Grey-scale and power Doppler sonography of unusual cervical lymphadenopathy

What is this bump in my neck? Ultrasonographic evaluation of pediatric neck masses

Neck masses are common in pediatric patients, with benign etiologies such as congenital or inflammatory lesions accounting most of these masses. Anatomic location (most important), clinical history, and the appearance in ultrasonography (US) are helpful clues to narrow down differential diagnosis. Because of widespread availability, lack of ionizing radiation, and no need for sedation or contrast administration, US is the preferred initial modality for the evaluation. Further evaluation with cross-sectional imagings is needed for more extensive lesions with trans-spatial extension or suspicion of intrathoracic or retropharyngeal extension. This review will focus on US appearance and clinical presentation of masses of the neck in children, to enable radiologist to arrive at a reasonable differential diagnosis. We also briefly discuss more complex pathologies that need to be evaluated with cross-sectional modalities such as CT scan and magnetic resonance imaging.

Diagnostic value of endobronchial ultrasound image features: A specialized review

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) technology is important in the diagnosis of intrathoracic benign and malignant lymph nodes (LNs). With the development of EBUS imaging technology, its role in noninvasive diagnosis, as a supplement to pathology diagnosis, has been given increasing attention in recent years. Many studies have explored qualitative and quantitative methods for the three EBUS modes, as well as a variety of multimodal analysis methods, to find the optimal method for the noninvasive diagnosis using EBUS for LNs. Here, we review and comment on the research methods and predictive diagnostic value, discuss the existing problems, and look ahead to the future application of EBUS imaging.

Acoustic radiation force impulse imaging of biopsy-proven Kikuchi disease: initial experiences for evaluating feasibility in pediatric patients

Purpose

This study evaluated the feasibility of acoustic radiation force impulse (ARFI) elastography and characterized the sonographic features of lymph nodes (LNs) with Kikuchi disease in pediatric patients.

Methods

Seventy-six cervical LN biopsies were performed for the diagnosis of cervical lymphadenopathy. ARFI imaging was performed, and the characteristic ultrasound features of the biopsied LNs and the contralateral LNs were analyzed. We also reviewed clinical and conventional ultrasonographic findings.

Results

On histology, 56 patients were diagnosed with Kikuchi disease. These LNs were large and elongated, with increased perinodal echogenicity and capsular thickening. In 38 of them, ARFI elastography was performed, and the median shear wave velocity (SWV) of the biopsied LNs with Kikuchi disease (2.19 m/sec; range, 1.45 to 4.57 m/sec) was higher than of the contralateral LNs (1.72 m/sec; range, 0.95 to 2.65 m/sec; P<0.001). In patients with reactive hyperplasia, the mean SWV of the biopsied LNs (2.00 m/sec; range, 1.49 to 2.26 m/sec) was higher than that of the contralateral LNs (1.55 m/sec; range, 1.21 to 2.32 m/sec; P=0.031).

Conclusion

The SWV of LNs with Kikuchi disease was significantly higher than that of the contralateral LNs. Morphologically, LNs with Kikuchi disease showed an enlarged, elongated, and oval shape, increased perinodal echogenicity, and capsular thickening. In addition to the conventional ultrasonographic findings, the application of ARFI is feasible even in pediatric patients for the evaluation of cervical lymphadenopathy.

18F-fluoro-2-deoxyglucose positron emission-computed tomography in a rare cutaneous form of Rosai-Dorfman disease: A case report

Rosai-Dorfman disease (RDD), or sinus histiocytosis with massive lymphadenopathy, commonly involves the lymph nodes but may secondarily involve the skin. Purely cutaneous disease without lymphatics or internal organ involvement occurs rarely. The present report detailed a rare case of ¹⁸F-fluoro-2-deoxyglucose positron emission-computed tomography (¹⁸FDG PET-CT) performed in a 33-year-old male soldier with a purely cutaneous form of RDD. Staging with ¹⁸FDG PET-CT was ordered prior to excisional biopsies of the aforedescribed masses and pathology reported RDD. The case demonstrated accurate localization of increased radioglucose metabolism. The present case was also discussed in light of literature data in terms of clinical features, etiologies, histology, medical imaging, therapy planning and prognosis.

Comparison of Ultrasonographic Findings of Biopsy-Proven Tuberculous Lymphadenitis and Kikuchi Disease

Objective

Although tuberculous lymphadenitis and Kikuchi disease are common causes of cervical lymphadenopathy in Asians and exhibit similar clinical manifestations, their treatment strategies are totally different. The purpose of this study was to identify ultrasonographic features that distinguish these two diseases.

Materials and Methods

This study was approved by the Institutional Review Board. The study included 77 patients with tuberculous lymphadenitis and 135 patients with Kikuchi disease. The sex and age distributions of the patients were analyzed. The size and shape of lymph nodes (LNs), presence of conglomeration, increased perinodal echogenicity, echogenic hilum, posterior neck involvement, internal calcification, patterns of internal necrosis, laterality of involved LNs, and hilar vascular patterns on ultrasonography were compared between the two groups. Multiple logistic regression analysis was conducted to identify independent findings to discriminate tuberculous lymphadenitis from Kikuchi disease. Finally, diagnostic accuracies were calculated using the independent findings.

Results

The presence of an echogenic hilum, internal calcification, patterns of internal necrosis, and LN hilar vascular structures on power Doppler ultrasonography were independent findings that discriminated tuberculous lymphadenitis from Kikuchi disease. The diagnostic accuracy of each of these four factors was 84.9% (181/212), 76.9% (163/212), 84% (178/212), and 89.2% (189/212), respectively. A combination of internal calcification and hilar vascular structures showed the best accuracy of 89.6% (190/212) (sensitivity, 86.7% [117/135]; specificity, 94.8% [73/77]) for diagnosing Kikuchi disease.

Conclusion

The presence of an echogenic hilum, internal calcification, pattern of internal necrosis, and LN hilar vascular structures are useful ultrasonographic findings to differentiate tuberculous lymphadenitis from Kikuchi disease.

Neck lymph nodes in chronic autoimmune thyroiditis: the sonographic pattern

BACKGROUND

Neck lymph nodes may be involved in the pathogenesis of chronic autoimmune thyroiditis (CAT). This study was undertaken to identify which of the sonographic features of cervical lymph nodes are readily applicable to patients affected by CAT compared to healthy control subjects.

METHODS

We recruited 106 patients (92 females and 14 males) with CAT and 70 control subjects (53 females and 17 males) without clinical, biochemical, and ultrasonographic evidence of thyroid and neck diseases. We performed laboratory tests (thyrotropin, antithyroperoxidase antibodies, antithyroglobulin antibodies, and ultrasonography) to evaluate in each group: (i) thyroid function, autoimmunity, and morphology; (ii) number, topographic distribution (levels I-VI), and morphology of neck nodes (long-axis diameter; short-axis diameter; short-axis/long-axis ratio; absence or presence of hilus).

RESULTS

Total number of neck nodes with long-axis diameter >10 mm was significantly higher in the CAT group than in the control group (mean±standard deviation [SD]: 3.7±2.4 vs. 0.8±1.3; p<0.001) with significantly increased differences in levels II (1.4±0.8 vs. 0.3±0.5; p<0.001), III (2±1.2 vs. 0.3±0.7; p<0.001), and IV (0.7±0.7 vs. 0.07±0.2; p<0.001). More nodes with a hilus were found in the CAT group than in the control group (mean number of nodes±SD: 2.8±1.9 vs. 0.7±1.1; p<0.001). Short-axis diameter of level III (4.4±1 vs. 3.7±1.2 mm; p=0.002) and level IV nodes (3.9±1 vs. 3.1±0.5 mm p=0.030) was increased in CAT patients when compared with healthy controls.

CONCLUSIONS

The present study is the first one aiming at a systematic description of the sonographic pattern of cervical lymph nodes in CAT. An increased number of benign hyperplastic neck nodes, especially in levels II-IV, appears to be a characteristic sonographic finding associated with CAT.

Gray scale and power Doppler study of biopsy-proven Kikuchi disease

OBJECTIVES

Kikuchi disease is a benign, self-limiting cause of cervical lymphadenopathy. It can show sonographic features similar to those of other common causes of lymphadenopathy. The purpose of this study was to characterize the sonographic features of Kikuchi disease that can contribute in differentiating between Kikuchi disease and other diseases causing cervical lymphadenopathy.

METHODS

Sonographic findings of 175 patients with biopsy-proven Kikuchi disease were retrospectively reviewed. The mean age of the patients was 27.3 years, and the female to male ratio was 3.5:1. All patients had undergone sonographically guided core biopsy. Pathologic findings were classified into proliferative (n = 57), necrotizing (n = 109), and xanthomatous (n = 9) types. On gray scale sonography, lymph nodes were assessed by their size, shape (shortest/longest axis ratio), location, echogenicity, presence of conglomeration, gross necrosis, calcification, echogenic nodal hilum, and increased perinodal echogenicity. The vascular pattern was assessed on power Doppler imaging.

RESULTS

The mean maximum diameter of the lymph nodes was 1.6 cm. Forty-four percent of them (77 of 175) were oval (shortest/longest axis ratio, 0.5-0.7) and 48% (84 of 175) were elongated (shortest/longest axis ratio, <0.5). Most were located in levels II and V. Seventeen lymph nodes showed gross necrosis, and none showed calcification. One hundred fifty-two lymph nodes (86.8%) had an echogenic hilum, and 76% (133 of 175) showed increased perinodal echogenicity. Increased perinodal echogenicity was seen in 93.5% of the necrotizing type (102 of 109) and 43.8% of the proliferative type (25 of 57); the difference between the two types was statistically significant (P = .001). Normal (n = 161), displaced (n = 13), and absent (n = 1) hilar vascularity was seen on power Doppler studies.

CONCLUSIONS

Sonographic findings of Kikuchi disease can contribute to the differentiation between Kikuchi disease and other causes of cervical lymphadenopathy.

Rosai-Dorfman disease manifesting as a mediastinal mass with calcifications

Sinus histiocytosis with massive lymphadenopathy, also known as Rosai-Dorfman disease, is a rare entity predominantly affecting children and young adults, characterized in 95% of patients by painless bilateral cervical limphadenopathy. We report the case of a 30-year-old female with an anterior mediastinal mass due to lymph node enlargement, which showed calcifications on computed tomography. To our knowledge, calcification in lymphadenopathy, as is present in this case, has never been described in Rosai-Dorfman disease.

Enlarged benign-appearing cervical lymph nodes by ultrasonography are associated with increased likelihood of cancer somewhere within the thyroid in patients undergoing thyroid nodule evaluation

BACKGROUND

Benign-appearing cervical lymph nodes (CLN) are easy to assess during an ultrasonography (US) evaluation for a guided fine-needle aspiration biopsy of a suspicious thyroid nodule, but their clinical significance regarding thyroid cancer risk is not known. Non-malignant-appearing nodes may be an indicator of early malignancy in the thyroid. We hypothesize that there is an increased prediction of thyroid cancer when benign-appearing enlarged CLN (ECLN) > 1 cm in any dimension are present during an US evaluation of thyroid nodules.

METHOD

A review of 269 consecutive patients' charts sent for thyroid nodule assessment that underwent thyroidectomy was conducted to compare ECLN, with the presence of thyroid cancer during an ultrasound-guided fine-needle aspiration biopsy of the thyroid nodule. Surgical excision pathology confirmed all abnormal cytology reports.

RESULTS

From the final 265 charts reviewed, 213 had benign thyroid pathology and 52 had thyroid cancer. Sex, number, and size of the biggest thyroid nodule were not different between groups. Patients with cancer were on average 10 years younger and had higher thyroid-stimulating hormone (TSH) values (p < 0.003) as well as a 10-fold increase in enlarged non-malignant-appearing lymph nodes than their peers without cancer. The presence of ECLN had an 82% sensitivity, 90% specificity, and a 68% positive predictive value for thyroid cancer. There was also an 80% negative predictive value when enlarged lymph nodes were not present. In 8 of the 37 (21.6%) patients with malignancy and ECLN, the primary dominant thyroid nodule was negative on cytologic evaluation, but malignancies were confirmed on surgical specimen, in contralateral nodules on the same side as the ECLN. These nodules were mostly subcentimeric, ranging from 0.2 to 1.14 cm and were not biopsied due to their inconspicuous appearance. After multiple logistic regression analysis, enlarged lymph nodes had a 53.8 odds ratio for cancer (20.49-141.33, p < 0.01).

CONCLUSION

Discovering the presence of ECLN in routine assessment of thyroid nodules is an easy and fast surveillance technique that increases the predictive value in diagnosing thyroid cancer, especially when the enlarged lymph nodes are on the same side as the thyroid nodule.

The utility of sonographic features during endobronchial ultrasound-guided transbronchial needle aspiration for lymph node staging in patients with lung cancer: a standard endobronchial ultrasound image classification system

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure with a high yield for lymph node staging of lung cancer. The aim of this study was to assess the utility of sonographic features of lymph nodes during EBUS-TBNA for the prediction of metastasis in patients with lung cancer and to establish a standard endobronchial ultrasound (EBUS) image classification system.

METHODS

Digital images of lymph nodes obtained during EBUS-TBNA in patients with lung cancer were categorized according to the following characteristics: (1) size (short axis) less or more than 1 cm, (2) shape (oval or round), (3) margin (indistinct or distinct), (4) echogenicity (homogeneous or heterogeneous), (5) presence or absence of central hilar structure, and (6) presence or absence of coagulation necrosis sign. The sonographic findings were compared with the final pathologic results.

RESULTS

A total of 1,061 lymph nodes were retrospectively evaluated in 487 patients. The accuracy of predicting metastatic property for each category was as high as 63.8% to 86.0%. A multivariate analysis revealed that round shape, distinct margin, heterogeneous echogenicity, and presence of coagulation necrosis sign were independent predictive factors for metastasis. Two hundred eighty-five of the 664 lymph nodes (42.9%) having at least one metastatic feature of the four categories were pathologically proven metastatic, and 96.0% of lymph nodes (381/397) were proven not metastatic when all four categories were determined as benign.

CONCLUSIONS

Sonographic features of lymph nodes based on the new EBUS imaging classification may be helpful in the prediction of metastatic lymph nodes during EBUS-TBNA.

Rosai-Dorfman disease of the subglottis diagnosed by ultrasound-guided fine-needle aspiration biopsy: a case report

We report a case of subglottic narrowing caused by an extranodal deposit of sinus histiocytosis in a 55-year-old man. To the best of our knowledge, no previous reports have described diagnosis using sonographic-guided fine-needle aspiration cytology for Rosai-Dorfman disease of the subglottis. This patient was diagnosed by sonographic-guided fine-needle aspiration biopsy, which revealed lymphocytes, plasma cells, and many foamy, multinuclear histiocytes with preserved lymphocytes in their cytoplasm (emperipolesis). The patient underwent an incisional biopsy of the tumor and received postoperative steroids and low-dose chemotherapy. The subglottic tumor was markedly regressed 6 months later.

Axillary and intramammary lymphadenopathy caused by Kikuchi-Fujimoto disease mimicking malignant lymphoma

We describe a rare case of intramammary and axillary lymphadenopathy caused by Kikuchi-Fujimoto disease (KFD). A 30-year-old woman presented with enlarged axillary lymph nodes and a right breast mass with tenderness. Computed tomography, ultrasonography, F-2-deoxy-fluoro-D-glucose positron emission tomography and fine-needle aspiration cytology were performed, and malignant lymphoma (ML) was suspected. Histological diagnosis of a needle biopsy and surgical specimen showed histiocytic necrotizing lymphadenitis. It is important to differentiate KFD from ML because of differences in treatment choice and clinical outcome.

Sonographic features of axillary lymphadenopathy caused by Kikuchi disease

OBJECTIVE

The purpose of this study was to document the sonographic findings of axillary lymphadenopathy in Kikuchi disease.

METHODS

The medical records and sonographic findings of 7 patients with a pathologic diagnosis of Kikuchi disease in the axillary lymph node by sonographically guided core needle biopsy (n=6) or excisional biopsy (n=1) were reviewed. On sonograms, lymph nodes were assessed for their distribution, size, shape, border, echogenicity, and internal architecture, and those sonographic features of each node were evaluated to determine whether the findings favored malignant or benign lymphadenopathy.

RESULTS

Of the 7 patients (1 man and 6 women; mean age +/- SD, 34.3+/-7.7 years), 29 affected lymph nodes (5-38 mm; mean, 14.8+/-7.2 mm) were identified on sonograms. The sonographic characteristics were as follows: the shortest axis/longest axis ratio of the node (mean, 0.595) was 0.5 or greater in 22 nodes (76%); the border was sharp in 16 (55%); the cortex was hypoechoic in 20 (69%) and isoechoic in 9 (31%); the hilum was narrow in 1 (4%) and absent in 16 (55%); and cortical thickening was found in 13 (45%, concentric in 6 and eccentric in 7). Nineteen lymph nodes (66%) were classified as having malignant-favoring features, and 10 (34%) were classified as having benign-favoring features.

CONCLUSIONS

Many axillary lymph nodes in Kikuchi disease look suspicious sonographically. When lymph nodes in the axilla show suspicious findings on sonograms of relatively young patients, Kikuchi disease can be considered a possible differential diagnosis, and image-guided percutaneous biopsy should be done.

Comparison of sonographic appearance of normal and postradiotherapy parotid glands: a preliminary study

This study was undertaken to evaluate and compare the grey-scale and Doppler sonographic features of postradiotherapy (RT) and normal parotid glands. A total of 10 patients with previous head and neck RT and with different degrees of xerostomia were included. Another 10 healthy subjects, who are age and gender-matched with the 10 patients, were also recruited. Grey-scale and Doppler ultrasound examinations of parotid glands were performed on both the patients and healthy subjects. The parotid glands were assessed for their size, echogenicity, echotexture, conspicuity of intraparotid ducts, blood flow velocity and vascular resistance. Results showed that post-RT parotid glands tended to be smaller than normal parotid glands with a significant difference in the transverse dimension (p < 0.05). Normal parotid glands appeared homogeneous, hyperechoic relative to the adjacent muscles and had marginally seen intraparotid ducts. Post-RT parotid glands were heterogeneous, isoechoic (50%) or hypoechoic (50%) relative to the adjacent muscles, and the intraparotid ducts were either marginally (50%) or obviously (50%) seen on ultrasound. The PSV, RI and PI of normal parotid glands were significantly higher than that of post-RT parotid glands (p < 0.05). However, the difference in EDV between normal and post-RT parotid glands was not significant (p > 0.05). In conclusion, ultrasound is useful in assessing parotid glands. To avoid image misinterpretation, post-RT changes in the sonographic appearance of parotid glands should be considered in examining patients with previous head and neck RT.

Reliability of 3-D ultrasound measurements of cervical lymph node volume

This study was undertaken to evaluate the reliability of three-dimensional (3-D) ultrasound in measuring cervical lymph node volume. Ultrasound examination of the neck was performed on 15 healthy subjects (eight men and seven women). For each subject, the volume of cervical lymph nodes was measured twice with 3-D ultrasound by two operators, to evaluate the reproducibility of measurements (interoperator variability). 3-D ultrasound measurements of cervical node volume were performed with and without using SonoCT and XRES imaging. Each 3-D data set was reviewed and remeasured by the operators to evaluate the repeatability of measurements (intra-operator variability). Results showed that the reproducibility and repeatability of 3-D ultrasound volumetric measurements of cervical nodes was improved when SonoCT and XRES imaging were used. There was a high repeatability of 3-D ultrasound measurements of cervical node volume (> 90%). A high reproducibility of measurements was found in the posterior triangle nodes (90.3% - 90.9%). When SonoCT and XRES imaging were used with the scanning, there was a high reproducibility for parotid node measurements (87.4%) and a satisfactory level of reproducibility for submental (61.8%), submandibular (69.3%) and upper cervical node (79%) measurements. 3-D ultrasound is a useful and reliable method in measuring cervical lymph node volume. However, further studies to improve the reproducibility of 3-D ultrasound measurements of submental, submandibular and upper cervical node volume are suggested.

Sonographic Evaluation of Cervical Lymph Nodes

OBJECTIVE

Sonography is a useful imaging tool in the evaluation of cervical lymph nodes. Gray-scale sonography and color and power Doppler sonography are commonly used in clinical practice. This article documents the common sonographic appearances of different causes of cervical lymphadenopathy.

CONCLUSION

The sonographic appearances of normal nodes differ from those of abnormal nodes. Sonographic features that help to identify abnormal nodes include shape (round), absent hilus, intranodal necrosis, reticulation, calcification, matting, soft-tissue edema, and peripheral vascularity.