was accurate in all the cases of reactive hyperplasia, 93% in tubercular

lymphadenitis, 90% in Hodgkin’s Lymphoma, 86% in Non-Hodgkin’s Lymphoma

and 91% in metastatic lymphadenopathy and concluded that fine needle aspiration

technique proved to be reliable, rapid and inexpensive procedures in diagnosis of

lymphadenopathy. It can well differentiate between inflammatory and neoplastic

lesions.41

In 2008, Khan et al conducted a clinicopathological study of significant

lymphadenopathy in children using fine needle aspiration technique and observed that

reactive hyperplasia was the most common type of lymphadenitis followed by

granulomatous lymphadenitis. He concluded that fine needle aspiration is a valuable

9

diagnostic tool in the management of children with the clinical presentation of

enlarged cervical lymph nodes. The technique reduces the need for more invasive and

costly procedures, especially in a third world country. Culture and histopathology,

however should be considered in cases where repeated fine needle aspiration cytology

is non-diagnostic.40

Chau et al conducted a study on rapid access multidisciplinary lymph node

diagnostic clinic: analysis of 550 patients in 2003. They found that mean age of

presentation of lymphadenopathy was 40 years and cervical lymph nodes were more

common site of involvement. Accuracy of diagnosing metastatic carcinoma in lymph

nodes by fine needle aspiration was more than 90%.42

Hsu C et al conducted study on efficacy of fine needle aspiration and sampling of

lymph nodes in 1,484 Chinese patients and found that overall sensitivity and

specificity is 95% and 96.5% respectively. FNAC showed a sensitivity of 76.9% in

the detection of AFB in Tubercular lymphadenopathy. 45

R K Narang et al studied the place of fine needle aspiration cytology in the diagnosis

of lymphadenopathy and found that sensitivity for diagnosing the tubercular

lymphadenopathy is 87% by FNAC. Reasons for false negativity were non

availability of epitheloid cells or giant cells.47

Mohammad Rakhshan and Azadeh Rakhshan had done study which includes 178

patients of enlarged lymph nodes of neck region. Both FNAC and biopsy had done.

They found that the reactive lymphadenitis is most common presentation. Diagnostic

accuracy of FNAC was about 88%. Sensitivity, Specificity was 75.8% and 96.6%

respectively.51

Tippu Ishar, Ram kumar Gupta and Arvind Khajuria had done study on the role

of FNAC in non-thyroidal lesions and found that reactive lymphadenitis is the most

common presentation of enlarged lymph nodes. Sensitivity of FNAC was 83.3%.

They concluded that FNAC is a reliable and safe diagnostic modality for enlarged

lymph node swellings. It has high degree of diagnostic yield and sensitivity to

diagnose lymph node lesions , thereby obviating the need for open biopsy.52

10

In the study conducted by Dr. Manjunath B S on FNAC of head and neck lesions

excluding thyroid, he found that cervical lymph nodes were more commonly involved

in both benign and malignant condition. Male: Female: 1.33:1. Age range was 2-

85yrs. benign lesions includes reactive lymphadenitis (22%), Tubercular

lymphadenitis (34.8%). Malignant lesions were more common in the 6th

decade.

Primary malignant lesions formed 2.3% whereas metastatic lesions were 16.8% of all

the FNACs’. 53

Bharathi K et al did study on FNAC of lymph nodes and found that age range was

15-75yrs. Male: Female = 1:1.08. Cervical lymph nodes were more commonly

involved in metastasis and more commonly by squamous cell carcinoma. Primary

malignancy was 1% whereas metastasis was 41%. Sensitivity, Specificity was 96.4%

and 66.6% respectively. Diagnostic accuracy was 90%. 54

In the study done by Hirachand et al on FNAC of lymph nodes, found that cervical

lymph nodes were more commonly involved. Male: Female= 1:0.9. Age range was 3-

85yrs. Incidences of different lesions were as follows: Reactive lymphadenitis

(41.5%), Tubercular lymphadenitis (28%), metastases (12.3%), Granulomatous

lymphadenitis (9.2%), Lymphoma (6%), Suppurative lymphadenitis (3%). The

sensitivity and specificity of metastatic lesions were 100%. 55

In the study conducted by Adhikari 56

, he found that incidence of benign and

malignant lesions were 87.2% and 12.8% respectively. Most common age group was

2nd

decade. Males were more common than females. The sensitivity, specificity, false

positive, false negative, positive predictive and negative predictive value of FNAC of

lymphadenopathies to diagnose tubercular lymphadenopathies were 80%, 100%, 0%,

20%, 100% and 82.14% respectively. The sensitivity and specificity of FNAC of

lymphadenopathies to differentiate benign and malignant lesions were 100% each.

Overall false positive, false negative, positive predictive and negative predictive

values were 0%, 0%, 100% and 100% respectively. Overall correlation of FNAC and

HPE was 90.9%.

In the study done by Nasuti et al FNAC was used in 21% of the cases and this

method gave useful diagnostic information in 86% including detection of acid-fast

11

bacilli in a background of granulomatous inflammation; mucin in poorly

differentiated carcinoma; the presence of Prostate Specific Antigen, Leukocyte

Common Antigen, Epithelial Membrane Antigen and Vimentin in metastases from a

known primary or helped to establish the tissue of origin in patients who initially

presented with metastatic diseases. The use of flow cytometry on the FNAC material

was found to be extremely helpful in ruling out lymphoma in two patients with

reactive lymphadenopathy and in the detection and characterization of a monoclonal

population of lymphoma cells in three patients. 28

Carter et al studied the role of FNAC in diagnosis of lymphomas. Morphologic

subclassification of the lymphomas was attempted for 60 needle aspirates in their

study and was found to be identical to the histological subclassification in 51 cases.

FNAC provided the initial diagnosis of a hematolymphoid malignancy in 51% of the

cases and allowed the documentation of recurrent disease in 49%. These results

demonstrated the usefulness of FNAC for the diagnosis and management of patients

with lymphoma. 32

Landgren et al reported that FNAC is an accurate method in the diagnosis of

lymphoma when cytological diagnosis is corroborated by immunotyping. They also

noted the fact that, an increasing use of FNAC for primary diagnosis and

classification of lymphomas may results in a loss of archival tissues for

complementary analysis, reclassification and research purposes. In addition, some of

the lymphoma entities are impossible to diagnose with the use of FNAC alone.33

Prasad et al in their study of 2,418 cases of lymph node FNACs concluded that

immunocytochemical tests performed on the aspirated material helped in classifying

the metastatic poorly differentiated tumors and confirming the diagnosis of Non-

Hodgkin’s lymphomas. Effects of FNAC on subsequent biopsy in 81 lymph nodes

with benign hyperplasia were studied, which showed that aspiration does not interfere

with subsequent histological assessment. 26

Steel et al had studied 1,103 lymph node FNACs and observed that aspirates from

supraclavicular nodes were most likely to be malignant (85%) , followed by those

from deep nodes (67%). The most challenging lesions to assess using FNAC were

12

lymphomas, accounting for 15 of the 23 false negative cytological diagnoses in their

study. 25

Dr. Madhusmita J (2011), Dr. Rashmi Kushwaha (2009), Dilip K. Das (2001) has

published case report of Rosai Dorfmann disease of lymph node diagnosed by fine

needle aspiration technique, later confirmed by biopsy. 48, 49, 50

13

ANATOMY AND CYTOLOGICAL FEATURES OF LYMPH NODE

Lymph nodes are encapsulated center of the antigen presentation and lymphocyte

activation, differentiation and proliferation. They generate mature antigen primed T

and B lymphocyte and filter particles including microbes from the lymph by the

action of numerous phagocytic macrophages. 1

A normal young adult body contains upto 450 lymph nodes, of which 60-70 are found

in the head and neck region, 100 in thorax as many as 250 in the abdomen and pelvis.

By far greatest number lies close to the viscera, especially in the mesentery.

Embryology of lymph node

Thymus is formed from the third pharyngeal pouch by the end of sixth week of

gestation. By seventh week, lymphatic sacs are developed adjacent to the blood

vessels. By eight weeks, the lymphocytes start accumulating within developing

lymphatic sac. Small blood vessels grow into it and the internal organization of the

lymph node gradually appears.1

Anatomy of Lymph node3

14

Lymph nodes are small oval or kidney shaped bodies, 0.1 – 2.5 cm lying along the

course of the lymphatic vessels. Each usually has a slight indentation on one side, the

hilum, through which blood vessels enter and leave and the efferent lymphatic vessels

leaves. Several afferent lymphatic vessels enter the capsule round the periphery.

Lymph nodes are surrounded by a connective tissue capsule. The capsule is composed

mainly of collagen fibers, elastin fibers and few fibroblasts. From the surface of

lymph node, capsule extends the trabeculae of dense connective tissue radially into

the interior of the node. They are continuous with a network of the fiber type III

collagen fibrils which supports the lymphoid tissue. At the hilum, dense fibrous tissue

may extend into the medulla surrounding the efferent lymphatic vessels.

Below the capsule, three distinct regions can be recognized within the normal lymph

nodes, these regions are

Cortex

Para Cortex

Medulla

Cortex: 1

Cells are densely packed; hence appear darker on Hematoxylin and Eosin stain

when compared to medulla. In the outer cortical area, these cells form lymphoid

follicles or nodules. These follicles are populated by B lymphocytes and specialized

follicular dendritic cells. The lymphoid follicles are of two types. A Primary follicle is

uniformly populated by small, quiescent lymphocyte. It is seen in all lymph nodes

when they are in “inactive” state without any antigen exposure. A Secondary follicle

has a germinal center which is composed mainly of antigen stimulated B cells and

seen secondary to antigen exposure. These B lymphocytes are larger, less deeply stain

and more rapidly dividing than that of the periphery. The role of germinal center is to

provide a micro-environment which allows the effective maturation of B lymphocyte.

So that as the immune response progress the strength with which antibodies bind with

their antigen also increases. There are several zones in the germinal center. In the dark

zone, the B lymphocytes (centroblast) undergo differentiation which is associated

with hypermutation of their antibodies molecules. They then move into the light zone

(centrocyte), where they can interact with follicular dendritic cells which carry

15

unprocessed antigen on their surface. The centrocyte compete for binding to the

antigen. Those centrocyte which bind to the antigen survive and rest will die. It also

consists of T cell and macrophage.

The mantle zone is produced as surrounding cells are marginalized by the rapidly

growing germinal center. It is populated by cells similar to those found in the primary

follicle mainly quiescent B cells with condensed heterochromatic nuclei and little

cytoplasm, hence stain deeply basophilic on Hematoxylin and Eosin stain.

Paracortex: 1

The paracortex (deep cortex) lies between the cortex and medulla. It is populated by T

lymphocytes belongs to both CD 4 and CD 8 type. It also contains Langerhan’s cells

from skin and other squamous epithelial cells which have migrated along with lymph

to the draining lymph node. Their role is to present the processed antigen to T

lymphocytes. This region expands greatly in T lymphocyte dominant immune

response.

Medulla: 1

The medulla is the innermost part of lymph node completely surrounded by cortex

except at hilum. The medulla mainly contains sinuses which are lined by

macrophages. Lymph from the afferent lymphatics enters initially into subcapsular

sinus, marginal sinus finally into medullary sinuses. The lining macrophages

phagocytose particulate material within the lymph. Between the sinuses in the

medulla lie the medullary cords which contain numerous plasma cells and are one of

the main sites of antibody secretions within the lymph node.

Lymphatic and vascular supply:

Lymph nodes are permeated by channels through which lymph percolates after its

entry from the afferent vessels. These afferent vessels enter at many points from the

convex surface of the lymph node to form dense intracapsular plexus. It opens into the

subcapsular sinus which is peripheral to the whole cortex except at the hilum.

Numerous radial cortical sinuses (para-trabecular) lead from the subcapsular sinus to

the medulla where these coalesce as large medullary sinuses. These latter become

confluent at the hilum to become efferent lymphatic vessel which drain the lymph

16

from the lymph node. All the sinus spaces are lined by continuous endothelium and

macrophages. These macrophages phagocytose the foreign antigen, apoptotic

lymphocytes etc. Arteries and veins serving the lymph node pass through the hilum,

giving off the straight branches which traverse the medulla. Then it gives off the

minor branches. In the cortex, arteries form dense arcade of arterioles and capillaries

in numerous anatomizing loops eventually retiring to highly branched venules and

veins. Capillaries mainly surround the lymphoid follicles. Post capillary high

endothelial venules are abundant in the paracortical zone. These venules join to form

vein which leave the lymph node through hilum.

General features of FNAC of lymph node: 4, 12

Highly cellular smears

Smears mainly contain dispersed cells with lack of cellular cohesion.

The cytoplasm of lymphoid cells is very fragile and many cells are represented

by naked nuclei or have only rim of cytoplasm.

A variable number of rounded cytoplasmic fragments measuring upto 8 µm in

diameter are seen scattered in the background. They stain an even pale-blue

identical to the cytoplasm of intact cells with giemsa stain. They are called

“lymphoglandular bodies”, “lymphoid –globules”, “soderstrom bodies”.

Cytological findings of normal lymph node aspirate10, 11

Different types of cells are present in the normal lymph node aspirate; predominant

among them are mature small lymphocytes. Other cells are centrocytes, centroblasts,

immunoblasts, plasmablasts, plasma cells, dentritic reticulum cells, macrophages.

Cytomorphological description of all these cells is discussed below.

Lymphocytes:

These may be either T or B lymphocytes.

Cells measure 7-8µm having scanty cytoplasm with dense dark nucleus.

Centrocytes:

These are B cells derived from germinal centre.

These cells measure 10 -11 µm with basophilic scanty cytoplasm and cleaved

nucleus having fine chromatin with small indistinct nucleoli.

17

Centroblasts:

These cells are larger than centrocytes, also derived from germinal center.

These cells have scanty basophilic cytoplasm and round nucleus with granular

chromatin, small peripherally situated nucleoli.

Immunoblasts:

These are the largest of all the cells of lymph node.

These cells measure 20-30 µm with moderate amount of basophilic cytoplasm

and eccentrically placed round nucleus with single large basophilic nucleoli.

Plasmablasts:

These cells measure 20-30 µm with abundant basophilic cytoplasm and

eccentrically placed clear perinuclear halo.

These may be bi-nucleated cells. Nucleus is round with coarse condensed

chromatin and centrally placed prominent nucleoli.

Plasma cells:

These are mature B cells measuring 15-17 µm.

These have an eccentrically placed nucleus with coarse clumped chromatin

and arranged in cartwheel like pattern.

The cytoplasm is abundant, basophilic and well defined paranuclear clearing.

Dentritic – reticulum cells:

These are Macrophages,

These are phagocytic cells measure upto 40 µm.

These cells have abundant foamy cytoplasm and round to kidney shaped

vesicular nucleus and inconspicuous nucleoli.

Tingle body macrophages are the macrophages containing phagocytosed

cellular debris. These are seen in inflamed lymph nodes.

18

CLASSIFICATION OF LYMPH NODE LESIONS3, 8, 9

1. INFLAMMATORY AND HYPERPLASTIC LESIONS:

a) Non-Specific Lymphadenitis:

i) Acute Non- Specific Lymphadenitis

ii) Chronic Non-Specific Lymphadenitis

b) Specific Lymphadenitis:

i) Reactive states with Follicular Hyperplasia:

- Systemic Lupus erythematous

- Rheumatoid Arthritis

- Adult onset still’s disease

- Sjogren’s Syndrome

- Kimura’s disease

- Cat-scratch disease

- Toxoplasmosis

- Syphilis

- HIV infection

- Kikuchi Fujimoto Disease

- Castleman’s Disease

ii) Reactive States with Interfollicular Hyperplasia:

- Infectious mononucleosis

- Lipophagic reaction

- Langerhan’s Cell Histiocytosis

- Sinus Histiocytosis with massive lymphadenopathy

- Hemophagocytic syndrome

- Dermatopathic Lymphadenopathy

- Post-transplant lymphoproliferative Disorders.

19

iii) Reactive States causing Diffuse Architectural Effacement:

- Angioimmunoblastic and Immunoblastic Lymphadenopathy with

Dysproteinemia

- Sarcoidosis

- Phenytoin induced and other drug reaction induced Lymphadenopathy

- Lymph node infarction

- Vasoproliferative and spindle cell lesions of Lymph node

- Inflammatory Pseudotumor of Lymph node

- Mycobacterial Spindle cell Pseudotumor

- Vascular Transformation of Lymph node sinuses

- Bacillary Angiomatosis

- Epitheloid Vascular Neoplasms of Lymph Node

- Smooth Muscle Proliferation

- Palisaded Myofibroblastoma

- Mastocytosis

- Mucocutaneous Lymph node Syndrome ( Kawasaki’s disease)

iv) Granulomatous Conditions:

- Tuberculosis

- Sarcoidosis

- Cat-Scratch Disease

- Toxoplasmosis

- Leprosy

- Tularemia

- Brucellosis

- Fungal Infections

- Chronic Granulomatous Disease

- Foreign Body Granulomas

- Lymphogranuloma Venereum

- Yersinia Lymphadenitis

20

2. MALIGNANT LESIONS

A. Malignant Lymphomas:

I. Non- Hodgkin’s Lymphoma: WHO classification (2000)

B-CELL NEOPLASMS

Precursor B-cell neoplasms

- Precursor B-Lymphoblastic Leukemia/Lymphoma

Mature B-cell neoplasms

- B-cell chronic Lymphocytic Leukemia/Small Lymphocytic Leukemia

- B-cell Prolymphocytic Leukemia

- Lymphoplasmacytic Lymphoma

- Splenic marginal zone B-cell Lymphoma

- Hairy cell Leukemia

- Plasma cell Myeloma

- Solitary plasmacytoma of bone

- Extraosseous plasmacytoma

- Extra-nodal marginal zone B-cell Lymphoma of mucosa associated Lymphoid

Tissue

- Nodal marginal zone B-cell Lymphoma

- Follicular Lymphoma

- Mantle cell Lymphoma

- Diffuse Large B-cell Lymphoma

- Mediastinal (thymic) Large B-cell Lymphoma

- Intravascular Large B-cell Lymphoma

- Primary Effusion Lymphoma

- Burkitt’s Lymphoma / Burkitt cell Lymphoma

B-cell proliferation of uncertain malignant potential

- Lymphomatoid granulomatosis

- Post-transplant Lymphoproliferative disorder, polymorphic

21

T-CELL AND NK-CELL NEOPLASMS

Precursor T-cell Neoplasms

- Precursor T-Lymphoblastic Leukemia/Lymphoma

- Blastic NK cell Lymphoma

Mature (peripheral) T-cell & NK cell neoplasms

- T-cell Prolymphocytic Leukemia

- T-cell Large Granular Lymphocytic Leukemia

- Aggressive NK-cell Leukemia

- Adult T-cell Leukemia/Lymphoma

- Extra nodal NK/T-cell Lymphoma, nasal type

- Enteropathy type T-cell Lymphoma

- Hepatosplenic gamma-delta T-cell Lymphoma

- Subcutaneous panniculitis-like T-cell Lymphoma

- Mycosis fungoides /Sezary Syndrome

- Anaplastic Large cell Lymphoma, T/null cell, primary cutaneous type

- Angioimmunoblastic T-cell Lymphoma

- Anaplastic Large cell Lymphomas, T/null, Primary Systemic type

ii) Hodgkin’s Lymphoma: REAL/WHO classification (1994)

Nodular Lymphocyte Predominant Hodgkin’s Lymphoma

Classical Hodgkin’s Lymphoma

o Nodular Sclerosis

o Mixed Cellularity

o Lymphocyte Depleted

o Lymphocyte Rich

B Malignant Histiocytosis

C Tumors of Dendritic Cells and Macrophages:

i) Dendritic Follicular Cell Tumor / Follicular Dendritic Cell Sarcoma

ii) Interdigitating Dendritic Cell Tumor / Interdigitating Reticulum Cell

Sarcoma

iii) True Histiocytic Lymphomas (Sarcomas)

22

D Lymphomas Associated with Immunocompromised State

E Lymph Node Metastases

3. NON-NEOPLASTIC LESIONS OF LYMPH NODE AND LYMPH NODE

INCLUSIONS

i. Adipose Metaplasia

ii. Vasculitis

iii. Proteinaceous Lymphadenopathy

iv. Hyaline Material

v. Foreign Material e.g. Silicon

vi. Lymph node inclusions: Salivary gland tissue, Squamous epithelium,

Thyroid follicles, Decidual reaction, Mullerian-type epithelium, Nevus

cells, Mesothelial Cells and breast tissue.

23

Cytological findings in various pathological conditions of lymph nodes

Non-Specific Reactive Hyperplasia: 4, 10,12,13,14

Polymorphous population of cells

Predominant cells are mature small lymphocytes. Other cells are centrocytes,

centroblast, immunoblast, plasmablast, plasma cells, and dendritic-reticulum

cells.

Tingible body macrophages are seen scattered among the lymphoid cells.

Neutrophils, eosinophils, endothelial cells, histiocytes are also seen.

Acute suppurative lymphadenitis: 4,10,12,13

Polymorphous population of lymphoid cells.

Large numbers of intact and degenerated neutrophils are seen.

Some neutrophils may show phagocytosed bacteria.

Few admixed lymphocytes, plasma cells and histiocytes are seen.

The background may show cellular debris.

Granulomatous Lymphadenitis: 4, 8,13,10,12

It is a type of hypersensitivity reaction seen in various conditions of infectious and

non-infectious etiology.

Infectious etiology: Tuberculosis, Atypical mycobacteriosis, Leprosy, Toxoplasmosis,

Brucellosis, Cat-scratch disease, Tularemia, Leishmaniasis, fungal infections (e.g.

histoplasmosis and paracoccidiodomycosis).

Non-infectious etiology: Sarcoidosis, Chronic granulomatous disease, foreign body

reaction, secondary response in lymph node draining carcinoma.

Cytological features of granulomatous lymphadenitis are,

Presence of Epitheloid cells, which are modified histiocyte, having elongated

nuclei described as foot print shaped. The nuclei have slight lateral indentation

and finely granular chromatin. These cells have abundant pale cytoplasm and

are arranged in a syncytial fashion.

24

Presence of Langhan’s type of giant cell, especially in case of Tuberculosis,

has abundant eosinophilic cytoplasm and multiple nuclei polarized in an arc at

one part of the cell border.

Presence of Foreign body giant cells which are characterized by abundant

cytoplasm and multiple nuclei arranged randomly.

Presence of lymphocytes, histiocytes in the background.

Necrosis may or may not present.

If no etiological agent is found , then only Granulomatous lymphadenitis is given as

an impression on FNAC report so that the findings has to be co-related clinically to

arrive at the proper diagnosis.

Tuberculous lymphadenitis: 3, 4,6,10,12,13,15

Epitheloid granulomas characterized by presence of epitheloid cells,

Langhan’s type of giant cells, lymphocytes, histiocytes.

Background may show necrosis.

Only necrosis without epitheloid or Langhan’s giant cells are not uncommon

when aspiration is taken from necrotic region of granuloma or in case of

confluent granuloma.

Demonstration of acid fast bacilli i.e. mycobacterium tubercle bacilli is must for the

diagnosis of tubercular lymphadenitis.

Tubercle bacilli appear as beaded, rod-shaped acid fast bacilli in Ziehl-Neelsen stain.

It can be demonstrable by other stains like Kinyoun and under fluorescent microscope

using Auramine and Rhodhamine stain.

Diagnosis of tubercular etiology is confirmed by the growth of bacilli in Lowenstein-

Jensen medium.

Polymerase chain reaction can also be performed on the aspirated material to detect

tubercular antigen whose sensitivity is less than that of culture.

25

Necrotizing Non-granulomatous lymphadenitis: 13

Heterogeneous population of small and large lymphocytes, immunoblast,

phagocytic histiocytes, plasmacytoid monocytes, necrosis and

karyorrhectic debris.

Absence of neutrophils and eosinophils.

Phagocytic histiocyte is a large cell with round contours and a crescent shaped

nucleus, the convex side of which appears to fuse with the cell membrane. The

nucleus is irregular twisted and inconspicuous nucleoli. Their abundant cytoplasm is

pale and contains phagocytosed debris.

Lymphomas:

Hodgkin’s lymphoma: 4,10,12,16

Hodgkin’s lymphoma is characterized by the presence of Reed-Sternberg cells and

their variants in an appropriate background of inflammatory cells, accompanied by

fibrosis.

Reed-Sternberg cells and their variant:

RS cells are considered the pathognomic feature of Hodgkin’s lymphoma. Diagnostic

RS cells are necessary but not sufficient for the diagnosis of Hodgkin’s lymphoma.

Therefore to render a diagnosis of Hodgkin’s lymphoma, RS cells must be in a

cellular background appropriate for the specific subtypes of Hodgkin’s lymphoma.

Classical RS cell:

It is a large cell measuring 20-60µm in diameter with morphologic hallmark of

polyploidy. ( double, multiple or multilobed nuclei)

It has variable amount of cytoplasm that is weakly eosinophilic or

amphophilic.

The nuclei are large with thick nuclear membrane.

Classical bilobed nucleus is seen with two lobes symmetrically facing each

other, resulting in a “mirror image” appearance. Each nuclear lobe has a

single, gigantic, inclusion like eosinophilic nucleolus (larger than RBC), often

surrounded by a halo. It is also described as “owl’s-eye” nucleoli.

26

Mononuclear RS cells (Hodgkin’s cells):

These are large mononuclear cells with a prominent nucleolus and abundant

cytoplasm like the classical RS cells. These cells also are rare or absent in

Nodular Lymphocyte predominant Hodgkin’s lymphoma.

Lymphocytic and Histiocytic cells (Pop corn cells):

RS cells show nuclear convolutions or lobulations with thin nuclear

membranes instead of binucleation and multinucleation. They possess fine

chromatin and multiple small basophilic or eosinophilic nucleoli, hence the

eponym pop corn cells.

These cells are seen in Nodular lymphocyte-predominant Hodgkin’s

lymphoma.

Lacunar cells:

These cells possess round or lobated nuclei, vesicular chromatin and multiple

distinct small to medium sized nucleoli. Their cytoplasm is pale and retracted

and the tumor cells appear to lie within lacunae.

These cells are seen in Nodular sclerosis Hodgkin’s lymphoma.

Pleomorphic RS cells:

These cells are large bizarre polypoid nuclei.

These cells are seen in Lymphocyte depleted Hodgkin’s lymphoma.

Mummified RS cells:

These are large necrobiotic cells in which the nuclear details are no longer

discernable and the cytoplasm is deeply eosinophilic.

WHO classification of Hodgkin’s lymphoma:

1. Nodular Lymphocyte- Predominant Hodgkin’s Lymphoma:

Classical RS cells are rare or absent.

Lymphocytic and Histiocytic cells are seen admixed with large numbers of

lymphocytes.

27

2. Classical Hodgkin’s Lymphoma:

Lymphocyte Rich Hodgkin’s Lymphoma:

Smears show an overwhelming population of lymphocytes.

Classical RS cells or Hodgkin’s cells are occasionally seen.

Pop corn cells are commonly observed.

Eosinophils and plasma cells are rare.

Many non-neoplastic histiocytes or epitheloid histiocytes are sometimes

observed in groups or in dissociated form.

Mixed cellularity Hodgkin’s Lymphoma:

Classical RS cells and Hodgkin’s cells are frequently encountered in the

smears.

Other reactive components like eosinophils, plasma cells and benign

histiocytes are also present.

Lymphocyte Depleted Hodgkin’s Lymphoma:

Marked increase in classical RS cells and Hodgkin’s cells are seen.

Corresponding decrease in lymphocytic population is seen.

RS cells are often pleomorphic.

Nodular Sclerosis Hodgkin’s Lymphoma:

The smears are often poorly cellular.

Lacunar cells are commonly observed.

Classical RS cells or Hodgkin’s cells are occasionally seen.

Fibrocollagenous tissue, giving rise to a nodular pattern on histopathology is

rarely aspirated.

Non-Hodgkin’s Lymphoma: 4,10,12,13

B-cell Lymphomas:

1. Small Lymphocytic Lymphoma / Chronic Lymphocytic Lymphoma:

A monotonous population of small lymphoid cells.

Mainly having round nuclei slightly larger than those of normal small mature

lymphocyte.

28

Characteristically coarse granular nuclear chromatin without nucleoli is seen

A varying number of prolymphocytes having larger size, more cytoplasm, pale

chromatin and single central nucleoli are seen.

Blasts and macrophages may be present.

2. Lymphoblastic Lymphoma:

The predominant cell is slightly larger than a mature lymphocyte.

It has an eccentric nucleus with plasma cell like chromatin pattern.

The cytoplasm is basophilic and abundant.

Additional cells such as plasma cells, mast cells and a few immunoblasts are

regularly observed.

3. Plasmacytic Lymphoma:

The neoplastic cells may have morphology almost identical to that of a normal

mature plasma cell but usually shows atypia such as enlarged pleomorphic

nuclei, double nuclei and large irregular cytoplasm.

Immature plasma cells containing nucleoli may be seen.

4. Follicular Lymphoma:

They are composed of a mixture of centrocytic and centroblastic cells.

In the WHO classification follicular lymphoma are divided into 3 grades-

Grade I – predominantly centrocytes

Grade II – a mixture of centrocytes and centroblasts.

Grade III – predominantly centroblasts.

The centrocytes have a tendency to form clusters.

Usually a relatively small number of small lymphocytes and macrophages may

be seen.

5. Mantle cell Lymphoma:

The smears are monotonous and composed of small to medium sized

lymphoid cells slightly larger than lymphocytes.

Their nuclei are cleaved and have a dispersed chromatin, inconspicuous

nucleoli and a thin pale cytoplasm.

29

Occasional histiocytes may be observed.

Blastic component /transformation may occur.

6. Marginal Zone B-cell Lymphoma:

Heterogeneous population of cells is observed.

The tumor cell population is dominated by small to medium sized cells, the

marginal zone cells, which are centrocyte-like, but with indistinct nucleoli and

a more abundant cytoplasm.

Mature small lymphocytes, plasma cells, centroblasts and variable numbers of

monocytoid cells with clear cytoplasm are seen.

7. Diffuse Large B-Cell Lymphoma:

It has 4 variants: Centroblastic, Immunoblastic, T-Cell Rich and Anaplastic.

CENTROBLASTIC VARIANT:-

Composed mainly of large round centroblasts which has round nuclei with

multiple small nucleoli, often at the nuclear membrane.

Variable proportion of indented/ cleaved or even multilobated nuclei is often

present.

Immunoblasts with abundant basophilic cytoplasm and large central nucleoli

may be present.

Other cells such as centrocytes, small mature lymphocytes and macrophages.

IMMUNOBLASTIC VARIANT:-

A pleomorphic cell population dominated by large blasts is observed,

sometimes exhibiting extreme pleomorphism and multinucleation.

Nuclear chromatin is unevenly distributed with prominent single central

nucleolus.

Mitosis are frequent

Abundant blue cytoplasm with perinuclear pale zone is found on Giemsa stain.

30

T-CELL RICH VARIANT:-

Majority of cells are small mature lymphocytes with variable number of

epitheloid histiocytes and scattered large lymphoid cells.

8. Burkitt’s Lymphoma:

A relatively uniform cell population

These cells have round nuclei of variable size with granular or speckled

chromatin pattern with multiple small but prominent nucleoli is seen.

These cells have dense blue cytoplasm with small punched out lipid vacuoles

on MGG stained smears.

Starry sky macrophages are often prominent.

9. Precursor B-Lymphoblastic Leukemia/ Lymphoma:

A homogenous population of cells is seen.

These cells have round nuclei mainly of intermediate size with finely granular

or speckled nuclear chromatin with multiple small nucleoli.

They have moderately basophilic and fragile cytoplasm

Starry sky macrophages may be present.

T-Cell Lymphomas

1. Precursor T- Lymphoblastic Lymphoma

A relatively uniform cell population with high mitotic rate is observed.

They show intermediate size nuclei, often with prominent anisonucleosis.

Variable numbers of convoluted nuclei are found.

The nucleus shows dense finely granular chromatin with mostly inconspicuous

nucleoli.

These cells have scanty, pale, fragile cytoplasm.

2. Angioimmunoblastic T-Cell Lymphoma:

Heterogeneous cell population with a spectrum of atypical cells ranging in size

from small to large is seen.

Small irregular lymphocytes are observed.

31

There are variable number of large cells including immunoblasts and at times

pleomorphic.

Reactive background of small round lymphocytes, eosinophils, plasma cells,

epitheloid and non-epitheloid histiocytes and dendritic cells is observed.

Fragments of vessels are often found in the smears.

3. Anaplastic Large Cell Lymphoma:

Markedly pleomorphic large cells multilobated , horseshoe or ring shaped

nuclei and multinucleation

They possess abundant pale grey vacuolated cytoplasm seen in MGG stained

smears.

Also seen reactive lymphoid cells.

4. Mycosis Fungoides:

Smears show predominantly small to medium sized cells exhibiting irregular

folded nuclei.

Large atypical cells resembling Hodgkin’s cells are occasionally seen.

5. True Histiocytic Lymphoma / Histiocytic Sarcoma:

A pleomorphic cell population with multilobed nuclei.

Multinucleated cells are also seen.

32

Metastases:

TABLE NO.1: Most common site of primary tumor draining to regional lymph node.

Sl.

No

Sites of lymph

node Site of Primary tumor

1 Sub mental Anterior part of oral cavity, lip, anterior part of tongue

2 Submandibular Oral cavity (tongue, tonsils, floor of mouth, cheeks, lips)

3 Cervical Oral cavity (tongue, tonsils, floor of mouth, cheeks, lips), salivary

glands, nasopharynx, larynx, thyroid, skin of face, scalp.

4 Preauricular Skin covering in front of ear, anterior and temporal scalp, anterior

ear canal and pinna, conjunctiva

5 Postauricular Posterior part of temporoparietal region, upper part of the cranial

surface of the auricle, back of the external acoustic meatus.

6 Supraclavicular

Gastrointestinal tract, head and neck malignancies, breasts, lungs,

pancreas, prostate, kidneys, gonads, skin of face, scalp, upper

extremities and trunk.

7 Occipital Posterior part of Scalp

Lymph nodes are the most common site of metastatic malignancy. Sometimes, lymph

node metastases are discovered before an occult primary tumor is detected.

Lymphadenopathy may be the first sign of malignancy in a patient. In such cases,

extensive studies of the lymph node metastases, including primary tumor, extensive

studies of the lymph node metastases, including immunohistochemistry and electron

microscopy in addition to detailed histopathology, are often necessary.3

Metastases to lymph nodes are common with carcinoma, malignant melanomas and

germ cell tumors, and rare with sarcomas and central nervous system tumors.

Virchow’s nodes are left supraclavicular nodes involved by intra-abdominal

malignancies .3

Cytology:

FNAC is a well established method for the initial diagnosis of metastatic

malignancies. The key to the diagnosis of lymph node metastasis is the presence of

abnormal non-lymphoid cells forming aggregates and clusters, amongst the normal

lymphoid cells, and the absence of lymphoglandular bodies. FNAC not only confirms

the presence of metastatic disease, but also gives clues regarding the nature and origin

of the primary tumor. In patients with enlarged lymph nodes and previously

documented malignancy, FNAC can obviate further surgery performed merely to

confirm the presence of metastases.17

33

The cytological patterns seen in the aspirated smears of metastatic lymph nodes are

often clues to the site of primary malignancy. 4

Squamous cell carcinoma: 10, 12

Well differentiated keratinizing tumors are easily identified when cells with

abundant, sharply demarcated, dense, eosinophilic cytoplasm and pyknotic

nuclei are present in smears.

These cells are found singly and in clusters.

The cellular atypia is minimal.

Anucleated squames, spindle-shaped and tadpole-shaped cells arranged in a

cell-within-cell pattern may be present.

Aspirates from poorly-differentiating squamous cell carcinoma yield cohesive

fragments of hyperchromatic pleomorphic cells.

Few cells show intracellular keratin.

Adenocarcinoma: 10, 12

Aspirates usually contain tumor cells that are arranged singly or in cohesive

groups.

The cell groups may consists of ball-like clusters, papillary fragments, loose

clusters or acini with central lumina.

The tumor cells may be cuboidal or columnar.

The cytoplasm may be homogenous to markedly vacuolated. The vacuoles

may be small and numerous or large causing margination and indentation of

the nucleus.

Large signet-ring cells with intracytoplasmic mucin are commonly associated

with gastric carcinomas.

Columnar cells with elongated, palisading nuclei in a background of necrotic

debris suggest a colonic primary tumor.

Aspirates from nodes with metastatic ductal carcinomas show poor glandular

differentiation. Tumor cells are arranged singly and in cohesive groups, or

both. Sometimes, a monolayer of dispersed cells with intact cytoplasm is

observed. These cells have mild nuclear pleomorphism. The characteristic

feature of this tumor is the presence of miniature signet-ring cells that mucin

34

within the cytoplasm vacuoles. These cells stain strongly positive for mucin

and have been named “magenta cells “in MGG stained smears.12

Metastasis of papillary carcinoma usually has their origin in thyroid.

Psammoma bodies are the most frequent in metastasis originating from

thyroid. It shows papillary fragments, monolayered sheets, syncytial groups

and single cells on cytology. The nuclei are often oval-shaped, have fine,

granular chromatin, intranuclear grooves and small nucleoli. The cytoplasm is

usually dense and well defined. The presence of colloid is a helpful

distinguishing feature.12

Nasopharyngeal carcinoma:

This tumor is subtyped as keratinizing squamous cell carcinoma,

nonkeratinizing carcinoma and undifferentiated carcinoma also known as

lymphoepithelial or Schimke tumor.

Cervical lymphadenopathy may be the first manifestation of this disease.

Aspirates show epithelial tumor cells arranged in dense clusters or occurring

singly, variable numbers of lymphocytes in the background.

The undifferentiated tumors show epithelial cells with hyperchromatic oval or

spindle shaped with irregular nuclear borders. One to two prominent central

nucleoli are present. The cytoplasm is thin and wispy and often gets stripped

off in smears.

Epstein –Barr virus has been associated with this neoplasm and documentation

of the presence of EBV in lymph node aspirates is helpful in establishing the

diagnosis.

Small cell carcinoma: 4, 10, 12, 13

Small cell carcinoma can be found in larynx, paranasal sinuses and skin.

Aspirates from these metastases yield crowded ragged clusters of small tumor

cells with scanty cytoplasm, nuclear moulding, angulated nuclear contours,

darkly staining coarse chromatin, very high nuclear-cytoplasmic ratio,

frequent mitosis and inconspicuous or absent nucleoli.

35

There is usually extensive necrosis. Crushed nuclear debris and strands of

smeared chromatin are usually prominent as “blue streaks” of DNA in the

background of the smears.

“Tear drop” nuclear artefacts caused by smearing are characteristics of small

cell carcinoma.

Immunostaining may be helpful in the diagnosis because small cell carcinoma

is positive for synaptophysin and cytokeratin and negative for CD45 or

Leucocyte Common Antigen.

Malignant melanoma: 4, 12

Aspirates of metastases of malignant melanoma show a dissociated cell

population.

Tumor cells are usually round or polygonal with abundant cytoplasm and well

defined cell borders.

The nuclei are often eccentrically located giving the cell a plasmacytoid

appearance. They have uniformly dense chromatin and may show intranuclear

cytoplasmic inclusions.

Binucleated or multinucleated cells are frequently seen with round to

pleomorphic nuclei having fine, granular chromatin with single or several

prominent nucleoli.

Fine, granular melanin pigment in the cytoplasm of some tumor cells may be

present. The pigment appears brown on hematoxylin and eosin staining.

Malignant cells with abundant cytoplasm and dark staining paranuclear areas

are a clue for diagnosing amelanotic melanoma.

Melanoma cells show positive immunocytochemical staining for HMB-45,

MART-1 and S-100 protein.

36

4. MATERIALS AND METHODS

Source of data:

All the patients with enlarged lymph nodes clinically, attending the M.V.J Medical

College Hospital and Research Hospital, Hoskote, Bangalore were included in the

study.

Collection of data:

All the patients referred to the department of Pathology, M.V.J Medical College

Hospital and Research Hospital, Hoskote, Bangalore for FNAC of palpable lymph

node lesions were enrolled for the study. FNAC was done and the standard method

for the procedure was adopted. All the slides were reviewed and diagnosis was given.

Inclusion criteria:

All superficial lymph node swellings of the head and neck region

Exclusion criteria:

1. All non-lymphoid aspirates from the head and neck region

2. Inadequate aspirate

Materials.

1. 5ml/10ml disposable syringe

2. 22-26 gauge needle

3. Cameco syringe holder

4. Clean non grease glass slide

5. Cotton swab

6. Methylated spirit

7. 95% ethyl alcohol in coupling jars

8. Haematoxylene & Eosin stain

9. Giemsa stain.

37

Method:

A total of 100 patients were included in our study, referred from the department of

Medicine, Pediatrics, Surgery, ENT, Chest Medicine and Tuberculosis. These patients

were clinically evaluated and informed consent was obtained for the procedure. The

limitations and complications of FNAC were explained to the patients.

- Skin over the lymph node to be aspirated is cleaned and disinfected.

- Lymph node is fixed in the left hand between index finger & thumb.

- A 24 gauge needle attached to syringe is mounted in the cameco syringe

holder and introduced into the lymph node.

- A vacuum is created in the syringe by pulling back the plunger.

- Needle is carefully moved in different directions to dislodge the material.

- When adequate material is aspirated into the syringe, suction is gently released

to equalize the pressure. This prevents sucking of aspirated material into the

barrel of syringe.

- Aspirated material is well spread on the slides.

- 2-3 wet slides are fixed in 95% ethyl alcohol used for staining with

Haematoxylene-Eosin stain and Papanicolaou stain.

- Air dried smear used for doing Giemsa stain.

- Few slides for special stains wherever required eg. AFB for tuberculosis etc

- Examine the slides under microscope.

Lymph node biopsy was done in 20 out of 100 cases and was fixed in formalin. Bits

were given from entire node for routine tissue processing. After the routine processing

and paraffin embedding, sections of three to four microns were taken. Clearing of the

slides were done which was followed by H&E staining.

Immunohistochemistry has been done in our department in cases of Lymphoma to

confirm the diagnosis. The markers used are CD15, CD30, CD19, CD20, and CD3.

38

Image-2: Materials used for Fine needle aspiration

(Sterile Gloves, Glass slide, Syringe, Cameco syringe holder,

cotton swab, spirit, 90% ethyl alcohol as fixative)

Image-3: Method of doing fine needle aspiration of left cervical

group of lymph node using 5ml syringe under a septic precaution.

39

Interpretation of aspiration was done as follows:

Assessment of the adequacy and representativeness of material in the smear.

Cytomorphological features like the overall cell population, predominant

pattern were assessed by examination under low power. The individual cell

morphology was studied under high power.

Final interpretation was given.

40

5. OBSERVATIONS AND RESULTS

TABLE 2: Year wise distribution of all lymph node lesions aspirated.

YEAR NUMBER OF FNAC % OF FNAC

2010 ( MAY – DEC ) 23 23 %

2011 ( JAN – DEC ) 55 55 %

2012 ( JAN – APR ) 22 22 %

TOTAL CASES 100 100 %

GRAPH 1: Year wise distribution of all lymph node lesions aspirated.

2010 2011 2012

NUMBER OF FNAC ( N = 100) 23 55 22

0

10

20

30

40

50

60

NU

MB

ER

OF

CA

SES

TOTAL NUMBER OF FNAC

41

TABLE 3: Year wise distribution of the lymph node biopsy.

YEAR NUMBER OF FNAC % OF FNAC

2010 ( MAY – DEC ) 08 40 %

2011 ( JAN – DEC ) 10 50 %

2012 ( JAN – APR ) 02 10 %

TOTAL CASES 20 100 %

GRAPH 2: Year wise distribution of the lymph node biopsy.

42

TABLE 4: Age wise distribution of the lymph node lesions aspirated..

AGE GROUP

( IN YEARS ) NUMBER OF CASES % OF CASES

0-10 08 08 %

11-20 17 17 %

21-30 25 25 %

31-40 10 10 %

41-50 16 16 %

51-60 09 09 %

61-70 09 09 %

> 70 06 06 %

TOTAL 100 100 %

GRAPH 3: Age wise distribution of the lymph node lesions aspirated.

43

TABLE 5: Gender wise distribution of the lymph node lesions aspirated.

GENDER TOTAL CASES % OF CASES

Male 46 46 %

Female 54 54 %

Total 100 100 %

GRAPH 4: Gender wise distribution of the lymph nodes aspirated.

44

TABLE 6: Age and Gender wise distribution of the lymph node lesions aspirated.

AGE GROUP

(IN YEARS) MALE FEMALE TOTAL CASES % OF CASES

0 -10 04 04 08 08 %

11 – 20 06 11 17 17 %

21 – 30 10 15 25 25 %

31 – 40 03 07 10 10 %

41 – 50 11 05 16 16 %

51 – 60 03 06 09 09 %

61 - 70 05 04 09 09 %

> 70 04 02 06 06 %

TOTAL CASES 46 54 100 100 %

GRAPH 5: Age and Gender wise distribution of the lymph node lesions

aspirated.

NUMBER

OF CASES

45

TABLE 7 Site wise distribution of the lymph node lesions aspirated.

SITES OF LYMPH NODE NUMBER OF CASES % OF CASES

Cervical 83 83 %

Submandibular 09 09 %

Submental 03 03 %

Pre-auricular 01 01 %

Post-auricular 00 00 %

Parotid 00 00 %

Occipital 01 01 %

Supraclavicular 03 03 %

Total 100 100 %

GRAPH 6: Site wise distribution of the lymph node lesions aspirated.

46

TABLE 8: Incidence of benign and malignant lesions of FNAC of the lymph node.

NUMBER OF CASES % OF CASES

Benign lesions 77 77 %

Malignant lesions 23 23 %

Total cases 100 100 %

GRAPH 7: Incidence of benign and malignant lesions of FNAC of the lymph node

aspirated.

47

TABLE 9: Incidence of primary and secondary malignant lesions of FNAC of lymph

node.

NUMBER OF CASES % OF CASES

Primary lesion 04 17.4 %

Metastases 19 82.6 %

Total cases 23 100 %

GRAPH 8: Incidence of primary malignant and metastatic lesions of FNAC of lymph

node.

48

TABLE 10: Site wise distribution of FNAC on benign lesions of lymph node.

SITES OF LESION NUMBER OF CASES % OF CASES

Cervical 67 87 %

Submandibular 04 05 %

Submental 02 03 %

Pre-auricular 01 01 %

Post-auricular 00 00 %

Parotid 00 00 %

Occipital 01 01 %

Supraclavicular 02 03 %

Total cases 77 100 %

GRAPH 9: Site wise distribution of FNAC on benign lesions of lymph nodes

49

TABLE 11: Site wise distribution of FNAC on malignant lesions of lymph node.

SITES OF LESION NUMBER OF CASES % OF CASES

Cervical 16 70 %

Submandibular 05 22 %

Submental 01 04 %

Pre-auricular 00 00 %

Post-auricular 00 00 %

Parotid 00 00 %

Occipital 00 00 %

Supraclavicular 01 04 %

Total cases 23 100 %

GRAPH 10: Site wise distribution of FNAC on malignant lesions of of lymph nodes

50

TABLE 12: Site wise distribution of FNAC of primary malignancy of lymph

node.

SITES OF LESION NUMBER OF CASES % OF CASES

Cervical 04 100 %

Submandibular 00 00 %

Submental 00 00 %

Pre-auricular 00 00 %

Post-auricular 00 00 %

Parotid 00 00 %

Occipital 00 00 %

Supraclavicular 00 00 %

Total cases 04 100%

GRAPH 11: Site wise distribution of FNAC of primary malignancy of lymph node

51

TABLE 13: Site wise distribution of FNAC on metastatic lesions of lymph node.

SITES OF LESION NUMBER OF CASES % OF CASES

Cervical 13 65 %

Submandibular 05 25 %

Submental 01 05 %

Pre-auricular 00 00 %

Post-auricular 00 00 %

Parotid 00 00 %

Occipital 00 00 %

Supraclavicular 01 05 %

Total cases 19 100 %

GRAPH 12: Site wise distribution of FNAC on metastatic lesions in the lymph node.

52

TABLE 14: Age wise distribution of FNAC on benign lesions of lymph node.

AGE GROUP

( IN YEARS ) NUMBER OF CASES % OF CASES

0-10 08 10 %

11-20 16 21 %

21-30 22 29 %

31-40 10 13 %

41-50 11 14 %

51-60 06 08 %

61-70 02 2.5 %

> 70 02 2.5 %

TOTAL 77 100 %

GRAPH NO.13: Age wise distribution of FNAC on benign lesions of lymph node.

53

TABLE 15: Age wise distribution of FNAC of primary malignancy of lymph node.

AGE GROUP

( IN YEARS ) NUMBER OF CASES % OF CASES

0-10 00 00 %

11-20 01 25 %

21-30 02 50 %

31-40 00 00 %

41-50 00 00 %

51-60 00 00 %

61-70 00 00 %

> 70 01 25 %

TOTAL 04 100 %

GRAPH 14: Age wise distribution of FNAC on primary malignany of lymph node.

54

TABLE 16: Age wise distribution of FNAC on metastatic lesion of lymph node

AGE GROUP

( IN YEARS ) NUMBER OF CASES % OF CASES

0-10 00 00 %

11-20 00 00 %

21-30 01 05 %

31-40 00 00 %

41-50 05 27 %

51-60 03 15.5 %

61-70 07 37 %

> 70 03 15.5 %

TOTAL 19 100 %

GRAPH 15: Age wise distribution of FNAC on metastatic lesion of lymph node.

55

TABLE 17: Gender wise distribution of FNAC on benign lesions of lymph node.

Gender NUMBER OF CASES % OF CASES

Male 32 41.5 %

Female 45 58.5 %

Total cases 77 100 %

GRAPH 16: Gender wise distribution of FNAC on benign lesions of lymph node.

MALE41.5%

FEMALE58.5%

Gender wise distribution of benign lymph node lesion by FNAC

56

TABLE 18: Gender wise distribution of FNAC of primary malignancy of lymph

node.

GENDER NUMBER OF CASES % OF CASES

Male 1 25 %

Female 3 75 %

Total cases 04 100 %

GRAPH 17: Gender wise distribution of FNAC on primary malignancy of lymph

node.

57

TABLE 19: Gender wise distribution of FNAC on metastatic lesions of lymph node.

GENDER NUMBER OF CASES % OF CASES

Male 13 69 %

Female 06 31 %

Total cases 19 100 %

GRAPH 18: Gender wise distribution of FNAC on metastatic lesion of lymph node.

58

TABLE 20: Cytopathological diagnosis of FNAC of lymph nodes.

CYTOPATHOLOGICAL

DIAGNOSIS

NUMBER

OF CASES

% OF

CASES

GENDER AGE

RANGE

( YRS) MALE FEMALE

BENIGN LESIONS

Non-specific reactive

lymphadenitis 37 37 % 16 21 2.5 – 60

Granulomatous

lymphadenitis 24 24 % 11 13 8 – 75

Tubercular lymphadenitis 15 15 % 04 11 13- 55

Rosai -Dorfmann disease 01 01 % 01 00 21

MALIGNANT LESION

Hodgkin’s lymphoma 03 03 % 01 02 12- 72

Non-Hodgkin’s lymphoma 01 01 % 00 01 24

Metastases 19 19 % 13 06 27 – 82

TOTAL CASES 100 100 % 46 54 2.5 – 82

GRAPH 19: Cytopathological diagnosis of FNAC of lymph nodes.

59

TABLE 21: Incidence of benign lesions of lymph node on FNAC.

BENIGN LESIONS NUMBER OF

CASES % OF CASES

GENDER

MALE FEMALE

Non-specific reactive

lymphadenitis 37 48 % 16 21

Granulomatous

lymphadenitis 24 31 % 11 13

Tubercular

lymphadenitis 15 19.5 % 04 11

Rosai dorfmann

disease 01 1.5 % 01 00

TOTAL CASES 77 100 %

GRAPH 20: Incidence of benign lesions of lymph nodes by FNAC.

Numbers of cases

60

TABLE 22: Incidence of malignant lesions of lymph node on FNAC.

MALIGNANT

LESIONS

NUMBER OF

CASES % OF CASES

GENDER

MALE FEMALE

Hodgkin’s lymphoma 03 13 % 01 02

Non-hodgkin’s

lymphoma 01 04 % 00 01

Metastases 19 83 % 13 06

TOTAL CASES 23 100 %

GRAPH 21: Incidence of malignant lesions of lymph node by FNAC.

0 5 10 15 20

Hodgkin's lymphoma

Non-hodgkin's lymphoma

Metastasis

Hodgkin's lymphoma

Non-hodgkin's lymphoma

Metastasis

Incidence of malignant lesions by FNAC( N= 23)

3 1 19

Incidence of malignant lesions by FNAC

Numbers of cases

61

TABLE 23: Site wise distribution of FNAC on benign lesions of lymph node.

NON-SPECIFIC

REACTIVE

LYMPHADENITIS

GRANULOMATOUS

LYMPHADENITIS

TUBERCULAR

LYMPHADENITIS

ROSAI

DORFMANN

DISEASE

TOTAL

CASES

Cervical 32 21 13 01 67

Submandibular 02 01 01 00 04

Submental 01 01 00 00 02

Pre-auricular 01 00 00 00 01

Post-auricular 00 00 00 00 00

Parotid 00 00 00 00 00

Occiptal 01 00 00 00 01

Supraclavicular 00 01 01 00 02

TOTAL

CASES 37 24 15 01 77

GRAPH 22: Site wise distribution of FNAC on non-specific reactive lymphadenitis

of lymph node.

62

GRAPH 23: Site wise distribution of FNAC on granulomatous lymphadenitis of

lymph node.

0

5

10

15

20

25 21

1 1 0 0 0 0 1

Granulomatous lymphadenitis

GRAPH 24: Site wise distribution of FNAC on tubercular lymphadenitis of lymph

node.

63

TABLE 24: Site wise distribution of FNAC on malignant leions of lymph node.

HODGKIN’S

LYMPHOMA

NON-HODGKIN’S

LYMPHOMA METASTASES

TOTAL

CASES

Cervical 03 01 12 16

Submandibular 00 00 05 05

Submental 00 00 01 01

Pre-auricular 00 00 00 00

Post-auricular 00 00 00 00

Parotid 00 00 00 00

Occiptal 00 00 00 00

Supraclavicular 00 00 01 01

TOTAL CASES 03 01 19 23

GRAPH 25: Site wise distribution of FNAC on Hodgkin’s lymphoma of lymph node.

64

GRAPH 26: Site wise distribution of metastatic lesions of lymph node by FNAC.

65

TABLE 25 Table demonstrating FNAC diagnosis with histopathological diagnosis.

CYTOLOGICAL

DIAGNOSIS

NUMBER OF

CASES

HISTOPATHOLOGICAL

DIAGNOSIS

NUMBER OF

CASES

Non-specific

reactive

lymphadenitis

05

Non-specific reactive

lymphadenitis 03

Tubercular lymphadenitis 01

Lymphoproliferative

disorder 01

Granulomatous

lymphadenitis 08

Non-specific reactive

lymphadenitis 01

Tubercular lymphadenitis 06

Non-Hodgkin’s lymphoma 01

Tubercular

lymphadenitis 03 Tubercular lymphadenitis 03

Hodgkin’s

lymphoma 02 Hodgkin’s lymphoma 02

Non-Hodgkin’s

lymphoma 01 Hodgkin’s lymphoma 01

Metastases 01 Metastases 01

TOTAL CASES 20 20

TABLE 26: Correlation between cytological and histopathological diagnosis of

lymph node.

CYTOLOGICAL

DIAGNOSIS

NUMBER

OF CASES

% OF

CASES

HISTOPATHOLOGICAL

DIAGNOSIS

BENIGN MALIGNANT

NO. OF

CASES

% OF

CASES

NO OF

CASES

% OF

CASES

Benign 16 80 14 87.5% 02 12.5%

Malignant 04 20 00 ---- 04 100%

Total 20 100% 14 70 % 06 30%

66

TABLE 27: Statistical analysis of the malignant and benign diagnosis from the data

available for correlation

STATISTICAL INDICES PERCENTAGE %

Sensitivity 100 %

Specificity 66.66%

Percentage of False Positive 25%

Percentage of False Negative 00

Positive Predictive Value 87.5

Negative Predictive Value 100 %

Accuracy 90%

67

IMAGE 4: FNAC smear of Non specific reactive lymphadenitis of lymph node

showing mixed population of reactive lymphoid cells. (H&E X 400)

IMAGE 5: FNAC smear of Non specific reactive lymphadenitis of lymph node

showing tingible body macrophage ingesting debris. (H&E X 1000)

68

IMAGE 6: Histopathological section of Non specific reactive lymphadenitis of lymph

node showing mixed population of reactive lymphoid cells. (H&E X 400)

IMAGE 7: FNAC smear of tubercular lymph node showing granuloma consists of

epitheloid cells, fibroblast, lymphocyte and necrosis. (H&E 400).

69

IMAGE 8: FNAC smear of tubercular lymph node showing caseous necrotic material.

(H&E 400).

IMAGE 9: FNAC smear of tubercular lymph node showing tubercle bacilli (Acid fast

bacilli) in the background of necrosis. (ZN 1000).

70

IMAGE 10: Histopathological section of tubercular lymph node showing multiple

granuloma consists of epitheloid cells, Langhan’s giant cell, fibroblast, lymphocyte

and necrosis. (H&E 400).

IMAGE 11: Histopathological section of tubercular lymph node showing granuloma

consists of epitheloid cells, Langhan’s giant cell, fibroblast, lymphocyte and necrosis.

(H&E 1000).

71

IMAGE 12: FNAC smear of metastatic lymph node showing tumor cells of squamoid

type in a background of lymphoid cells. (H&E 100).

IMAGE 13: FNAC smear of metastatic lymph node showing tumor necrosis.

(MGG 400).

72

IMAGE 14: Histopathological section of metastatic lymph node showing metastasis

of tumor cells (right) of squamoid type with lymphoid parenchyma (left). (H&E 100).

IMAGE 15: Histopathogical section of metastatic lymph node showing metastasis of

tumor cells (right) of squamoid type with lymphoid parenchyma ( left). (H&E 400).

73

IMAGE 16: Histopathogical section of metastatic lymph node showing keratin

(center) with tumor cells (right) and lymphoid parenchyma (left). (H&E 1000).

IMAGE 17: FNAC smear of lymph node of Hodgkin’s lymphoma showing

monomorphic tumor cells. (MGG 400).

74

IMAGE 18: FNAC smear of lymph node of Hodgkin’s lymphoma showing Classical

Reed-Sternberg cell. (MGG 1000).

IMAGE 19: Histopathological section of lymph node of Hodgkin’s lymphoma

showing diffuse effacement of architecture with replacement of normal parenchyma

by monomorphic tumor cells. (H&E 400).

75

IMAGE 20: Histopathological section of lymph node of Hodgkin’s lymphoma

showing monomorphic tumor cells with few mitosis. (H&E 400)

IMAGE 21: Histopathological section of lymph node of Hodgkin’s lymphoma

showing classical Reed Sternberg cell. (H&E 1000).

76

IMAGE 22: Immunohistochemistry showing positivity for CD15 marker in

Hodgkin’s lymphoma on histopathological section. (X1000).

IMAGE 23: Immunohistochemistry showing positivity for CD30 marker in

Hodgkin’s lymphoma on histopathological section. (X1000).

77

IMAGE 24: Immunohistochemistry showing positivity for CD19 marker in

Hodgkin’s lymphoma on histopathological section. (X1000).

IMAGE 25: Immunohistochemistry showing positivity for CD20 marker in

Hodgkin’s lymphoma on histopathological section. (X1000).

78

IMAGE26: FNAC smear of lymph node of Non-Hodgkin’s lymphoma showing

monomorphic tumor cells of high grade. (MGG 1000).

IMAGE 27: FNAC smear of lymph node of Rosai-Dorfmann disease showing

polymorphous population of lymphoid cells consisting of histiocytes, lymphocytes,

plasma cells. (MGG 100).

79

IMAGE 28 FNAC smear of lymph node of Rosia-Dorfmann disease showing

histiocyte ingested lymphocyte (emperipolesis). (PAP 1000).

IMAGE 29: FNAC smear of lymph node of Rosia-Dorfmann disease showing

histiocyte ingested lymphocyte (emperipolesis). (MGG X 1000).

80

6. DISCUSSION

The present study consists of FNAC of lymph nodes of the Head and Neck region

with histopathological correlation wherever possible. It includes total 100 cases out of

which 20 cases have histopathological correlation. Patients have been referred from

the department of Medicine, Pediatric, Surgery, ENT, Orthopaedics and Chest

Medicine and Tuberculosis of MVJ Medical College and Research Hospital.

Year wise distribution of FNACs’ of lymph nodes of the Head and Neck region

Our study duration was from May 2010 to April 2012, a 2 year prospective study of

FNAC of all enlarged lymph nodes of the Head and Neck region referred to the

laboratory of Pathology.

From May-Dec 2010, we got 23 cases. From Jan-Dec, 2011, we had 55 cases and

from Jan- April, 2012, we had 22 cases. So totally in 2 year duration, we had done

total 100 FNACs’ of lymph node of the Head and Neck region. The cases where there

is no adequate material to give a definitive diagnosis or non-lymphoid aspirates have

been excluded from the study. (Also Refer: TABLE 2)

Year wise distribution of biopsies of lymph nodes of the Head and Neck region

In our study, out of 100 cases, 20 cases had excision biopsies which were sent for

histopathological study. Our study has little more histopathological correlation than

study done by Ishar et al 52

and Ahmad et al 46

.

From May – Dec, 2010, we got 08 cases. From Jan-Dec, 2011, we had 10 cases and

from Jan- April, 2012, we had 02 cases. (Also Refer Table No: 3)

81

TABLE 28: Comparison of FNACs’ which have histopathological correlation with

various other studies

Ishar T et al 52

Ahmad et al 46

Present study

Histopathological

correlation (%) 11.2% 11.5% 20%

Age group vs Lymphadenopathy

The age group of all the cases included in our study is in the range of 2.5 yrs to 82 yrs

of age. Other studies also show the same range of distribution.

TABLE 29: Comparison of age range of all the cases with various other studies.

Rakhshan

M et al 51

Ishar T et

al 52

Manjuna

th BS 53

Bharathi

K 54

Hirachand

S et al 55

Present

Study

Age

Range 1-87yrs 1m- 85yrs 2-85yrs 15-75yrs 13-84yrs

2.5 – 82

yrs

In our study ,the most common age group for lymphadenopathy in the Head and Neck

region was 3rd

decade, which is correlating with study of Narang et al 47

, Pandit et al,

Rakhshan M et al 51

, Hirachand S et al 55

( Also Refer Table No.4).

TABLE 30: Comparison of the most common age group of lymphadenopathy of the

Head and Neck region with various other studies.

Narang et

al 47

Ahmad et

al 46

Pandit et

al 39

Rakhshan

M et al 51

Hirachand

S et al 55

Present

study

Most

common

age group

3rd

decade 2nd

decade 3rd

decade 3rd

decade 3rd

decade 3rd

decade

Age group vs Benign and Malignant Lymphadenopathy

In our study, benign lymphadenopathy of the Head and Neck region is more common

in 3rd

decade whereas malignant lymphadenopathies are more common in 6th

decade.

(Also Refer TABLE 15 & 16)

82

TABLE 31: Comparison of the most common age group of benign and malignant

lymphadenopathies with various other studies.

Ahmad et al 46

Manjunath BS 53

Present study

Benign 2nd

decade 3nd

decade 3rd

decade

Malignant 6th

decade 6th

decade 6th

decade

Sex ratio vs Lymphadenopathy

In our study, sex ratio of the lymphadenopathy of the Head and Neck region is M: F=

1: 1.2, Which is correlating with study of Pandit et al 39

, Bharathi K et al 54

(Also

Refer TABLE 5)

TABLE 32: Comparison of sex ratio of the FNACs’ of lymph nodes of Head and

Neck region with various other studies

Pandit

et al 39

Rakhshan

M et al 51

Ishar T

et al 52

Manjunath

BS et al 53

Bharathi

K et al 54

Hirachand

S et al 55

Present

study

Sex

ratio 1:1.3 1.7:1 1.5:1 1.3:1 1:1.08 1.09:1 1:1.2

Site predilection vs Lymphadenopathy

In our study, Cervical lymphadenopathy is the most common among all the lymph

nodes of the Head and Neck region, which is correlated well with the studies

conducted by Steel et al 25

, Khan et al 40

, Chau et al 42

, Bezabih et al 43

, Lee et al 44

,

Pandit et al 39

, Manjunath BS et al 53,

Bharathi K et al 54

, Hirachand S et al 55

. (Also

Refer Table No.7).

Cervical lymphadenopathy is the most common in both benign and malignant

lymphadenopathy constituting about 67% and 70% respectively. In benign lesions,

cervical lymph nodes are followed by submandibular group of lymph nodes in

frequency (5%). Among malignant lesions, cervical lymph nodes are followed by

submandibular group of lymph nodes (22%). Among primary malignancy of lymph

nodes, cervical group of lymph nodes are most commonly involved. Among

metastatic lesions of lymph nodes, again cervical lymph nodes are most commonly

involved (65%) followed by submandibular group of lymph nodes(25%) . In both

83

benign and malignant lesions, pre-auricular, post-auricular and parotid group of

lymph nodes are rarely involved. (Also Refer Table No.10,11,12,13).

Benign vs Malignant Lymphadenopathy:

In our study, benign lymphadenopathy is the most common presentation of

lymphadenopathy of the Head and Neck region amounting to 77% of all cases. Our

findings are correlating well with the study done by Ishar T 52

, Manjunath BS et al 53,

and Hirachand S et al 55

.

Malignant lymphadenopathies are seen in rest of the 23% of cases in our study which

is also correlating with the study done by Ishar T 52

, Manjunath BS et al 53,

and

Hirachand S et al 55

.

TABLE 33: Comparison of FNACs’ of Benign and Malignant lymphadenopathies of

the Head and Neck region with various other studies

Rakhshan

M et al 51

Ishar T

et al 52

Manjunath

BS et al 53

Bharathi

K et al 54

Hirachand

S et al 55

Present

study

Benign

lesions 59.6%. 79.2% 68.2% 58% 81.7% 77%

Malignant

lesions 40.4% 20.8% 31.8% 42% 18.3% 23%

Discussion on incidence of various benign lesions with other studies:

In our study, benign lesions are more common than malignant one. Among benign

lesions, Non-specific reactive lymphadenitis is the most common findings of enlarged

lymph nodes of the Head and Neck region amounting to 48%, followed by

granulomatous lymphadenitis amounting to 32% and tubercular lymphadenitis

includes 20%. Our findings are correlated well with the study of Ishar et al 52

,

Hirachand et al 55

, Ahmad et al 46

, and Lee et al 44

. (Also Refer TABLE 21)

84

TABLE 34: Comparison of various benign lesions of lymphadenopathies of the Head

and Neck region with other studies.

Cytological

Diagnosis

Ishar

T et al

52

Manjunath

BS et al 53

Bharathi

K et al

54

Hirachand

S et al 55

Ahmad

et al 46

Lee et

al 44

Present

study

Non-specific

Reactive

Lymphadenitis

52.4% 33.3% 28% 44.5% 53.6% 51.5% 48%

Granulomatous

Lymphadenitis -- 11.7% -- 9.2% -- -- 32%

Tubercular

Lymphadenitis 26.7% 35.7% 30% 28% 32.8% 25.7% 20%

Discussion on incidence of various malignant lesions with other studies:

In our study, malignant lesions forms 23% of all the cases undergone FNACs’ of the

Head and Neck region. Among 23 cases, 4 were primary malignancies. Three cases

were diagnosed as Hodgkin’s lymphoma and one case as Non-Hodgkin’s lymphoma

on cytology. Rests of the 19 cases were metastases to the lymph nodes. (Also Refer

TABLE 21)

All the 3 patients of Hodgkin’s lymphoma presented with enlarged cervical nodes

initially later to generalise. All cases show Reed-Sternberg cells on cytology. These

RS cells are of classical type. Background shows mixed inflammatory cells. Among 3

cases, two cases have histopathological correlation and both of them have turned out

to be Hodgkin’s lymphoma only. Immunohistochemistry shows positive for

cytoplasmic and cell surface staining for CD30 and CD 20 and paranuclear deposit

with cell surface and cytoplasmic staining for CD15 38

.

One case of Non-Hodgkin’s lymphoma shows large lymphoid cells with abundant

cytoplasm, multinucleation and partly lobulated nuclei and prominent nucleoli.

Background shows histiocytoid cells with phagocytic cells. On cytology, it was

diagnosed as anaplastic large cell lymphoma. But on histopathology, it was finally

diagnosed as Hodgkin’s lymphoma. Immunohistochemistry shows positive for

85

cytoplasmic and cell surface staining for CD30 and CD 20 and paranuclear deposit

with cell surface and cytoplasmic staining for CD15 38

. According to Landgren O et al

33, Carter et al

32 study, about 13-15% of cases shows discordance between Hodgkin’s

and Non-Hodgkin’s lymphoma on cytology.

Out of total 100 cases, 19 cases were found to have metastatic tumor cells. 17 cases

were diagnosed as metastatic squamous cell carcinoma and 2 cases were diagnosed as

poorly differentiated carcinoma. Among two cases, one case has histopathologic

correlation which also shows poorly differentiated carcinoma. So, the most common

metastasising tumor to the lymph nodes of the Head and Neck region is squamous cell

carcinoma. The most common group of lymph nodes is the cervical region. The most

common age group is 6th

decade. All these findings are correlated well with study

conducted by Bagwan et al 17

, Rakhshan M et al 51

, Manjunath BS et al 53

, and

Bharathi K et al 54.

TABLE 35: Comparison of malignant lesions of lymph node of the Head and Neck

region with various other studies

Ishar T

et al 52

Manjunath

BS et al 53

Bharathi

K et al 54

Hirachand

S et al 55

Lee et

al 44

Ahmad

et al 46

Present

study

Hodgkin’s

Lymphoma 7.3% 2.3% 1% 6% 3.5% 4.5%

3%

Non-Hodgkin’s

lymphoma 1%

Metastases 12.8% 16.8% 41% 12.3% 19.3% 9.5% 19%

Discussion on the histopathological correlation and comparison with various

other studies:

Out of 100 cases, 20 cases have histopathological correlation. Cytological diagnosis

of these 20 cases are as below: 5 cases were diagnosed as Non-specific reactive

lymphadenitis, 8 cases as granulomatous lymphadenitis, 3 cases as tubercular

lymphadenitis, 2 cases as Hodgkin’s lymphoma, 1 cases as Non-Hodgkin’s lymphoma

and last one case as metastasis.

86

On histopathology, out of 5 cases of Non-specific reactive lymphadenitis, 3 cases

showed consistent diagnosis, 1 case was tubercular lymphadenitis and another was

turn out to be lymphoproliferative disorder.

On histopathology, out of 8 cases of granulomatous lymphadenitis, all cases have

consistent findings and diagnosed as tubercular lymphadenitis. These cases were not

diagnosed as tubercular on cytology because of negativity of Acid Fast Bacilli.

According to the study conducted by Hsu C et al 45

, Shamshad AS 46

, Narang RK 47

,

Adhikari P et al 56

, cases of tuberculosis which are in early stage or when load of

bacteria is less or partially treated patients, it is not possible to find the AFB on

cytology. Hence, such cases will be diagnosed as granulomatous, most probably

tubercular etiology and adviced to correlate with the clinical signs and symptoms.

On histopathology, all 3 cases of tubercular lymphadenitis have consistent findings

and diagnosed as tubercular lymphadenopathy. The lymph node biopsy has been done

in these patients because the patient is not responding to anti-tubercular treatment,

some have non-healing sinuses which surgeons have excised as a part of treatment.

On histopathology, 2 cases of Hodgkin’s lymphoma have same diagnosis as cytology.

One case was subclassified as mixed cellularity and another one was lymphocytic

depletion type. Immunohistochemistry has been done and shows positive for

cytoplasmic and cell surface staining for CD30 and CD 20 and paranuclear deposit

with cell surface and cytoplasmic staining for CD15 38

. So, sensitivity and accuracy is

100% correlated well with the sudies conducted by Carter et al 32

, Ishar T et al 52

Non-Hodgkin’s lymphoma is diagnosed as Hodgkin’s lymphoma on histopathology.

It is of Nodular sclerosis type. Classical Reed-Sternberg cells are present in the

background of mixed inflammatory cells. Immunohistochemistry has been done and

shows positive for cytoplasmic and cell surface staining for CD30 and CD20 and

paranuclear deposit with cell surface and cytoplasmic staining for CD15 38

. Due to

absence of Reed-Sternberg cells on cytology it is misdiagnosed as Non-Hodgkin’s

lymphoma. Such misinterpretations have also been observed in the study done by

Landgren O et al 33

, Carter et al 32.

87

Finally out of 16 cases reported as benign on cytology, 14 cases have consistent

findings with histopathology. In rest of the two cases, one case of lymphoproliferative

disease is misdiagnosed as non-specific reactive lymphadenitis and another case of

Non- Hodgkin’s lymphoma is misdiagnosed as granulomatous lymphadenitis. So,

sensitivity and specificity of FNACs’ of benign lesions as 87.5% and 66.6%

respectively.

All the 4 cases reported as malignant on cytology has come out to be malignant on

histopathology. So, Sensitivity of FNACs’ of malignant lesions is 100%.

So, overall sensitivity, specificity and accuracy of FNACs’ of enlarged lymph nodes

of the Head and Neck region in our study is 100%, 66.6% and 90%. It is correlating

well with the study done by Ahmad et al 46

, Bharathi K 54

.

TABLE 36: Comparison of Sensitivity, Specificity and Accuracy of FNACs’ of

lymph node of the Head and Neck region with various other studies.

Rakhshan M

et al 51

Bharathi K

et al 54

Hirachand S

et al 55

Ahmad et

al 46

Present

study

Sensitivity 75.8 96.4 100 91.6 100

Specificity 96.6 66.6 95.6 99 66.6

Accuracy 88 90 -- 97.3 90

Interesting case in our study

A 21yr old young patient presented with generalised lymphadenopathy. In Head and

Neck region, it involved bilateral cervical group of lymph nodes measuring 3x3cm,

firm in consistency. On aspiration, it shows polymorphous population consists of

mature lymphocytes, plasma cells, neutrophils with histiocytes. Some of the

histiocytes were showing engulfed lymphocytes in the cytoplasm (emperipolesis). So,

final impression was given as sinus histiocytosis with massive lymphadenoopathy

(Rosai -Dorfmann disease). Further biopsy has not been done to confirm the

diagnosis.

88

7. SUMMARY AND CONCLUSION

Lymphadenopathy is the most common presentation in the head and neck region and

may occur due to inflammatory conditions, as well as primary and secondary

neoplasms. An early and accurate diagnosis helps the clinicians in starting the specific

therapy on time, thus reducing morbidity and mortality.

The present study was undertaken to know the spectrum of lesions found in the

enlarged lymph nodes of the Head and Neck region in 100 patients. Cervical group of

lymph nodes is the most common presentation in both benign and malignant

condition. Non-specific reactive lymphadenitis is the most common benign pathology

associated with enlarged lymph nodes whereas metastasis is the most common

malignant condition. Most common age group of enlarged lymph nodes in benign

category was 3rd

decade and in malignant category was 6th

decade.

The sensitivity and specificity of FNAC is fare enough with lot of various other

advantages like rapid diagnosis, reliable, less traumatic, minimal complication,

repeatability, economical and convenient.

Fine needle aspiration cytology in our experience provides a reliable method of

investigating lymph node enlargement, the efficacy of which approaches that of other

similar diagnostic procedures and in the present study, over all accuracy and

sensitivity was 90% and100% respectively.

However, it must be realized that FNA not only offers tissue diagnosis but serves as a

preliminary screening procedure for a number of clinical considerations e.g.

lymphoma, leukemia, metastasis, tuberculosis and lymphadenopathy, not otherwise

specified. Decision regarding biopsy from appropriate sites, if necessary, can be done

to confirm the diagnosis.

Although FNAC has proven to be a simple and cost effective diagnostic tool for

lymphadenopathies, the limitations of the procedure in the diagnosis of low grade

malignant lymphoma needs to be understood.

89

The highest diagnostic accuracy with FNAC was observed in metastatic carcinoma ,

followed by tuberculous lymphadenitis, Non specific reactive hyperplasia and

lymphoma, where as in some cases, the differentiation between Hodgkin’s lymphoma

and Non- Hodgkin’s lymphoma in case of absence of Reed – Sternberg cells proved

difficult to diagnose on cytology.

Our results clearly demonstrate the use of FNAC on enlarged lymph node lesions and

offers many advantages to clinician and pathologist, as it is an easy and reliable

method and two years study of our own and others’ long term studies, demonstrate its

safety.

In conclusion, FNAC is a very useful and accurate approach in diagnosing various

benign and malignant lymphadenopathies, as it has the diagnostic value of the first

step, in the workup of patients with nodal enlargement.

90

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97

PROFORMA

Date: Thesis Case No:

Name of the patient: Age/Sex:

IP / OP No: Dept:

Cytology No: Histopath No:

Significant Clinical history:

Description of lymphadenopathy

Duration: Size:

Site: Unilateral/ Bilateral

Number of lymph nodes: Matted: Yes / No

Consistency: soft / firm / rubbery / hard /stony hard

Sinus/ fistula: Yes / No Other swellings:

On Aspiration

Color of aspirate: Grey / bloody / Pus like/ Cheesy

Cytological features:

1. Non specific reactive lymphadenitis:

- Polymorphous population of cells

- Predominant cell type:

- Other cells:

Centrocyte / Centroblast/ Immunoblast / tingle body macrophage / Neutrophil

/ Plasma cells / Eosinophil / small lymphocyte

- Necrosis : yes / No

98

2. Granulomatous lymphadenitis:

- Cells of granuloma: Epitheloid cells / Giant cells / fibroblast / lymphocyte

- Well formed granuloma / Ill formed granuloma

- Necrosis : Yes / No

3. Tubercular lymphadenitis:

- Cells of granuloma: Epitheloid cells / Langhan’s giant cells / fibroblast /

lymphocyte

- Well formed granuloma / Ill formed granuloma

- Necrosis : Yes / No

- AFB: Present / Absent, if present, ____ / OIF

4. Rosai – Dorfmann disease:

- Predominant cells: lymphocyte / centrocyte / centroblast / histiocytes

- Emperipolesis: present / absent

5. Hodgkin’s Lymphoma:

- Monomorphous population: Yes / No

- Predominant cell:

- Other cells: lymphocyte / Histiocyte / eosinophils /plasma cells

- RS cells: Present / absent. Type:

6. Non-Hodgkin’s lymphoma:

- Monomorphous population : Yes / No

- Predominant cell:

- Other cells: lymphocyte / Histiocyte / eosinophils / plasma cells

7. Metastases:

- Pattern of arrangement: Squamoid / Glandular

- Type of cells: squamous /columnar / melanotic

- Morphology of tumor cells : Cytoplasm:

N: C ratio: Nucleomegaly:

Chromatin: Nucleoli:

99

- Tumor necrosis: Yes / No Keratin: Present / Absent

- Mucin: Present / Absent Special stains:

Cytological Diagnosis:

Histopathology report:

Special stains:

100

KEY TO MASTER CHART

Sl. No Serial number

OP No Out patient number

IP No In patient number

M Male

F Female

Sur Surgery

Med Medicine

Ortho Orthopaedics

OBG Obstretics and Gyaenecology

CDTB Chest Medicine and Tuberculosis

Paed Paediatrics

Opth Opthalmology

Cerv Cervical

SMB Submandibular

SM Submental

SO Suboccipital

Pre-aur Pre-auricular

SC Supra clavicular

NSRL Non-specific reactive lymphadenitis

GL Granulomatous lymphadenitis

TL Tubercular lymphadenitis

Mets Metastasis

RDD Rosai-Dorfmann disease

HL Hodgkin’s Lymphoma

NHL Non-Hodgkin’s Lymphoma

LPD Lymphoproliferative disorder

Pos Positive

Neg Negative

AFB Acid fast bacilli

FNAC Fine needle aspiration cytology

Dept Department

101

LN Lymph node

Pop. Population

RS cell Reed Sternberg cell

NA Not Applicable

BL Bilateral

Wk Week

Mon Month

D Days

Cy Centrocyte

Cb Centroblast

Lm Lymphocyte

EPI,GC,LM Epitheloid cells, giant cell, lymphocyte

S Squamous

P Poorly differentiated

K Keratin

HP Histopathology

101

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1 05/18/10 gangareddy 28 m 553529 sur 613-10 SM 3mon 3x3 2 firm yes grey p NA yes EPI,GC,LM yes neg NA NA NA NA NA NA GL

2 05/19/10 narayanappa 65 m 551487 117134 sur 619-10 right cerv 10mon 2x2 3 hard no bloody p NA NA NA yes neg NA yes S well yes k mets

3 05/31/10 sandeep 16 m 556908 sur 678-10 left cerv 4mon 4x4 3 soft yes grey p NA yes EPI,GC,LM no neg NA NA NA NA NA NA GL

4 06/01/10 raghvendra 16 m 118527 paed 687-10 left cerv 2wk 1x1 1 firm - grey p cy neg NA no neg NA NA NA NA NA NA NSRL

5 06/21/10 muniyappa 60 m 562623 120773 ent 788-10 left cerv 12mon 3x3 4 hard no bloody p NA NA NA yes neg NA yes S well yes k mets

6 06/22/10 krishnamurthy 42 m 563831 ent 795-10 left cerv 1wk 1x2 2 firm - grey p lm neg NA no neg NA NA NA NA NA NA NSRL

7 07/13/10 geetha 20 f 569867 122994 med 907-10 left cerv 2wk 2x1 1 firm - bloody p cy neg NA no neg NA NA NA NA NA NA NSRL

8 08/17/10 nagesh 38 f 580751 ent 1093-10 left cerv 2mon 4x3 2 firm no grey p NA yes EPI,GC,LM no neg NA NA NA NA NA NA GL

9 09/17/10 prakash 38 m 588961 129087 med 1245-10 left cerv 3wk 2x1 2 firm - grey p cy neg NA no neg NA NA NA NA NA NA NSRL

10 09/20/10 chandrshekar 8 m 590146 ent 1256-10 right cerv 3mon 5x4 3 firm yes bloody p NA yes EPI,GC,LM yes neg NA NA NA NA NA NA GL

11 09/29/10 neelamma 15 f 592734 tbcd 1306-10 right cerv 4wk 2x2 3 firm - grey p cb neg NA no neg NA NA NA NA NA NA NSRL

12 10/09/10 venu 35 m 593659 130670 med 1349-10 right cerv 1wk 2x3 2 soft - bloody p cy neg NA no neg NA NA NA NA NA NA NSRL

13 10/09/10 gowthami 21 f 586224 130675 ent 1348-10 right cerv 6mon 2x2 3 firm yes grey p NA yes EPI,GC,LM yes pos NA NA NA NA NA NA TL

14 10/14/10 radha 23 f 592672 ent 1373-10 left cerv 3wk 3x3 1 firm - grey p cy neg NA no neg NA NA NA NA NA NA NSRL

15 10/18/10 shanthamma 38 f 131204 tbcd 1386-10 left smd 3mon 4x4 4 firm no grey p NA yes EPI,GC,LM yes neg NA NA NA NA NA NA GL

16 10/19/10 srinivas 21 m 597624 131650 med 1390-10 BL cerv 9mon 3x3 5 firm no grey p lm NA NA no neg NA NA NA NA NA NA RDD

17 10/23/10 leelavathy 45 f 595289 med 1407-10 left cerv 2wk 1x3 3 soft - grey p lm neg NA no neg NA NA NA NA NA NA NSRL

18 10/24/10 krishnappa 46 m 132100 sur 1413-10 right cerv 9mon 2x3 5 hard no bloody p NA NA NA yes neg NA yes S well yes k mets

19 10/24/10 roshilla 81 f 598913 132061 sur 1411-10 left cerv 2wk 1x2 4 firm - grey p lm neg NA no neg NA NA NA NA NA NA NSRL

20 10/29/10 krishnappa 65 m 598533 132098 ent 1437-10 right cerv 8mon 4x4 3 hard no bloody p NA NA NA yes neg NA yes S well yes k mets

21 12/09/10 sujatha 31 f 610262 opth 1599-10 left cerv 1wk 2x3 1 soft - grey p cy neg NA no neg NA NA NA NA NA NA NSRL

22 12/24/10 nagamma 35 f 613513 136782 ortho 1669-10 right SC 5mon 3x3 4 soft yes grey p NA yes EPI,GC,LM yes pos NA NA NA NA NA NA TL

23 12/27/10 nagamma 23 f 615497 ent 1680-10 right cerv 6mon 4x3 2 soft yes bloody p NA yes EPI,GC,LM no neg NA NA NA NA NA NA GL

24 01/10/11 dinesh shetty 47 m 691581 130311 med 1260-11 BL cerv 10mon 4x3 4 hard no bloody p NA NA NA yes neg NA yes S well yes k mets

25 01/12/11 ramappa 65 m 707926 166526 ent 1530-11 right cerv 9mon 3x4 5 hard no bloody p NA NA NA yes neg NA yes S well yes k mets

26 02/04/11 manjunath 22 m 626140 141325 ent 156-11 right cerv 4mon 4x4 3 soft no grey p NA yes EPI,GC,LM yes neg NA NA NA NA NA NA GL 521-11 TL pos

27 02/07/11 thyamma 60 f 626688 140487 ent 163-11 right smd 8mon 4x2 4 hard no bloody p NA NA NA yes neg NA yes S well yes k mets

28 02/11/11 nanjamma 25 f 624885 ent 187-11 left cerv 6mon 3x3 4 firm no bloody p NA yes EPI,GC,LM no neg NA NA NA NA NA NA GL

29 02/11/11 rajeshwari 20 f 570202 140729 tbcd 186-11 right cerv 9mon 3x3 5 firm yes grey p NA yes EPI,GC,LM yes pos NA NA NA NA NA NA TL 486-11 TL pos

30 02/11/11 sanjay 12 m 699846 163780 ent 1389-11 BL cerv 6mon 4x4 6 rub no grey m blast NA NA NO neg yes NA NA NA NA NA HL 2925-11 HL

102

31 02/12/11 deepika 23 f 628203 ent 194-11 right cerv 8mon 4x4 3 firm yes grey p NA yes EPI,GC,LM yes pos NA NA NA NA NA NA TL

32 02/17/11 nethravathi 24 f 628269 141200 med 210-11 BL cerv 10mon 5x5 6 rub neg grey m blast NA NA no neg absent NA NA NA NA NA NHL 547-11 HL

33 02/18/11 gowramma 55 f 629365 ent 217-11 left cerv 6mon 2x2 4 firm yes grey p NA yes EPI,GC,LM yes pos NA NA NA NA NA NA TL

34 02/24/11 nalini 18 f 630622 141851 med 246-11 right cerv 6mon 3x3 2 firm yes grey p NA yes EPI,GC,LM no pos NA NA NA NA NA NA TL

35 02/28/11 gowramma 65 f 631494 142130 tbcd 264-11 left smd 10mon 4x1 5 hard no bloody p NA NA NA yes neg NA yes S well yes k mets

36 02/28/11 pramod kumar 27 m 629967 ent 263-11 left cerv 9mon 4x4 3 soft yes grey p NA yes EPI,GC,LM no pos NA NA NA NA NA NA TL

37 03/09/11 tanushree 8 f 683112 ------ ent 1125-11 left cerv 5mon 5x5 3 soft no cheesy p NA yes EPI,GC,LM yes neg NA NA NA NA NA NA GL

38 04/01/11 sujatha 28 f 640368 ent 416-11 left cerv 4mon 4x4 3 soft no cheesy p NA yes EPI,GC,LM yes neg NA NA NA NA NA NA GL

39 04/08/11 shanthamma 50 f 641866 sur 444-11 left cerv 3mon 3x4 4 firm yes cheesy p NA yes EPI,GC,LM yes neg NA NA NA NA NA NA GL

40 04/21/11 rajamma 55 f 146105 ent 502-11 left cerv 5mon 3x4 4 soft no bloody p NA yes EPI,GC,LM no neg NA NA NA NA NA NA GL

41 04/22/11 narayanamma 55 f 645497 146330 med 505-11 left cerv 4mon 4x4 2 firm no cheesy p NA yes EPI,GC,LM no neg NA NA NA NA NA NA GL 1155-11 TL pos

42 04/23/11 anand 40 m 620123 sur 508-11 right sc 7mon 4x4 5 soft no grey p NA yes EPI,GC,LM no neg NA NA NA NA NA NA GL 1432-11 TL pos

43 05/03/11 venkatesh 27 m 647812 ent 549-11 left smd 9mon 2x1 3 hard no bloody p NA NA NA yes neg NA yes S well yes k mets

44 13/08/11 narasimha 80 m 677440 -- ent 1037-11 left cerv 7mon 3x3 5 hard no bloody p NA NA NA yes neg NA yes S well yes k mets

45 13/08/11 farhan taj 18 f 677361 --- ent 1036-11 left cerv 9mon 4x4 3 firm no cheesy p NA yes EPI,GC,LM yes neg NA NA NA NA NA NA GL

46 14/11/11 shabina taj 25 f 702310 --- ent 1442-11 BL cerv 5d 2x4 2 firm - bloody p lm neg NA no neg NA NA NA NA NA NA NSRL

47 16/03/11 satish 30 m 635613 143445 sur 340-11 left cerv 10mon 5x5 4 firm yes bloody p NA yes EPI,GC,LM yes neg NA NA NA NA NA NA GL

48 19/09/11 dushantprasad 5 m 686651 159564 ent 1204-11 left cerv 4d 2x3 5 firm - bloody p cy neg NA no neg NA NA NA NA NA NA NSRL

49 22/07/11 shree harsha 3 m 671838 --- paed 927-11 left cerv 2wk 3x1 2 firm - bloody p lm neg NA no neg NA NA NA NA NA NA NSRL

50 22/08/11 kavitha 23 f 680439 -- sur 1074-11 right cerv 3wk 3x2 3 firm - bloody p lm neg NA no neg NA NA NA NA NA NA NSRL

51 23/07/11 satish 27 m 672117 154659 sur 932-11 SM 1wk 3x4 1 firm - grey p lm neg NA no neg NA NA NA NA NA NA NSRL

52 25/03/11 chnadra roa 48 m 142431 sur 381-11 right cerv 5mon 5x5 3 firm yes cheesy p NA yes EPI,GC,LM yes neg NA NA NA NA NA NA GL

53 26/07/11 sakamma 70 f 668657 154654 sur 943-11 left cerv 6mon 3x4 4 hard no bloody p NA NA NA yes neg NA yes S well yes k mets

54 28/11/11 lalithamma 35 f 707255 --- med 1510-11 right cerv 7mon 4x4 4 firm yes grey p NA yes EPI,GC,LM yes neg NA NA NA NA NA NA GL

55 30/09/11 narasimahi 65 m 687467 160702 med 1255-11 right SC 9mon 4x4 5 hard no bloody p NA NA NA yes neg NA yes S well yes k mets

56 30/11/11 jigappa 80 m 707866 --- sur 1522-11 right cerv 7mon 5x5 3 hard no bloody p NA NA NA yes neg NA yes S well yes k mets

57 05/07/11 narayanappa 82 m 665903 152863 sur 850-11 right cerv 10mon 5x6 2 hard no bloody p NA NA NA yes neg NA yes S well yes k mets

58 05/12/11 ramakka 25 m 709152 --- ent 1544-11 left cerv 5mon 3x3 3 soft no bloody p NA yes EPI,GC,LM yes neg NA NA NA NA NA NA GL

59 05/12/11 mubin taj 29 f 643892 ent 585-11 right cerv 9mon 6x6 8 rub no grey m blast NA NA NO neg yes NA NA NA NA NA HL 1334-11 HL

60 05/13/11 bharath 11 m 552642 117510 sur 596-11 left cerv 2d 4x4 3 soft - bloody p lm neg NA no neg NA NA NA NA NA NA NSRL 1453-11 NSRL neg

61 06/06/11 muniyappa 70 m 656123 149672 sur 703-11 left cerv 4mon 4x4 3 soft no grey p NA yes EPI,GC,LM yes neg NA NA NA NA NA NA GL

62 06/17/11 ramesh 45 m 501590 120309 med 769-11 BL cerv 10mon 4x3 5 soft yes bloody p NA yes EPI,GC,LM no pos NA NA NA NA NA NA TL 1759-11 TL pos

63 06/18/11 akbar 50 m 562862 med 775-11 BL cerv 7mon 3x2 3 soft no cheesy p NA yes EPI,GC,LM yes neg NA NA NA NA NA NA GL 2240-11 NHL

64 07/01/11 sahifulla 14 f 566298 ent 846-11 right cerv 8mon 4x2 3 soft no bloody p NA yes EPI,GC,LM yes neg NA NA NA NA NA NA GL 1904-11 TL pos

65 07/06/11 thimakka 50 m 658141 ---- ent 710-11 SM 12mon 5x4 4 hard no bloody p NA NA NA yes neg NA yes S well yes k mets

66 07/10/11 Laxmidevi 25 f ----- ---- ent 1278-11 right cerv 3d 2x4 2 soft - grey p lm neg NA no neg NA NA NA NA NA NA NSRL

67 07/10/11 kesha 14 m 692231 161280 med 1279-11 left cerv 3wk 3x2 1 soft - bloody p lm neg NA no neg NA NA NA NA NA NA NSRL 2798-11 NSRL neg

68 07/14/11 rajeshwari 20 f 123126 med 913-11 left smd 9mon 3x3 4 soft yes bloody p NA yes EPI,GC,LM no pos NA NA NA NA NA NA TL 2165-11 TL pos

69 08/08/11 gowramma 72 f 675739 1559671 sur 1009-11 left cerv 10mon 3x3 12 rub no bloody m blast NA NA NO neg yes NA NA NA NA NA HL

70 08/08/11 kempamma 70 f 675744 155990 sur 1007-11 right smd 9mon 6x5 4 hard no bloody p NA NA NA yes neg NA yes S well yes k mets

103

71 08/11/11 sonnappa 46 m 700718 164124 tbcd 1412-11 right cerv 8mon 4x3 4 hard no bloody p NA NA NA yes neg NA yes S well yes k mets

72 08/21/11 asma 27 f 581672 sur 1121-11 left cerv 2wk 2x1 4 firm - grey p lm neg NA no neg NA NA NA NA NA NA NSRL 2442-11 NSRL neg

73 09/09/11 ravichandra 41 m 683751 158574 sur 1155-11 left cerv 3wk 2x2 2 soft - bloody p lm neg NA no neg NA NA NA NA NA NA NSRL

74 09/11/11 pragathi 7 f 700469 ---- paed 1419-11 left cerv 2wk 2x3 1 firm - grey p cy neg NA no neg NA NA NA NA NA NA NSRL

75 10/08/11 manjunath 23 m 676643 --- sur 1018-11 left cerv 2wk 2x4 3 soft - bloody p lm neg NA no neg NA NA NA NA NA NA NSRL

76 11/18/11 thahera 24 f 605486 133925 sur 1502-11 right cerv 3wk 4x4 1 firm - grey p lm neg NA no neg NA NA NA NA NA NA NSRL 3190-11 LPD

77 12/02/11 jyothi 23 f 608765 sur 1570-11 right cerv 5mon 4x3 3 firm no grey p NA yes EPI,GC,LM yes neg NA NA NA NA NA NA GL 3348-11 NSRL neg

78 12/28/11 prabhakar 30 m 611385 137045 sur 1690-11 left cerv 8mon 2x2 3 soft yes cheesy p NA yes EPI,GC,LM no pos NA NA NA NA NA NA TL

79 01/17/12 chethan 14 m 619747 138705 ent 71-12 left smd 3d 1x1 4 soft - bloody p lm neg NA no neg NA NA NA NA NA NA NSRL

80 02/03/12 muniyappa 75 m 726006 172771 med 157-12 left cerv 4mon 3x3 4 soft yes cheesy p NA yes EPI,GC,LM yes neg NA NA NA NA NA NA GL 505-12 TL pos

81 02/04/12 savithramma 66 f 726883 sur 162-12 left cerv 4d 1x2 1 soft - grey p lm neg NA no neg NA NA NA NA NA NA NSRL

82 02/12/12 munithayamma 60 f 627849 140840 sur 192-12 right cerv 2wk 1x3 2 firm - grey p cy neg NA no neg NA NA NA NA NA NA NSRL

83 03/02/12 Muniyamma 45 f 726594 173005 sur 254-12 left cerv 6mon 4x4 3 hard no bloody p NA NA NA yes neg NA yes P poor yes k mets 222-12 mets

84 03/08/12 pavithra 13 f 142836 paed 299-12 left cerv 6mon 3x2 6 soft yes cheesy p NA yes EPI,GC,LM yes pos NA NA NA NA NA NA TL

85 04/01/12 lakshmaiaha 52 m 593575 144577 med 417-12 left cerv 9mon 4x3 5 firm yes cheesy p NA yes EPI,GC,LM yes pos NA NA NA NA NA NA TL

86 04/07/12 nagaveni 17 f 665937 --- med 845-12 left cerv 4wk 2x2 3 firm - grey p lm neg NA no neg NA NA NA NA NA NA NSRL

87 04/08/12 krishnamma 40 f 641618 145336 med 446-12 right cerv 8mon 4x3 3 firm yes cheesy p NA yes EPI,GC,LM yes pos NA NA NA NA NA NA TL

88 04/15/12 shylaja 35 f 644378 ent 468-12 left cerv 4mon 4x4 4 firm yes cheesy p NA yes EPI,GC,LM yes pos NA NA NA NA NA NA TL

89 04/21/12 sharadhamma 46 F 514957 med 500-12 SO 2wk 2x2 4 firm - grey p lm neg NA no neg NA NA NA NA NA NA NSRL

90 05/16/12 venkatadri 18 f 651445 med 602-12 left cerv 3wk 3x3 2 firm - grey p lm neg NA no neg NA NA NA NA NA NA NSRL

91 06/03/12 deepthi 8 f 657212 sur 693-12 left cerv 2wk 3x4 3 soft - grey p lm neg NA no neg NA NA NA NA NA NA NSRL

92 06/03/12 shamiulla 50 m 649336 150008 ent 695-12 right cerv 2wk 4x4 4 soft - grey p lm neg NA no neg N A NA NA NA NA NA NSRL

93 18/03/12 muniguruppa 50 m 602059 143659 tbcd 352-12 left cerv 3wk 2x3 2 soft - bloody p lm neg NA no neg NA NA NA NA NA NA NSRL

94 23/01/12 nithyashree 10 f 460132 ------ tbcd 105-12 left cerv 3d 2x3 1 soft - grey p lm neg NA no neg NA NA NA NA NA NA NSRL

95 25/01/12 ramlakshmamma 55 f 723865 171902 sur 115-12 right smd 10mon 5x5 2 hard no bloody p NA NA NA yes neg NA yes P poor yes k mets

96 28/03/12 aswath khan 2.5 m 638990 144401 paed 394-12 right cerv 2wk 3x3 2 firm - grey p lm neg NA no neg NA NA NA NA NA NA NSRL

97 06/06/12 ramaswamy 60 m 657489 150199 sur 705-12 left pre-aur 4wk 1x3 3 soft - bloody p lm neg NA no neg NA NA NA NA NA NA NSRL 1200-12 TL pos

98 29/03/12 gayathramma 21 f 639308 144514 med 400-12 left cerv 1wk 1x2 2 firm - bloody p lm neg NA no neg NA NA NA NA NA NA NSRL 802-12 TL pos

99 29/06/12 jayalakshmi 45 f 662369 151556 med 821-12 left smd 1wk 1x2 1 soft - bloody p lm neg NA no neg NA NA NA NA NA NA NSRL

100 30/03/12 humara banu 20 f 639786 med 404-12 left cerv 8mon 5x5 3 firm yes cheesy p NA yes EPI,GC,LM yes pos NA NA NA NA NA NA TL