Lymph Node Cytology

Mr. I. J. Oringo
Clinical Cytologist
12 April, 2022
 Enlarged Lymph node
• Enlarged lymph nodes >1cm are prime targets for FNA.
• FNA- useful for superficial and deep-seated lymph nodes e.g.
mediastinal, retroperitoneal, abdominal.
• Enlarged lymph nodes common- children >adults >new-born
(absent).
• Round, firm, fixed, well-defined, >8 weeks do FNA.
Terminology
• Localized/regional LN;- within contiguous anatomic regions.
• Generalized LN;- more than 2 non contiguous nodal regions e.g.
hepatosplenomegaly.
 Cont.
• Palpable regional/generalized LN- due to non-neoplastic
pathologic conditions in children/adults.
• Likely caused by bacteria, viral, Mycobacterium.
• Firm, fixed regional LN are more commonly malignant except
non-Hodgkin lymphoma.
• Generalized LN- commonly associated with non-Hodgkin.
 Indications of FNA
• Confirm clinical expression of reactive hyperplasia.
• Diagnose suspected malignancy (HL, non-HL, metastatic tumor)
• Document metastasis (staging), recurrence.
• Diagnose suspected infections
 Requirements
• Clinical history
• Available lab. tests, and U/S scan results
• Physical examination- duration, local symptoms, prior medical
history, history of cat-scratch.
• History of exposure to endemic areas (EBV)
• Family history of malignancy
• Medicine intake (antibiotics)
• Palpation findings- location, overlying skin appearance,
tenderness, fixation, size, matted or single.
• B- symptoms -fever, weight loss, night sweat.
 Advantages of FNA
• Rapid TAT
• Low cost of the procedure
• Easily provides cells for immunophenotyping/ molecular
diagnostics
• Less morbidity

Limitations
• Sampling error- necrosis, nodular fibrosis, small/ deep-seated
mass.
• Important architectural/ vascular pattern is lost in some entities.
 Reporting terminologies
• Non- diagnostic
• Negative
• Atypical
• Suspicious for malignancy
• Positive for malignancy
 Ancillary tests and studies
• Microbiology;- Gram stain, GMS, PAS, ZN, culture.
• Flow cytometry- light scattered by laser beam in different
direction
• Molecular genetic studies- PCR, FISH, NGS
• ICC/ IHC- antigen- antibody reaction

Applications
• Distinguish lymph node from non-lymph nodes
• Distinguish non-Hodgkin from reactive lymph node
• Subclassify lymphoma
 Histology
• All lymphoid cells originate from the bone marrow
• B-cells mature in the bone marrow, T-cells mature in the thymus.
• Cells colonize secondary lymphoid organs (lymph node, spleen,
MALT)
Cortex;-
• B- cell dependent area.
• Composed of primary and secondary follicles.
• Primary follicles- non stimulated, Naïve B-cells.
• Secondary follicles- stimulated, germinal center, mantle zone,
marginal zone (centroblasts, centrocytes, small lymphocytes, FDCs).
 Cont.
Paracortex;-
• T-cell dependent area.
• Variable cell sizes- small lymphocytes, T/B immunoblasts, IgM+
blasts, IDCs.
Medullary area;-
• Main area for antibody production
• Contains lymphocytes, plasmacytoid lymphocytes, plasmablasts,
mature plasma cells.
• Medullary sinus contains lymph, monocytes, macrophages, mast
cells, few lymphocytes
 Cytology
Small lymphocytes Large lymphocytes
• Measures 6-12um • Measures >20um
• Nuclear size 2x RBCs. • Nucleus 3x RBCs, larger than
• Regular nuclear contours histiocyte nucleus (1.5-2x)
• Dense coarse chromatin • Coarsely textured chromatin.
• Inconspicuous nucleoli • Includes immunoblasts and
centroblasts.
• Narrow rim of cytoplasm.
Cont.

Intermediate-sized lymphocytes Monocytoid lymphocytes

• Measures between small and • Intermediate-sized
large lymphocytes • Oval, indented, bean-shaped
• Include centrocytes and most nuclei.
centroblasts. • Abundant pale cytology.
Cont.
Centrocytes
• Intermediate-sized cells
• Irregular/ cleaved nucleus
• Inconspicuous nucleoli
• Finely granular chromatin
• Scant cytoplasm
Centroblasts
• Large lymphoid cells
• Round nucleus
• Multiple (1-3) peripheral
nucleoli
• Dispersed vesicular chromatin
• Narrow rim of basophilic
cytoplasm.
Cont.
Plasmacytoid monocytes
• Ill-defined cell borders
• Slightly larger nucleus than
small lymphocytes
• Round pale nuclei
• Pale cytoplasm
Immunoblasts
• Largest lymphoid cells
• Round to irregular nucleus
• Large central nucleolus
• Fine “open chromatin”
• Moderate to abundant pale
cytoplasm
Cont.
Follicular dendritic cells
(FDCs)
• Large pale cells
• oval/ elongated nucleus
• Small nucleolus
• Cytoplasmic process
• Binucleated/ multinucleated
epithelioid cells
Histiocytes (Tingible body
macrophage)
• Loose aggregates/single large
phagocytic cells
• Spherical/ovoid, bean-shaped
nucleus
• Finely granular chromatin
• Small distinct nucleoli
• Delicate debris-laden
cytoplasm
Cont.
Plasma cells
• Produce immunoglobulin
• Round, regular eccentric
nucleus
• Perinuclear hoff “clock face”
appearance.
• Uniform pale blue cytoplasm
Mast cells
• Large cells
• Abundant granulated
cytoplasm
• Round central nucleus
• Coarse granular cytoplasm
 Cont.

Lymphoglandular bodies
• Round, homogeneous cytoplasmic fragments
• May be vacuolated.
• Small 2-10um
• Pale blue or blue-gray in DQ.
Normal lymphnode
Patterns
 Non- neoplastic conditions
Reactive lymphoid hyperplasia
• Polymorphous lymphoid population
• Small, and plasmacytoid lymphocytes
• Centrocytes, centroblasts, immunoblasts
• Tingible body macrophages
• Dendritic cells
• Lymphoglandular bodies
• Capillaries, eosinophils, mast cells
Cont.
Inflammatory
Sarcoidosis
• A systemic granulomatous disease
• Hypocellular smear
• Epithelioid histiocytes
• Granulomas
• Multinucleated giant cells
• Lymphocytes
• Clean background
Cont.
Acute lymphadenitis
• A purulent aspirate
• Hypercellular smear
• Predominantly pure population of degenerated neutrophils
• Granulomas may be present
• Organisms include Cryptococcus N, Histoplasma capsulatum,
Staph. A, Strep ssp.
• Special stains, culture to identify organisms.
Cont.
Cat scratch disease
• Caused by Bartonella Henselae infection (Gram – bacillus)
• Node resolves in 1-4 months
• Loose or tight aggregates of epithelioid histiocytes (granulomas)
• Numerous neutrophils
• Necrosis
Cont.
Mycobacterium Tuberculosis
• Necrosis
• loose aggregates of histiocytes (Granuloma)
• Neutrophils
• Intracellular/ extracellular bacilli
• Acid fast staining bacilli
Cont.
Rosai Dorfman disease
• Bilateral, painless cervical mass in adult/children
• Numerous small lymphocytes
• Reactive lymphocytes, plasmacytoid lymphocytes, immunoblasts
• Histiocytes with emperipolesis
Cont.

Kikuchi lymphadenitis
• Histiocytic necrotizing lymphadenitis
• Small phagocytic histiocytes, sharply angulated nucleus
• Necrotic debris, karyorrhexis
• Cytoplasmic tingible bodies
• Immunoblasts, and plasmacytoid dendritic cells
• Absence of neutrophils and plasma cells
Cont.
Infectious mononucleosis
• Caused by EBV infection
• Numerous immunoblasts, plasmacytoid lymphocytes and plasma
cells
• Few dendritic-lymphocytic aggregates
• Few tingible body macrophages.
Cont.
Dermatopathic lymphadenitis
• Heterogenous lymphoid population
• Melanin-laden macrophages
• Non-pigmented dendritic cells/ macrophages present
Neoplasms
 Hodgkin's Lymphoma(HL)
• Represents approx. 30% of all lymphomas
Classical HL
• Large multinucleated Reed Sternberg cells
• Mononuclear Reed Sternberg cells present
• Small lymphocytes
• Eosinophils
• Neutrophils,
• Histiocytes
• Plasma cells
Cont.
Nodular lymphocyte predominant (NLPHL)
• Common in male 30-50 years
• Large “popcorn” cells
• Single large, folded or convoluted lymphoid nucleus
 Non- Hodgkin lymphoma
Follicular lymphoma
• Accounts for 35% of lymphoma in adults, >50 years
• Transform to DLBCL in 25-35% patients
• Lymphoid cell aggregates
• Predominantly small irregular/cleaved lymphocytes
• Large cleaved/noncleaved lymphocytes (High grade)
• Single, large clear cytoplasmic vacuole (signet-ring cells)
• Few tingible body macrophages
Cont.
Cont.
Marginal zone lymphoma
• Polymorphous population
• Small to intermediate-sized lymphoid cells
• Irregular nuclear outline
• Occasional monocytoid cells (arrow)
• Plasma cells
• FDC, TBM, follicular aggregates, immunoblasts
• Numerous lymphoglandular bodies
Marginal zone
Cont.
Small lymphocytic lymphoma (SLL/CLL)
• Monomorphous small lymphocytes
• Coarse clumped chromatin
• Smooth, round nuclear contour
• Inconspicuous nucleoli
• Scant cytoplasm
• Prolymphocytes and paraimmunoblast
• Rare TBM, follicular aggregates
Cont.
Cont.
Mantle cell lymphoma
• Monomorphous small to intermediate- size cells
• Irregular nuclear outline
• Fine chromatin
• Absent nucleoli
• Scant cytoplasm
• Lymphoid cell aggregates
• No centroblasts/immunoblasts
Cont.
DLBCL
• Predominantly large cells
• Vesicular chromatin
• Nucleus 2.5-5x larger than small lymphocytes
• Distinct to large nucleoli
• Moderate cytoplasm
• Lymphoglandular bodies
• TBM
• Dendritic-lymphocytic aggregates absent
Cont.
Cont.
Burkitt’s lymphoma
• Monotonous uniformly intermediate-sized cells
• Round nuclei, coarse chromatin
• 2-5 small nucleoli
• Scant blue vacuolated cytoplasm
• Apoptosis (necrosis) and mitoses-dirty background
• Randomly dispersed tingible body macrophages
Cont.
Cont.
Plasmablastic lymphoma
• Dispersed large dyscohesive cells
• Eccentric nucleus
• Large central nucleoli
Peripheral T- cell lymphoma
• Lymphoma of the mixed cell type (small, medium, and large
cells)
• Monomorphous small, large lymphocytes or a mixture of both
cells
• Irregular nuclei
• Histiocytes, plasma cells, eosinophils
• Reed-Sternberg-like cells
Anaplastic large cell lymphoma
• Intermediate and large cells
• irregular nuclei-horseshoe shaped
• Reed Sternberg-like cells, smaller nucleoli
• Histiocytes, neutrophils
• Few/ no lymphoglandular bodies
• No TBM or DL aggregates
Lymphoblastic lymphoma
• Pure population of blasts
• Round or convoluted nucleus
• Finely dispersed granular chromatin
• Inconspicuous nucleolus
• Nuclear molding
• Scant or moderate amount of cytoplasm
• Mitotic figures
Metastatic neoplasms
Small cell carcinoma
• Sparse cell clusters
• Nuclear smearing
• Necrotic debris in background
• Fragments of necrotic cells
Large cell carcinoma
• Predominantly large cell clusters
• No lymphoglandular bodies
• Abundant necrosis- colorectal carcinoma
• Signet-ring cells- gastric, breast carcinoma
• Abundant clear cytoplasm- renal cell, ovarian carcinoma
• Intranuclear inclusion- PTC, Melanoma
Squamous cell carcinoma
• HPV- associated head and neck.
• Commonly basaloid cell pattern
• Immature non-keratinizing cells
• Cystic debris, necrosis, mitoses
• Keratinizing cell variant
Nasopharyngeal carcinoma
• Clusters of undifferentiated large cells
• Large round to oval nuclei
• Indistinct cell borders
• Prominent nucleolus
• Abundant cytoplasm
• Lymphocytes
• Lymphoglandular bodies
• Stains positive for EBV
Malignant melanoma
• Dispersed single cells/ loose clusters
• Epithelioid, spindle, pleomorphic shapes
• Eccentric nuclei-binucleated
• Nuclear inclusions
• Single small to large nucleoli
• Cytoplasm-melanin pigment or vacuoles(bubbles)
Seminoma
• Dispersed large cells
• Macronucleolus
• Vacuolated detached cytoplasmic strips(tigroid appearance)
• Large germ cells
• Small lymphocytes