Fine-needle Aspiration vs. Core Needle Biopsy for Cervical Lymphadenopathy: A Multicenter Retrospective Study

Introduction: Fine-needle aspiration (FNA) is the current standard first-line biopsy technique for cervical lymphadenopathy, but core needle biopsy (CNB) has replaced FNA in other organ systems. This study compares the diagnostic performance and safety of FNA versus CNB in adults with cervical lymphadenopathy.

Methods: Adults who underwent cervical lymph node needle biopsy within Kaiser Permanente Northern California between January 2016 and December 2020 were retrospectively identified. Biopsy outcomes were classified as insufficient, indeterminate, or successful based on pathology report review. For successful biopsies, sensitivity for malignancy was determined by linkage with the KPNC SEER Cancer Registry. Adverse events were assessed via chart review, with minor events evaluated in a random subset of patients. Statistical analyses were performed using Stata v19.

Results: A total of 3,542 biopsies were analyzed, including 2,199 FNAs and 1,343 CNBs, performed by otolaryngology, radiology, and pathology providers. CNB demonstrated lower rates of insufficient (14.4% vs. 28.8%) and indeterminate (7.2% vs. 16.0%) results, yielding a higher diagnostic success rate than FNA (78.4% vs. 55.2%, p< 0.0001). Among successful biopsies, 49.2% diagnosed malignancy, including 400 lymphomas and 714 non-lymphoma cancers. CNB demonstrated higher sensitivity for malignancy compared to FNA (96% [95% CI, 95–98%] vs. 85% [95% CI, 82–88%], p< 0.0001). The performance advantage was most pronounced for lymphoma (98% vs. 49%, p< 0.0001) but persisted for non-lymphoma malignancies (95% vs. 91%, p=0.027). Major and minor adverse events were rare and similar between modalities, occurring in < 0.5% and < 4% of cases, respectively.

Conclusions: In the largest comparative study to date, CNB outperformed FNA as an initial diagnostic modality for cervical lymphadenopathy, demonstrating higher diagnostic success and sensitivity without increased complications. These findings support reconsideration of FNA as the default first-line biopsy method and broader adoption of CNB for the initial evaluation of suspicious cervical lymph nodes.