Diagnostic Lymph Node Pathology (Hodder Arnold Publication)

171 Pages·2006·26.35 MB·English

by  Dennis H. Wright

Diagnostic Lymph Node
Pathology
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Diagnostic Lymph Node
Pathology
Dennis H. Wright
Emeritus Professor of Pathology, Southampton University, Southampton, UK
Bruce J. Addis
Consultant Histopathologist, Department of Cellular Pathology, Southampton
General Hospital, Southampton, UK
Anthony S.-Y. Leong
Medical Director, Hunter Area Pathology Service, Professor and Chair, Discipline of
Anatomical Pathology, University of Newcastle, Australia
Hodder Arnold
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First published in Great Britain in 2006 by
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© 2006 Wright, Addis & Leong
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accurate at the date of going to press, neither the author[s] nor the publisher
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disclaimer) every effort has been made to check drug dosages; however it is still
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of the drugs recommended in this book.
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ISBN-10 0 340 70609 0
ISBN-13 978 0 340 70609 1
1 2 3 4 5 6 7 8 9 10
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Contents
Preface vii
1 Handling of lymph node biopsies, diagnostic procedures and recognition of
lymph node patterns 1
2 Normal/reactive lymph nodes: structure and cells 11
3 Reactive and infective lymphadenopathy 17
4 Precursor B- and T-cell lymphomas 49
5 Mature B-cell lymphomas 55
6 T-Cell lymphomas 91
7 Immunodeficiency-associated lymphoproliferative disorders 113
8 Hodgkin lymphoma 117
9 Histiocytic and dendritic cell neoplasms, mastocytosis and myeloid sarcoma 131
10 Non-haematolymphoid tumours of lymph nodes 141
11 Needle core biopsies of lymph nodes 143
Index 155
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preface
Haematopathology has become the subject of specialist or differential diagnosis, based on morphology before
reporting in many countries in the developed world. ordering or embarking on the interpretation of immuno-
This is seen as a necessary evolution and a consequence histochemical preparations. In the final analysis the
of the increasing complexity of the subject, the need morphology and immunohistochemistry should be
for sophisticated ancillary investigations in some cases compatible, and it is the concordance of these tech-
and the fundamental need for an accurate diagnosis on niques that provides security of diagnosis.
which to base further patient management. Neverthe- We are aware of the time constraints facing patholo-
less most lymph node biopsies will land on the desks gists and have aimed to make the basic information
of general pathologists who will need to make the on entities easily accessible by presenting the clinical,
judgement as to whether the pathology is that of a morphological and immunohistochemical features of
reactive or neoplastic process and whether referral is each disease together with illustrations in boxes. More
necessary. We have aimed this book at general pathol- detailed information is provided in the text.
ogists and trainees, although we hope that dedicated Since we began writing this book we have seen a
haematopathologists may find some gems between its year on year growth of the proportion of lymph node
covers. In the light of our target readership we have biopsies received as needle biopsies. These are usually
placed our main emphasis on morphology rather than taken by radiologists using CT guidance. The most obvi-
molecular techniques. ousvalue of this technique is in taking biopsies of deep
A number of authors have tried to base lymph node seated lesions and thus avoiding the need for surgery.
diagnosis on the low power structure of the node. While Most pathologists would probably wish that superficial
this is a good starting point it is not always helpful and nodes were obtained by whole lymph node biopsy. How-
can be misleading. For example, although an overall ever, as clinicians realise that a definitive diagnosis can
nodular pattern is characteristic of follicular lymphoma be obtained on a high proportion of superficial nodes
it can also be the dominant low power feature of mantle using needle biopsies, this type of biopsy is likely to
cell and marginal zone lymphomas. We would never- become more common in view of its ease of applica-
theless emphasise the importance of both low power tion and low morbidity. We have therefore included in
and high power morphologic examination based on the book a chapter specifically on the interpretation of
good quality sections. It is wise to arrive at a diagnosis, needle biopsies.
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Handling of lymph node
biopsies, diagnostic
1 procedures and
recognition of lymph
node patterns
Taking and handling of lymph node biopsies 1 Prominent sinuses 8
Introduction 1 Capsule 8
Processing, sectioning and staining 2 Reactive follicles 9
Immunohistochemistry 3 Overall growth pattern 9
Diagnosing the ‘undiagnosable’ biopsy 7 Paracortex 9
Where to begin? Recognizing lymph Marginal zone 9
node patterns 8 Necrosis 9
Introduction 8 Apoptosis 9
Sinus architecture 8 Granulomas 9
TAKING AND HANDLING OF LYMPH NODE BIOPSIES
INTRODUCTION usually most severe when the biopsy tissue is very fibrotic
or has to be taken from a confined space, such as the
Suboptimal techniques in the taking and handling of anterior mediastinum.
lymph node biopsies are probably the biggest obstacle to Needle biopsies are now more frequently used for the
achieving a correct diagnosis. All concerned with this diagnosis of lymph node pathology. When possible,
process should bear in mind that the objective of the open lymph node biopsies should be used for superficial
biopsy is to achieve a timely and accurate diagnosis on accessible lymph nodes; however, needle biopsies have
which the subsequent management of the patient can be a lower morbidity than open biopsies and are of particu-
based. Feedback information at multidisciplinary team lar value in sampling abdominal and retroperitoneal
meetings is a valuable means of achieving and main- lymph nodes, avoiding the need for laparotomy. These
taining a high standard of lymph node biopsies. In the biopsies are usually taken by radiologists using ultra-
absence of such meetings, personal contact is needed to sound or computed tomography (CT) guidance. Needle
ensure that any shortcomings in the biopsy technique biopsies fixed quickly give good morphological preser-
and handling of the specimen are rectified. vation, which, together with immunohistochemistry,
Lymph nodes should be selected for biopsy on the allows the precise identification of most common
likelihood that they contain the pathological process. lymphomas. The technique may be less successful in
They should be dissected out whole, if possible, and with the identification of non-neoplastic proliferations.
the capsule intact. Fragmented nodes may be more diffi- Fine needle aspiration biopsies have their greatest
cult to diagnose than intact nodes, depending on the value in the separation of carcinoma from lymphoma
pathological process involved. Traction artefacts are and for the identification of recurrences or for staging.