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FNA of Lymph Nodes

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:

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FNA of Lymph Nodes

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

  2. Objectives: At the end of the course, participants should be able to: • Recognize and differentiate the cytopathology of various lymphoid neoplasms and non-neoplasticlesions 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.

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

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

  5. 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 .

  6. 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.

  7. 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 lymphnodesinuses, 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.

  8. 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.

  9. Practical Benefits of LN FNAs 1- Triage of Patient with Lymphadenopathy • Confirms that the mass is lymphoid tissue. • Can preselect those patients without a prior medical history of cancer that would require surgery ( e.g. 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.

  10. 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.

  11. 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.

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

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

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

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

  16. 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

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

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

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

  20. 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.

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

  22. 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.

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

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

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

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

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

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