Malignant Lymphadenopathy Research Articles

Navigating the Diagnostic Challenges in Lymph Node Cytology: The Case of Reactive Hyperplasia.

Fine needle cytology (FNC) is a pivotal diagnostic tool for distinguishing between benign and malignant lymphadenopathies mainly because of its minimal invasiveness, cost-effectiveness and accuracy. A major requirement for maximising diagnostic accuracy is proper sample management of aspirated cellular material. In this diagnostic process, the morphological evaluation of adequate smears is paramount, guiding cytopathologists in the selection of appropriate ancillary tests through the recognition of cell size and patterns of distribution. Here, we describe a peculiar 'concentric ovals distribution pattern', frequently observed in the FNC of benign reactive lymph nodes, which may represent an aid in the cytological diagnosis of reactive hyperplasia.

Intranodal Hemangioma: Case Report and Systematic Review

ABSTRACT Background: Intranodal hemangiomas are rare benign vascular tumors of the lymph nodes, often misdiagnosed as malignant lymphadenopathies due to their clinical and radiological features. This case report and systematic review aim to elucidate the epidemiology, clinical profile, and therapeutic interventions for intranodal hemangioma, enhancing diagnostic accuracy and management. Methods: A systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Searches were conducted in PubMed, Scopus, Web of Science, and Google Scholar up to March 15, 2024, using keywords like “intranodal hemangioma,” “primary intranodal hemangioma,” “nodal hemangioma,” “vascular tumor,” and “lymph node hemangioma.” Inclusion criteria included studies on clinical presentation, diagnostic strategies, and therapeutic interventions for intranodal hemangioma in patients of all ages. Excluded were reviews, opinion pieces, non-English studies, cases of hemangioendothelioma, sclerosing hemangioma, and animal studies. Key aspects analyzed included demographics, clinical presentation, management strategies, and histopathological findings. Results: Our case involves a 3-year-old female with a submandibular mass, initially diagnosed with hemangioma. After no response to beta-blocker therapy and conflicting imaging results, surgical excision was performed. Histopathology confirmed intranodal hemangioma. From 233 records, 19 publications (36 patients, including our case) met the inclusion criteria. The review shows common clinical presentations as painless, slowly enlarging lymph nodes, primarily in the cervical and axillary regions. Diagnostic challenges often require imaging and biopsy to differentiate from malignancies. Conclusion: Recognizing intranodal hemangiomas, particularly in childhood, is crucial to prevent misdiagnosis and inappropriate treatment. The rarity of these tumors in childhood and their clinical presentation similar to malignancies in older patients make diagnosis challenging without widespread awareness. Surgical excision remains the mainstay of both diagnosis and treatment, often leading to favorable outcomes.

Radiology of malignant cervical adenopathy

Imaging of neck and skull base has significantly improved the diagnosis and management of neck conditions. Prior to the use of CT, MRI and PET imaging, the value of plain radiographs of the neck was limited. Today, modern imaging techniques are an essential adjunct to the physical examination of the neck, can confidently limit the differential, and in many clinical scenarios yield a specific diagnosis. In addition, the value of imaging cannot be understated in surgical planning and surveillance. This article will review the techniques used in neck lymph node imaging and cover several of the most common conditions that result in malignant lymphadenopathy in the neck.

The dilemma of mediastinal lymphadenopathy between invasive and non-invasive procedures: ROC analysis of T2WI and DWI-MRI advanced parameters correlated with PET-CT and biopsy

BackgroundThe characterization of pathologically enlarged mediastinal lymph nodes is clinically essential for effective disease management and accurate prognosis. Malignancy (metastases and lymphoma) and granulomatous conditions (sarcoidosis and tuberculosis) are the most common causes. Magnetic resonance imaging (MRI) is a good modality to characterize the mediastinal pathologically enlarged lymph nodes based on the excellent soft tissue contrast. It can save high-risk patients from radiation exposure and hazards of intervention such as general anesthesia and biopsy.Aim of the workTo estimate the accuracy of different advanced MRI quantitative parameters in the differentiation between benign and malignant mediastinal lymphadenopathy. This would involve the lesion-to-cord signal intensity ratio (SIR) in the T2-WI and diffusion weighted image (DWI), the lesion-to-chest wall muscle SIR in T2-WI and DWI, and the mean apparent diffusion coefficient (ADC) values. These values would be correlated with the prospective pathological data and the results of the positron emission tomography (PET-CT).ResultsProspectively, the study was conducted during the period between June 2022 and September 2023 on 45 patients with indeterminate or suspicious mediastinal lymphadenopathy identified by CT. MRI examination, PET-CT, and biopsy were applied for all patients. The intra-class correlation coefficient ranged between 0.89 and 0.95. (A) The lesion-to-cord SIR in T2-WI in the malignant group (1.49 ± 0.30) was higher than that in the benign group (0.83 ± 0.24) with P < 0.001. The statistically calculated cutoff value (> 1.2) estimated 90% sensitivity, 100% specificity, with AUC = 0.989. (B) The lesion-to-chest wall muscle SIR in T2-WI in malignant nodes (3.13 ± 0.84) was significantly higher than that in the benign nodes (1.90 ± 0.80) with P < 0.001. The statistically calculated cutoff value (> 2.4) estimated 86.67% sensitivity, 86.67% specificity, with AUC = 0.88. (C) The lesion-to-cord signal SIR in b500-DWI in the malignant node (1.80 ± 0.54) was higher than that in the benign group (0.75 ± 0.29) with P < 0.001. The statistically calculated cutoff value (> 1.2) estimated 100% sensitivity and specificity with AUC = 1.00. (D) The lesion-to-chest wall SIR in b500-DWI in the malignant node (6.43 ± 1.28) was higher than that in the benign node (2.63 ± 0.94) with P < 0.001. The statistically calculated cutoff value (> 4.1) estimated 96.67% sensitivity, 100% specificity, with AUC = 0.997. € The mean ADC values in the malignant nodes (0.83 ± 0.20 × 10–3 mm2/s) were significantly lower than that in the benign nodes (1.85 ± 0.19 × 10−3 mm2/s) with P < 0.001. The statistically calculated cutoff value (≤ 1.2) estimated 100% sensitivity and specificity with AUC = 1.00.ConclusionsBiopsy remains the main diagnostic modality for the characterization of mediastinal lymphadenopathy despite its hazards and limitations. This study proved that MRI could be accepted as an alternative non-invasive imaging tool that can overcome the PET-CT limitations. The lesion signal-to-cord and to-muscle ratios in both T2-WI and DWI-MRI side by side with the mean ADC value showed high statistical accuracy.

Peripheral lymphadenopathy of unknown origin in adults: a diagnostic approach emphasizing the malignancy hypothesis.

The term lymphadenopathy refers to an abnormality in size, consistency or morphological aspect of one or several lymph nodes. Although lymphadenopathies are commonly observed in everyday clinical practice, the difficulty of differentiating benign and malignant disease may delay therapeutic approaches. The present review aims to update diagnostic algorithms in different clinical situations based on the currently available literature. A literature review was performed to assess current knowledge of and to update the diagnostic approach. A short clinical vignette was used as an example of a typical clinical presentation. This case of metastatic lymphadenopathy with incomplete patient history demonstrates how misleading such lymphadenopathy may be, leading to a delayed diagnosis and even a fatal outcome. Any lymphadenopathy persisting for more than 2 weeks should be considered suspicious and deserves further investigation. Precise clinical examination, meticulous history-taking and a search for associated symptomatology are still cornerstones for diagnosing the origin of the condition. The next diagnostic step depends on the anatomical region and the specific patient's situation. Imaging starts with ultrasound, while computed tomography (CT) and magnetic resonance imaging (MRI) allow assessment of the surrounding structures. If the diagnosis remains uncertain, tissue sampling and histological analyses should be performed. Except for head and neck loco-regional lymphadenopathy, there are no methodical guidelines for persistent lymphadenopathy. The present review clarifies several confusing and complex situations. The accuracy of fine needle aspiration cytology could be increased by using core needle biopsy with immunocytologic and flow cytometric methods. Notably, except in the head and neck area, open biopsy remains the best option when lymphoma is suspected or when inconclusive results of previous fine needle aspiration cytology or core needle biopsy are obtained. The incidence of malignant lymphadenopathy varies with its location and the various diagnostic strategies. In metastatic lymphadenopathy of unknown primary origin, European Society for Medical Oncology (ESMO) guidelines and modern methods like next-generation sequencing (NGS) may help to manage such complex cases.

Clinical prediction model for pediatric lymphadenopathy: enhancing diagnostic precision and treatment decision making.

Lymph node enlargement is common in children, with 90% of physiologically palpable lymph nodes. This study aimed to develop a predictive model based on clinical characteristics to enhance the diagnosis of pediatric lymphadenopathy and provide insights into biopsy outcomes. A clinical prediction rule was developed using a retrospective, cross-sectional design for patients under 15years who underwent lymph node biopsy from 2012 to 2022. Multivariable risk regression was used to analyze benign and malignant lesions, presenting results through risk difference and AUROC for each group. Predicted probabilities were applied in a logistic regression equation to classify patients' lymphadenopathy as reactive hyperplasia, benign, or malignant. Of 188 children, 70 (37.2%) had benign lymphadenopathy beyond reactive hyperplasia, and 27 (14.4%) had malignant lymphadenopathy. The predictive model included 12 characteristics such as size, location, duration, associated symptoms, and lymph node examination. Predictive accuracy was 92.2% for benign cases (AUROC = 0.92; 95% CI 0.87-0.96) and 98.6% for malignancy (AUROC = 0.98; 95% CI 0.94-0.99). Overall accuracy for predicting both benign and malignant tumors was 68.3%. The model demonstrated reasonably accurate predictions for the clinical characteristics of pediatric lymphadenopathy. It tended to overestimate malignancy but did not miss diagnoses, aiding in reducing unnecessary lymph node biopsies in benign cases.

Distinguishing Axillary Lymphadenopathy after COVID-19 Vaccination from Malignant Lymphadenopathy.

Objectives: To study the differences between malignant hypermetabolic axillary lymphadenopathy (MHL) and COVID-19 vaccine-associated axillary hypermetabolic lymphadenopathy (VAHL) using clinical imaging. Methods: A total of 1096 patients underwent Positron Emission Tomography-Computed Tomography (PET-CT) between 1 June 2021 and 30 April 2022 at Ehime University Hospital. In total, 188 patients with axillary lymphadenopathy after the COVID-19 vaccination were evaluated. The patients were classified into three groups such as VAHL (n = 27), MHL (n = 21), and equivocal hypermetabolic axillary lymphadenopathy (EqHL; n = 140). Differences in lymph node (LN) swellings were statistically analyzed using clinical imaging (echography, CT, and 18F-FDG PET). Results: MHL included a higher female population (90.5%) owing to a higher frequency of breast cancer (80.9%). Axillary LNs of MHL did not show any LN fatty hilums (0%); however, those of VAHL and EqHL did (15.8 and 36%, respectively). After the logistic regression analysis of the patients who had axillary lymphadenopathy without any LN fatty hilums, the minor axis length and ellipticity (minor axis/major axis) in the largest axillary LN, SUVmax, and Tissue-to-Background Ratio (TBR) were useful in distinguishing malignant lymphadenopathies. A receiver-operating characteristic (ROC) analysis indicated that a cut-off value of ≥7.3 mm for the axillary LN minor axis (sensitivity: 0.714, specificity: 0.684) and of ≥0.671 for ellipticity (0.667 and 0.773, respectively) in the largest LN with the highest SUVmax and TBR were predictive of MHL. Conclusions: Axillary lymphadenopathy of the minor axis and ellipticity in LN without fatty hilums may be useful to be suspicious for malignancy, even in patients who have received COVID-19 vaccination. Further examinations, such as 18F-FDG PET, are recommended for such patients.

Evaluation of Peripheral Lymphadenopathies in Children in a Single Center: Predictive Factors for Malignancy.

Lymphadenopathy (LAP) is a common finding in pediatric patients. It was aimed to determine predictive factors in distinguishing cases with malignant or benign lymphadenopathy in this study. Between January 2022 and January 2023, 101 patients (1-16 years old) with lymphadenopathy were retrospectively examined. LAP was localized in 80.2% (n=81) cases and generalized in 19.8% (n=20) cases. In 60 cases (59.4%), lymph node sizes were found to be greater than 20×20 mm in width and length. The most common infectious causative agent was Epstein Barr Virus (EBV). Seven (6.9%) patients underwent biopsy and all were diagnosed with malignancy. When the benign and malignant groups were compared, age, lymph node length, and width on physical examination, anteroposterior and longitudinal diameter of the lymph node on ultrasonography (USG) were statistically significantly higher in the malignant group (p<0.05). The presence of supraclavicular lymphadenopathy was found to be an important factor in differentiating the malignant group (p<0.003). The most important factors in distinguishing the groups are respectively were the anteroposterior diameter of the lymph node on ultrasonography and the presence supraclavicular lymph node in multivariate logistic regression analysis. It is not always easy to distinguish benign and malignant etiologies in patients with lymphadenopathy. A detailed history, a careful physical examination, laboratory studies, and excisional biopsy are guiding.

Exploring the Spectrum of Lymphadenopathy: Insights From a Three-Year Fine Needle Aspiration Cytology Study in a Tertiary Care Center.

Introduction Lymphadenopathy, characterized by the enlargement of lymph nodes, is a common concern encountered by physicians in outpatient settings. It is deemed significant and warrants evaluation due to the diverse range of potential causes, ranging from treatable infections to incurable metastatic malignancies. Fine needle aspiration cytology (FNAC) emerges as a crucial tool in addressing these concerns, acknowledged for its rapid diagnostic capabilities, simplicity, accuracy, and minimal invasiveness. Objectives This retrospective study aims to characterize the spectrum of lymphadenopathy cases observed in a tertiary care center over a specified period, shedding light on the prevalence, etiology, and clinical outcomes associated with this condition. Methods Electronic medical records of patients presenting with lymphadenopathy to the tertiary care center between May 2021 and June 2023 were reviewed. Data on patient demographics, clinical presentation, imaging findings, and cytopathological and histopathological diagnoses were analyzed. Results A total of 300 cases of lymphadenopathy were identified during the study period. The study population exhibited a diverse range of age groups, with a slight predilection for the age range of 11-20 years. The most common sites of lymphadenopathy were in the cervical group, and the predominant clinical presentations included tender lymph nodes and fever. Etiologically, infectious causes, such as accounted for the majority of cases, followed by inflammatory and neoplastic etiologies. Notably, 2.6 % of cases presented with non-specific lymphadenopathy, warranting further investigation. Diagnostic modalities, including imaging studies and histopathological examinations, played a crucial role in establishing accurate diagnoses. The study also highlights the challenges in differentiating benign from malignant lymphadenopathy, emphasizing the need for a comprehensive diagnostic approach. Conclusion This study provides a comprehensive overview of the lymphadenopathy spectrum in a tertiary care center, emphasizing the importance of a multidisciplinary approach for accurate diagnosis and management. The findings contribute to our understanding of the epidemiology and etiological patterns of lymphadenopathy, guiding clinicians in optimizing patient care and outcomes in a tertiary healthcare setting.

Utility of perioperative ultrasonography and fine-needle aspiration cytology in differentiation between benign and malignant cervical lymphadenopathy: a retrospective cohort study

Background: The preoperative differentiation of benign form malignant cervical lymphadenopathy (CLA) is crucial in determining the need for surgical intervention. This study aims to assess the diagnostic performance of ultrasonography (US), fine-needle aspiration cytology (FNAC), and their combination with the postoperative histopathological diagnoses of CLA. Method: In a retrospective study between April 2021 and May 2023, 214 patients with CLA were assessed with preoperative US and FNAC. The morphological parameters, including tissue margins, vascularity, and fatty hilum echogenicity, were collected and analyzed retrospectively. The diagnostic efficacies of US, FNAC, and their combined use were compared to the postoperative histopathological findings. Result: In the final histopathological examination, 185 cases (86.4%) were found to be benign, while 29 cases (13.6%) were determined to be malignant. The US features of fatty hilum, echogenicity, and vascularity pattern had the highest diagnostic accuracy in characterizing CLA patterns, with values of 88.3%, 85.5%, and 85.0%, respectively. The ROC curve showed a significantly higher AUC value of 0.883 (95% CI: 0.832 to 0.923; P&lt;0.0001) for the combined use of all US parameters with better sensitivity (93.10%) and specificity (68.65%) than individual parameters. The overall sensitivity, specificity, and accuracy of FNAC were 97.3%, 82.8%, and 95.3%, respectively. Additionally, US parameters and FNAC together showed a significantly higher AUC value of 0.924 (95% CI: 0.880 to 0.956; P&lt;0.0001) and achieved a sensitivity of 86.21% and specificity of 88.65%. Conclusions: The combined use of US and FNAC provides high sensitivity, specificity, and diagnostic accuracy in characterizing CLA patterns. In limited-resources settings, this approach is feasible, less invasive, and cost-effective thereby enabling clear management strategies and avoiding additional surgical interventions.

A case report of extranodal diffuse large B-cell lymphoma involving upper limb soft tissue in a patient with rheumatoid arthritis on immunosuppressive therapy

An 80-year-old woman affected by rheumatoid arthritis on immunosuppressive therapy was evaluated for an 11-month history of swelling of her left upper limb. The patient did not report systemic symptoms. Ultrasonographic examination showed hypoechoic masses in the upper limb soft tissue, brachial vein thrombosis, and suspected malignant axillary lymphadenopathy. The patient underwent an excisional biopsy of the lymphadenopathy for histologic examination; a diagnosis of diffuse large B-cell lymphoma was made. The patient started anticoagulation therapy and chemotherapy, with a follow-up at a hematology clinic. At a 3-month follow-up visit in our clinic, the swelling of her left upper limb decreased, and an ultrasonographic control demonstrated a reduction in the size and number of the soft tissue masses and resolution of vein thrombosis.

Development of a Novel Contrast-Enhanced Ultrasound-Based Nomogram for Superficial Lymphadenopathy Differentiation: Postvascular Phase Value

ObjectiveThe aim of this study was to develop and prospectively validate a prediction model for superficial lymphadenopathy differentiation using Sonazoid contrast-enhanced ultrasound (CEUS) combined with ultrasound (US) and clinical data. MethodsThe training cohort comprised 260 retrospectively enrolled patients with 260 pathological lymph nodes imaged between January and December 2020. Two clinical US-CEUS models were created using multivariable logistic regression analysis and compared using receiver operating characteristic curve analysis: Model 1 included clinical and US characteristics; Model 2 included all confirmed predictors, including CEUS characteristics. Feature contributions were evaluated using the SHapley Additive exPlanations (SHAP) algorithm. Data from 172 patients were prospectively collected between January and May 2021 for model validation. ResultsAge, tumor history, long-axis diameter of lymph node, blood flow distribution, echogenic hilus, and the mean postvascular phase intensity (MPI) were identified as independent predictors for malignant lymphadenopathy. The area under the curve (AUC), sensitivity, specificity, and accuracy of MPI alone was 0.858 (95% confidence interval [CI], 0.817–0.891), 86.47%, 74.55%, and 81.2%, respectively. Model 2 had an AUC of 0.919 (95% CI, 0.879–0.949) and good calibration in training and validation cohorts. The incorporation of MPI significantly enhanced diagnostic capability (p < 0.0001 and p = 0.002 for training and validation cohorts, respectively). Decision curve analysis indicated Model 2 as the superior diagnostic tool. SHAP analysis highlighted MPI as the most pivotal feature in the diagnostic process. ConclusionThe employment of our straightforward prediction model has the potential to enhance clinical decision-making and mitigate the need for unwarranted biopsies.

Role of FNAC in Diagnosis of Malignant Lymphadenopathy: A Five-Year Cross-sectional Study at A Tertiary Care Centre, Mumbai, India

Introduction: Fine Needle Aspiration Cytology (FNAC) of the lymph node is a simple tool in the diagnosis of suspected and unsuspected primary and secondary lymph node malignancy. It is a useful first-line investigation to distinguish between infective and malignant lymphadenopathy, especially in a low-resource setting like our country. Aim: To study the utility of FNAC in the diagnosis of lymph node malignancy and to evaluate the efficacy of cytology in diagnosing the primary site of malignancy in case of metastasis. Materials and Methods: A cross-sectional retrospective and prospective study was conducted for a five-year period from July 2015 to June 2020, in the pathology department of Dr. RN Cooper Municipal General Hospital, Mumbai, Maharashtra, India. A total of 112 patients diagnosed with malignancy on FNAC of lymph nodes were studied. The FNAC procedure was performed by cytopathologists using a 23/24G needle attached to a 10 ml syringe. The alcohol-fixed smears were stained with Haematoxylin &amp; Eosin (H&amp;E) stain and Papanicolaou (PAP) stains, while the airdried smears were stained with Giemsa stain. Diagnosis was based on cytomorphological features and clinical presentation. Results: A total of 112 patients were diagnosed with malignancy on FNAC, of which 90 were males and 22 were females, with a male-to-female ratio of 4:1. Cytological analysis of these nodes revealed metastasis in 98 cases (87.50%) and lymphoma in 14 cases (12.50%). The maximum number of patients were in the 51-60 years age group, with 38 cases (33.92%). The most common site of involvement was cervical lymph nodes, with 75 cases (66.96%). The most common cytological diagnosis was metastatic squamous cell carcinoma in 65 cases (58.02%), followed by metastatic un-differentiated carcinoma in 26 cases (23.20%). Conclusion: Fine Needle Aspiration (FNA) is a simple, safe, accurate, cost-effective, and valuable tool in the evaluation of malignant lymphadenopathy. Malignant diseases were easily diagnosed by this simple diagnostic procedure. In the case of a diagnosis of lymphoma, surgery can be completely avoided. It helps in planning further surgical management for metastatic disease, where definitive operative intervention can be performed in one session. In the case of an un-detected primary tumour, FNAC directs further investigations towards the possible primary site.

Fine Needle Aspiration Cytology of Lymph Nodes in Metastatic Cancer and Lymphoma: Our Single-institution Experience.

Lymphadenopathy is a common finding in clinical practice. The cause of enlarged nodes on clinical examination alone is challenging and there may be multiple reasons for this enlargement. It may become enlarged due to stimulation by infectious agents or the involvement of metastasis or malignant diseases, such as lymphoma. The aim of the study was to investigate the diagnostic role of fine needle aspiration cytology of lymph nodes in metastatic cancer and lymphoma. A total of 48 FNAC lymph nodes suspicious for malignancy were sampled with follow-up biopsy in Clinical Center of University of Sarajevo from 2017 to 2023. Lymph nodes were aspirated using 20-22 G needle with minimally 2 passes, spread on slides, air-dried, stained with May-Grünwald-Giemsa or Papanikolaou and residual material sent for cytoblock. Out of 48 cytological samples, 30 (62.5%) revealed metastatic epithelial cells and 12 (25%) lymphoproliferative neoplasm. Three samples were suspected for malignancies, one sample was unrepresentative, one inconclusive and one falsely negative. Histopathological confirmation had 35 patients, while others were confirmed based on clinical presentation and radiological techniques. Compared to histopathological diagnosis, cytology had a sensitivity of 89.47%, specificity of 93.33%, positive predictive value (PPV) 95.04% and negative predictive values (NPV) 86.13% for epithelial metastatic cancer. The overall diagnostic test accuracy was 91.06%. For lymphoproliferative neoplasms cytology in comparison to histopathology had sensitivity 85.71%, specificity 91.18%, PPV 76.4% and NPV 95.04%. The overall diagnostic test accuracy was 89.81%. In both ways cytology is showing significant possibility to be used as a primary tool in detecting cancers. FNAC is a fast, reliable, and efficient method for diagnosing malignant lymphadenopathy. The cytological diagnosis can sometimes be accepted as the definitive diagnosis without further correlation with histopathology, especially in advanced malignancies and known primary malignancies.

Advanced Pediatric-Type Follicular Lymphoma, Consequences of a Late Presentation in a Resource-Poor Setting: Case Report and Literature Review

AbstractPediatric-type follicular lymphoma (PFL) is a rare, nonaggressive, slow-growing (indolent), non-Hodgkin lymphoma that is typically seen in males as a localized disease with excellent outcomes. It is largely different from follicular lymphoma (FL). Few published studies on PFL are case series in developed nations. We report on a patient with advanced PFL, a 14-year-old female with 5-year history of neck swellings, abdominal distension for a month, and pericardial effusion, among others. The swellings waxed and waned; and involved all the peripheral lymph nodes. Tuberculosis (TB) GeneXpert and human immunodeficiency virus (HIV) screening were negative. She received anti-TB drugs prior to presentation in our hospital where nodal histopathology showed effaced architecture with diffuse follicles and abundant blastoid cells as well as negative CD5 and BCL2, and positive CD10 and CD20. Diagnosis of PFL (stage 3) was made. She completed six courses of cyclophosphamide, doxorubicin, vincristine, and prednisolone and is well 9 months after therapy. The PFL usually presents with stage 1 or 2 disease unlike in the index female case that was also complicated by effusion and ascites due to late presentation. It responded to chemotherapy and has not reoccurred; in contrast to classic FL and reactive follicular hyperplasia (RFH) which should be differentiated from PFL. Although RFH can be caused by TB or HIV, they are not causes of malignant lymphadenopathy. Physicians should be aware of PFL which may present in high clinical stages, but still retain its good prognosis, for the purposes of counseling.

The value of multimodal ultrasound in diagnosis of cervical lymphadenopathy: can real-time elastography help identify benign and malignant lymph nodes?

AimTo investigate the multimodal ultrasound(MMUS) features of cervical lymphadenopathy and to assess its value in the differential diagnosis of benign and malignant cervical lymph nodes.MethodsA retrospective analysis of 169 patients with cervical lymph node enlargement who attended Hangzhou Red Cross Hospital from March 2020 to October 2022. All patients underwent conventional ultrasound (CUS), contrast-enhanced ultrasound (CEUS), and real-time elastography (RTE), and were divided into training set and validation set. Univariate analysis was applied to screen out statistically significant parameters, and CUS model and MMUS model were constructed by multifactorial logistic regression analysis. The receiver operator characteristic (ROC) curve was established, and the area under the curve (AUC) was used to compare CUS model with MMUS model to assess the value of MMUS.ResultsOf the cervical 169 lymph nodes in 169 patients included in the study. The 169 enrolled patients were divided into a training set (132 patients) and a validation set (37 patients). In the training set, univariate analysis showed statistically significant differences in long diameter/short diameter(L/S), border, margin, hilus, dermal medulla boundary, blood flow type, enhancement mode, enhancement type, and RTE score (all p&amp;lt; 0.05). Multifactor logistic analysis showed that L/S, blood flow type, enhancement mode and enhancement type were correlates of malignant lymph nodes (all p&amp;lt; 0.05). The comparison of AUC demonstrated that the discriminative ability of the MMUS model was superior to using the CUS model, both in the training set(p = 0.004) and validation set (p&amp;lt;0.001).ConclusionIn this study, MMUS shows higher diagnostic efficiency than CUS. Ultrasound features such as L/S, blood flow type, mode of enhancement, type of enhancement are helpful in distinguishing benign and malignant lymphadenopathy. The addition of CEUS can greatly improve the sensitivity and specificity of ultrasonic diagnosis of malignant cervical lymph nodes. RTE score is of limited value in the diagnosis of malignant cervical lymph nodes.

Evaluation of Fine Needle Aspiration for diagnosis of Tuberculous Lymphadenitis in Children using the Xpert MTB/RIF Ultra at the University Teaching Hospitals Children’s Hospital, Lusaka, Zambia

Background: Tuberculous Lymphadenitis (TBL) is the commonest form of Extra Pulmonary TB and poses diagnostic challenges in setting with no access to Histopathology. Our goal was to evaluate the diagnostic yield of Xpert MTB Ultra performed on lymph node aspirate obtained using Fine Needle Aspiration (FNA) in children with suspected TBL. Methods: This was a cross-sectional study conducted at a tertiary and main referral hospital in Zambia. Children aged 6 months to 15 years with lymphadenopathy and presumed TBL were enrolled. FNA was performed and lymph node aspirate samples were analysed using XPERT MTB/RIF ULTRA. Data was collected and analysed as frequencies and percentages. Logistic regression was used to measure the odds of testing positive for MTB. Results: Sixty one children were enrolled in the study, 34(55.7%) were males and a median age of 6 years (IQR: 3-11 years). Sixteen (26%) were diagnosed with TB, 7 on clinical basis while, one was positive on gastric lavage, five (31%) were positive for TB on lymph node FNA using Xpert MTB/RIF Ultra. Then, 3 were positive Histopathology, with one also positive on XPERT MTB/RIF Ultra. Alternative diagnosis included malignancies like lymphomas and acute Leukemias. While non malignant lymphadenopathy included, benign reactive lymphadenopathy and HIV associated lymphadenopathy. The prevalence of HIV among the children diagnosed with TB was 37.5% (6/16). Thirty one percent (5/16) of children with TB had a close contact with TB, OR=9.0 (95% CI: 1.3-77, p-value (&lt;0.05). Conclusion: TBL is not uncommon in children presenting with Lymphadenopathy. FNA is a less invasive, inexpensive technique and coupled with use of Xpert MTB/RIF Ultra has potential for early diagnosis of TBL, in a low resource setting with limited Histopathology services.

Role of Dynamic Contrast-Enhanced MRI in Differentiation Between Malignant and Benign Cervical Lymph Nodes: A Case-Control Study

Background: Changes in signals and parameters of time-signal intensity curve (TIC) resulting from dynamic magnetic resonance imaging (MRI) have been considered for determining malignancy. However, the specific diagnostic criteria of TIC for detecting malignancy in various organs, such as lymph nodes, are not yet well-established. Objectives: This study aimed to evaluate the role of some TIC parameters in identifying malignant cervical lymph nodes. Patients and Methods: In this case-control study, patients with cervical lymphadenopathy were examined by dynamic contrast-enhanced MRI (DCE-MRI) before excisional biopsy. They were then divided into malignant and benign groups based on histopathology. Malignant patients were considered as the case group, while benign cases were considered as the control group. The TIC parameters included the signal intensity (SI) at 45 seconds, 90 seconds, 120 seconds, 5 minutes, and 10 minutes, as well as maximum signal intensity (SImax), the time at which the maximum signal intensity occurs (Tmax), the peak signal intensity (SI peak), and the time at which the peak signal intensity occurs (T peak). Additionally, the enhancement slope (ES), washout ratio (WR), and washout slope (WS) were evaluated at 5 and 10 minutes. Results: A total of 63 patients were enrolled in the study, including 31 (49.2%) patients with benign lymphadenopathies and 32 (50.8%) patients with malignant lymphadenopathies. Among the variables under study, significant differences were observed between the malignant (M) group and the benign (B) group in terms of the SI-5 min, SI-10 min, WR-5 min, WR-10 min, and WS-5 min (SI-5 min: 124.4 ± 145 (B) vs. 219.2 ± 93.8 (M), P = 0.003; SI-10 min: 109.9 ± 134.6 (B) vs. 188.9 ± 83.7 (M), P = 0.007; WR-5 min: 0.58 ± 0.38 (B) vs. 0.15 ± 0.13 (M), P &lt; 0.001; WR-10 min: 0.63 ± 0.36 (B) vs. 0.26 ± 0.17 (M), P &lt; 0.001; and WS-5 min: 0.93 ± 1.20 (B) vs. 1.40 ± 4.44 (M), P = 0.001). In the receiver operating characteristic (ROC) curve analysis, WS-5 min showed specificity of 29.1%, 75%, 90%, and 95% and sensitivity of 88.2%, 70.6%, 47.1%, and 47.1% at cutoff points of 0.1, 0.37, 0.57, and 0.66, respectively. Conclusion: The WR-5 min can be considered as a potential TIC index in DCE-MRI for the diagnosis of malignant cervical lymphadenopathies.

Back to the basics–risk factor identification of pediatric malignant lymphadenopathy proven by pathological studies

PurposeLymphadenopathy (LAP) is a common problem in the pediatric patient. History, physical examinations (PE), ultrasounds, and blood tests were often obtained while studying such lesions. Malignancy should be highly suspected in certain conditions. This study evaluates the relationship between malignant LAP and risk factors for pediatric patients. Materials and methodsMedical records of matched patients are reviewed, and data are retrospectively collected. History, PE findings, laboratory data, ultrasound findings, and pathological findings were recorded and analyzed. The median values (interquartile range, IQR) were expressed for continuous variables, and the number of patients (percentage) for categorical variables. Comparisons between groups were performed using the Mann–Whitney U test and the chi-squared test. The significance was set as p value < 0.05. ResultsA total of 142 pediatric patients underwent a biopsy in our department for LAP from July 2004 to August 2021. Among them, 108 (76.1 %) patients had benign lesions, and 34 (23.9 %) had malignancies. Weight loss, fixed LAP, firm consistency, and serum lactate dehydrogenase (LDH) exceeding 240 U/L were more related to malignant LAP than other risk factors. Multiple regression analysis revealed two independent risk factors. The receiver operating characteristic curve regarding LDH level predicting malignancy revealed a sensitivity of 79.31 % and specificity of 36.51 % by applying the criterion as 230 U/L. ConclusionsFor pediatric LAP, history-taking and physical examinations remained the most important approaches. Ultrasounds, serum LDH, and other laboratory studies may only provide clues. The cutoff level of LDH revealed low sensitivity and specificity for malignant LAP. With firm LAP, which is fixed, a biopsy for tissue proof should be performed.

Diagnostic accuracy of B-mode, Doppler ultrasound, strain elastography, and 2D shear wave elastography in differentiation between benign and malignant lymphadenopathy

BackgroundConventional ultrasound is used as an imaging modality for differentiation between benign and malignant lymph nodes, but with different accuracy, sensitivity, and specificity between different studies. A biopsy is the gold standard diagnosis modality but has a drawback due to its invasive nature. In general, metastatic lymph nodes present with a higher stiffness than benign lymph nodes, so ultrasound elastography could be used as an imaging modality for lymphadenopathy differentiation based on its ability to assess tissue stiffness. However, more studies should be done to assess its accuracy. Therefore, we aimed to assess the accuracy of B-mode, Doppler ultrasound, strain elastography, and 2D shear wave elastography criteria in differentiation between benign from malignant lymph nodes.MethodsA cross-sectional study included 60 patients with lymphadenopathy. B-mode, Doppler ultrasound, strain elastography, and 2D shear wave elastography criteria were assessed for accuracy, sensitivity, and specificity compared to the final histopathological diagnosis, whether by core biopsy, fine needle aspiration, or excision biopsy.ResultsWe assessed 60 patients in our study (20 benign and 40 malignant). Of these ultrasound criteria that achieved statistical significance, the highest accuracy was for elasticity ratio 88.9%, followed by strain ratio 83.8%. Also, the highest specificity was for an elasticity ratio of 80%, followed by strain score and strain ratio of 75% and 70%, respectively. Cortical asymmetry achieved the highest sensitivity, 100%, followed by strain ratio and elasticity ratio, with a sensitivity of 90% and 87.5%, respectively. However, cortical asymmetry had an extremely low specificity of 25%.ConclusionsUltrasound elastography criteria achieved higher accuracy compared to conventional ultrasound. So it can be used as an effective imaging modality to differentiate between benign and malignant lymph nodes.