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CASE REPORT
Year : 2012  |  Volume : 6  |  Issue : 1  |  Page : 47-49

Cytodiagnosis of microfilarial lymphadenitis coexistent with metastatic squamous cell carcinoma in a left cervical lymph node: An unusual presentation


Department of Pathology, Navodaya Medical College, Raichur, Karnataka, India

Date of Web Publication28-Aug-2012

Correspondence Address:
Trupti V Katti
c/o V. A. Katti, Gurukrupa Bldg, New Vaddem, Vasco-Da-Gama, Goa - 403802
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0331-3131.100228

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   Abstract 

Filariasis is one of the parasitic diseases endemic in India, manifesting as acute, chronic or asymptomatic disease. Wuchereria bancrofti accounts for 90% of cases. Microfilaria in fine-needle aspiration cytology is not a common finding. It has been occasionally detected in association with neoplasms. Coexistence with metastatic deposits is even rarer on cytology. We found it incidentally in metastasis to cervical lymph node from squamous cell carcinoma growing in the middle third of the esophagus on fine-needle aspiration (FNA). This patient presented with left-sided neck swelling for 2 months and complete hemogram and peripheral blood smear were normal. We report this case for the rarity of pathology.

Keywords: Cervical lymph node, fine needle aspiration, microfilaria, metastatic squamous cell carcinoma, esophagus


How to cite this article:
Katti TV, Athanikar VS, Ananthrao AS, Rathod CV. Cytodiagnosis of microfilarial lymphadenitis coexistent with metastatic squamous cell carcinoma in a left cervical lymph node: An unusual presentation. Ann Nigerian Med 2012;6:47-9

How to cite this URL:
Katti TV, Athanikar VS, Ananthrao AS, Rathod CV. Cytodiagnosis of microfilarial lymphadenitis coexistent with metastatic squamous cell carcinoma in a left cervical lymph node: An unusual presentation. Ann Nigerian Med [serial online] 2012 [cited 2020 Oct 27];6:47-9. Available from: https://www.anmjournal.com/text.asp?2012/6/1/47/100228


   Introduction Top


Lymphatic filariasis is a major public health problem in tropical and subtropical countries like India, China, Indonesia, Africa, and the Far East. It is endemic all over India. Filariasis can exist without microfilaremia or remain extremely transient and overlooked. Despite high incidence, it is infrequent to find microfilariae in fine-needle aspiration cytology (FNAC) smears and body fluids. They have been observed coincidentally with inflammatory conditions and neoplasms, but the coexistence with metastatic deposits is rare. [1] We present one such case.


   Case Report Top


A 52-year-old male presented with a gradually increasing swelling on the left side of the neck for 2 months. On examination, it was firm measuring 4 × 5 cm in size and was fixed to underlying structures. Clinical suspicion was malignant lymph node swelling.

We performed FNAC and obtained a hemorrhagic aspirate. Smears were stained with Giemsa and Hematoxylin and Eosin stain and revealed microfilariae with malignant squamous cells in the background of polymorphous population of lymphocytes and immunoblasts. The tumor cells showed moderate amount of eosinophilic cytoplasm and hyperchromatic nuclei exhibiting moderate pleomorphism [Figure 1]. Wuchereria bancrofti was identified by the presence of a hyaline sheath, length of the cephalic space and the presence of somatic cells (nuclei) [Figure 2]. The somatic cells appeared as granules that extended from the head to tail; the tail tip was free of nuclei. Few chronic inflammatory cells were seen in the background. Other areas showed a polymorphous cell population. The diagnosis of metastatic squamous cell carcinoma with coexistent microfilaria in the left cervical lymph node was made. The patient was subjected to postero-anterior (PA) and lateral chest x-ray and upper gastrointestinal endoscopy to look for the primary. Proliferative growth was observed in middle third of esophagus and confirmed as squamous cell carcinoma on biopsy. Peripheral blood smear obtained at night showed normal picture. ESR was raised 56 mm/h.
Figure 1: Cytology smears showing malignant squamous cells in clusters against hemorrhagic background. (H and E, ×40)

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Figure 2: Cytology smears showing microfilaria with malignant squamous cells and few chronic inflammatory cells. (H and E, ×40)

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   Discussion Top


Wuchereria bancrofti is responsible for 90% of filarial cases. The disease has acute, chronic, and asymptomatic phases. Eosinophilia and microfilaremia are common in the acute phase. The chronic stage of bancroftian filariasis is characterized by lymphadenopathy, lymphoedema, hydrocele, and elephantiasis. A significant number of infected individuals in endemic areas remain asymptomatic throughout their life. The latter situation is traditionally classified as "endemic normals." [2]

Common methods of diagnosis of filariasis are by demonstration of microfilaria in stained or unstained blood films, circulating filarial antigen detection and demonstration of organism in histopathological sections. Fluid cytology or fine-needle aspiration cytology (FNAC) are rarely applied for routine diagnosis of clinically suspected filariasis. But it can be detected in cytological smears from various sites of body in clinically unsuspected cases. Such lesions may be primarily caused by the organism or it may be associated with other pathology such as malignancy. Incidental detection has been reported in cytological smears from almost any part of body. Forms of bancroftian filaria and background pathology, however, can vary. Microfilaria is the most common form of filarial organism detected in cytological smears. [2]

The presence of microfilariae along with neoplasms is generally regarded as a chance association. [1] In our case, where there was a strong clinical suspicion of metastatic malignancy involving the cervical lymph node, microfilaria was an incidental finding. This may be due to its transmigration along with metastatic emboli. Kumar et al. [3] reported a case of microfilaria in the background of malignant cells in aspiration cytology of the left supraclavicular lymph node. The primary was gastric carcinoma and such a case was reported for the first time in the literature. Microfilariae have been reported in association with neoplastic lesions such as hemangioma of the liver, Ewing's sarcoma of the bone, squamous cell carcinoma of the maxillary antrum, anaplastic astrocytoma of the thalamus, low-grade astrocytoma of C6-D1 spinal segment, cranipharyngioma of the third ventricle, non-Hodgkin lymphoma, transitional cell carcinoma of the bladder, follicular carcinoma of the thyroid, and seminoma of undescended testis. Others include meningioma, intracranial hemagioblastoma, fibromyxoma, squamous cell, and undifferentiated carcinoma of the uterine cervix, carcinoma of the pharynx, metastatic melanoma to the bladder, leukemia, lymphangiosarcoma, carcinoma of pancreas, dentigerous cyst, and carcinoma of the breast.

As the parasite circulates in the lymphatic and vascular systems, appearance of filarial organism in tissue fluids and exfoliated surface material probably occurs due to conditions causing lympho-vascular obstruction leading to extravasation of blood and release of microfilariae. Such aberrant migration to these dead end sites is probably determined by local factors such as lymphatic blockage by scars or tumors and damage to the vessel wall by inflammation, trauma or stasis. Rich blood supply in the tumors could be a reason for concentration of parasites at these sites. It has been suggested in a few reports that filarial organisms may be involved in tumorogenesis by releasing certain toxic mediators or by chronic mechanical irritation at the sites of infestation. [2] Sinha et al.[4] reported a case of microfilaria coexistent with breast carcinoma on FNAC.

Microfilariae wander in tissue fluids and may get trapped in needle during aspiration. [5] Jha et al.[2] conducted a study and detected microfilariae in association with metastatic malignant cells in pleural fluid, peritoneal fluid, and pericardial fluid. Other cytological findings associated with filarial organism are reactive lymphoid cells, acute inflammatory cells including neutrophils, granular debris, eosinophils, macrophages, epithelioid cells, epithelioid granulomas, and necrosis. Sometimes smears show few inflammatory cells. It is observed that microfilarial load is higher in smears from nonneoplastic than neoplastic lesions. Peripheral blood smear shows microfilaria only in a handful cases of filariasis diagnosed by cytology. Jha et al.[2] reported four cases of axillary lymph nodes showing microfilaria coexistent with metastatic deposits from adenocarcinoma of lung, anaplastic carcinoma of thyroid, pancreatic adenocarcinoma, and paraganglioma.


   Conclusion Top


From our case, we have shown that the entire spectrum of changes in filariasis should be kept in mind in endemic areas and careful screening of cytology smears for coexistence with other benign or malignant pathology are key to the correct diagnosis.

 
   References Top

1.Kolte SS, Satarkar RN, Mane PM. Microfilaria concomitant with metastatic deposits of adenocarcinoma in lymph node fine needle aspiration cytology-A chance finding. J Cytol 2010;27:78-80.  Back to cited text no. 1
    
2.Jha A, Shrestha R, Aryal G, Pant AD, Adhikari RC, Sayami G. Cytological diagnosis of bancrofti filariasis in lesions clinically anticipated as neoplastic. Nepal Med Coll J 2008;10:108-14.  Back to cited text no. 2
[PUBMED]    
3.Kumar R. Microfilariae in lymph node aspirate associated with metastatic gastric carcinoma-A case report. Acta Cytol 2010;54:319-20.  Back to cited text no. 3
[PUBMED]    
4.Sinha BK, Prabhakar PC, Kumar A, Salhotra M. Microfilaria in a fine needle aspirate of breast carcinoma-An unusual presentation. J Cytol 2008;25:117-8.  Back to cited text no. 4
    
5.Gupta R. Significance of incidental detection of filariasis on aspiration smears: A case series. Diagn Cytopathol 2010;38:517-20.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]


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