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
network of medullary
cords composed 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 gatewaysfor 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.
Lymphadenopathyis 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 previous bursting of
abscess or operation.
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
 Lymphomas

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.

41. 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.

42. 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.

43. Generalized lymphadenopathy in a case of lymphoma

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

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

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

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

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

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

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

52. Immunologicdiseases
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

53. Malignantdiseases
◦ Hematologic—Hodgkin's disease, non-Hodgkin's
lymphomas, acute or chronic lymphocytic leukemia,
hairy cell leukemia, malignant histiocytosis, amyloidosis
◦ Metastatic—from numerous primary sites
Lipidstoragediseases—Gaucher's, Niemann-Pick, Fabry,
Tangier
Endocrinediseases—hyperthyroidism, Adrenal
insufficiency, Thyroiditis.

54. Otherdisorders
◦ 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.

55. CYTOLOGY OF LYMPH NODE

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

57. 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.

58. • 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

59. PLASMA CELL

60. 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

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

62. 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

63. 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

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

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

67. 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).

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

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

70. 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

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

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

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

74. 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.

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

76. 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

77. 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

78. 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

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

80. 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)

81. 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

82. 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.

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

84. 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

85. 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.

86. 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.

87.  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

88. 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

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

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

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

92. 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)

93. 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

94. 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

95. 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)

96. 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

97.  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

98. Metastatic malignancy
 CRITERIA FOR DIAGNOSIS
 Abnormal nonlymphoid cells amongst normal/reactive lymphoid cells

99. 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

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

101. THANK YOU