Can Cutting-Needle Biopsy Be an Alternative to Excisional Biopsy in Lymph Node Pathologies?
Aydan KILIÇARSLAN1, Mehmet DOĞAN2, Nuran SÜNGÜ1, Emre KARAKÖK3, Leman KARABEKMEZ4, Mesut AKYOL5, Hayriye Tatli Doğan1
1Department of Pathology 1University of Ankara Yıldırım Beyazıt School of Medicine, ANKARA, TURKEY
2Dr. Abdurrahman Yurtaslan Oncology Education and Research Hospital, ANKARA, TURKEY
3Atatürk Education and Research Hospital, ANKARA, TURKEY
4Department of Radiology, University of Ankara Yıldırım Beyazıt, School of Medicine, ANKARA, TURKEY
5Department of Biostatistics, University of Ankara Yıldırım Beyazıt, School of Medicine, ANKARA, TURKEY
Keywords: Lymphoma, Needle biopsy, Lymph nodes
We aimed to compare cutting-needle biopsy (CNB) diagnoses with excisional biopsy diagnoses of enlarging lymph nodes and to
determine the diagnostic value of CNB.
Material and Method: Out of the 291 cases that underwent CNB from lymph nodes between 2010 and 2016, 60 were included in the study in
which pathological lymph nodes were excised after CNB. Demographic information, pathology and imaging reports, the diameters of the lymph
nodes and the length of the CNBs of these cases were obtained from the hospital registry system. Diagnoses of the CNBs and excisional biopsies
were then compared.
Results: According to the excisional biopsy diagnosis, 7 of the 60 cases (11.7%) were benign and 53 of them (88.3%) were malignant. 28 (53%) of
the malignant cases were diagnosed as Hodgkin’s lymphoma while the others (47%) got a non-Hodgkin’s lymphoma diagnosis.
In the 8 non-diagnostic CNBs, 3(37%) of them were found to be benign/reactive, while 5 (63%) were diagnosed as malign lymphoma in excisional
biopsy. Similarly, 7(64%) of the 11 cases diagnosed as benign/reactive in CNB, were found to be malignant with excisional biopsy. When CNB
and excisional biopsy were compared, sensitivity and specificity were 90% and 100%; positive predictive value (PPV) and negative predictive
value (NPV) were 100% and 0%, respectively, and the diagnostic accuracy rate (DV) was 86.5%. The mean diameter of the benign lymph nodes
was 26.1 mm and the mean diameter of the malignant ones was 35.6 mm. There was no significant difference between malignant and benign
lymph node size (p>0.05). There was also no statistically significant difference between CNB length and correct diagnosis (p=0.233).
Conclusion: CNB is a non-invasive procedure. It is an alternative to excisional biopsy because of its low morbidity and low cost. However,
the sensitivity of CNB is lower than its specificity, and we recommend the surgical excision of lymph nodes with a clinically strong neoplasm
suspicion because of the presence of false negatives in 7 cases.
Malignant lymphomas (i. e., both Hodgkin and non-
Hodgkin lymphomas) are often associated with lymph
nodes that are enlarging in the neck region and tissue
samples are needed for diagnosis. Today, a diagnosis of
malignant lymphoma is insufficient for oncologic therapy
unless it is subclassified1
. Excisional biopsy of the lymph
node is accepted as the gold standard in exact diagnosis of
. In some cases, in order to perform
excisional or incisional biopsies, the patient needs to be
hosted in a hospital and operating room conditions. In
addition, complications such as temporary or permanent
seroma at the site of incision, necrosis at flap border, wound
infection, scarring, nerve injury, thrombophlebitis and
bleeding may occur6,7
. Image (CT or ultrasound)-guided cutting-needle biopsy (CNB) is a less invasive method and
an alternative to excisional biopsy4
. CNB is a generally
cheap, feasible, fast, simple and well tolerable method. Many
centers prefer tissue sampling with CNB. In recent years,
the role of percutaneous biopsies of lymphoproliferative
diseases is gaining importance with advances in biopsy,
histopathology and immunohistochemistry techniques4,8-10
. CNB allows not only to simply differentiate the
lymphoproliferative diseases as malignant or benign,
but also allows for the definitive diagnosis of Hodgkin’s
lymphoma (HL) and non-Hodgkin’s lymphoma (NHL)
Our aim in this study was to compare the diagnoses
obtained by CNB and excisional biopsy and to demonstrate
the diagnostic value of CNB.
Two hundred and ninety-one cases that underwent
ultrasound-guided CNB between 2010 and 2016 were
evaluated retrospectively. Among these, 60 patients who
underwent lymph node excision for diagnostic purposes
after a CNB with a minimum of 1 month and a maximum
of 6 months duration were taken as the study group. In
addition to the demographic (age, sex) information of
the cases, ultrasound results and pathologic diagnoses
were obtained through the hospital information system.
The localization of the enlarged lymph nodes, the longest
diameter at ultrasound and the length of the CNB tissue of
all these cases were recorded.
CNB and excisional biopsy sections were obtained
from formalin fixed-paraffin embedded tissues, stained
with hematoxylin-eosin and examined under the light
microscope. Immunohistochemical tests required for
diagnosis were performed with standard protocols.
Lymphoma subtyping was performed according to the
WHO classification13. The final diagnosis of CNB and
excision of the same lymph nodes were compared.
The Chi-square McNemar test was used for statistical
analysis. Sensitivity, specificity, negative predictive value
(NPV), positive predictive value (PPV) and true accuracy
rates were calculated.
Of these 60 cases, 37 were male and 23 were female.
The mean age was 50.8 (19-74). 21 of the excised lymph
nodes were cervical, 16 were axillary, 9 were inguinal, 5
were supraclavicular, 5 were intraabdominal, and 4 were
submandibular. The CNB and excision biopsy diagnoses of
these 60 cases were reviewed and compared. When CNB
diagnoses were examined, 8 (13.3%) were found to be
non-diagnostic, 11(18.3%) were benign and the remaining
41 (68.3%) received various lymphoma diagnoses (Figure
). The distribution of the CNB diagnoses and the
final diagnosis of excisional biopsy is shown in Table I
The excisional biopsy diagnosis of 8 inadequate CNB cases
were found as follows: 3 benign (37.5%), 2 HL (25%), 1 T
cell / histiocyte-rich large B-cell lymphoma (THRLBCL)
(12.5%), 1 diffuse large B-cell lymphoma (DLBCL) (12.5%)
and 1 mantle cell lymphoma (MCL) (12.5%). As for the
excisional biopsy diagnosis of 11 cases who has received
a benign diagnosis in CNBs, 4 were found to be benign
(36.3%), while in 7 (63.7%) the diagnosis was changed
to a malignant lymphoma (5 HL, 1 DLBCL, 1 Follicular
lymphoma-FL). Among the 11 cases with a B cell lymphoma
suspicion, 9 (81.8%) of them were diagnosed as DLBCL and 2 (18.2%) as MCL. 12 cases with a HL diagnosis and 9
cases with HL suspicion with CNBs were all diagnosed as
HL with excisional biopsies (Figure 2A-D
). There was no
difference between excisional biopsy and CNB diagnoses in
other lymphoma types.
Click Here to Zoom
|Table I: Distribution and comparison of CNB and excisional biopsy diagnoses
Click Here to Zoom
|Figure 1: A) Small amount of lymphoid tissue and surrounding
soft tissue (H&E; x40). B) Lymphoid tissue showing crush artefact
around adipose tissue (H&E; x100). C) Lymphoid tissue showing
significant crush artifact (H&E; x400).
Click Here to Zoom
|Figure 2: A,B) Numerous Hodgkin and Reed-Sternberg cells in reactive ground on CNB sections (H&E; x40 and x400). C) CD30 positive
Hodgkin’s cells (CD30; x100). D) In the excisional biopsy of the same case, a large number of Hodgkin and Reed-Sternberg cells (H&E; x400).
Excluding 8 non-diagnostic CNBs from evaluation, CNB
and excisional biopsy diagnoses were compared. As shown
in Table II, among the 11 cases diagnosed as benign with
CNB, 4 of them were diagnosed as benign while 7 were
diagnosed as malignant in excisional biopsy. All the 41
cases of malignant CNB diagnoses also had a malignant
diagnosis with excisional biopsies, leading to 41 true
positive, 4 true negative, 7 false negative and 0 false positive
cases among the CNB diagnoses. According to these data,
sensitivity of CNB was calculated as 90%, while specificity,
positive predictive value (PPV), negative predictive value
(NPV) and diagnostic accuracy (DV) were found 100%,
100%, 0% and 86.5%, respectively.
Click Here to Zoom
|Table II: Comparison of cutting-needle biopsy (CNB) and
excisional biopsy diagnoses of lymph nodes
Applying the Chi-square McNemar test, a linear, moderate
power correlation was found between CNB and excision
biopsy diagnoses (Rho=0.534 ; p<0.001).
The mean lymph node diameter of the 8 benign cases was
26.1 cm, while it was 35.6 cm in the 52 malignant cases,
showing no statistically significant difference between the
benign and malignant groups (p>0.05).
We also evaluated whether there was a correlation between
the CNB lengths of these 60 cases and the final excisional
biopsy diagnoses. The biopsy core length median value was
analyzed according to the diagnosis consistency of the cases.
Inconsistently determined median core length was 1.25 cm,
while consistently determined median core length was 1.5
cm. There was no difference in core length median value according to diagnosis consistency (Z=1.192 ; p=0.233).
Finally, ROC analysis was performed to see if a cut-off point
for core length exists for diagnostic accuracy, but significant
results were not obtained (AUC=0.609; p=0.244).
A CNB procedure performed under ultrasound or CT
guidance is a successful diagnostic method performed on a
wide variety of organs3,14
. The CNB procedure applied
to the lymph nodes has excellent results with a low risk of
damage to surrounding tissues and minor complications11,14,15
. Instead of excision of deeply-located lymph nodes,
especially in the difficult to reach mediastinum or abdomen,
the CNB procedure reduces the patient’s morbidity and
hospital stay and provides considerable advantages15,16
Recent developments in histopathological and especially
immunohistochemical examination have changed the CNB
approach and made it possible to make a diagnosis even in
small tissue specimens8,11,15
. CNB allows the enlarging
lymph nodes to be distinguished not just as benign or
malignant, but can even lead to diagnoses of the HL and
. Subtyping of some lymphomas can be
very difficult with CNB but subtyping in excisional biopsies
may also be impossible8
. In the literature, different ratios
for the sensitivity and specificity of image-guided biopsy have been reported. In a study by Demharter et al., 89%
sensitivity and 97% specificity for malignant lymphomas
while Pfeiffer and colleagues provided
rates of 89.7% and 100%, respectively, with a diagnostic
accuracy rate of 93.3%12
. In our study, we found 90%
sensitivity and 100% specificity of CNBs on enlarged lymph
nodes. Our results were consistent with the literature.
Five of the 7 cases initially reported as benign/reactive and
were diagnosed as HL in excisional biopsies specimens
were re-evaluated, as well as the ones diagnosed as DLBCL
and FL. The reason for the missed diagnosis of HL was found to be CNB being performed from fields where there
were only a few atypical cells on a reactive background. The
FL case had a heterogeneous developmental pattern and a
benign diagnosis was given due to the presence of reactive
lymphoid follicles in the CNB biopsy specimen. As for the
DLBCL case, the histomorphologic appearance could not
be clearly selected due to the significant crush artifact in the
tissue and immunohistochemistry did not work properly.
Re-evaluation was also done for the 8 non-diagnostic
cases. It was noticed that in four cases there were lymphoid
cell-free fibroadipose tissue and in two cases, most of the material consisted of fibroadipose tissue and very few
lymphoid cells existed. In one case, there was adequate
lymphoid tissue in the primary sections, whereas in the
serial sections for immunohistochemical studies, lymphoid
tissue disappeared. In the last one, a clear diagnosis could
not be made due to the obvious degeneration at the edges
of the tissue.
Pedersen et al. reported that the diameter of the lymph
nodes with a malignant diagnosis was greater than benign
ones and found a statistically significant difference11. In
our study, there was no statistically significant difference
between the diameter of the lymph nodes and the malignant/
benign diagnosis. This may be due to the fact that clinicians
and surgeons may decide on the excision of lymph nodes
that have pathologic diameters and signs of malignancy on
Like the diameter of the lymph nodes, there was no
statistically significant difference between the length of
the CNBs and a correct diagnosis (p=0.898). It may be
concluded that a smaller but well-preserved tissue piece
obtained by CNB without crushing artifacts is more
valuable than a bigger but improper sample in reflecting the
pathology of lymph node.
This study is confined to CNB cases that later underwent
excisional biopsy, although it is used as a diagnostic method
in our hospital. This may be considered the weakness of the
study and can be overcome by using larger series via patient
In conclusion, CNB is an alternative to excisional biopsy,
because it provides rapid and reliable diagnosis and
subclassification of malign lymphomas, not only in
peripheral lymph nodes but also especially in deeply
located ones that are particularly difficult to excise. CNB
is advantageous in terms of low morbidity and cost and
can take the place of excisional biopsies in many cases.
However, if clinical, laboratory, and radiological findings
strongly suggest malignant lymphoma, we recommend
using the excisional method in cases where there is no
definite or negative CNB diagnosis.
CONFLICT of INTEREST
The authors declare no conflict of interest.
1) Agid R, Sklair-Levy M, Bloom AI, Lieberman S, Polliack A,
Ben-Yehuda D, Sherman Y, Libson E. CT-guided biopsy with
cutting-edge needle for the diagnosis of malignant lymphoma:
Experience of 267 biopsies. Clin Radiol. 2003;58:143-7.
2) Whelan JS, Reznek RH, Daniell SJ, Norton AJ, Lister TA,
Rohatiner AZ. Computed tomography (CT) and ultrasound
(US) guided core biopsy in the management of non-Hodgkin’s
lymphoma. Br J Cancer. 1991;63:460-2.
3) Demharter J, Neukirchen S, Wagner T, Schlimok G, Bohndorf K,
Kirchhof K. Do ultrasound-guided core needle biopsies of lymph
nodes allow for subclassification of malignant lymphomas? Rofo.
4) de Kerviler E, de Bazelaire C, Mounier N, Mathieu O, Brethon
B, Briere J, Marolleau JP, Brice P, Gisselbrecht C, Frija J. Imageguided
core-needle biopsy of peripheral lymph nodes allows the
diagnosis of lymphomas. Eur Radiol. 2007;17:843-9.
5) Laffers W, Eggert K, Schildhaus HU, Bootz F, Gerstner AO.
Histologic diagnoses in persistently swollen cervical lymph
nodes. Head Neck. 2012;34:371-5.
6) Picardi M, Gennarelli N, Ciancia R, De Renzo A, Gargiulo G,
Ciancia G, Sparano L, Zeppa P, Martinelli V, Pettinato G, Lobello
R, Pane F, Rotoli B. Randomized comparison of power Doppler
ultrasound-directed excisional biopsy with standard excisional
biopsy for the characterization of lymphadenopathies in patients
with suspected lymphoma. J Clin Oncol. 2004;22:3733-40.
7) Shaw JH, Rumball EM. Complications and local recurrence
following lymphadenectomy. Br J Surg. 1990;7:760-4.
8) Sklair-Levy M, Amir G, Spectre G, Lebensart P, Applbaum
Y, Agid R, Lieberman S, Ben-Yehuda D, Sherman Y, Libson E.
Image-guided cutting-edge-needle biopsy of peripheral lymph
nodes and superficial masses for the diagnosis of lymphoma. J
Comput Assist Tomogr. 2005; 29:369-72.
9) de Kerviler E, Benet C, Briere J, de Bazelaire C. Image-guided
needle biopsy for diagnosis and molecular biology in lymphomas.
Best Pract Res Clin Haematol. 2012;25:29-39.
10) R ikabi A, Hussain S. Diagnostic usefulness of tru-cut biopsy in
the diagnosis of breast lesions. Oman Med J. 2013;28:125-7.
11) Pedersen OM, Aarstad HJ, Lokeland T, Bostad L. Diagnostic yield
of biopsies of cervical lymph nodes using a large (14-gauge) core
biopsy needle. Apmis. 2013;121:1119-30.
12) Pfeiffer J, Kayser G, Ridder GJ. Sonography-assisted cutting needle
biopsy in the head and neck for the diagnosis of lymphoma: Can
it replace lymph node extirpation? Laryngoscope. 2009;119:689-95.
13) Swerdlow SH, Elias C, Harris N L, Jaffe ES, Pileri SA, Stein H,
Thiele J, Vardiman J W. WHO Classification of Tumours of
Haematopoietic and Lymphoid Tissues. 4 th ed. Lyon:IARC;2008.
14) Screaton NJ, Berman LH, Grant JW. Head and neck
lymphadenopathy: Evaluation with US-guided cutting-needle
biopsy. Radiology. 2002;224:75-81.
15) Demharter J, Muller P, Wagner T, Schlimok G, Haude K, Bohndorf
K. Percutaneous core-needle biopsy of enlarged lymph nodes in
the diagnosis and subclassification of malignant lymphomas. Eur
16) de Kerviler E, Guermazi A, Zagdanski AM, Meignin V, Gossot D,
Oksenhendler E, Mariette X, Brice P, Frija J. Image-guided coreneedle
biopsy in patients with suspected or recurrent lymphomas.