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Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
For authors, the manuscripts can be uploaded online through an easily navigable portal, on other hand, reviewers appreciate the systematic handling of all manuscripts. The way JCDR has emerged as an effective medium for publishing wide array of observations in Indian context, I wish the editorial team success in their endeavour"



Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"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."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
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.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
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.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(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.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


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.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
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)
E-mail: drrajendrak1@rediffmail.com
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.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2024 | Month : July | Volume : 18 | Issue : 7 | Page : EC06 - EC10 Full Version

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

Published: July 1, 2024 | DOI: https://doi.org/10.7860/JCDR/2024/68608.19579

Manisha S Khare, Prashant V Kumavat, Swapnil Kumavat, Yasmeen Khatib

1. Professor and Head, Department of Pathology, HBTMC and Dr. RN Cooper Hospital, Mumbai, Maharashtra, India. 2. Associate Professor, Department of Pathology, HBTMC and Dr. RN Cooper Hospital, Mumbai, Maharashtra, India. 3. Assistant Professor, Department of Pathology, Pacific Medical College and Hospital, Udaipur, Rajasthan, India. 4. Additional Professor, Department of Pathology, HBTMC and Dr. RN Cooper Hospital, Mumbai, Maharashtra, India.

Correspondence Address :
Dr. Yasmeen Khatib,
Additional Professor, Department of Pathology, HBTMC and Dr. RN Cooper Hospital, Juhu, Mumbai-400056, Maharashtra, India.
E-mail: dryasmeenkhatib1965@gmail.com

Abstract

Introduction: Fine Needle Aspiration Cytology (FNAC) of the lymph node is a simple tool in the diagnosis of suspected and unsuspected primary and secondary lymph node malignancy. It is a useful first-line investigation to distinguish between infective and malignant lymphadenopathy, especially in a low-resource setting like our country.

Aim: To study the utility of FNAC in the diagnosis of lymph node malignancy and to evaluate the efficacy of cytology in diagnosing the primary site of malignancy in case of metastasis.

Materials and Methods: A cross-sectional retrospective and prospective study was conducted for a five-year period from July 2015 to June 2020, in the pathology department of Dr. RN Cooper Municipal General Hospital, Mumbai, Maharashtra, India. A total of 112 patients diagnosed with malignancy on FNAC of lymph nodes were studied. The FNAC procedure was performed by cytopathologists using a 23/24G needle attached to a 10 ml syringe. The alcohol-fixed smears were stained with Haematoxylin & Eosin (H&E) stain and Papanicolaou (PAP) stains, while the air-dried smears were stained with Giemsa stain. Diagnosis was based on cytomorphological features and clinical presentation.

Results: A total of 112 patients were diagnosed with malignancy on FNAC, of which 90 were males and 22 were females, with a male-to-female ratio of 4:1. Cytological analysis of these nodes revealed metastasis in 98 cases (87.50%) and lymphoma in 14 cases (12.50%). The maximum number of patients were in the 51-60 years age group, with 38 cases (33.92%). The most common site of involvement was cervical lymph nodes, with 75 cases (66.96%). The most common cytological diagnosis was metastatic squamous cell carcinoma in 65 cases (58.02%), followed by metastatic un-differentiated carcinoma in 26 cases (23.20%).

Conclusion: Fine Needle Aspiration (FNA) is a simple, safe, accurate, cost-effective, and valuable tool in the evaluation of malignant lymphadenopathy. Malignant diseases were easily diagnosed by this simple diagnostic procedure. In the case of a diagnosis of lymphoma, surgery can be completely avoided. It helps in planning further surgical management for metastatic disease, where definitive operative intervention can be performed in one session. In the case of an un-detected primary tumour, FNAC directs further investigations towards the possible primary site.

Keywords

Fine needle aspiration cytology, Lymphoma, Malignancy

Introduction
The FNAC is a rapid, inexpensive, and safe procedure that can be done at the time of the patient’s first presentation and immediately after regional physical examination. FNAC has been extensively utilised as a primary diagnostic tool to examine enlarged lymph nodes and to exclude involvement of alternative organs, such as the salivary gland, head, neck, or other subcutaneous masses. It is a minimally invasive approach that allows fast diagnosis and treatment (1). DeMay RM has summarised the advantages of FNAC with the acronym “SAFE,” which means Simple, Accurate, Fast, And Economical (2). Enlarged lymph nodes are easily accessible for FNAC, and hence it forms an important diagnostic tool in the diagnosis of lymph node lesions. FNAC not only confirms the presence of metastatic disease but also gives a clue regarding the nature and origin of the primary tumour (3). It also gives an idea about the prognosis and management of patients for staging purposes. FNAC avoids the physical and psychological trauma occasionally encountered after an open surgical biopsy, is convenient for the patient and physician alike, and is a useful outpatient procedure (4). FNAC is also useful in the detection of recurrent malignancy.

This study was conducted to determine the utility of FNAC in diagnosing malignant lymphadenopathy and also to differentiate between lymphoma and metastasis. In cases with a known primary, cytological examination confirms the presence of metastasis, which helps in planning further surgery. In cases with an unknown primary, correlation of FNAC findings with clinical and radiological details in these cases can help to detect its site. FNAC along with ancillary techniques like immunocytochemistry and cell block preparations can help in identifying the primary metastasis. (5). Though previous similar studies have been done in the past (3),(5), the present study included a large sample size and reflected the common primaries in the Mumbai region. Moreover, cases of both lymphoma and metastasis were included.

Hence, the study was conducted to understand relative frequency and different cytomorphological features of malignancy in lymph node FNAC and to assess the cytomorphological features in metastasis to diagnose the primary site of malignancy.
Material and Methods
A five year retrospective and prospective cross-sectional study was conducted on malignant lymph node aspirates in the Department of Pathology of Dr. RN Cooper Municipal General Hospital from July 2015 to June 2020. The patients were referred from various clinical departments of Dr. RN Cooper Municipal General Hospital and other attached peripheral hospitals.

The study was approved by the Institutional Ethical Committee (IEC) with ethical clearance NHBTMC/IEC/03 dated 14/12/2019. A total of 5919 FNACs done in the five-year period, with 2452 (41.42%) performed on lymph nodes. A total of 112 patients, 63 retrospective and 49 prospective, who presented with lymph node enlargement and were diagnosed with malignancy on FNAC, were studied. Patients with lymphadenopathy due to causes except malignancy were excluded from the study.

Procedure

In every case, demographic data, brief history, physical examination, along with evaluation of relevant investigations, if available, was carried out. In retrospective cases, cytology slides were retrieved from archival collections and reviewed, while clinical data was retrieved from the medical record department. For prospective cases, after obtaining informed consent, cytopathologists performed the FNAC procedure using a 23/24G needle attached to a 10 ml syringe, taking aseptic precautions. Multiple sites were aspirated, and the material was smeared onto slides. The smears were stained with H&E, PAP, and Giemsa stains and evaluated by a cytopathologist. Diagnosis was based on cytomorphological features and clinic pathological concordance, with noted concordance between cytological and histopathological diagnosis where possible.

Statistical Analysis

Statistical analysis was conducted using Statistical Package for Social Sciences (SPSS) IBM version 21.0, with data entry checks was done at regular intervals to ensure valid entries. Results were expressed as frequency and percentage, thus not requiring further statistical analysis.
Results
The results showed that out of 112 (4.56%) lymph node aspirates that were malignant on cytology, 14 cases (12.50%) were lymphoma and 98 cases (87.50%) were metastasis. (Table/Fig 1) demonstrates the age and gender distribution of the cases studied. Patient ages ranging from 8 to 87 years. The maximum number of cases (33.93%) was in the 51-60 years age group, followed by the 41-50 years. The male population was more commonly affected, with 90 cases (80.36%) compared to 22 female cases (19.64%), with the male-to-female ratio of 4:1.

Lymphoma cases were most prevalent in the third decade (21.43%), while metastatic lymphadenopathy was commonly in the sixth decade (36.73%). There were 14 lymphoma cases, with 9 males (64.29%) and 5 females (35.71%), and 98 patients with metastatic lymphadenopathy, of which 81 (82.65%) were males and 17 (17.35%) were females.

The most common symptom was weight loss, observed in 79 cases (70.53%), followed by generalised weakness in 36 cases (32.14%). Other symptoms included fever in 29 cases (25.89%), dysphagia in 27 cases (24.10%), palpable liver in 25 cases (22.32%), splenomegaly in 5 cases (4.46%), skin rash in 7 cases (6.25%), and night sweats in 10 cases (8.92%).

(Table/Fig 2) displays the various sites of lymph nodes aspirated. The most commonly involved lymph nodes were in the cervical group, with 75 cases (66.96%). The majority of lymphoma lymph nodes with 75(66.96%) cases. Maximum cases of Lymphoma showed involvement of cervical lymph nodes, with seven cases (50%), followed by axillary nodes with five cases (35.71%). Out of the 98 cases of metastatic lymphadenopathy, 68 cases (69.39%) were detected in cervical lymph nodes, followed by 18 cases (18.39%) in supraclavicular lymph nodes.

(Table/Fig 3) presents the cytological diagnosis of all cases. There were 10 cases (8.93%) of Hodgkin’s lymphoma and four cases (3.57%) of Non-Hodgkin’s lymphoma. In the remaining, 98 cases (87.5%) of metastatic lymphadenopathy, the most common finding was metastasis of squamous cell carcinoma (65 cases), followed by metastasis of undifferentiated carcinoma (26 cases).

In the 10 cases of Hodgkin lymphoma, classical Reed-Sternberg cells were present in four cases, while mononuclear Hodgkin’s cells were seen in eight cases, and one case additionally showed ill-formed epithelioid cell granulomas (Table/Fig 4)a. In the four cases of Non-Hodgkin’s lymphoma, a monotonous population of small-to-medium-sized lymphoid cells was seen (Table/Fig 4)b.

Out of the total 112 cases, biopsies were performed in all 14 cases of lymphoma, with 100% concordance between cytology and histopathology. In 98 out of 112 cases of metastatic diseases, biopsies were performed at the primary site in 54 cases, with cytohistopathological concordance found in 45 out of 54 cases (83.33%). In nine discordant cases of undifferentiated carcinoma, further typing could not be done due to high-grade malignancy and lack of IHC on both cytology and histopathology. In 44 out of 98 cases, due to multiple metastases and advanced disease on radiology, the primary site could not be identified, and biopsies were not performed in those cases.

(Table/Fig 5) shows the primary site of malignancy in the metastatic nodes. In the category of metastatic squamous cell carcinoma with 65 cases, the primary site was the oral cavity in 18 cases (27.70%), followed by the larynx in 11 cases (16.92%), oesophagus in 8 cases (12.30%), and oropharynx in 2 cases (3.08%). In 26 cases, the diagnosis of metastatic squamous cell carcinoma was primarily made through FNAC, as patients presented with lymph node enlargement without clinical suspicion of malignancy.

All cases of SCC showed malignant squamous cells with varied morphology, and 48 cases showed background necrosis and nuclear debris (Table/Fig 6)a. In cases of metastatic undifferentiated carcinoma, the primary site was the nasopharynx in six cases (23.08%), oral cavity in two cases (7.69%), and lung in one case (3.85%) (Table/Fig 6)b. The primary site remained unknown in 17 cases (65.35%). Metastatic melanoma was seen in two cases of inguinal lymph nodes, with the primary site being the toe in one case and the anal canal in another [Table/Fig-6c]. [Table/Fig-6d] shows one case of metastasis of papillary thyroid carcinoma with intranuclear pseudo inclusion. (Table/Fig 7) displays histopathological images of lymphoma and metastatic SCC and papillary thyroid carcinoma.
Discussion
Enlarged lymph nodes are accessible for FNAC and are important in diagnosing the underlying disease. FNAC is a diagnostic tool that is cost-effective, simple, and minimally invasive. It can provide clues in the presence of an occult primary and sometimes surprise clinicians who do not suspect malignancy (6). FNAC has become a well-established method for diagnosing metastatic malignancies in lymph nodes (7). The diagnosis based on cytological material is accepted and sometimes there is no further correlation with histopathology is not always necessary, especially in cases of advanced malignancies (3). (Table/Fig 8) compares the present study to other studies (3),(5),(6),(7),(8),(9),(10),(11),(12).

Malignancies in lymph nodes are predominantly metastatic, with an incidence varying from 65.7% to 80.4%, while lymphomas range from 2% to 15.3% of lymph nodes aspirated from all sites (3). In this study, lymph node involvement by metastasis (87.50%) was more common compared to primary lymphoid neoplasms (12.50%). This aligns with findings from other studies as shown in (Table/Fig 8) (3),(5),(7). In the present study, 4.50% yielded malignant diagnosis, which is significantly lower than in other studies where the incidence ranged from 4.8% (8) to 69.74% (7). This difference may be because our institute being a general hospital serving a diverse population where infectious aetiology is predominant.

In the present study, males were predominantly affected with 90 cases (80.36%), compared to females with 22 cases (19.64%), resulting in a male-to-female ratio of 4:1. A male preponderance was also noted by Rathod G and Singla D (3.2:1), Arora S et al., (3.5:1), and Mehdi G et al., (3.1:1) (6),(9),(10). The most common age group in the present study was 51-60 years, similar to findings by Chakravarty-Vartak US et al., Mehdi G et al., and Meena P and Mishra RT (8),(10),(11).

The most common symptom in patients with malignant lymphadenopathy was weight loss, seen in 79 cases (70.53%). Bosch X et al., noted that the most common clinical symptom was a palpable liver in 88 (24%) cases, followed by weight loss in 86 (23%) patients in their study (13). In the present study, hepatomegaly was seen in only 25 cases (22.3%). This may be because Bosch X et al., had more cases of lymphoma, hence hepatomegaly is a common finding in their study (13). The cervical group was the most common group of lymph nodes involved, followed by supraclavicular nodes. This was similar to the findings of Gupta C et al., Rathod G and Singla D; Arundhati JP, and Meena P and Mishra RT (5),(6),(7),(11). The oral cavity was the most common primary site of malignancy in the present study, and similar findings were noted by the other authors (3),(5),(6),(8),(10),(11),(12).

The cervical group of lymph nodes was also the most common site of FNAC in lymphomas with 7/14 cases (50%), followed by the axillary group of lymph nodes, i.e., 5/14 cases (35.71%). This may be explained by the large number of cases with metastatic head and neck malignancies and the easy accessibility of cervical nodes for examination and evaluation. The most common cytological diagnosis in the present study was metastasis of squamous cell carcinoma, reported in 65 cases (58.02%), which was similar to findings in other studies (3),(5),(6),(8),(9),(10),(11),(12). The second most common diagnosis was metastasis of undifferentiated carcinoma in 26 cases (23.20%), and similar findings were noted by Arora S et al., (9). Lymphomas were found in 14 cases (12.5%), with 10 cases (8.93%) of Hodgkin’s lymphoma and four cases (3.57%) of Non-Hodgkin’s lymphoma, which was similar to the findings noted by Martins MR and Santos GD, who reported 14.2% lymphomas, of which 8.6% were Hodgkin’s lymphoma and 3.7% were Non-Hodgkin’s lymphoma (14).

Other studies by Wilkinson AR et al., and Arora S et al., have reported a higher proportion of Non-Hodgkin’s Lymphoma in their studies (3),(9). The most common primary site for squamous cell carcinoma and undifferentiated carcinoma was the upper aerodigestive tract in 48/112 cases (42.86%) with involvement of the oral cavity in (17.85%), larynx in (9.8%), and pharynx in (8.1%) patients. Similar findings were noted by Wilkinson AR et al., Gupta C et al., Rathod G and Singla D; Meena P and Mishra RT; Sheikh S and Parmar JK; (3),(5),(6),(11),(12). In 44 cases (39.29%), patients presented primarily with lymphadenopathy and were diagnosed to have metastatic disease from an unknown primary on FNAC. Out of these, there were 26 cases (23.2%) of metastatic squamous cell carcinoma, 17 cases (15.1%) of undifferentiated carcinoma, and a single case of metastatic high-grade papillary carcinoma. Similar findings were noted by Mehdi G et al., who reported 45.1% of cases with an unknown primary (10). Even after thorough history taking and examination, the primary site could not be found. Most of these patients were referred to higher oncology centers and were lost to follow-up. In these cases, the cervical lymph node was most commonly affected, and the most common cytological diagnosis in this category was SCC and poorly differentiated carcinoma, which was similar to findings by Mehdi G et al., (10).

In the present study, two cases were labeled as metastasis of melanoma to the inguinal lymph nodes; the primary site was found to be in the foot and anal canal, respectively. Kaur A et al., studied 39 cases of malignant melanoma with 32 cases of metastatic melanoma (15). Hence, metastatic melanoma is detected easily on FNAC, especially due to the presence of pigment. In the present study, although metastasis could be detected in 98 cases, the primary site could only be found in 54 out of 98 cases, while 44 cases presented as an unknown primary. The use of immunocytochemistry can further help in the detection of the primary in these cases.

Limitation(s)

The diagnosis of metastasis or lymphoma was given on FNAC; however, immunohistochemistry was not done at our institute, and cases were referred to higher centers for further work-up.
Conclusion
The FNAC is a simple tool to distinguish between lymphoma and metastasis. The present study included a large sample size and reflected the common types of primary malignancies in the Mumbai region. The cytomorphological features can help identify the primary site in metastasis and detect the presence of lymphomas. FNAC of malignant lymphadenopathy is an important diagnostic tool in a poor resource setting, where most patients present in the advanced stage and cannot afford expensive investigations.
Reference
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DOI and Others
DOI: 10.7860/JCDR/2024/68608.19579

Date of Submission: Nov 15, 2023
Date of Peer Review: Jan 20, 2024
Date of Acceptance: Apr 12, 2024
Date of Publishing: Jul 01, 2024

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• 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 CHECKING METHODS:
• Plagiarism X-checker: Nov 20, 2023
• Manual Googling: Jan 23, 2024
• iThenticate Software: Apr 11, 2024 (14%)

ETYMOLOGY: Author Origin

EMENDATIONS: 7
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