i. Excisional: The entire affected lymph node is removed and submitted for histopathology

This is the pathologist’s preference. We’re not being greedy – it just removes all doubt that the sample may not be representative. Some lymph node lesions are localised or multifocal and such an uneven pattern is more likely to be appreciable when we have the whole node to examine. Some metastatic tumours may only be present in small areas of the node and even some lymphomas may not be diffuse (e.g. early stage, emerging).

ii. Incisional, e.g. wedge of lymph node

This may be enough in many cases, especially in diffuse nodal lesions such as reactive lymphoid hyperplasia and most lymphomas. However, as mentioned above, this method may not capture early metastatic neoplasia or lesions that are not always diffuse, such as lymphadenitis, so there are limitations.

iii. Tru-cut biopsy

We do not receive many Tru-cut biopsies of lymph node and we would not recommend this technique as there is even more risk of not capturing potentially pertinent lesions. In a very enlarged lymph node, where there is more chance of reaching a diagnosis, there are still potential drawbacks, such as an inability to confirm or classify a lymphoma. Tru-cut biopsies are prone to fragmentation and, in small fragments, isolated germinal centres may appear very similar to small portions of tissue affected with lymphoma, i.e. they are impossible to distinguish without wider architectural context (Fig 1 and 2).

Furthermore, Tru-cut biopsies may not sample sufficient volume of tissue for further testing, such as immunohistochemistry or PARR.