Cervical Node Biopsy Research Articles

Thrombotic Thrombocytopenic Purpura Associated With Hodgkin Lymphoma

Introduction Thrombotic thrombocytopenic purpura (TTP) is characterized by microangiopathic hemolytic anemia and thrombocytopenia with usually less than <5% ADAMTS13 (a disintegrin and metalloprotease with thrombospondin repeats) activity level. Hodgkin lymphoma (HL) comprises 10% of newly diagnosed lymphoma cases. Case Report A 45 year old healthy African American male presented with diffuse abdominal pain with associated nausea and constipation. Labs showed decreased hemoglobin, platelets, and haptoglobin with elevated bilirubin, lactate dehydrogenase, and creatinine. ADAMTS13 level was <1%. Peripheral smear revealed schistocytes. CT imaging demonstrated multiple lesions of liver, pleura, and bone, as well as diffuse adenopathy, all later confirmed to be hypermetabolic by PET scan. Pleura biopsy suggested HL. TTP was diagnosed, prompting start of high dose prednisone and plasma exchange (PE). Labs normalized after 5 exchanges, allowing for outpatient steroid and PE tapers. A pleura biopsy was suspicious but not definitive for HL. Three weeks later, he was admitted for opioid-induced constipation. He was still on PE. Despite labs without evidence of TTP, his ADAMTS13 persisted at <1%. A definitive excisional cervical lymph node biopsy yielded classical nodular sclerosing HL. Patient started systemic chemotherapy with doxorubicin, bleomycin, vincblastine, and dacarbazine (ABVD). PE was discontinued 7 days later. At follow-up 3 weeks from cycle #1, ADAMTS13 was 55% without evidence of TTP. Conclusion A 2012 review notes 4 cases of microangiopathic hemolytic anemia associated with HL, proposing an underlying immune component to this uncommon entity. Though rare, management of TTP associated HL can be challenging due to underlying cytopenias delaying systemic chemotherapy and yet refractoriness of ADAMTS13 to correct, portending a high risk of TTP relapse, without chemotherapy. Supportive measures to stabilize TTP and prompt initiation of chemotherapy can be an effective approach. Disclosures: No relevant conflicts of interest to declare.

Cutting cancer waiting times: streamlining cervical lymph node biopsy

Patients with enlarged lymph nodes present to a number of different specialties and diagnosis is often made following a biopsy. This study aimed to establish department waiting times for cervical lymph node biopsy, and compare these to the cancer services guidelines. A retrospective audit was carried out to record patient waiting times (defined as the number of days from referral to biopsy) between May and December 2010. A proforma for referral was introduced. In addition, appointments for biopsies were arranged by a co-ordinator. A prospective re-audit was carried out from March to September 2011. The first audit showed that national guidelines were not met; there was a median waiting time of 74 days (interquartile range, 47-113). Re-audit demonstrated a significant reduction in waiting times using the proforma; the median waiting time had decreased to 18 days (interquartile range, 9-22). A proforma for lymph node biopsy and a designated co-ordinator streamlined the service, significantly reducing waiting times. Together, these can aid referral for meeting guidelines and improve patient care.

Value of immunohistochemistry in the diagnosis of malignant cervical lymph nodes

The cervical lymph nodes are relevant due to the diversity of clinical entities. The use of immunohistochemistry is a real method to elucidate the diagnosis of adenopathy, both primary and metastatic neoplasms. ObjectiveTo assess the value of immunohistochemistry in the diagnosis of cervical lymph nodes malignancies. MethodRetrospective study of the database histopathological specimens from 2009 to 2011. ResultsOut of 32 biopsies of cervical lymph nodes, in 16 (50%) the immunohistochemistry was employed, being 68.75% (11) in hematological neoplasms and 31.25% (5) in carcinomas. It was used in all cases of lymphoma. ConclusionThe immunohistochemistry was used in 50% of the biopsies of lymph nodes under suspicion of malignancy, being 31.25% in epithelial lesions and 68.75% in lymphoproliferative lesions.

CD30-Targeted Therapy with Brentuximab Vedotin and DLI in a Patient with T-Cell Posttransplantation Lymphoma

CD30-Targeted Therapy with Brentuximab Vedotin and DLI in a Patient with T-Cell Posttransplantation Lymphoma

Rosai‐dorfman disease with extranodal involvement

Rosai-Dorfman disease is a rare condition of marrow hematopoietic stem-cell origin. Patients can show extranodal involvement as well as lymphatic involvement, but only about 5% of extranodal cases involve intracranial lesions. A 53-year-old male was admitted to our hospital with bilateral cervical lymphadenopathy. Intracranial tumors and bone lesions were also detected. Cervical lymph node biopsy and intracranial tumor resection were performed, and histopathological examination revealed Rosai-Dorfman disease. The patient showed good clinical course without significant enlargement of the tumor. This study describes the case of a patient with Rosai-Dorfman disease presenting with massive cervical lymphadenopathy mimicking malignant neoplasm.

Response to Sorafenib in a Pediatric Patient with Papillary Thyroid Carcinoma with Diffuse Nodular Pulmonary Disease Requiring Mechanical Ventilation

Papillary thyroid cancer (PTC) presents with local and distant metastases more frequently in children than in adults. However, hypoxemia secondary to pulmonary metastases has not been reported in the literature. Sorafenib is a small-molecule multikinase inhibitor used in radioactive iodine ((131)I)-refractive papillary thyroid carcinoma. An eight-year-old boy presented with fever and hypoxemia and was found to have H1N1 viral pneumonia requiring mechanical ventilation and antiviral and glucocorticoid treatment. After initial improvement, he was readmitted one month later because of persistent hypoxemia. A high-resolution computed tomography of the chest and neck revealed multiple 1-4 mm nodules and necrotic lymph nodes on the right side of the neck. Left lung wedge resection and right deep cervical node biopsies were consistent with PTC. He underwent a total thyroidectomy with a central neck node dissection and postoperatively required prolonged mechanical ventilation. Due to the inability to be weaned from mechanical ventilation, treatment with sorafenib 200 mg daily (10 mg/kg/day, 250 mg/m(2)) was initiated. Eight days thereafter, ventilation support was discontinued and the child was extubated. However, he failed extubation secondary to supraglottic edema, and seven days later tracheostomy was performed. The dosage of sorafenib was increased to 200 mg twice daily (20 mg/kg/day, 500 mg/m(2)). After 52 days of therapy, a repeat computed tomography scan showed reduction in the lung nodule size to 1-2 mm. He underwent (131)I therapy 87 days after sorafenib was started. A post-treatment scan showed extensive uptake throughout the lungs and thyroid bed, supraclavicular nodes, and cervical nodes. This is the first reported case of a pediatric patient with respiratory failure possibly secondary to diffuse micronodular PTC requiring mechanical ventilation and subsequent delay in definitive therapy. Sorafenib could be considered for gap therapy when (131)I therapy cannot be administered in a timely manner. Treatment with this multikinase inhibitor does not seem to adversely affect the uptake of (131)I in radiation-naïve patients.

Cardiac metastasis from yolk sac tumor: case report and review

Cardiac metastasis of germ cell tumors is extremely rare, particularly in females. We report a case of a 26-year-old previously healthy woman who presented with a 5-month history of abdominal pain, weight loss, fever, generalized lymphadenopathy, and acanthosis nigricans. Biopsy of cervical lymph nodes revealed a poorly differentiated neoplasm. Immunohistochemical staining was positive for alpha-fetoprotein suggesting the diagnosis of a germ cell tumor. During the investigation, the patient developed heart failure and a mass attached to the right ventricle was detected by the echocardiogram. In a few days, she developed multiple organ failure and died. Post-mortem examination revealed a malignant mixed germ cell tumor of the right ovary with extensive hematogenic and lymphatic dissemination, a polypoid mass attached to the right ventricle, emboli in the endocardial and epicardial vessels, and infiltration surrounding the coronary arteries. To the best of our knowledge this is the third report of grossly visible heart metastases from a yolk sac tumor in a female patient. A summary of all published cases of germ cell tumors with cardiac metastasis over the last 20 years is also presented.

Improvement of the sentinel lymph node detection rate of cervical sentinel lymph node biopsy using real‐time fluorescence navigation with indocyanine green in head and neck skin cancer

The standard technique using lymphoscintigraphy, blue dye and a gamma probe has established a reliable method for sentinel node biopsy for skin cancer. However, the detection rate of cervical sentinel lymph nodes (SLN) is generally lower than that of inguinal or axillary SLN because of the complexity of lymphatic drainage in the head and neck region and the "shine-through" phenomenon. Recently, indocyanine green fluorescence imaging has been reported as a new method to detect SLN. We hypothesized that fluorescence navigation with indocyanine green in combination with the standard technique would improve the detection rate of cervical sentinel nodes. We performed cervical sentinel node biopsies using the standard technique in 20 basins of 18 patients (group A) and using fluorescence navigation in combination with the standard technique in 12 basins of 16 patients (group B). The mean number of sentinel nodes was two per basin (range, 1-4) in group A and three per basin (range, 1-5) in group B. The detection rate of sentinel nodes was 83% (29/35) in group A and 95% (36/38) in group B. The false-negative rate was 6% (1/18 patients) in group A and 0% in group B. Fluorescence navigation with indocyanine green may improve the cervical sentinel node detection rate. However, greater collection of data regarding the usefulness of cervical sentinel node biopsy using indocyanine green is necessary.

Diagnostic yield of biopsies of cervical lymph nodes using a large (14‐gauge) core biopsy needle

The purpose of this study was to assess retrospectively complications and diagnostic yield of core needle biopsy (CNB) of cervical lymph nodes using 14-gauge as sole needle bore. During a 10-year period ultrasound (US)-guided CNB, using a 14-gauge Tru-Cut needle (non-advancing), was performed in 140 consecutive cases (135 patients, aged 8-88 years) when a detailed histological diagnosis was required to guide therapy. CNB findings were consistent with the final diagnosis in 129 of the 140 cases, comprising 36 benign lesions, 40 metastases, and 53 lymphomas (40 NHL and 13 HL) of which subclassification (WHO criteria) was partial in 5NHL, and complete in 35 (87.5%) NHL and 13 HL (100%), including all 7 lymphomatous nodes with short-axis diameter ≤1.0 cm. Two lymphomas were falsely interpreted as reactive hyperplasia. Nine samples (6.4%) were inadequate for histopathological analysis. One patient experienced pain in an arm lasting 3-4 days. No other immediate or delayed complications were diagnosed. A 14-gauge may be used safely as the sole needle bore in US-guided CNB of cervical lymph nodes, rendering samples sufficient for full subtyping in lymphoma, even in the smallest nodes.

Histomorphological Pattern of Cervical Lymphadenopathy

Background: Enlarged palpable cervical lymph nodes as a primary presenting sign are very common and may be due to inflammatory lesions and tumors. Correlation between clinical findings and laboratory data is essential in arriving at a diagnosis. In patients presenting with cervical lymphadenopathy, excision biopsy provides material to establish an early diagnosis. We designed this study in our population for histological evaluation of cervical lymph node biopsies that might be important in the management of these patients. Objective: Histopathological evaluation of different diseases involving the cervical lymph nodes in relation to age and sex of the study population. Materials and Methods: It was a cross sectional study conducted in the department of Pathology, Enam Medical College & Hospital, Savar, Dhaka during the period from January 2006 to December 2010. A total of 107 patients were evaluated for specific cause of cervical lymphadenopathy in relation to age and sex. Lymph node biopsies of all patients of both sexes and all age groups were included in the study. Results: Among the 107 subjects 58 (54.2%) were males and 49 (45.8%) were females with a male to female ratio of 1.2:1. The age of the patients ranged from 2 to 85 years with a mean age of 32.68 ± 18.01 years. Of the 107 lymph node biopsies, 34 cases (31.8%) were reactive lymphadenitis, 41 cases (38.3%) were tuberculosis, 2 cases (1.9%) were non-caseous granuloma, 6 cases (5.6%) were Hodgkin lymphoma, 8 cases (7.5%) were non-Hodgkin lymphoma, 12 cases (11.2%) were metastatic neoplasm and 4 cases (3.7%) were other specific lesions. Conclusion: The commonest cause of cervical lymphadenopathy was tuberculosis, followed by reactive lymphadenitis, lymphoma and metastatic neoplasm. DOI: http://dx.doi.org/10.3329/jemc.v3i1.13837 J Enam Med Col 2013; 3(1): 13-17

Radiological remission and recovery of thirst appreciation after infliximab therapy in adipsic diabetes insipidus secondary to neurosarcoidosis

Neurosarcoidosis is a rare and aggressive variant of systemic sarcoidosis which may result in hypothalamic-pituitary dysfunction. We report a case of hypothalamic hypopituitarism secondary to neurosarcoidosis complicated by adipsic diabetes insipidus (ADI). Initiation of anti-tumour necrosis factor-α (TNF-α) therapy resulted in both radiological disease remission and recovery of osmoregulated thirst appreciation after 3 months. A 22-year-old man was referred to the endocrinology service with profound weight gain, polyuria and lethargy. Biochemical testing confirmed anterior hypopituitarism while posterior pituitary failure was confirmed by hypotonic polyuria responding to desmopressin. Magnetic resonance imaging (MRI) demonstrated extensive hypothalamic infiltration; neurosarcoidosis was confirmed histologically after excisional cervical lymph node biopsy. Osmoregulated thirst appreciation was normal early in the disease course despite severe hypotonic polyuria. However, subsequent subjective loss of thirst appreciation and development of severe hypernatraemia in the setting of normal cognitive function indicated onset of ADI. Clinical management involved daily weighing, regular plasma sodium measurement, fixed daily fluid intake and oral desmopressin. We initiated immunosuppressive therapy with pulsed intravenous anti-TNF-α therapy (infliximab) after multidisciplinary team consultation. Infliximab therapy resulted in successful radiological disease remission and complete recovery of osmoregulated thirst appreciation. This was confirmed by subjective return of thirst response and maintenance of plasma sodium in the normal range in the absence of close biochemical monitoring.

The case of the sinister spores: The patient was hospitalized for a menacing infection in the second trimester of pregnancy

The case of the sinister spores: The patient was hospitalized for a menacing infection in the second trimester of pregnancy

IgG4‐related disease with hypergammaglobulinemic hyperviscosity and retinopathy

Immunoglobulin G4-related disease (IgG4-RD) is a recently described entity with protean manifestations. We describe a novel case of IgG4-RD with hypergammaglobulinemic hyperviscosity responsive to fludarabine and rituximab. A 33-year-old Asian man developed bilateral lacrimal gland and submandibular salivary gland swelling with cervical lymphadenopathy. Biopsies of the affected tissues revealed reactive follicular hyperplasia. Seven years later, he presented with bilateral retinal hemorrhages due to hyperviscosity syndrome from profound polyclonal increase in IgG, including marked IgG4 elevation. Despite plasmapheresis, overproduction of IgG continued and he was refractory to systemic steroids, azathioprine, interferon alpha, and cyclophosphamide. IgG4-RD was suspected following a myocardial infarction and detection of aneurysmal coronary arteries indicating large vessel vasculitis. Review of the cervical lymph node and lacrimal gland biopsies with immunohistochemical staining for IgG4-positive plasma cells confirmed IgG4-RD. B-cell depletion with rituximab produced a partial response, but clinical symptoms and elevated protein levels persisted. Fludarabine was added to rituximab to suppress T-cell activity, and this resulted in an excellent clinical and biochemical response. Combination therapy with fludarabine and rituximab in IgG4-RD has not previously been reported and can be considered in patients with severe refractory disease.

Sinus histiocytosis with lymphadenopathy - a case report

Sinus histiocytosis with lymphadenopathy is a rare condition of unknown etiology that is characterized by the overproduction of histiocytes accumulating in the lymph node sinuses and in the lymphatics of extranodal sites if involved. Lymph nodes of the neck are the most common place of histiocyte accumulation, although other lymph nodes and organs may involve, as well. The common sites of the disease outside the lymph nodes are skin, soft tissues, upper respiratory tract, the sinuses, kidney, thyroid, small bowel, breast, and bone. Hepatosplenomegaly is uncommon. The symptoms of this disease vary with the site of involvement. It is often referred to as sinus histiocytosis with massive lymphadenopathy (SHML). In this article an adult male of 38 years, has been described who presented with bilateral cervical and axillary lymphadenopathy clinically suspected of infectious (tubercular-in the context of our country) or hematological malignant etiology. However on fine needle aspiration cytology, the smears showed many histiocytes, lymphocytes and plasma cells. Biopsy of cervical lymph node showed dilated sinuses filled with histiocytes and lymph node architecture showing inflammatory cells having lymphocytes and histiocytes. These findings were considered consistent with sinus histiocytosis with chronic lymphadenitis.DOI: http://dx.doi.org/10.3329/kyamcj.v2i2.13266KYAMC Journal Vol.2(2) January 2012, 205-208

Lymphoma and cervical lymphadenopathya

Introduction: Cervical lymphadenopathy is a common presentation with diverse etiologies. Lymphoma with all its subtypes is considered to be one of the common pathologies that cause lymphadenopathy especially in the neck.Lymphoma is one of the commonest malignancies all over the globe., and is considered as one of the second commonest malignancy in Saudi Arabia.Aim: To report the incidence of lymphoma in cervical lymphadenopathy at a single institution (King Abdulaziz University Hospital, Jeddah) over a 6 years period (2006 – 2011).Design: A retrospective study was conducted. Approval from the ethic committee for research was obtained. Due to the diversity of different software for the data base, all the following nomenclatures were considered potential cases: cervical lymph node biopsy, lymphadenopathy, lymph node biopsy, neck node biopsy, neck dissection, true cut neck biopsy and lymphadenectomy.Results: There were 271 cases of cervical lymph node biopsies, 86 of which were diagnosed as lymphoma.Conclusion: This incidence showed that lymphoma should be on top of the differential diagnosis list for both genders and cross all age groups.

A Case Report of Fever of Unknown Origin (FUO)

A 10-year-old boy had a long time of fever, and was diagnosed as JRA at first, but the patient’s condition got worse and worse after the treatment, then we did the cervical lymph node biopsy, which showed ALCL (Anaplastic Large Cell Lymphoma). After receiving the correct treatment, the patient’s condition got better.

Transformation of Nonfunctioning Pancreatic Neuroendocrine Carcinoma Cells into Insulin Producing Cells after Treatment with Sunitinib

We report a rare case of severe hypoglycemia after sunitinib treatment for pancreatic neuroendocrine carcinoma. We describe the initial clinical presentation, laboratory results, pathologic findings, and managment in a patient with a nonfunctioning pancreatic neuroendocrine carcinoma with liver metastases who developed life threatening hypoglycemia after 2 months of sunitinib therapy. A 46-year-old woman presented to the emergency department with loss of consciousness from hypoglycemia. Serum C-peptide and insulin levels at fasting state revealed that the hypoglycemia resulted from endogenous hyperinsulinemia. She had been diagnosed with nonfunctioning pancreatic neuroendocrine carcinoma based on a biopsy of metastatic cervical lymph node and was being treated with sunitinib, a small molecule tyrosine kinase inhibitor. Immunohistochemical stain of the metastatic liver mass demonstrated that the initially nonfunctioning neuroendocrine carcinoma cells had changed into insulin-producing cells after sunitinib therapy. Transarterial chemoembolization of the liver masses and systemic chemotherapy with streptozotocin/adriamycin relieved the hypoglycemia. A nonfunctioning pancreatic neuroendocrine carcinoma was transformed into an insulin-producing tumor after treatment with sunitinib, causing endogenous hyperinsulinemia and severe hypoglycemia.

Coexistence of Hodgkin’s Lymphoma and Castleman’s Disease: A Case Report with Successful Response to Chemotherapy and Radiotherapy

Background. Castleman's disease is a rare clinicopathological entity of unknown origin. Coexistence of Hodgkin's lymphoma and Castleman's disease is rare. We report a case of Hodgkin's disease of cervical lymph nodes in a patient previously diagnosed with Castleman's disease. Case Presentation. A 43-year-old man admitted in July 2009 for a right cervical pain with lymph node at the physician examination. He underwent a right adenectomy and histological studies showed typical features of Castleman's disease. Three years after, the patient consulted for increasing the volume of cervical lymph node. Clinical examination showed a right cervical lymph node of 3 cm. The computed tomography scan of chest, abdominal and pelvic was normal. Histological and immunohistochemical studies of cervical lymph node biopsy specimen were in favor of Castleman's disease associated with Hodgkin's disease. Reed-Sternberg cells were positive for CD15 and CD30. The patient received chemotherapy based on anthracyclines, bleomycin, vinblastine, and dacarbazine (ABVD) and radiotherapy with complete response. Conclusion. Prevalence of Hodgkin's lymphoma in Castleman's disease is more difficult to establish because of the low number of cases reported in the literature.

Classical Hodgkin's lymphoma infiltrated both lungs.

Usually Hodgkin's lymphoma occurs in the mediastinum and head and neck regions. On rare occasions, the first manifestation of Hodgkin's lymphoma may be a disorder of an extranodal site, such as the gastrointestinal tract, nasopharyngeal region, central nervous system, kidney, or other sites. Few cases of classical Hodgkin's lymphoma with pulmonary infiltration have been reported in the literature. Herein, we report a case of classical Hodgkin's lymphoma with infiltration of both lungs. Ultrasound detected many enlarged lymph nodes in the neck region, without blood flow signals shown by Color Doppler Flow Imaging CDFI. The chest CT scan revealed many enlarged lymph nodes in the mediastinum and multiple scattered consolidation lesions involving both lungs. The diagnosis of classical Hodgkin's lymphoma, nodular sclerosis subtype, was made on a subsequent cervical lymph node biopsy.

P50 Pituitary Granulomata - TB or Not TB

Granulomatous disease of the pituitary gland is rare and of this pituitary tuberculosis (TB) is the rarest, making its diagnosis or exclusion challenging. We discuss six cases. Patients ages ranged...