1. 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

2. 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

3. 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

4. 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

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

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

7. 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)

8. 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

9. 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

10. 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.

11. 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)

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

13. 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

14. 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

15. 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

16. Thank you for your attentions