Excision Biopsy of Lymph Node

The general principle is to remove a representative lymph node and submit it for histology with minimal tissue distortion - this requires careful surgical expertise.

If only a single enlarged lymph node is identified, it is removed for histological assessment. In cases of widespread lymphadenopathy, excision of a large node is more diagnostically useful than a smaller, easily accessible lymph node, which may be uninvolved or only focally involved by the disease process.

Table 44.4. Subtypes of Hodgkin's lymphoma

Nodular sclerosis

Lymphocyte rich

Mixed cellularity

Lymphocyte-depleted

NLPHL

Clinical Most common

Stage I/II in

High stage at

Rarest subtype.

Occurs in young, often

subtype.

peripheral nodes.

presentation.

Frequently

single cervical node

Peripheral/

Rare B symptoms".

B symptoms"

associated with

involved. Stage I

mediastinal LN.

Mediastinal

common. Spleen

HIV. Involves

common. Frequent

Usually Stage II.

disease uncommon.

involved in 30%.

abdominal organs,

relapses, usually

Usually peripheral

retroperitoneal LN

chemosensitive.

node involvement.

and bone marrow.

Presents as high-

stage disease.

Architecture Prominent

Commonly nodular,

Obliterated

May have diffuse

Nodular/nodular and

nodularity.

rarely diffuse.

architecture.

fibrosis.

diffuse.

Collagen bands

No fibrous bands.

at least around

one nodule.

Cytology Lacunar R-S cells.

Scattered R-S cells

Typical R-S cells

Variable numbers of

Nodules contain darkly

Grade I: > 75%

against a nodular

against a

pleomorphic R-S cells

staining small

nodules contain

background of small

polymorphous

and few lymphocytes.

B-lymphocytes,

few R-S cells in a

lymphocytes.

background of

Can look anaplastic or

neoplastic 'popcorn'

lymphocyte-rich,

cells including

fibrohistiocytic.

L&H cells and rare

mixed-cellularity

eosinophils,

classic R-S cells.

or fibrohistiocytic

neutrophils,

background.

histiocytes and

Grade II: at least

plasma cells.

25% nodules are

lymphocyte-

depleted and have

increased R-S cells.

IHC CD30/15+, BSAP+

Same as nodular

Same as nodular

Same as nodular

CD20/CD79a/EMA

in 90% cases.

sclerosis.

sclerosis.

sclerosis. HIV +

/bcl6+, transcription

CD20-/+. EMA,

EBVLMP1+ in

patients express

factors Oct2/BoB1 + in

ALK neg.

75% cases.

EBVLMP1.

L&H cells. CD15/30

EBVLMP1+/-

usually negative.

Prognosis Slightly better

As good as NLPHL

Intermediate

Aggressive in HIV +

Excellent prognosis in

than mixed

between nodular

patients but with

Stage I. High-stage

cellularity or

sclerosis and

modern

disease is rare but

lymphocyte-

lymphocyte-

chemotherapy

death occurs in

depleted. Bulky

depleted but

prognosis similar to

1-2 yrs.

mediastinal

differences not

other subtypes in

disease is an

observed with

immunocompetent

adverse risk factor.

modern

patients.

chemotherapy.

a Symptoms, e.g., weight loss, night sweats, pain.

Some lymph node groups are virtually always pathological, i.e., Virchow's/supraclavicular. Inguinal lymph nodes usually show non-specific lymphadenitis or scarring and are unlikely to be informative except when markedly enlarged or the patient has a previous history of malignancy.

Obtaining biopsies from deep lymph nodes is difficult and it may not be possible to distinguish lymphadenopathy from visceral or soft tissue malignancies. In such situations, FNAs and needle core biopsies may be taken under radiological guidance. Note that interpretation may be hindered by handling artefact and cell size/lymphoma grade underestimated, diagnosis being limited to lymphoma without further typing possible.

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