| Abstract|| |
Background: Lymph node ratio (LNR) in cancer staging is the ratio of nodal metastases (LNM) to total nodes harvested (LNH). Reactive nodal hyperplasia can exhibit morphological patterns I to VI. Aims: To measure LNR and evaluate it with tumor stage, tumor grade, LN reactive patterns, and LN size. Setting and Design: Retrospective, observational study of 100 cancer resections including breast, gastrointestinal (GIT), genitourinary (GUT), and head, face, neck, and thyroid (HFNT). Materials and Methods: Total 1463 LNs were reviewed for metastases and reactivity patterns I–VI as per the World Health Organization (WHO) protocol. LNR was calculated from LNM and LNH. Statistical Analysis Used: Association between qualitative variables was assessed by the Chi-square test and Fisher's exact test, those between quantitative variables using the unpaired t-test and Mann–Whitney U test. Results: Mean LNH (23.7) was highest in HFNT and lowest (6.6) in GIT (P = 0.008). Mean LNR was highest (0.29) in breast and least (0.06) in HFNT (P = 0.861). Commonest LN reactive patterns were sinus histiocytosis (60), mixed (48), and follicular hyperplasia (46) (P = 0.000). Maximum cases of breast (59.6%), GUT (53.8%), and HFNT (45%) belonged to stage T2, while GIT (60.0%) to stage T3 (P = 0.000). Maximum well-differentiated cases belonged to HFNT (13, 59.0%), while moderately poorly differentiated cases of breast (38, 55.8% and 7, 70.0%) (P = 0.000). The largest and smallest metastatic LN was 2.4 cm and 0.4 cm (P = 0.009). LNs with thickened capsule showed nodal metastases in 75.7% (P = 0.003871). Conclusions: LNH and LNR cut-off values show organ-wise variation and need standardization. LNR shows stronger relation with tumor grade than tumor stage. Commonest LN reactive patterns include sinus histiocytosis and follicular hyperplasia. Thickened LN capsule strongly suggests nodal metastases. A longitudinal follow-up is warranted to study prognostic association between LNR and LN reactive pattern.
Keywords: Lymph node harvest, lymph node metastases, lymph node ratio, lymph node reactive patterns
|How to cite this article:|
Sweety SV, Narayankar AS. Evaluation of lymph node ratio and morphologic patterns of nodal reactive hyperplasia in primary organ malignancy. Indian J Pathol Microbiol 2019;62:216-21
|How to cite this URL:|
Sweety SV, Narayankar AS. Evaluation of lymph node ratio and morphologic patterns of nodal reactive hyperplasia in primary organ malignancy. Indian J Pathol Microbiol [serial online] 2019 [cited 2019 Apr 23];62:216-21. Available from: http://www.ijpmonline.org/text.asp?2019/62/2/216/255833
| Introduction|| |
Lymph nodes (LNs) draining a tumor may enlarge due to metastasis (LNM) or reactive hyperplasia. The LNM can be used to calculate lymph node ratio (LNR) i.e., ratio of LNM to lymph node harvest (LNH). Reactive hyperplasia patterns consist of lymphocyte predominance (I), germinal center predominance (II), sinus histiocytosis (III), vascular transformation of sinuses (IV), lymphocyte depletion (V), and granulomatous reaction (VI). The routine inclusion of LNR and LN reactive patterns in tumor reporting by pathologists may become a prognostic aid for clinicians alongside tumor stage and tumor grade.
Aims and objectives
- To measure total LNH, LNM, and LNR in resected specimens of primary organ malignancy
- To study LN reactive hyperplasia patterns
- To evaluate LNR with tumor stage, tumor grade, LN reactive patterns, and LN size.
| Materials and Methods|| |
Total 108 resection cases of primary organ malignancy with local LN clearance were found as per archival records in a retrospective 1-year study. Slides and blocks of 8 cases were unavailable and hence total 100 cases were included in this study. Age, gender, tumor stage of primary organ malignancy, total LNs dissected per case, and LN sizes were accessed from surgical histopathology records. Slides were reviewed to evaluate LNM and LNR was calculated per specimen.
LN reactive hyperplasia was categorized into following morphological patterns:
All data were recorded in MS Excel sheet. The statistical analysis was done using MS Excel and SPSS software. Association between qualitative variables was assessed by the Chi-square test and Fisher's exact test. Association between quantitative variables was done using unpaired t-test and Mann–Whitney U test.
|Figure 1: (a) Photomicrograph (H and E, ×10) pattern I (lymphocyte predominance) shows T-cell hyperplasia and expanded paracortex (blue double arrow) with adjacent lymphoid follicle (star symbol). (b) Photomicrograph (H and E, ×40) pattern I with prominent post-capillary venules (orange arrow) and mottled appearance|
Click here to view
|Figure 2: (a) Photomicrograph (H and E, ×10) pattern II (germinal center predominance) shows B-cell hyperplasia with enlarged lymphoid follicles. (b) Prominent germinal centers (H and E, ×40)|
Click here to view
|Figure 3: (a) Photomicrograph (H and E, ×10) and (b) (×40) pattern III (sinus histiocytosis) with dilated subcapsular sinus filled with plump histiocytes (red arrows)|
Click here to view
|Figure 4: (a) Photomicrograph (H and E, ×10) pattern IV (vascular transformation of sinuses) with extensively dilated and congested intranodal sinuses. (b) Photomicrograph (H and E, ×10) pattern V (lymphocyte depletion) with extensive replacement of parenchyma with hyalinized fibrosis and depleted lymphocytic population|
Click here to view
- Ethics approval was obtained from the Institutional Ethics Committee ECARP Project no.(ECARP Reference No) ECARP/2015/06.
| Results|| |
Distribution as per primary organ, gender, and age
There were 47, 20, 13, and 20 cases each of breast, gastrointestinal tract (GIT), genitourinary tract (GUT), and head, face, neck, and thyroid (HFNT) malignancy. GIT cases included colon (15), stomach (2), rectum (2), and periampullary region (1). GUT cases included urinary bladder (11), ovary (1), and vulva (1). HFNT cases included buccal mucosa (11), tongue (6), and thyroid (3).
There was a marked female preponderance (64) over males (36), especially in breast (93.6%) and GUT cases (53.8%), with male predominance in GIT (70%) and HFNT cases (65%) (P < 0.001) [Graph 1].
Maximum cases of breast (31.9%) and HFNT (35%) were seen in 36–45 years, of GIT in 46–55 years (40.0%), and of GUT in 56–65 years (30.8%) (P = 0.756) [Graph 2].
LNH and LNM [Table 1], total 1463 LNs were harvested from 100 cases. HFNT (23.7) and GIT (6.6) had the highest and lowest LNH, respectively (P = 0.008). LNM were observed in 257 LNs (54 cases), namely breast (28.6%), GIT (20.6%), GUT (9.3%), and HFNT (2.5%) (P = 0.595).
|Table 1: Distribution of lymph node harvest and lymph node metastases in primary organ malignancy cases (n=100)|
Click here to view
Lymph node immune hyperplasia patterns as per primary organ malignancy [Graph 3]
Overall, pattern III was the commonest (60) followed by pattern II (46), pattern I (31), pattern IV (17), pattern VI (6), and pattern V (3) (P = 0.000). A mixed pattern was observed in 48 cases, commonest combination being pattern II and III (21). The commonest combination of pattern I was with pattern II (15) that of pattern IV was with pattern I (7), and of pattern VI was with pattern II (5).
Stage and grade of primary organ tumor [Graph 4] and [Graph 5]
There were 20, 47, 26, and 7 cases, respectively, in tumor stage T1, T2, T3, and T4. Maximum cases of breast (59.6%), GUT (53.8%), and HFNT (45%) belonged to T2 stage, while GIT (60.0%) belonged to T3 (P = 0.000). Distribution as per tumor grade showed well-differentiated (22), moderately differentiated (68), and poorly differentiated (10) cases. Maximum well-differentiated cases belonged to HFNT (13, 59.0%), while maximum moderately differentiated and poorly differentiated to breast (38, 55.8%) and (7, 70.0%), respectively (P = 0.000). Maximum total cases showing nodal metastases were moderately differentiated (77.8%) and belonged to stage T2 (48.1%).
Primary organ cases, T stage, and lymph node ratio [Table 2]
Mean calculated LNR for breast was 0.29 (range 0.0–1.0), for GIT was 0.26 (0.0–1.0), for GUT was 0.1 (0.0–0.56), and for HFNT 0.06 (0.0–0.67) (P = 0.8617). Majority breast, GUT, and HFNT cases below and above the mean LNR belonged to stage T2 (P = 0.92, P = 0.098, and P = 0.93, respectively). Majority GIT cases below and above the mean LNR belonged to stage T3 (P = 0.32).
|Table 2: Distribution of primary organ of malignancy cases as per tumor stage and lymph node ratio (n=100)|
Click here to view
Primary organ cases, lymph node reactive pattern, and lymph node ratio [Table 3]
Overall, pattern III was the commonest (60) followed by pattern II (46), pattern I (31), pattern IV (17), pattern VI (6), and pattern V (3) (P = 0.000). Total 82 LN reactive patterns were seen in 47 breast cases. Majority breast cases with LNR <0.3 (20) showed pattern II while those with LNR > 0.3 (10) showed pattern III (P = 0.56). Total 32 LN reactive patterns were seen in 20 GIT cases, of which pattern III (10 and 4, respectively) was the commonest irrespective of mean LNR cut-off (P = 0.54). Total 21 LN reactive patterns were seen in 13 GUT cases, of which pattern II (5) was commonest with LNR <0.1 and pattern III (4) was commonest in LNR >0.1 (P = 0.18). Total 28 LN immune reactive patterns were seen in 20 HFNT cases. Pattern III (8) and pattern II (4) were commonest with LNR below and above 0.06, respectively (P = 0.439).
|Table 3: Distribution of primary organ of malignancy cases as per lymph nodes reactive pattern and lymph node ratio (n=100)|
Click here to view
Primary organ cases, lymph node reactive pattern, and T stage [Table 4]
Amongst breast cases, patterns I–IV and VI were highest in stage T2, while pattern V in T1 stage (P = 0.92). In GIT cases, patterns I–III and VI were highest in stage T3, while pattern IV was equally distributed in T2 and T3 (P = 0.74). Amongst GUT cases, patterns II, III, and V were commonest in stage T2, pattern I was equal in T1 and T2, pattern IV in T1, and pattern VI in T4 (P = 0.78). In HFNT cases, patterns I and II were equally distributed in stages T1 and T2 while patterns III–VI were highest in T1 (P = 0.97).
|Table 4: Distribution of primary organ of malignancy cases as per tumor stage and lymph node reactive pattern (n=100)|
Click here to view
Lymph node size
The largest metastatic node measured 2.1 cm and 2.4 cm in breast and GUT (P = 0.009 and 0.039, respectively) while 1.2 cm and 2.3 cm for GIT and HFNT (P = 0.463 and 0.163, respectively). The smallest metastatic node measured 0.4 cm. Negative nodes (46 cases) varied from 0.1–3.0 cm.
Metastases were observed in 28 cases (75.7%) with thickened LN capsule [Figure 5]a and [Figure 5]b and in only 26 cases (41.3%) with normal capsule (P = 0.003871). Twelve cases showed extranodal tumor deposits, of which 9 (75%) belonged to T2 and T3 stage.
|Figure 5: (a) Photomicrograph (H and E, ×10) shows fibrotically thickened lymph node capsule (blue arrows) while (b) lymph node capsular tumor deposits with thickened capsule (red arrows)|
Click here to view
| Discussion|| |
The present study evaluated LNM, LNR, and LN reactive patterns from primary organ malignancies resected with local nodal clearance. LNH, LNM, LNR, and LN patterns were studied for correlation with tumor stage and tumor grade.
Gender and age-wise distribution of cases
Akagi et al. and Zeng et al. reported male predominance in colorectal and gastric carcinoma, as did Chen et al. in oropharyngeal malignancy.,, Rubinstein et al. found 88.5% male preponderance in urinary bladder malignancies, whereas we found a female preponderance. The male predominance in GIT and HFNT malignancies may reflect lifestyle-related behavior as alcoholism, processed junk food, smoking, and tobacco chewing. The peak age groups of malignancy were a decade younger compared to other studies.,,,,,,,,,
Lymph node harvested
The recommended LNH values are 10, 12, 12, and 40 in breast, GIT, GUT, and HFNT, respectively.,,, It varies from 10 to 23 in breast cases, and 18.5 to 28 in colorectal cancers., Koppie et al. found values 7.5, 8.6, and 14.7 in pelvic cancers over three decades. Mean LNH for oropharyngeal cancers varies from 9 to 18 and 7.9 to 20, for thyroid cancers. Techniques to further improve the yield of LNH include meticulous dissection during grossing, intratumoral India ink injection during surgery, ex-vivo intra-arterial injection of methylene blue, and chemical fat clearance using acetone and alcohol.,
Lymph node metastases
Titipungul et al. found mean LNM of 3.2 in breast cases, while Freneaux et al. found 47.3% LNM., Mean LNM was 1–6 in GIT cases,, 0.2 and 45.5% in urinary bladder malignancies,, 70 and 58% in oral cancers,, and 4.5–10 in papillary thyroid carcinoma.,
Serial recuts, use of immunohistochemistry, one step nucleic acid amplification (OSNA), and polymerase chain reaction can further aid in detecting minute nodal metastases.,,
Lymph node reactive patterns
Khetarpal et al. found pattern I (0.4%), pattern II (23.7%), pattern III (12.3%), and mixed patterns (25.7%) in breast cancers. Ninan et al. found pattern II commonest (32) while pattern V (1) rarest in colorectal cancers. They found the commonest combination patterns as II + IV, II + III, and II + I (17, 14, 9, respectively). Suchitra et al. found pattern I (53.49%), pattern II (31.5%), and pattern V (4.6%) oral cancers.
Tumor stage and tumor grade
Titipungul et al. found majority of breast malignancy cases (55.7%) in T2 stage and 32% moderately differentiated. Khetarpal et al. found 76% moderately differentiated, 18% well differentiated, and 6% poorly differentiated breast cases. Dedavid et al. found 82% of colorectal cancers in stage T3/T4 and 61% belonging to well/moderately differentiated group. Akagi et al. found a recurrence rate of 64.9% for T3 colorectal carcinomas. Most urinary bladder malignancies were reported in stage T3 (37 and 41.3%)., Suchitra et al. found 40% oral malignancies in T4 stage.
Breast cases lymph node ratio, T stage, and lymph node reactive pattern
Titipungul et al. found LNR had a higher predictive value than N stage. They classified breast cancers as low risk (LNR 0.01–0.2), intermediate risk (LNR 0.21–0.65), and high risk (LNR 0.66–1.0) with the 5-year survival being 66.7%, 50%, and 0.0%, respectively. Our cases qualify as intermediate risk LNR and showed high tumor grade. Khetarpal et al. found pattern III associated with high tumor grade and nodal metastases in breast.
Gastrointestinal cases lymph node ratio, T stage, and lymph node reactive patterns
Dedavid et al. found mean LNR 0.15 as the best predictor of recurrence in colon cancer. We observed higher LNR, possibly due to lowest LNH yield as also related to majority cases being in stage T3. Akagi et al. found recurrence rate of 64.9% in stage T3 in colon cancers. Ninan et al. found pattern I commonest in non-metastatic cases and high tumor grade. Zeng et al. found LNR to have high prognostic value in gastric cancers using cut-off points as 0, 0.5, and 0.8 to categorize low, intermediate, and high risk.
Genitourinary cases lymph node ratio, T stage, and lymph node reactive patterns
Rubinstein et al., Wright et al., and Pedrosa et al. used 2.4, 0.12, and 0.2 LNR cut-off, respectively, for urinary bladder malignancies.,, Wright et al. found higher LNR (12.6–25%) associated with higher risk of death, while Pedrosa et al. found stage T2 significantly associated with LNH.
Head, face, neck, and thyroid cases lymph node ratio, T stage, and lymph node reactive patterns
Chen et al. categorized head and neck cancers as low LNR <0.06, medium 0.06–0.17, and high LNR >0.17. They found low LNR to have longer 3-year survival and metastasis-free survival. They found 71.7% cases in stage T4 and LNM was 53.8%. Our cases qualify as low LNR, had highest LNH, and were predominantly low grade tumors. Vered et al. found 87.5% of non-metastatic nodes and 63.5% metastatic nodes in stage T1 and T2. Suchitra et al. found positive nodes showing pattern II (18.9%), pattern III (23.5%), and pattern IV (54.4%).
Lang et al. classified papillary thyroid carcinoma having LNR value 0.0–0.33, 0.34–0.66, and 0.67–1.0. LNR was associated with higher rate of post-ablative thyroglobulin levels and higher recurrence rate.
Lymph node metastases versus lymph node size
Märkl et al. found 49.5% LNM in nodes <0.5 cm and 25% in >1.0 cm of colon cancers. Burusapat et al. found mean size of positive nodes as 0.3 cm in oral cancers. We observed metastases in small LNs up to 0.4 cm, while even LNs up to 3.0 cm showed non-metastatic reactive hyperplasia.
Additional lymph node findings
As in our study, Vered et al. found LN capsule thickness positively associated with LNM.
| Conclusions|| |
Nodal metastases can co-exist with reactive hyperplasia. LNH and LNR cut-off values show organ-wise variation, hence need standardization before their usage in cancer staging systems. LNR showed stronger relation with tumor grade than with tumor stage. Commonest LN reactive patterns included sinus histiocytosis and follicular hyperplasia, irrespective of nodal metastases. In breast and GUT cases, pattern changed from II (humoral) to III (cellular) with higher T stage while the reverse was observed in HFNT, although not statistically significant. Thickened LN capsule is strongly suggestive of nodal metastases. A longitudinal follow-up study is warranted to confirm prognostic association, if any, for LNR and LN reactive pattern.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Young B, O'Dowd G, Woodford P, editors. Immune system. In: Wheater's Functional Histology a Text and Colour Atlas. 6th
ed. Philadelphia: Elsevier Churchill Livingstone; 2014. p. 207-14.
Ioachim HL, Medeiros JL, editors. Tumor-reactive lymphadenopathy. In: Ioachim's Lymph Node Pathology. 4th
ed. Philadelphia: Wolters Kluwer/Lippincott Williams and Wilkins; 2009. p. 243-7.
Zeng WJ, Hu WQ, Wang LW, Yan SG, Li JD, Zhao HL, et al.
Lymph node ratio is a better prognosticator than lymph node status for gastric cancer: A retrospective study of 138 cases. Oncol Lett 2013;6:1693-700.
Akagi Y, Kansakar R, Shirouzu K. The prognostic significance of number of lymph node metastasis in colon cancer- based on Japanese techniques of resection & handling of resected specimens. In: Eltarh R, editor. Colorectal Cancer – From Prevention to Patient Care. Croatia: InTech; 2012. p. 509-20.
Chen CC, Lin JC, Chen KW. Lymph node ratio as a prognostic factor in head and neck cancer patients. Radiat Oncol 2015;10:181.
Rubinstein J, Bar-On T, Bahouth Z, Mano R, Shoshany O, Baniel J, et al
. A mathematical model for predicting tumor recurrence within 24 months following surgery in patients with T1 high-grade bladder cancer treated with BCG immunotherapy. Bladder 2015;2:18.
Jayasinghe UW, Pathmanathan N, Elder E, Boyages J. Prognostic value of the lymph node ratio for lymph-node-positive breast cancer- is it just a denominator problem? Springerplus 2015;4:121.
Fréneaux P, Nos C, Vincent-Salomon A, Genin P, Sigal-Zafrani B, Al Ghuzlan A, et al.
Histological detection of minimal metastatic involvement in axillary sentinel nodes: A rational basis for a sensitive methodology usable in daily practice. Mod Pathol 2002;15:641-6.
Wright JL, Lin DW, Porter MP. The association between extent of lymphadenectomy and survival among patients with lymph node metastases undergoing radical cystectomy. Cancer 2008;112:2401-8.
Suchitra G, Puranik RS, Vanaki SS, Prasad BG, Malgaonkar NI. Immuno-reactivity of excised lymph nodes in neck dissections of squamous cell carcinomas of oral cavity. J Oral Maxillofac Pathol 2015;19:128-33.
] [Full text]
Lang BH, Tang AH, Wong KP, Shek TW, Wan KY, Lo CY, et al.
Significance of size of lymph node metastasis on postsurgical stimulated thyroglobulin levels after prophylactic unilateral central neck dissection in papillary thyroid carcinoma. Ann Surg Oncol 2012;19:3472-8.
Schneider DF, Chen H, Sippel RS. Impact of lymph node ratio on survival in papillary thyroid cancer. Ann Surg Oncol 2013;20:1906-11.
Titipungul T, Intarawichian P, Waraasawapati S, Sangkhamanon S, Chaisuriya N, Pairojkul C, et al
. Axillary lymph node ratio is an independent prognostic factor in Thai breast cancer patients. Asian Arch Pathol 2015;11:26-35.
Dedavid e Silva TL, Damin DC. Lymph node ratio predicts tumor recurrence in stage III colon cancer. Rev Col Bras Cir 2013;40:463-70.
Märkl B, Rößle J, Arnholdt HM, Schaller T, Krammer I, Cacchi C, et al.
The clinical significance of lymph node size in colon cancer. Mod Pathol 2012;25:1413-22.
Pedrosa JA, Koch MO, Cheng L. Lymph node – Positive bladder cancer. Expert Rev Anticancer Ther 2013;13:1281-95.
Koppie TM, Vickers AJ, Vora K, Dalbagni G, Bochner BH. Standardization of pelvic lymphadenectomy performed at radical cystectomy: Can we establish a minimum number of lymph nodes that should be removed? Cancer 2006;107:2368-74.
Vered M, Schiby G, Schnaiderman-Shapiro A, Novikov I, Bello IO, Salo T, et al.
Key architectural changes in tumor-negative lymph nodes from metastatic-free oral cancer patients are valuable prognostic factors. Clin Exp Metastasis 2014;31:327-38.
Jeon MJ, Yoon JH, Han JM, Yim JH, Hong SJ, Song DE, et al.
The prognostic value of the metastatic lymph node ratio and maximal metastatic tumor size in pathological N1a papillary thyroid carcinoma. Eur J Endocrinol 2013;168:219-25.
Weaver DL. Pathology evaluation of sentinel lymph nodes in breast cancer: Protocol recommendations and rationale. Mod Pathol 2010;23 Suppl 2:S26-32.
Ong ML, Schofield JB. Assessment of lymph node involvement in colorectal cancer. World J Gastrointest Surg 2016;8:179-92.
Verrill C, Carr NJ, Wilkinson-Smith E, Seel EH. Histopathological assessment of lymph nodes in colorectal carcinoma: Does triple levelling detect significantly more metastases? J Clin Pathol 2004;57:1165-7.
Khetarpal S, Mathur S, Sethi D, Sen R. Immune hyperplasia patterns in lymph nodes draining breast cancer: A correlation with histomorphological parameters. Clin Cancer Investig J 2013;2:330-8. [Full text]
Ninan RM, Saldanha P, Rai HS. Importance of histomorphological assessment of regional lymph nodes draining colorectal carcinomas. IJRTSAT 2016;19:171-6.
Burusapat C, Jarungroongruangchai W, Charoenpitakchai M. Prognostic factors of cervical node status in head and neck squamous cell carcinoma. World J Surg Oncol 2015;13:51.
Ashwini Sardar Narayankar
Department of Pathology, T.N Medical College and B.Y.L Nair Hospital, Mumbai - 400 008, Maharashtra
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4]