Exuberant blood flow in enlarged lymph nodes: findings on color flow Doppler

Color Doppler ultrasonography for treatment response prediction and evaluation in breast cancer

Primary systemic therapy is a well-established modality of treatment in locally advanced breast cancer. Assessment of tumor response to chemotherapy not only helps in assessing the efficacy of the regimen used but also predicts the overall outcome of the patient. The tumor vascularity is a surrogate marker of tumor burden and this can be readily assessed by color Doppler ultrasound using various indices (resistivity index, pulsatility index and maximum flow velocity). The pre- and post-chemotherapy indices can be compared with in order assess the response to chemotherapy. Among various imaging modalities, MRI and PET have the highest sensitivity in detecting the tumor response, but they are not cost effective. Color Doppler ultrasound is a promising alternative for tumor response assessment owing to its availability, reproducibility and cost–effectiveness.

Current uses of ultrasound in the evaluation of the breast

Ultrasound is an important imaging modality in evaluating the breast. One of the most common uses of ultrasound is to help distinguish benign from malignant breast disease, primarily with gray-scale ultrasound but also with Doppler ultrasound. Another common use is to provide guidance for interventional procedures. Less common uses include assisting in staging of breast cancer and evaluating patients with implants. Recently there has been an interest in using ultrasound to screen asymptomatic women for breast cancer, as is done with mammography. Further studies must be performed to assess if this reduces mortality from breast cancer. Although primarily used to image the female breast, ultrasound also can be used to evaluate breast-related concerns in men. Uses of contrast-enhanced ultrasound are still experimental and would add an invasive component to an otherwise noninvasive study.

Use of Doppler ultrasound in the evaluation of breast carcinoma

Ultrasound is an imaging modality commonly used to evaluate breast lesions in hopes to distinguish benign from malignant solid masses. Angiogenesis, defined as the emergence of new vessels to further the growth of tumor, has stimulated interest in the potential uses of Doppler ultrasound in patients with breast cancer. This article describes different forms of Doppler ultrasound, including color Doppler (CD), power Doppler (PD), and spectral Doppler (SD), as well as 3-dimensional (3D) ultrasound and ultrasound contrast media. We review the role of Doppler ultrasound in distinguishing benign from malignant solid breast masses. We also discuss the role of ultrasound in predicting tumor grade, histology, node status, and lymphatic vascular invasion, and in monitoring breast cancer treatment.

Patients with breast cancer: differences in color Doppler flow and gray-scale US features of benign and malignant axillary lymph nodes

PURPOSE

To document differences in color Doppler flow and gray-scale ultrasonographic (US) features between benign and malignant axillary lymph nodes in women with primary breast cancer.

MATERIALS AND METHODS

The longitudinal-transverse axis ratio and hilar status on color Doppler flow and gray-scale US images were prospectively studied for each of 145 axillary nodes in 135 women (74 palpable nodes in 69 women, 71 nonpalpable nodes in 66 women) with primary breast cancer. Intranodal flow distribution was described as peripheral, central, or central perhilar. Resistive and pulsatility indexes and peak systolic velocity were documented. For comparison of benign and malignant features, nodes were divided into three groups: palpable and nonpalpable, palpable, and nonpalpable.

RESULTS

Color flow was demonstrated equally well in benign and malignant axillary lymph nodes for all three groups. For all nodes, peripheral flow was significantly higher in malignant (118 of 153 nodes [77%]) than benign (45 of 160 nodes [28%]) nodes (P <.001); central flow and central perhilar flow were significantly greater (P <.002 and <.001, respectively) in benign than malignant nodes. Similar differences were not observed in nonpalpable nodes. The mean longitudinal-transverse axis ratio (+/- SD) was significantly lower in malignant (1.8 +/- 0.6) than benign (2.6 +/- 0.8) nodes. Logistic regression analysis showed peripheral, central, and central perhilar flow and the mean longitudinal-transverse axis ratio to be significant independent predictors of malignancy.

CONCLUSION

Color Doppler flow and gray-scale US features applicable to the identification of disease in palpable axillary nodes in patients with breast cancer are not applicable to nonpalpable nodes.

Lymph node metastases of cutaneous melanoma: diagnosis by B-scan and color Doppler sonography

BACKGROUND

Sonography is a sensitive, noninvasive method that can be used to detect regional lymph node metastases. Color Doppler sonography (CDS) can supply further information on lymph node perfusion.

OBJECTIVE

We evaluated the usefulness of CDS for differentiating between benign lymphadenopathies and lymph node metastases of cutaneous melanoma.

METHODS

In a prospective study, reactive inflammatory lymph nodes (rLN) and lymph node metastases of cutaneous melanoma (mLN) were examined by sonography and CDS. Lymph node echogenicity and shape (length/depth ratio) were determined by sonography. The vascularization pattern of the lymph nodes was established with CDS. We recorded the Doppler frequency spectra at the hili of the lymph nodes and then calculated the resistance and pulsatility indices (RI, PI).

RESULTS

The echogenicity of the lymph node centers had a sensitivity of 96% and a specificity of 100%. The shape differed highly significantly between the two groups (P <.001). The criterion length/depth ratio < 2 had a sensitivity of 85% and specificity of 86%. Hilus vessels could be detected in 14 of 22 rLN (64%). These vessels, however, were not present in any of the metastases. The RI and the PI in detectable lymph node vessels differed between the two groups (RI: P <.05; PI: not significant), but because of the overlap between the two groups, these indices were of no diagnostic value. In the presence of 2 or more of the following 3 criteria: length/depth ratio < 2, hypoechoic center, and the absence of hilus vessels, diagnosis of metastasis of malignant melanoma had a sensitivity of 100% and a specificity of 96%.

CONCLUSION

CDS improves the diagnostic accuracy of conventional sonography. The measurement of Doppler curves in lymph node vessels and the calculation of pulsatility and resistance indices, on the other hand, is time-consuming and seems to be of no diagnostic value.

Differential diagnosis of cervical lymphadenopathy with intranodal color Doppler flow signals in patients with oral squamous cell carcinoma

OBJECTIVE

The purpose of this study was to differentiate reactively enlarged cervical nodes from metastatic nodes by means of color Doppler flow imaging in patients with oral squamous cell carcinoma.

STUDY DESIGN

Enlarged lymph nodes with long-axis diameters greater than 10 mm in 30 patients were classified into 4 groups according to color Doppler flow imaging findings. After the patients underwent neck dissection, the findings were correlated with the pathologic features.

RESULTS

Color Doppler flow imaging detected 58 enlarged nodes with long-axis diameters greater than 10 mm. Thirty-five lymph nodes showed no color flow signals; of these, 32 (91%) were metastatic and 3 were reactive. Of the 12 lymph nodes with central color flow signals, 11 (92%) were reactively enlarged and 1 was metastatic.

CONCLUSIONS

The presence of central signals on color Doppler flow imaging appeared to be a significant parameter associated with reactively enlarged benign nodes in patients with oral squamous cell carcinoma.

Colour Doppler flow in normal axillary lymph nodes

81 women with carcinoma of the breast who underwent axillary nodal dissection were studied pre-operatively with colour Doppler ultrasound. The presence of colour Doppler flow was demonstrated in 83.6% of normal lymph nodes compared with 87.5% of metastatic lymph nodes. Using the presence of colour Doppler signal as the sole diagnostic criterion for the diagnosis of metastasis gave a sensitivity of 92.5%, specificity of 9.52%, accuracy of 50%, positive predictive value of 49.3% and negative predictive value of 57.1%. Using grey scale sonographic criteria, where a metastatic node was defined as a node with loss of central fatty hilum and/or eccentric cortical hypertrophy, a sensitivity of 79.5%, specificity of 94.0%, accuracy of 87.6%, positive predictive value of 91.2% and negative predictive value of 85.5% were obtained. Colour Doppler studies of the axillary nodes in a second group of 106 women who attended for breast cancer screening and had no significant breast or axillary pathology also showed colour Doppler signal in 86.7% of nodes. It is concluded that colour Doppler flow signals can be demonstrated in both normal and metastatic axillary lymph nodes, and is highly non-specific when used as the sole diagnostic criterion in the diagnosis of malignancy.

Color and pulsed Doppler evaluation of benign and malignant adenopathy

A color and pulsed Doppler evaluation of 140 benign and malignant lymphnodes in 85 patients has been performed: The nodes have been classified into non-vascularized (flow-), normal-vascularized (flow +), and hypervascularized (flow +2); we also considered the presence of central or peripheral flow. Resistivity index was also measured. The only parameters showing statistical significance were flow - and flow +. The authors conclude that there is a higher probability of benignancy than malignancy in an avascular node, while the opposite is true in a node with moderate flow.

Evaluation of vascular patterns of cervical lymph nodes with power Doppler sonography

Power Doppler sonography was used to evaluate 105 benign and malignant cervical lymph nodes in 60 patients. Three main vascular patterns were identified: type I (single vascular pole), type II (hypertrophic vascular pole), and type III (mainly peripheral vascularity). The first one was related to chronic inflammation (sensitivity 85%, specificity 90%); the second and third were related, to a lesser extent, to acute inflammation and neoplasm (sensitivity 68% and 55%, specificity 47% and 91%, respectively). The authors conclude that the sensitivity and specificity of power Doppler sonography cannot compete with those of fine-needle aspiration biopsy in the diagnosis of adenopathy.