Clinicopathological Outcome of Cervical Lymphadenopathy

 Introduction

Approximately two-thirds of lymph nodes are found in the neck. Given the abundance of etiological agents and their role as an indicator of the spread of infections or cancer, the growth of these lymph nodes is highly relevant.¹ Cervical lymphadenopathy is a standard clinical condition. An enlargement of the lymph nodes of more than 1 cm² indicates a clinical manifestation of regional or systemic disease. It serves as an excellent clue to the underlying disease.² Persistent enlargement of the lymph node necessitates detailed investigations to reveal an underlying pathology.

While a clinical diagnosis can often be precise, it's essential to conduct histopathological tests to confirm the diagnosis definitively. This challenge can be addressed by performing a fine needle aspiration (FNAC), as it is a straightforward, rapid, and cost-effective procedure that only necessitates the expertise of a cytologist.³

The most frequent causes of cervical lymphadenopathy are lymphomas, nonspecific lymphadenitis, secondaries in the cervical lymph nodes, and tuberculous lymphadenitis, which is a common symptom of extrapulmonary tuberculosis.⁴ In India, TB is a serious health problem because of social and economic limitations. A rise in the overall incidence of tuberculosis (TB), as well as an increased percentage of military, disseminated, and extrapulmonary TB cases including lymphadenitis have been linked to the HIV epidemic. Although acute infective lymphadenopathy typically resolves on its own with antibiotic treatment, abscess formation might happen and necessitate aspiration or incision and drainage.⁵ Numerous genetically different and widely distributed sub-linages of tuberculosis have emerged, displaying a range of disease phenotypic traits that have been shown in animal models and epidemiological investigations. This may help explain the broad clinical and pathological spectrum of the disease in individuals who cannot control their infections, together with the variability of the host immune response. In the younger age range, pyogenic and granulomatous illnesses are the primary cause of cervical lymphadenopathy; in the older age group, head and neck cancer is the most common cause.^6,7,8

Fine Needle Aspiration Cytology (FNAC) has demonstrated high sensitivity and specificity in many studies.^9,10 The etiology of cervical lymphadenopathy may range from inflammation to malignancies or tuberculosis; sometimes, it is non-specific. Tubercular lymphadenitis is common in India. It is diagnosed by FNAC, which is one of the most reliable and least expensive diagnostic procedures for a definitive and confirmed diagnosis.^11,12 Compared to open biopsy, FNAC has emerged as a parallel yet separate discipline for the diagnosis of cervical lymphadenopathy. Diagnosis is quick with negligible complications. Neck masses are a common problem in infants, children, and adults.^13,14

Cervical lymphadenopathy is classified into three categories based on duration: acute lymphadenopathy (2 weeks or less), subacute lymphadenopathy (2-6 weeks), and chronic lymphadenopathy (more than 6 weeks).¹⁵ With this background, we evaluated patients with cervical lymphadenopathy clinically and with a pathological study to confirm the diagnosis. Also, we studied the clinical behavior, management, and outcome of cervical lymph nodes on follow-up for 6 months.

Materials and Methods

This cross-sectional prospective study was done at a tertiary care center over 2 years, from April 2022 to March 2024. The patients presenting with cervical lymphadenopathy of age more than 10 years presented with neck nodes for more than 3 weeks were included. Patients who were diagnosed with ultrasonography (USG)/CT scan of the neck were also included. Patients presenting with an acute attack of lymphadenitis of less than 3 weeks or underlying bleeding disorders were excluded from the study.

Data collection

All patients with cervical lymphadenopathy attending the outpatient or inpatient in the Department of General Surgery were selected for the study. After taking written informed consent, data was collected regarding age, sex, duration of symptoms, constitutional symptoms, and history of contact with tuberculosis patients.

A detailed local and complete general physical examination was carried out. After making a clinical diagnosis, further relevant investigations such as complete blood count (CBC), erythrocyte sedimentation rate (ESR), ultrasound of the neck, FNAC and excision biopsy will be carried out. Following diagnosis confirmation, appropriate treatment was administered. All patients were monitored post-discharge and provided with necessary guidance.

Statistical analysis

Data was collected by structure proforma, entered in an MS Excel sheet, and analyzed using SPSS 24.0 version IBM USA. Qualitative data was evaluated in terms of proportions. Quantitative data was assessed in terms of Mean and Standard deviation. The association between the two qualitative variables was seen by using Fischer’s exact test. The diagnostic accuracy of the FNAC was evaluated by sensitivity and specificity.

A P value of <0.05 was considered statistically significant, whereas a P value of <0.01 was regarded as highly significant.

Results

A total of 50 patients were included in the study. Out of 50 subjects, the majority were from the 31-40 years age group, i.e., 15(30%), followed by 14 (28%) each from the less than 20 years and 21-30 years age group. The least number of patients were seen from the 41-50 (8%) and above 50 years (6%). In our study, males were 56% and females were 44%. Males were predominant, with a male to female ratio of 1.27:1.

Clinical features revealed fever in 42%, followed by pain in 26%, weight loss and cough in 22% each, and malaise and loss of appetite in 18% each (Figure 1). Examination of lymph nodes revealed firm consistency in the most patients i.e., 42 (84%). In 3 (6%) of the patients, it was hard and rubbery (Figure 2). The lymph nodes were found to be adherent in 22% of cases. The lymph nodes were found to be caseating in 24% (12) cases. Only 3 (6%) patients gave a history of contact with TB patients. The LNs were observed to be multiple in 26 patients (52%) and single in 24 (48%) cases. In 45 cases (90%), LNs were unilateral, and in 5 (10%) cases, it was bilateral.

Clinical diagnosis revealed that TB lymphadenitis was present in 31 cases, accounting for 62%, followed by acute suppurative lymphadenitis in 9 cases, or 18%, malignant metastasis in 3 cases, or 6%, and acute lymphadenitis in 2 cases, or 4% (Table 1).

FNAC diagnosis revealed TB lymphadenitis in 27 cases (54%), followed by acute suppurative lympha-denitis in 7 cases (14%), and chronic nonspecific lymphadenitis in 4 cases (8%). The diagnostic accuracy of FNAC demonstrated a sensitivity of 71.05% and a specificity of 100% (Table 2).

Excision biopsy diagnosis revealed TB lymphadenitis in 38 cases (76%), followed by acute suppurative lymphadenitis in 4 cases (8%), Hodgkin's lymphoma, and well differentiated squamous cell carcinoma in 2 cases (4%) (Table 3).

The prevalence of neoplastic lymphadenopathy was 12% in the current study, and the remaining 88% were nonneoplastic. ATT was started in 36 patients (72%), and antibiotics in 8 cases (16%) (Table 4).

Discussion

Our study included 50 patients, with the highest proportion (30%) in the 31-40 years age group, followed by 28% each in the <20 and 21-30 years groups. Fewer cases were observed in the 41-50 (8%) and >50 years (6%) groups. TB lymphadenitis was most prevalent in the 31-40 years group (93.3%), followed by 78.6% in the 21-30 years group and 64.3% in the <20 years group, showing a significant association (P<0.05). Males constituted 56% of the cases, with a male-to-female ratio of 1.27:1.

Melkundi et al., conducted a study on 50 cases of cervical lymphadenopathy, and the age distribution showed that 26% of patients were in the 11-20 and 21-30 age groups, followed by 12% in the 41-50 group. Only 2% were in the 71-80 age group. The male-to-female ratio from their study was found to be similar to the current study.¹⁶

Bhavani et al., conducted a study in 2004 and found that the highest number of cases occurred in the 4-30 age group, with 22% (11 cases). TB lymphadenitis was most common in the 21-30 age group, while secondary malignancies were more frequently observed in the 41-50 age group. Additionally, 16% of cases were in both the 11-20 and 31-40 age groups.¹⁷

In the series of Chamyal et al., the incidence of cervical lymphadenopathy was highest in 41-60 age group, followed by 1-20 years.¹⁸ Bhargava et al., reported a male-to-female ratio of 1:1.6, while Schwarz et al., observed a ratio of 1.43:1.7.^19,20 In the study by Kulal et al., the highest number of cases were in the 21-30 age group (32%), followed by the 31-40 age group (22%). Our findings closely align with these studies.²¹

Clinical features revealed fever in 42%, followed by pain in 26%, weight loss and cough in 22% each, and malaise and loss of appetite in 18% each. Kulal et al. reported that the constitutional symptoms were fever, pain, cough, loss of appetite, loss of weight, sinus, and change in voice.²¹ The presence of any of the symptoms was considered positive for constitutional symptoms. All cases presented with swelling in the neck. Fever was the most common symptom, seen in 19% of cases, followed by loss of weight in 17% of cases. Veetil et al. reported that nearly 18% of patients presented with pain, 18% with fever, 12% with cough, 16% with weight loss, and 12% with loss of appetite.²² Our findings are almost similar to the findings of the above-mentioned authors.

Examination of lymph nodes revealed firm consistency in the majority of the patients, i.e., 42 (84%). In 3 (6%) of the patients, it was hard and rubbery. The lymph nodes were found to be adherent in 22% of cases. The lymph nodes were found to be caseating in 24% of cases. The LNs were observed to be multiple in 26 patients (52%) and single in 24 (48%) cases. In 45 cases (90%), LNs were unilateral, and in 5(10%) cases, it was bilateral. Melkundi et al., reported that 23 cases (46%) were found to have in the right side followed by the left side 19 (38%).16 Thirty-nine cases were found firm, and no soft consistency of lymph nodes was observed. Among the patients, 36 (72%) had the condition of lymph node, whereas 5 (10%) had fixed lymph nodes. Bhavani et al., showed that left side involvement is more common. The left side of the neck was involved in 25 cases (50%), the right side in 21 cases (42%), and bilateral involvement was seen in 4 cases (8%) in her study.¹⁷ They also reported that firm LNs constituted 70%, hard 28%. In Chamyal et al., the series consisted of firm nodes (65.5%), hard nodes (29.1%), cystic nodes (3.6%), and soft nodes (1.8%).¹⁸

Kulal et al., reported that out of 53 cases of tuberculosis cervical lymphadenopathy, in 20 cases, the lymph nodes were matted (37.74%), and the rest were discrete (62.26%).²¹ Jha et al., study showed matted lymph nodes in 38.3% of cases, which is comparable with the present study.²³ Our findings are almost similar to the findings of the above-mentioned authors.

In our study, the clinical diagnosis revealed that TB lymphadenitis was present in 31 cases, accounting for 62%, followed by acute suppurative lymphadenitis in 9 cases, or 18%, malignant metastasis in 3 cases, or 6%, and acute lymphadenitis in 2 cases or 4%. Melkundi et al., stated that on clinical diagnosis of 50 cases, 38 cases were benign, of which 26 cases were TB lymphadenitis (52%), and 12 cases (24%) nonspecific lymphadenitis.¹⁶

Remaining accounted for malignancy i.e., secondaries in the neck accounted for 10 cases (20%) and lymphomas 2 cases (4%). In the reports of Sarda et al., of 359 patients, 253 cases (86%) had tuberculous lymphadenitis, 42 had nonspecific lymphadenitis, 36 had secondaries, and 18 had lymphomas.²⁴

In our study, FNAC diagnosis revealed TB lymphade-nitis in 27 cases (54%), followed by acute suppurative lymphadenitis in 7 cases (14%), and Chronic non-specific lymphadenitis in 4 cases (8%). Excision biopsy diagnosis revealed TB lymphadenitis in 38 cases, i.e., 76%, followed by acute suppurative lymphadenitis in 4 cases (8%), Hodgkin's lymphoma and well-differentiated squamous cell carcinoma in 2 cases (4%). The prevalence of neoplastic lymphadenopathy was 12% in our study, and the remaining 88% were nonneoplastic.

Bhavani et al., studied 50 cases with cervical lym-phadenopathy; 34 cases (68%) were benign, and 16 were malignant (32%).17 In the study of Chamyal et al., benign constituted 57.2%, and malignancy accounted for 40.9%.¹⁸ Kulal et al., observed that on histopathology, the maximum incidence was found to be of tuberculosis, which were 53 (53%) cases.²¹ Next was reactive lymphadenitis 27(27%) followed by secondaries (14%) and lymphomas (6%).

The diagnostic accuracy of FNAC in detecting acute lymphadenitis revealed a sensitivity of 50% and a specificity of 100%. The diagnostic accuracy of FNAC in detecting acute suppurative lymphadenitis revealed a sensitivity of 50% and a specificity of 100%. The diagnostic accuracy of FNAC in detecting chronic non-specific lymphadenitis revealed a sensitivity of 0% and a specificity of 91.3%. The diagnostic accuracy of FNAC in detecting Hodgkin’s lymphoma revealed a sensitivity of 50% and a specificity of 100%. The diagnostic accuracy of FNAC in detecting non- Hodgkin’s lymphoma revealed a sensitivity of 100% and specificity of 100%. The diagnostic accuracy of FNAC in detecting TB lymphadenitis was revealed to be 71.05% sensitivity and 100% specificity.

Melkundi et al., observed that among 24 lymph node biopsies done in this study, reports were consistent with FNAC reports, two not consistent with FNAC reports.¹⁶ Hence, the accuracy of FNAC with respect to biopsy in this study was 91.66%. Sarda et al., reported diagnostic accuracy of FNAC was 97%.²⁴ Chamyal et al., reported  the FNAC accuracy was 88.3%, and Bhargave et al., stated FNAC accuracy was 98%.^18,19 Kulal et al., reported that the diagnostic accuracy of FNAC in detecting tubercular lymphadenitis revealed a sensitivity of 75.5% and a specificity of 100%.²¹ They found that the diagnostic accuracy of FNAC in detecting reactive lymphadenitis and secondaries in cervical lymph nodes was 100% and 92.8% sensitivity and 93.1% and 100% specificity, respectively. They reported that FNAC had a diagnostic accuracy of 83.3% sensitivity and 100% specificity in detecting secondaries in cervical lymph nodes.

The study by Jha et al., reported a sensitivity of 92.8% in diagnosing tubercular lymphadenitis.23 Dandapet et al., reported a sensitivity of 83% for tuberculosis.²⁵ The study by Chao et al., showed a sensitivity of 88% and a specificity of 96% for the same.²⁶ Similarly, Dasgupta et al., reported a sensitivity of 84.4% for tuberculosis and 89% for malignant secondary deposits.²⁷ Prasad et al., studied 2216 cases and reported the following sensitivity and specificity values: 84% and 95% for tubercular lymphadenitis, 97% and 99% for metastatic deposits, 80% and 98% for Hodgkin’s disease, and 81% and 96% for non-Hodgkin’s lymphoma.²⁸ Mili et al., found that both the sensitivity and specificity of FNAC for malignant secondaries in their study was 100%, whereas, for tuberculosis, sensitivity was only 86.20%, and specificity was 100%.¹ The findings of our study are almost consistent with the study carried out by the above-mentioned authors.

Conclusion

Tubercular lymphadenitis, acute suppurative lymphadenitis, and malignancies are the most common causes of cervical lymphadenopathy in our study. FNAC is an extremely sensitive and highly specific investigation for early, accurate diagnosis.

Conflict of Interest

None

Source of Support

Nil