Testing a Scoring System for Predicting Lymph Node

Malignancy in Ultrasound Guided FNA PracticeMaoxin Wu, Hua Chen, XiaoYong Zheng, David

BursteinMount Sinai School of Medicine, New York

Proposed Scoring System (S)

• 0.06 x (age) + 4.76 x (S/L ratio) + 2.15 x (internal echo) + 1.80 x (vascular pattern)

• S < 7….Benign• S > 7….Malignant

• Reference: Li-Jen Liao et al “ Real-time and computerized sonographic scoring system for predicting malignant cervical Lymphadenopathy Head and Neck, Published on line, 19 Aug 2009

Example 127 year old HIV+ male with bilateral cervical

lymphadenopathy, FNA of largest one

S1

• = 0.06 x 27 + 4.76 x (0.86/2.38) + 2.15 x (0) + 1.80 x (0)

• = 3.46 <7

• FNA Cytology: Benign

• Flow: -

Example 251 year old male with Hx of PTC, FNA of Level IV LN

S2

• = 0.06 x 51 + 4.76 x (0.33/0.54) + 2.15 x (1) + 1.80 x (0)

• = 8.12 >7

• FNA Cytology: Positive for met PTC

Study Design

• Retrospective study • N=83 • USG-FNA of Head and Neck LNs • Period: 7/1/2008 to 4/28/2010• Factors: age, S/L ratio, internal echo and

vascular pattern • Gold standard: FNA cytology diagnosis, flow

surgical diagnosis (some cases)• Score calculation and statistical analysis

Cut off =7

• > 7 indicative for malignancy• < 7 indicative for benign

ResultsUSGFNA

(N=83)

MalignantPathology

BenignPathology

Statistics

Score >7 (malignant)

38(TP)

8(FP)

PPV (TP/TP+FP)

83%Score <7 (benign)

0(FN)

37(TN)

NPV (TN/TN+FN)

100%Statistics Sensitivity

(TP/TP+FN)

100%

Specificity (TN/TN+FP)

82%

Accuracy(TP + TN)/(TP +FP+FN+TN)

90%

Case # Age sex S(cm) L(cm) Echon vascular Score FNA Cytology diagnosis

Flow/Surgical Flow-up

Comments

PC-10-07873 89 F 0.31 0.57 0 7.93 Negative for malignancy- Non-specific lymph node

- on 7 month FU Hx SCC 5yr ago

PC-09-05708 59 M 1.86 3.46 1 0 8.25 acute lymphadenitis + 0n 11 month FU FNA (pc10-2900- Met SCC); MS-10-53227-RT tonsil: PDSCC

STUDY the case!

PC-10-04289 77 F 0.66 0.81 0 0 8.50 Favor reactive lymphadenopathy.- No evidence of carcinoma

- on 8 month FU Hx of adenoid cystic carcinoma 3 years ago

PC-10-05713 63 F 0.3 0.3 0 0 8.54 Negative for malignant cells- Reactive lymphadenopathy

MS-10-55720: Thyroid-PTC;

- on 7 month FU

PC-09-31763 61 M 0.44 0.71 1 0 8.76 Reactive; Rare anucleated squamous cells, favor skin origin

- on 10 month FU H/O squamous ca 16 month ago

PC-09-24923 60 M 1.4 1.6 1 0 9.92 Atypical lymphoadenopathy, low-grade lymphoma cannot be ruled out

- on 12 month FU Parotid tumors: PS-09-20575 (RT): Basal cell adenoma,

(LT)MS-09-74098: PA; Warthin

PC-10-04297 64 M 0.69 0.79 1 0 10.15 Proteinaceous debris and rare anucleated squamous cells only.- NO malignant cells seen.

+ on 4 month FU repeat FNA (PC-10-17151)

PC-09-20181 62 M 1.84 1.84 1 0 10.63 Non-specific reactive lymphoid hyperplasia; although Hodgkin's lymphoma cannot be completely ruled out

Flow:-; but subsequent MS-09-74267:Diffuse LCL partially involved

8 “False Positive” Cases

• 3/8 (37.5%) True Positive !

Case 1

59 yr old male with Hx of PTC 3yrs ago, now with a level II RT neck mass and B-symptoms

(PC09-5708)

• FNA Cytology:– Reactive lymphoid population and acute

inflammatory cells• Flow: -• Culture: -

• S=8.25 !• Recommended further investigation

Repeat FNA of the Same Node11 month later

PC-10-2900

p63

Immuno Profile

• P63: +• Pancytokeratins: +

• TTF-1: -• TG: -• S100: -• Synaptophysin: -• Chromogranin: -

Final FNA diagnosis

• Metastatic squamous cell carcinoma, poorly differentiated

Surgical Resection of RT Tonsil: Poorly Differentiated SCC

(MS10-53227)

Case 264 yr old male with Hx of tonsilar SCC S/P

Chemo/Radiation Tx, now with PET+ level IV node

FNA of the level IV node (Pc10-4297)

S = 10.15!

• Recommended further investigation

Repeated FNA after 3 months

Metastatic SCC(Pc10-17151)

Case 362 yr old male LT neck LN and Hx of being

scratched by a cat

PC-09-20181

CD79a

Ancillary studies

• CD3, CD4, & CD5: – + in most of smaller

cells• CD79a &CD20:

– + in small and larger cells

• CD30:– + in rare blasts

• CD15 and CD68: – + in follicular dendritic

cells

• Special stains:– Steiner : -/?– AFB: -– GMS: -

• Flow: – B-cells were polyclonal

based on K&L

• FNA cytology:– Compatible with reactive lymphoid

hyperplasia presently, however, Hodgkin’s or other types of malignancy cannot be ruled

• S=10.63 !• Recommend further investigation

Surgical excision of the node 2 months later

Diffuse large B-cell lymphoma, Grade 3A, partially involved

• CD20: +• CD79a: +• BCL6: +• PAX5: +• MUM-1: +• CD23: + in disrupted

follicular dendritic cell net work

• CD5:-• CD10: -• Cyclin D1: -• BCL2: -• CD30: -

Lesson learnt

• Repeat USG-FNA should be performed in high Score cases

• Surgical bx may be necessary for high Score cases

Conclusion

• This scoring system may serve as a complementary tool to USG-FNA practice in determining:– How aggressive a FNA procedure should be– How a FNA sample of LN should be triaged

for ancillary study – How closely a patient with lymphadenopathy

should be followed up.

Recommendation

LN

Clinical FNA

Benign

US Score

Suspicious

Flow

Benign Malignant<7 >7 Benign Clonal

Clinical FUClinical FU Hem-Onco Surgical Bx

Flow Chat for LN Work Up