Peripheral lymphadenopathy indicates any lymph node enlargement that is detectable on palpation at a location other than intrathoracic, mediastinal, intra-abdominal, or retroperitoneal [
The retrospective reviews from the west suggest most of these to be self-limiting with biopsies yielding a malignant process only in the small group beyond 50 years [
We studied the efficacy of open lymph nodal biopsy interpreting the results in view of rural population, the prevalent diseases, lack of modern facilities, and poor patient follow-up.
A retrospective analysis was done in the United Mission Hospital, Tansen, of rural western Nepal between 1 May 2011 and 30 April 2013. A total of 132 patients were enrolled following institutional approval. Relevant medical records of patients who underwent PLNB were reviewed. The following were the various indications for the procedure: Significant localized or generalized peripheral lymphadenopathy lasting more than 2 weeks without a documented infectious cause Lack of response to conservative treatment Suspicion of a hematological malignancy Suspicion of a secondary metastasis with occult primary cancer
The exclusions were made if the PLNB was not performed in isolation or was done as a part of a more elaborate procedure, for example: Neck dissection for a known head and neck cancer with cervical lymphadenopathy Axillary dissection for a known breast cancer with axillary lymphadenopathy Inguinal block dissection for a known lower extremity malignancy Intra-abdominal or retroperitoneal lymph node biopsy done for known malignancy
The results were analyzed using Microsoft Excel and SPSS Version 25.
Of 132 patients, 51 (38.63%) were male and 81 (61.36%) were female. There were 48 (36.3%) patients belonging to the age group less than 16 years and 84 (63.6%) in the group above 16 years. Of these, children (<16 years) underwent the procedure under sedation, and those above 16 years tolerated the procedure well under local anesthesia. There was no event of perioperative complication. Postoperatively, pain was well controlled with oral analgesics, and all could be started on oral feeds and discharged the same day. Of these, one patient had a minor wound infection that was detected on the fifth postoperative day and treated with daily dressings and oral antibiotics, while none of the rest had any notable complications.
The most common site of biopsy was the neck in 114 (86.36%) patients as shown in Table
Distribution of the lymph nodal biopsy site
Lymph nodal site | Number of cases (%) |
---|---|
Neck | 114 (86.36%) |
Groin | 11 (8.3%) |
Axilla | 7 (5.3%) |
Total | 132 (100%) |
In the age group >16 years, 59/84 (70%) had significant pathological yield, while in those <16 years, only 11/48 (23%) had significant findings as shown in Table
Significant pathological yield.
Age group | TB lymphadenitis | Primary lymph nodal malignancy | Metastatic secondary | Total |
---|---|---|---|---|
<16 years | 9 | 2 | 0 | 11 |
>16 years | 51 | 5 | 3 | 59 |
Few benign, self-limiting diseases were also encountered in both the groups as listed in Table
Distribution of diseases in biopsied lymph nodes
Disease | Number of patients (%) |
---|---|
Tuberculosis | 60 (45.4%) |
Lymphoma | 7 (5.3%) |
Metastatic secondary | 3 (2.2%) |
Acute lymphadenitis | 7 (5.3%) |
Nonspecific granuloma | 18 (13.6%) |
Reactive lymphadenitis | 29 (22%) |
Other causes | 8 (6%) |
(i) Sinus histiocytosis | 4 (3%) |
(ii) Cat-scratch disease | 2 (1.5%) |
(iii) Parasitic cause | 2 (1.5%) |
Total | 132 (100%) |
Lymphadenitis due to parasitic and reactive causes was clearly more in children as shown in Figure
The findings of nonsignificant pathologies in the lymph nodal biopsies
A lymph node may be enlarged in certain situations, for example, an immune response to an infective agent (bacteria and virus), as a result of inflammatory cells in infections involving the lymph node (lymphadenitis), due to the infiltration of neoplastic cells carried to the node by lymphatic or blood circulation (metastasis), due to localized neoplastic proliferation of lymphocytes or macrophages (lymphomas), and as a result of infiltration of macrophages filled with metabolite deposits (lipid storage diseases) [
Peripheral lymphadenopathy may broadly be classified into generalized (when 2 or more noncontiguous areas are involved) or localized (when only 1 area is involved) [
While generalized lymphadenopathy is more concerning and almost always indicative of a significant systemic disease, it is the localized disease that presents with a bigger diagnostic challenge [
In this regard, several studies have been done to reach to a sensible rationale of performing a PLNB. Many studies have tried developing a diagnostic algorithm with biopsy as the ultimate and last option, in order to avoid unnecessary biopsies especially when the yield of cancer has been reported to be fairly low [
These studies have suggested a histologically benign disease in 17–45% of cases in different sets of data [
The yield of pathologically significant findings in our study was found to be much more when PLNB was performed in adult patients as compared to children
This seems to be in keeping with the high prevalence of TB in the community presenting still as a major disease burden and mortality. A recent study seems to follow a similar pattern, wherein the commonest diagnosis was TB (42%) [
While in the developed world, the practice has been to limit such biopsies much supported by the use of high-frequency USG (which can itself suggest diagnosis in expert hands) combined with FNAC and PLNB, which somehow seems to be imperative and unavoidable at various clinical situations in our setup [
The fact of relevance is that if an infectious workup is nondiagnostic and the patient has persistent or progressive lymphadenopathy of unknown cause, a biopsy is indicated [
In our setup, we prefer to biopsy those patients who present with significant localized or generalized peripheral lymph nodes of more than 2- to 3-week duration without a documented infectious cause.
There are studies that quote a three- to four-week period of observation and some even up to 6 months [
The incidence of a significant pathological diagnosis in our study was 53% (70/132), and this certainly demanded further evaluation. Had the biopsy not been done, the likelihood of missing these findings would be high, and hence the morbidity and mortality. In patients in whom the yield was insignificant, this could have caused psychological stress, but the overall end result can still be considered favorable in eliminating diagnostic doubt and dilemma. However, PLNB needs to be considered with caution in children in whom the likelihood of a pathologically significant yield seems less likely.
In our experience, we have found PLNB to be a relatively simple procedure.
Therefore, in view of its simplicity, good diagnostic yield, and lack of significant morbidity or mortality, in a rural setup like ours where expertise in terms of USG or FNACs is unavailable, it still seems to be a good diagnostic tool and an extremely useful procedure.
The limitations of our study include the bias associated with a retrospective observational study.
Peripheral lymphadenopathy is a common presentation in all age groups and often puts up a decisive dilemma regarding biopsy. A good clinical understanding can avoid an unnecessary biopsy in most cases, more so if facilities like USG combined with FNAC are available. However, these are not available to all.
With background knowledge of prevalent potentially curable diseases in the community like TB, it becomes desirable to consider this option when the patient follow-up is questionable. It is also advisable to biopsy the most abnormal node that may not necessarily be the most accessible one.
In view of simplicity, good diagnostic yield, and lack of significant morbidity or mortality, we conclude that open lymph node biopsy is an effective diagnostic tool in a peripheral setup.
Ultrasonogram
Tuberculosis
Fine-needle aspiration cytology
Peripheral lymph node biopsy.
The authors declare that there are no conflicts of interest regarding the publication of this paper.
Ashish Lal Shrestha and Pradita Shrestha contributed equally to drafting, literature search, and writing of the paper.
The authors would like to thank the ward staff of the hospital for providing support and helping in management of the patients.