Diagnosis of lymphadenopathies by FNAC: a …ijhbr.com/pdf/October 2014 127-137.pdfaccuracy rate of...

11
International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 01, October 2014, Pages 127-137 127 www.ijhbr.com ISSN: 2319-7072 Original article: Diagnosis of lymphadenopathies by FNAC: a prospective study Dr. Kandukuri Mahesh Kumar, Dr. Chinthakindi Sravan, Dr. Swarupa Ravuri, Dr. Divyagna Department of Pathology, Malla Reddy Institute of Medical Sciences, Suraram , Hyderabad, India Corresponding author : Dr. Kandukuri Mahesh Kumar Abstract: Objective: To determine the incidence of various pathological lesions involving lymph nodes by using simple and easy diagnostic tool (FNAC) and prove the diagnostic importance of FNAC. Materials and methods: Our study included 1926 cases of lymphadenopathy, between January 2012 and December 2013. Patients with palpable lymph nodes anywhere in the body with a valid requisition were included in the study. All the demographic details, history and clinical findings of the swelling are taken by the attending pathologist. Results: Our study included 1926 cases of lymphadenopathy , we reported 1136 cases (59 %) as granulomatous lymphadenitis , 500 cases ( 26 %) of Non-specific lymphadenitis , 232 cases (12%) of Lympho-proliferative disorders (Hodgkin’s and Non- Hodgkin’s disease) 58 cases (03%) metastases from primary site. Our study also showed the incidence of lympho-proliferative diseases in association with Human Immuno-deficiency Virus (HIV) infection (144 cases). Majority of the granulomatous lymphadenitis cases were associated with HIV cases constituting about 66.5 % (756 cases). Conclusion: Fine Needle Aspiration Cytology is a simple, safe, rapid, cost effective and reasonably accurate method of establishing the diagnosis of lymphadenopathy. Overall accuracy of FNAC in comparison with the histopathological study is very high and may obviate the need of excision biopsy when the findings are compatible with the clinical diagnosis. The high accuracy rate of aspiration cytology of lymph nodes calls for its wide application in daily practice. Keywords: Lymphadenopathy, Lympho-proliferative disorder, FNAC. Introduction: Lymphadenopathy is one of the commonest clinical presentations of patients, attending the outdoor clinics in most hospitals. The aetiology varies from an inflammatory process to a malignant condition. (1) The use of fine needle aspiration cytology (FNAC) in the investigation of lymphadenopathy has become an acceptable and widely practiced , safe, simple, rapid, painless and minimally invasive technique. FNAC is highly cost effective out-patient procedure and has high accuracy. FNAC was initially conceived as a means to confirm a clinical suspicion of local recurrence or metastasis of known malignancy without subjecting the patient to further surgical intervention. Many clinicians feel that this remains the most important contribution of the technique from practical point of view, but the clinical value of FNAC is not limited to neoplastic conditions. FNAC is also valuable in the diagnosis of inflammatory, infectious, reactive, degenerative conditions. Samples which were aspirated from the swelling can be used for microbiological and biochemical analysis in addition to cytological preparations. Now –a-days FNAC is used as a first line investigative technique in any palpable and visible swellings of the body. Few of the differential diagnoses of the lymphadenopathy include reactive hyperplasia/ inflammatory conditions, granulomatous disorders and malignancy.

Transcript of Diagnosis of lymphadenopathies by FNAC: a …ijhbr.com/pdf/October 2014 127-137.pdfaccuracy rate of...

International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 01, October 2014, Pages 127-137

127 www.ijhbr.com ISSN: 2319-7072

Original article:

Diagnosis of lymphadenopathies by FNAC: a prospective study

Dr. Kandukuri Mahesh Kumar, Dr. Chinthakindi Sravan, Dr. Swarupa Ravuri, Dr. Divyagna

Department of Pathology, Malla Reddy Institute of Medical Sciences, Suraram , Hyderabad, India

Corresponding author : Dr. Kandukuri Mahesh Kumar

Abstract:

Objective: To determine the incidence of various pathological lesions involving lymph nodes by using simple and easy

diagnostic tool (FNAC) and prove the diagnostic importance of FNAC.

Materials and methods: Our study included 1926 cases of lymphadenopathy, between January 2012 and December 2013.

Patients with palpable lymph nodes anywhere in the body with a valid requisition were included in the study. All the

demographic details, history and clinical findings of the swelling are taken by the attending pathologist.

Results: Our study included 1926 cases of lymphadenopathy , we reported 1136 cases (59 %) as granulomatous lymphadenitis ,

500 cases ( 26 %) of Non-specific lymphadenitis , 232 cases (12%) of Lympho-proliferative disorders (Hodgkin’s and Non-

Hodgkin’s disease) 58 cases (03%) metastases from primary site. Our study also showed the incidence of lympho-proliferative

diseases in association with Human Immuno-deficiency Virus (HIV) infection (144 cases). Majority of the granulomatous

lymphadenitis cases were associated with HIV cases constituting about 66.5 % (756 cases).

Conclusion: Fine Needle Aspiration Cytology is a simple, safe, rapid, cost effective and reasonably accurate method of

establishing the diagnosis of lymphadenopathy. Overall accuracy of FNAC in comparison with the histopathological study is

very high and may obviate the need of excision biopsy when the findings are compatible with the clinical diagnosis. The high

accuracy rate of aspiration cytology of lymph nodes calls for its wide application in daily practice.

Keywords: Lymphadenopathy, Lympho-proliferative disorder, FNAC.

Introduction: Lymphadenopathy is one of the

commonest clinical presentations of patients,

attending the outdoor clinics in most hospitals. The

aetiology varies from an inflammatory process to a

malignant condition.(1)The use of fine needle

aspiration cytology (FNAC) in the investigation of

lymphadenopathy has become an acceptable and

widely practiced , safe, simple, rapid, painless and

minimally invasive technique. FNAC is highly cost

effective out-patient procedure and has high

accuracy. FNAC was initially conceived as a means

to confirm a clinical suspicion of local recurrence or

metastasis of known malignancy without subjecting

the patient to further surgical intervention. Many

clinicians feel that this remains the most important

contribution of the technique from practical point of

view, but the clinical value of FNAC is not limited to

neoplastic conditions. FNAC is also valuable in the

diagnosis of inflammatory, infectious, reactive,

degenerative conditions. Samples which were

aspirated from the swelling can be used for

microbiological and biochemical analysis in addition

to cytological preparations. Now –a-days FNAC is

used as a first line investigative technique in any

palpable and visible swellings of the body. Few of

the differential diagnoses of the lymphadenopathy

include reactive hyperplasia/ inflammatory

conditions, granulomatous disorders and malignancy.

International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 01, October 2014, Pages 127-137

128 www.ijhbr.com ISSN: 2319-7072

Thus FNAC gives a clear picture of the case/cases

requiring further investigations, medical

management, surgical intervention or just clinical

follow-up. FNAC is a valuable diagnostic technique

with least number or nil contraindications. Shakya et

al. also mentioned that the cytology is more readily

accepted for the evaluation of deeply seated lymph

nodes (i.e. surgically inaccessible) with primary

lymphoma or for medically unfit patients for surgery.

We planned study to determine the incidence of

various pathological lesions involving lymph nodes

by using simple and easy diagnostic tool (FNAC) and

prove the diagnostic importance and accuracy of

FNAC.

MATERIALS AND METHODS

Our study included 1926 cases of lymphadenopathy,

between January 2012 and December 2013. Patients

with palpable nodes were referred to department of

pathology after clinical examination by the clinician

and surgeon .Routine FNAC was performed by the

attending pathologist on receiving the requisition

duly filled by the consultant surgeon. All the

demographic details of the patient, history and

clinical findings of the swelling are taken by the

attending pathologist and entered in a cytology

register. Under aseptic precautions, aspiration of

enlarged lymph nodes was performed free hand using

a 23 G needle with 5 cc or 10 cc syringe. The cellular

aspirate is spread on a dust-free glass slide and

immediately transferred to coplin jars filled with

alcohol for fixation. After fixation, slides are stained

with Hematoxylin and Eosin (H & E). Diagnosis was

given on the same of FNAC procedure.

Granulomatous inflammation is recognized

cytologically by observing aggregates of histiocytes

with or without associated multinucleated giant cells.

A dirty necrotic background would suggest caseation

and possibly tuberculosis. In cases where an infective

aetiology was suspected, needle washings were sent

for bacteriological culture and sensitivity. When TB

was suspected, an additional sample was sent for

culture and slides were also stained with Ziehl-

Neelsen methods to detect acid fast bacilli (AFB)

directly. The eventual diagnosis of granulomatous

inflammation by FNAC was confirmed either by

other supportive laboratory investigations or by

surgery in difficult or in doubtful cases where the

definitive opinion is not possible. In non-specific or

reactive lymphadenopathy cases, a repeat FNAC was

done after a period of 7 to 10 days after a course of

antibiotic therapy. In Lympho-proliferative disorders,

malignancies or metastases, FNAC diagnosis was re-

confirmed by histopathological examination.

RESULTS

In our study, we reported 1926 cases presented with

lymphadenopathy at various locations of the body,

most common being cervical lymphadenopathy.

1) In a total study of 1926 cases of

lymphadenopathy , we reported 1136 cases

(59 %) as granulomatous lymphadenitis ,

500 cases ( 26 %) of Non-specific

lymphadenitis , 232 cases (12%) of

Lympho-proliferative disorders (Hodgkin’s

and Non- Hodgkin’s disease ,58 cases (03%)

metastases from primary site.

2) Our study also showed the relative incidence

of lympho-proliferative diseases in

adults(218 cases) and pediatric population

(14 cases ) and also incidence of lympho-

proliferative diseases in association with

Human Immuno-deficiency Virus (HIV)

infection (144 cases).( FIGURE 1 & 2)

3) Among the total incidence of granulomatous

lymphadenitis reported, 71 % (806 cases)of

International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 01, October 2014, Pages 127-137

129 www.ijhbr.com ISSN: 2319-7072

the cases were reported in adults and 29 %

(330) of cases were reported in the pediatric

population. Majority of the granulomatous

lymphadenitis cases were associated with

HIV cases constituting about 66.5 % (756

cases).(FIGURE 3 & 4)

FIGURE 1 – Incidence of Lymph proliferative diseases in adults (218 cases) and paediatric age group (14

cases)

FIGURE 2- Incidence of Lympho-proliferative diseases associated with HIV (88 cases )

050

100150200250 218

14

HIV

Non- HIV

144 Cases Associated

with HIV

88 Cases in Non- HIV

International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 01, October 2014, Pages 127-137

128 www.ijhbr.com ISSN: 2319-7072

FIGURE 3- Incidence of granulomatous lymphadenitis in adult (806 cases) and pediatric population (330

cases)

INCIDENCE OF GRANULOMATOUS LYMPHADENITIS IN HIV PATIENTS

FIGURE 4- Incidence of Granulomatous Lymphadenitis in HIV patients ( 756 cases).

DISCUSSION

The well-defined role of FNAC in the investigation

of lymphadenopathy has previously been studied. (2,3)

In the context of granulomatous disorders, the

possible aetiology is wide and the use of FNAC with

other ancillary tests (microbiological,

immunohistochemical, radiological, biochemical and

special staining techniques) is useful for obtaining a

definitive diagnosis. The algorithm shows a useful

classification of the aetiology of granulomatous

lymphadenopathy. (FIGURE 5)

0

500

1000 806330

HIV

756 HIV cases showing

Granulomatous lymphadenitis

380 non-HIV cases

showing

Granulomatous

lymphadenitis

130

International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 01, October 2014, Pages 127-137

128 www.ijhbr.com ISSN: 2319-7072

Aetiologies of Lymphadenopathies :

FNAC OF LYMPHADENOPATHY

Non- Granulomatous Inflammations Granulomatous Inflammations

Infective Neoplastic

Tuberculosis

Atypical Mycobacterium

Sarcoidosis

Toxoplasmosis

Lymphoma Carcinoma

Hodgkin’s Lymphoma Metastatic

Non-Hodgkin’s Lymphoma

Tuberculosis cervical lymphadenopathy usually

present with multiple lymph node enlargements, less

constitutional symptoms, tuberculosis is an important

public health problem (4) and it is commonest cause

of infectious diseases affecting the lymphatic tissues

of the body (5). The diagnosis is based on high index

of doubt with hematological and pathological

investigations this diseases can be diagnose with

FNAC (FIGURE 7). In our study family history was

not present in most of the patients while commonest

age group affected was 18 to 35 years, and male were

predominant , the upper deep jugular nodes in

posterior triangle were most commonly involved.

Tuberculosis lymphadenopathy constituted the

commonest lesion followed reactive lymphadenitis,

lymphoproliferative disorders and metastatic

malignancies, which is correlating with most of the

studies of Indian authors (6-10). Maximum AFB

positivity is seen in cases showing caseous necrosis

with occasional epithelioid cells. Sometimes in

absence of AFB positivity the diagnosis of highly

suspicious of tuberculosis was given in these lesions

with strong clinical suspicion, high ESR and chest X-

131

International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 01, October 2014, Pages 127-137

128 www.ijhbr.com ISSN: 2319-7072

ray findings. The tuberculosis in HIV positive cases

showed caseous necrosis, while granulomas were less

and ill formed.

A suspicious clinical history of TB (pyrexia, night

sweats, recent travel to endemic areas, no previous

BCG vaccination) coupled with positive aspirate,

blood, sputum or urine tests for AFB and good

response to anti-tuberculous therapy supports the

diagnosis of TB. One disadvantage is the inherent

delay in culture result, but it is anticipated that as

polymerase chain reaction and other amplification

techniques become more common, detection time for

the organism will shorten, improving the value of

FNA in clinical practice. The presence of epithelioid

cells either with caseation or positive Ziehl-Neelsen

stain for acid-fast bacilli appears to be the best

criterion to diagnose tuberculous lymphadenitis by

fine needle aspiration. Bezabih et al found FNAC

reliable in helping to avert more invasive surgical

procedures undertaken in the diagnosis of

tuberculous lymphadenitis (11).

The typical FNAC features of toxoplasmosis include

the presence of follicular hyperplasia with secondary

germinal centre rich in macrophages, presence of

groups of epithelioid cells and presence of

monocytoid histiocytes have been previously

described(12,13). A combination of FNA features with

positive serological testing and history of animal

contact gives the diagnosis of toxoplasmosis and thus

avoids unnecessary surgical excision. Sarcoidosis is a

disease of unknown aetiology that can be

characterized by the histological hallmark of

epithelioid non-caseating granulomas, usually

accompanied by multinucleated giant cells. Although

there is no single gold standard test, the important

role of FNAC in histological diagnosis and its under

utilization was highlighted by Tambouret et al (14).We

agree with the authors that FNAC used in

conjunction with clinical findings, radiological and

laboratory investigations can be a cost effective

method in diagnosis toxoplasmosis.

The reactive pattern is variable depending on the

degree of stimulation, the number and size of the

germinal centres and on whether the sample derives

mainly from a germinal centre or from interfollicular

or paracortical tissue. Germinal centre material is

represented by poorly defined tissue fragments of

poorly cohesive cells. These fragments include

centroblasts, centrocytes, tingible body macrophages

and a number of lymphocytes which adhere to the

syncytial cytoplasm of dendritic reticulum cells.

Dendritic reticulum cells have oval or round nuclei

with a smooth nuclear membrane, a coarsely

granular, uniformly distributed chromatin and small

distinct nucleoli. The cytoplasm is dispersed in the

background. A smear, which derives mainly from

interfollicular tissue, consists predominantly of

lymphocytes with a variable but much smaller

number of scattered immunoblasts, plasma cells, non-

specific histiocytes and endothelial cells. (FIGURE

8)

The main features which distinguish a reactive

process from lymphoma are:

a) A mixed population of lymphoid cells

representing the whole range of lymphocyte

transformation from small lymphocytes to

immunoblasts and plasma cells.

b) A predominance if small , sometimes

slightly larger stimulated lymphocytes ,

which have small round nuclei and a

characteristic chromatin pattern of large ill-

defined condensations

132

International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 01, October 2014, Pages 127-137

129 www.ijhbr.com ISSN: 2319-7072

c) Centroblasts and centrocytes associated with

dendritic reticulum cells and tingible body

macrophages derived from germinal centres.

FNAC as a first line screening method has been

recommended in suspected malignancy (3&15).

Granulomas may be encountered in both Hodgkin’s

disease and non-Hodgkin’s lymphoma, particularly

T-cell lymphoma(16) Hodgkin’s lymphoma is

characterized by the classic Reed Sternberg cells in a

background of sarcoid-like granuloma, reactive

lymphoid cells and occasional eosinophils.

Occasionally, lymph nodes containing metastatic

carcinoma may also show features of granuloma.

Previous reports have been described in metastatic

nasopharyngeal carcinoma, seminoma and malignant

melanoma where granulomas were seen mimicking

granulomatous lymphadenitis. Histologically, non-

caseating granuloma composed of epithelioid

histiocytes with multinucleated giant cells are seen,

but these can be indistinguishable from

granulomatous inflammation from other causes. A

series by Khurana et al (17) highlighted the difficulties

encountered in making a definitive diagnosis of

malignant neoplasm that mimics, or occurs, in

association with granuloma. Granulomatous

inflammation found in lymph nodes draining

carcinomas is a recognized phenomenon. Such

phenomenon is reported in pulmonary small cell

carcinoma, malignant melanoma, papillary thyroid

carcinoma, gastric carcinoma, and

rhabdomyosarcoma. This has been suggested to be

either a response to necrotic material or an

immunological T-cell mediated hypersensitivity

reaction to cell surface antigens. However, the

precise mechanism is largely speculative as the exact

tumor or host factors that enable such a response

remain unknown. We agree with Lui et al (18) in their

pragmatic approach of diligent examination of FNAC

slides combined with ancillary clinical, serological

and imaging investigations in the drainage areas to

identify any occult malignancy.

In the present study 232 cases of lymphomas have

been reported 163 cases of Hodgkin's lymphoma

which was diagnosed on FNAC due to preserved

Reed Sternberg (RS) cells (FIGURE 9 & 10). In

lymphoma group, with presence of RS cell, the

cytological diagnosis of Hodgkin's lymphoma is easy.

FNAC is helpful in diagnosis of Hodgkin's

lymphoma though biopsy is recommended for

confirmation and classification.

Cytological sub-typing of lymphoma in FNAC

smears is difficult and requires extensive experience.

It can be possible where the team of experience

pathologists and oncologists are present. It is

believed by many authors that in non-Hodgkin's

lymphoma biopsy are mandatory, and we also believe

in it.

Below mentioned algorithm is useful in sub-typing

the Lymphomas on FNAC. (FIGURE 6)

Indian J of Basic and Applied Medical Research

Is now with

IC Value 5.09

133

International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 01, October 2014, Pages 127-137

128 www.ijhbr.com ISSN: 2319-7072

ALGORITHM

CLASSIFICATION OF LYMPHOMA

FNAC LYMPHOID POPULATION OF CELLS

Monotonous population Heterogenous population Pleomorphic population

Predominant cell type Mainly small cells Large cells

Small Medium Large

Small Burkitt’s Diffuse a)Reactive hyperplasia a)Reactive Immunoblastic

Lymphocytic Lymphoma Large B cell b) Follicular Lymphoma(Gr 3)

Lymphoma Lymphomas b)Follicular Lymphoma

c) Peripheral T cell lymphoma

c) Marginal Zone lymphoma

a )Mantle cell Lymphoma d)Lymphoplasmacytic Lymphoma

b) Lymphocyte Predominant Hodgkin’s Lymphoma

c) Lymphocyte Rich Hodgkin’s Lymphoma

d)T-cell rich B cell Lymphoma

a) Anaplastic large cell lymphoma

b) Large cell Pleomorphic lymphomas (T-Cell & B-Cell type)

c) True histiocytic lymphoma (Histiocytic sarcoma)

d)Anaplastic plasmacytoma

134

International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 01, October 2014, Pages 127-137

129 www.ijhbr.com ISSN: 2319-7072

CONCLUSION

Fine Needle Aspiration Cytology is a simple, safe,

rapid, cost effective and reasonably accurate method

of establishing the diagnosis of lymphadenopathy.

Non representative sampling usually in small

metastatic deposits may be an important cause of

false negative diagnosis and granulomatous reaction

to metastatic tumors may be misinterpreted as

granulomatous lymphadenitis on FNAC. In such

cases biopsy should be advised to support or confirm

the FNAC diagnosis. Whenever necrosis is abundant

in cases of metastatic malignancy, cytomorphological

interpretation of smears should be done with caution.

Overall accuracy of FNAC in comparison with the

histopathological study is very high and may obviate

the need of excision biopsy when the findings are

compatible with the clinical diagnosis. The high

accuracy rate of aspiration cytology of lymph nodes

FIGURE 7 FIGURE 8

FIGURE 9 FIGURE 10

FIGURE 7- Smear shows clusters of epithelioid cells, lymphocytes , plasma cells , caseous necrosis.(TB

lymphadenitis)

FIGURE 8-Smear shows small and large lymphocytes, tingible body macrophages, centroblasts, centrocytes in

a hemorrhagic background.( Reactive Lymphadenitis)

FIGURE 9-Smear shows polymorphous population of cells comprising of lymphocytes , eosinophils ,

occasional plasma cells and large mono-nucleate and bi-nucleate pleomorphic Reed-Sternberg(RS) cells in a

hemorrhagic background (Hodgkin’s Lymphoma).

FIGURE 10- Smears shows bi-nucleate pleomorphic Reed- Sternberg (RS) cell.

FIGURE 9 FIGURE 10

135

International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 01, October 2014, Pages 127-137

128 www.ijhbr.com ISSN: 2319-7072

calls for its wide application in daily practice. Thus in

conclusion this simple procedure should be

advocated by the clinicians so that early diagnosis of

cervical lymphadenopathy is possible in shortest

period of time and also makes the clinician decide

about the treatment so as to prevent the progress of

the disease.

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;7(26):139–42.

2. Steel BL, Schwart MR, Ramzy I. Fine needle aspiration biopsy in the diagnosis of lymphadenopathy in

1103 patients. Role, limitations and analysis of diagnostic pitfalls. Acta Cytol 1995; 39(1): 76-81.

3. Lioe TF, Elliott H, Allen DC, Spence RA. The role of fine needle aspiration cytology (FNAC) in the

investigation of superficial lymphadenopathy; uses and limitations of the technique. Cytopathol 1998;

10(5): 291-7.

4. Gilbert RL, Antoine D, French CEl; The impact of immigration on tuberculosis rates in the United

Kingdom compared Int J Tuberc Lung Dis. 2009 ;13(5):645-51.

5. Zeshan QM, Mehrukh M, Shahid P. Audit of lymph node biopsies in suspected cases of

lymphoproliferative malignancies,implications on the tissue diagnosis and patient management. J Pak Med

Assoc 2000;50:179- 82.

6. Bhargava P, Jain AK. Chronic cervical lymphadenopathy a study of 100 cases. Ind J Surg 2002;64:344-46.

7. Singh JP, Chaturvedi NK, Das A. Role of fine needle biopsy cytology in the diagnosis of tuberculous

lymphadenitis. Indian J Pathol Microbiol 1998; 32:100-04.

8. Raj shekaran S et al: Tuberculous cervical lymphadenitis in HIV positive and negative patients. Ind Jour

Tub 2001;48:201-204.

9. Gupta AK, Nayar M, Chandra M: Reliability and limitation of fine needle aspiration cytology of

lymphadenopathies, an analysis of 1261 cases. Acta Cytol 1991;35:777-83.

10. Bandopadhyay SN, Roy KK, Dasgupta A, Ghosh RN.: Role of fine needle aspiration cytology in the

diagnosis of cervical lymphadenopathy. IJO & HNS 1996;48:289-94.

11. Bezabih M, Mariam DW, Selassie SG. Fine needle aspiration cytology of suspected tuberculous

lymphadenitis. Cytopathology 2002 Oct; 13 (5): 284-90.

12. Putschar WG. Can toxoplasmic lymphadenitis be diagnosed histologically? N Engl J Med 1973; 289: 913-

4.

13. Saxen E, Saxen L, Gronross P. Glandular toxoplasmosis: A report on 23 histologically diagnosed cases.

Acta Pathol Microbiol Scand 1958;44: 319-328.

14. Tambouret R, Geisinger KR, Power CN, Khurana KK, Silverman JF, Bardales R., et al. The clinical

application and cost analysis of fine needle aspiration biopsy in the diagnosis of mass lesion in sarcoidosis.

Chest 2000; 117(4): 1004-11.

136

International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 01, October 2014, Pages 127-137

128 www.ijhbr.com ISSN: 2319-7072

15. Klemi PJ, Elo JJ, Joensuu H. Fine needle aspiration biopsy in granulomatous disorders. Sarcoidosis 1987;

4(1): 38-41.

16. Schneider DR, Taylor CR, Parker JW, Cramer AC, Meyer PR, Lukes RJ. Immunoblastic sarcoma of T- and

B- cell types: morphologic description and comparison. Hum Pathol 1985; 16(5): 885-900.

17. Khurana KK, Stanley MW, Powers CN, Pitman MB. Aspiration cytology of malignant neoplasms

associated with granulomas and granuloma-like features: diagnostic dilemmas. Cancer 1998; 84(2): 84-91.

18. Lui PC, Chow LT, Tsang RK, Chan AB, Tse GM. Fine needle aspiration cytology of lymph node with

metastatic undifferentiated carcinoma and granulomatous (sarcoid-like) reaction. Pathology 2004; 36(3):

273-4.

137