Significance of lymph node fine needle aspiration for the diagnosis of HIV-associated lymphoma in a low-resource setting

Abstract

Objective:Fine needle aspiration (FNA) is an early step in the work-up of lymphadenopathy in people with HIV (PWH). We set out to characterize the FNA cytology in PWH and report on the time to lymphoma diagnosis through the FNA clinics in the public healthcare system in Johannesburg, South Africa.Design:Retrospective review of laboratory database.Methods:A retrospective chart review of patients undergoing FNA through the department of cytopathology at the National Health Laboratory Service (NHLS) was undertaken. Results of FNAs performed between March and May 2018 were reviewed. Medical record chart abstraction included general demographics, HIV status, site and results of FNA, prior history of malignancy and other laboratory data.Results:Five hundred and thirty-nine lymph node FNAs were performed on PWH. Pathological findings included tuberculosis 47% (252), inadequate sampling 14% (75), reactive adenopathy 13% (71), benign disease 12% (63), suspicious for lymphoproliferative neoplasm 8% (45), other malignancy 4% (21) and inflammation 2% (n = 12). Only 53% (24) of lymphomas were confirmed by biopsy. Those not confirmed had a high mortality (57%) and loss to follow-up rate (29%) over the following year. The median diagnostic interval exceeded 8 weeks from time of FNA to lymphoma diagnosis.Conclusion:FNA is an important screening modality in this high HIV and tuberculosis (TB) burden region. Patients with cytology suggestive for lymphoma, but without biopsy confirmation, have a high mortality rate suggesting undiagnosed lymphoma. A better understanding of the barriers to appropriate diagnostic triage for lymphoma is needed.

Focused investigations to expedite cancer diagnosis among patients with lymphadenopathy in a tuberculosis and HIV-endemic region

“…In a recent South-African publication, the linkage to care following an FNAC suspicious for lymphoma was abysmal: of 45 PWH with cytology suggestive of lymphoma, only 24 (53%) returned for a biopsy confirming the diagnosis. Among the patients lost to follow-up at the one-year timepoint, 57% had died, 29% were untraceable, and only 14% were confirmed alive [21]. We stopped performing cytology early in our 592 AIDS 2023, Vol 37 No 4 study due to poor diagnostic yield for lymphoma, even though the aspirate came from the same site as a biopsy (i. e., confirming representative tissue), and best-practice guidelines were followed.…”

Fine needle aspiration biopsy in low‐ and middle‐income countries

“…The study highlights the need to improve the diagnostic pathway for lymphoma in low-resource settings and discusses potential interventions, such as upfront lymph node resection or upfront core-needle biopsy and the incorporation of molecular studies to expedite diagnosis and treatment decisions. 27…”

Leveraging fine-needle aspiration to improve HIV-associated lymphoma diagnostic capacity in resource-limited settings

“…Within a low-resource environment with high TB prevalence, Vogt et al [13] report their results of a retrospective study of FNAs performed in PWH in this issue of AIDS. Vogt et al [13] identified 539 lymph node a FNAs performed in PWH presenting to an FNA clinic that were reviewed by the National Health Laboratory Service (NHLS) in Johannesburg, South Africa over a 3-month period in 2018. As standard practice in NHLS, all lymph nodes underwent additional testing for drug-susceptible and multidrug-resistant TB with a PCR platform.…”

“…This study by Vogt et al [13] highlights the need for scaleup of pathology services for the diagnosis of HIVassociated cancers in low-income and middle-income countries (LMICs) and the linkage of diagnosis to cancer care. The number and specialty training of pathologists as well as adequate laboratory support for sample processing are lacking in many LMICs, leading to likely underdiagnosis or misdiagnosis of lymphomas [15,16].…”

“…New technologies, such as those that utilize machine-learning and inexpensive gene expression profiling to classify lymphoma subtypes could potentially aid in scale-up of lymphoma diagnostic capacity across LMICs [17]. As suggested by Vogt et al [13] augmentation of FNA with additional diagnostic tools and technology could improve outcomes for people with HIV-associated lymphomas while keeping costs low by limiting the need for unnecessary diagnostic tissue biopsies in a population with prevalent infectious causes of lymphadenopathy.…”