Cervical Node Biopsy Research Articles

SUN-627 Unexpected Presentation of a Primary Thyroid T-Cell Lymphoma

Background Thyroid T-cell lymphoma is an unusual diagnosis, responsible for less than 2% of all thyroid malignancies and all extra-nodal lymphomas. Hashimoto’s thyroiditis may predispose patients to its development, but only half of the cases reported were associated with it. We present a case of a 42 years old man with generalized skin rash with subsequent development of a rapidly growing anterior neck mass arising from the thyroid gland without TFT impairments. Ultimately, an excisional cervical node biopsy disclosed immune-pathological characteristics of Angioimmunoblastic T-cell lymphoma. Clinical Course A 42 y/o Hispanic male patient without past medical history, presents for the first time complaining of a generalized intense pruritic-excoriated skin rash of 3-week duration. Rest of physical examination and biochemical test were unremarkable. Five weeks later, he reports worsening skin rash and rapid enlargement of a painless anterior neck mass. Review of systems was non contributory. An enormous, not previously palpated, left thyroid mass and a cervical lymphadenopathy was found. Laboratory data reported leukocytosis with lymphocytic predominance, microcytic hypochromic anemia and mild hypercalcemia. Analysis of ANA test, HIV test, Hepatitis profile and VDRL were negative. TFT within normal reference, and negative TPO-antibodies. Auxiliary laboratory test as CRP, ESR and LDH were elevated. A thyroid ultrasound showed multiple cervical lymph nodes with intense hilar vascularity and a large isoechoic nodularity involving upper, lower and interpolar left thyroid region, measuring 7.4cm-CC x 3.9 cm-AP x 5.3 cm-TRV. FNA biopsy reported unspecific lymphoma. Supplemental excisional lymph node biopsy disclosed pathological diagnosis of a T-cell lymphoma with immunophenotype of Angioimmunoblastic type. Further PET CT and CT scans of head, neck and abdominopelvic area, suggested a large enhancing posteriorly extended neck mass, intimately associated and originating from the left thyroid gland. The diagnosis of a Primary Thyroid Angioimmunoblastic T-cell Lymphoma was established and patient was referred to an Oncology evaluation for staging and management considerations. Discussion Angioimmunoblastic T-cell Lymphoma is a rare form of non-Hodgkin lymphoma arising from the lymphatic system not from the thyroid gland. In addition, a metastatic process in our patient was ruled out, following the definition of primary thyroid lymphoma which exclude direct malignant invasion to the thyroid gland. According to our literature revision, no cases of such pathology have yet been reported. We consider that our case poses a unique etiological manifestation with extraordinary clinical significance worthy to be the first one communicated in order to diversify diagnostic approach of unexpected manifestations of a thyroid diseases.

A CASE REPORT OF SYNCHRONOUS PRIMARY MALIGNANCY: PAPILLARY THYROID CARCINOMA AND NON-HODGKIN’S LYMPHOMA

Multiple primary malignancies involving papillary thyroid carcinoma and non-Hodgkin’s lymphoma (NHL) is an extremely unusual event. Here, we report the case of a 70-year-old man presented with high-grade fevers and abdominal discomfort and were found to have pancytopenia. He had generalized lymphadenopathy, hepatosplenomegaly, goiter, and tracheal shift. Biopsy of the left cervical lymph node was positive for papillary carcinoma of the thyroid. He underwent excision biopsy of axillary lymph node which was suggestive of high-grade NHL. The patient was started on chemotherapy (R-CHOP) and his fevers resolved promptly. He then underwent total thyroidectomy and the histopathology of the thyroid gland post-operative showed papillary carcinoma. The second primary malignancy is a second malignant neoplasm occurring in a patient with known cancer. This case highlights the unusual synchronous occurrence of the papillary carcinoma of thyroid and NHL and the diagnostic challenges involved in such cases.

Pneumococcus a Rare Cause of Cellulitis

Streptococcus Pneumoniae (S. pneumoniae) is a common cause of community-acquired pneumonia, although its manifestation as a skin infection is a rare phenomenon. Most skin infections are secondary to Staphylococcus aureus or Streptococcus pyogenes, however, cellulitis caused by pneumococci is an infrequent finding. Pneumococcal cellulitis most often occurs due to bacteremia in patients with chronic illnesses such as diabetes, underlying malignancies, immunosuppressed patients, and patients with the history of injection drug abuse. The nature of the infection can be very fatal leading to fasciitis, myonecrosis, septic shock and ultimately death. We present a case of a 61-year-old female who developed painful swelling and redness of the right face along with bilateral leg involvement. In the emergency room, physical examination revealed multiple cervical lymphadenopathies. Further diagnostic investigations disclosed Low-grade B-cell non-Hodgkin lymphoma upon cervical lymph node biopsy. Blood culture grew Streptococcus pneumoniae as a source of cellulitis. This case demonstrates the importance of immune defects and the ensuing development of pneumococcal-induced cellulitis. Physicians should be vigilant while treating Pneumococcal cellulitis as this may be a sign of the serious underlying medical condition.

Development of Gray Zone Lymphoma during Remission of Classical Hodgkin Lymphoma

Although Hodgkin lymphoma (HL) is largely curable with frontline treatment, many patients will not have a complete response or will later relapse. Recurrence of HL often occurs within the first five years in remission. However, recurrence rates vary widely and are largely dependent on lymphoma type, stage, patient age, and other variables [Devita, 2015]. In this case, we discuss an individual with HL in remission for over a decade, who was found to have Gray Zone Lymphoma (GZL). GZL is a rare lymphoma with intermediate features between classical Hodgkin lymphoma (cHL) and Diffuse Large B-cell Lymphoma (DLBCL), but cannot be classified as one or the other [Evans, 2015]. We report this case to discuss the recurrence of HL that progressed and transformed into GZL.A 75-year-old male with a significant history of HL in remission, presented with sudden onset of bilateral lower extremity weakness. The patient had associated back pain, 3 weeks of fatigue, decreased appetite, and decreased urine output for the last two days. He denied any nausea, vomiting, fever, chest pain, cough, and bowel or bladder incontinence.Vital signs were significant for blood pressure of 97/56 mmHg and fever of 102.5°F. Pertinent physical examination findings included diffuse cervical, axillary, and inguinal lymphadenopathies, and hepatomegaly. Pedal edema was also noted on both lower extremities, but more pronounced on the right lower extremity. Initial pertinent labs were a leukocytosis (37,600 u/L), lactic acid of 6.4 (0-1.99 mmol/L), hyponatremia (133 u/L), and bicarbonate of 18 (22-30 mEq/L) with a normal anion gap.The patient was admitted for sepsis of unknown origin and was started on vancomycin and meropenem. Ultra sound of the right leg, CT chest, and abdominal CT angiogram with and without contrast revealed right deep venous thrombosis, pulmonary embolism in the segmental branch of the left lung, and lymphadenopathy in the chest, abdomen and numerous retroperitoneal soft tissue masses that were suspicious for enlarged lymph nodes respectively. The patient was started on therapeutic enoxaparin.The bone marrow aspirate was found to be inconclusive. Cervical lymph node biopsy showed CD30+ large cell hematolymphoid neoplasm with features intermediate between DLBCL and HL - otherwise classified as GZL. There is no standard treatment for GZL, therefore the patient was given cHL chemotherapy regimen of ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine). The patient received 1 dose of ABVD in the hospital and was discharged to follow as outpatient. Although the patient was initially admitted for sepsis, pan cultures were unremarkable, suggesting that his symptoms were attributable to malignancy.We discuss this case to describe the recurrence and progression of Hodgkin lymphoma to Grey Zone lymphoma. Very few cases of GZL have been described in literature. To date, a treatment regimen for GZL remains to be elucidated due to the sparsity of this phenomenon. Because GZL shows intermediate characteristics between cHL and DLBCL, it is currently treated as either cHL and DLBCL [Pilichowska, 2017].[Pilichowska, 2017]. DisclosuresNo relevant conflicts of interest to declare.

RECURRENT FEVER IN A 17-MONTH-OLD MALE BORN VIA ASSISTED REPRODUCTIVE TECHNOLOGY

Introduction While assisted reproductive technology using third-party gamete donors has enabled many live births, the industry remains largely unregulated in testing for heritable diseases. We present the case of a 17-month-old male, born to a same-sex couple via oocyte donation, who developed recurrent fevers with new onset of generalized lymphadenopathy (LAD). Case Description A 17-month-old male presented with 7 months of intermittent fever ranging from 2 days to 2 months and new onset LAD, most prominent in the cervical node, with presumptive diagnosis of periodic fever adenitis pharyngitis aphthous ulcer (PFAPA) syndrome. However, the fevers were responsive to empiric oral antibiotics, which suggested an infectious rather than auto-inflammatory etiology. Dihydrorhodamine (DHR) flow cytometry revealed an oxidative burst pattern consistent with X-linked chronic granulomatous disease (X-CGD) confirmed by genetic testing. Cervical lymph node biopsy and culture grew Serratia marcescens. The patient was referred for bone marrow transplant. Discussion Regulations regarding gamete donation by the FDA solely encompass screening for infectious agents. The American Society for Reproductive Medicine has practice guidelines recommending a thorough family history and genetic testing as indicated. Yet, there remains considerable variability in screening practices among fertility centers. Expanded carrier screening is available for genetic disorders but this would increase the cost of screening and potentially shrink the available gamete donor pool. A solution balancing the rare but devastating outcome of having a child with a genetic disorder with the downside of expanded screening is needed to prevent such cases in the future.

A Case of Primary Biliary Tuberculosis with Subsequent Pulmonary Presentation

Introduction: The term hepatobiliary tuberculosis refers to the rare and localized form of hepatic tuberculosis as a distinct clinical entity, with signs and symptoms related to the hepatobiliary tract. We aimed to report a case of the primary biliary tuberculosis with subsequent pulmonary presentation. Case Presentation: A 28-year-old woman was admitted to our hospital due to recurrent abdominal pain, low-grade fever, and icterus and with a temperature of 38.2°C. According to magnetic resonance cholangiopancreatography (MRCP) with bile duct dilatation, IgG4, and high eosinophil with impression of autoimmune cholangiopathy, corticosteroid was administered. A few weeks later, she was hospitalized again because of fever and leukocytosis and the creation of multiple lymph nodes in the neck and abdomen. Biopsy of cervical lymph node was performed, which was not diagnostic. Smear, culture, and polymerase chain reaction (PCR) to detect tuberculosis were negative. According to eosinophilia and hypointense masses with the possibility of parasitic causes (Fasciola hepatica) triclabendazole was started. The symptoms briefly improved and she had little weight gain, but four months later she was hospitalized with pulmonary symptoms. Culture and sputum smear were positive for acid-fast bacilli. Conclusions: Hepatobiliary tuberculosis has delayed presentations with nonspecific manifestations. In our patient, despite that clinical presentations matched those of hepatobilliary tuberculosis, multiple biopsies from the abdominal and prepheral lymph nodes could not verify it. Therefore, diagnosis was made with delay, and finally, pulmonary presentation and positive smear for acid-fast bacilli confirmed tuberculosis.

ENDOBRONCHIAL PRESENTATION OF HODGKIN'S LYMPHOMA

SESSION TITLE: Lung Pathology 1 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Lymphomas commonly present with constitutional symptoms and lymphadenopathy. Rarely do they present as endobronchial tumors (1). We report a rare case of endobronchial presentation of Hodgkin’s Lymphoma. CASE PRESENTATION: 66-year old female with diabetes, hypertension, Hodgkin’s lymphoma (diagnosed 1 month prior, with an excisional biopsy of cervical lymph node) status post 1 dose of Rituximab, presented to the ER with fever, cough, chills and a purulent carbuncle on her right thigh. She was afebrile, tachycardic with a heart rate of 107 but otherwise had normal vitals, with an oxygen saturation of 100% on room air. Laboratory results showed Hemoglobin and Hematocrit of 7.4 g/dL and 23.8, and lactic acid of 3.8 mmol/l. CT chest showed multiple patchy opacities in both lungs, large consolidation in the lingula (new compared to her previous scan done 6 weeks earlier), stable mediastinal adenopathy and bilateral axillary adenopathy which was new. Patient was started on broad spectrum antibiotics to cover pneumonia and bronchodilators for symptomatic relief. Despite this patient continued to worsen with regard to her respiratory symptoms requiring commencement of systemic steroids for bronchospasm. Even though she had symptomatic relief, repeat chest imaging showed worsening of lung infiltrates and hence she underwent bronchoscopy. Bronchoscopy showed an endobronchial mass in the left main stem bronchus, resembling a mucus plug. Core biopsy and brushings were sent for histopathological analysis which showed Hodgkin’s lymphoma, classical type. Patient was started on chemotherapy and is currently being followed up in our cancer center. DISCUSSION: Hodgkin’s disease of the lung usually presents as mediastinal lymphadenopathy (2). Presentation of Hodgkin's disease as an endobronchial lesion is uncommon (<5%). The possible mechanism responsible for endobronchial disease is either by direct bronchial invasion or by hematogenous dissemination. Patients usually develop respiratory symptoms due to compression of the airways. Gross appearance of the lesion can mimic small cell cancer. It has been proposed that to be recognized as an endobronchial presentation of Hodgkin's disease, the case has to fulfill the following criteria at the time of initial diagnosis: (i) histological features of Hodgkin's disease (whatever the site of biopsy) and (ii) bronchoscopic visualization of an endobronchial tumor. It is a potentially curable disease with dual chemotherapy regimen. CONCLUSIONS: A bronchoscopy may be warranted in patients that have been diagnosed with Hodgkin’s lymphoma and develop new respiratory symptoms. Though infections should always be in the differential diagnosis, especially as these patients are also immunocompromised, the possibility of endobronchial involvement must be considered. If unrecognized, this can lead to under-staging of a potentially curable disease, that can compromise the cure. Reference #1: 1. Prakash R. Malur, Gajanan S. Gaude, Hema B. Bannur, Shivappa B. Anurshetru, Vijayalaxmi V. Suranagi, Ranjit P. Kangle, Annasaheb J. Dhumale, Pradeep H. Patil, and Reshma Davanagere. Primary endobronchial Hodgkin's disease. Lung India. 2009 Oct-Dec; 26(4): 136–138. Reference #2: 2. Ben Naoum Y, Chapuis E, Coste E, Marty-Double C, Vincent D. [Bronchial presentation of stage IVB Hodgkins disease]. Rev Mal Respir. 2004 Jun;21(3 Pt 1):599-601. DISCLOSURES: No relevant relationships by Anna Abbasi, source=Web Response No relevant relationships by Prarthna Chandar, source=Web Response No relevant relationships by Kabu Chawla, source=Admin input No relevant relationships by William Pascal, source=Web Response No relevant relationships by Anand Rai, source=Web Response No relevant relationships by Ben Shamian, source=Web Response No relevant relationships by Shyam Shankar, source=Web Response

Cervical Lymph Node Fine-Needle Aspiration and Needle-Wash Thyroglobulin Reflex Test for Papillary Thyroid Carcinoma.

Fine-needle aspiration (FNA) cytology coupled with needle-wash thyroglobulin (FNA-Tg) testing is recommended for cervical lymph node (LN) biopsies in patients with a history of papillary thyroid carcinoma (PTC). However, the procedure has not been standardized with the assay for FNA-Tg testing. A standard operating procedure (SOP) has been generated at our facility for cervical LN FNAs with Tg reflex testing on patients with a history of PTC. The procedure requires FNA cytology to be reviewed first, and all cases not positive for PTC are reflexed for FNA-Tg testing with the Beckman Access thyroglobulin assay. The thyroglobulin cutoff value is ≤ 1.0ng/mL. From 2016 to 2017, 117 patients, including 71 women and 46 men, were identified as having a history of PTC. Patients' clinical characteristics were collected from medical records. A total of 143 LN biopsies were investigated for these patients. The results show that four out of 11 (36.4%) non-diagnostic LNs and five out of five (100%) atypical/suspicious LNs tested positive for FNA-Tg. Among these nine patients with positive thyroglobulin testing, LN metastases were proven histologically for all nine patients, and two patients were treated with LN ablation. Out of 68 LNs positive for PTC, three had FNA-Tg results. FNA-Tg testing was ordered for unknown reasons on two positive LNs (> 5000ng/mL thyroglobulin) from one patient. The third LN was tested due to non-classic morphology, and the result was less than the cutoff value. Three patients with negative LN biopsies were tested to have elevated (> 1.0ng/mL) thyroglobulin levels. One patient (FNA-Tg ng/mL) was proven to have multiple metastatic LNs through follow-up surgery. However, no positive LN was identified for the other two patients who had FNA-Tg level of 4.1ng/mL and 37ng/mL respectively. This is likely due to contamination, as these two patients had intact thyroids. In our practice, the FNA-Tg test is a very useful adjunct test to LN FNA specimens with a non-positive diagnosis in patients with a history of PTC. Furthermore, FNA-Tg testing increases diagnostic sensitivity among non-diagnostic and atypical/suspicious LNs. However, FNA-Tg testing should not substitute conventional cytology due to the following reasons: (1) false-negative thyroglobulin lab results; (2) PTC with loss of thyroglobulin expression; (3) LN metastasis from other origins; and (4) false-positive thyroglobulin testing due to blood contamination in patients who are not completely athyrotic.

PS01.108: SPONTANEOUS ESOPHAGOCUTANEOUS FISTULA IN KIKUCHI DISEASE

Abstract Background Kikuchi disease is a rare, self-limiting condition that is characterized by histiocytic necrotizing lymphadenitis with unknown pathogenesis. Common presentation is cervical lymphadenopathy and fever in a previously well young female. Mediastinal lymph node involvement is uncommon. Methods We report a case of spontaneous esophagocutaneous fistula secondary to necrotizing mediastinal lymphadenopathy in a patient with Kikuchi disease. Results A 38-year-old lady presented with fever and right back pain of two weeks duration. She had background history of Kikuchi disease which was diagnosed 1 year ago. Examination revealed multiple enlarged left cervical lymph nodes and right back tenderness. CT scan showed an esophagocutaneous fistula with right paraspinal abscess and multiple enlarged cervical and mediastinal lymph nodes. OGDS revealed a 5mm fistula opening at right posterior wall of distal esophageal, 3cm proximal to esophagogastric junction. Rest of esophagus and stomach were normal. Tuberculosis and SLE workup were negative. Cervical lymph node biopsy was consistent with Kikuchi disease. She was treated as spontaneous esophagocutaneous fistula secondary to necrotizing mediastinal lymph node with underlying Kikuchi disease. Percutaneous drainage of paraspinal abscess was done and antibiotics were commenced. Laparoscopic feeding jejunostomy was done for feeding. Esophageal stenting and endoscopic clipping of fistula were attempted but the fistula tract persisted. She then underwent laparoscopic excision of esophageal fistula tract (LEEFT). Intraoperative findings were dense inflamed paraesophageal tissue with thickened fistula tract at right posterolateral wall of distal esophagus with multiple enlarged mediastinal lymph nodes. Fistula tract and the lymph nodes were excised via laparoscopic transhiatal approach. She had an uneventful recovery and was discharged on post-operative day 7. Conclusion Spontaneous esophageal fistula is rare and necrotizing mediastinal lymphadenopathy needs to be considered. Laparoscopic excision of esophageal fistula tract (LEEFT) is a novel transhiatal approach and it is feasible in distally located fistula. Disclosure All authors have declared no conflicts of interest.

Ultrasonography-guided core needle biopsy of cervical lymph nodes for diagnosing head and neck lymphoma compared with open surgical biopsy: Exploration for factors that shape diagnostic yield

PurposeThis study was conducted to compare the diagnostic yields of Ultrasonography-guided core needle biopsy (USG-CNB) and open surgical biopsy (OSB) in head and neck (HN) lymphoma and to identify the factors that shape USG-CNB diagnostic yield. Materials and methodsAll consecutive patients who were diagnosed with HN lymphoma in our hospital were analyzed. The frequencies with which these first-line procedures yielded a sample that permitted histological confirmation of lymphoma were determined. To identify the factors that shape the diagnostic yield of USG-CNB, the patients in whom USG-CNB was and was not sufficiently confirmatory were compared in terms of demographics, computed tomography (CT) and pathological findings. ResultsIn total, 83 patients underwent USG-CNB (n = 26, 31.3%) or OSB (n = 57, 68.7%) for confirming lymphoma. USG-CNB yielded a fully sufficient diagnosis in 18 (69.2%) patients. By contrast, OSB yielded a confirmative diagnosis in 56 (98.2%) patients. Maximal standardized uptake value (SUVmax) of targeted LN on positron emission tomography-CT (PET-CT) in confirmatively diagnosed subjects was much higher than deferred counterparts (22.9 ± 13.4 vs. 10.1 ± 5.2, p = 0.017), however, there was no significant difference in other parameters associated with the first-line USG-CNB diagnostic success. ConclusionsFirst-line USG-CNB was less frequently successful than OSB for diagnosing HN lymphoma involving cervical LN. Mean SUVmax of LN on PET-CT in confirmatively diagnosed subjects was higher than deferred counterparts on USG-CNB.

Reliability of sonoelastography in predicting pediatric cervical lymph node malignancy

Controversy exists as regards the best non-invasive diagnostic tool for pediatric cervical lymphadenopathy. The current work aimed to evaluate the reliability, sensitivity, specificity, and accuracy of sonoelastography in diagnosing benign and/or malignant pediatric cervical lymphadenopathy. Prospective study took place over a period of 4years from January 2013 to December 2016. A total of 177 lymph nodes (LNs) in 128 children with an age ranging from 11months to 12years were recruited in this study. Patients were 77 males and 51 females with a ratio of 3:2. All patients underwent a thorough history taking and clinical examination of the neck focusing on the cervical lymph nodes. After that, a B-mode sonography, Color Doppler ultrasound, and Sonoelastography were performed. Elastographic patterns of 1-5 were evaluated, whereas patterns of 3-5 (firm to hard) were suspected to have a malignant nature. Sonographic-guided aspiration cytology took place in 107 lymph nodes and excisional biopsy in 102 lymph nodes, whereas 13 lymph nodes responded adequately to conservative treatment. They proved to be benign reactive hyperplasia. The majority of LNs (87%) were of the malignant type that showed an elastographic pattern of 3-5. The same patterns were observed in only 6 (3.4%) of the benign LNs. Sonoelastography showed a sensitivity of 85.9%, specificity of 100%, PPV of 100%, NPV of 75.96%, and overall accuracy of 90.23% in distinguishing benign from malignant lymph nodes. Using the B-Mode ultrasound, an abnormal hilum was seen in 75%. The accuracy of color Doppler US reached 82.7%. Sonoelastography may be superior to other US modalities in elucidating different cervical lymph node biopsy helping to distinguish benign from malignant lesions. This may replace the lymph node biopsies in the future. Moreover, its use in the follow-up of patients with cervical malignancies may reduce the number of future biopsies. Further studies with more patients may be needed for a better assessment of results.

Sensitivity and specificity of sentinel lymph node biopsy in patients with oral squamous cell carcinomas using indocyanine green fluorescence imaging

PurposeThe purpose of this clinical study was to evaluate the sensitivity and specificity of cervical sentinel lymph node biopsy after mapping with indocyanine green fluorescence (ICG) for imaging early-stage oral cancer. Patients and methodsA sentinel lymph node biopsy (SLNB) was performed during a selective neck dissection (SND) in 20 patients with oral squamous cell carcinoma (OSCC, cT1 or cT2, N0 status). The sentinel lymph nodes (SLN) were identified using an infrared video camera after ICG injection. Lymph nodes were examined histologically. The endpoint of this study was to investigate the rate of false-negative results in SLNB. ResultsSentinel lymph nodes could be detected after 8.1 min (range 1–22 min). In eight out of 20 cases, lymph node metastases were found during histopathological evaluation of the neck dissection specimen. In four cases a metastasis could be found in the detected SLN (sensitivity 50%). In the other four cases metastases were found in different lymph nodes. Specificity was 100%, positive predictive value 100%, and negative predictive value 75%. ConclusionIn this study, reliability of sentinel lymph node biopsy after ICG imaging could not be verified, as there were false-negative results in 50% of the cases. Therefore, SND can still be recommended as for patients with cT1 or cT2 OSCC, and a N0 neck status.

B-chronic lymphocytic leukemia showed triple transformation, to diffuse large B cell, CD20-negative, and T-cell neoplasm during ofatumumab treatment: a case report

BackgroundChronic lymphocytic leukemia (CLL) is a mature lymphoid neoplasm currently categorized as an indolent type of malignant lymphoma. CLL progresses slowly over years, but it eventually transforms to a more aggressive lymphoma such as the diffuse large B-cell (DLBCL) type, also known as Richter’s syndrome.Case presentationWe treated a 69-year-old Japanese male who was histologically diagnosed with Richter’s syndrome after 6 years of CLL. His lymphadenopathy had systemically progressed for years, with lymphocyte counts of less than 10,000 cells/μL and a disease status of Rai classification stage I and Binet classification B. He had high fever and hepatosplenomegaly upon Richter’s transformation. The patient was treated with ofatumumab for refractory CLL, which relieved his febrile lymphadenopathy. He received a total of 11 ofatumumab courses and achieved partial remission. On the day of the 12th course of ofatumumab, his disease relapsed with febrile lymphadenopathy. Computed tomography revealed multiple liver masses and systemic lymphadenopathy, while a liver biopsy confirmed T-cell lymphoma. Concomitantly, CD20-lacking CLL cells were detected in his peripheral blood and bone marrow, and pathological examination of his left cervical lymph node biopsy showed CD20-positive DLBCL. The final diagnosis was three different types of lymphoma pathologies: (1) CD20-positive DLBCL of the lymph nodes, (2) CD20-lacking CLL of the peripheral blood and bone marrow, and (3) peripheral T-cell lymphoma (PTCL) of the liver. He received intravenous and oral dexamethasone therapy as palliative care. He died because of the rapid progression of abdominal masses 2 months after the diagnosis of triple transformation CLL. An autopsy revealed aggressive PTCL with aggressive systemic involvement of the liver, spleen, gall bladder, pericardium, bone marrow, and mediastinal–paraaortic–intraceliac lymph nodes. T-cell receptor study of an autopsy specimen supported the diagnosis of PTCL that spread to the intraceliac organs and lymph nodes. We concluded that his pathogenicity progressed to a mixture of triple lymphoma as a result of double malignant transformations, which included PTCL from CLL, CD20-negative CLL, and CD20-positive DLBCL by Richter’s transformation.ConclusionsOur case provides information on the biology of CLL, to transform from a low-grade chemosensitive status to a malignant chemoresistant status.

Role of the fine-needle aspiration biopsy of cervical lymph nodes with thyreoglobulin washing tests in management patients with differentiate thyroid cancer.

Role of the fine-needle aspiration biopsy of cervical lymph nodes with thyreoglobulin washing tests in management patients with differentiate thyroid cancer.

Severe refractory TAFRO syndrome requiring continuous renal replacement therapy complicated with Trichosporon asahii infection in the lungs and myocardial infarction: an autopsy case report and literature review

BackgroundTAFRO (thrombocytopenia, anasarca, fever, reticulin myelofibrosis/renal failure, and organomegaly) syndrome is a systemic inflammatory disorder and unique clinicopathological variant of idiopathic multicentric Castleman disease that was proposed in Japan. Prompt diagnosis is critical because TAFRO syndrome is a progressive and life threating disease. Some cases are refractory to immunosuppressive treatments. Renal impairment is frequently observed in patients with TAFRO syndrome, and some severe cases require hemodialysis. Histological evaluation is important to understand the pathophysiology of TAFRO syndrome. However, systemic histopathological evaluation through autopsy in TAFRO syndrome has been rarely reported previously.Case presentationA 46-year-old Japanese man with chief complaints of fever and abdominal distension was diagnosed with TAFRO syndrome through imaging studies, laboratory findings, and pathological findings on cervical lymph node and bone marrow biopsies. Interleukin (IL)-6 and vascular endothelial growth factor (VEGF) levels were remarkably elevated in both blood and ascites. Methylprednisolone (mPSL) pulse therapy was initiated on day 10, followed by combination therapy with PSL and cyclosporine A. However, the amount of ascites did not respond to the treatment. The patient became anuric, and continuous renal replacement therapy was initiated from day 50. However, the patient suddenly experienced cardiac arrest associated with myocardial infarction (MI) on the same day. Although the emergent percutaneous coronary intervention was successfully performed, the patient died on day 52, despite intensive care. Autopsy was performed to ascertain the cause of MI and to identify the histopathological characteristics of TAFRO syndrome.ConclusionsBacterial peritonitis, systemic cytomegalovirus infection, and Trichosporon asahii infection in the lungs were observed on autopsy. In addition, sepsis-related myocardial calcification was suspected. Management of infectious diseases is critical to reduce mortality in patients with TAFRO syndrome. Although the exact cause of MI could not be identified on autopsy, we considered embolization by fungal hyphae as a possible cause. Endothelial injury possibly caused by excessive secretion of IL-6 and VEGF contributed to renal impairment. Fibrotic changes in anterior mediastinal fat tissue could be a characteristic pathological finding in patients with TAFRO syndrome.

Additional Cervical Lymph Node Biopsy is Not a Significant Prognostic Factor for Nasopharyngeal Carcinoma in the Intensity-Modulated Radiation Therapy Era: A Propensity Score-matched Analysis from an Epidemic Area.

Introduction: This study aimed to evaluate the prognostic value of cervical lymph node biopsy and whether different biopsy methods would lead different outcomes in NPC in the intensity-modulated radiotherapy (IMRT) era.Material and Methods: 1492 patients with biopsy-proven, non-metastatic NPC, and treated by IMRT with or without chemotherapy were retrospectively reviewed. Cervical lymph node biopsy was performed in 183 (12.3%) patients: 61(4.1%) by needle puncture and 118(7.9%) by excision biopsy. Propensity-score matching was used to match patients in both arms at an equal ratio. Overall survival (OS), distant metastasis-free survival (DMFS), locoregional relapse-free survival (LRFS), and nodal relapse-free survival (NRFS) were assessed using the Kaplan-Meier method and compared using the log-rank test. Independent prognostic factors were identified using the Cox proportional hazards model.Results: In the original cohort of 1492 patients, patients receiving cervical lymph node biopsy had comparable survival (OS: P = 0.736, DMFS: P = 0.749, LRFS: P = 0.538, NRFS: P = 0.093,) with patients receiving isolated napharynx biopsy. The results for the propensity-match cohort of 316 patients were similar. Interestingly, compared with the control group and needle puncture biopsy group, a slightly lower nodal recurrence rate was observed in the excision biopsy group (P = 0.082 and P = 0.072, respectively). Adjusting for the known prognostic factors in multivariate analysis, cervical biopsy did not cause a higher risk of death, distant metastasis, or nodal relapse.Conclusions: Pretreatment cervical lymph node biopsy is not associated with impaired survival in NPC, suggesting the resist of the biopsy and more aggressive treatment after the biopsy may be unnecessary.

Frequency of Infection in Cervical Lymph Node Biopsy Site using Chlorhexidine and Povidine Iodine

Abstract:Background: Lymph node are located throughout the lymphatic system, they are concentrated in certain areas of the body including head and neck. Cervical lymph nodes are lymph nodes found in the neck. Of the 800 lymph nodes in the human body, 300 are in the neck. Cervical lymph nodes are subject to several different pathological conditions including tumours, infection and inflammation.Methodology: The Povidine-iodine and chlorhexidine for preoperative skin preparation in cervical lymph node biopsy procedure were used in this study and patients were asked for follow up after a week. On follow up day their wounds were checked, assessed and withdraw all stiches and complications were recorded accordingly and analysed them. It was discussed and showed that which one of Povidine-iodine and chlorhexidine is best to use for preoperative skin preparation in cervical lymph node biopsy procedures to reduce surgical site infection and economical one.Results: Out of 150 patients, 46% (69) were males and 54% (81) were females that had cervical lymphadenopathy after skin preparation by chlorhexidine antiseptic solution showed frequency of infection in total of 150 patients 16.67% (25) were infected while the other 83.33%(125) were not infected. Out of 150 patients who were underwent cervical lymphadenopathy after using povidine iodine skin preparatory antiseptic solution, 42% (63) were males and 58% (87) were females and among those frequency of infection showed 44.67% (67) were infected while the others 55.33% (83) were not.Conclusion: Preoperative scrubbing of the patient’s skin with chlorhexidine–alcohol is better than scrubbing with povidone–iodine for preventing surgical-site infection after cervical lymph node biopsy.

Frequency of Infection in Cervical Lymph Node Biopsy Site using Chlorhexidine and Povidine Iodine

Frequency of Infection in Cervical Lymph Node Biopsy Site using Chlorhexidine and Povidine Iodine

Cervical Lymph Nodes in CA Prostate: An Easiest Tool to Deal with Diagnostic Dilemma

Cervical lymphadepathy is very common in many benign and malignant conditions. It is not only the easiest accessible tissues for making the correct diagnosis by histopathologic examination (HPE) but also may be the only presenting feature of the disease. We herein present a case of prostate cancer that was diagnosed only by the HPE and Immunohistochemistry (IHC) of the excised cervical lymph nodes. The importance of cervical lymph node biopsy has also been discussed.

IgG4-Related Disease with lymphadenopathy Presenting as a Cervical lymph node enlargement

During the course of evaluation and management of neck masses, consideration for Immunoglobulin G4-related disease (IgG4-RD) should be given. IgG4-RD is relatively a new growing entity of immune-mediated origin, characterized by a mass-forming lesion, the infiltration of IgG4-positive plasma cells and occasionally elevated serum IgG4. The most common manifestations are parotid and lacrimal swelling, lymphadenopathy and autoimmune pancreatitis.A previously healthy 72-year-old man was referred to our clinic with a 2-month history of left cervical lymph node enlargement without systemic manifestations . A cervical lymph node biopsy was planned because of elevated serum IgG4 levels. Pathological findings showed prominent infiltration of IgG4-postive plasma cells in the lymph node. After steroid therapy, a computed tomography scan revealed a decrease in the cervical lymph node size.This case illustrates the importance of including IgG4-RD in the differential diagnosis of a cervical lymph node enlargement.