A Study on role of Excision Biopsy in Cervical Lymphadenopathy patients in Rajiv Gandhi Government General Hospital, Chennai

INTRODUCTION: The neck is the part of the trunk that joins the head and the chest and constitutes its most mobile part. It is essentially cylindrical in shape; length is constant while diameter varies. The expression “long neck/short neck” is incorrect, because the length of the neck, understood to be the cervical portion of the vertebral column, does not present significant variations. Conversely, neck width, determined by the development of muscular and adipose masses is extremely variable. Significant anatomical structures: superficial, middle, and deep cervical fasciae; lymph nodes. Landmarks: mandible, external auditory canal, mastoid, clavicle, jugulum. Its upper limits run along the inferior and posterior borders of the mandible, the extreme posterior of the zygomatic arches, the anteroinferior borders of the external auditory canals, the profiles of the mastoid apophyses, the superior nuchal line, and the external occipital protuberance. Its lower boundaries liealong the superior border of the sternum and clavicles, the acromioclavicular joints, and an imaginary line joining the acromioclavicular joints to the spinous process of the seventh cervical vertebra. AIMS AND OBJECTIVES: Study Design: Observational study (Prospective and Retrospective). 1. To study the role of excision biopsy in arriving at a histopathological diagnosis. 2. To compare the role of FNAC and excision biopsy in solving the diagnostic Dilemma. 3. To follow the outcome of patients arrived at a histopathological diagnosis. MATERIALS AND METHODS: Duration of Study: Oct 2015 to Sep 2016. Study Centre: Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai. Sample Size: Approximately 50. Inclusion Criteria: All patients presenting with cervical lymphadenopathy with or without other group of lymph nodes in the body. Exclusion Criteria: All paediatric patients(< 13 years of age), All oral malignancy patients with associated cervical lymphadenopathy. METHEDOLOGY: All Patients who fit the inclusion criteria will be observed and following data collected 1.Details of the patient like; age, duration of the swelling, contact history with tuberculosis patients, associated complaints. 2. Routine blood investigations: Hemoglobin, Hematocrit, Total count and differential count, Peripheral smear, Total and direct bilirubin, Blood urea and serum creatinine, LDH. 3. High frequency ultrasound of the neck, 4. FNAC of the swelling, 5. Chest x ray, CECT neck in selective cases, 6. Mantoux test and sputum AFB, 7. Excision biopsy in case of diagnostic dilemma, 8. Post operative biopsy report, 9. The final treatment plan and the follow up of the patients till discharge or during their future visit to RGGGH. All collected data will be analysed and conclusions derived. CONCLUSION: Excision biopsy in inconclusive FNAC report Out of 50 patients. 1. FNAC was conclusive in 10 patients. 2. Diagnostic dilemma in 40 patients. • Out of 10 patients in whom FNAC was conclusive, 8 had reports suggestive of Tuberculosis ,2 had reports of carcinomatous deposits. • 8 patients were subjected to anti tuberculous regimen after Mantoux test and chest X ray without further delay. • 2 patients were subjected to triple endoscopy and primaries were identified and were managed based on the biopsy of the primary. • The remaining 40 patients had inconclusive FNAC. • In the 18 patients with reactive adenitis, with histopathology report and gene x pert studies the final diagnosis was tuberculous lymphadenitis. • These patients were subjected to category 1 anti tuberculous regime and follow up of all 18 patients had regression of the tuberculosis symptoms. • In the 14 patients suggestive of lympho-proliferative disorder 7 patients had Hodgkin’s lymphoma and another 7 patients had Non -Hodgkin’s lymphoma. • Immuno histo-chemistry was done and appropriate chemotherapy was Started. • These patients on follow up had good resolution of the swelling and till date no recurrence was detected. • In the 8 patients where FNAC was inconclusive ,6 patients were diagnosed as lympho- proliferative disorder. • All were subjected to chemotherapy after doing IHC marker study. • 2 patients HPE came as secondaries neck and these patients were evaluated further and no primary was detected. • 1 patients HPE report came as squamous cell deposits and was subjected to Radiotherapy. • The second patients HPE report came as adenocarcinoma and was subjected to chemotherapy. • Both patients expired after three months. • Thus from the above study it is clear that excision biopsy helps in the identification of tuberculosis with gene expert studies and starting of appropriate chemotherapy drugs which is more sensitive to the bacterium. • In lympho-proliferative disorder it helps in identifying the morphology and has an added advantage of immuno-histochemistry marker study which in turn helps to start the ideal NCCN chemotherapy regimen. • In secondaries neck it helps to find out the morphology of deposits which in turn helps to start chemo-radiotherapy. • Thus excision biopsy’s role in cervical lymphadenopathy patients is far and wide. • The next modality of choice when FNAC is inconclusive will always be Excision

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