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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 9  |  Issue : 3  |  Page : 132-136

A clinicopathological study of cervical lymphadenopathy – A hospital-based cross-sectional study


Department of General Surgery, Malla Reddy Institute of Medical Sciences, Hyderabad, Telangana, India

Date of Submission12-Feb-2021
Date of Decision06-May-2021
Date of Acceptance28-May-2021
Date of Web Publication25-Sep-2021

Correspondence Address:
Dr. Koilakonda Ajay Kumar
Department of General Surgery, Malla Reddy Institute of Medical Sciences, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjhs.mjhs_14_21

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  Abstract 


Introduction: The enlargement of lymph nodes is an index of spread of infection and malignancy. Fine-needle aspiration cytology (FNAC) has the ability to provide rapid diagnosis and has good economic saving, reduces patient anxiety, and can be used for patients who have anesthetic risks.
Aims and Objectives: The aim of the study is to study the various clinical presentations of cervical lymphadenopathy.
Materials and Methods: This study was conducted from June 2019 to August 2020 over a period of 14 months. The study consists of 100 consecutive cases, both outpatients and inpatients at the surgical outpatient/wards at Malla Reddy Institute of Medical Sciences, Hyderabad. In all cases, FNAC was done. Excisional biopsy was done in all 100 cases.
Results: The incidence of cervical lymphadenopathy was highest in the 12–40 years age group (73%). Males were more affected than females with a male-to-female ratio of 1.22:1. Tuberculosis was the most common etiology accounting for 51%. Posterior group of cervical lymph nodes were the most common to get involved in tuberculosis (31.3%). Sixteen cases out of 51 cases of tubercular lymphadenitis showed constitutional symptoms. The sensitivity of FNAC for tuberculosis – 86%, chronic nonspecific lymphadenitis – 73.3%, malignant secondaries – 87.5%, and lymphomas – 90%. Histopathological examination is the most dependable diagnostic tool.
Conclusion: The most common disease affecting lymph nodes is tuberculosis. Dependence on clinical evidence alone would lead to erroneous diagnosis in most of the cases. FNAC is an important frontline investigation. Histopathological examination remains the most dependable diagnostic tool.

Keywords: Excision biopsy, fine-needle aspiration cytology, lymphomas, tuberculosis


How to cite this article:
Kokkonda PK, Kumar KA, Paul VA, Prasad K, Nelluri N, Pulim SR. A clinicopathological study of cervical lymphadenopathy – A hospital-based cross-sectional study. MRIMS J Health Sci 2021;9:132-6

How to cite this URL:
Kokkonda PK, Kumar KA, Paul VA, Prasad K, Nelluri N, Pulim SR. A clinicopathological study of cervical lymphadenopathy – A hospital-based cross-sectional study. MRIMS J Health Sci [serial online] 2021 [cited 2021 Oct 25];9:132-6. Available from: http://www.mrimsjournal.com/text.asp?2021/9/3/132/326728




  Introduction Top


The lymph nodes are discrete nodules composed of lymphoid tissue and located constantly at certain points along the course of the lymph vessels. Toldt was the first man who advocated the name “lymph node” at the anatomical congress at Basel. It was only in 1955, the term lymph node was adopted in the “Nomina Anatomica” at Paris. There are approximately 800 lymph nodes in the body. The neck contains about 300 lymph nodes.[1] Neck consists of one-third of total lymph nodes in the body. These are small oval or bean or kidney-shaped bodies situated along the course of lymphatic vessels, ranging from 1 mm to 20 mm.[2],[3] Each node is formed by a cortical sinus and a medullary sinus. It has an afferent vessel reaching it and efferent vessels leaving it.[4] Apart from the lymph nodes, lymphoid tissue is also present in the Peyer's patches of small intestines, submucosa of respiratory tract, in the bone marrow, in spleen, and also in the liver.[2],[3] Lymph nodes can be the primary site of the disease or can be associated with abnormality in the organ which the lymph node drains.

Following Lindber's study in 1972, the Memorial Sloan-Kettering Hospital published in 1981 a number of levels of regions within the neck which contain groups of lymph nodes that represent the first echelon sites for metastases from head-and-neck primary sites.[5]

There has been rise in acceptance of fine-needle aspiration cytology (FNAC) by both pathologists and clinicians since its resurgence in 1950. Its diagnostic accuracy is similar to traditional histopathology following open biopsy in many instances, and sophisticated radiological imaging methods have taken the FNAC from its traditional role in investigating superficial masses to many deeply placed lesions. Radiology has enabled directed sampling of organs and tissues such as lungs, pancreas, kidney, adrenal, liver, retroperitoneal masses, and even spleen. It has also been suggested as the first diagnostic technique for the diagnosis of peripheral lymphadenopathy.[6] The ability to provide rapid diagnosis has undeniable economic saving, reduces patient anxiety, and can be the method of choice for patients who are anesthetic risks. For cysts and abscesses, the technique can be both diagnostic and therapeutic.[7]

Aims and objectives

  • To study about the various clinical presentations of cervical lymphadenopathy
  • To correlate pathological findings with the clinical diagnosis
  • To study the sensitivity and specificity of FNAC by comparing with the confirmed biopsy report (final histopathological diagnosis).



  Materials and Methods Top


Study design

A hospital-based cross-sectional study.

Study duration

For a period of 14 months (June 2019–August 2020).

Study participants

A total of 100 patients with cervical lymph node enlargement, both outpatients and inpatients at the surgical outpatient/wards in Malla Reddy Institute of Medical Sciences, Hyderabad, were included after considering inclusion and exclusion criteria.

Inclusion criteria

  • Patients with >12 years of age
  • Patients with cervical lymph node enlargement.


Exclusion criteria

  • Patients with <12 years of age
  • Patients already diagnosed of any condition causing cervical lymphadenopathy
  • Patients not willing for FNAC and biopsy.


Methodology

The study was conducted after taking approval from the institutional ethics committee. The study was considered after taking written consent from all the study participants. The study participants were explained about the purpose of the study. A detailed history was taken. Information regarding the history of onset, duration, progression of swelling and associated complaints such as pain, fever, cough, breathlessness, easy fatigability, loss of appetite, loss of weight, and any family history was taken. A thorough general physical examination of patient was done. Examination of swelling was done giving importance to number, site, size, matted or discrete, and level of group of lymph node involved. Other group of lymph nodes was also examined. All cases were subjected to routine laboratory investigations. Specific investigations like FNAC of the swelling was done. X-ray neck anterior-posterior view/lateral view, X-ray chest, ultrasonography of neck, ultrasonography of abdomen were done. Lymph node biopsy was taken and sent to pathology department for further evaluation. In all cases, FNAC was done. Excisional biopsy was done in all 100 cases.

Statistical analysis

Data were entered in Microsoft Excel sheet and analysis was done using simple proportions.

[TAG:2]Results [/TAG:2]

It was observed in the present study, the incidence of cervical lymphadenopathy was highest in the age group of 12–40 years (73%) followed by 36% in the age group of 21–30 years, 14% was seen in 31–40 years, and 12% in 41–50 years of age group, respectively [Table 1].
Table 1: Age-wise distribution

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Male predominance was seen in the present study with a male-to-female ratio of 1.22: [Table 2].
Table 2: Gender distribution

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Tuberculosis was the most common etiology found in the present study accounting for 51%, followed by reactive lymphadenitis in 16% cases, chronic nonspecific lymphadenitis in 15% cases, malignant secondaries in 8%, and lymphomas in 10% cases [Table 3]. The causes of cervical lymphadenopathy were broadly classified as neoplastic and nonneoplastic lesions. About 82 were nonneoplastic lesions and 18 were neoplastic lesions [Figure 1].
Table 3: Causes of cervical lymphadenopathy

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Figure 1: Pie chart showing neoplastic and nonneoplastic lesions

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The common constitutional symptoms were fever, malaise, weight loss, loss of appetite, difficulty in swallowing, change of voice, and cough. 16 cases (31.4%) out of 51 cases of tubercular lymphadenitis showed constitutional symptoms, while 2 cases (25%) out of 8 cases of secondaries in the neck showed the presence of symptoms. In comparison, 10 cases (62.5%) out of 16 cases of reactive lymphadenitis showed the presence of symptoms. Half the patients of lymphomas showed constitutional symptoms [Table 4].
Table 4: Distribution of study participants with the presence/absence of constitutional symptoms

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[Table 5] shows that the posterior triangle group was the most common to get involved in tuberculosis (31.3%), followed by upper deep jugular group (21.5%). Levels 1, 3, and 4 were equally involved. About 30% cases had more than one site involvement. In comparison, 90% cases of lymphomas had more than one site involvement with only 10% cases afflicting the posterior triangle group of lymph nodes [Figure 2].
Table 5: Site distribution of tubercular cervical lymphadenitis and lymphomas

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Figure 2: Bar graph showing lymph node site distribution of tubercular lymphadenitis and lymphomas

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[Table 6] shows that out of the 51 histopathologically confirmed cases of tuberculous cervical lymphadenitis, a diagnosis of tuberculosis was made in 41 cases by FNAC. The other 10 cases were diagnosed as chronic nonspecific lymphadenitis. There were no false-positive cases on FNAC. About 49 cases were true negative for tuberculosis. The sensitivity and specificity of FNAC for diagnosing tuberculous lymphadenitis are therefore 80.3% and 100%, respectively.
Table 6: Sensitivity and specificity of fine-needle aspiration cytology

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  Discussion Top


In the present study “A Clinicopathological Study of Cervical Lymphadenopathy,” the discussion is focused mainly on analysis and observations made regarding presenting symptoms, clinical behavior, signs, investigations, management, and postoperative events in 100 cases of cervical lymph node enlargement.

The incidence of cervical lymphadenopathy was highest in 12–40 years age group (73%). The most common age group affected in the present study is 21–30 years accounting for 36% of cases, followed by 12–20 years (23%) and 31–40 years (14%). The most common age group involved was 11–20 years in a study done by Jha et al.[8] while in other study done by Ullah et al.[9] 72% cases were in the age group of 11–30 years, which is comparable with the present study. The study done by Kim et al.[10] is also comparable with the present study, as it had maximum number of cases between 20 and 50 years of age.

Among 100 cases of cervical lymphadenopathy, 55 cases were males and 45 cases were females. Male-to-female ratio was 1.22:1. In most of the studies, females were more affected. Few studies such as Purohit et al.[11] and Tripathy et al.[12] are comparable with the present study with a male preponderance.

In the present study, 31.4% of cases with tuberculosis had constitutional symptoms. Twenty-five percent of cases with malignant secondaries had symptoms. In comparison, 62.5%, 60%, and 50% presented with symptoms in reactive lymphadenitis, chronic nonspecific lymphadenitis, and lymphomas, respectively. Similar observations were made by Jha et al.[8] and Jindal et al.[13]

In the present study in tuberculosis, the Level 5 (posterior triangle group) was most commonly affected (31.3%) followed by Level 2 (upper jugular group) at 21.5%. Fifteen cases (29.4%) had more than one site involved in the neck and 90% of lymphoma cases had more than one site involvement. In the study by Jha et al.,[8] upper deep jugular group was the most commonly involved. In the study by Baskota et al.,[14] posterior triangle was the most common at 51% (comparable to the present study). In the Manolidis study, anterior triangle (excluding submandibular) was the most commonly involved (35.1%).

In the present study, sensitivity of FNAC was 80.3% for tubercular lymphadenitis while specificity was 100%. Jha et al.[8] reported a sensitivity of 92.8% in diagnosing tubercular lymphadenitis in his study. Chao[15] showed sensitivity of 88% and specificity of 96% for the same. Similarly, Dandapat et al.[16] reported a sensitivity of 83% for tuberculosis.

In the present study, sensitivity of FNAC was 73.3% for chronic nonspecific lymphadenitis while specificity was 87%. In the present study, sensitivity of FNAC was 87.5% for malignant secondaries while specificity was 100%. In the present study, sensitivity of FNAC was 90% for lymphomas while specificity was 100%.

Dasgupta et al.[17] reported a sensitivity of 84.4% for tuberculosis and 89% for malignant secondary deposits. In a larger series of 444 cases, Mondal et al.[18] reported 100% sensitivity in diagnosing tubercular and pyogenic lymphadenitis, and also Hodgkin's disease, 98% for metastatic deposits, 97% for chronic nonspecific lymphadenitis, 92% for non-Hodgkin's lymphomas.

After studying 2216 cases, Prasad et al.[19] noted sensitivity and specificity of 84% and 95%, respectively, for tubercular lymphadenitis, 97% and 99% for metastatic deposits, 80% and 98% for Hodgkin's disease, and 81% and 96% for non-Hodgkin's lymphomas.


  Conclusion Top


The most common disease affecting lymph nodes is tuberculosis. It is a curable with antituberculous drugs. Clinical symptoms in cervical lymphadenopathy have limited significance, and clinical behavior can be highly variable. Dependence on clinical evidence alone would lead to erroneous diagnosis in most of the cases. FNAC is an important frontline investigation. Histopathological examination remains the most dependable diagnostic tool.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mann CV, Russell RC. The neck-cervical lymphadenitis. In: Mann CV, Russell RC, editors. Bailey and Love's Short Practice of Surgery. 21st ed. 11 New Fetter Lane, London: Chapman and Hall Medical, CRC Press; 1991. p. 726-9.  Back to cited text no. 1
    
2.
Histology. A Text and Atlas. In: Ross MH, Romrell LY, Kaye GI, editors. 3rd ed. Philadelphia, United States: Lippincott Williams and Wilkins; 2001. p. 162-64.  Back to cited text no. 2
    
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Ham AW, Cormack DH. Ham' s Histology. 9th ed. Philadelphia: Lippincott; 1987. p. 249-53.  Back to cited text no. 3
    
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Sembulingam K, Sembulingam P. White blood cells. In: Sembulingam K, Sembulingam P, editors. Essentials of Medical Physiology. 2nd ed. New Delhi: Jaypee Brothers Medical Publishers; 2003. p. 103-5.  Back to cited text no. 4
    
5.
Stell WJ. Maran”sHead and Neck Surgery. 4th ed.: Oxford: Butterworth Heinemann; 2000. p. 192-201.  Back to cited text no. 5
    
6.
Lau SK, Wei WI, Hsu C, Engzell UC. Efficacy of fine needle aspiration cytology in the diagnosis of tuberculous cervical lymphadenopathy. J Laryngol Otol 1990;104:24-7.  Back to cited text no. 6
    
7.
Gupta AK, Nayar M, Chandra M. Critical appraisal of fine needle aspiration cytology in tuberculous lymphadenitis. Acta Cytol 1992;36:391-4.  Back to cited text no. 7
    
8.
Jha BC, Dass A, Nagarkar NM, Gupta R, Singhal S. Cervical tuberculous lymphadenopathy: changing clinical pattern and concepts in management. Postgrad Med J 2001;77:185-7.  Back to cited text no. 8
    
9.
Ullah S, Shah SH, Rehman AU, Kamal A, Begum N. Tuberculous lymphadenitis in Afghan refugees. J Ayub Med Coll Abbottabad 2002;14:22-3.  Back to cited text no. 9
    
10.
Kim LH, Peh SC, Chan KS, Chai SP. Pattern of lymph node pathology in a private pathology laboratory. Malays J Pathol 1999;21:87-93.  Back to cited text no. 10
    
11.
Purohit SD, Sarkar SK, Gupta ML, Jain DK, Gupta PR, Mehta YR. Dietary constituents and rifampicin absorption. Tubercle 1987;68:151-2.  Back to cited text no. 11
    
12.
Tripathy SN, Mishra N, Patel NM, Samantray DK, Das BK, Mania RN. Place of aspiration biopsy in the diagnosis of lymphadenopathy. Ind J Tub 1985;32:678-83.  Back to cited text no. 12
    
13.
Jindal N, Devi B, Aggarwal A. Mycobacterial cervical lymphadenopathy in childhood. Post-Graduate Med J 2002;81:182-3.  Back to cited text no. 13
    
14.
Baskota DK, Prasad R, Kumar, Sinha B, Amatya RC. Distribution of lymph nodes in the neck in cases of tubercular lymphadenitis. Acta Otolaryngol 2004;124:1095-8.  Back to cited text no. 14
    
15.
Chao SS, Loh KS, Tan KK, Chong SM. Tuberculous and nontuberculous cervical lymphadenitis: A clinical review. Otolaryngol Head Neck Surg 2002;126:176-9.  Back to cited text no. 15
    
16.
Dandapat MC, Mishra BM, Dash SP, Kar PK. Peripheral lymph node tuberculosis: A review of 80 cases. Br J Surg 1990;77:911-2.  Back to cited text no. 16
    
17.
Dasgupta A, Ghosh RN, Poddar AK. FNAC of cervical lymph nodes with special reference to tuberculosis. J Indian Med Assoc 1994;92:44-6.  Back to cited text no. 17
    
18.
Mondal A, Mukherjee D, Chatterjee DN. FNAC in diagnosis of cervical lymphadenopathy. J Ind Med Assoc 1989;87:281-3.  Back to cited text no. 18
    
19.
Prasad RR, Narasimhan R, Sankaran V, Veliath AJ. Fine-needle aspiration cytology in the diagnosis of superficial lymphadenopathy: An analysis of 2,418 cases. Diagn Cytopathol 1996;15:382-6.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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