Histological Surprises in Benign Cytologies after Lymph Node Biopsy-Surgeon's Knife Improving Patient Care

Lymphadenopathy can be due to multitude of causes. Owing to the high prevalence of infectious diseases in India, and malignancy being a life threatening cause for lymphadenopathy; accurate diagnosis is important in preventing delay or misdiagnosis and in improving patient care, thereby increasing longevity with quality. Fine needle aspiration cytology (FNAC) is the first line investigation commonly done. Should the doctor be contented with the benign FNAC or is a lymph node biopsy needed in this age? The aims of this study are the following: (1) to study the spectral pattern of lymph node biopsies done in a surgical oncology unit of tertiary care centre, (2) to assess the yield of malignant cases from lymph node biopsy and (3) to compare the reliability of benign FNAC with lymph node biopsy. Cross-sectional study of 114 cases that underwent lymph node biopsy during the year 2014, at the Surgical Oncology Department of St. John's Medical College Hospital, Bangalore. Lymph node biopsies were done in the outpatient department (OPD) under local anaesthesia or in the operation theatre under local anaesthesia/monitored anaesthesia care based on the clinical condition of the patient. Regional lymph node dissections, central node biopsy, patients with known case of malignancy were excluded. Specimen sent for histopathological study and immunohistochemistry (IHC) done when needed. 58.8% were males among study population, age ranging from 15 to 80 years, 57% cervical and 29.8% axillary lymph node biopsies done. Sixty-seven percent (67%) of biopsies done in OPD. Thirty-three percent (33%) of biopsies in the operation theatre among which 60.5% under local anaesthesia only. 35.1% cases were reactive hyperplasia, 24.6% lymphomas with non-Hodgkin's lymphoma being the commonest, 13.2% metastatic disease with adenocarcinoma being the commonest. 72.7% of the supraclavicular nodes were malignant. 47.4% of subjects had prior FNAC of the lymph node. Twenty-five percent (25%) of the reactive hyperplasia's on FNAC (p < 0.0001), 33.3% of inadequate FNAC (p = 0.003) and 75% of atypical cells in FNAC turned to be malignant on lymph node biopsy with a discordance rate of 20.3%. Lymph node size didn't correlate with neoplasm. In our study, benign cytologies were malignant on biopsy and statistically significant. Lymph node biopsies are reliable in detecting malignancy and subtyping of the disease. In the presence of strong clinical suspicion, lymph node biopsy is essential even when the FNAC is promisingly benign in a country with limited resources. Lymph node biopsy can be safely done in OPD under local anaesthesia at a lower cost, resulting in a reliable diagnosis thereby improving patient care.