Differential diagnosis of pediatric cervical lymph node lesions based on simple clinical features

This study aims to to establish a diagnosis model based on simple clinical features for children with cervical histiocytic necrotizing lymphadenitis or malignant lymphoma. Simple clinical features of pediatric patients were analyzed to develop a diagnosis model based on a comparison of classical machine-learning algorithms. This was a single-center retrospective study in a tertiary pediatrics hospital. Pediatric patients treated for cervical histiocytic necrotizing lymphadenitis or malignant lymphoma treated at our institution in recent 5 years were included. Demographic data and laboratory values were recorded and binary logistics regression analysis was applied to select possible predictors to develop diagnostic models with different algorithms. The diagnostic efficiency and stability of each algorithm were evaluated to select the best one to help establish the final model. Eighty-three children were included with 45 cases of histiocytic necrotizing lymphadenitis and 38 cases of malignant lymphoma. Peak temperature, white blood cell count, monocyte percentage, and urea value were selected as possible predictors based on the binary logistics regression analysis, together with imaging features already reported (size, boundary, and distribution of mass). In the ten-round random testing sets, the discriminant analysis algorithm achieved the best performance with an average accuracy of 89.0% (95% CI 86.2-93.6%) and an average AUC value of 0.971 (95% CI 0.957-0.995).

CONCLUSION

A discriminant analysis model based on simple clinical features can be effective in differential diagnosis of cervical histiocytic necrotizing lymphadenitis and malignant lymphoma in children. Peak body temperature, white blood cell count, and short diameter of the largest mass are significant predictors.

WHAT IS KNOWN

• Several multivariate diagnostic models for HNL and ML have been proposed based on B-ultrasound or CT features in adults. • The differences between children and adults are nonnegligible in the clinical featues of HNL.

WHAT IS NEW

• The study firstly report a large-sample diagnostic model between the HNL and MLin pediatric patients. • Non-imaging clinical features has also been proven with quite good diagnostic value.

Lymphadenopathy Secondary to Metastatic Squamous Cell Carcinoma Mistaken for Malignant Lymphoma

OBJECTIVE

It is difficult to identify disease entities underlying lymphadenopathy in the head and neck region based solely on imaging. This often results in metastatic squamous cell carcinoma (Sqcc)-induced lymphadenopathy being mistaken for lymphoma. This study aimed to analyze clinical characteristics and computed tomographic features that aid in distinguishing between metastatic Sqcc and lymphoma when lymphadenopathy resembles a large solitary lymphoma.

METHODS

The authors retrospectively enrolled 5 patients, managed between 2010 and 2024, with metastatic Sqcc mistaken for lymphoma and 9 patients with lymphadenopathy of 2 cm or larger due to lymphoma.

RESULTS

Among the 5 patients, 3 exhibited a homogeneous lymphadenopathy phenotype, whereas the remaining 2 displayed heterogeneous enhancement with multiple small necrotic areas within the affected masses. Measurement of the Hounsfield units (HU) for lymphadenopathy, the sternocleidomastoid muscle, and the submandibular gland (SMG) was conducted for each patient. The ratio of lymphadenopathy HU to the average HU of the sternocleidomastoid muscle and the SMG was significantly higher in patients diagnosed with metastatic Sqcc compared with those with lymphoma (P = 0.01).

CONCLUSION

In computed tomography scans, heterogeneous lymphadenopathy or enhancement levels that approach or exceed those of the SMG may indicate the likelihood of Sqcc rather than lymphoma.

Silicone Cervical Lymphadenopathy: A Rare Complication After Breast Augmentation

A 66-year-old female patient, who had undergone breast augmentation 10 years ago, presented with unilateral neck pain, dysphagia, and hoarseness. Subsequent imaging revealed right-sided supraclavicular and axillary lymphadenopathy and a breast implant rupture on the same side. A lymph node core biopsy under sonographic guidance revealed silicone lymphadenopathy. Implant extirpation was offered to the patient. Cervical lymphadenopathy warrants an initial workup to exclude sinister chronic inflammatory or malignant conditions. Nonetheless, in cases of diagnostic uncertainty and a history of breast augmentation, the otolaryngologist should be cognizant of distal silicone lymphadenopathy. This condition is associated with silicone leakage and lymphatic dissemination of silicone particles. Even though silicone-related granuloma formation is a rare entity, its incidence is slowly rising as the population that has undergone breast augmentation grows older.

The value of multimodal ultrasonography in evaluating therapeutic response of cervical tuberculous lymphadenitis to anti-tuberculosis drugs

Purpose

In order to research the value of multimodal ultrasonography in evaluating therapeutic response of cervical tuberculous lymphadenitis to anti-tuberculosis drugs.

Materials and methods

Sixty-one patients with cervical tuberculous lymphadenitis were enrolled in this study. Ultrasound examination was performed before systemic standard anti-tuberculosis treatment and within 1-2 months after treatment, and the patients were divided into effective group and ineffective group according to the follow-up at the sixth month. The multimodal ultrasound signs of the two groups were compared and analyzed.

Results

In the effective group, there were significant differences in the maximum diameter of lymph nodes, the echo of the surrounding tissue and the enlargement of the contrast area before and after treatment (p < 0.05). At 1-2 months after treatment, there were significant differences in the maximum diameter, pus changes, CDFI, elasticity scores, echo of surrounding tissues, changes in enlarged and non-enhanced areas after contrast enhancement between the effective group and the ineffective group (p < 0.05).

Conclusion

The multimodal ultrasound signs of the appearance of internal pus or non-enhancement area enlargement, enhanced echo of the surrounding tissue and enlargement after CEUS are related to poor prognosis, and may be used to evaluate the response of anti-tuberculosis chemotherapy when the size change of lymph node is not obvious in individual treatment.

A combination of ultrasound and contrast-enhanced ultrasound improves diagnostic accuracy for the differentiation of cervical tuberculous lymphadenitis from primary lymphoma

OBJECTIVES

To present a method combining ultrasound (US) and contrast-enhanced ultrasound (CEUS) features for differential diagnosis of cervical tuberculous lymphadenitis (CTL) and primary lymphoma.

METHODS

A total of 155 patients with CTL (n = 49) and lymphoma (n = 106) who underwent US and CEUS were retrospectively included. The features extracted from US and CEUS and the significant clinical data were created three models using the least absolute shrinkage and selection operator and logistic regression analysis. The diagnostic performance of the models was assessed using the area under the curve (AUC).

RESULTS

The combined model outperformed US model and CEUS model in distinguish CTL from lymphoma achieved favorable performances in training set and validation set with AUCs of 0.958 and 0.946 as well as high accuracies (91.7% and 87.2%), sensitivities (95.9% and 84.4%) and specificities (82.4% and 93.3%). Delong's test showed that among the three models, combined model was significantly different from the other two models in training set (p = 0.011 and 0.029, respectively) and validation set (p = 0.018 and 0.001, respectively).

CONCLUSIONS

A combination of US and CEUS achieved good diagnostic performance in differentiating lymphoma and CTL, which might aid in clinical decision-making.

Deep learning radiomics of dual-modality ultrasound images for hierarchical diagnosis of unexplained cervical lymphadenopathy

BACKGROUND

Accurate diagnosis of unexplained cervical lymphadenopathy (CLA) using medical images heavily relies on the experience of radiologists, which is even worse for CLA patients in underdeveloped countries and regions, because of lack of expertise and reliable medical history. This study aimed to develop a deep learning (DL) radiomics model based on B-mode and color Doppler ultrasound images for assisting radiologists to improve their diagnoses of the etiology of unexplained CLA.

METHODS

Patients with unexplained CLA who received ultrasound examinations from three hospitals located in underdeveloped areas of China were retrospectively enrolled. They were all pathologically confirmed with reactive hyperplasia, tuberculous lymphadenitis, lymphoma, or metastatic carcinoma. By mimicking the diagnosis logic of radiologists, three DL sub-models were developed to achieve the primary diagnosis of benign and malignant, the secondary diagnosis of reactive hyperplasia and tuberculous lymphadenitis in benign candidates, and of lymphoma and metastatic carcinoma in malignant candidates, respectively. Then, a CLA hierarchical diagnostic model (CLA-HDM) integrating all sub-models was proposed to classify the specific etiology of each unexplained CLA. The assistant effectiveness of CLA-HDM was assessed by comparing six radiologists between without and with using the DL-based classification and heatmap guidance.

RESULTS

A total of 763 patients with unexplained CLA were enrolled and were split into the training cohort (n=395), internal testing cohort (n=171), and external testing cohorts 1 (n=105) and 2 (n=92). The CLA-HDM for diagnosing four common etiologies of unexplained CLA achieved AUCs of 0.873 (95% CI: 0.838-0.908), 0.837 (95% CI: 0.789-0.889), and 0.840 (95% CI: 0.789-0.898) in the three testing cohorts, respectively, which was systematically more accurate than all the participating radiologists. With its assistance, the accuracy, sensitivity, and specificity of six radiologists with different levels of experience were generally improved, reducing the false-negative rate of 2.2-10% and the false-positive rate of 0.7-3.1%.

CONCLUSIONS

Multi-cohort testing demonstrated our DL model integrating dual-modality ultrasound images achieved accurate diagnosis of unexplained CLA. With its assistance, the gap between radiologists with different levels of experience was narrowed, which is potentially of great significance for benefiting CLA patients in underdeveloped countries and regions worldwide.

Ultrasound Elastography in the Diagnosis of Malignant Cervical Lymphadenopathy in Children: Can It Replace Surgical Biopsy?

INTRODUCTION

 We aimed to assess the accuracy of ultrasound elastography in detecting pediatric malignant cervical lymph nodes, and if this modality can obviate the need for surgical biopsies.

MATERIAL AND METHODS

 A prospective study from September 2017 to September 2020 included 64 children with persistent cervical lymphadenopathy. Patients were evaluated by meticulous history and physical assessment. B-mode ultrasound, color Doppler, and sonoelastography were conducted thereafter. Elastography scans were classified into five patterns, and patterns from 3 to 5 were considered as malignancies. All children underwent open biopsies followed by pathological examination. Results of tissue diagnosis were compared with patterns of elastography to determine its accuracy.

RESULTS

 Twenty-eight patients (43.8%) had malignant nodes and the remaining 36 (56.2%) were due to benign causes. Elastography patterns of 1 and 2 were documented in 30 patients, and all of them were diagnosed as benign lesions. Patterns of 3 to 5 were demonstrated in 34 patients. Out of them, 28 were confirmed as malignancies, while 6 children were of benign nature (false positive). Ultrasound elastography achieved sensitivity and specificity of 100 and 85.7%, respectively, and an overall accuracy of 90.6% in the differentiation between malignant and benign entities. The overall accuracy of B-mode and color Doppler were 75 and 82.2%, respectively.

CONCLUSION

 Elastography is a useful tool that should be added to ultrasound modalities during the diagnosis of pediatric cervical lymphadenopathy. Surgical biopsy in eligible patients is imperative to commence proper therapy or to discharge the child. Despite favorable results of elastography, it cannot replace surgical biopsy or change its indications.

Logistic Regression Analysis of Conventional Ultrasound, and Contrast-Enhanced Ultrasound Characteristics: Is It Helpful in Differentiating Benign and Malignant Superficial Lymph Nodes?

OBJECTIVES

This study aimed to screen the significant sonographic features for differentiation of benign and malignant superficial lymph nodes (LNs) by logistic regression analysis and fit a model to diagnose LNs.

METHODS

A total of 204 pathological LNs were analyzed retrospectively. All the LNs underwent conventional ultrasound (US) and contrast-enhanced ultrasound (CEUS) examinations. A total of 16 suspicious sonographic features were used to assess LNs. All variables that were statistically related to the diagnosis of LNs were included in the logistic regression analysis in order to ascertain the significant features of diagnosing LNs, and to establish a logistic regression analysis model.

RESULTS

The significant features in the logistic regression analysis model of diagnosing malignant LNs were absence of echogenic hilus, age, and absence of hilum after enhancement. According to the results of logistic regression analysis, the formula to predict whether LNs were malignant was established. The area under the receiver operating curve (ROC) was 0.908 and the accuracy, sensitivity, and specificity were 85.0%, 92.9%, and 85.3%, respectively.

CONCLUSION

The logistic regression model for the significant sonographic features of conventional US and CEUS is an effective and accurate diagnostic tool for differentiating malignant and benign LNs.

Reassessing the Value of Contrast-Enhanced Ultrasonography in Differential Diagnosis of Cervical Tuberculous Lymphadenitis and Lymph Node Metastasis of Papillary Thyroid Carcinoma

Aim

We aimed to evaluate the ability of contrast-enhanced ultrasonography (CEUS) to perform differential diagnosis of cervical tuberculous lymphadenitis and lymph node metastasis from papillary thyroid cancer (PTC).

Methods

We analyzed 102 enlarged cervical lymph nodes as diagnosed by conventional ultrasound (US) and CEUS. The US and CEUS enhancement pattern and the time intensity curve (TIC) of the metastatic lymph nodes or tuberculous lymph nodes were compared following standard pathological protocols. The TIC included peak time (TTP), peak intensity (PI), and area under the gamma curve (AUC).

Results

Pathological results demonstrated that 48 out of the 102 enlarged lymph nodes were lymph node metastasis from PTC, while 54 were tuberculous lymphadenitis. There was statistically significant differences in hyperechoic islands, pulse-like enhancement, and asynchronous enhancement between tuberculous lymphadenitis and lymph node metastasis (P < 0.05), but their diagnostic sensitivity and specificity were unsatisfactory. In addition, our data did not show statistically significant difference in enhancement direction, enlarged range on CEUS, and perfusion defect (P > 0.05). Similarly, quantitative parameters such as PI, TTP, and AUC did not yield significant differences between the groups.

Conclusion

Taken together, the present results demonstrate that CEUS can provide valuable information on lymph node blood flow, which can be used to identify tuberculous lymphadenitis and lymph node metastasis of PTC.

Lymphadenopathy in children: A streamlined approach for the surgeon - A report from the APSA Cancer Committee

BACKGROUND/PURPOSE

Lymphadenopathy is a common complaint in children. Pediatric surgeons are often called upon to evaluate, treat, and/or biopsy enlarged lymph nodes. With many nonsurgical causes in the differential diagnosis, the surgeon plays the important role of providing reassurance and timely diagnosis while minimizing the pain and morbidity associated with surgical interventions in children. The purpose of this summary paper is to provide a management guide for surgeons working up children with lymphadenopathy.

MATERIALS/METHODS

The English language literature was searched for "lymphadenopathy in children". All manuscript types were considered for review, regardless of medical specialty, with emphasis placed on published guidelines, algorithms, and reviews. After thorough review of these manuscripts and cross-referencing of their bibliographies, the attached algorithm was developed, with emphasis on the role and timing of surgical intervention.

RESULTS

The APSA Cancer Committee developed the attached algorithm to fill a gap in the surgical literature. It outlines lymphadenopathy workup and treatment with emphasis on the role and timing of surgical intervention.

CONCLUSION

This review defines and summarizes the common etiologies and presentations of lymphadenopathy in children, and offers a straightforward algorithm for evaluation of and treatment with an emphasis on malignancy risk and surgical management.

TYPE OF STUDY

Summary paper.

LEVEL OF EVIDENCE

Level V.

Cervical lymphadenopathy in children: a diagnostic tree analysis model based on ultrasonographic and clinical findings

OBJECTIVES

To establish a diagnostic tree analysis (DTA) model based on ultrasonography (US) findings and clinical characteristics for differential diagnosis of common causes of cervical lymphadenopathy in children.

METHODS

A total of 242 patients (131 boys, 111 girls; mean age, 11.2 ± 0.3 years; range, 1 month-18 years) with pathologically confirmed Kikuchi disease (n = 127), reactive hyperplasia (n = 64), lymphoma (n = 24), or suppurative lymphadenitis (n = 27) who underwent neck US were included. US images were retrospectively reviewed to assess lymph node (LN) characteristics, and clinical information was collected from patient records. DTA models were created using a classification and regression tree algorithm on the basis of US imaging and clinical findings. The patients were randomly divided into training (70%, 170/242) and validation (30%, 72/242) datasets to assess the diagnostic performance of the DTA models.

RESULTS

In the DTA model based on all predictors, perinodal fat hyperechogenicity, LN echogenicity, and short diameter of the largest LN were significant predictors for differential diagnosis of cervical lymphadenopathy (overall accuracy, 85.3% and 83.3% in the training and validation datasets). In the model based on categorical parameters alone, perinodal fat hyperechogenicity, LN echogenicity, and loss of fatty hilum were significant predictors (overall accuracy, 84.7% and 86.1% in the training and validation datasets).

CONCLUSIONS

Perinodal fat hyperechogenicity, heterogeneous echotexture, short diameter of the largest LN, and loss of fatty hilum were significant US findings in the DTA for differential diagnosis of cervical lymphadenopathy in children.

KEY POINTS

• Diagnostic tree analysis model based on ultrasonography and clinical findings would be helpful in differential diagnosis of pediatric cervical lymphadenopathy. • Significant predictors were perinodal fat hyperechogenicity, heterogeneous echotexture, short diameter of the largest LN, and loss of fatty hilum.

Diagnostic lymph node extirpation in CUP syndrome - useful or damaging?

OBJECTIVE

In a proportion of patients with cervical lymph node metastasis no primary can be found even with modern imaging and careful clinical examination (cancer of unknown primary syndrome = CUP syndrome). The ideal diagnostic approach is still debated on.

METHODS

The clinical data of 75 patients (median age: 61.8 years; 16 females and 59 males), which have been treated for cervical squamous cell carcinoma of unknown primary syndrome in our hospital were retrospectively analyzed.

RESULTS

In 12% of patients (n = 9) the primary demarcated in a time period of up to 5.3 years after diagnosis. In the patients who did not receive adjuvant radiotherapy (n = 13), primary became apparent in 38%. Diagnostic lymph node extirpation delayed time until therapeutic neck dissection on average for 3 weeks. In 62% of patients with previous lymph node extirpation (pN2a-N2c), a modified radical neck dissection was required compared to 41% when the surgical site was not operated on.

CONCLUSIONS

In 12% of patients' primary demarcated in the course of the disease. A diagnostic lymph node extirpation was compared to direct therapeutic neck dissection after frozen section analysis associated with a three weeks delayed therapy and higher rate of modified radical neck dissection.