Author disclosures Alejandro Ariel Gru is a paid consultant for Seattle Genetics and has an ongoing relationship with Innate Pharma. John Zic is a site principal investigator for clinical trials for products from Elora and Galderma. The other authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies. The manufacturers did not provide equipment or other forms of material support.
Lauren Pinter-Brown. Many patients, particularly those with advanced skin disease, may have palpable lymph nodes that are reacting to their skin disease and on pathology would be dermatopathic. That would not change my management. I pay attention to the quality of the lymph node—if it’s very firm, if it’s > 2 cm, if it is persistent—before I biopsy. These patients have a higher incidence of wound infection after excisional biopsy. If the patient has pathologic lymph node involvement and effacement of the node with malignant cells, I would change my management. I do need to know that sort of information.
John Zic. Alejandro, as a hematopathologist can you comment on the debate about whether or not we actually do need an excisional biopsy or whether or not we can get a core lymph node biopsy to give you all the information that you need to grade it?
Alejandro Ariel Gru. There are 2 main modalities of biopsies we typically see for lymph nodes for evaluation and staging for involvement of CTCL. One is the traditional excisional biopsy that for the most part requires surgery with general anesthesia and has all the major implications that that type of procedure has. Many centers are looking at less invasive types of procedures, and needle core biopsies have become one of the most common forms of biopsy for all lymphoma subtypes. Excisional biopsies have the advantage of being able to see the whole lymph node, so you can determine and evaluate the architecture very well. Whereas needle core biopsies typically use a small needle to obtain a small piece of the tissue.
The likelihood of a successful diagnosis and accurate staging was compared recently in the British Journal of Dermatology.9 They were able to perform accurate staging in needle core biopsies of patients with MF. However, this is still a matter of debate; many people feel they are more likely to get enough information from an excisional biopsy. As we know, excisional biopsies sometimes can be hard, particularly if the large lymph node is located in an area that is difficult to access, for example, a retroperitoneal lymph node.
There are many staging categories that are used in the pathologic evaluation of lymph node involvement. On one hand, we could see the so-called dermatopathic changes, which is a reactive form of lymphadenopathy that typically happens in patients who have skin rashes and where there is no evidence of direct involvement by the disease (although there are some patients who can have T-cell clones by molecular methods). The patients who have clonal T cells perhaps might not do as well as the ones who do not. On the other hand, we have patients for whom the whole architecture of the lymph node is effaced or replaced by neoplastic malignant cells. Those patients are probably going to need more aggressive forms of therapy.10
John Zic. The type of lymph node biopsy has been a hot topic. If patients have palpable lymph nodes in the cervical, axillary, and inguinal area, I don’t know if it’s a consensus, but the recommendation right now is to consider performing a lymph node biopsy of the cervical lymph nodes first, axillary second, and inguinal lymph nodes third. That might have to do with the complication rates for those different areas.
