Lymph Node Aspirates Research Articles

A prospective cohort study on active surveillance after neoadjuvant chemoradiotherapy for esophageal cancer: protocol of Surgery As Needed for Oesophageal cancer-2

BackgroundNeoadjuvant chemoradiotherapy (nCRT) followed by esophagectomy is a standard treatment for potentially curable esophageal cancer. Active surveillance in patients with a clinically complete response (cCR) 12 weeks after nCRT is regarded as possible alternative to standard surgery. The aim of this study is to monitor the safety, adherence and effectiveness of active surveillance in patients outside a randomized trial.MethodsThis nationwide prospective cohort study aims to accrue operable patients with non-metastatic histologically proven adenocarcinoma or squamous cell carcinoma of the esophagus or esophagogastric junction. Patients receive nCRT and response evaluation consists of upper endoscopy with bite-on-bite biopsies, endoscopic ultrasonography plus fine-needle aspiration of suspicious lymph nodes and 18F-fluorodeoxyglucose positron emission tomography/computed tomography scan. When residue or regrowth of tumor in the absence of distant metastases is detected, surgical resection is advised. Patients with cCR after nCRT are suitable to undergo active surveillance. Patients can consult an independent physician or psychologist to support decision-making. Primary endpoint is the number and severity of adverse events in patients with cCR undergoing active surveillance, defined as complications from response evaluations, delayed surgery and the development of distant metastases. Secondary endpoints include timing and quality of diagnostic modalities, overall survival, progression-free survival, fear of cancer recurrence and decisional regret.DiscussionActive surveillance after nCRT may be an alternative to standard surgery in patients with esophageal cancer. Similar to organ-sparing approaches applied in other cancer types, the safety and efficacy of active surveillance needs monitoring before data from randomized trials are available.Trial registrationThe SANO-2 study has been registered at ClinicalTrials.gov as NCT04886635 (May 14, 2021) – Retrospectively registered.

Abstract 6347: Preliminary results of an exploratory phase I clinical trial of anchored canine interleukin-12 (cANK-101) in dogs with advanced oral malignant melanoma

Abstract Background: Malignant melanoma is the most common form of oral cancer in canines with a median survival of 3 months for dogs with stage III or IV disease. Currently, there are limited effective systemic treatment options for these patients with advanced disease. We have developed an anchored immunotherapy approach in which canine interleukin-12 is stably linked to aluminum hydroxide (cANK-101). The anchored IL-12 forms a stable, functional depot of IL-12 and is expected to increase therapeutic responses with limited systemic toxicity. We report the preliminary results of an exploratory Phase I study of cANK-101 in dogs with advanced melanoma. Methods: The clinical study was approved by the University of Illinois IACUC, conducted at the College of Veterinary Medicine, and all pet owners provided written informed consent. The primary objective of the trial was to determine the safety and tolerability of cANK-101 in dogs with advanced melanoma. A standard 3+3 dose-escalation design was used with three dose levels (1, 3, and 10 µg/kg) cANK-101 given by intratumoral injection every three weeks for 4 cycles. In the absence of overt clinical progression, dogs were allowed to receive a second course of four cycles. Dogs were monitored for adverse events via VCOG-CTCAE and clinical responses were measured using RECISTv1.1. Serum was collected for pharmacokinetic (PK) and immunogenicity analyses. In addition, serial tumor biopsy and lymph node cytology were performed. Serum cytokines were assayed via ELISA while immunophenotyping of PBMC and lymph node aspirates were assessed by flow cytometry. Tumor-infiltrating lymphocyte (TIL) analysis was performed by immunohistochemistry (IHC) and gene expression profiling (Nanostring). Descriptive statistics were used for analyses. Results: As of November 16, 2022, 8 dogs have been enrolled and all dogs remain on treatment. Thirteen adverse events have been reported in 6 dogs, all being grade 1. However, only two are considered related to the study drug (tumor site inflammation and pain). Treatment was associated with increases in serum IFNγ and IL-10, as well as increases in peripheral CD4+ T and CD21+ T cells. Additional data on PK analyses, anti-drug antibody levels, gene expression, and clinical responses will be presented. Conclusions: Thus far, cANK-101 appears to be safe and tolerable in dogs with advanced melanoma. Data from this trial will help inform human clinical trials and may represent a new therapeutic option for dogs with advanced melanoma and perhaps other solid tumors. Our experience further suggests that companion animal trials could serve as relevant translational models for early immuno-oncology drug development. Citation Format: Matheus Moreno Passos Barbosa, Angel J. Lopez, Rachel Uyehara, Rebecca L. Kamerer, Michael Schmidt, Sailaja Battula, Howard L. Kaufman, Timothy M. Fan. Preliminary results of an exploratory phase I clinical trial of anchored canine interleukin-12 (cANK-101) in dogs with advanced oral malignant melanoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 6347.

Latent Mycobacterial fortuitum infection presenting as ocular sarcoidosis

A 62-year-old lady presented with bilateral granulomatous uveitis and cystoid macular edema. A diagnosis of ocular sarcoidosis was made (revised International Workshop on Ocular Sarcoidosis [IWOS] criteria) on the basis of lymphopenia, negative Mantoux, and QuantiFERON TB gold tests. Enlarged mediastinal lymph nodes, subpleural nodules, and nodular interstitial thickening were seen on high-resolution computed tomography (HRCT) thorax. Non-necrotizing granulomato us inflammation, negative for mycobacteria on staining and GeneXpert, was noted on endobronchial ultrasound-guided transbronchial lymph node aspiration (EBUS-TBNA). However, culture grew Mycobacterium fortuitum after 3 weeks. This case highlights a rare presentation of latent M. fortuitum infection presenting as ocular sarcoidosis, speculating the coexistence of two diseases in an individual, one possibly triggering the other.

Role of FNAC in the diagnosis of lymph node malignancies - An institutional experience

Lymphadenopathy is a sign of underlying infection, primary or metastatic malignancy. Fine-needle aspiration is a simple and reliable tool for its initial investigation. To analyse the cytomorphological features of malignant lymph node lesions and to determine the frequency of different lymph node malignancies. It was an observational, retrospective study conducted in the cytology section of Department of Pathology, Govt. Medical College, Jammu. It included lymph node aspirates that were reported as malignant. May-Grunwald-Giemsa (MGG) and Papanicolaou (PAP) stained smears were examined under light microscope and the cytological features were studied. A total of 97 malignant lymph node aspirates were included in this study. Metastatic malignancy accounted for maximum number of cases (78, 80.4%) followed by lymphoma (19, 19.6%). Squamous cell carcinoma was the most common metastatic malignancy and also the most frequently diagnosed malignant lesion in our study (42, 43.3%). Cervical lymph nodes were the most commonly aspirated lymph nodes.FNAC of lymph nodes is a simple and valuable tool in the diagnosis of lymph node malignancies.

Conversion surgery after lenvatinib treatment for anaplastic thyroid carcinoma: a case report

BackgroundAnaplastic thyroid carcinoma (ATC) is the most aggressive form of thyroid carcinoma. Lenvatinib, a multikinase inhibitor, is rarely used in preoperative settings due to adverse effects including delayed wound healing and fistula formation. Herein, we report the use of lenvatinib treatment prior to conversion surgery for the treatment of ATC.Case presentationA 71-year-old woman was referred to our hospital with suspected thyroid cancer with recurrent laryngeal nerve invasion and cervical lymph node metastasis based on the results of ultrasonography. Computed tomography demonstrated the presence of a thyroid tumor invading the trachea and esophagus with no evidence of distant metastasis. Fine needle aspiration of the left cervical lymph node indicated the lymph node metastasis of ATC. As the tumor had widely invaded the trachea and esophagus, unresectable ATC was diagnosed and treatment with lenvatinib was initiated at a dose of 24 mg/day. On day 13 of lenvatinib treatment, the primary tumor and lymph node metastases demonstrated a partial response to therapy. As the tumor was now considered resectable, the decision was made to perform conversion surgery. Total thyroidectomy and left lateral neck node dissection were performed 7 days after the withdrawal of lenvatinib. The patient was discharged on postoperative day 5 with no complications. Histopathological examination demonstrated that the tumor contained the component of papillary thyroid carcinoma, squamoid ATC cells, and granulation tissue. In areas of granulation tissue, atypical cells with spindle-shaped or polygonal morphology, pyknotic nuclei, and scant cytoplasm were observed. Immunohistochemically, these cells were positive for cytokeratin AE1/AE3, TTF-1, and p53 and negative for thyroglobulin and PAX8. Therefore, the areas of granulation tissue observed within tumor samples were also considered ATC that were affected by lenvatinib treatment. In total, approximately 50% of resected tumor comprised ATC, and 70% of them had been changed to granulation tissue.ConclusionsThe findings in the present case indicate that lenvatinib may have significant antitumor effects in preoperative settings. Lenvatinib may represent a promising candidate therapy for unresectable ATC by increasing tumor resectability.

A Familial Case of Multiple Endocrine Neoplasia 2A: From Morphology to Genetic Alterations Penetration in Three Generations of a Family

This paper illustrates a rare syndrome of multiple endocrine neoplasia type 2A (MEN2A) in a family of three generations. In our case, the father, son and one daughter developed phaeochromocytoma (PHEO) and medullary thyroid carcinoma (MTC) over a period of 35 years. Because of the metachronous onset of the disease and lack of digital medical records in the past, the syndrome was not found until a recent fine needle aspiration of an MTC-metastasized lymph node from the son. All resected tumors from the family members were then reviewed and supplemented with immunohistochemical studies, previously wrong diagnoses were then corrected. Further molecular study of targeted sequencing also revealed a RET germline mutation (C634G) in the family tree including the three members with onset of the disease and one granddaughter who had no disease at the time of testing. Despite the syndrome being well-known, it may still be misdiagnosed because of its rarity and long disease onset. A few lessons can be learned from this unique case. Successful diagnosis requires high suspicion and surveillance and a tri-level methodology including a careful review of family history, pathology and genetic counselling.

Fine Needle Aspiration Cytology Study of Tuberculous Lymphadenitis with Ancillary Diagnostic Procedures- Analytical Study from A Resource Limited Domicile of East Coastal Region

Tuberculosis remains one of the major causes of morbidity and mortality in developing countries like India despite intense health campaigning and Government Programmes. Tuberculous lymphadenitis is the most common extrapulmonary manifestation of tuberculosis; the incidence is still on a higher margin, especially in resource-poor areas, which often goes unnoticed and remains to date as a diagnostic challenge to Pathologists. The novel aim was to advocate the best method for early and correct diagnosis of tuberculous lymphadenitis to initiate early appropriate treatment.: In the prospective study conducted in our institute, Puducherry, a total number of 145 cases clinically suspected of tuberculous lymphadenopathy were included, and patients with neoplastic lesions were excluded from this study. The lymph node aspirate collected was analyzed for tuberculous cytomorphological changes using routine cytological stains and correlated observations with the results of various ancillary diagnostic procedures. Among 145 cases studied, 25 aspirates showed classical tuberculous patterns on cytomorphology, correlating well with histopathology (100%), PCR (100%), and culture (92%), respectively. In the rest of the 120 cases carrying non-tuberculous patterns on cytology, further exploration by ancillary diagnostic procedures revealed tuberculosis in 35 cases on histopathology, which PCR confirms in 25 available cases and culture study.FNAC results in adjunction with histopathology, and PCR showed increased reliability and pick-up rate in diagnosing atypical presentations of tuberculous lymphadenitis. Therefore, the PCR procedure of even conventional method should be widely employed in endemic areas of resource-poor regions.

A RARE CASE OF PAPILLARY CARCINOMA OF THYROID IN A YOUNG FEMALE: A CASE REPORT

Background: The papillary carcinoma thyroid is a rare disease in adolescents and children. A high level of suspicion should arouse as soon as the physician comes across swelling in neck. Appropriate management yields a good survival rate.
 Case history: We present a case of the papillary carcinoma thyroid in a 13-year old girl presented to outdoor of Jinnah Hospital, Lahore with painless swelling in right side of neck for three months. There were associated smaller swelling matted on palpation. No history of palpitations, fever, weight loss and family history of tuberculosis contact or cancer in family. Initial radiology and blood investigations showed an euthyroid goitre. The fine needle aspiration of lymph node only showed reactive hyperplasia. The matted lymph node was partially excised for histopathology as suspicion of tuberculosis existed due to its endemic feature. Later, it was found to be papillary carcinoma of thyroid. Total thyroidectomy was done with neck dissection followed by treatment at nuclear medicine department.
 Conclusion: Thyroid cancer is quite uncommon in adolescents but strong suspicion should arise when dealing with neck swelling even in this age group. Thorough history, watchful physical examination and timely investigations can save clinician from missing the diagnosis.

Comparative study between CBNAAT and acid-fast bacilli culture in extra pulmonary tuberculosis

Introduction: Mycobacterium Tuberculosis is a complex organism in which lungs are the main portal of infection. Tuberculosis affecting organs other than lungs called as extrapulmonary tuberculosis. Tuberculous lymphadenitis is the most common form of Extrapulmonary Tuberculosis contributing to 35 percent of Extrapulmonary Tuberculosis cases. CBNAAT is a cartridge based nucleic acid amplification test which detects the presence of Mycobacterium Tuberculosis as well as Rifampicin resistance. Materials and Methodology: Samples were collected from the appropriate extrapulmonary sites which included Lymph Node aspirate, Pleural fluid, Ascitic fluid, Abscess, Cerebrospinal Fluid. The samples were sent for AFB smear, CBNAAT and AFB culture. The data was analyzed and results were compared. Results: This cross-sectional study was conducted in a sample size of 89 patients attending the outpatient department in a tertiary care center in the Department of Respiratory Medicine at Santosh Hospital, Ghaziabad who were clinically suspected cases of Extra Pulmonary Tuberculosis. MTB was detected in CBNAAT in 33(37%) cases giving a Yield of 37% with RIF resistance in 2(2.2%) cases and MTB was detected in 53(59.5%) giving it a yield of 59.5% with RIF resistance in 2. Conclusion: There was statistically significant weak agreement seen between CBNAAT finding and AFB culture finding (Kappa value = 0.48; p value <0.01).

Cytological features of mesonephric-like adenocarcinoma of the uterine corpus.

Although several studies have documented the histological features of uterine mesonephric-like adenocarcinoma (MLA), its cytological features have been rarely reported. We searched for histologically confirmed uterine MLA cases in the pathology archives of three institutions between 2010 and 2021. All available cytology slides were examined to identify the cytological features of uterine MLA. We included 16 patients with uterine MLA and reviewed the slides obtained from 21 cytology samples. Samples were obtained from the cervicovagina (9/21, 42.9%), peritoneal washing (8/21, 38.1%), pleural effusion (2/21, 9.5%), and transbronchial needle aspiration of mediastinal lymph node (2/21, 9.5%). Preparation methods included ThinPrep (11/21, 52.4%), SurePath (8/21, 38.1%), and conventional smear (2/21, 9.5%). Regardless of the sampling site and preparation method, cytology samples displayed tight three-dimensional cellular clusters showing monotonous, small-to-medium-sized, round, hyperchromatic nuclei, indistinct nucleoli, scant cytoplasm, and high nuclear-to-cytoplasmic ratio. Approximately half of the samples (10/21, 47.6%) showed hyaline-like globules. Mitotic figures (7/21, 33.3%) and apoptotic bodies (13/21, 61.9%) were also observed. No tumor diathesis or nuclear feathering was identified. Irrespective of sampling site and preparation method, the majority of uterine MLA cases showed the following cytological features: tight three-dimensional cellular clusters showing small-to-medium-sized, round, hyperchromatic nuclei with indistinct nucleoli and high nuclear-to-cytoplasm ratio. In case a cytology sample suspicious of a glandular lesion displays these cytological features, which are distinct from those of endocervical adenocarcinoma, uterine MLA should be included in the differential diagnosis.

Fluoroquinolone resistance mutations among Mycobacterium tuberculosis and their interconnection with treatment outcome.

Fluoroquinolone (FQ) antibiotics are among the most potent second-line antitubercular drugs these days. The aim of the study was to analyze the frequency and pattern of genetic mutation in preextensive (pre-XDR) and extensively drug-resistant Mycobacterium tuberculosis using second-line line probe assay (LPA) and to compare drug-resistant mutations with different treatment outcomes. Sputum, lymph node aspirate, and cold accesses from patients with rifampicin-resistant Tuberculosis (TB) were subjected to first-line and second-line LPA (Genotype MTBDRsl by Hain Life Science, Germany) to assess additional drug resistance to fluoroquinolones (levofloxacin and moxifloxacin). Final treatment outcomes as per the National TB Elimination Program were assessed and compared with the mutation profile. One hundred and fifty subjects were observed to have mutations associated with resistance to FQs and constituted the final study population. The most frequent mutation observed among GyrA drug resistance mutation was D94G (Gyr A MUT3C, 44/150, 66%) corresponding to high-level resistance to levofloxacin and moxifloxacin. The same mutation was associated with poor treatment outcome as died or treatment failure (odds ratio 2.50, relative risk 1.67, P = 0.043). The most common hetero-resistance mutation pattern observed in GyrA gene was wild type plus Asp94Gly mutation in 24.6% of isolates. GyrA MUT3C hybridization corresponding to single-point mutation of aspartic acid to glycine at codon 94 constitutes the most common mutation in GyrA gene locus in M. tuberculosis with significant association with treatment outcome as died compared to those with treatment outcome as cured.

Identification of sentinel lymph nodes in esophageal cancer patients using contrast-enhanced EUS with peritumoral injections.

The objective of this pilot study was to compare the performance of contrast-enhanced EUS (CE-EUS)-guided fine-needle aspiration (FNA) with EUS-FNA for lymph node (LN) staging in esophageal cancer. Thirty-seven subjects with esophageal cancer undergoing EUS staging were enrolled, and 30 completed this institutional review board-approved study. A Prosound F75 US system (Hitachi Medical Systems, Tokyo, Japan) with harmonic contrast imaging software and GF-UCT180 curvilinear endoscope (Olympus, Tokyo, Japan) was utilized. All LNs identified by standard EUS were first noted. Sonazoid (dose: 1 mL; GE Healthcare, Oslo, Norway) was administered peritumorally, and all enhanced LNs were recorded. Fine-needle aspiration was performed on LNs considered suspicious by EUS alone, as well as LNs enhanced on CE-EUS. Performance of each modality was compared using FNA cytology as reference standard. A total of 132 LNs were detected with EUS, of which 59 showed enhancement on CE-EUS. Fifty-three LNs underwent FNA, and 22 LNs were determined to be malignant. Among the latter, 10 were considered suspicious by EUS, whereas the other 12 LNs underwent FNA only because of CE-EUS enhancement. Contrast-enhanced EUS showed enhancement in 19 of the 22 malignant LNs. The rate of metastatic node identification from EUS was 45% (10/22), and it was 86% (19/22; P = 0.008) for CE-EUS. Eight subjects (8/30 [27% of study total]) had nodal status upgraded by the addition of CE-EUS, which influenced LN staging and clinical management. Fine-needle aspiration of LNs identified by CE-EUS may increase metastasis positive rate by ruling out LNs not associated with the tumor drainage pattern. In addition, CE-EUS seems to identify more metastatic LNs that would not be biopsied under the standard EUS criteria.

The physician factor and anatomical site in 8846 consecutive mediastinal lymph node aspirations in a cross-sectional study

Mediastinal lymph node fine needle aspiration (MLN-FNA) is a common procedure; however, the physician factor in pathological category, and anatomical site are not routinely assessed. Cytology reports for endobronchial ultrasound (EBUS)/endoscopic ultrasound (EUS) MLN-FNA specimens (8846) were retrieved for July 2012–Dec 2019, classified by hierarchical free text string match algorithm into 51 diagnostic categories, four mutually exclusive diagnostic groups (benign |suspicious |malignant |insufficient), and 24 anatomical sites. Pathologist and submitting physician/surgeon bias were assessed using logistic regression and funnel plots|control charts centered on the group median (diagnostic/capture) rate. Eleven pathologists and seven submitting physician/surgeon were involved in more than 250 specimens each. Overall, the MLN-FNAs were benign|suspicious|malignant|insufficient in 46%|4%|25%|24% of specimens. Percent malignant (number of samples) varied by station; 7| 4R| 4L| 2R| 10R| 11R| 11L were respectively 21%(3,101), 27%(2,453), 19%(1,289), 41%(435), 27%(497), 24%(357), 26%(229). The number of outlier (P < 0.05/P < 0.001) pathologists of 11 from the group median rate for benign|suspicious|malignant|insufficient was 0/0| 3/1| 0/0| 3/0 respectively. The outlier (P < 0.05/P < 0.001) submitting physicians/surgeons of 7 for benign|suspicious|malignant|insufficient was 3/2| 2/2| 3/2| 3/2 respectively. The physician and anatomical site are significant predictors of MLN-FNA pathology.

Factors contributing to discordance between clinical and pathological staging of operable non-small cell lung cancer

Background: Clinical staging of non-small cell lung cancer (NSCLC) by CT and PET, with or without endobronchial ultrasound-guided transbronchial needle aspiration of lymph nodes (EBUS-TBNA), is essential for prognostication and to direct treatment. Our study investigated the accuracy of clinical staging compared to definitive pathological staging. Methods: Retrospective audit of clinical and pathological staging of all surgical lung cancer cases 2016–present (484 cases). Results: Discordance of clinical and pathological TNM staging (excluding sub-staging) was identified in 93 (25.9%) cases where complete data was available. This included clinical understaging in 61 (17%) and N2 disease in 20 (5.6%) cases. EBUS-TBNA was performed in 14 of the cases with N2 disease, and in five of these cases, involvement of N2 nodes detected post-surgery had been called benign at EBUS-TBNA. Factors contributing to clinical understaging may include delays between clinical staging studies and surgery [CT: median 110 days (IQR 82.5-151), PET: 81 days (59–119), EBUS-TBNA 62 days (43–95)], with significantly longer delays evident during the COVID-19 pandemic. Conclusions: Improved technical quality of lung cancer clinical staging studies and hospital management workflows will potentially increase concordance between clinical and pathological staging of operable NSCLC, improving outcomes for early stage disease. My contribution to this work has focused on the 2022 cases, analysis of which has elucidated the impact of COVID-19 on the lung cancer staging process in comparison to pre-COVID results.

Xpert MTB/RIF in the Diagnosis of Mediastinal Tuberculous Lymphadenitis by Endoscopic Ultrasound-Guided Needle Aspiration Techniques: A Systematic Review and Meta-Analysis

Background: Lymphadenopathy is one of the most prevalent clinical manifestations of extrapulmonary tuberculosis. Endosonography is the recommended technique in the diagnostic work-up of mediastinal lymphadenopathies. Xpert MTB/RIF assay is a self-contained cartridge-based fully automated DNA testing platform which can accurately detect both tuberculosis and mycobacterial resistance to rifampicin. A few studies assessed its accuracy for mediastinal lymph node aspirates collected using endosonography. A systematic review of observational studies was performed to provide a pooled estimate of sensitivity and specificity of Xpert MTB/RIF in the diagnosis of mediastinal tuberculous lymphadenitis using endoscopic ultrasound-guided needle aspiration techniques. Methods: A search of the scientific evidence was carried out using PubMed, Embase, and Scopus. Articles describing observational studies on Xpert MTB/RIF in the diagnosis of mediastinal tuberculous lymphadenitis using endoscopic ultrasound-guided needle aspiration techniques were selected. Results: Eight studies met the inclusion criteria. The overall pooled sensitivity was 61% (95% CI = 55–68%; I² = 66.3%; p = 0.004), overall pooled specificity was 89% (95% CI = 85–91%; I² = 90.1%; p < 0.0001). Area under the sROC curve was 0.68. Only one study reported data on rifampin resistance detection and showed a sensitivity of 83.3% and a specificity of 16%. Conclusions: Xpert MTB/RIF shows a good accuracy in the diagnosis of mediastinal mycobacterial lymphadenitis by endosonographic needle aspiration techniques. It should be always recommended for suspected mediastinal tuberculosis.

An Exceptional Cause of Increased 18F-Fluorodeoxyglucose Uptake on PET/CT in a Thyroid Nodule.

A 41-year-old female underwent a cervical spine CT for the workup of posterior neck pain irradiating to the shoulders for several months. An incidental thyroid nodule was found and classified as Bethesda III on the Fine-needle aspiration cytology (FNAC) results. Three months later, the patient developed mild shortness of breath, dry cough, and fever. Chest X-ray revealed a mild enlargement in the bilateral hilar regions. CT showed mediastinal and bilateral hilar enlarged lymph nodes and pulmonary micronodules. The workup was further completed with a 18F-FDG PET/CT, showing intense FDG uptake in the mediastinal and bilateral hilar lymph nodes and increased uptake in the thyroid nodule. Endobronchial Ultrasound-guided Transbronchial needle aspiration (EBUS-TBNA) of a left hilar lymph node showed epithelioid non-necrotizing granulomas. Because of the FNAC results, size of the nodule and tracheal shift, thyroid lobectomy was performed one month later. Histopathological results also revealed multiple non-necrotizing epithelioid granulomas, suggesting systemic sarcoidosis with involvement of the thyroid. To our knowledge, this is the first report of thyroid sarcoidosis detected on 18F-FDG PET/CT. Although an increased FDG uptake in a thyroid nodule is usually suggestive of thyroid malignancy, toxic nodule, or follicular hyperplasia, our case report shows that it could also suggest thyroid sarcoidosis.

Structured Reporting of Lymph Node Cytopathology using the 2020 Sydney System Guidelines-A Retrospective Study

Introduction: Fine Needle Aspiration Cytology (FNAC) is a valuable diagnostic aid for evaluation of lymph node pathology. The new Sydney System (2020) for classification and reporting of lymph node FNAC has put forth guidelines for a categorical classification using uniform terminology and morphologic criteria, a major step towards standardisation. Aim: The study was aimed to evaluate cytopathology of lymph node lesions during 2 year period by applying the proposed Sydney system and to assess the category wise Risk Of Malignancy (ROM) by comparing with histopathology diagnosis in available cases. Materials and Methods: A retrospective observational study was conducted in 2021 December, on lymph node aspirates obtained during two-year period from January 2018 till January 2020 in the department of Pathology of a tertiary care centre. FNAC of 250 lymph node aspirates were evaluated. Smears were reviewed and categorised as per the Sydney System of reporting as, L1: non diagnostic/inadequate, L2: benign, L3: atypical cells/atypical lymphoid cells of undetermined significance, L4: suspicious for malignancy, L5: malignant. The diagnostic accuracy of cytology and ROM in each category was assessed comparing with the gold standard histopathology diagnosis where available. Results: Category wise distribution of 250 cytological diagnosis of lymphadenopathy reclassified in Sydney system were L1-14 (5.60%); L2-159 (63.60%); L3-04 (1.60%); L4-05 (2%); and L5-68 (27.20%) cases. Using histopathology as gold standard available in 53 cases, the ROM in each category was found to be 0%, 3%, 66.66%, 100% and 100%, respectively. The sensitivity, specificity, Positive Predictive Value (PPV), Negative Predictive Value (NPV) and diagnostic accuracy of cytological diagnosis was found to be 95.65%, 96.29%, 95.65%, 96.29% and 96%, respectively. Reactive lymphadenitis in 86 (34.40%) and metastatic carcinoma in 61 (24.40%) cases were the most common benign and malignant lesions respectively. Conclusion: The Sydney system of structured reporting in lymph node cytology provides a clear-cut terminology, uniformity, and reproducibility of reports. It enhances the role of FNAC by alerting the clinician for follow-up and ancillary studies in atypical and equivocal cases. In the non diagnostic L1 category, repeat procedure or biopsy should be recommended to avoid False Negative (FN) diagnosis.

THE EVALUATION OF LYMPH NODE FINE NEEDLE ASPIRATION CYTOPATHOLOGY USING THE SYDNEY SYSTEM OF REPORTING – A TEACHING INSTITUTIONAL EXPERIENCE

Background: Fine-needle cytology (FNC) is a useful diagnostic tool in the rst line evaluation of lymphadenopathy of unknown etiology. Due to a lack of standard uniform criteria and reporting systems, the use of FNC in lymph nodes is still not universally acknowledged by clinicians. Aims/objectives: To categorize the lymph node lesions according to Sydney system of reporting the lymph node aspiration cytology cases and assess the risk of malignancy (ROM) for each diagnostic category wherever applicable. Cross sectional retrospective study Study Design: Material and methods: This study was conducted by including all the lymph node aspiration cases over a period of three years. All lymph node cytology the slides were retrieved and reviewed and categorized according to Sydney system of reporting. Corresponding histopathology slides were reviewed and risk of malignancy were calculated. There were 422 lymph node Results: cytology cases. Majority of cases (323) belonged to benign/L2 group followed by L5/malignancy (92 cases), L1/ Non diagnostic (04 cases), L3/ALUS (02 cases) and one case in L4/ suspicious category. By using standardized reporting methods, one can communicate clinically Conclusion: important information in a reproducible manner while limiting interobserver variability

Diagnostic and quantitative performance of the GeneXpert Mycobacterium tuberculosis/resistance to rifampin assay on pulmonary and extrapulmonary tuberculosis samples

INTRODUCTION: No study has simultaneously assessed the diagnostic and quantitative performance of the GeneXpert Mycobacterium tuberculosis/resistance to rifampicin (MTB/RIF) assay on pulmonary and extrapulmonary samples processed in an Indian laboratory. We examined this to assess if GeneXpert can complement existing diagnostic facilities.METHODS: The performance of GeneXpert and acid-fast microscopy were evaluated against culture in 455 pulmonary and 69 extrapulmonary specimens. Their sensitivity, specificity, predictive values and area under the curve (AUC) were estimated. GeneXpert cycle threshold (Ct) cut-offs were also computed to assess their utility in predicting smear positivity and time to culture positivity (TTCP).RESULTS: GeneXpert was significantly more sensitive (100% vs. 84.4%; P < 0.001) and nearly as specific (94.8% vs. 96.7%; P = 0.344), with a greater AUC (0.97 vs. 0.91; P = 0.002) than acid-fast microscopy. It was sensitive and specific for pulmonary (100%; 94.1%) and extrapulmonary (100%; 96.5%) samples, and 100% sensitive for sputum, bronchoalveolar lavage (BAL), lymph node aspirates, pleural fluid, pus and urine. It detected smear-negative specimens with 100% sensitivity. GeneXpert Ct was inversely correlated with sputum smear grading (ρ = −0.66) and positively with TTCP (ρ =0.70). Mean Ct cut-offs of 21.4, 20.1 and 24.6 predicted smear positivity with maximum sensitivity and specificity in sputum, BAL and extrapulmonary samples, respectively. Rifampicin resistance was seen in 17% of samples.CONCLUSIONS: GeneXpert can be a reliable first-line diagnostic for both pulmonary and extrapulmonary samples. It can effectively detect smear-negative and paucibacillary patients, and estimate smear positivity and bacillary burden. This can help Indian laboratories to detect cases early and interrupt community transmission.

Myelofibrosis secondary to Hodgkin’s lymphoma: A case report

A 23-year-old male was misdiagnosed as a case of tubercular lymphadenitis based on fever with B-symptoms and finding of epithelioid granuloma on fine-needle aspiration of mesenteric lymph node and was started on antitubercular treatment from an outside hospital. Since the patient had progression of symptoms, we re-evaluated the case. Contrast-enhanced computed tomography showed multiple conglomerated necrotic cervical, peritoneal lymph nodes, hepatosplenomegaly, and multiple mixed sclerotic lytic lesions in multiple vertebral bodies and pelvis. An excision lymph node biopsy was suggestive of a nodular sclerosis variant of Hodgkin’s lymphoma. A bone marrow study was performed subsequent to new-onset bicytopenia. Bone marrow aspiration was dry and bone marrow biopsy showed myelofibrosis. Thus, a diagnosis of myelofibrosis secondary to Hodgkin’s lymphoma was made.