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Dr Ruchi A et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-41 2016 17-23 17 IJAMSCR |Volume 4 | Issue 1 | Jan – Mar - 2016 www.ijamscr.com Research article Medical research Diagnostic utility of fine needle aspiration cytology in superficial lymphadenopathy in pediatric patients Agarwal Ruchi1 Duhan Amrita 2 Kundu Rana Parveen 3 Kamra Hemlata 4 Verma Sanjay 5 Beniwal Kalpana 6 123 M.D Pathology Assistant Professor Department of Pathology Bhagat Phool Singh Government Medical College for Women Khanpur Kalan Sonepat 124305 4 M.D Pathology Associate Professor Department of Pathology Bhagat Phool Singh Government Medical College for Women Khanpur Kalan Sonepat 124305 5 6 M.D Pathology Senior Resident Department of Pathology Bhagat Phool Singh Government Medical College for Women Khanpur Kalan Sonepat 124305 Corresponding author: Dr Ruchi Agarwal Email: pg.ruchigmail.com ABSTRACT Background Lymphadenopathy is one of the common clinical presentations in outdoor patient department especially in pediatric age group. Fine needle aspiration cytology FNAC of the lymph nodes has become an integral part of initial diagnosis and management of patients. The aim of this study is to evaluate the diagnostic utility of FNAC of lymph nodes and to study the spectrum of diseases in pediatric patients with superficial lymphadenopathy. Methods This study was carried out in Department of Pathology Bhagat Phool Singh Government Medical College for Women Khanpur Kalan Sonepat from July 2012 to June 2015. A total of 217 cases of superficially palpable lymph nodes in pediatric age group 0-14 years were included in this study. Observation In this study M: F ratio is 1.4:1. Most common cause of lymphadenopathy was non-specific reactive hyperplasia 118 54.88 followed by granulomatous lymphadenitis 79 36.74 acute suppurative lymphadenitis 146.51 and neoplastic 4 1.86. Among malignant group all 4 cases are primary lymphoma. Male showed preponderance for reactive hyperplasia and suppurative lymphadenitis while tuberculous lymphadenitis was more common in females. Cervical group of lymph nodes were most frequently involved by all causes of lymphadenopathy. Conclusion FNAC is a simple reliable rapid and safe diagnostic modality for the etiologic workup in significant lymphadenopathy in children. Keywords: FNAC Lymphadenopathy Granulomatous Necrotizing. ISSN:2347-6567 International Journal of Allied Medical Sciences and Clinical Research IJAMSCR

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Dr Ruchi A et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-41 2016 17-23 18 INTRODUCTION Lymphadenopathy is one of the common clinical presentations in outdoor patient department in most hospitals especially in pediatric age group. It is a clinical manifestation of regional or systemic disease and serves as an excellent clue to the underlying disease. The cause may range from an infectious process to a malignant condition. 1 Fine needle aspiration cytology FNAC of the lymph nodes is rapid simple safe cost effective and reliable diagnostic modality for establishing the etiology of significant lymphadenopathy. There is no requirement of anaesthesia for aspiration and can be carried out easily at outpatient department or bedside. 2 The sensitivity of FNAC for the diagnosis of lymphadenopathy averages 90 with a specificity of 95. 3 The common causes of lymphadenopathy in pediatric age group are inflammation reactive hyperplasia infection and lymphoproliferative disorders. 4 Tuberculous lymphadenitis is among the most frequent presentations of extra pulmonary tuberculosis. It is responsible for up to 43 of peripheral lymphadenopathy in the developing world. 5 The purpose of this study was to evaluate the diagnostic utility of FNAC on lymphadenopathy in the pediatric population and to study the spectrum of diagnosis in pediatric patients with superficial lymphadenopathy. MATERIAL AND METHOD This study was carried out at Department of Pathology Bhagat Phool Singh Government Medical College for Women Khanpur Kalan Sonepat from July 2012 to June 2015. Significant lymphadenopathy was considered when the size of lymph node in the cervical and axillary group was 1.0cm and the inguinal group was 1.5cm. A total of 217 cases of superficially palpable lymph nodes in pediatric age group 0-14 years were included in this study. In each case a brief history thorough physical examination and relevant investigations are evaluated. The FNAC was performed using 21 to 25 G needle attached to 20 cc syringe without local anesthetic. Aspirate was collected in the needle hub and syringe and immediately slides were prepared as per standard procedure. Two slides were immediately fixed in 95 ethanol and stained with Papanicolaou stain. Rest Smears were air-dried and stained with Romanowsky stain. Special stains like Ziehl- Neelsen ZN stain for acid fast bacilli using 20 H 2SO 4 was done when required. The cytological diagnoses were classified as non-specific reactive hyperplasia acute suppurative lymphadenitis granulomatous lymphadenitis and neoplastic. Further all granulomatous lymphadenitis was subdivided into pure granulomatous necrotizing and necrotizing granulomatous lymphadenitis based on cytomorphological features. RESULTS In the present study a total of 217 cases of superficial palpable lymphadenopathy in pediatric patients were studied during the period of three years. Two cases were inconclusive due to unsatisfactory smears and excluded from the study. The age of the patients ranged from 9 months to 14 years. 86 patients 40 belong to the age group of 0-7 years while 129 patients 60 belong to 7-14 years age group. Out of total 215 patients 126 patients 58.60 were male and 89 patients 41.40 were female Table-1. Non- specific reactive hyperplasia was the most common cause of lymph node enlargement in 118 54.88 followed by tuberculous lymphadenopathy 79 36.74 acute s u p p u r a t i v e l y m p h a d e n i t i s in 14 6.51 and neoplastic in 4 cases 1.86 Table-2. The peak incidence of reactive hyperplasia was seen in males of 0-7 years age group were as tuberculous lymphadenopathy is maximally seen in females of 7-14 years age group. Males were more commonly affected by reactive hyperplasia 71.19 while in contrast tuberculous lymphadenopathy was common in females 62.03 Table-3. Cervical group of lymph nodes was most commonly involved by all causes of lymphadenopathy. It has been observed that 93.22 of the reactive lymph nodes and 91.14 of tuberculous lymph nodes involve cervical group. Inguinal and epitrochlear groups are least involved with all types of lymphadenopathy both accounting for 1.40 of the total cases Table 4.

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Dr Ruchi A et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-41 2016 17-23 19 Table-1 Age and sex distribution of total 215 patients Age group Male Female Total 0-7 years 55 31 86 7-14 years 71 58 129 Total 126 89 Table -2 Cytological diagnosis of 215 cases of lymphadenopathy Cytological diagnosis No. of cases Percentage Reactive hyperplasia of lymph node 118 54.88 Acute suppurative lymphadenitis 14 6.51 Tuberculosis 79 36.74 Neoplastic 4 1.86 Table-3 Age and sex distribution of various types of lymphadenopathy Cytological diagnosis 0-7 yrs 7-14 yrs Non-specific reactive hyperplasia M 43 F 16 M 41 F 18 Acute suppurative lymphadenitis 4 4 5 1 Tuberculosis 6 10 24 39 Neoplastic 2 0 1 1 Total 55 30 71 59 Table-4 Group wise distribution of various types of lymphadenopathy Diagnosis Cervical Axillary Inguinal Epitrochlear Reactive hyperplasia 110 5 2 1 Acute suppurative lymphadenitis 13 1 0 0 Tuberculosis 72 4 1 2 Neoplastic 3 1 0 0 Total 198 11 3 3 Table-5 Cytological features and AFB staining of 79 cases of tubercular lymphadenitis Cytological diagnosis Total cases AFB Positive Necrotizing granulomatous lymphadenitis 37 26 Granulomatous lymphadenitis 30 3 Necrotizing lymphadenitis 12 7 Total 7 36

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Dr Ruchi A et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-41 2016 17-23 20 Figure 1. Microphotograph showing reactive lymphoid cells Romanowsky stainX400. Figure 2. Microphotograph showing epithelioid cells granulomas in tuberculous lymphadenitis Romanowsky stain X200. Figure 3. Microphotograph showing granular pink caseous necrotic material in tuberculous lymphadenitis Romanowsky stain X200.

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Dr Ruchi A et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-41 2016 17-23 21 Figure 4. Microphotograph showing Reed-Sternberg cell in background of lymphoid cells and eosinophils in case of Hogdkins lymphoma Romanowsky stain X400 The lymph node aspirates with either only epithelioid cell granulomas without any necrosis or epithelioid cell granulomas with caseation necrosis or only granular necrotic material were suggestive of tuberculous lesions. Acid Fast Bacilli AFB staining was done by Ziehl-Neelsen method in all suspicious cases of tuberculosis and average positivity was found to be 45.57. It was also observed that 70.27 cases of necrotizing granulomatous lymphadenitis and 58.33 cases of necrotizing lymphadenitis were AFB positive whereas only 10 cases of granulomatous lymphadenitis turn out to be AFB positive Table 5. DISCUSSION Fine needle aspiration cytology of lymph node has become an integral part of the initial diagnosis and management of patients with lymphadenopathy due to the early availability of results simplicity and minimal trauma with less complication. 6 It almost offers an accurate diagnosis of non-specific reactive hyperplasia infectious disease granulomatous lymphadenitis and metastatic malignancy. Thus it can avoid the need for surgical excision in most cases a n d allows rapid onset of therapy. 7 In the present study 215 cases of superficial palpable lymphadenopathy in pediatric patients were studied during the period of three years. In our study more than half of the cases 54.88 were non-specific reactive hyperplasia. This is because of frequent infections of nose ear and throat in pediatric age group. Similar findings were observed by Sharique A et al 69.20 and Maria et al 70. 58 In another study Patar et al found 41.75 cases of rective hyperplasia whereas Lee et al reported 54.9 cases in children and adolescent patients. 49 Tuberculous lymphadenitis 36.74 was found to be the most common cause of infectious lymphadenopathy in current study. This finding is higher as compared to studies conducted by Peter et al 26.9 Maria et al 14 and Sharique et al 22.45. 4 5 8 This etiological variation of pediatric patients with lymphadenopathy may be due to variation in socioeconomic and nutritional status in different geographical areas of the world. Tuberculosis TB is a major cause of childhood morbidity and mortality in developing countries. 1011 Accurate figures on the prevalence of pediatric TB are not available because the health information system in endemic countries is inadequate and limited attention is paid to children who contribute little to TB transmission in affected countries. More than 80 of children with TB are sputum smear-negative and extrapulmonary TB is common in these patients. 12 Despite of the latest advances in knowledge and technology TB still remains a major health problem in developing countries. In rural India the prevalence of tubercular lymphadenopathy in children up to 14 years of age is approximately 4.4 cases per 1000 Narang et al 2005. 13 Indian Academy of Pediatrics recommends FNAC of all suspected cases of TB. 14 It not only offers a diagnostic tool for confirmation of TB but also fine needle aspirate can be used for culture and drug sensitivity testing. 12 The sensitivity specificity and diagnostic accuracy of FNAC in childhood

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Dr Ruchi A et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-41 2016 17-23 22 tuberculosis were found to be 98 100 and 99 respectively. 15 AFB positivity for lymph node by Ziehl-Neelsen method varies from 25 to 88.7 with an average of 52.9. 1617 The finding of AFB positivity in an increasing order in the three cytologic groups is described as epithelioid granuloma without necrosis average 7.4 epithelioid granuloma with necrosis average 35.6 and necrosis without epithelioid granuloma average 54.2. 171819 However we observed that 41.94 cases of necrotizing granulomatous lymphadenitis and 35.29 cases of necrotizing lymphadenitis were AFB positive whereas only 9.09 cases of granulomatous lymphadenitis turn out to be AFB positive. All four cases of neoplasia in our study were reported as lymphoma. A similar finding of lymphoma being the most common neoplastic lesion in pediatric age group was observed by Maria et al Sharique et al and Peter et al. 458 The present study showed that male patients predominate over female patients with M: F ratio 1.4:1. Similar finding was observed by Sharique et al with M:F of 1.79:1 while Patar et al show contrasting results of female preponderance with M:F ratio of 1:1.09. 48 We found that males were more commonly affected by reactive hyperplasia 79.75 while in contrast tuberculous lymphadenopathy was common in females 71.19. Similar findings were observed by Sharique et al that male more commonly involved by reactive hyperplasia 68.79 and female by tuberculous lymphadenopathy 51.91. 8 This may be attributed to poor nutritional status and poor accessibility to health care services by females. On correlating the pattern of lymphadenopathy with age group it revealed that reactive hyperplasia and neoplastic lesions are equal in both age subgroups of 0-7 years and 7-14 years. In contrast acute suppurative lymphadenitis is frequent in 0-7 years age while tuberculous lymphadenopathy is common in 7-14 years age group. We also found that cervical group were most commonly involved group of lymph nodes followed by axillary. CONCLUSION Despite many limitations and pitfalls FNAC appears as a good first line method for investigating the cases of lymphadenopathy especially for children. It is safe cost effective rapid and minimally invasive modality with no reported complications. In our study non-specific reactive hyperplasia is the most common cause of lymph node enlargement in children followed by tuberculosis. FNAC is not only useful as a first line diagnostic method but aspirated material can also be used for ancillary techniques like immunohistochemistry to help in further confirmation of diagnosis. REFERENCES 1. Hirachand S Lakhey M Akhter J Thapa B. Evaluation of fine needle aspiration cytology of lymph nodes in Kathmandu Medical College Teaching hospital. Kathmandu Univ Med J 2009 726:139-42. 2. Melcher D Linehan J Smith R. Fine needle aspiration cytology. Recent advances in histopathology No. 11 Churchill Livingstone 1981 pp263-80. 3. Ahmed T Naeem M Ahmad S Samad A Nasir A. Fine needle aspiration cytology and neck swelling in the surgical outpatient. J Ayub Med Coll 2013 30-2. 4. Patar M Borsaiki K Biraj K. Das BK Hazarika A. A clinicopathological evaluation of cervical lymphadenopathy in children 0-14 Years by fine needle aspiration cytology and histopathological examination A hospital based study. National Journal of Otorhinolaryngology and Head Neck Surgery Vol. 211 No. 2 12-4. 5. Maria I Viggo B and Christoffer HH. Evaluation of cervical lymphadenopathy in children: advantages drawbacks of diagnostic methods. Dan Med J. 60/8. Aug 3013: 1-3. 6. Keith VE Harsharan SK Jerald GZ. Fine needle Aspiration biopsy of lymph nodes in the modern era: reactive lymphadenopathies. Pathol Case Rev 2007 121:27-35. 7. Howlett DC Harper B Quante M Berresford A morley M Grant J. Diagnostioc adequacy and ccuracy of fine needle aspiration cytology in neck lump assessment: result from a regional cancer network over a one year period. J Larygol Otol 2007 1216:571-9.

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Dr Ruchi A et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-41 2016 17-23 23 8. Sharique A Nasim A Shivam S and Geetika S. FNAC as a diagnostic tool in pediatric patients with lymphadenopathy. Ann Biol Res 2013 4 4:92-5. 9. Lee SM Oh YJ Jun YH Hong YJ Son BK KimSK Han JY Chu YC. Fine needle aspiration cytology of enlarged lymph nodes in children and adolescents. Korean J Pediatr 2006 Feb 492:167-72. 10. Chintu C et al: Lung diseases at necropsy in African children dying from respiratory illnesses: a descriptive necropsy study. Lancet 2002 3609338:985 –90. 11. Marais BJ et al: Tuberculosis in women and children. Lancet 2010 3759731:2057 –59. 12. Fanny ML Beyam N Gody JC Zandanga G YangoF Manirakiz A Rigouts L Audigier CP Gicque B and Bobossi G. Fine-needle aspiration for diagnosis of tuberculous lymphadenitis in children in Bangui Central African Republic. BMC Pediatrics 2012 12:191 13. Narang P Narang R Prevalence of Tubercular lymphadenitis in children in Wardha district Maharastra state India. Int. J Tuberc Lung Dis 2005 9:188. 14. Verma K Kapila K. Aspiration cytology for the diagnosis of tuberculosis perspective in India. Indian J Pediatr 2002 69 Suppl: S39-43. 15. Balaji J Sundaram SS Rathinam SN Rajeshwari PA Kumari ML. Fine needle aspiration cytology in childhood TB lymphadenitis. Indian J Pedaitr 2009 Dec 76 12:1241-6. 16. Metre S Jayaram G. Acid-fast bacilli in aspiration smears from tuberculosis lymph nodes: an analysis of 255 cases. Acta Cytol. 19873117-19 17. Das DK Pank JN Chachra KL et al. Tuberculous lymphadenitis: correlation of cellular components and necrosis in lymph node aspirate with AFB positivity and bacillary count.1990331-10. 18. Das DK Pant CS. Fine needle aspiration cytologic diagnosis of gastrointestinal lesions: a study of 78 cases. Acta Cytol.1994 38:723-9. 19. Radhika S Rajwanshi A Kochhar R et al. Abdominal tuberculosis diagnosis by fine needle aspiration cytology. Acta Cytol. 1993 37:673-8 How to cite this article: Agarwal Ruchi Duhan Amrita Kundu Rana Parveen Kamra Hemlata Verma Sanjay Beniwal Kalpana Diagnostic utility of fine needle aspiration cytology in superficial lymphadenopathy in pediatric patients. Int J of Allied Med Sci and Clin Res 2016 41:17-23. Source of Support: Nil. Conflict of Interest: None declared.