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Year : 2015  |  Volume : 29  |  Issue : 3  |  Page : 160-163

Aspiration cytology of metastatic neck node: A 5-year study

Department of Pathology, Regional Institute of Medical Sciences, Imphal, Manipur, India

Date of Web Publication1-Dec-2015

Correspondence Address:
Sucheta Devi Khuraijam
Department of Pathology, Regional Institute of Medical Sciences, Lamphel, Imphal-795004, Manipur
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0972-4958.170798

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Background: Benign as well as malignant lesions can present as lymphadenopathy in the head and neck region. Fine-needle aspiration cytology (FNAC) is the least expensive and a well-established method for diagnosing palpable neck nodes. Aim: This was a baseline study done to evaluate the different cytomorphological patterns of metastatic neck nodes, the age and sex distribution of the same, and to study the patterns of lymph node involvement. Materials and Methods: This was a 5-year retrospective study carried out at the Department of Pathology, Regional Institute of Medical Sciences, Imphal, Manipur for the period between September 2005 and August 2010. The FNAC results were reviewed and the morphology of the individual cells and their patterns were studied in detail. All hematolymphoid neoplasms were excluded. Result: A total of 380 cases with metastasis to the head and neck nodes were encountered. Three hundred and twenty-six (90.2%) of the cases were seen in patients above 40 years of age. Males [248 (65.3%)] were affected more than females [132 (34.7%)], with a male-to-female ratio of 1.8:1. Metastatic squamous cell carcinoma [126 (31.3%)] was the most common tumor type. Single-lymph node involvement was noted in 360 (94.7%) cases and cervical lymph nodes were the most frequently involved in 241 (63.4%). Conclusion: An early diagnosis of metastatic neck node can be made by FNAC. Squamous cell carcinoma was the predominant cell type in our study, and undifferentiated carcinoma accounts for a significant proportion. Increasing age and male sex is associated with higher chances of developing metastasis.

Keywords: Fine-needle aspiration cytology (FNAC), metastatic lymph node, nasopharyngeal carcinoma (NPC), squamous cell carcinoma

How to cite this article:
Khuraijam SD, Sarkar R, Haldar B, Rasaily N, Khuraijam S, Debnath K. Aspiration cytology of metastatic neck node: A 5-year study. J Med Soc 2015;29:160-3

How to cite this URL:
Khuraijam SD, Sarkar R, Haldar B, Rasaily N, Khuraijam S, Debnath K. Aspiration cytology of metastatic neck node: A 5-year study. J Med Soc [serial online] 2015 [cited 2021 Dec 8];29:160-3. Available from:

  Introduction Top

An enlarged neck node is frequently the first clinical manifestation of a neoplastic process in the head and neck region. [1],[2] Metastatic neck nodes are usually from the upper aerodigestive tract and salivary gland or as cancer of unknown primary (CUP). [3],[4] It can also be from the gastrointestinal tract, kidney, lung, cervix, ovary, or urinary bladder.

The earlier the diagnosis is made, the greater the chance of improved survival. Fine-needle aspiration cytology (FNAC) is now a well-established diagnostic test for evaluating enlarged neck nodes. FNAC is a cost-effective, simple procedure with minimal complications; is well tolerated by patients; can be done on an outpatient basis; and is repeatable. It can also prevent unnecessary surgery that would have to be done to confirm the presence of metastasis.

However, further evaluation by imaging, endoscopy, and biopsy may be required for confirmative diagnosis and effective management. [5],[6]

The present study will address metastasis occurring in the lymph nodes of the head and neck region. As there is paucity of literature on these matters from our region, this study will highlight for the same the cytomorphological patterns of neck node metastasis.

  Materials and Methods Top

This was a 5-year retrospective study carried out at the Department of Pathology, Regional Institute of Medical Science, Imphal, Manipur, a tertiary referral center, for the period between September 2005 and August 2010. All the patients of metastatic lymphadenopathy diagnosed on FNAC were studied. Cases for which slides were not available, and smears with inadequate material and which were not optimally preserved were not included in the study. The clinical records of these patients were retrieved and the demographic data, site, number and distribution of nodes were noted.

Geimsa- and Papanicolaou (PAP)-stained FNAC smears of all the available cases were reviewed, and the morphology of the individual cells and their pattern in the smears were studied. Patients of hematolymphoid malignancy were excluded from the study.

Ethical clearance was obtained from the institutional Ethics Committee.

  Results Top

In this 5-year period, a total of 380 cases with metastasis to the head and neck area were found. Male preponderance was noted with a male-to-female ratio of 1.8:1, and the ages ranged 8-94 years. Metastatic neck node was uncommon up to the third decade of life [Table 1]. Ninety percent (90%) of the cases occurred in the fifth decade and above. The two most common incidences were seen in the age groups 61-70 years and 51-60 years at 99 (26.1%) and 98 (25.8%) cases, respectively. Among males, the highest incidence of metastatic neck node was found in the age group of 50-60 years, whereas among females, it was in the age group of 61-70 years.
Table 1: Age incidence of metastatic neck node (N = 380)

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On cytological examination, squamous cell carcinoma was found to be the most common tumor type with 126 (33.1%) cases [Table 2]. Smears show metastatic squamous cell carcinoma in single form [Figure 1] and clusters in a necrotic background. Cystic change in the metastatic lymph node was noted in 21 cases. Squamous cell carcinoma most commonly metastasized to the cervical lymph nodes. Males were much more commonly affected than females [Table 2].
Figure 1: Aspiration cytology smears showing dispersed metastatic keratinizing squamous carcinoma in a lymph node. (PAP 400×)

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Table 2: Distribution of the metastatic tumors in the head and neck region

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Metastasis of adenocarcinoma was observed in 82 cases (21.5%) with tumor cells in clusters, glandular formation [Figure 2], and a few with mucin production. Abundant mucin secretion was seen in 12 cases. The supraclavicular lymph nodes were most commonly involved. Males and females were equally affected in this type.
Figure 2: Aspiration cytology smears showing metastases of adenocarcinoma in the supraclavicular lymph node. (MGG 400×)

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Seventy-eight (20.5%) aspirates revealed large, primitive-looking tumor cells with round vesicular nuclei, prominent nucleoli, and ill-defined cytoplasm [Figure 3]. These cases were grouped under undifferentiated carcinoma and these were most likely to have spread from a primary in the nasopharynx. The majority of the cases infiltrated the cervical lymph nodes (71/78). Male preponderance was also observed for this tumor type.
Figure 3: Aspiration cytology smears showing clusters as well as dispersed large malignant cells with round vesicular nuclei and prominent nucleoli indicating metastasis of undifferentiated carcinoma. (MGG 400×)

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Anaplastic carcinoma formed a significant component in this study, comprising 78 cases (19.4%). Cervical lymph nodes were most commonly involved.

Metastatic papillary carcinoma was noted in 7 cases and 4 of them were confirmed to be from the thyroid [Figure 4]. Two cases of metastatic follicular carcinoma with suspected primary in the thyroid were also encountered.
Figure 4: Aspiration cytology smears showing metastatic papillary carcinoma, with some of the cells showing intranuclear inclusions. (MGG 400×)

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A case with signet ring pattern metastatic to the left supraclavicular lymph node was also present.

The majority of the cases showed single-node involvement in 360 (97%) cases, and 20 (5.3%) cases revealed multiple-node involvement. Cervical nodes were most commonly involved with 241 (63.4%) cases [Table 3]. One hundred and fourteen cases [114 (30%)] showed the involvement of supraclavicular lymph nodes. Submandibular and submental lymph nodes were infiltrated in 21 (5.5%) and 4 (1.0%) cases, respectively.
Table 3: Site distribution of involved lymph nodes

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  Discussion Top

Metastatic neck node is one of the earliest presentations of malignancy, particularly in the head and neck. More than half of the total nodes are distributed in the neck, draining the head and neck region, which is studded with a dense capillary network of lymphatics. Thus, the rate at which malignancy spreads from this region to the neck is very high.

On cytological typing of the metastatic tumors, squamous cell carcinoma was the most common type, comprising of 126 (33.1%) cases. Though this finding is similar with other studies, their frequency of incidence is 80-85% of the cases, which is much higher. [7],[8],[9] A significant finding in this study is the high rate of adenocarcinoma [82 (21.57%)] and undifferentiated carcinoma [74 (19.47%)]. The high rate of metastatic undifferentiated carcinoma in our study may be related to the increased incidence of nasopharyngeal carcinoma (NPC) in this part of the country. [10],[11] The striking feature of NPC in North East India is that its incidence can go as high as approximately 20/100,000 population. [11] According to the latest National Cancer Registry Programme (NCRP), 2006-2009, the age-adjusted incidence rate in Manipur is 4.85/1,000 population. However, a higher incidence rate of approximately 30-50 cases/100,000 population has been reported in South China. [12] A recent study in North East India has identified the association of NPC with a susceptibility locus in the HLA class I region, which has complex interactios with viral DNA and environmental factors. [13] According to Linberg's classic study, NPC is associated with the highest incidence of cervical lymph node involvement of any head and neck cancer subtype: approximately 8%.

Lymph node involvement was single in 360 (94.7%) patients and multiple in 20 (5.3%) cases. A study of metastatic neck disease done by Snow et al. at the Netherland Cancer Institute, Amsterdam obtained 61.3% cases of single-node enlargement and 38.7 of multiple-node enlargement. [14]

The most commonly involved lymph nodes were those of the cervical region, which were predominantly infiltrated by metastatic squamous cell carcinoma and the majority of undifferentiated carcinomas. This study is found to be in agreement with other studies carried out in our region. [10],[13]

On the correlation pattern of lymphadenopathy with age groups, it was revealed that 90.2% of the cases occurred in the fifth decade and above. Male preponderance was noted in our study as well in other studies done earlier. [15]

  Conclusion Top

The diagnosis of metastatic neck node can be made by FNAC as an early and reliable method. Unnecessary invasive procedures such as surgical biopsy can be avoided. Though squamous cell carcinoma is the predominant metastatic tumor, undifferentiated carcinoma also accounts for a significant proportion. This may be related to the high incidence of NPC in this region. Increasing age and male sex are associated with higher chances of developing metastasis. Any enlarged neck node must be investigated to rule out metastasis.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Jones AS, Cook JA, Phillips DE, Roland NR. Squamous carcinoma presenting as an enlarged cervical lymph node. Cancer 1993; 72:1756-61.  Back to cited text no. 1
Stell PM, Dalby JE, Sing SD, Taylor W. The fixed cervical lymph node. Cancer 1984;53:336-41.  Back to cited text no. 2
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Pavlidis N, Pentheroudakis G. Cancer of unknown primary site: 20 questions to be answered. Ann Oncol 2010;21(Suppl 7):vii303-7.  Back to cited text no. 4
Waltonen JD, Ozer E, Hall NC, Schuller DE, Agrawal A. Metastatic carcinoma of the neck of unknown primary origin: Evolution and efficacy of the modern work up. Arch Otolaryngol Head Neck Surg 2009;135:1024-9.  Back to cited text no. 5
Popescu B, Ene P, Bertesteanu SV, Ene R, Cirstoiu C, Popescu CR. Methods of investigating metastatic lymph nodes in head and neck cancer. Maedica (Buchar) 2013;8:384-7.  Back to cited text no. 6
Qadri SK, Hamdani NH, Shah P, Baba KM. Metastatic lymphadenopathy in Kashmir valley: A clinicopathological study. Asian Pac J Cancer Prev 2014;15:419-22.  Back to cited text no. 7
Donaduzzi LC, De-Conto F, Kuze LS, Rovani G, Flores ME, Pasqualotti A. Occurrence of contralateral lymph neck node metastasis in patients with squamous cell carcinoma of the oral cavity. J Clin Exp Dent 2014;6:e209-13.  Back to cited text no. 8
Mistry RC, Qureshi SS, Talole SD, Deshmukh S. Cervical lymph node metastases of squamous cell carcinoma from an unknown primary: Outcomes and patterns of failure. Indian J Cancer 2008;45:54-8.  Back to cited text no. 9
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Sharma TD, Singh TT, Laishram RS, Sharma LD, Sunita AK, Imchen LT. Nasopharyngeal carcinoma - A clinico-pathological study in a regional cancer centre of northeastern India. Asian Pac J Cancer Prev 2011;12:1583-7.  Back to cited text no. 10
Kataki AC, Simons MJ, Das AK, Sharma K, Mehra NK. Nasopharyngeal carcinoma in the Northeastern states of India. Chin J Cancer 2011;30:106-13.   Back to cited text no. 11
Wang W, Feng M, Fan Z, Li J, Lang J. Clinical outcomes and prognostic factors of 695 nasopharyngeal carcinoma patients treated with intensity-modulated radiotherapy. Biomed Res Int 2014;2014:814948.   Back to cited text no. 12
Lakhanpal M, Singh LC, Rahman T, Sharma J, Singh MM, Kataki AC, et al. Contribution of susceptibility locus at HLA class I region and environmental factors to occurrence of nasopharyngeal cancer in northeast India. Tumour Biol 2015;36:3061-73.  Back to cited text no. 13
Snow GB, Annyas AA, van Slooten EA, Bartelink H, Hart AA. A Clin Otolaryngol Allied Sci 1982;7:185-92.  Back to cited text no. 14
Jesse RH, Perez CA, Fletcher GH. Cervical lymph node metastasis: Unknown primary cancer. Cancer 1971;31:854-9.  Back to cited text no. 15


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

  [Table 1], [Table 2], [Table 3]


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