Posted September 1, 2009
Masha Catherine Nzabi, MD
Lymph node enlargement is a very common condition that may be part of a localized or generalized disease process. Physicians commonly use fine-needle aspiration (FNA) for lymph node evaluation, as it provides a fast and relatively cost-effective way of determining the diagnosis and the subsequent patient management. Ancillary testing for cellular markers (immunophenotyping) by flow cytometry can be done by saving material in a cell culture type liquid media (RPMI). The material saved can be obtained by either rinsing out the remainder of the aspirate from the needle or performing a separate pass specifically for this purpose. Cell blocks can also be used to perform ancillary studies (cytochemistry).
Enlarged lymph nodes can have either benign or malignant neoplastic diseases.
Malignant hematological neoplasms can be broadly grouped as Hodgkin and non-Hodgkin
lymphomas. In non-Hodgkin lymphoma, a triad of morphology, immunology, and genetics
is used for diagnosis. The cytological features can be morphologically grouped
into those with small cells such as small lymphocytic lymphoma and those with
large cells such as large cell lymphoma. In the small cell type, the aspirate
largely consists of a homogenous population of lymphocytes without tingible-body
macrophages, and rare transformed larger cells1 (Figures 1a, 1b,
and 2). In large cell lymphomas, the cells may be up to five times the size
of a mature lymphocyte, with nuclear pleomorphism and moderate amounts of cytoplasm
(Figure 3). Immunophenotyping by flow cytometry may identify unique antigens
that help definitely identify the lymphoma.2,3 The presence of CD10
can identify those lymphomas that may have follicular architecture; unique combinations
of cell markers can confirm the presence of small lymphocytic and mantle cell
lymphoma. Genetic analysis can confirm typical translocations seen in many non-Hodgkin
Hodgkin lymphoma requires the presence of classic Reed-Sternberg cells 5,6,7 or variants amidst a heterogeneous lymphocytic cellular aspirate (Figures 4a and 4b). Flow cytometry has no role in assisting in the diagnosis of Hodgkin lymphoma,3 but special stains on a cell block are helpful in confirming Hodgkin lymphoma.8 In general, subclassification of Hodgkin lymphoma is not possible using fine-needle aspiration.2
General points in the use of FNA cytology of hematological neoplasms:
- FNA is widely used for diagnosis; it is a direct and rapid method of evaluating patients with enlarged lymph nodes.
- Ancillary studies are critical in the evaluation of lymphoma and can easily be performed on material obtained from FNA. Flow cytometry has the advantage of detecting many cell markers on a small sample of cells.3,9
- In Hodgkin lymphoma, the presence of the characteristic Reed-Sternberg cell is essential to the diagnosis.5
- FNA is useful in the follow-up of newly enlarged lymph nodes in patients with a known lymphoma.
- Knowledge of the clinical presentation of the patient is crucial to the interpretation of FNA.
- In summary, FNA is an important tool in the evaluation of enlarged lymph nodes. Ancillary studies and clinical correlation are essential in attaining the diagnosis.
- Chhieng DC, Cohen JM, Cangiarella JF. Cytology and immunophenotyping of low- and intermediate-grade B-cell non-Hodgkin’s lymphomas with a predominant small-cell component: a study of 56 cases. Diagn Cytopathol. 2001;24(2):90-97.
- Meda BA, Buss DH, Woodruff RD et al. Diagnosis and subclassification of primary and recurrent lymphomas. The usefulness and limitations of combined fine-needle aspiration cytomorphology and flow cytometry. Am J Clin Pathol. 2000;113(5):688-699.
- Zeppa P, Marino G, Troncone G et al. Fine-needle cytology and flow cytometry immunophenotyping and subclassification of non-Hodgkin lymphoma: a critical review of 307 cases with technical suggestions. Cancer. 2004;102(1):55-65.
- Swerdlow SH, Campo E, Harris NL et al, eds. World Health Organization Classification of Tumours. Pathology and Genetics of Tumours of Haematopoietic and Lymphoid Tissues. 4th Edition. Lyon, France: IARC Press; 2008.
- Chhieng DC, Cangiarella JF, Symmans WF et al. Fine-needle aspiration cytology of Hodgkin disease: a study of 89 cases with emphasis on the false-negative cases. Cancer. 2001;93(1):52-59.
- Kardos TF, Vinson JH, Behm FG et al. Hodgkin’s disease: diagnosis by fine-needle aspiration biopsy. Analysis of cytologic criteria from a selected series. Am J Clin Pathol. 1986;86(3):286-291.
- Fulciniti F, Vetrani A, Zeppa P et al. Hodgkin’s disease: diagnostic accuracy of fine needle aspiration; a report based on 62 consecutive cases. Cytopathology. 1994;5(4):226-233.
- Tani E, Ersoz C, Svedmyr E et al. Fine-needle aspiration cytology and immunocytochemistry of Hodgkin’s disease, suppurative type. Diagn Cytopathol. 1998;18(6):437-440.
- Dong HY, Harris NL, Preffer FI et al. Fine-needle aspiration biopsy in the diagnosis and classification of primary and recurrent lymphoma: a retrospective analysis of the utility of cytomorphology and flow cytometry. Mod Pathol. 2001;14(5):472-481.
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