Emad Raddaoui, MD, FCAP, FASC King Khalid University Hospital, FNA of Lymph Nodes Emad Raddaoui, MD, FCAP, FASC King Khalid University Hospital, College Of Medicine, King Saud University

Objectives: At the end of the course, participants should be able to: Recognize and differentiate the cytopathology of various lymphoid neoplasms and non-neoplastic lesions of lymph nodes. Identify cytopathologic imitators of malignant lymphoma and various non-lymphoid lesions, metastatic to lymph nodes. Define the application of immunophenotyping to the cytopathologic diagnosis of malignant lymphoma. Discuss the limitations of aspiration cytopathology as applied to lymph nodes and lymphoid malignancies.

FNA Of Lymph Nodes …… Introduction Three debatable areas in the field of FNA cytology that General Pathologists (specially those who have no interest in cytology) and some clinicians dislike, and these are: - Lymph node, - Salivary glands, - and the breast.

FNA Of Lymph Nodes …… Introduction Rationale for sampling an enlarged lymph node with a thin gauge needle is in general used to determine the cause of lymphadenopathy. Previously, the Diagnosis and classification of lymphoma was achieved by histological examination of excised lymph nodes or tissues. Now, the pathologist is pressured to diagnose/classify lymphoma from tiny needle biopsies or fine needle aspirates (FNA).

FNA Of Lymph Nodes …… Introduction Can we accurately diagnose and classify lymphoma using such limited material? The answer is: yes and no There are then two schools : 1- The yes school, saying that FNA is a great tool, and we have 97% sensitivity and 100% specificity. 2- Skeptical school, we always need tissue .

FNA Of Lymph Nodes Remember To achieve a high quality Lymph node FNA practice, that gives us a very sensitive and specific results, you need the support of ancillary studies, namely Flow Cytometry, IHC, PCR, Cytogenetic, and Molecular studies.

LYMPH NODE FNA - LIMIT ATIONS - Sampling error secondary to: • Improper/poor technique. • Lymph node fibrosis, excessive necrosis, inflammation, or blood. • Partial involvement of lymph node by the lesion. • Small or deep seated lymph node. • Lymph node/mass too large. • Failure to obtain cells for ancillary studies, e:g. immunophenotyping, culture, molecular techniques. - Inability to evaluate Architecture/Vascular pattern • Examples: Progressive Transformation of Germinal Centers, Vascular transformation of lymph node sinuses, etc. • Sub-typing of some lymphoid disorders not possible - Interpretation error: • Limited experience/expertise. • Attempting to make specific diagnoses on limited or poorly preserved material.

FNA of Lymph Nodes Where should we stand You, the wise, will stand at the mid distance and focus on the advantages , disadvantages of the procedure, and take it from there. Understand to utilize it wisely , make sure you know the limitations of any FNA Generally, I would stand with the ‘Triage school’, and view FNA of lymphoid lesions as a screening tool for deciding whether or not a biopsy has to be obtained. In some and certain circumstances we are forced to make a final diagnosis by FNA and treat the patient depending solely on such a diagnosis.

Practical Benefits of LN FNAs 1- Triage of Patient with Lymphadenopathy • Confirms that the mass is lymphoid tissue. • Can preselect those patients without a prior medical history of cancer that would require surgery ( e.g. Hodgkin’s lymphoma) from those where it can be avoided (reactive hyperplasia, some non-Hodgkin lymphomas, many infectious conditions, metastatic tumor). • May help to focus laboratory testing for clinician thus resulting in a more informed and economical workup (e.g. granulomatous disease). • May suggest a primary site if metastatic tumor is found.

Practical Benefits of LN FNAs 2- Effective Diagnostic Tool • Rapid turnaround time (minutes for a preliminary interpretation). • High diagnostic sensitivity and specificity for experienced observers. • Ability to sample multiple nodes if necessary. • Minimal trauma, rare complications, Low cost. • Capable of obtaining cells for immunophenotyping, and other ancillary tests.

Practical Benefits of LN FNAs 3- Efficacious in the Cancer Patient • Documents metastasis in a known cancer patient. • Can confirm recurrence or transformation to a higher grade lymphoma in a patient with known malignant lymphoma. • Helps in staging of tumor.

Systematic Evaluation of Aspirate Smears In each aspirate we should evaluate five parameters: Smear cellularity . Cell arrangement/architecture. Cell composition. Cell morphology . Smear background.

Two basics are used in recognizing cells as lymphoid on a smear[ regardless of whether they are benign or malignant] : a.) cell distribution predominantly as non-clustered, individual cells (single cell pattern), b.) the presence of isolated globular or flake-like cytoplasmic fragments; LGBs [lymphoglandular bodies] in background.

A 32 y/o woman presents with an enlarged 2.0 cm. slightly firm right CASE 1 A 32 y/o woman presents with an enlarged 2.0 cm. slightly firm right cervical lymph node

Case 2 A 12 y/o girl is seen in the clinic with a 1.5 cm. right axillary node witch was noted by her mother 3 weeks earlier. The mass has increased slightly despite antibiotic therapy.

A 25 y/o female presented to clinic with CASE 3 A 25 y/o female presented to clinic with a 4 cm. non-tender left neck mass. The mass has been present for 3 weeks according to her mother

which she states appeared about four months ago CASE 4 A 44 y/o woman presents with enlarged cervical, axillary and inguinal lymph nodes which she states appeared about four months ago

Case 5 A 69 y/o man presents with a 2.0 cm. left posterior cervical lymph node

65 y/o woman underwent FNA of a left neck 3cm lymph node Case 6 65 y/o woman underwent FNA of a left neck 3cm lymph node

Physical examination revealed Case 7 A 15 y/o male presented to the emergency room with wheezing and difficulty breathing. Physical examination revealed a 4 cm. midline neck mass.

Case 8 One year old Saudi girl presented with paraspinal/spinal mass lesion with multiple rnlarged cervical and right supraclavicular lymph nodes.

Case 9 A 47 y/o man complained of a lump in his neck which has been present for about 2 weeks. Physical examination reveals a 2 x 3 cm . firm, left upper cervical lymph node.

34 year old Saudi female, right cervical lymph node Case 10 34 year old Saudi female, right cervical lymph node

No other clinical complaints Case 11 7 year old , Saudi boy with 4cm neck mass, No other clinical complaints

Case 12 31 year old ,Saudi Male, Anterior neck, probably Lymph Node, 3 cm in size

Conclusion : FNA of Lymph Nodes Where should we stand You, the wise, will stand at the mid distance and focus on the advantages , disadvantages of the procedure, and take it from there. Understand to utilize it wisely , make sure you know the limitations of any FNA Generally, I would stand with the ‘Triage school’, and view FNA of lymphoid lesions as a screening tool for deciding whether or not a biopsy has to be obtained.

Conclusion : FNA of Lymph Nodes In some and certain circumstances we are forced to make a final diagnosis by FNA and treat the patient depending solely on such a diagnosis.