Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018

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On Sep 2018

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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

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Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
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Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
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Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : December | Volume : 16 | Issue : 12 | Page : EC38 - EC41 Full Version

Diagnostic Utility of Proposed Sydney System of Lymph Node By Fine Needle Aspiration Cytology: A Cross-sectional Study

Published: December 1, 2022 | DOI:
Dhwani Pandya, Bharat Bhetariya, Prakhar Gupta

1. Fourth Year Resident, Department of Pathology, M. P. Shah Government Medical College, Jamnagar, Gujarat, India. 2. Associate Professor, Department of Pathology, M. P. Shah Government Medical College, Jamnagar, Gujarat, India. 3. Senior Resident, Department of Haematology, Sanjay Gandhi Postgraduate Institute, Lucknow, Uttar Pradesh, India.

Correspondence Address :
Dhwani Pandya,
Travadi Street, Near Chavand Gate, Lathi-365430, Gujarat, India.


Introduction: Fine needle aspiration cytology is the basic and simple technique for diagnosis and evaluation of lymphadenopathies. Although large numbers of conditions and cytomorphological overlapping may cause a challenging task in diagnosis. In 2020, an expert panel proposed the Sydney system for classification and reporting of lymph node based on cytology.

Aim: To evaluate the diagnostic utility of the recently proposed Sydney system of reporting for lymph node aspirations.

Materials and Methods: This retrospective cross-sectional study was conducted at M. P. Shah Government Medical College, Jamnagar, Gujarat, India, from January 2020 to January 2022. Total of 194 fine needle aspirations (FNA) of lymph node lesions performed were reviewed and cytologically re-evaluated and classified according to the Sydney system and were compared with its clinical and histopathological details. The statistical analysis was done with the help Statistical Package for Social Sciences (SPSS) version 26.0.

Results: Out of 194 FNA, 8 (4.12%) were inconclusive, 119 (61.34%) benign, 6 (3.09%) atypical lymphocytic lesions, 26 (13.4%) suspicious for malignancy and 35 (18.04%) were malignant including metastasis and lymphomas. Data of 82 cases of histopathological follow-up was available. The sensitivity was 95.2% and the specificity was 94.1%. The positive and negative predictive values were 98.3% and 84.21%, respectively. The Risk of Malignancy (ROM) in category L2 was 0.5%, in category L3 was 50% and in category L4 and L5 were 100%.

Conclusion: The proposed Sydney system for reporting lymph node cytology would be helpful in the improvement of quality of reports, better understanding and communication between clinician and pathologist and thereby improving patient care.


Cytopathology, Granulomatous lymphadenitis, Lymphoma, Sensitivity, Specificity

Fine needle aspiration cytology is most common method for evaluation of lymphadenopathy. It gives basic material for cytological evaluation as well as facilitates multitude of ancillary techniques such as, cell block preparation, flowcytometry and immunocytochemistry (ICC) (1). The reporting of the lymph node cytology is a difficult task as many lesions of lymph nodes share similar cytopathological features. Hence, it becomes subjective for pathologists to interpret the lesion. Presently the diagnosis of lymphoma in FNA is still followed by histopathological confirmation in practice and also due to the lack of a uniform reporting system in LN cytology along with previous challenges, the LN fine needle aspiration cytology is not preferred by clinical practitioners in routine practices (1).

In the year 2020, a categorical system for performance, classification, and reporting of lymph node cytopathology was proposed at the 20th International Congress of Cytology in Sydney (2). This system also referred to as the Sydney system, is based on well-documented international cytopathology studies, as well as years of experience of the contributing authors from all over the world. It allows for the categorisation of LN-FNA diagnoses, provides a management algorithm, and has been endorsed by the International Academy of Cytology and the European Federation of Cytology Societies (2).

The main purpose of this system was to provide consensus guidelines and a framework to facilitate communication among cytopathologists, haematopathologists, clinicians, surgeons, and other healthcare providers. It also provides the key diagnostic cytopathological features and management recommendations linked to the reporting categories (3).

The classification suggested two levels of diagnostic categories, in which first category is mandatory to categorise the lesion according to broad diagnosis from L1-L5, such as inadequate, benign and malignant. The second diagnostic level aimed at identification of specific diagnostic entities by using ancillary techniques like ICC, florescent in situ hybridisation, cell block is used to obtain more accurate diagnosis on cytopathological basis. The classification also recommended the format of lymph node reporting in cytopathological examination in which basic clinical data, radiological findings, site and basic diagnostic categories (L1-L5) are recommended. Additional data such as microscopic description, ancillary techniques and secondary diagnosis if any were also suggested (3). However the Sydney system remains underutilised and there is limited data in literature to date (4),(5). Therefore the present study was aimed to cognise the diagnostic utility of Sydney reporting system in fine needle aspiration cytology for lymph node lesions.

Material and Methods

This was a retrospective cross-sectional study conducted at M. P. Shah Government Medical College, Jamnagar, Gujarat, India from January 2020 to January 2022. The ethical approval was not taken as the study was to re-evaluate the data and done as a part of departmental audit.

Inclusion criteria: Data of all the cases of Lymph node aspirates from both sexes and all age groups were included.

Exclusion criteria: Non lymph node aspirates were excluded from the study.

A total of 194 cases of lymph nodes FNA performed over last two years with detailed history and diagnosis given at that time were examined. The cytopathological data of previously reported cases were analysed and classified according to the Sydney system of reporting (2).

Study Procedure

In all the cases the FNA was performed with patient consent,under aseptic conditions with 23 gauge needle. The superficial and palpable lymph node aspirations were taken blindly and for non palpable and deep lymph nodes, image guidance was taken, mostly by ultrasonography guided FNA.

Atleast two air dried and three wet fixed smears were made and stained with Papanicolaou, Haematoxylin and Eosin (H&E) as well as May Grunwald Giemsa (MGG) stain. Additional smears were made in suspected cases of tuberculosis and stained with ziehl nelson stain. Additional Immunohistochemical markers were also done for subtyping of suspected cases of lymphomas on histopathological samples.

The smears were reported and classified into 5 different diagnostic categories based on the proposed Sydney system of reporting (2).The first diagnostic level included cases from L1-L5 (2):

• L1: inadequate/non diagnostic
• L2: benign
• L3: atypical cells of undetermined significance/atypical lymphoid cells of uncertain significance (AUS/ALUS)
• L4: suspicious
• L5: malignant)

While, there was no case in the present study that fell under second diagnostic level.

To assess the diagnostic accuracy the FNA diagnosis, each diagnostic category was compared with histopathologic diagnosis; when no biopsy was performed,clinical follow-up was checked. Out of a total 194 FNA, data of 84 histopathological cases were available.

Risk of Malignancy (ROM) was calculated by dividing the number of cases with a confirmed malignant lesion by the total number of cases with a histological or clinical follow-up within each diagnostic category (4),(6).

Statistical Analysis

The statistical analysis was done with the help of software International Business Management (IBM) SPSS version 26.0. The sensitivity and specificity were calculated with the help of true positive and true negative results of FNA diagnosis, whereas positive predictive value and negative predictive value were derived from true malignant and false malignant results ratio with total malignant results.


Total 194 lymph node fine needle aspiration smears were reviewed during study period, in which 81.4% (n=158) were percutaneous aspiration and 18.6% (n=36) image guided aspirations were taken. The mean age of patients was 39.3 years with age range from 3 months to 90 years. Out of which, 112 (57.7% ) were male and 82 (42.3%) were females. Most common site for FNA was cervical lymph nodes, comprising 67.5% (n=131) cases. Second most common site was axillary lymph nodes with 12.3% (n=24) cases, followed by inguinal lymph nodes, 5.15% (n=10) cases, submandibular lymph nodes 5.15% (n=10) cases and 9.7% (n=19) cases from other sites including submental, supraclavicular and infraclavicular lymph nodes.

A total of 4.12% (n=8) cases were reported as non diagnostic/inconclusive (L1). The majority of them n=6 (75%) showed only blood and no cellularity. Remaining cases (n=2) showed only necrosis. Benign (L2) cytologic diagnosis was seen in 61.34% (n=119) cases, which included 63 (52.9%) cases of granulomatous lymphadenitis, 16 (13.4%) cases of non specific lymphadenitis, 24 (20.2%) cases of reactive lymphadenitis and 11 (9.2%) cases of necrotising lymphadenitis with 5 (4.2%) cases of acute suppurative lymphadenitis. Among granulomatous lymphadenitis, being tuberculosis was diagnosed as the most common cause based on their clinical as well as cytologic features consistent with epitheloid histiocytic cells, multinucleated Langerhans giant cells and areas of necrosis.

Atypia of undetermined significance (AUS) (L3) included 3.09% (n=6) cases with atypical lymphocytic population and atypical non lymphocytic population. Suspicious of malignancy-category L4 cytological diagnosis were rendered in 13.4% (n=26) cases including lymphomas in 8 (30.7%) cases and metastatic lesions in 18 (69.3%) cases.

Malignant lesions (L5) were seen in 35 cases. Amongst these 5 (14.3%) cases were reported as non Hodgkin’s lymphoma, 1 (2.9%) case as lymphoproliferative disorder, 82.8% (n=29) cases as metastatic lesions. Among me tastatic lesions, 68.9% (n=20) cases were of metastastic squamous cell carcinoma from the oral cavity or lung and 31.0% (n=09) cases were of metastatic adenocarcinoma from breast, lung and thyroid.

Corresponding histopathological diagnosis were available for 42.3% (n=82) cases, which included benign as well as malignant lesions. Of 82 cases,17 cases were from category L2, 4 cases from category L3, 26 cases from category L4 and 35 cases from L5 category. In the category L2, 10 granulomas and six reactive lymphnodes were concordant with the same histopathological diagnosis, but one case of diffuse large B cell lymphoma was misdiagnosed as reactive lymphadenitis. Also, two cases of Hodgkin’s lymphomas were classified as lymphoproliferative disorder and as atypical lymphocytes (L3), respectively in FNA (Table/Fig 1).

For the clinical follow-up of patients with category L2-out of 63 cases of granulomatous lymphadenitis, 10 cases were proven as granulomatous lymphadenitis in histopathological examination and 50 cases were Cartridge Based Nucleic Acid Amplification Test (CB-NAAT) proved cases with infection of M. Tuberculosis. Amongst the 24 cases of reactive lymphadenitis, 7 cases were followed-up based on histopathological biopsies and rest all (n=17) cases were followed-up with regression of lymph node size with antibiotic and anti-inflammatory therapy.

The sensitivity for the present study for Sydney system of reporting was 95.23%, specificity of 94.11%, the positive predictive value was 98.36% and negative predictive value was 84.21%. The details of cytopathological diagnosis according to Sydney reporting system categories along with follow-up histopathological diagnosis of each categories with ROM is mentioned in (Table/Fig 1).


After the successful establishment of Bethesda system for cervical (7) and thyroid cytology (8) and Milan system for salivary gland cytology (9), in 2020 proposal of Sydney system for lymph node was proposed to keep uniform reporting and better communication (3). The present study showed the diagnostic accuracy of Sydney system in Fine needle aspiration cytology of lymph node pathologies.

In the present study, 67.5% (n=131) patients were having cervical lymphadenopathy, both unilateral as well as bilateral. A study by Robert F suggested 55% of lymphadenopathy occurs at head and neck region (10) Similar findings were also suggested by Gupta P et al., Vigilar E et al., (4),(5) (Table/Fig 2)A.

In the present study, L2 category showed more prevalence (61.34%) which could be due to low sample size and also could be due to increased prevalence of tuberculosis in the area where study has been conducted. On the contrary, studies by Gupta P et al., Vigilar E et al., (4),(5). showed equal distribution between benign and malignant lesion catagories (Table/Fig 2)B.

No histopathological follow-up was rendered in the category L1 in the present study, as six cases showed only blood and two showed necrosis, and risk of malignancy could not be calculated. Whereas, in a study by Gupta P et al., (4) 11 aspirates from category L1 found to be malignant lesions on follow-up examination therefore, the risk of malignancy (ROM) was 27.1%, where as in study of Vigilar E et al., (5) ROM was 50%, which was comparatively higher.

In the category L2, only one case of the benign lesion was falsely interpreted as reactive lymphadenitis which on histopathological and IHC examination was diagnosed as diffuse large B cell lymphoma therefore the ROM was 0.5%. Vigilar E et al., (5) have reported ROM for this category as 1.92% which was similar to the present study.

On the contrary, in a study by Gupta P et al., 35 cases out of 304 cases were found to be malignant and the ROM of this category was 11.5% (4).

Maximum discordant results (false negative) results were found in category L3 where 3 cases were reported as atypical lymphoid and non lymphoid cells which later were diagnosed as Non Hodgkin’s lymphoma in 2 cases and metastasis from epithelial malignancy in one of the case. Hence the ROM was 50%. Where as in study of Gupta P et al., (4) , total 16 cases were discordant in the category L3 and the ROM was 66.7. Similarly, the ROM for category L3 was 58.3% in a study by Vigilar E et al., (5). In the category L4 and L5 the risk of malignancy was found to be 100% , similar to Vigilar E et al., (5) and Gupta P et al., (4) where the ROM was reported to be 88% for L4 and 99.6% for L5.

In the category L5, the sub typing of the Non Hodgkin’s lymphoma were followed-up with histopathological examination and Immunohistochemistry (IHC), as IHC was the only ancillary technique which was available at the institute (11). Due to lack of other ancillary methods like flowcytometry and cell block preparation, those results could not be correlated.

The sensitivity of lymph node FNA in the malignant lesions is variable and it has range from 75-99% (12) while other studies have found that core biopsies for suspicious lymph nodes are more useful in diagnosing malignant lymph node lesions (13). The present study showed sensitivity and specificity of diagnosing FNA lymph node lesion by using Sydney system of reporting to be as 95.23% and 94.11%, respectively which is similar to the other studies by Vigilar E et al., and Cupato A et al., (4),(5),(14) (Table/Fig 3).


Small sample size, less histopathological follow-up and lack of adequate ancillary techniques were the main limitations of this study.


Lymph node fine needle aspiration cytology helps in the primary diagnosis of lymphadenopathy which is very useful for further management according to the lesions. The recently proposed Sydney system of lymph node reporting system is a promising and important classification system that is useful in risk stratification as well as management and has high sensitivity and specificity. However, multicentric studies with a larger sample size along with advanced ancillary techniques are required for more accurate results.


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DOI and Others

DOI: 10.7860/JCDR/2022/57693.17355

Date of Submission: May 11, 2022
Date of Peer Review: May 31, 2022
Date of Acceptance: Oct 08, 2022
Date of Publishing: Dec 01, 2022

• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? No
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

• Plagiarism X-checker: May 13, 2022
• Manual Googling: Aug 04, 2022
• iThenticate Software: Oct 04, 2022 (14%)

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