BH: A 50-year-old male presented with many bilateral LNs in the neck. Clinical preliminary diagnosis was lymphoma or metastasis. An assessment of the patient's file before the FNA MRI report revealed a description of a 22 mm × 18 mm asymmetrical mass lesion in the nasopharynx. Unfortunately, this information was not indicated on the FNA requisition form. US findings: the radiologist detected many conglomerated LNs in the right and left sides of the neck during the US before the FNA. An FNA was performed from the largest LNs located at the left and right supraclavicular regions, which were18 mm × 10 mm and 30 mm × 18 mm in size, respectively. Cytologic findings: malignant tumor cells were observed individually or in scattered groups on a lymphoid background and appeared reactive. Thin fusiform particles were detected inside the nucleus in some cells in malignant clusters []. Cytologic diagnosis: Undifferentiated malignant tumor. Comment: the cytologic differential included the metastasis of head/neck-associated carcinoma and Hodgkin's lymphoma due to atypical mononuclear cells in the reactive lymphoid background. Histopathology: the nasopharyngeal biopsy showed undifferentiated nasopharyngeal carcinoma.\nTHM: (1) Metastasis in the LNs in undifferentiated carcinoma of the nasopharynx involves diagnostic challenges during the FNA.[] This condition may be confused with other nonkeratinized carcinoma metastases and lymphomas (especially Hodgkin's lymphoma). (2) Bizarre cells observed in undifferentiated nasopharyngeal carcinoma may resemble atypical mononuclear cells in Hodgkin's lymphoma (Hodgkin cells) and Reed–Sternberg cells [].
BH: A 6-year-old male had an LN 30 mm in diameter in the right submandibular region and multiple LNs, the largest of which measured 25 mm and 15 mm, in the right cervicojugular region. US findings: Compatible with abscess/necrotic appearance. A US-FNA was performed on the largest LN (3 cm in size) in the right submandibular region. The procedure could not be repeated on the other LNs, as the pediatric patient could not be controlled.\nCytologic findings: Epithelioid histiocytes, epithelioid histiocytic granulomas, and Langhans-type giant cells were observed adjacent to a cell population with a high number of large atypical lymphoid cells []. Cytologic diagnosis: atypical lymphoid proliferation comprising granulomatous structures. Comment: granulomatous structures may be components of granulomatous inflammation (e.g., tuberculosis, sarcoid) or may develop secondarily to a lymphoproliferative lesion or carcinoma metastasis. Histopathology: Burkitt lymphoma with secondary granulomatous inflammatory foci (no information could be obtained regarding the cause of granulomatous inflammation proposed in histopathological diagnosis).\nTHM: (1) In the absence of typical cytological components of granulomatous inflammation, individually or sporadically represented epithelioid histiocytes and granuloma-like structures are not sufficient for the diagnosis of “granulomatous inflammation.” (2) In such cases, it would be more appropriate to write “granulomatous reaction” and add a remark in a similar context like our above-mentioned comment. (3) Granulomatous reactions and granulomas are not usually expected to accompany non-Hodgkin's lymphoma; they mostly accompany Hodgkin's lymphoma.[]