Fine-needle aspiration of peripheral lymph nodes in patients with tuberculosis and HIV

Causes of necrotic features in fine-needle aspirates from cervical lymph nodes

BACKGROUND

Lymph node fine-needle aspiration (LN FNA) cytology indicates necrosis in various diseases. Dominant necrotic features make the diagnosis of underlying conditions very difficult.

METHODS

We retrospectively reviewed 460 patients who underwent cervical LN aspiration cytology that revealed necrotic findings at Keimyung University Dongsan Hospital in Daegu, Korea, from 2003-2017. Each specimen was evaluated and analyzed in association with the clinical findings, biopsy findings, and/or other ancillary tests, including acid-fast bacilli staining and molecular testing for Mycobacterium tuberculosis.

RESULTS

When necrotic features were noted upon cervical LN FNA cytology, the most common pathologic LN FNA category was necrosis alone (31.5%). The second most common category was granulomatous inflammation (31.3%), followed by Kikuchi disease (20.0%) and malignant neoplasm (8.7%). In cases where the cervical LN FNA revealed necrosis alone, the most common final diagnosis was tuberculosis. In young patients, Kikuchi disease should be considered as one cervical LN FNA category, while metastatic carcinoma should be suspected in older patients.

CONCLUSIONS

Even when necrosis alone is observed in LN FNA cytology, it is important to determine the cause through further evaluation.

FINE NEEDLE ASPIRATION CYTOLOGY OF LYMPH NODES IN HIV INFECTED PATIENTS

Lymphadenopathy is the commonest presentation in HIV positive individuals. Fine needle aspiration cytology of 196 HIV positive patients was studied during six monthly review. 75% paients in this study who were asymptomatic were detected to have lymphadenopathy during the surveillance. 82% had lymph nodes smaller than 1cm size. Lymphadenopathy at more than one site was observed in 46.8% cases. Commonest opportunistic infection noticed was tuberculosis (TB) in 34.2%. Cyto-morphologically reactive pattern with Add fast bacilli (AFB) positivity was observed in 16.4% of TB cases. In 2.9% cases AFB were detected even in the tissue fluid. Negative images of AFB were observed in the macrophages in 3 cases. TB was detected with equal frequency in both asymptomatic and symptomatic groups. Axillary nodes pose problem due to deeper location. False positives were a case of dermatopathic lymphadenopathy and a case of Kimura's disease. False negatives include two cases of TB lymphadenitis. Pathogens should be looked for irrespective of cyto-morphology. Biopsy should be done to confirm cases of lymphomas. Fine needle aspiration cytology should be included in the protocol of six monthly review of HIV infected cases.

Basics of cytology

This overview is intended to give a general outline about the basics of Cytopathology. This is a field that is gaining tremendous momentum all over the world due to its speed, accuracy and cost effectiveness. This review will include a brief description about the history of cytology from its inception followed by recent developments. Discussion about the different types of specimens, whether exfoliative or aspiration will be presented with explanation of its rule as a screening and diagnostic test. A brief description of the indications, utilization, sensitivity, specificity, cost effectiveness, speed and accuracy will be carried out. The role that cytopathology plays in early detection of cancer will be emphasized. The ability to provide all types of ancillary studies necessary to make specific diagnosis that will dictate treatment protocols will be demonstrated. A brief description of the general rules of cytomorphology differentiating benign from malignant will be presented. Emphasis on communication between clinicians and pathologist will be underscored. The limitations and potential problems in the form of false positive and false negative will be briefly discussed. Few representative examples will be shown. A brief description of the different techniques in performing fine needle aspirations will be presented. General recommendation for the safest methods and hints to enhance the sensitivity of different sample procurement will be given. It is hoped that this review will benefit all practicing clinicians that may face certain diagnostic challenges requiring the use of cytological material.

Fine needle aspiration cytology in HIV-related lymphadenopathy: experience at a single centre in north India

OBJECTIVE

Fine needle aspiration (FNA) is emerging as a rapid and minimally invasive tool in evaluating lymphadenopathy associated with human immunodeficiency virus (HIV). We evaluated the role of FNA in differentiating various causes of lymphadenopathy in patients with HIV and correlated the cytological diagnosis with CD4 counts.

METHODS

Seventy-nine HIV-positive patients (median age 35 years, 68 male) underwent ultrasound-guided (n = 16) and unguided (n = 63) FNA from 1999 to 2006. Smears were stained with May-Grünwald-Giemsa, haematoxylin & eosin and Papanicolaou stains. Ziehl-Neelsen (ZN) staining for acid-fast bacilli (AFB) was performed in all cases. Staining for fungus was performed whenever required.

RESULTS

The aspirates were adequate in 75 cases (95%). Non-specific reactive hyperplasia was the most common FNA diagnosis (39, 52%) followed by granulomatous necrotizing lymphadenitis (15, 20%), necrotizing lymphadenitis (13, 17.3%) and granulomatous lymphadenitis (4, 5.2%). Fungal infection and non-Hodgkin lymphoma (NHL) were seen in two patients each. ZN staining was positive for AFB in 25 (33.3%) cases. One of these was morphologically interpreted as reactive hyperplasia, 12 as necrotizing lymphadenitis and 12 as granulomatous necrotizing lymphadenitis. Both patients with NHL had CD4 counts below 100/dl. Necrotizing lymphadenitis and granulomatous lymphadenitis were significantly associated with CD4 counts below and above 200/dl, respectively (P = 0.0002).

CONCLUSIONS

FNA is an important tool for assessing the cause of lymphadenopathy in HIV patients. Necrotizing inflammation is more often seen in patients with low CD4 counts. AFB are commonly found in necrotic aspirates with or without granulomas. However, a stain for AFB should be performed in all aspirates from HIV-related lymphadenopathy including reactive hyperplasia.

Fine-needle aspiration cytology in tuberculous lymphadenitis of patients with and without HIV infection

A study of the cytologic features and role of fine-needle aspiration cytology (FNAC) in tuberculous lymphadenitis (TBL) of 21 patients with HIV (group 1) and 21 patients without HIV (group 2) infection was undertaken. Four cytologic patterns were observed, of which necrotizing lymphadenitis (42.9%) and necrotizing suppurative lymphadenitis (28.6%) were predominant in group 1 while necrotizing granulomatous lymphadenitis (47.7%) and granulomatous lymphadenitis (23.8%) were more common in group 2. No pattern was found specific for either group. Zeihl-Neelsen-stained cytology smears of group 1 showed a much higher percentage of positively (61.9%) and a higher density of acid-fast bacilli than group 2. Definitive diagnoses of TBL on FNAC could be provided in 61.9% of group 1 as against 9.5% of group 2. The need for culture or biopsy for definitive diagnosis was higher in group 2. In suspected TBL, diagnostic efficacy can be improved and the need for surgical biopsy reduced if material collected on FNA is also used for culture.

Fine-needle aspiration cytology in lymphadenopathy of HIV-positive patients

Fine-needle aspiration cytology (FNAC) of 32 HIV-positive cases presenting with lymphadenopathy was performed to evaluate its role in this group of patients. For each case air-dried smears were stained with Leishman, hematoxylin and eosin, and Zeihl-Neelsen stains for acid fast bacilli (AFB). The results were tuberculous (TB) lymphadenopathy (15), reactive lymphadenopathy (10), acute lymphadenitis/abscess (5), and suspected malignancy (2). In seven cases of TB lymphadenitis findings were suggestive of TB since no AFB was demonstrable on the cytology smears. In TB lymphadenitis, two additional patterns besides necrotising granulomatous (4) and granulomatous (2) were observed. These were necrotising (6) and necrotising suppurative (3) patterns. FNAC is a simple, inexpensive, rapid investigative procedure which can reduce surgical excisions and provide definite guidelines about further management.

The clinical application and cost analysis of fine-needle aspiration biopsy in the diagnosis of mass lesions in sarcoidosis

BACKGROUND

Sarcoidosis is a prevalent disease of unknown cause characterized by granulomatous inflammation that often creates deep and/or superficial mass lesions. Tissue samples are considered the "gold standard" in diagnosis; however, it is a medically treated disease. We analyzed the utility and relative cost-effectiveness of fine-needle aspiration biopsy (FNAB) in the clinical investigation of patients with both suspected and unsuspected sarcoidosis.

METHODS

All FNAB cases with sarcoidosis either as the cytologic diagnosis or mentioned as part of the differential diagnosis were retrospectively reviewed for clinical history, follow-up, cytologic features, and surgical pathology findings. Comparative analysis of cost of FNAB and excisional biopsy were also made.

RESULTS

Thirty-two FNABs in 28 patients included 17 women and 11 men. Anatomic sites included lymph node (n = 17), lung (n = 5), salivary gland (n = 8), and liver (n = 2). Sarcoidosis had already been diagnosed or was a clinical consideration prior to FNAB in 14 cases. Chest radiograph showed abnormal findings in 19 cases. Angiotensin-converting enzyme (ACE) was measured in seven patients and was elevated in four. All aspirates showed granulomatous inflammation; in 22 patients, special stains or cultures for microorganisms were negative. Simultaneous or subsequent excisional biopsies confirmed the FNAB findings in 17 patients. Institutional ratios of excisional biopsy to FNAB in the diagnosis of sarcoidosis ranged from 4 to 19:1. The cost of FNAB was only 12.5 to 50% that of tissue biopsy.

CONCLUSIONS

FNAB appears to be underutilized in the diagnosis of sarcoidosis. When used in conjunction with radiologic and laboratory data, FNAB may be a reliable and cost-effective method of diagnosis, especially in patients with an established diagnosis of sarcoidosis.