ETIOPATHOGENESIS:

The body has approximately 600 lymph nodes, but only those in the sub
mandibular, axillary or inguinal regions may normally be palpable in healthy
people.
Lymphadenopathy refers to nodes that are abnormal in size, consistency or
number.
There are various classifications of lymphadenopathy, but a simple and clinically
useful system is to classify lymphadenopathy as “generalized” if lymph nodes are
enlarged in two or more non contiguous areas or “localized” if only one area is
involved. In primary care patients with unexplained lymphadenopathy,
approximately three fourth of patients will present with localized
lymphadenopathy
and one fourth with generalized lymphadenopathy (30).

Etiopathogenesis of lymphadenopathy:

PRINCIPAL LESIONS OF LYMPH NODES(22)

Benign
Lymphomas Metastatic Tumors
Lymphadenopathies

Acute or subacute Hodgkin Metastases from

lymphadenitis lymphoma various primary sites
Hyperplastic lymphnodes Non-Hodgkin
Chronic lymphomas
Lymphadenitis
(Reactive Hyperplasia)
Paracortical
hyperplasia
Granulomatous
lymphadenitis
Sinusoidal expansion

Acute(suppurative) Lymphadenitis(22):

Clinically, acute lymphadenitis usually appears as a red, hot, tender area.

Superficial lymph nodes that drain a dental abscess, an inflamed appendix, a tubo-

1
 ovarian abscess, or an infected wound are typically affected. The most common
causes of acute lymphadenitis are bacteria or their toxic products.
In the Early aspirates contain an admixture of neutrophils and lymphocytes.
Later, the aspirates contain a purulent material composed of neutrophils and
cellular debris . As the acute inflammatory process subsides, neutrophils are
admixed with plasma cells and large macrophages containing fragments of
phagocytized material, known as tingible body macrophages.
Chronic Lymphadenitis (Reactive Hyperplasia)

Chronic lymphadenitis, more often referred to as reactive hyperplasia of lymph

nodes, is the most common cause of lymphadenopathy and the most common
diagnosis made on lymph node aspirates.
Lymph node enlargement in chronic conditions may be caused by an enlargement
of the lymphoid follicles, the pulp of the lymph nodes, the peripheral sinuses, or a
combination of all three. In reactive hyperplasia, one component of the lymph
node usually predominates and, therefore, the disorder is usually classified by
pattern . However, the architectural pattern cannot be assessed by FNA and,
therefore, it is difficult to determine specific causes of benign hyperplasia in a cell
sample.
Follicular and Paracortical Hyperplasia
Follicular hyperplasia can occur at any age, but it is more common in children.
The cervical, axillary, and inguinal lymph nodes are frequently involved .
Reactive nodes are usually less than 3 cm in diameter, although they may be
larger in children.(22)

Cytology
In general, the aspirates are quite cellular and are composed of dispersed, isolated,
single cells with marked variability in size and configuration. Small lymphocytes
are usually the dominant cell type . Follicle center cells, which are a mixture of
small and large lymphocytes with cleaved nuclei, large cells with vesicular nuclei,
and immunoblasts, are present in varying proportions. Plasma cells and tingible
body macrophages are usually present.Dense, basophilic fragments of apoptotic
nuclei and occasional mitotic figures may be seen.

2
 CONDITIONS ASSOCIATED
WITH REACTIVE LYMPHOID
HYPERPLASIA: PREDOMINANT
HISTOLOGIC PATTERN BY
ETIOLOGY
Type of hyperplasia
Follicular and paracortical
hyperplasia
Granulomatous lymphadenitis
Sinusoidal expansion
3
Lesion assosciated
Rheumatoid arthritis
Castleman disease
Syphilis
Bacterial infection (early)
Dermatopathic lymphadenopathy
Kimura disease
Viral infection
Post vaccinal lymphadenopathy
Drug-induced hypersensitivity
Kikuchi lymphadenitis
Systemic lupus erythematosus
Lymph nodes draining carcinoma
(rare)
Whipple disease (some cases)
Mycobacterial infections
Fungal infections
Toxoplasmosis
Whipple disease (some cases)
Berylliosis
Bacterial infections, including cat-
scratch disease, lymphogranuloma
venereum, tularemia, and yersinial
lymphadenitis
Lymphoma (some cases)
Lymph nodes draining carcinoma
(few cases)
Sinus histiocytosis with massive
 lymphdenpathy
Lymphangiogram effect
Whipple disease (some cases)

FOLLICULAR AND PARACORTICAL HYPERPLASIA :

Rheumatoid arthritis is an autoimmune disease that is associated with

lymphadenopathy. In rheumatoid arthritis, aspirates show florid, reactive
hyperplasia and numerous plasma cells with eosinophilic, cytoplasmic inclusions,
known as Russell bodies.

Systemic lupus erythematosus (SLE) is also associated with lymphadenopathy.

Aspirates taken from patients with SLE show numerous small lymphocytes,
transformed lymphocytes, and tingible body macrophages in a background of
necrosis. In addition, LE cells in various stages of formation may be observed.
The LE cells contain amorphous basophilic bodies, composed of aggregates of
DNA, polysac-charides, and immunoglobulins, and ranging from 5 to 12 microns
in diameter .(31)

Castleman disease :

Castleman disease is also known as giant lymph node or angiofollicular

hyperplasia. There are two morphologic subtypes: the more common hyaline-
vascular and the less common plasma cell variant. The hyaline-vascular type can
affect patients of any age, but most are asymptomatic young adults. The
mediastinum is most commonly involved, followed by the cervical lymph nodes.
Aspirates taken from patients with the hyaline-vascular form of Castleman
disease show primarily small, mature lymphocytes and occasionally larger,
atypical cells consistent with follicular dendritic cells. Capillaries are often
intermixed with the lymphocytes and reticular cells .
The plasma cell variant of Castleman disease may be localized or multicentric.
The localized form tends to affect the mediastinum and the intraabdominal lymph
nodes. The multicentric form is more common in patients who are middle-aged or
older and who have peripheral lymphadenopathy; they tend to have more severe
systemic symptoms than patients with the localized form. Aspirates show a
polymorphous lymphoid population with occasional immunoblasts and higher
than normal numbers of plasma cells, some of which contain Russell bodies.
(32,33)

4
 Kikuchi lymphadenitis :

It is a self-limited disease of unknown cause . Most patients are young women

who have painful unilateral cervical lymphadenopathy. Infrequently, the
lymphadenopathy is generalized. Histologically, there are localized areas of
necrosis in cortical or paracortical areas with prominent karyorrhexis but no
polymorphonuclear infiltrate. Atypical mononuclear cells and immunoblasts are
on the periphery. Some patients have hematologic abnormalities.
Smears taken from such patients show a heterogeneous population of small and
large transformed lymphocytes and tingible body macrophages. Scattered in the
background are necrotic debris and karyorrhectic (apoptotic) cells.(34,35)

Kimura disease:

It is a chronic inflammatory disorder of unknown origin that may be an aberrant

immune reaction to an unknown stimulus. This disease is more prevalent in men
than in women among Asian populations. Patients often have painless
lymphadenopathy of the head and neck region with cutaneous or subcutaneous
nodular lymphoid infiltrates. Aspirates are consistent with florid reactive
lymphoid hyperplasia with Warthin-Finkeldey-type multinucleated giant cells .
(36)

Dermatopathic Lymphadenopathy :

In the presence of chronic skin disorders, lymph node enlargement is common.

Histologically, there is follicular and paracortical hyperplasia and accumulation of
phagocytized granules of melanin. Pigment from tattoos may mimic melanin
accumulation The principal cells involved are the interdigitating reticulum cells .
(37)

VIRAL INFECTIONS:

Virus infections, such as with the Epstein-Barr virus (EBV) and the human
immunodeficiency virus (HIV), are usually associated with lymphadenopathy.
Occasionally, cytomegalovirus, the measles- and varicella-zoster viruses, and
herpesvirus can also affect the lymph nodes.

Infectious mononucleosis:

Infectious mononucleosis is associated with EBV. It is a self-limited infectious

disease that affects young patients and can result in fever, pharyngitis, rash, and

5
 cervical adenopathy. The axillary and inguinal lymph nodes can also be affected.
Atypical lymphocytes are present in the peripheral blood. Most of these cases are
diagnosed clinically and confirmed with a heterophil antibody (Monospot) test.,.
Aspirates of infectious mononucleosis can be quite variable, but they usually
show a polymorphous population of small and large transformed lymphocytes,
immunoblasts with binucleation, tingible body macrophages, plasma cells,
eosinophils, and mast cells. The immunoblastic proliferation may be so florid that
it may be mistaken for lymphoma, but the spectrum of immunoblastic maturation
in cells with plasmacytoid features is not seen in lymphomas. Binucleated
immunoblasts, resembling the Reed-Sternberg cells observed in Hodgkin
lymphoma, have been described in infectious mononucleosis and postvaccinal
lymphadenitis; however, these cells usually do not meet the strict criteria for
Reed-Sternberg cells .(38,39)

Infection with Human Immunodeficiency Virus:

Individuals infected with HIV commonly have lymphadenopathy. HIV

lymphadenitis may be associated with a spectrum of changes, ranging from florid
lymphoid hyperplasia to marked lymphoid depletion. As in other types of viral
lymphadenitis, aspirates from florid lymphoid hyperplasia typically show a
heterogeneous population of small, intermediate, and large lymphocytes; plasma
cells; and tingible body macrophages(40) . Multinucleated giant cells or
polykaryocytes with multiple small nuclei that resemble osteoclasts (Warthin-
Finkeldey cells, also seen in measles) and epithelioid histiocytes have also been
observed.
In the depletion phase, aspirates often have sparse follicular center cells,
immunoblasts, and tingible body macrophages but high numbers of plasma cells.
Macrophages may also be seen. In such cases, infections caused by mycobacteria
and fungi should be ruled out.

GRANULOMATOUS LYMPHADENITIS(22)

In histologic sections, the presence of granulomas, composed of epithelioid and

giant cells with or without central necrosis, is the hallmark of granulomatous
lymphadenitis. Granulomas are approximately spherical structures of various
sizes, composed of elongated epithelioid cells with pale, eosinophilic cytoplasm
and giant cells, usually of Langhans type, with a garland of peripheral, small
nuclei. Granulomatous lymphadenitis can be seen, not only in infectious
processes such as tuberculosis, atypical mycobacteriosis, brucellosis, or
infections caused by fungi or Pneumocystis carinii, but also in sarcoidosis,
foreign-body reactions, non-Hodgkin lymphoma, Hodgkin lymphoma, and, rarely,
lymph node-draining carcinoma.

6
 Cytology :

In aspirates, granulomatous lymphadenitis is characterized by epithelioid

histiocytes in a background of lymphocytes and plasma cells. Epithelioid
histiocytes are elongated polygonal cells with pale cytoplasm, indistinct cell
borders, and elliptical, sometimes comma- or boomerang-shaped pale nuclei with
finely granular chromatin, and frequently slight lateral indentations . These cells
may form loose aggregates or cohesive clusters that are reminiscent of
granulomas when seen in tissue sections. Multinucleated giant cells of foreign-
body-type with dispersed nuclei or Langhans type giant cells are often present.
Granulomatous lymphadenitis may or may not show associated necrosis, which
appears as acellular granular material on smears.

Conditions Associated with Granulomatous Lymphadenitis:

Mycobacterial infections, including those caused by Mycobacterium tuberculosis

and atypical mycobacteria, are associated with granulomatous lymphadenitis.
World-wide, tuberculosis is the leading infectious cause of morbidity and
mortality. The number of new cases of tuberculosis has increased over the last
decade, primarily in areas where HIV infection is prevalent. Individuals at high
risk for tuberculosis include infants and young children, elderly adults, and
immunocompromised patients such as those infected with HIV.

Very rarely, smears from the lymph nodes of patients with tuberculous
lymphadenitis may show only necrotic material and neutrophils . The
demonstration of AFB is done by the Ziehl-Neelsen stain which is available in
many laboratories

Negative images of bacilli are seen in Romanowsky stained smears as the bacilli
have a lipid coat which resists the Romanowsky stain.(41) The bacilli are seen as
optically clear rods or striations. These may be extra or intracellular and are not
visible with Papanicolaou stain. or striations.

Cytomorphological features of tuberculous lymphadenitis shows three major

patterns :
1) Epithelioid granulomas with caseous necrosis
2) Epithelioid granulomas without caseous necrosis
3) Necrosis alone without epthelioid granulomas.(57,58)

Cytodiagnositc criteria for tuberculous lymphadenitis 37

Cytologic feature ZN stain Diagnostic label.

7
 A. Epithelioid cells + a) AFB positive a) Tuberculous
multinucleated giant b) AFB negative lymphadenitis
cells b) Granulomatous
+ necrosis lymphadenitis
likely to be of
tuberculous
etiology, however
stain for AFB
is negative.

B. Necrotic material a) AFB positive. a)Tuberculous

without epithelioid b) AFB negative lymphadenitis
cells b) Repeat FNAC
advised for
cytodiagnosis, ZN
staining and /or for
culture of AFB.

Mycobacterium avium-intracellulare infection shows aggregates of large

histiocytes filled with negatively stained linear cytoplasmic inclusions,
particularly in patients who are immunosuppressed(42) . In lepromatous leprosy,
the characteristic cell is a syncytial histiocyte (Virchow or globus cell), which is
frequently multinucleated and has a vacuolated cytoplasm that contains numerous
lepra bacilli(43).

Fungal infections like Histoplasma capsulatum, Coccidioides immitis, and

Cryptococcus neoformans, may involve lymph nodes.
.
Histoplasmosis involving the mediastinal lymph nodes may be associated with
inflammation and proliferation of fibrous tissue resulting in sclerosing
mediastinitis. Aspirates of lymph nodes from patients with coccidioidomycosis
often show extensive necrosis; careful examination may reveal thick-walled cysts
containing endospores .

Cryptococcus may affect both immunocompetent and immunosuppressed

patients. Aspirates of lymph nodes from infected patients show epithelioid
histiocytes, yeast-filled giant cells, and

lymphocytes . The narrow-based budding yeasts usually have a thick

mucopolysaccharide capsule that stains positive with mucicarmine stain..(44)

8
 Lymphadenitis in toxoplasmosis usually affects the posterior cervical lymph
nodes, although other lymph nodes may be involved. Infection most commonly
results from exposure to contaminated cat feces or ingestion of undercooked meat.
Aspirates show a polymorphous lymphoid population admixed with loosely
aggregated epithelioid histiocytes and tingible body macrophages. The crescent-
shaped organisms are rarely observed in aspirates (45). Pneumocystis carinii can
also cause granulomatous lymphadenitis in AIDS.
Sarcoidosis is a granulomatous disease usually diagnosed in the third and fourth
decades of life. It can affect any organ, including cervical and hilar lymph nodes .
Similar granulomas may occur in lymph nodes draining metastatic cancer.

Cat-scratch disease is caused by a pleomorphic Gramnegative bacillus, Bartonella

henselae. The disease should be suspected if the aspirate from an axillary or neck
lymph node reveals granulomatous inflammation accompanied by neutrophils,
necrosis, and occasional multinucleated giant cells (suppurative granulomatous
inflammation) in a young patient who has had close contact with a cat.(22)

Lymphogranuloma venereum, caused by Chlamydia trachomatis, should be

considered when the aspirate of an inguinal lymph node exhibits suppurative
granulomatous inflammation .

SINUSOIDAL EXPANSION OF LYMPH NODES :

Sinus histiocytosis is a common type of lymph node hyperplasia that affects

mainly the axillary and inguinal areas. This type of hyperplasia may also be
observed in lymph nodes that drain cancers. In histologic sections of lymph
nodes, the markedly dilated sinuses are filled with macrophages that have
abundant, foamy cytoplasm. In aspirates, a few macrophages with phagocytic
material and occasional neutrophils are seen.(46,47))
Conditions Associated with Sinusoidal Expansion:

Sinus histiocytosis with massive lymphadenopathy, also known as Rosai-

Dorfman disease, is a benign, generally self-limited condition. It usually affects
children and adolescents , is characterized by bilateral cervical lymphadenopathy.
Aspirates usually contain numerous histiocytes, some containing whole
lymphocytes within their cytoplasm (a phenomenon known as emperipolesis) ,
plasma cells, and few neutrophils .

Langerhans cell histiocytosis is a rare disorder, usually occurring in children and

young adults. It most commonly presents as a single lytic bone lesion
(eosinophilic granuloma), composed of mature, lipid-laden histiocytes,
Langerhans' cells with pale eosinophilic cytoplasm, and a finely textured
characteristically indented or grooved nuclei (48)and varying numbers of
eosinophils, plasma cells, and neutrophils with a few multinucleated giant cells.
(49)

9
 Leaking or rupture of silicone implants used in breast augmentations or joint
prostheses may result in silicone reaching the regional lymph nodes, which are
generally enlarged.

Aspirates from the lymph nodes of such patients may show silicone
lymphadenopathy, which is characterized by the presence of numerous vacuolated
macrophages and multinucleated giant cells. The vacuoles contain silicon, a
refractile homogeneous material that is not birefringent. Asteroid bodies, which
are crystalloid structures resembling stars, may be seen in the cytoplasm of the
macrophages(50) .

POSTTRANSPLANTATION LYMPHOPROLIFERATIVE
DISORDERS:

Posttransplantation lymphoproliferative disorders occur in approximately 2% of

organ-transplant recipients who were given immunosuppressive therapy. Epstein-
Barr virus (EBV) is commonly associated with these disorders..

Aspirates from patients who have posttransplantation lymphoproliferative

disorder may have either a polymorphous or monomorphous cell population. In
the former, aspirates show a heterogeneous population of mature and immature
lymphocytes, with scattered plasma cells and histiocytes in the background,
whereas aspirates from the latter contain predominantly large cells resembling
lymphoma.(51,52).

Knowles et al (1995) classified posttransplantation lymphoproliferative disorders

into three categories according to distinct morphologic and molecular findings:
 Plasmacytic hyperplasia
 Polymorphic B-cell hyperplasia and polymorphic B-cell lymphoma
 Immunoblastic lymphoma or multiple myeloma(22)

MALIGNANT LYMPHOMAS :

In the past, the principal role of FNA of lymph nodes was to determine the
presence of metastatic carcinoma or sarcoma. The idea that one could diagnose
and subclassify lymphoid neoplasms by FNA was met with skepticism by
pathologists and clinicians (Hajdu and Melamed, 1984). Although the presence of
an atypical lymphoid population was recognized on FNA specimens in most
instances of lymphoma, a definitive diagnosis of lymphoma was usually rendered
only on excised lymph nodes. The use of FNA to render a primary diagnosis of
lymphoma remains controversial .

10
 Many of the limitations of FNA in the diagnosis of lymphoproliferative disorders
have been addressed by Katz and Caraway (1995). One of the major drawbacks to
the use of FNA is the lack of lymph node architecture that is important in the
subclassification of some lymphomas. However, because many lymphomas have
distinctive cytomorphologic, immunophenotypic, and proliferative profiles, the
absence of architecture can be overcome in these instances by
immunophenotyping. A subsequent lymph node excision is performed if the
material is inadequate, if the results are ambiguous, or if the clinical and
radiographic findings are not in accord with the cytologic interpretation.

CLASSIFICATION OF LYMPHOMAS :

Revised European-American Classification of Lymphoid Neoplasms (REAL) was

proposed by the International Lymphoma Study Group (55). The REAL system
categorizes entities on the basis of the neoplasm's cell of origin. Because this
system places greater emphasis than previous systems on cytomorphologic
features, immunophenotype, and results of molecular studies, it can be applied
easily, using a multiparameter approach to FNA specimens. The new (1998)
World Health Organization (WHO) classification for lymphomas is similar to the
REAL system; minor modifications have been made as additional data have
become available (56).

WORLD HEALTH ORGANIZATION CLASSIFICATION OF THE NEOPLASTIC

DISEASES OF THE LYMPHOID TISSUES(22)

B-Cell Neoplasms

Precursor B-cell lymphoblastic leukemia/lymphoma

Mature B-cell neoplasms

 Chronic lymphocytic leukemia/small lymphocytic lymphoma

 Prolymphocytic leukemia

 Lymphoplasmacytic lymphoma (lymphoplasmacytoid lymphoma)

 Mantle cell lymphoma

 Follicular lymphoma (follicle center lymphoma)

 Marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) type

11
  Nodal marginal zone lymphoma with or without monocytoid B-cells

 Splenic marginal zone B-cell lymphoma

 Hairy cell leukemia
 Diffuse large B-cell lymphoma
o Subtypes: mediastinal (thymic),
o intravascular,
o primary effusion lymphoma

 Burkitt
lymphoma

 Plasmacytoma
 Plasma cell myeloma

T-Cell and NK-cell Neoplasms

Precursor T-cell lymphoblastic leukemia/lymphoma

Mature T-cell and NK-cell neoplasms
 T-cell prolymphocytic leukemia
 T-cell large granular lymphocytic leukemia
 NK-cell leukemia
 Extranodal NK/T-cell lymphoma, nasal-type (angiocentric lymphoma)
 Mycosis fungoides
 Sézary syndrome
 Angioimmunoblastic T-cell lymphoma
 Peripheral T-cell lymphoma (unspecified)
 Adult T-cell leukemia/lymphoma (HTLV1+)
 Systemic anaplastic large cell lymphoma (T- and null-cell types)
 Primary cutaneous anaplastic large cell lymphoma
 Subcutaneous panniculitis-like T-cell lymphoma
 Enteropathy-type intestinal T-cell lymphoma
 Hepatosplenic γ/Δ T-cell lymphoma

Hodgkin's lymphoma

Nodular lymphocyte predominance Hodgkin's lymphoma

Classic Hodgkin lymphoma
 Hodgkin lymphoma, nodular sclerosis type (grades I and II)
 Classic Hodgkin lymphoma, lymphocyte-rich
 Hodgkin lymphoma, mixed cellularity

12
  Hodgkin lymphoma, lymphocytic depletion (includes “Hodgkin-like anaplastic
large cell lymphoma”)

Principles of Cytologic Diagnosis of Malignant Lymphomas:

The population of cells in non-Hodgkin's lymphomas is usually monotonous, that is, the cells
are of approximately equal sizes. In assessing smears, the lymphoid cells are classified as
“small” if they are equal in size or slightly larger than normal resting lymphocytes;
“intermediate” if they are one and one-half times larger than the size of a normal lymphocyte
but not larger than the nucleus of a macrophage; or “large” if they are two or more times the
size of a normal lymphocyte.
The nuclei are round, cleaved, or lobulated, or show irregularities of the membrane with
small protrusions. The coarse or fine patterns of chromatin distribution and the presence or
absence of nucleoli must be noted.
Lymphoglandular bodies (Søderstrøm bodies) are helpful in recognizing the lymphocytic
origin of a neoplasm if the cell population is difficult to classify, as is sometimes the case in
large-cell lymphomas.
B-CELL LYMPHOMA:

Mature B-cell lymphomas comprise the majority of lymphoid neoplasms worldwide and are
more common in developing countries. The subclassification of these neoplasms requires a
multiparameter approach.
Small Lymphocytic Lymphoma:

Most cases of the small lymphocytic lymphomas occur in older adults, and most patients have
bone marrow and peripheral blood involvement, although occasionally the disease is limited
to the lymph nodes. Many patients with the latter form eventually develop disease in the bone
marrow and blood. The clinical course is indolent but the disease is not curable. The disease

13
 may undergo transformation into prolymphocytic lymphoma, large-cell lymphoma (Richter
syndrome), or, rarely, Hodgkin lymphoma.

Cytology:

Small lymphocytic lymphoma comprises a monomorphous population of small,

round lymphocytes with nuclei that have a checkerboard pattern of clumped
chromatin, known as “cellules grumelées” or “lumpy cells,” characterized by
numerous coarse aggregates of chromatin in otherwise spherical nuclei. Seidel
and Garbes (1985) reviewed the diagnostic value of this feature and found it
to be a useful fixation artifact Scattered in the background are large
cells—prolymphocytes and paraimmunoblasts. Prolymphocytes are slightly larger
than paraimmunoblasts, but both have round nuclei with prominent nucleoli and
gray-blue cytoplasm.(22)The cytologic manifestations of unfavorable accelerated
course are increased number of paraimmunoblasts, plasmacytoid cells, mitotic
figures, apoptotic bodies, necrosis, and a myxoid, dirty background .
The predominance of large cells is indicative of a transformation of small
cell lymphoma into a large B-cell lymphoma (Richter lymphoma).

Lymphoplasmacytic Lymphoma:

Lymphoplasmacytic lymphoma occurs primarily in older adults and can involve the bone
marrow, lymph nodes, and spleen; peripheral blood and extranodal sites are less frequently
affected. Most patients have an elevated level of monoclonal serum paraprotein of the
immunoglobulin M type that sometimes results in symptoms of hyperviscosity (Waldenström
macroglobulinemia).

Cytology
Smears of lymphoplasmacytic lymphoma show numerous small lymphocytes,
plasmacytoid, and plasma cells. Occasionally, intranuclear inclusions known as
Dutcher bodies may be observed.(22)

Mantle Cell Lymphoma:

Mantle cell lymphoma usually occurs in older adults, mostly men. At the time of
diagnosis, the disease is often widespread and can involve the lymph nodes, spleen,
bone marrow, blood, and extranodal sites. It is more aggressive than the other B-cell,
non-Hodgkin lymphomas that are composed of small cells; patients have a median
survival time of 3 to 5 years.
Cytology
Classic mantle cell lymphoma usually consists of a monomorphous population of
small to intermediate cells with nuclear membrane irregularities and indentations,
fine nuclear chromatin, inconspicuous nucleoli, and scant cytoplasm . In some
cases, the nuclei are

14
 round or only slightly irregular, whereas others contain markedly angulated and
cleaved nuclei. Paraimmunoblasts are absent .(58)

Marginal Zone and MALT Lymphoma :

Marginal zone lymphoma is a rare low-grade, B-cell neoplasm that can have
several clinical manifestations, including the involvement of extranodal sites,
lymph nodes, the spleen, and the gastrointestinal tract. Each of these is considered
a distinct entity in the updated WHO classification system(56) . Extranodal
marginal zone lymphoma is also known as mucosa-associated lymphoid tissue
lymphoma (MALT), and most patients have localized disease. Nodal marginal
zone lymphoma is also known as monocytoid B-cell lymphoma . (59)

Cytology
Lymph node aspirates from patients with marginal zone lymphoma can be quite
variable but usually have a heterogeneous population of monocytoid cells, small
cleaved cells, large noncleaved cells, and plasma cells . The monocytoid cells are
of intermediate size with moderate to abundant amounts of pale cytoplasm; they
may have a plasmacytoid appearance. The nuclei can be somewhat variable with
oval or reniform nuclei, vesicular or coarse chromatin, and inconspicuous
nucleoli. Tingible body macrophages have also been observed in some cases .
.
Follicular Lymphomas:
Follicular lymphomas (FLs) are B-cell neoplasms composed of a mixture of
cleaved follicle center cells (centrocytes) and large noncleaved follicle center
cells (centroblasts). In the REAL classification, the FLs are subdivided into three
cytologic grades: I, predominantly small cells; II, mixed small and large cells; and
III, predominantly large cells.(60 & 55 SAME)
Cytology
Smears of follicular lymphomas are composed of a mixture of small, irregular
lymphocytes and larger cells. The lymphocytes, only slightly larger than normal
lymphocytes, have nuclei showing irregular contours and inconspicuous nucleoli.
The larger cells are centroblasts characterized by sharply demarcated basophilic
cytoplasm and round, non-cleaved nuclei with finely granular chromatin and 2 to
3 peripheral nucleoli . Centroblasts must be differentiated from centrocytes with

15
 cleaved nuclei and follicular dendritic cells, characterized by wispy cytoplasm,
indented reniform nuclei, and small nucleoli. An increase in the proportion of
centroblasts indicates a higher grade of FL

DIFFERENTIAL DIAGNOSIS OF SMALL CELL LYMPHOMAS

cytogenetics
CD5 CD23 CD10 CD20
lymphoma
CLL/SLL + + - Trisomy 2
+
Lymphoplsmacytic - + - No specif
+ abnormality

Mantle cell + - t(11;14)

+
Marginal zone - +/ - Trisomy
- + t(11;18)

Follicular - +/- t(14,18)

+

Large B-Cell Lymphoma:

Large B-cell lymphomas comprise 30% to 40% of adult non-Hodgkin

lymphomas. They usually occur in the sixth decade of life, but the age range is
broad and includes children and young adults. Patients typically present with a
rapidly enlarging neck or retroperitoneal mass.

16
 Cytology
Large B-cell lymphoma is a heterogeneous group of neoplasms consisting
primarily of large cleaved and noncleaved cells. In large noncleaved cell
lymphoma, the cells have round to ovoid nuclei that contain one or more distinct
nucleoli . Large cleaved cell lymphoma, on the other hand, features irregular
nuclear profiles, often with nuclear protrusions (“nipples”). Nuclei may be
vesicular with inconspicuous nucleoli. Lymphoglandular bodies are usually
numerous.(60)
Ancillary Studies :
Immunophenotyping shows positive staining for B-cell-associated antigens
(CD19 and CD20). Expression of CD45 and CD10 is variable. DNA ploidy
analysis usually demonstrates a diploid population with high proliferative
activity . Approximately 30% of cases show bcl-2 gene rearrangement .

Burkitt Lymphoma :
Burkitt lymphoma occurs predominantly in children. Cases reported in adults are
often associated with immunodeficiency. In endemic areas in Africa, the jaws and
facial bones are the most commonly involved sites, whereas in nonendemic areas,
the disease involves distal ileum, cecum, ovaries, retroperitoneum, kidneys, or
breasts. Epstein-Barr virus (EBV) is commonly present in the endemic form of
this lymphoma but rarely in the nonendemic cases. Burkitt lymphoma may
sometimes mimic an acute leukemia. This tumor is highly aggressive but
potentially curable. In histologic sections, Burkitt lymphoma has the typical
“starry-sky” pattern caused by the large number of macrophages intermingled
with lymphoma cells.
Cytology
Aspirates are composed of malignant lymphocytic cells. The nuclei are spherical,
with a fine to coarse chromatin pattern, and they contain two to five distinct
nucleoli . On air-dried Diff-Quik smears, the cells have deeply basophilic
cytoplasm and prominent cytoplasmic vacuoles . A “starry-sky” pattern may be
present as the result of an admixture of tingible body macrophages. Necrotic
debris and mitotic figures are frequently seen .(61)
Ancillary Studies
Immunophenotyping shows positivity for B-cell-associated antigens (CD19 and
CD20) and CD10, and negativity for CD5 and CD23.

Plasmacytoma/Plasma Cell Myeloma :

Plasmacytoma occurs in adults, usually as a disseminated bone marrow disease
(plasma cell myeloma), but sometimes as a solitary bone or extramedullary tumor.
(56) Involvement of the lymph nodes is rare
Cytology
The tumor cells resemble mature or immature plasma cells with abundant
cytoplasm with an eccentrically located nucleus . The nuclei are usually round

17
 with coarsely clumped chromatin (cartwheel arrangement of chromatin), but they
may also be cleaved or resemble immunoblasts .(62)

T-CELL LYMPHOMAS :

Lymphomas of T-cell lineage comprise only a small proportion of nodal

lymphomas. They are more difficult to identify on FNA than B-cell lymphomas
by routine analysis because of difficulties in detecting the clonal population of
abnormal T-cells by immunophenotyping.

Peripheral T-Cell Lymphoma

Smears exhibit a spectrum of atypical cells with nuclei varying in shape and
ranging from small to large . The small nuclei are often convoluted with
condensed chromatin , whereas the larger nuclei are round or irregular, with either
vesicular or condensed chromatin. The background contains a variable admixture
of neutrophils, eosinophils, plasma cells, and epithelioid and nonepithelioid
histiocytes. (63)

Mycosis Fungoides and Sézary Syndrome :(22)

Mycosis fungoides and Sézary syndrome are two different manifestations of the
same or similar disorder, having in common the presence of abnormal T-helper
cells with characteristic cerebriform configuration of nuclei
Cytology
In fixed smears stained with Papanicolaou, the abnormal lymphocytes have
irregularly shaped nuclei showing peripheral indentations and large nucleoli. The
peculiar small lymphocytes with longitudinally grooved, cerebriform
configuration of chromatin are much better seen in air-dried smears, stained with
one of the hematologic stains .

Lymphoblastic Lymphoma :
Lymphoblastic lymphoma occurs predominantly in adolescents and young adult
men but it can occur in all age groups. The first manifestation of disease is usually
a mediastinal mass. The disease progresses rapidly to involve the peripheral
blood, bone marrow, central nervous system, and gonads.
Cytology
Aspirates taken from patients with lymphoblastic lymphoma show a
monomorphous population of lymphoid cells of intermediate size with nuclei that
may be lobulated, convoluted, or, less often, round or oval. The chromatin is
finely granular or opaque, and the nucleoli are inconspicuous . (64)

Anaplastic Large-Cell Lymphoma :

18
 Most commonly, aspirates contain large cells with pleomorphic, hyperchromatic
nuclei and abundant cytoplasm, often mimicking epithelial cancer cells. Small cell
and lymphohistiocytic variants have also been described. In the pleomorphic
type, the nuclei can be multilobulated, horseshoe-shaped, bagel-shaped, or
multiple and contain one or more prominent nucleoli . The multinucleated forms
may resemble Reed-Sternberg cells.(22)

HODGKIN LYMPHOMA :

Hodgkin lymphoma accounts for approximately 20% of newly diagnosed

lymphomas. The updated WHO classification lists two distinct types of Hodgkin's
lymphoma—classic and nodular lymphocyte-predominant.(56)

FNA has an important but limited role in the initial diagnosis of Hodgkin
lymphoma (63). If the cytomorphologic features and immunophenotypic findings
are suggestive of a diagnosis of Hodgkin lymphoma, then a tissue biopsy is
recommended for confirmation and subclassification. However, FNA is very
useful in diagnosing recurrent disease.(66,67) The diagnosis of Hodgkin’s
lymphoma can be made with more
confidence than a diagnosis of NHL on cytology according to Iyengar et al.30

Cytology
The cytologic diagnosis of Hodgkin lymphoma mainly is made on the basis of the
presence of classic Reed-Sternberg cells in a background of lymphocytes, plasma
cells, eosinophils, and histiocytes. Classic Reed-Sternberg cells are large
binucleated or multinucleated cells with pale abundant cytoplasm that contain
nuclei with reticulated chromatin and prominent macronucleoli . The nucleus
often appears surrounded by a clear, empty cytoplasmic halo. Instead of classic
Reed-Sternberg cells some aspirates contain Hodgkin cells, which are large
mononuclear cells with reticulated chromatin and one or two prominent nucleoli
Aspirates from lymph nodes of patients with nodular, sclerosing Hodgkin
lymphoma, the most common subtype, usually contain classic Reed-Sternberg
cells, lacunar cells, eosinophils, lymphocytes, and histiocytes. Lacunar cells are
large cells with abundant clear or pale cytoplasm that contain indented or
overlapping segmented nuclei; these cells are not specific for Hodgkin lymphoma.
The mixed cellularity subtype of Hodgkin lymphoma has cells very similar to
those of the nodular sclerosis subtype, except for the absence of lacunar cells.(22)

In the lymphocytic depletion subtype of Hodgkin lymphoma, aspirates are often

sparsely cellular consi
sting of Reed-Sternberg and Hodgkin cells in a background of lymphocytes or
fibroblasts.

19
 The nodular lymphocyte-predominant subtype of Hodgkin lymphoma may be
suggested by cytologic preparations that have epithelioid histiocytes and the
polyploid variant of Reed-Sternberg or the so called L and H cells in a
background of mature lymphocytes.

Ancillary Studies:
Most Reed-Sternberg cells and their variants are positive for CD15 and CD30
except for those in nodular lymphocyte-predominant Hodgkin lymphoma, and are
negative for CD45 and EMA . They are usually negative for B-cell and T-cell
markers. The lymphocytes in Hodgkin lymphoma are nonneoplastic and have a T-
cell origin.(22)

CELLS THAT MIMICK REED-STERNBERG CELLS

 Immunoblasts
 Megakaryocytes
 Plasmablasts
 Anaplastic Lymphoma Cells
 Large Cell Lymphoma Cells
 Melanoma
 Large cell carcinoma
TABLE 31-11 PRIMARY SITES OF NEOPLASMS AND COMMON SITES OF
LYMPH NODE METASTASES

METASTATIC TUMORS IN LYMPH NODES

 Metastatic cancer is a far more common cause of enlarged peripheral lymph nodes
than malignant lymphoma, especially in patients older than 50 years. FNA is a
reliable method of diagnosing metastatic cancer, a task that is much easier than
diagnosing lymphomas. Aspirates serve to not only establish the diagnosis of a
metastatic tumor, but to also usually permit a definition of the histologic type and
sometimes the organ of origin of the metastasis. (48)

Carcinomas, melanomas, germ cell tumors, and sarcomas can all metastasize to
lymph nodes; carcinomas are the most frequent.
Squamous Carcinoma
The cytologic appearance of squamous carcinoma depends on the degree of
differentiation by the tumor. Keratinizing cancers are readily identified when cells
with abundant, sharply demarcated, dense, eosinophilic cytoplasm and pyknotic
nuclei are present in smears.
Nonkeratinizing squamous carcinomas or epidermoid carcinomas are
represented by round, oval, or polygonal cells with sharply demarcated pale
cytoplasm and coarsely granular nuclear chromatin.(22)

20
 Nasopharyngeal carcinoma is subtyped as keratinizing squamous carcinoma
(type 1), nonkeratinizing carcinoma (type 2), and undifferentiated carcinoma,
also known as lymph-oepithelioma or Schimke tumor . It is a common tumor in
Asians, affects men more commonly than women, and has a bimodal age
distribution with peaks in the second and sixth decades. Cervical
lymphadenopathy may be the first manifestation of this disease, although nasal
discharge or epistaxis, and middle ear symptoms may be noted. (22)

Cytomorphology of nasopharyngeal
Carcinoma(69)
• clusters of undifferentiated large cells
• large nuclei with pale chromatin
• with or without prominent nucleolus
• moderate amount of cytoplasm
• lymphocytes, often commingled with epithelial
cells
• lymphoglandular bodies

PRIMARY SITES OF NEOPLASMS AND COMMON SITES OF LYMPH NODE METASTASES

(22)

Cervical Lymph Nodes

 Oral Cavity
 Larynx
 Nasopharynx
 Thyroid
 Skin of Face

Mediastinal Lymph Nodes

 Lung
 Axillary Lymph Nodes
 Breast
 Skin (Melanoma)

Abdominal (retroperitoneal) Lymph Nodes

 Gastrointestinal Tract
 Pancreatabiliary Tract
 Kidney
 Uterine corpus
 Gonads
21
Pelvic Lymph Nodes

 Ceviix
 Adenocarcinoma:

Adenocarcinoma:Aspirates from the lymph nodes of patients with metastatic

adenocarcinomas, regardless of the site of origin, usually contain tumor cells that
are arranged singly or in cohesive groups consisting of ball-like clusters, papillary
fragments, loose clusters, or acini with central lumina. The tumor cells may be
round, cuboidal, or columnar. The appearance of the cytoplasm may vary from
homogeneous to markedly vacuolated. Left supraclavicular lymph node (Virchow
node) may be the site of metastases of gastrointestinal tumors.
Large signet-ring cells with intracytoplasmic mucin are commonly associated
with gastric carcinomas
Columnar cancer cells with elongated, palisading nuclei in a background of
necrotic debris suggest a colonic primary tumor
In general, the presence of intracytoplasmic mucin excludes hepatocellular,
renal, adrenal, or thyroid carcinomas. (22)

Renal cell carcinoma :

The cells of this tumor are usually arranged in monolayered sheets of various
sizes, have abundant clear cytoplasm, often with well-defined cytoplasmic
borders, and round nuclei with prominent nucleoli.
In men, glandular cells, arranged in a cribriform pattern with round nuclei and
prominent nucleoli or occurring in small clusters, are suggestive of a prostatic
primary tumor.(48)

Thyroid papillary carcinoma :

Thyroid papillary carcinomas often metastasize to the lymph nodes of the neck.
Smears from aspirates may show papillary fragments, monolayered sheets,

22
 syncytial groups, and/or single cells. The nuclei are often oval-shaped and have
fine, powdery chromatin, intranuclear cytoplasmic inclusions, intranuclear
grooves, and small nucleoli . The cytoplasm is usually dense and well defined.
Psammoma bodies alone, even if not accompanied by cells observed in an
aspirate from a neck lymph node, are suggestive of metastatic thyroid
carcinoma. The presence of colloid is a helpful distinguishing characteristic.
These tumors show positive immunostaining with thyroglobulin and thyroid
transcription factor-1 (TTF-1) (70)
Metastatic breast carcinoma should be one of the diagnoses considered when
evaluating axillary lymph node aspirates from women, especially those older
than 50 years. Aspirates from the nodes of patients with metastatic ductal
carcinoma show cancer cells singly, in cohesive groups, or both.

Small-Cell Carcinoma :
Small-cell carcinoma most often arises in the lung, but it also can be observed in
other primary sites such as the prostate, urinary bladder, larynx, paranasal sinuses,
cervix, and skin (e.g, Merkel cell carcinoma). Aspirates from the lymph nodes of
patients with metastatic small-cell carcinoma usually contain small cancer cells
occurring singly and in loosely cohesive groups. The tumor cells are two to three
times larger than mature lymphocytes and have only a small rim of cytoplasm.
The nuclear chromatin is finely granular but the nuclei can be hyperchromatic
and, at times, pyknotic . Nucleoli are inconspicuous or absent. The presence of
aggregates of tumor cells with nuclear molding and extensive necrosis is
characteristic of small-cell carcinoma(71) . The necrotic material derived from
crushed nuclei may appear in the form of “blue streaks” of DNA in the
background of the smear.

Malignant Melanoma :
Malignant melanoma is aptly named the great masquerader.
Lymph nodes are among the most commonly aspirated
metastatic sites.(72)
Cytomorphology of melanoma:
• dispersed single cells and loose clusters
• epithelioid, spindle, or pleomorphic shapes
• nuclei eccentrically placed, commonly binucleated
• nuclear inclusions
• single small to large nucleoli
• cytoplasm: melanin pigment variable, vacuoles variable
• no lymphoglandular bodies

23
 Melanin pigment is seen in less than 50% of aspirate smears. (72)The differential
diagnosis of amelanotic malignant melanoma includes DLBL,Seminoma or
Germinoma
Testicular and mediastinal seminomas or germinomas commonly metastasize to
deep lymph nodes of the abdomen and chest, respectively.
Cytomorphology of seminoma and germinoma:
• dispersed large cells
• macronucleolus
• voluminous cytoplasm, peripherally placed vacuoles with large blister-like
quality
• small round lymphocytes and lymphoglandular bodies
• granulomas
• “tigroid” background

Sarcomas :
Most sarcomas tend not to metastasize to lymph nodes: less than 3% of patients
with sarcoma develop lymphnode metastases. A subset of sarcomas breaks rank
with the “anti-lymph node” imperative, however.
Sarcomas that more commonly involve lymph
nodes include:
• synovial sarcoma
• epithelioid sarcoma
• angiosarcoma
• rhabdomyosarcoma
• Kaposi sarcoma
• follicular dendritic cell sarcoma

synovial sarcoma :
synovial sarcoma has monomorphic,bland-appearing ovoid nuclei with finely
granular chromatin,smooth nuclear outlines, and scant amounts of tapering
cytoplasm.

Kaposis sarcoma :
Smears are variably cellular with abundant red cells, and the cytomorphology is
similar to that of any spindle cell sarcoma.(75) Hyaline globules, a typical
histologic feature, are usually difficult to find in smears. Definitive diagnosis
nearly always requires immunocytochemistry. The spindle
cells are positive for CD31 and CD34.

24
 Follicular dendritic cell sarcoma:
It is a rare tumor of young to middle-aged adults that arises in lymph nodes and
in extranodal sites. It is a slow-growing tumor with metastatic potential. Smears
show loose, flat aggregates
and single cells with oval and spindle shapes.(76)Intermediate-sized nuclei have
smooth borders andsmall, inapparent nucleoli.

Germ Cell Tumors :

Germ cells tumors occur more frequently in men than in women and have a peak
incidence in the second and third decade. Although these tumors usually arise
from the testes and ovaries, they occasionally develop in extragonadal sites,
usually located along the midline, such as the mediastinum, retroperitoneum,
sacrococcygeal area, and pineal body. These tumors may metastasize to regional
lymph nodes, most commonly those in the retroperitoneum. Aspirates of the
lymph nodes from patients with seminoma show a predominantly dispersed
population of large cancer cells admixed with small mature lymphocytes, plasma
cells, and sometimes epithelioid histiocytes and multinucleated giant cells. The
tumor cells have moderate amounts of cytoplasm that occasionally contain
multiple small vacuoles. Nuclei are round to slightly irregular, have fine, granular
chromatin, and often have one large prominent nucleolus . The cytoplasm is
fragile and may be stripped during smearing, resulting in peculiar streaks of
basophilic material, known as a tigroid background, best seen on Diff-Quik
preparations . The tigroid background is a helpful feature, but it is observed in
only 39% of cases (73). Both embryonal carcinomas (Fig. 31-56) and endodermal
sinus tumors (or yolk-sac tumors) show cohesive groups of large cells with
pleomorphic nuclei. Aspirated cells from endodermal sinus tumors have
markedly vacuolated cytoplasm that may contain homogeneous hyaline
inclusions containing alpha fetoprotein(74)

The three commonest causes of lymph node enlargement in the in India are
tuberculous lymphadenitis, malignant lymphoma and metastasis in the neck
nodes. It should not be taken for granted that nodes are due to particular cause
alone, history suggestive of lymphoma and secondary neck nodes should be
elicited, even if all signs and symptoms point in direction of tuberculosis.

INDICATIONS AND ADVANTAGES OF FNAC :

Enlarged lymph nodes are a prime target for fine-needle aspiration (FNA). In an
adult, lymphadenopathy is an immediate source of concern, and unless the cause
is evident, the enlarged node is usually aspirated. In children,lymphadenopathy is
common and usually the result of reactive hyperplasia; for this reason, it is often
watched and not aspirated. Nevertheless, FNA is readily applicable to children
also, particularly if lymphadenopathy persists.

25
 Indications for lymph node fine-needle aspiration:

 Confirm a clinical impression of reactive hyperplasia

 Diagnose a suspected infection
 Diagnose a suspected malignancy
 Hodgkin lymphoma
 Non-Hodgkin lymphoma
 Metastatic tumor of unknown primary
 Document a metastasis in a patient with a known malignancy
 Confirm transformation of a known lymphoma to one of higher grade.

Advantages of lymph node fine-needle aspiration over biopsy:

 Rapid turn around time

 Low cost
 Easily provides cells for immunophenotyping and
 Provides material for molecular diagnostic tests
 Less morbidity
 Sensitivity and specificity are high.
 It eliminates or modifies lengthy periods of “watchful waiting.”
 It is safe and almost painless.
 It usually is an office procedure, necessitating neither patient preparation nor
specialized anesthesia.

FNA avoids uncommon but serious morbidity associated with lymph node
excision, like accessory spinal nerve injury.(77 )FNA is ideal particularly for
those with rapidly progressive disease,an oncologic emergency (e.g., spinal cord
compression,airway compromise, superior vena cava syndrome),deep or
surgically inaccessible nodes, advanced age, or
comorbid clinical conditions that preclude surgical biopsy
or excision.(78)

Limitations of lymph node fine-needle aspiration:

 Sampling error
Small or deep-seated lymph node
Nodal fibrosis
Excessive necrosis or inflammation
 Partial involvement of lymph node by the lesion
 Important architectural or vascular patterns are lost in some entities:
 Progressively transformed germinal centers
 Human immunodeficiency virus (HIV) Lymphadenopathy
 Vascular transformation of lymph node sinuses
 Toxoplasma lymphadenitis

26
  Castleman disease
 Nodular lymphocyte predominant Hodgkin
 Lymphoma
 Diffuse large B-cell lymphoma arising in follicular lymphoma.

Contraindications to FNAC are few:.
 1. Hemorrhagic diathesis
 2. Known suspected aneurysm, vascular malformations.

DIAGNOSTIC ACCURACY:
The frequency of nondiagnostic (unsatisfactory) results ranges from 5%
to 15% of cases FNA of lymph nodes has high sensitivity and specificity
in the distinction between a benign and malignant lesion. Accuracy estimates for
lymph node FNA vary because of local variations in technique and referral
patterns, but most investigators report over 90% accuracy in the diagnosis of
metastatic tumor to lymph nodes, and a positive predictive value of almost 100%.
Similarly, the accuracy of a diagnosis of Hodgkin lymphoma is high, with a
positive predictive value over 90%. Most studies published in the last decade
show a sensitivity for recognizing NHL that is higher than 80%, with specificity
greater than 90%. Accuracy is even higher when FNA is performed for recurrent,
as opposed to newly diagnosed, NHL.

Table showing comparison of FNAC and Biopsy

Biopsy FNAC
1. Length of procedure > 5 minutes < 5 minutes

2.. Anaesthesia Required Not Required

Not required

3.Report 1-2 days 1-2 hours

4.False positive None Rare
5.False negatives Very few Some
6.cost High Low
7.Done In operation theatre As an outpatient
8.Trauma More Little if any

Ancillary Studies :
When evaluating a lymph node FNA for a possible lymphoproliferative disorder,
a variety of specializedstudies like flow

27
 cytometry,immunocytochemistry,polymerase chain reaction,FISH,gene
expression profiling are indispensable. These require additional
effort and increase the turnaround time of the case, but the extra effort and time
are often rewarded by precise diagnosis and classification of the neoplastic
process.
Ancillary studies help to:
 Distinguish lymphoid from nonlymphoid lesions
 Distinguish NHL from reactive lesions by confirming clonality
 Subclassify a lymphoma

28