Lymphadenopathy is a clinical indication for biopsy. Pathological diagnosis based on excisional biopsy of the lymph node has been considered to be the gold standard, though the procedure is traumatic. Fine-needle aspiration cytology (FNAC) is frequently used due to its less invasive nature and relatively high sensitivity.1,2 However, the disadvantage of FNAC is that it cannot reach deep seated tumors or provide adequate histological architecture of the lesion, which limits its application in lymph node diagnosis, especially the diagnosis of lymphoma as proposed by the NCCN guideline.3-5 The development of interventional imaging has opened a new field of interventional diagnosis. Image-guided core-needle biopsy (CNB) becomes a powerful tool to reach nearly all the lymph nodes in the body. Some complicated cases can be diagnosed by CNB.6,7 However, it is a great challenge for pathologists to make diagnoses and subclassifications on much smaller specimens.
Many published papers about the efficacy of ultrasonography (US)-guided CNB8-13 are focused either on lymphomas or on the lymph nodes of certain locations.14-19 Few papers has made an assessment of pathological diagnosis of common lesions of lymph nodes. The purpose of our study was to survey and evaluate the accuracy of pathological diagnosis using US-guided CNB of the lymph node.
A retrospective analysis of pathological diagnoses of 1119 consecutive patients that underwent US-guided CNB of lymph nodes at the Chinese People’s Liberation Army (PLA) General Hospital between January 2001 and December 2007 was carried out. All the patients had at least an enlarged lymph node at a certain location of the body. Informed consents were obtained from all patients. Patients with coagulopathy, inability to cooperate, or anatomic and vascular contraindications were not suitable for biopsy.
All CNBs were performed under US (Sequoia512, SIEMENS, Germany) guidance. The biopsies were done by suitable route, usually through the maximum diameter of the lymph node in order to obtain enough lymphoid tissue for diagnosis. The tissues were obtained by using automated cutting gun and 18-gauge cutting needles (BARD, USA), and 2 to 4 tissue cores for each patient were obtained.
Specimens were fixed in 10% buffered formalin, embedded in paraffin, and sectioned at 4 μm as the routine procedure. The sections were stained with hematoxylin-eosin (HE). Immunohistochemistry (IHC) and special stainings, such as acid-fast and Epstein-Barr virus-encoded RNA (EBER) in situ hybridization (Dako, Denmark), were applied when necessary. IHC was preformed with EnVision two step method20 on a panel of antibodies: AFP, CD20, CD3, CD56, CD79a, EMA, LCA, Kappa, Lambda, S-100 (Dako, USA), AE1, AE3, ALK, Bcl-2, Bcl-6, CD10, CD15, CD56, CD99, CgA (Invitrogen, USA), EBV, HMB45, Heppar-1, Mum-1, PAX-5, PLAP, Syn, TTF1 (Santa Cruz, USA), and CD30 (Novocastra, England).
The clinical and pathological data were reviewed, including age, sex, site of biopsy, immunohistochemical and special stainings, and pathological diagnosis.
The number of the lymph node CNB increased with time, from 32 cases in 2001 to 570 cases in 2007. The age range of 1119 patients was 1 year old to 85 years old (mean: 51 years old). The locations of biopsied lymph nodes were summarized in Table 1. The most common sites were the cervical area, clavicular region and retroperitoneum. Among metastatic carcinoma cases, there were 175 cases in the cervical area and 153 cases in the clavicular region. The diagnosis of tuberculosis was made mainly in the lymph nodes at the cervical and clavicular region, with 63 cases and 19 cases, respectively. Hodgkin’s lymphoma diagnoses were made mainly from cervical lymph nodes (n=9), while the non-Hodgkin’s lymphoma were from retroperitoneum lymph nodes (n=43).
Of all the cases, the histological diagnoses were conclusive in 815 cases (73%) and inconclusive in 304 cases (27%). The conclusive cases mainly include metastatic carcinoma (n=449), tuberculosis (n=111), lymphoma/leukemia (n=124), reactive hyperplasia (n=87), and other rare diseases (n=44) (Table 2). Most of the metastatic carcinoma cases could be diagnosed on HE staining and only 86 cases required IHC staining. The main pathological subtypes were adenocarcinoma (n=120) and squamous cell carcinoma (n=211). The primary carcinomas of 120 cases could be determined according to histological architectures, or IHC staining of the metastatic carcinomas together with the clinical history. The most common sites of primary carcinomas were lung (n=34), thyroid gland (n=26), and breast (n=19).
One hundred and twenty-two lymphoma cases all required IHC staining to make the diagnosis and subclassification, while 39 cases with inconclusive diagnosis were suspected to be lymphoma. The accuracy of lymphoma diagnosis in our series was 76%. There were 21 cases (17%) of classic Hodgkin’s lymphoma, including 13 cases of nodular sclerosis type and 4 cases of mixed cellularity type. They were characterized by a background of eosinophils, lymphocytes, plasma cells, and classic Reed-Sternberg (R-S) cells or the variants of R-S cells, which were positive for CD30 and weakly positive for PAX-5.
Among 101 cases of non-Hodgkin’s lymphoma, 78 cases were B-cell lymphoma, and 13 cases were T-cell lymphoma. In 78 cases of B-cell lymphoma, 34 were diagnosed as diffuse large B cell lymphoma, with the large tumor cells positive for CD20 (Figure 1). Four cases were diagnosed as marginal zone lymphoma, which had medium tumor cells, indented nuclei, abundant cytoplasm, and were positive for CD20, CD79a and CD43. Three cases were diagnosed as small lymphocytic lymphoma, which had small, monotonous lymphocytes and were positive for CD20, CD23 and CD5. Two cases were follicular lymphoma, with cetrocytes and centroblasts in follicles positive for CD20, CD10 and CD79a, and intrafollicular lymphocytes positive for Bcl-2. Two cases were mantle cell lymphoma, which were composed of small to medium lymphocytes positive for CD20, CD5 and cyclin D1 (Figure 2). Among 13 cases of T cell lymphoma, there were 5 cases of anaplastic large cell lymphoma with hallmark cells and were positive for CD30 and ALK (Figure 3). One case was T lymphoblast cell lymphoma, which had medium to large tumor cells and positive for TdT, CD3 and CD5. Seven cases of T cell lymphoma could not be subclassified.
As the above results presented, the number of lymph node CNBs increased dramatically from 2001 to 2007 in our hospital. Sites of biopsy included nearly all locations of lymph nodes in the body. Obviously, the US-guided CNB of lymph nodes has become routine procedure in clinical practice. Because it is minimally invasive, relatively safe and easy to perform, it has been increasingly applied to obtain tissues for diagnosis in patients with lymphadenopathy and a clinical suspicion of lymphoma.8
Faced with a dramatic increase in the number of specimens obtained by US-guided CNBs, many pathologists in China are not yet fully prepared for the challenge of making diagnosis on lymph node CNB, especially for lymphoma diagnosis. Therefore it is important to evaluate the effectiveness of pathological diagnosis on the CNB of lymph nodes. Our data showed that more than 70% lymph node CNBs can be diagnosed conclusively, of which more than 50% were metastatic carcinomas and 15% were malignant lymphomas. Immunohistochemistry was of great help in the diagnosis of both metastatic carcinoma and lymphoma, which provided useful information on the origin of the carcinoma and subclassification of lymphoma.
The accuracy of 122 lymphoma diagnoses in our series is lower than the results of de Larrinoa et al.4 who evaluated 102 US-guided CNB of malignant lymphomas. Their overall diagnostic accuracy was 88.2% (90/102). They concluded that US-guided CNB was effective in the diagnosis of malignant lymphomas and could be used as the first diagnostic approach in selected clinical situations. Demharter et al21 discussed how often US-guided CNBs of lymph nodes yielded subclassification of malignant lymphoma according to World Health Organization (WHO) criteria and helped to avoid excisional biopsies. And they concluded that lymphoma can be reliably diagnosed and subclassified if preferably 5 cores were obtained with 14-G needles. A more recent study of 101 lymphoma cases by Lachar suggested that CNB may be used safely and reliably as a first-line diagnostic technique.8 Experience from our study also indicated that 3 effective cores of the 18-G needle were optimal for pathological diagnosis as well as for subsequent IHC and molecular study.
Most biopsied tissues in our series obtained with 18-G cutting needles satisfied the application of IHC staining. Lymphomas showing special immunophenotypes, such as Hodgkin lymphoma, ALK positive anaplastic large cell lymphoma, diffuse large B cell lymphoma, lymphoblastic lymphoma, mantel cell lymphoma, etc. can be accurately diagnosed and precisely subclassified. Pathologists need to be trained and to get experienced through daily practice.
In our study, 27% cases did not get conclusive diagnoses. The reasons were as follows: insufficient material, necrotic tissue, crushing artifacts of tissue and noncompliance of outpatients. If biopsied tissues obtained with 18-G cutting needles were not adequate for diagnosis, we would suggest the clinician to perform subsequent excisional biopsies. Of course, crushing artifacts should be avoided through careful performance of the operator. Good follow-up of outpatients and close contact with clinicians will also increase the accuracy of the CNB diagnosis. Furthermore Lachar et al8 indicated that molecular pathology technique, such as gene rearrangement analysis, can be used to aid in the diagnosis of lymphoma from small tissue cores, particularly when IHC stains and morphology are inconclusive and when fresh tissue is not available for flow cytometry studies. With improved tissue biopsy and routine practice of molecular pathology, more accurate diagnoses of lymph node CNB can be achieved.
US-guided CNB can obtain lymphoid tissues from nearly all parts of the body for diagnostic purposes. Conclusive pathological diagnosis can be made in most of cases when adequate material was provided. Besides metastatic carcinoma, lymphomas with special immunophenotype can be accurately diagnosed and subclassified on CNB.
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