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Diagnostic performance and clinical implications of the World Health Organization Reporting System for Lymph Node Cytopathology

Ehinger, Mats LU ; Rajabian, Nilofar LU ; Wistén, Erik ; Hashemi, Yas LU ; Cortas, Gaêlle LU and Ericson Lindquist, Kajsa LU (2026) In Journal of the American Society of Cytopathology
Abstract

Introduction A World Health Organization (WHO) system has recently been introduced to standardize reporting of lymph node fine-needle aspiration biopsy (LN-FNAB) cytopathology. Herein, we analyze its diagnostic performance in a routine setting.Materials and methodsWe reviewed 2274 consecutive lymph node fine-needle aspiration biopsies categorized according to the WHO system. Corresponding histological material, radiological images, or uneventful clinical follow-up over 12 months were used as ground truths for classifying LNs as malignant or benign.ResultsThe diagnostic accuracy of the WHO system was 91.8% without and 95.9% with ancillary techniques. The risk of malignancy (ROM) was 21.8% for the “Insufficient/Inadequate/Non-diagnostic”,... (More)

Introduction A World Health Organization (WHO) system has recently been introduced to standardize reporting of lymph node fine-needle aspiration biopsy (LN-FNAB) cytopathology. Herein, we analyze its diagnostic performance in a routine setting.Materials and methodsWe reviewed 2274 consecutive lymph node fine-needle aspiration biopsies categorized according to the WHO system. Corresponding histological material, radiological images, or uneventful clinical follow-up over 12 months were used as ground truths for classifying LNs as malignant or benign.ResultsThe diagnostic accuracy of the WHO system was 91.8% without and 95.9% with ancillary techniques. The risk of malignancy (ROM) was 21.8% for the “Insufficient/Inadequate/Non-diagnostic”, 6.6% for the “Benign”, 29.7% for the “Atypical”, 91.2% for the “Suspicious for malignancy”, and 99.6% for the “Malignant” category. ROM increased with lymph node size, with a significant rise to 33.1% in the 10-14 mm size interval. The ratio of risk of lymphoma (ROL) to risk of metastasis (ROMet) was significantly lower in lymph nodes <15 mm and depended on the anatomical site with the highest ROL in abdominal/pelvic and the highest ROMet in axillary/mammary lymph nodes. The ROL-to-ROMet ratio was higher if the question was lymphoma (36.7%-8.0%) or unspecified (8.3%-8.3%) compared to any other question.ConclusionsThe WHO system demonstrates high diagnostic accuracy, increasing with the use of ancillary techniques, particularly flow cytometry. The ROM, ROL, and ROMet depend on lymph node size, the anatomical site, and the clinical question. A lymph node size of 10 mm may be an appropriate threshold for further investigation, depending on the clinical context.

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author
; ; ; ; and
organization
publishing date
type
Contribution to journal
publication status
epub
subject
keywords
Lymph node site, Lymph node size/site, Risk of lymphoma, Risk of malignancy, Risk of metastasis, World Health Organization reporting system for lymph node cytopathology
in
Journal of the American Society of Cytopathology
publisher
Elsevier
external identifiers
  • pmid:41881775
  • scopus:105034693211
ISSN
2213-2945
DOI
10.1016/j.jasc.2026.01.004
language
English
LU publication?
yes
id
03a30501-5f12-493d-9d93-29bc04a4e0b0
date added to LUP
2026-04-28 15:54:36
date last changed
2026-05-12 16:47:51
@article{03a30501-5f12-493d-9d93-29bc04a4e0b0,
  abstract     = {{<p>Introduction A World Health Organization (WHO) system has recently been introduced to standardize reporting of lymph node fine-needle aspiration biopsy (LN-FNAB) cytopathology. Herein, we analyze its diagnostic performance in a routine setting.Materials and methodsWe reviewed 2274 consecutive lymph node fine-needle aspiration biopsies categorized according to the WHO system. Corresponding histological material, radiological images, or uneventful clinical follow-up over 12 months were used as ground truths for classifying LNs as malignant or benign.ResultsThe diagnostic accuracy of the WHO system was 91.8% without and 95.9% with ancillary techniques. The risk of malignancy (ROM) was 21.8% for the “Insufficient/Inadequate/Non-diagnostic”, 6.6% for the “Benign”, 29.7% for the “Atypical”, 91.2% for the “Suspicious for malignancy”, and 99.6% for the “Malignant” category. ROM increased with lymph node size, with a significant rise to 33.1% in the 10-14 mm size interval. The ratio of risk of lymphoma (ROL) to risk of metastasis (ROMet) was significantly lower in lymph nodes &lt;15 mm and depended on the anatomical site with the highest ROL in abdominal/pelvic and the highest ROMet in axillary/mammary lymph nodes. The ROL-to-ROMet ratio was higher if the question was lymphoma (36.7%-8.0%) or unspecified (8.3%-8.3%) compared to any other question.ConclusionsThe WHO system demonstrates high diagnostic accuracy, increasing with the use of ancillary techniques, particularly flow cytometry. The ROM, ROL, and ROMet depend on lymph node size, the anatomical site, and the clinical question. A lymph node size of 10 mm may be an appropriate threshold for further investigation, depending on the clinical context.</p>}},
  author       = {{Ehinger, Mats and Rajabian, Nilofar and Wistén, Erik and Hashemi, Yas and Cortas, Gaêlle and Ericson Lindquist, Kajsa}},
  issn         = {{2213-2945}},
  keywords     = {{Lymph node site; Lymph node size/site; Risk of lymphoma; Risk of malignancy; Risk of metastasis; World Health Organization reporting system for lymph node cytopathology}},
  language     = {{eng}},
  publisher    = {{Elsevier}},
  series       = {{Journal of the American Society of Cytopathology}},
  title        = {{Diagnostic performance and clinical implications of the World Health Organization Reporting System for Lymph Node Cytopathology}},
  url          = {{http://dx.doi.org/10.1016/j.jasc.2026.01.004}},
  doi          = {{10.1016/j.jasc.2026.01.004}},
  year         = {{2026}},
}