approach to lymph node cytology part 1

brief discussion on approach to diagnosis of lymph node via cytology

1. APPROACH TO LYMPH NODE CYTOLOGY DR KAMALESH LENKA MODERATOR DR SWAGATIKA AGARWAL

2.  Lymph nodes are bean shaped organs found in clusters along the distribution of lymph channels of the body.  Every tissue supplied by blood vessels is supplied by lymphatic's except placenta and brain.  There are over 800 lymph nodes in the body and around 300 are located in the head and neck

3. A lymph node is an elongated or bean-shaped structure, usually less than 3 cm long, often with an indentation called the hilum on one side. It is enclosed in a fibrous capsule with extensions (trabeculae) that incompletely divide the interior of the node into compartments. The interior consists of a stroma of reticular connective tissue (reticular fibers and reticular cells) and a parenchyma of lymphocytes and antigen-presenting cells.

4. Between the capsule and parenchyma is a narrow space called the subcapsular sinus, which contains reticular fibers, macrophages, and dendritic cells. The parenchyma is divided into an outer cortex and, near the hilum, an inner medulla. The cortex consists mainly of ovoid lymphatic nodules. When the lymph node is fighting a pathogen, these nodules acquire light-staining germinal centers where B cells multiply and differentiate into plasma cells.

5.  The medulla largely of a consists branching net w o r k of medu l l ary cor d s c o m p o s e d of lymphocytes, plasma cells, macrophages, reticular cells, and reticular fibers. 

6.  The superficial nodes are located in the subcutaneous connective tissue, and deeper nodes lie beneath the fascia & muscles and within various body cavities.  They are numerous and tiny, but some may have size as large as 0.5 to 1 cm in diameter.  The superficial nodes are the gateways for assessing the health of the entire lymphatic system

7.  When a lymph node is under challenge from a foreign antigen, it may become swollen and painful to the touch— a condition called lymphadenitis .  Commonly palpated and accessible lymph nodes are - the cervical, axillary, and inguinal.  Lymph nodes are common sites of metastatic cancer because cancer cells from almost any organ can break loose, enter the lymphatic capillaries, and lodge in the nodes.  Lymphadenopathy is a collective term for all lymph node diseases

8. LYMPH NODE GROUPS

9.  History  Physical examination Inspection palpation

10. Lymph nodes are palpable as early as neonatal period and a majority of healthy children have palpable cervical lymph nodes The rate of malignant aetiologies of lymphadenopathy is very low in childhood, but increases with age . Vast majority of cases of lymphadenopathy in children have infectious etiology .

11. Lymphadenopathy that has been present for less than 2 weeks has a very low chance of representing a malignant condition Additionally, lymphadenopathy that has been present for more than 1 year and has been stable in size over the year has a very low chance of being malignant However, exceptions to the latter may include indolent non-Hodgkin’s and low-grade Hodgkin’s lymphomas DURATION

12. EXPOSURE HISTORY A complete exposure history is essential to determining the etiology of lymphadenopathy History of contact with patient of tuberculosis in family or in close proximity Exposure to animals and biting insects chronic use of medications infectious contacts history of recurrent infections Travel-related exposures immunization status

13. MEDICATION CAUSING LYMPHADENOPATHY Phenytoin Sulphonamide Carbamazepine Captopril Atenolol Allopurinol

14. PERSONAL AND OCCUPATIONAL HISTORY Environmental exposures- Tobacco Alcohol ultraviolet radiation

15. Occupational exposure- Silicon Beryllium

16. Sexual history and orientation are important in determining potential sexually transmitted causes of inguinal and cervical lymphadenopathy.

17.  May raise suspicion for certain neoplastic causes of lymphadenopathy, such as carcinomas or tuberculosis .

18. ASSOCIATED SYMPTOMS Knowledge of associated factors is critical to determining the management of unexplained lymphadenopathy – Constitutional symptoms fever , malaise , fatigue, cachexia, unexplained loss of weight , loss of appetite

19. Adenopathy in presence of fever could indicate both infection and malignancy Nature of fever may help differentiate the cause Eg -evening rise of temperature - tuberculosis. Pel epstien type of fever- Hodgkin's lymphoma

20. Pel ebstien fever is that patient experinces in which experiences fevers which cyclically increase then decrease over an average period of one or two weeks.

21. Symptoms often associated with autoimmune diseases are Arthralgia muscle weakness, unusual rashes

22. Symptoms that when associated with lymphadenopathy should be considered as red flags for malignancy are fevers, night sweats unexplained weight loss (>10% of normal body weight)

23.  The physical examination should be regionally directed by knowledge of the lymphatic drainage patterns and should include a complete lymphatic examination looking for generalized lymphadenopathy .

24.  Swellings at the known sites of lymph nodes should be considered to have arisen from them unless some outstanding clinical findings prove their origin to be otherwise.  All the normal anatomic sites should be inspected for any obvious enlargements.

25. When lymphadenopathy is localized, the clinician should examine the region drained by the nodes for evidence of infection, lesions or tumors. Other nodal sites should also be carefully examined to exclude the possibility of generalized lymphadenopathy.

26. The lymph nodes are examined in the same fashion as any other swelling. That means number, site, size, surface Number : is important to know whether a single or multiple groups are involved.  A few conditions are known to cause generalized lymphadenopathy  Eg: Lymphomas, Tuberculosis, lymphatic leukemia, Brucellosis, Sarcoidosis etc…

27.  Position : is important as it will not only give an idea as to which group of lymph node is affected, but also the diagnosis.  Eg: Hodgkin’s disease and the Tuberculosis affect the cervical lymph nodes in the earlier stages.

28.  In acute lymphadenitis the skin becomes inflamed with redness, edema and brawny induration. 

29. In chronic lymphadenitis such angriness is not seen  Skin over tuberculous lymphadenitis becomes red and glossy when they reach the point of bursting. Scar often indicates previou s b ursting o f a bsce s s o r o p eration. TUBERCULAR LYMPHADENITIS

30.  Over a rapidly growing lymphoma, the skin appears tense, stretched with dilated subcutaneous veins.  In secondary carcinoma, the skin may become fixed .

31.  Most of the lymph nodes are best palpated with the examiner standing behind the patient who is comfortably seated .  Palpation of the lymph nodes is ideally done commencing from the most superior lymph node and then working down to the clavicle region.  Nodes are palpated for consistency, size, tenderness, fixity to the surrounding structures.

32. Enlarged lymph nodes should be palpated carefully with palmar aspect of 3 fingers. While rolling the fingers over the lymph node, slight pressure has to be applied to know the consistency of the node. Enlarged lymph nodes could be Soft (fluctuant) Elastic , rubbery Firm, Stony hard Variable

33. consistency of lymph node Soft – infection or inflammation Fluctuant – suppurated nodes Stony hard- typical of carcinoma usually metastatic Firm rubbery – usually lymphoma

34.  When a lymph node increases in size its capsule stretches and causes pain.  But pain may also be seen when there is hemorrhage into the necrotic center of a malignant node.  The presence or absence of tenderness does not necessarily differentiate benign from malignant nodes.

35.  A group of lymph nodes that feels connected and move as a unit is said to be matted.  Nodes that are matted could be NON MALIGNANT CAUSES Tuberculosis Sarcoidosis Lymphogranuloma venerum MALIGNANT CAUSES Metastatic carcinoma Lym p homas

36.  SIZE :  Nodes are generally considered to be normal if they are up to 1cm in diameter .  Little information exists to suggest that a specific diagnosis can be based node on size alone.

37. The enlarged nodes should be carefully palpated to know if they are fixed to the skin, deep fascia, muscles. Any primary malignant growth or secondary carcinoma is often fixed to the surroundings . First the deep fascia and the underlying muscle, the surrounding structures and finally the skin is involved. Upper deep cervical lymph nodes when involved secondarily from any carcinoma of its drainage area may involve the hypoglossal nerve and cause hemiparesis of the tongue which will be deviated towards the side of the lesion when asked to protrude out. Cases are not uncommon when patient may complain of dyspnoea & dysphagia due to pressure on trachea or esophagus by enlarged lymph nodes from Hodgkin’s disease or secondary carcinoma.

38.  Lymphadenopathy - enlargement of the lymph nodes.  It may be an incidental finding in patients being examined for various reasons, or it may be a presenting sign or symptom of the patient's illness.  Soft, flat, submandibular nodes (<1 cm) are often palpable in healthy children and young adults;  Healthy adults may have palpable inguinal nodes of up to 2 cm, which are considered normal.

39.  It has been defined as involvement of three or more noncontiguous lymph node areas.  Generalized lymphadenopathy is frequently associated with nonmalignant disorders such as infectious mononucleosis [Epstein-Barr virus (EBV) or cytomegalovirus (CMV)],toxoplasmosis, AIDS, other viral infections, systemic lupus erythematosus (SLE), and mixed connective tissue disease.  Acute and chronic lymphocytic leukemias and malignant lymphomas also produce generalized adenopathy in adults.

40. Generalized lymphadenopathy in a case of lymphoma

41.  Implies involvement of a single anatomic area.  The site of localized or regional adenopathy may provide a useful clue about the cause.  .

42. ANTERIOR AURICULAR – Tularemia Sarcoidosis Rubella Viral Conjunctivitis Trachoma POST.AURICLAR Rubella Scalp infection

43. SUB MANDIBULAR- Buccal cavity infection Pharyngitis Nasopharyngeal tumour Thyroid malignancy CERVICAL- IMN Sarcoidosis B/L Toxoplasmosis pharyngitis

44. RIGHT SUPRA CLAVICULAR Pulmonary malignancy • Mediastinal malignancy • Esophageal malignancy LEFT SUPRA CLAVICULAR Intra abdominal malignancy Renal ca Testicular or ovarianclavicular malignancy

45. AXILLARY LYMPHADENOPATHY Ca breast / infection • Upper extremity infection EPITROCHLEAR LYMPHADENOPATHY Syphilis(b/l ) • CLL • IMN • Lymphoma • Hand infection(u/l)

46. INGUINAL LYMPHADENOPATHY Syphilis • Genital herpes • Lympho granuloma venereum • Chancroid • Lower extremity/local infection HILAR LYMPHADENOPATHY Lymphoma Bronchogenic ca TB sarcoidosis

47. ABDOMINAL LYMPHADENOPATHY Adeno ca of gut • Hodgkin’s d/s • TB • Bladder ca • Gastric ca SISTER MARY JOSEPH NODULE

48.  Immunologic diseases  Rheumatoid arthritis  Juvenile rheumatoid arthritis  Mixed connective tissue disease  Systemic lupus erythematosus  Dermatomyositis  Sjögren's syndrome  Serum sickness  Drug hypersensitivity—diphenylhydantoin, hydralazine, allopurinol, primidone, gold, carbamazepine, etc.  Angioimmunoblastic lymphadenopathy  Primary biliary cirrhosis  Graft-vs.-host disease  Silicone-associated  Autoimmune lymphoproliferative syndrome

49.  Malignant diseases Hematologic—Hodgkin's disease, non-Hodgkin's lymphomas, acute or chronic lymphocytic leukemia, hairy cell leukemia, malignant histiocytosis, amyloidosis Metastatic—from numerous primary sites  Lipid storage diseases —Gaucher's, Niemann-Pick, Fabry, Tangier  Endocrine diseases —hyperthyroidism, Adrenal insufficiency, Thyroiditis.

50.  Other disorders Castleman's disease (giant lymph node hyperplasia) Sarcoidosis Dermatopathic lymphadenitis Lymphomatoid granulomatosis Histiocytic necrotizing lymphadenitis (Kikuchi's disease) Sinus histiocytosis with massive lymphadenopathy (Rosai- Dorfman disease) Mucocutaneous lymph node syndrome (Kawasaki's disease) Histiocytosis X Familial Mediterranean fever Severe hypertriglyceridemia Vascular transformation of sinuses Inflammatory pseudotumor of lymph node Congestive heart failureAbbreviations: CMV, cytomegalovirus; EBV, Epstein-Barr virus.

51. CYTOLOGY OF LYMPH NODE

52. CYTOLOGY OF NORMAL LYMPH NODE Mature lymphocytes of either B or T phenotype Plasma cells Centrocytes Centroblasts Immunoblasts Macrophages

53. LYMPHOCYTE They have a dense nucleus They have coarse chromatin They have pale-blue rim of cytoplasm Mature lymphocytes of either B or T phenotype measure around 8 μ m in air-dried smears.

54. PLASMA CELL Plasma cells are characterised by their eccentrically placed nucleus The chromatin arranged in a cartwheel-like pattern The abundant cytoplasm often shows a less intense basophilic staining in the paranuclear area

55. PLASMA CELL

56. CENTROCYTE Centrocytes are B cells which measure around 10 μ m They have sparse, weakly stained basophilic cytoplasm The nucleus has a fine chromatin pattern , is usually irregular in shape and may be cleaved

57. CENTROBLAST Centroblasts are larger than centrocytes characteristic round nucleus usually with several marginal nucleoli The cytoplasm is sparse and may contain some vacuoles

58. IMMUNOBLAST Immunoblasts of either B or T phenotype are the largest of the lymphoid cells and measure 20 – 30 μ m They have a round nucleus, often eccentrically placed, with 1 – 3 large strongly basophilic nucleoli . The cytoplasm is usually also intensely basophilic but may be lacking

59. MACROPHAGES Macrophages have a round to oval nucleus with evenly distributed chromatin and an inconspicuous nucleolus . The poorly defi ned cytoplasm varies markedly in size but may measure up to 45 μ m . In stimulated lymph nodes the macrophages contain phagocytosed cellular debris consisting of darkly stained particles, often referred to as tingible bodies

60. Numerous spherical fragments of blue cytoplasm of variable sizes dispersed between the lymphoid cells; some nuclear fragments. LYMPHO GLANDULAR BODY

61. Lymphoid cells and histiocytes adhering to a strand of endothelial cells representing a small blood vessel

62. REACTIVE LYMPH NODE CRITERIA FOR DIAGNOSIS A mixed population of lymphoid cells,  Numerical predominance of small lymphocytes, Centroblasts , centrocytes , immunoblasts and plasma cells in variable but ‘logical’ proportions, Dendritic reticulum cells associated with centroblasts and centrocytes (derived from germinal centers ) Scattered histiocytes with intracytoplasmic nuclear debris ( tingible body macrophages), Pale histiocytes , interdigitating cells, endothelial cells, eosinophils, neutrophils (variable).

63. Tissue section showing detail of germinal center with centroblasts , centrocytes and tingible body macrophages. Outer rim of small lymphocytes

64. Smear derived from reactive follicle. Centroblasts , centrocytes , small lymphocytes and tingible body macrophages with nuclear fragments

65. Smear derived from germinal center ; loose tissue fragment of dendritic reticulum cells with ovoid nuclei and granular chromatin, centroblasts , centrocytes and some lymphocytes; syncytial background of pale cytoplasm

66. Mixed population of lymphoid cells; two nuclei of dendritic reticulum cells with granular chromatin and small distinct nucleoli lower mid

67. INFECTIOUS MONONUCLEOSIS immunoblasts , plasmacytoid , cells , mature plasma cells and atypical ,lymphocytes can be numerous the range of cells is still in logical proportions

68. INFECTIOUS MONO NUCLEOSIS Many transforming lymphocytes, plasmacytoid cells and immunoblasts high proportion of transformed lymphocytes and a mitotic figure

69. DILANTIN HYPERSENSITIVITY LYMPHADENITIS Abnormal immunoblastic reactions with prominent immunoblasts sometimes Reed-Sternberg-like cells can be seen at times be difficult to distinguish from large cell lymphoma Similar features are seen in post vaccinal lymphadenitis.

70. Immunoblastic reaction Several immunoblasts including a binucleate form; case of Dilantin lymphadenopathy

71. SINUS HISTIOCYTOSIS WITH MASSIVE LYMPHADENOPATHY Rare form of sinus histiocytosis first described by rosai and dorfman Massive bilateral nontender lymph node enlargement of cervical lymph node followed by fever There are numerous lymphocyte with large and pale histicocytes Histiocytes have vesicular nuclei with small nucleoli and an abundant cytoplasm. Histiocytes have well preserved lymphocytes known as lymphophagocytosis or emeripolesis

72. Tissue section showing very large histiocytes harboring many lymphocytes (and some plasma cells) in their cytoplasm, Smear showing large histiocytes with intracytoplasmic lymphocytes and plasma cells

73. TOXOPLASMOSIS Scattered small clusters of a few histiocytes with ovoid, pale nuclei and abundant cytoplasm resembling epithelioid cells in a smear consistent overall with follicular hyperplasia Well-formed histiocytic granulomata resembling sarcoid granulomata are unusual but occur occasionally . Lymphoid cells with relatively large , ovoid, pale nuclei may also be seen

74. Granuloma-like cluster of histiocytes with epithelioid features; Activated lymphoid cells possibly including some monocytoid B-cell forms.

75. DERMATOPATHIC LYMPHADENOPATHY Numerous noncohesive , pale, histiocyte -like cells ( interdigitating cells ) with typical folded nuclei Some macrophages containing pigment, either hemosiderin or melanin, are usually found . These have smaller and more consistently oval , nonfolded nuclei different from interdigitating cells, and have a better-defined cytoplasm There may be a variable number of eosinophils The background is predominantly of lymphocytes, which may appear slightly ‘atypical’ with small pale, central nucleoli (stimulated T cells)

76. Numerous pale histiocytes /interdigitating cells in a background of predominantly small lymphocytes. Intracytoplasmic pigment was sparse in this case Interdigitating cells with conspicuous nuclear folding due to long channel-like invaginations of the nuclear membrane

77. LANGERHANS HISTIOCYTOSIS The histiocytes of Langerhans cell histiocytosis ( histiocytosis X ) have characteristically large nuclei of irregular shape They may be folded, convoluted, lobulated and grooved Mitotic activity may be seen and sometimes necrosis .

78. Loose cluster of large histiocytic cells with large, vesicular, irregularly folded, lobated or convoluted nuclei

79. Reactive lymph node vs lymphoma 1. a mixed population of lymphoid cells representing the whole range of lymphocyte transformation from small lymphocytes to immunoblasts and plasma cells, 2. a predominance of small, sometimes slightly larger ‘stimulated’ lymphocytes, which have small round nuclei and a characteristic chromatin pattern of large, ill-defined condensations, 3. centroblasts and centrocytes associated with dendritic reticulum cells and tingible body macrophages derived from germinal centres

80. Granulomatous lymphadenitis Histiocytes of epithelioid type forming cohesive clusters are characteristic, Multinucleated giant cells usually of Langhans type Granulomatous lymphadenitis may or may not show necrosis or suppuration.

81. epithelioid cell Epithelioid cells are quite distinctive in FNB smears. They have elongated nuclei the shape of which resembles the sole of a shoe or boomerang. The nuclear chromatin is finely granular and pale and the cytoplasm is pale without distinct cell borders Epithelioid cells of granulomatous lymphadenitis form clusters; large clusters resemble granulomas in tissue sections.

82. Necrosis may be of fibrinoid or caseous types Caseous material appears granular and eosinophilic in smears and usually lacks recognizable cell remnants Granulomata with caseous necrosis is the hallmark of tuberculous lymphadenitis

83. TUBERCULOSIS Granulomalike group of epithelioid histiocytes in a background of granular caseous necrosis Granular material of caseous necrosis with degenerating and fragmented nuclei. Note presence of polymorphs, a not uncommon feature, particularly in AIDS patients

84. Noninfectious granulomata 1) Sarcoidosis lymphadenitis 2) Sarcoid-like lymphadenitis 3) Berylliosis

85. SARCOIDOSIS Clusters of loosely cohesive epithelioid histiocytes with characteristically pale, elongated sole-shaped nuclei; few lymphocytes; no necrosis; no giant cells seen in this

86. A.Suppurative 1) Tularemia lymphadenitis 2) Cat scratch lymphadenitis 3) Yersinia lymphadenitis 4) Lymphogranuloma venereum 5) Fungal infection Infectious granuloma

87. Infectious granuloma B.Non-suppurative 1) Tuberculous lymphadenitis 2) Atypical mycobacterial infection 3) BCG-lymphadenitis 4) Toxoplasma lymphadenitis ( Piringer-Kuchinka lymphadenopathy) 5) Lepra 6) Syphilis 7) Brucellosis 8) Fungal infection (Cryptococcus, Histoplasma, Coccidioidomycosis , Pneumocystis)

88. Lymph node necrosis Focal, extensive or total necrosis/infarction of lymph nodes occurs In some inflammatory processes (e.g. viral and bacterial infections) in metastatic malignancy in malignant lymphoma vasculitis (e.g. Kawasaki’s disease) trauma

89. Necrotising lymphadenitis (Kikuchi- Fujimoto disease) condition of unknown aetiology, seen mainly in young women there is focal necrosis with a proliferation usually in cervical lymph nodes of histiocytes , lymphocytes plasmacytoid dendritic cells

90. Many large pale histiocytes with crescentic nuclei and phagocytosed debris with background of reactive lymphocytes; necrosis obvious in the tissue section ( A , smear, MGG, HP; B , tissue section H&E)

91. Immunocompromised patients The typical inflammatory reactions to common infectious agents may be both deficient and atypical, and unusual and opportunistic infections may be present , In these patients, suppurative lymphadenitis suggests not only a bacterial infection, but also disseminated fungal infection , most commonly Aspergillus spp , Cryptococcus neoformans or Candida spp infection

92. In Giemsa-stained smears mycobacterial infection may produce large numbers of plump histiocytes with cross-hatched cytoplasm representing ‘negative image’ bacilli neutrophils are admixed with spindle cells and histiocytes , Negative image of curved beaded atypical mycobacteria in histiocyte cytoplasm and serum background

93. Metastatic malignancy CRITERIA FOR DIAGNOSIS  Abnormal nonlymphoid cells amongst normal/reactive lymphoid cells

94. PROBLEMS AND DIFFERENTIAL DIAGNOSIS  Representative sampling – small metastatic deposits in a reactive lymph node,  Benign epithelial, mesothelial or nevoid inclusions,  Necrosis or cystic change,  Malignant lymphoma,  Pseudoepithelial clustering of lymphoid cells or histiocytes in

95. Prostatic carcinoma Supraclavicular node aspirate containing malignant cells from a metastatic adenocarcinoma

96. THANK YOU