The Advantages and Limitations of the Role of Core Needle and Fine Needle Aspiration Biopsy of Lymph Nodes in the Modern Era

Abstract

Fine-needle aspiration (FNA) has proven to be a rapid, cost-effective, and accurate means for evaluating a wide variety of conditions in most organ systems, although the FNA diagnosis of lymphoma (especially the primary diagnosis) remains controversial. However, recent changes to the World Health Organization classification of lymphomas place more emphasis on cytology and less emphasis on architecture, thus opening the door to a more expanded use of FNA, particularly in non-Hodgkin lymphomas. A review of the literature over the past 10 years reveals sensitivity in the range of 66%-100% and specificity in the range of 58%-100%. The complementary use of cytomorphology, immunohistochemistry, and flow cytometry has proven more accurate that any single modality alone. Sophisticated techniques once reserved for the research laboratory (ie, FISH and PCR) are now often used in the clinical setting and provide important diagnostic and prognostic information. The evaluation of Hodgkin lymphomas and some large-cell nonHodgkin lymphomas remains problematic and may require tissue core biopsy. We also briefly consider the use of FNA in workup of metastatic tumors in lymph nodes. Rapid and accurate assessment of metastatic disease, particularly carcinomas and melanomas, is readily accomplished by FNA biopsy, with an overall sensitivity, specificity, and accuracy of over 90%. In these cases, cell block material can be obtained to perform various ancillary studies for additional useful prognostic information. CASE REPORTT he patient was a 60-year-old woman with a 2-week history of rapidly enlarging lymphadenopathy. She had a 20-pack/year smoking history but no prior malignancy. Palpable lymph nodes were noted in the supraclavicular region and axilla. Imaging studies of the thorax revealed more widespread lymphadenopathy, involving the mediastinum and para-aortic regions. There was no discrete pulmonary mass. A fine-needle aspiration (FNA) biopsy was performed. Immediate evaluation revealed a mixed population of small and large lymphocytes and tingible body macrophages, suggesting a reactive process (Fig. 1A, B). Given the clinically worrisome presentation, additional passes were obtained for flow cytometry studies. The majority of the analyzed B-cells proved to be polyclonal, consistent with a reactive process (Fig. 1C). However, a small separate population was noted in the region. Back-gating on this population confirmed that a small monoclonal B-cell population was present (Fig. 1D). Furthermore, this monoclonal population showed forward scatter characteristics, indicating a large cell size relative to the reactive population. The findings were consistent with a small monoclonal B-cell population, confirming the clinical suspicion of lymphoma. DISCUSSIONFNA is a rapid, cost-effective, and accurate means for evaluating lymphadenopathy. Often, a lymph node FNA specimen provides sufficient information to decide whether a patient requires simple observation, antimicrobial therapy for an infectious process, radiation or chemotherapy...

Role of FNAC in the diagnosis of cervical lymphadenopathy

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