Open Node Biopsy Research Articles

A Case of Kikuchi-Fujimoto Disease in a 7-Year-Old African American Patient: A Case Report and Review of Literature

Patient: Female, 7-year-old FinalDiagnosis: Kikuchi-Fujimoto lymphadenitisSymptoms: LymphadenopathyMedication:—Clinical Procedure: BiopsySpecialty: Immunology • RheumatologyObjective:Rare diseaseBackground:Kikuchi-Fujimoto disease (KFD) is a rare self-limited necrotizing lymphadenitis which is likely under-diagnosed in pediatric patients who present with fever of unknown origin and lymphadenopathy. Definitive diagnosis is challenging as it requires an invasive open lymph node biopsy or lymph node needle aspiration cytology that shows pathologic findings of histiocytic necrotizing lymphadenitis.Case Report:We report the case of one of the youngest patients diagnosed with KFD in the United States, at the age of 7 years. KFD has a higher prevalence in patients of Asian descent, but this patient was an African American. This case report shows the often convoluted and complicated course these patients undergo with their presenting complaints of fever of unknown origin and lymphadenopathy and highlights particular clinical findings that suggest KFD.Conclusions:This patient is one of the youngest persons diagnosed with KFD in the United States, with an atypical ethnic background. It is likely that KFD is under-recognized and under-diagnosed in this population. With a broad differential diagnosis for fever of unknown origin and lymphadenopathy, awareness of KFD as a potential diagnosis may reduce other unnecessary investigations. The increased risk of patients with KFD of developing systemic lupus erythematosus (SLE) accentuates the importance of an accurate diagnosis and appropriate referral for heightened surveillance after recovery.

Erratum to: Rare association of cystic squamous cell carcinoma and small lymphocytic Bcell lymphoma: successful surgical approach.

Non-melanoma skin cancer is the most common type of cutaneous neoplasm worldwide. While basal cell carcinoma is the most common tumor, squamous cell carcinoma (SCC) causes higher morbidity and has a risk of metastatic spread, depending on immune status, tumor size, and desmoplastic growth. We reported the case of a 77 year old male patient with retroauricular tumor, which started growing 3 years ago and was excised, buth relapsed three times. The initial diagnosis was infundibular cyst. Delayed Mohs surgery was performed, as was an additional open lymph node biopsy of the patient’s right groin, on the occasion of an indolent swelling of the same which developed within 3 months. The first histopathological report confirmed the diagnosis of a cystic squamous cell carcinoma. The histopathologic evaluation of the groin tumor revealed a small lymphocytic B cell lymphoma (BCL). The patient fulfilled the following criteria for high-risk SCC: tumor size ≥2 cm (or 1 cm on the head and 6 mm on the genitals, hands, and feet), tumor thickness ≥4 mm, recurrent tumor, rapid growth. Therefore, lymph node metastasis had to be considered. High-risk SCC has a propensity to metastasize. In cases of primary tumor, Mohs surgery is the most effective treatment, particularly in relapsing tumors. The combination of cystic SCC with a small-sized BCL is very rare. The differential diagnosis and treatment may be challenging. In high-risk SCC, lymph node enlargement warrants histologic evaluation. However, not all suspicious lymph node lesions corroborate as metastatic.

Rare association of cystic squamous cell carcinoma and small lymphocytic Bcell lymphoma: successful surgical approach.

Non-melanoma skin cancer is the most common type of cutaneous neoplasm worldwide. While basal cell carcinoma is the most common tumor, squamous cell carcinoma (SCC) causes higher morbidity and has arisk of metastatic spread, depending on immune status, tumor size, and desmoplastic growth. We reported the case of a77 year old male patient with retroauricular tumor, which started growing 3 years ago and was excised, buth relapsed three times. The initial diagnosis was infundibular cyst. Delayed Mohs surgery was performed, as was an additional open lymph node biopsy of the patient's right groin, on the occasion of an indolent swelling of the same which developed within 3months. The first histopathological report confirmed the diagnosis of acystic squamous cell carcinoma. The histopathologic evaluation of the groin tumor revealed asmall lymphocytic Bcell lymphoma (BCL). The patient fulfilled the following criteria for high-risk SCC: tumor size ≥2cm (or 1cm on the head and 6mm on the genitals, hands, and feet), tumor thickness ≥4mm, recurrent tumor, rapid growth. Therefore, lymph node metastasis had to be considered. High-risk SCC has apropensity to metastasize. In cases of primary tumor, Mohs surgery is the most effective treatment, particularly in relapsing tumors. The combination of cystic SCC with asmall-sized BCL is very rare. The differential diagnosis and treatment may be challenging. In high-risk SCC, lymph node enlargement warrants histologic evaluation. However, not all suspicious lymph node lesions corroborate as metastatic.

Peripheral Lymphadenopathy in Children, Comparison of Fine Needle Aspiration Cytology with Open Biopsy

Objective: To compare the results of Fine Needle Aspiration Cytology (FNAC) with open biopsy in cases of Peripheral Lymphadenopathy. Design: A comparative study. Place and duration of study: Department of Paediatric Surgery & Department of Pathology, Nishtar Medical College & Hospital, Multan from January 2004 to September 2004. Subjects and methods: Patients presenting with Peripheral Lymphadenopathy in Paediatric Surgery out patient department were included in study. Relevant history and clinical findings were entered in performa and patients were submitted to investigations like FNAC and open lymphnode biopsy, after getting consent, on OPD basis. Results: Results of both FNAC and histopathology in 54 patients were available for comparison at the end of study. FNAC showed tuberculosis in 36 (66.67%), lymphoproliferative process in 16 (29.63%) and poor yield in 2 (3.71%) cases. Whereas open lymphnode biopsy on histopathology confirmed tuberculosis in 42 (77.78%), Hodgkin`s lymphoma in 4.(7.42%), Non Hodgkin`s in 6 (11.13%) and reactive hyperplasia in 2 (3.71%) cases. Sensitivity of FNAC in tuberculosis was 85.7% with a specificity of 100% in cases of tuberculosis while it was 71.5% in cases of lymphomatous process with an overall sensitivity of 78.5% in peripheral lymphadenopathy. Conclusion: In our setup lymphnode biopsy should be performed in all suspected cases to avoid long term morbidity and mortality especially in clinically malignant illnesses.

Diagnosis and treatment of invasive squamous cell carcinoma of the skin: European consensus-based interdisciplinary guideline

Cutaneous squamous cell carcinoma (cSCC) is one of the most common cancers in Caucasian populations, accounting for 20% of all cutaneous malignancies. A unique collaboration of multi-disciplinary experts from the European Dermatology Forum (EDF), the European Association of Dermato-Oncology (EADO) and the European Organization of Research and Treatment of Cancer (EORTC) was formed to make recommendations on cSCC diagnosis and management, based on a critical review of the literature, existing guidelines and the expert’s experience. The diagnosis of cSCC is primarily based on clinical features. A biopsy or excision and histologic confirmation should be performed in all clinically suspicious lesions in order to facilitate the prognostic classification and correct management of cSCC. The first line treatment of cutaneous SCC is complete surgical excision with histopathological control of excision margins. The EDF–EADO–EORTC consensus group recommends a standardised minimal margin of 5mm even for low-risk tumours. For tumours, with histological thickness of >6mm or in tumours with high risk pathological features, e.g. high histological grade, subcutaneous invasion, perineural invasion, recurrent tumours and/or tumours at high risk locations an extended margin of 10mm is recommended. As lymph node involvement by cSCC increases the risk of recurrence and mortality, a lymph node ultrasound is highly recommended, particularly in tumours with high-risk characteristics. In the case of clinical suspicion or positive findings upon imaging, a histologic confirmation should be sought either by fine needle aspiration or by open lymph node biopsy. In large infiltrating tumours with signs of involvement of underlying structures, additional imaging tests, such as CT or MRI imaging may be required to accurately assess the extent of the tumour and the presence of metastatic spread. Current staging systems for cSCC are not optimal, as they have been developed for head and neck tumours and lack extensive validation or adequate prognostic discrimination in certain stages with heterogeneous outcome measures. Sentinel lymph node biopsy has been used in patients with cSCC, but there is no conclusive evidence of its prognostic or therapeutic value. In the case of lymph node involvement by cSCC, the preferred treatment is a regional lymph node dissection. Radiation therapy represents a fair alternative to surgery in the non-surgical treatment of small cSCCs in low risk areas. It generally should be discussed either as a primary treatment for inoperable cSCC or in the adjuvant setting. Stage IV cSCC can be responsive to various chemotherapeutic agents; however, there is no standard regimen. EGFR inhibitors such as cetuximab or erlotinib, should be discussed as second line treatments after mono- or polychemotherapy failure and disease progression or within the framework of clinical trials. There is no standardised follow-up schedule for patients with cSCC. A close follow-up plan is recommended based on risk assessment of locoregional recurrences, metastatic spread or development of new lesions.

A clinico-etiological study of cervical lymphadenopathy in children with special reference to ultrasonography

Objectives: The aim of this study was to evaluate the etiological factors for cervical lymphadenopathy in children and the role of ultrasonography (USG) in diagnosis. Methods: A total of 200 children of significant cervical lymphadenopathy between 3 months to18 years were pro-spectively included in a tertiary referral hospital. All subjects were evaluated by history, examination, hemogram, chest X-ray, mantoux test, fine needle aspiration cytology (FNAC), acid-fast bacillus (AFB) staining, ultrasonography (USG) of lymph node. Open lymph node biopsy, bone marrow examination, serological tests were optional. Results: A total of 84 subjects (42%) identified as benign reactive, 80 (40%) as tuberculosis, 20 (10%) chronic lym-phadenitis, 12 (6%) non-Hodgkin and 4 (2%) Hodgkin’s lymphoma by USG. However, on USG among 84 subjects of benign reactive lymphadenopathy, 60 (71.4%) were having features of benign reactive lymph node, remaining 24 (28.6%) have normal sonogram; out of 80 subjects of tuberculosis lymphadenitis 66 (82.5%) have features of tuber-culosis and rest14 (17.5%) have nonspecific ultrasound changes; among 16 subjects of lymphoma, 10 (62.5%) have features of malignancy, rest 6 (37.5%) have nonspecific changes in USG examination. Male to Female ratio was1.68:1. Cervical lymphadenopathy was most prevalent in 6 to 10 years age group. Conclusion: Reactive lymphadenitis due to underlying acute bacterial or viral infection was the commonest cause of significant cervical lymphadenopathy in children and ultrasonography is a good noninvasive diagnostic modality, but requires other tests for definitive diagnosis.

Diagnostic yield of fine-needle aspiration cytology in HIV-infected patients with lymphadenopathy in the era of highly active antiretroviral therapy

Fine-needle aspiration (FNA) cytology has an established role in the investigation of lymphadenopathy in HIV-infected patients. However, changes in the spectrum of disease have been observed since the introduction of highly active antiretroviral therapy (HAART). The aim of the study was to establish whether FNA cytology remains a useful investigative tool in the post-HAART era and to determine whether the cytology results reflect the changing patterns of disease. Retrospective search of the cytopathology database at University College London Hospitals identified 73 FNA cytology procedures performed in 62 patients between January 1998 and December 2006. FNA cytology showed significant disease in 90% of adequate samples. The most common diagnoses were persistent generalized lymphadenopathy (PGL, 50%), infection (22%) and malignancy (18%). Diagnoses could not be made in 31% of patients because of inadequate sampling. An open lymph node biopsy was subsequently performed in 27% of patients. FNA cytology remains an important initial investigation in the post-HAART era, particularly in the diagnosis of PGL, infection and malignancy. Difficulties in diagnosis of Castleman disease and Hodgkin's lymphoma by FNA cytology are recognized.

PER-CUTANEOUS FNA BIOPSY WITH OPEN LYMPH NODE BIOPSY

Objective: To compare the efficacy of per cutaneous FNA biopsy with open lymph node biopsy. Setting: Nishtar Hospital, Multan. Sample size: 50 patients. Duration: One year. Results: Maximum numberof cases 35 (70%) were between the ages of 11-40 years. During this procedure adequate specimens were obtained from all cases for cytological interpretation and no complication was observed. Benign result in 30 cases while malignant disease was observed in 19 cases and an unsatisfactory result was observed in one case. Results of this study showed that tuberculosis is still a common disease in our population. Overall accuracy of FNAB cytology was 98% on comparison with histological diagnosis indicating the usefulnessof this technique. Conclusion: FNAB-C may be performed by clinician, pathologist or radiologist as an outpatient procedure. So along with other advantages it brings a new dimension of cooperation between the medical specialist, cytopathologist and radiologist in this era of emphasis on ambulatory care.

205 POSTER The role of open lymph node biopsy in the definitive diagnosis and treatment of peripheral lymphadenopathy

205 POSTER The role of open lymph node biopsy in the definitive diagnosis and treatment of peripheral lymphadenopathy

Retroperitoneal metastatic squamous cell carcinoma of the tonsil (with elevated beta human chorionic gonadotrophin): a misdiagnosis as extra-gonadal germ cell tumour

Head and neck cancers usually spread first to the regional lymph nodes but rarely may metastasize to distant sites. Metastasis to distant lymph node groups is a rare event. Furthermore, delayed multiple metastases without local recurrence is relatively uncommon. A case of retroperitoneal metastasis from a squamous cell carcinoma of the tonsil, secreting beta human chorionic gonadotrophin (beta-hCG), is reported. A 58-year-old man had undergone a tonsillectomy and chemo-radiotherapy for squamous cell carcinoma of the left tonsil and 13 months later presented with non-specific abdominal pain. The serum beta-hCG levels were high and an abdominal ultrasound scan revealed hydronephrosis on the left side. A computed tomography scan demonstrated para-aortic retroperitoneal lymphadenopathy. The patient underwent an open lymph node biopsy. The initial pathological analysis was interpreted as extra-gonadal germ cell tumour and the patient received chemotherapy. A subsequent review was consistent with a metastatic squamous cell carcinoma of the tonsil, as immunohistochemical studies showed positive staining for epithelial membrane antigen and cytokeratins 5/6 but a negative reaction to placental alkaline phosphatase. Following this, the chemotherapy regimen was changed; however, a restaging scan demonstrated progression, and the patient died from aspiration pneumonia secondary to alcohol intoxication. To our knowledge, this is the first reported case of retroperitoneal metastasis from a squamous cell carcinoma of the tonsil, secreting beta-hCG and causing hydronephrosis. This case highlights the necessity of using clinical, histological, immunohistological and ultrastructural examination to establish precise diagnosis and to avoid inappropriate treatment.

Hematologic Malignancies With Primary Retroperitoneal Presentation: Clinicopathologic Study of 32 Cases

The retroperitoneum is an uncommon location for primary lymphomatous involvement. Initial presentation of disease in this site (primary retroperitoneal lymphoma) is considered to be rare. Because of the uncommon anatomic location, the diagnosis and subsequent management of these patients tend to be difficult for both pathologists and clinicians. This report describes our experience during a period of 6 years 4 months with patients with hematologic malignancies primarily presenting in the retroperitoneum. A retrospective search of our medical records generated 32 patients who presented initially with abdominal pain or discomfort as their predominant symptom and who were found by imaging studies to have retroperitoneal mass or masses. All the histopathology slides were reviewed and classified based on the World Health Organization classification. There were 13 male and 19 female patients. Tumor types included diffuse large B-cell lymphoma (n = 12); grade 1 follicular lymphoma (n = 4); grade 3 follicular lymphoma (n = 1); B chronic lymphocytic leukemia/small lymphocytic lymphoma (n = 2); multiple myeloma (n = 1); mixed-cellularity Hodgkin lymphoma (n = 1); nodular sclerosis Hodgkin lymphoma (n = 1); aggressive B-cell lymphoma (n = 4); low-grade B-cell lymphoma (n = 4); lymphoblastic lymphoma, null cell type (n = 1); and precursor B-lymphoblastic lymphoma/leukemia (n = 1). More than half of the cases (17/32) were diagnosed on needle biopsy with immunophenotyping. Although open lymph node biopsy is a preferred method for diagnosis, needle biopsy plays a significant role in this setting, and, coupled with other information such as flow cytometry and immunohistochemistry, it is considered a practical and reliable method.

Giardia lamblia intestinalis: a new pathogen with possible link to Kikuchi-Fujimoto disease. An additional element in the disease jigsaw

A 16-year-old Caucasian girl of Albanian origin was admitted to the hospital complaining of intermittent fever (38 degrees C) for a week, nausea, vomiting, and abnormal laboratory findings (elevated serum aminotransferases levels AST/ALT 77/40 U/l and erythrocyte sedimentation rate 80 mm/first hour, as well as leukopenia 2.5 x 10(3)/mm3), which were found in a blood examination. Physical examination revealed slight hepatomegaly and splenomegaly, as well as cervical and axillary lymphadenopathy. A diagnostic open lymph node biopsy was performed and Kikuchi-Fujimoto disease (KFD) was established based on the characteristic histological pattern. Other abnormal laboratory findings were C-reactive protein 6.8 mg/dl and serum lactate dehydrogenase 900 U/l. Her history included a diarrhoea syndrome 2 months before the present admission, during the summer holidays, for which she was treated with metronidazole. At that time, characteristic cysts of giardia lamblia intestinalis were observed in the stools. Herein, we present this case hypothesising that the protozoal infection caused by the giardia lamblia intestinalis was probably triggering an immune response leading to KFD. The patient's age in combination with this firstly reported protozoal pathogen, as a triggering agent leading to KFD, consist a very interesting originality. Additionally, some review data is also given.

A technique for the threading of lymph nodes to facilitate excisional biopsy by the single surgeon.

Some clinical settings require open lymph node biopsy, even when the expertise for performing fine needle aspiration cytology (FNAC) is available. In many cases, the lymph node biopsy is performed by a junior surgical trainee or intern without any assistant, making the procedure even more difficult and an unpleasant experience for the patient. The author's technique of threading a lymph node facilitates its dissection in less time, thus minimizing discomfort to the patient and a delay in diagnosis. This surgical technique is simple and can be easily adopted by an inexperienced surgeon for self-help, especially when there is no assistant.

Indications for open cervical node biopsy in HIV-positive patients.

Open node biopsy was the method of choice for diagnosing human immunodeficiency virus (HIV) infection before serologic testing became available. Currently, the otolaryngologist is often called on to assist in the management of HIV-positive patients with troublesome cervical adenopathy. Today's questions are: what is the place of fine-needle aspiration (FNA), and when is open cervical node biopsy indicated. A retrospective review was undertaken of 93 consecutive cervical node biopsies performed by our department during the 5-year period from 1985 to 1989. Twenty of the patients who underwent biopsy were HIV-positive. Of these twenty, ten carried an established diagnosis of acquired immune deficiency syndrome (AIDS). Seventeen of these patients underwent FNA before biopsy. In the eight patients with persistent generalized lymph-adenopathy (PGL) and nontender, nonenlarging nodes, pathologic analysis revealed lymphoid hyperplasia. Five of these patients had antecedent FNA, none demonstrating any pathologic changes. Of the twelve patients with enlarging or tendon nodes, the diagnosis of mycobacterial adenitis was made in eight, Nocardial infection in two, Burkitt's lymphoma in one, and metastatic Kaposi's sarcoma in one. In four of the patients diagnosed with mycobacterial infections, FNA yielded cytologic evidence of acid-fast bacilli and open lymph node biopsy added nothing. In contrast, FNA failed to reveal the diagnosis in both patients with Nocardial infection, and in the two patients with neoplastic disease. We conclude that cervical node biopsy is not indicated in the HIV or AIDS patient with nontender or nonenlarging nodes.(ABSTRACT TRUNCATED AT 250 WORDS)

Lipoplastic lymphadenopathy presenting as an ovarian mass: A case report

Lipoplastic lymphadenopathy is a pathological condition wherein accumulations of intranodal fat result in lymph node enlargement and may mimic abdominal, pelvic, and retroperitoneal neoplasms, particularly lymphomas. The pathology appears to be different from lipomatosis in that benign, mature adipocytes and lipids are located within lymph nodes, rather than deposited in body cavities. The case of a 49-year-old woman presenting as an ovarian neoplasm is presented as an example of the pathology and its ability to masquerade as other neoplasms. The etiology of lipoplastic lymphadenopathy is unclear although associated causes are suggested. The difficulties of radiological examination of this case and others makes open lymph node biopsy important for the final diagnosis.