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CYTOJOURNAL QUIZ CASE
CytoJournal 2016,  13:8

Abdominal lymphadenopathy: An interesting and rare case diagnosed on endoscopic ultrasound-guided fine needle aspiration cytology


1 Department of Cytopathology, Sir Ganga Ram Hospital, New Delhi, India
2 Department of Gastroenterology, Sir Ganga Ram Hospital, New Delhi, India
3 Department of Histopathology, Sir Ganga Ram Hospital, New Delhi, India

Date of Submission06-Nov-2015
Date of Acceptance10-Jan-2016
Date of Web Publication18-Mar-2016

Correspondence Address:
Gagandeep Kaur
Department of Cytopathology, Sir Ganga Ram Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1742-6413.178997

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How to cite this article:
Grover A, Kaur G, Kumar A, Gupta V, Bakshi P, Jain S, Arora A, Verma K. Abdominal lymphadenopathy: An interesting and rare case diagnosed on endoscopic ultrasound-guided fine needle aspiration cytology . CytoJournal 2016;13:8

How to cite this URL:
Grover A, Kaur G, Kumar A, Gupta V, Bakshi P, Jain S, Arora A, Verma K. Abdominal lymphadenopathy: An interesting and rare case diagnosed on endoscopic ultrasound-guided fine needle aspiration cytology . CytoJournal [serial online] 2016 [cited 2017 Nov 20];13:8. Available from: http://www.cytojournal.com/text.asp?2016/13/1/8/178997


A 68-year-old woman presented to a gastroenterologist with abdominal pain, loss of appetite, and significant weight loss for last 5-6 months. Her history revealed that she had been having recurrent episodes of abdominal pain for last 15 years with postprandial distension and vomiting. She had taken two courses of anti-tubercular therapy (ATT) in the past. These were probably given empirically as no tissue diagnosis was available. She had been investigated extensively in another hospital for her present complaints; however, no diagnosis could be made. Computed tomography scan done outside revealed multiple calcified and noncalcified lymph nodes in the axilla, chest, and abdomen, and healed calcified foci in liver and spleen. There were fibro-calcified lesions in bilateral upper lobes of the lung. There was also mild ascites and bilateral pleural effusions. Physical examination revealed pallor, pedal edema, basal crepitation, and hepatomegaly. She had albuminuria, and 24 h urinary protein levels were raised. Her echocardiography revealed mild pulmonary arterial hypertension. She underwent endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of the abdominal lymph nodes with a clinical suspicion of tuberculosis. The EUS-FNA was performed using 22 G needle from the peri-pancreatic lymph nodes [Figure 1] and [Figure 2].
Figure 1: Fine needle aspiration smears of lymph node show basophilic clumps of acellular, homogenous material. Few lymphoid cells are also observed (May-Grunwald- Giemsa, ×400)

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Figure 2: Flocculent material was eosinophilic in Papanicolaou stain. Many spindle stromal cells were seen haphazardly intermixed with it (×400)

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 » QUESTION: WHAT IS YOUR INTERPRETATION AND WHICH SPECIAL STAIN WOULD YOU DO? Top


  1. Necrosis, Ziehl-Neelsen (ZN) stain
  2. Para-amyloid, periodic acid-Schiff stain
  3. Amyloid, Congo red stain
  4. Mucin, Mucicarmine stain.




Click here to view answer. View Answer

 » Additional quiz questions Top


Q1: The differential diagnoses of amyloid in cytology smears in clinically suspected cases would depend upon

  1. Organ involved
  2. Chemical nature of amyloid.
Q2: Which of the following could be difficult to differentiate from amyloid in lymph nodes without the aid of Congo red stain?

  1. Caseous necrosis
  2. Para-amyloid
  3. Protein deposition in angiocentric sclerosing lymphadenopathy
  4. All the above.
Q3: Amyloid lymphadenopathy is most commonly seen

  1. As a part of systemic amyloidosis
  2. In lymphoproliferative disorders
  3. As localized amyloidosis.




Click here to view answer. View Answer



 » Brief review of the topic Top


Diagnosis of amyloid lymphadenopathy was rendered on FNAC. No granuloma or atypical cells were observed in the smears. ZN staining for acid-fast bacilli was negative.

For confirmation of amyloidosis, the patient also underwent abdominal fat pad FNAC and liver biopsy. Abdominal fat pad aspiration is a relatively noninvasive, low-cost method for obtaining tissue to diagnose systemic amyloidosis. Cell block preparation, immunohistochemistry, and electron microscopy improve the detection of amyloid in fat pad aspiration. [10]

The abdominal fat pad aspiration smears showed linear deposits of amyloid on Congo red staining [Figure 5]. These showed apple green birefringence under polarized light. The liver biopsy showed partial disruption of the liver architecture with variable degree of deposition of amyloid in the sinuses and few portal vessels causing focal compression of the liver cell plates [Figure 6]. There was mild acute and chronic inflammation in portal areas. Congo red staining confirmed this to be amyloid. Immunohistochemical staining with Amyloid A (AA) was negative. The patient had been started on empirical ATT. She did not show any improvement, hence the ATT was stopped. The patient was investigated to exclude multiple myeloma. Her kappa, lambda-free light chains were within normal limits. She was put on supportive and symptomatic treatment. However, she succumbed to the disease within 2 months.
Figure 5: Congo red staining shows linear deposits of amyloid on abdominal fat pad aspiration(×400)

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Figure 6: Liver biopsy showing amyloid deposition (H and E, ×400)

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It is imperative to further classify amyloid as localized or systemic and primary, secondary, hereditary, or other rare types. Immunohistochemical panel comprising kappa and lambda light chains, antisera to AA, and anti-transthyretin can help recognize most forms of amyloid. In cases where immunohistochemistry is noncontributory, amino acid sequencing or ultrastructural examination is the definite method to characterize amyloid protein. [2]

In the present case, lymph node involvement was a part of systemic amyloidosis. The material in cell block was insufficient for immunohistochemistry. Immunostaining with AA done on liver biopsy was negative. The kappa- and lambda-free light chains and kappa/lambda ratio were also within normal limits. The exact chemical nature of amyloid protein could not be ascertained in this case.

The clinical symptoms of amyloidosis are variable and nonspecific and depend on the type and extent of organs involved. The radiologic features are also nonspecific. Calcifications, as observed radiologically in the present case, are not an infrequent feature. [11] The diagnosis of this entity is almost always confirmed by biopsy of the affected organ.

In deep-seated lymph nodes, the diagnosis of amyloidosis is usually made after surgery or by invasive biopsy techniques. [12] Krishna et al. recently described a case of pancreatic amyloidosis diagnosed on EUS-FNA. They emphasized on the potential role of EUS for procuring samples from extraluminal accessible sites for cytologic diagnosis of amyloidosis. [13] The present case is interesting because the diagnosis was initially clinched by EUS-guided FNA of abdominal lymph nodes. With the advent of newer imaging modalities, the cytopathologists will have a pivotal role in diagnosing a broader spectrum of entities than ever before.


 » Competing interests statement by all authors Top


The authors declared that they have no competing interests.


 » Authorship statement by all authors Top


AG, GK, AK, SJ, and VG have made substantial contribution to conception, design, and data acquisition. AG, GK, AK, VG, PB, KV, AA, and SJ participated in drafting the article and revising it critically.


 » Ethics statement by all authors Top


As this is a quiz case without identifiers, our institution does not require approval from Institutional Review Board (or its equivalent).


 » List of abbreviations Top


0(In alphabetic order)

AA - Amyloid A

ATT - Anti-Tubercular Therapy

EUS-

FNA - Endoscopic Ultrasound-Guided Fine Needle Aspiration

FNAC - FNA Cytology

ZN - Ziehl-Neelsen

 
 » References Top

1.
Michael CW, Naylor B. Amyloid in cytologic specimens. Differential diagnosis and diagnostic pitfalls. Acta Cytol 1999;43:746-55.  Back to cited text no. 1
    
2.
Gertz MA. The classification and typing of amyloid deposits. Am J Clin Pathol 2004;121:787-9.  Back to cited text no. 2
[PUBMED]    
3.
Halliday BE, Silverman JF, Finley JL. Fine-needle aspiration cytology of amyloid associated with nonneoplastic and malignant lesions. Diagn Cytopathol 1998;18:270-5.  Back to cited text no. 3
    
4.
Takahashi T, Miura H, Matsu-ura Y, Iwana S, Maruyama R, Harada T. Urine cytology of localized primary amyloidosis of the ureter: A case report. Acta Cytol 2005;49:319-22.  Back to cited text no. 4
    
5.
Gangane N, Anshu, Shivkumar VB, Sharta S. Cytodiagnosis of hepatic amyloidosis by fine needle aspiration cytology: A case report. Acta Cytol 2006;50:574-6  Back to cited text no. 5
    
6.
Sharma N, Sharma S, Bindra R. Plasmacytoma with amyloidosis masquerding as tuberculosis on cytology. J Cytol 2009;26:161-3.  Back to cited text no. 6
[PUBMED]  Medknow Journal  
7.
Manucha V, Kaur G, Verma K. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of mediastinal lymph nodes: Experience from region with high prevalence of tuberculosis. Diagn Cytopathol 2013;41:1019-22.  Back to cited text no. 7
    
8.
Chang KL, Arber DA, Gaal KK, Weiss LM. Lymph nodes and spleen. In: Wick MR, LiVolsi VA, Pfeifer JD, Stelow EB, Wakely PE, editors. Silverberg's Principles and Practice of Surgical Pathology and Cytopathology. England: Cambridge University Press; 2015. p. 688-812.  Back to cited text no. 8
    
9.
Vogel MN, Wehrmann M, Horger MS. Massive cervical and abdominal lymphadenopathy caused by localized amyloidosis. J Clin Oncol 2007;25:343-4.  Back to cited text no. 9
    
10.
Devata S, Hari P, Markelova N, Li R, Komorowski R, Shidham VB. Detection of amyloid in abdominal fat pad aspirates in early amyloidosis: Role of electron microscopy and Congo red stained cell block sections. Cytojournal 2011;8:11.  Back to cited text no. 10
[PUBMED]  Medknow Journal  
11.
Georgiades CS, Neyman EG, Barish MA, Fishman EK. Amyloidosis: Review and CT manifestations. Radiographics 2004;24:405-16.  Back to cited text no. 11
    
12.
Fujiwara T, Yasufuku K, Nakajima T, Chiyo M, Iyoda A, Yoshida S, et al. Primary amyloidosis involving mediastinal lymph nodes diagnosed by EBUS TBNA. Respir Med CME 2009;2:51-3.  Back to cited text no. 12
    
13.
Krishna SG, Bhutani MS, Mosher CH, Staerkel GA, Weston BR. A first report of endoscopic ultrasound for the diagnosis of pancreatic amyloid deposition in immunoglobulin light chain (AL) amyloidosis (primary amyloidosis). JOP 2013;14:283-5.  Back to cited text no. 13
    

Editorial/Peer Review Statement
To ensure the integrity and highest quality of CytoJournal publications, the review process of this manuscript was conducted under a double blind model (authors are blinded for reviewers and vice versa) through automatic online system.


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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