Pediatric Cervical Hodgkin’s Lymphoma Diagnosed by Ultrasound-guided Core Needle Biopsy A case report Chi-Maw Lin, MD Department of Otolaryngology, Head and Neck Surgery, National Taiwan University Hospital, Yunlin Branch 2017.11.02

Hodgkin’s lymphoma The most common pediatric H&N malignancy (31% of total pediatric malignancies) > 80% present with cervical lymphadenopathy Traditionally, H&N lymphoma is diagnosed by open excisional biopsy. However, ultrasound-guided core needle biopsy (US-CNB) may also sample sufficient tissues for lymphoma diagnosis to prevent surgery

Case presentation A 12 y/o boy with a right painless neck mass > 2 wks PE revealed one fixed and firm cervical mass, measuring 6*3 cm, at right level IV cervical region No history of fever, night sweats, or body weight loss Blood work revealed an elevated white cell count (14,480/mL) with 79% segments and 13.5% lymphocytes. Hb 11.7 g/dL, PLT 463,000/mL

Ultrasound exam Use a 12-MHz linear probe (Toshiba Aplio SSA 790, Toshiba Medical Systems, Tochigi-ken, Japan). Chen, C. N. et al. H&N ultrasound procedure and demonstration, 2012

Ultrasound images (1) One enlarged, ill-defined, confluent, hypoechoic, and heterogeneous mass lesion over the right level III-IV regions with some pseudocystic appearance

Ultrasound images (2) Multiple enlarged, well-defined, hypoechoic, and homogeneous lymphadenopathies were also noted over the right level II-III regions

US-CNB(1) Use free-hand technique with an 18-gauge core needle (Temno Evolution™ Biopsy Devices, Cardinal Health Inc., Dublin, CA, USA) under local anesthesia Chen, C. N. et al. Application of Ultrasound-Guided Core Biopsy to Minimal-Invasively Diagnose Supraclavicular Fossa Tumors and Minimize the Requirement of Invasive Diagnostic Surgery. Medicine. 95, 2172 (2016)

US-CNB(2) The tip position of the core needle was confirmed to be located in the targeted LN by US SCM SCM LN LN LN penetrate SCM SCM Pull out biopsy

Pathology report Sample size: 1.5*0.1cm Classical Hodgkin’s lymphoma, nodular sclerosis type Many large bizarre neoplastic cells, CD15(+), CD30(+), CD 45(-), CD3(-), CD20(-), LCA(-), EMA(-), EBER(-), CK(-), MPO(-). Fibrosis was abundant. HE, 400X CD 30, 400X CD 15, 400X

Typical lymphoma US features Hodgkin and non-Hodgkins had similar US features size (short axis) > 1cm, multiple, round (S/L >0.5), well-defined, homogeneous, hypoechoic, enhanced hilar and peripheral vascularity, pseudo-cystic with posterior acoustic enhance, intranodal reticulation intranodal reticulation posterior acoustic enhance Enhanced vascularity Ahuja AT, Ying M, Ho ST, et al. Ultrasound of malignant cervical lymph nodes. Cancer Imaging 2008;8:48-56.

US features of benign and metastatic LNs hetero and ill-defined linear hilum benign LN SCC meta LN necrosis calcified Papillary ca meta LN SCC meta LN Ying, M. et al. Review of ultrasonography of malignant neck nodes: greyscale, Doppler, contrast enhancement and elastography. Cancer Imaging 13, 658–669 (2013)

CNB in pediatric cervical LN (<18y/o) in NTUH Yunlin Branch (2012 >1.5 cm

Advantages and ability of US-CNB Prevent surgical settings and risks FNA seldom give final diagnosis of lymphoma CNB could fully classify lymphoma in 38-96% Burke et al.: 31/37 (84%) of diffuse large B-cell lymphoma conclusively diagnosed by CNB but only 8/16 (50%) of Hodgkin’s lymphoma

Disadvantages and risks of US-CNB Harder to approach target LN than FNA Difficult to perform CNB in small LN < 1 cm (long axis) Harder to penetrate skin and subcutaneous tissue Still need local anesthesia If the patient is too young and incorporated (e.g. <10 y/o), CNB is hard to perform Bleeding risk: minimal, if sparing great vessels Tumor seeding risk: minimal

Conclusions Though US-CNB cannot fully classify lymphoma, especially Hodgkin’s lymphoma, it is still an effective method giving us sufficient diagnosis information most of the time, and is an appropriate first-line method for the diagnosis of cervical LNs Suitable candidates: Age > 10 y/o Cooperated Suspect malignancy, esp lymphoma Target LN size > 1.5cm

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