Can FNA biopsy help point towards lymphoma or Hodgkin’s lymphoma?

[Spartan114]

I posted in the past, I have about 8 subcrntimeter lymph nodes that have slowly spread over about 10 months. I recently seen another ENT who wasn’t terribly concerned but agreed biopsy for peace of mind would be good given their odd behavior. I asked about core needle and he said Fine needle would be good as well for them, saying that while fine needle (and even core needle) generally aren’t the best for lymphomas for diagnosis they would still show indicators of inflammation or other oddities that would point to further evaluation if I had lymphoma or Hodgkin’s lymphoma.

My questions being-is that true? I know false negatives exist in just about every medical test in existence however I had read the FNA easily misses lymphoma, is it true that it would at least show indicators needing more evaluation if there were lymphomas in there?

[Ken_PA]

No one on the planet completely understands the immune system. In a sense, we are still in the stone age for that.

[Spartan114]

So to rule out HL what would I need ordered? The ENT said if there is signs of any inflammation they will do a full excisional biopsy, however I’ve read they can do that with just a numbing agent now.

[Ken_PA]

"I thought you initially made it sound like fibrosis is something that happens somewhat regularly to everyone after a bad infection."

Fibrosis in nodes is not usual in people generally. Usually, nodes go back down after an infection. But for those people who have nodes that stay enlarged, the most common cause would probably be fibrosis.

[Ken_PA]

Autoimmunity is just a subset of immune disorders. There are also autoinflammatory disorders. There are immune deficiency disorders. I don't recall exactly but I doubt that I have ever said that I think your problems are from autoimmunity. However, if there is immune dysfunction (as a catchall term) in the family, then generally that means you are more likely to have immune  dysfunction.

[Spartan114]

Okay, I think I understand. You’re implying that my family history in general would make me more likely for immune system quirks like fibrosis of nodes.

I should mention my geneticist appointment went well, with them confirming my cataracts are non syndromal in nature it rules out a LOT of their concern. My FNA is scheduled in a couple weeks and they actually mentioned on the mapping ultrasound that the nodes look a little smaller than before. Maybe it’s just the different machine but maybe they are getting smaller again.

[Ken_PA]

"you’ve said my lymph nodes are likely fibrosis-just basic scarring with no deeper insidious meaning. However you keep saying to lol for a diagnosis. I’m confused as to whether you think I’m fine or have an underlying condition"

I mean: to look for a diagnosis as to *why* the scarring occurred. Yes, I am guessing that you have an underlying (non-cancer) condition - and it's very possible that there is one basic thing that is causing all the varied symptoms.

"with no deeper insidious meaning"
Not necessarily so. It's probably not cancer, but it still might have bad effects (that possibly get worse) for the rest of your life.


If you don't have an immune disorder, then the next possibility would be a rare genetic mutation.

[Spartan114]

What’s the basis for that assumption however? Just my father having RA? I thought you initially made it sound like fibrosis is something that happens somewhat regularly to everyone after a bad infection. I’m genuinely curious, UIHC looked me over thoroughly and said while I was a freak of nature I was fine, they recently ran a complete autoimmune testing for lupus, celiac, RA, and several other conditions-some for the genes some just for antibodies, all of which came back normal. The cataracts I recently found out are actually a kind that are 100% known to be isolated with no deeper disorder connected which gives me a lot of peace of mind thankfully.

I guess my confusion is where the assumption of another disorder comes from if fibrosis can happen in anyone, and it’s not really that uncommon (from what drs have told me)

[Spartan114]

I should also mention my father had juvenile RA with major complications early on. The geneticists and even numerologists all said that if a pattern of any autoimmune inheritance is there it most likely would have manifested before age 18 given the onset delay. On top of that genetics also told me RA has very low yeuld inheritance rate to begin with only about 6% of direct relatives.

[Spartan114]

Onset of Dad’s*

[Ken_PA]

Well, one thing I was pointing out is that the evidence is contradictory, as to how accurate an FNA can be in finding either Hodgkin's or low grade non-Hodgkin's.

But I still would very much  recommend the FNA. If the FNA finds inflammatory (non-cancer) cells that shouldn't ordinarily be there, then that is good evidence that your enlarged nodes are not due to cancer.

"are you saying that there is a good chance the FNA would miss signs of Hoskins or other lymphomas"
It's possible.

"or are you saying they are still reliable for ruling them out."
Nope.

" I know it can’t nevessarily diagnose it"
Yes, it can. If the FNA finds cancer cells, then cancer is really there.

Here is the analogy that's long been used: imagine a loaf of bread in front of you. Is it plain or is it raisin bread? You can poke a few holes to try and find out. What if it is raisin bread, but by chance you miss the raisins?

[Ken_PA]

A much more complicated answer:

My thinking is that you should want the FNA to hopefully find clues as to what the real cause is -- which I believe is likely inflammatory, and not-cancer. You then have a credible alternative path to diagnosis. On the other hand, if on the small chance it shows a cancer, that is likely to be true  -- that's called the "Positive Predictive Value" of a test.

However, what you have been looking for is to rule out cancer. That concerns the "Negative Predictive Value". Luckily, there is an FFT (free full text):
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3918276/
Diagnostic Value of Fine-Needle Aspiration in Head and Neck Lymphoma: A Cross-Sectional Study

"It was found that FNA had...  a negative predictive value of 85.7%"

But if you are convinced you have cancer and want to prove it? "a sensitivity of 88%"


That paper is actually an excellent example of how important it can be to read an entire paper. That's because in your case, the abstract mostly doesn't apply to you. In the Discussion, we read:
"Our study showed a limited value for FNA in diagnosis of Hodgkin’s lymphoma. FNA could diagnose only five out of nine lymphoma cases." HL is your age group.

Also: "Since FNA could only diagnose two out of six cases with low grade malignant masses in our study, we concluded that FNA had a limited value in the diagnosis of such masses". If you have lymphoma, it is low grade (slow).

-----------

Then again,  this study says that FNA works very well for HL:
https://www.ncbi.nlm.nih.gov/pubmed/20432736/
"Value of fine-needle aspiration cytology in diagnosis of Hodgkin's lymphoma and anaplastic large cell lymphoma: one centre experience."

[Spartan114]

So I guess I’m not fully understanding, are you saying that there is a good chance the FNA would miss signs of Hoskins or other lymphomas or are you saying they are still reliable for ruling them out.

Forgive me, some of the medical jargon is going over my head, which is a bit surprising given how many docs I’ve seen growing up.

I guess I just want to know if this test will reliably rule out lymphoma of any kind. I know it can’t nevessarily diagnose it but if, hypothetically, something was in there that it would show it as such for further investigation.

My only other question then being; if this comes back normal-would you say that I can safely write off any concerns about them, cancer or autoimmune related?

(Also as a side note; the cataracts I was born with are Lamellar which I was informed are totally non syndromal and have no correlation to any systemic disease)

[Spartan114]

Are you saying if I were to have lymphoma that the FNA would only have a small chance of finding evidence of it, given it would likely be low grade?

Also another question, frequently you’ve said my lymph nodes are likely fibrosis-just basic scarring with no deeper insidious meaning. However you keep saying to lol for a diagnosis. I’m confused as to whether you think I’m fine or have an underlying condition, and please don’t think I’m upset I’m just genuinely wondering.

[Ken_PA]

"My questions being-is that true?"
Yes, and all of what this new doc says is also what I've been saying to you from the start. I like this new doc  :)

"I had read the FNA easily misses lymphoma..."
Well, I wouldn't agree with saying "easily". Overall accuracy is ~85%. But the accuracy might depend on different types of lymphoma.

"is it true that it would at least show indicators needing more evaluation if there were lymphomas in there?"
There could be a very small number of cases that are borderline, with cells that are abnormal under the microscope but are not quite cancer. Then a doc might order advanced testing like flow cytometry.


Btw, core needles aren't generally used much anymore, as accuracy isn't improved over FNA.