Color Doppler sonography in the evaluation of superficial lymphomatous lymph nodes

Comparison of microvascular flow imaging and contrast-enhanced ultrasound for blood flow analysis of cervical lymph node lesions

OBJECTIVE

To compare the diagnostic value of microvascular flow imaging (MVFI) with that of contrast-enhanced ultrasound (CEUS) for the analysis of blood flow in benign and malignant cervical lymph nodes.

MATERIAL AND METHODS

As a prospective study, 95 cervical enlarged lymph nodes (43 benign and 52 malignant) were observed in 95 patients using conventional ultrasonography (including gray and Color Doppler Flow Imaging), CEUS, and MVFI. Two researchers evaluated vascular parameters of MVFI (vascular distribution, internal vascular features, vascular index) and CEUS (enhancement mode, enhancement type) and compared the diagnostic effects of MVFI and CEUS.All results were compared with pathological findings.

RESULTS

There were significant differences in the vascular distribution and internal vascular features of benign and malignant lymph nodes on MVFI (P < 0.05). The vascular distribution of benign lymph nodes was mainly of the central and avascular types, the internal blood vessels were mostly normal, the vascular distribution of malignant lymph nodes was mainly mixed, the internal vessels were mainly tortuous and displaced. The optimal cut-off value of the benign and malignant lymph node vascular index (VI) was 15.55%, and the area under the receiver operating characteristic curve (AUC) of the VI was 0.876. There were also significant differences in the enhancement mode and types of benign and malignant lymph nodes in CEUS (P < 0.05). The benign lymph nodes showed centrifugal perfusion, and the enhancement types were mostly type I and type II. Most malignant lymph nodes showed centripetal or mixed perfusion, and the enhancement types were usually type III and type IV. The accuracy, sensitivity, and specificity of CEUS in the diagnosis of lymph node lesions were 84.2%, 84.6% and 83.7%, respectively, and the AUC was 0.845. The accuracy, sensitivity, and specificity of MVFI in the diagnosis of lymph node lesions were 85.3%, 84.6%, and 86.0%, respectively, and the AUC was 0.886.

CONCLUSION

Both CEUS and MVFI are valuable in differentiating benign and malignant lesions of lymph nodes and have a similar diagnostic performance; however, MVFI is less invasive and simpler than CEUS. Therefore it is preferred for auxiliary examination of enlarged lymph nodes that are difficult to diagnose by conventional ultrasound.

Development and validation of nomograms by radiomic features on ultrasound imaging for predicting overall survival in patients with primary nodal diffuse large B-cell lymphoma

Objectives

To develop and validate a nomogram to predict the overall survival (OS) of patients with primary nodal diffuse large B-cell lymphoma(N-DLBCL) based on radiomic features and clinical features.

Materials and methods

A retrospective analysis was performed on 145 patients confirmed with N-DLBCL and they were randomly assigned to training set(n=78), internal validation set(n=33), external validation set(n=34). First, a clinical model (model 1) was established according to clinical features and ultrasound (US) results. Then, based on the radiomics features extracted from conventional ultrasound images, a radiomic signature was constructed (model 2), and the radiomics score (Rad-Score) was calculated. Finally, a comprehensive model was established (model 3) combined with Rad-score and clinical features. Receiver operating characteristic (ROC) curves were employed to evaluate the performance of model 1, model 2 and model 3. Based on model 3, we plotted a nomogram. Calibration curves were used to test the effectiveness of the nomogram, and decision curve analysis (DCA) was used to asset the nomogram in clinical use.

Results

According to multivariate analysis, 3 clinical features and Rad-score were finally selected to construct the model 3, which showed better predictive value for OS in patients with N-DLBCL than mode 1 and model 2 in training (AUC,0. 891 vs. 0.779 vs.0.756), internal validation (AUC, 0.868 vs. 0.713, vs.0.756) and external validation (AUC, 914 vs. 0.866, vs.0.789) sets. Decision curve analysis demonstrated that the nomogram based on model 3 was more clinically useful than the other two models.

Conclusion

The developed nomogram is a useful tool for precisely analyzing the prognosis of N-DLBCL patients, which could help clinicians in making personalized survival predictions and assessing individualized clinical options.

Lymph Node Ultrasound in Lymphoproliferative Disorders: Where Are We Now?

Lymphoproliferative disorders are one of the most frequent hematological malignancies affecting the blood and lymphatic system. To better stratify patients, an accurate imaging evaluation is needed. Although computed tomography and positron emission tomography are considered the standard methods, these procedures have several clinical drawbacks, such as biological risk and high costs. Ultrasound (US) is a rapid and user-friendly method to evaluate lymph node (LN) and organ enlargements. US imaging provides more sensitive information about LN structure, vascularization, and metabolism and new techniques have increased its specificity, especially in malignant setting. However, validated and standardized criteria for its use are missing, with only several single-center experiences reported. Therefore, the aim of this paper is to review and briefly illustrate the status of the US knowledge and applications in lymphoproliferative workup, particularly concerning malignant LN pathology.

Role of ultrasound in the diagnosis of cervical tuberculous lymphadenitis in children

BACKGROUND

To describe sonographic characteristics of cervical tuberculous lymphadenitis (CTBL) in children, clinical information, and sonograms of 348 lymph nodes (LNs) from 57 children with CTBL were retrospectively analyzed in this study.

METHODS

We retrospectively reviewed the clinical data and sonograms of 348 LNs from 31 boys and 26 girls with CTBL, who were confirmed by pathology or laboratory examination, at the Hangzhou Red Cross Hospital between June 2014 and December 2020. The age of the children ranged from 1 to 14 years (average 7.1 ± 2.9 years).

RESULTS

Night sweats, fatigue and loss of appetite were the most common clinical symptoms observed in children with CTBL. Unilateral LN involvements were common. Occasionally, CTBL was found in healthy children with no symptoms. On sonography, the hilus was absent or unclear in all LNs. The short-to-long axis (S/L) ratio was ≥ 0.5, and the edges were unclear in most LNs. Other accompanying findings included necrosis (47.4%), an echogenic thin layer (36.8%), surrounding soft-tissue edema (38.5%), multiple intra-nodal strong echo (28.2%), sinus (22.7%) and abscess formation (6.9%). The Doppler ultrasound showed that the majority of vascularity patterns of CTBL were capsular or peripheral (33.3%).

CONCLUSIONS

Ultrasound is a recommended examination method for children from different age groups with cervical lymphadenitis. The ultrasonic signs of hilus absence, S/L ratio ≥ 0.5, unclear edge, necrosis, echogenic thin layer, strong echoes and capsular or peripheral vascularity may aid in the diagnosis of cervical tuberculous lymphadenitis.

The Value of CEUS in Distinguishing Cancerous Lymph Nodes From the Primary Lymphoma of the Head and Neck

Aim: The purpose of this study was to assess the ability of contrast-enhanced ultrasonography (CEUS) in the differential diagnosis of cancerous lymph nodes.

Methods: Contrast-enhanced ultrasonography was performed in the cervical nodules of included patients, and the diagnoses were confirmed by pathological examination. Contrast-enhanced ultrasonography images and parameters of head and neck lymphomas were compared with those of cancerous lymph nodes. Besides, receiver operating characteristic curve was operated to access the diagnostic value of CEUS.

Results: Finally, a total of 63 head and neck lymphomas and 80 cervical cancerous lymph nodes were enrolled in this study. Results showed that the CEUS images of lymphoma were mainly characterized by homogeneous enhancement (71.43%), and approximately half of them were centripetal perfusion (58.73%), whereas most CEUS images of cancerous lymph nodes were inhomogeneous enhancement (82.50%) and centripetal perfusion (92.50%). Quantitative analysis of CEUS parameters indicated that PI (derived peak intensity) and AUC (area under the curve) of lymphomas were both lower than those of cancerous lymph nodes (PI: 8.78 vs. 10.51, AUC: 652.62 vs. 784.09, respectively) (P < 0.05). Receiver operating characteristic analysis showed that the sensitivity of CEUS parameters in the differential diagnosis was significant (80.00%), although the specificity was not high (47.62%). When parameters were combined with the image features, the accuracy of diagnosis was greatly improved (from 0.655 to 0.899).

Conclusion: Contrast-enhanced ultrasonography could be a promising tool for the differential diagnosis of head and neck lymphomas and cancerous lymph nodes.

Subcapsular Injection of Ultrasonic Contrast Agent Distinguishes between Benign and Malignant Lymph Node Lesions Exhibiting Homogeneous Enhancement in Intravenous Contrast-Enhanced Ultrasound Images

We aimed to evaluate whether subcapsular injection of ultrasonic contrast agent (UCA) can distinguish between benign and malignant lymph node (LN) lesions exhibiting homogeneous enhancement in intravenous contrast-enhanced ultrasound (CEUS) images. From November 2012 to July 2015, 32 patients with superficial lymphadenopathy exhibiting homogeneous enhancement after intravenous CEUS were enrolled. A small amount of UCA was injected into LNs using a subcapsular approach, and perfusion characteristics were recorded. Using the pathology identified via core needle biopsy as the gold standard, we calculated the sensitivity, specificity and accuracy of the technique in terms of distinguishing between benign and malignant LN lesions. Pathology revealed 23 cases of true benign and 9 cases of true malignant LN lesions; the former included 2 cases of tuberculosis and 21 cases of reactive hyperplasia, and the latter included 7 lymphomas and 2 metastases. Subcapsular CEUS diagnosed 24 benign and 8 malignant LN lesions. Most lymphomas (6 of 7, 85.7%) exhibited heterogeneous perfusion, with lymphatic tract distortion in the absence of interruption. Reactive hyperplasia LNs manifested as diffuse homogeneous or brush-like perfusion from the subcapsular region to the center, without lymphatic tract distortion. Metastatic LNs had lymphatic tract interruptions. The sensitivity, specificity, consistency and positive and negative predictive values were 77.8%, 95.6%, 90.6%, 87.5% and 91.7%, respectively. For LNs exhibiting uniform enhancement in intravenous CEUS imaging, subcapsular CEUS may help to distinguish between benign and malignant lesions. In particular, lymphatic distortion without interruption may specifically indicate a lymphoma.

Homogeneity Parameter in Contrast-Enhanced Ultrasound Imaging Improves the Classification of Abnormal Cervical Lymph Node after Thyroidectomy in Patients with Papillary Thyroid Carcinoma

Objective

To explore the conventional and contrast-enhanced ultrasound (CEUS) features of cervical lymph node metastasis (CLNM) in papillary thyroid carcinoma (PTC) patients postoperatively and analyze its pathological basis.

Materials and Methods

Conventional and CEUS were performed in 86 abnormal cervical lymph nodes (ACLNs) from 56 PTC patients who had received thyroidectomy. Then, fine-needle aspiration (FNA) was taken to confirm pathological results, a multivariate analysis was performed to correlate the sonographic features of the CLNM, and then an equation for CLNM was established.

Results

Fifty-four lymph nodes were confirmed to be metastasis of PTC by FNA. Intensity at peak time, homogeneity, and color flow patterns, cystic change, or microcalcification and echogenicity were significantly associated with CLNM. Multivariate analysis showed three strongest features (homogeneity, intensity of peak, and cystic change or calcification) to be significantly associated with the evidence of CLNM. Then, the equation was established with the following significant predictive factors: P = 1/1 + exp∑[−3.213 + 2.77 ∗ cystic or calcification + 0.13 ∗ CDFI patterns + 3.65 ∗ homogeneity + 2.43 ∗ intensity at peak time].

Conclusion

Depiction of a heterogeneous hyperenhancement of cervical lymph nodes within CEUS studies and cystic change or microcalcification in conventional ultrasound were identified as predictive for metastatic lymph node invasion, and the equation was more accurate for predicting CLNM compared to single B-mode ultrasound and CEUS feature.

Differentiation Between Malignant and Benign Lymph Nodes: Role of Superb Microvascular Imaging in the Evaluation of Cervical Lymph Nodes

OBJECTIVES

This study aimed to assess the value of Superb Microvascular Imaging (SMI; Canon Medical Systems, Otawara, Japan) for distinguishing between benign and malignant cervical lymph nodes (LNs) and to compare SMI with power Doppler ultrasound (PDUS).

METHODS

Power Doppler ultrasound and SMI examinations were performed for patients' cervical LNs. The distribution of feeding vessels, number, and appearance of internal vessels were analyzed by 2 readers, and the results of PDUS and SMI were compared. Interobserver agreement was assessed. A subgroup analysis was performed to assess differences in vascular patterns between metastasis and tuberculous lymphadenitis and between Kikuchi disease and lymphoma. The diagnostic performance for distinguishing between benign and malignant LNs was calculated.

RESULTS

In total, 147 patients with 147 cervical LNs (85 benign and 62 malignant) were assessed. Interobserver agreement was moderate to strong for SMI. There were significant differences in the vascular patterns between benign and malignant LNs on SMI (distribution, number, and appearance, all P < .001), but not on PDUS. In the subgroup analysis, SMI showed a significant difference in the vascular patterns observed between metastasis and tuberculous lymphadenitis (distribution, P = .012; number, P = .014; and appearance, P = .005). Superb Microvascular Imaging detected significantly greater numbers of vessels in lymphoma than in Kikuchi disease (P = .012). The sensitivity of SMI was significantly greater than that of PDUS in distinguishing malignant from benign LNs (86.9% versus 54.1%; P < .001).

CONCLUSIONS

Superb Microvascular Imaging yields more detailed information about nodal vessels than does PDUS by enabling visualization of small nodal vessels. Superb Microvascular Imaging is useful and feasible for differentiating between malignant and benign cervical LNs.

Comparison of Contrast-Enhanced Ultrasound and Positron Emission Tomography/Computed Tomography (PET/CT) in Lymphoma

Background

This study aimed to assess the value of contrast-enhanced ultrasound (CEUS) in the diagnosis and prognosis of lymphoma based on PET-CT.

Material/Methods

Our study included 88 superficial lymph nodes and 63 patients who underwent ultrasound-guided biopsy or surgery for pathology from October 2015 to March 2017. All lymph nodes were assessed by CEUS and PET-CT. CEUS and PET-CT parameters were recorded, including arrive time (AT), time to peak (TTP), base intensity (BI), peak intensity (PI), ascending slope (AS), descending slope (DS), area under the TIC curve (AUC), maximum standardized uptake value (SUVmax), and mean standardized uptake value (SUVmean). Pearson’s correlation was used to assess the associations of CEUS and PET-CT parameters.

Results

Of the 88 lymph nodes examined,12 were Hodgkin’s lymphoma (HL) and76 were non-Hodgkin’s lymphoma (NHL). The variations of CEUS dose parameters (ΔI, AUC, and AS) were positively correlated with PET-CT results (SUVmax and TLG). Correlation coefficients were 0.609, 0.518, 0.456, 0.630, 0.593, and 0. 532, respectively. The remaining time values (AT, TP, and ΔT) were negatively associated with PET-CT results. Correlation coefficients were −0.239, −0.272, −0.284and −0.377, −0.391, and −0.320, respectively.

Conclusions

Quantitative CEUS data were correlated with PET-CT values, with potential use in the diagnosis of lymphoma.

Association between contrast-enhanced ultrasonography and histopathological findings of the metastatic lymph nodes of patients with head and neck cancer: A preliminary study

The present study aimed to investigate the usefulness of contrast-enhanced ultrasonography (CEUS) and a newly developed analysis software for the detection of microcapillary network distribution in lymph nodes of patients with head and neck cancer (HNC) by comparing the CEUS and histopathological findings. Patients that were diagnosed with HNC between February and September 2016 were enrolled. A total of five patients underwent resection of the primary tumor and neck dissection as their initial treatment. The cervical lymph nodes of these patients were analyzed by CEUS intraoperatively, and their surgical specimens were examined histopathologically. The patients were diagnosed using a combination of physical examination, computed tomography, magnetic resonance imaging and fluorodeoxyglucose-positron emission tomography. For CEUS examination, the microbubble contrast agent Sonazoid™ was injected into a peripheral vein. Video images of the metastatic lymph nodes were captured, and these were subjected to analysis by a newly developed image-analysis software. It was possible to perform intraoperative CEUS of metastatic lymph nodes and obtain accurate matched sections for histopathological examination. Hematoxylin and eosin and cluster of differentiation (CD)34 staining revealed that the software was able to accurately detect capillary vessels in metastatic lymph nodes. However, a number of perfusion deficits were observed in these lymph nodes. In conclusion, by using CEUS with the analysis software, the density and distribution of blood vessels in the metastatic lymph nodes of patients with HNC was revealed. Although the present study was limited and preliminary, it was concluded that this method may be useful to evaluate and to map the capillary vessels in the metastatic lymph nodes of patients with HNC.

The role of CEUS in characterization of superficial lymph nodes: a single center prospective study

Accurate lymph node characterization is important in a large number of clinical settings. We evaluated the usefulness of Contrast Enhanced Ultrasound (CEUS) in distinguishing between benign and malignant lymph nodes compared with conventional ultrasonography in the differential diagnosis of superficial lymphadenopathy.

We present our experience for 111 patients enrolled in a single center.

111 superficial lymph nodes were selected and only 1 lymph node per patient underwent CEUS. A definitive diagnosis for all lymph nodes was obtained by ultrasonographically guided biopsy and/or excision biopsy.

The size of the lymph nodes, the site (neck, axilla, inguinal region) being easily accessible for biopsy, and the US and color Doppler US characteristics guided us in selecting the nodes to be evaluated by CEUS.

In our study we identified different enhancement patterns in benign and malignant lymph nodes, with a high degree of diagnostic accuracy for superficial lymphadenopathy in comparison with conventional US.

Evaluation of supplementary diagnostic value of contrast-enhanced ultrasound for lymph node puncture biopsy

Background

Contrast enhanced ultrasound (CEUS) is an effective way to evaluate the distribution of micro vessels in organs with little invasiveness. The qualitative evaluation and differential diagnosis of lymph node is essential for a number of clinical situations, including appropriate examination selection, oncologic staging, therapy and prognosis beyond diagnosis itself. The purpose of this study is to investigate the contribution of characterization of cervical lymphadenopathies on CEUS as an indication for lymph node puncture biopsy.

Methods

Records of 157 lymph nodes from 103 patients who had undergone CEUS examination were studied retrospectively, and enhancement patterns and characteristics were evaluated. The diagnoses obtained by means of core-needle biopsy examination or surgical removal, or patients were closely followed-up for at least 6 months. Of the lymph nodes examined, 94 were benign (48 lymphadenitis and 46 tuberculosis) and 63 were malignant (55 metastases and 8 lymphomas). The vascular characterization of lymph nodes was compared with results obtained by pathologic examination.

Results

The study using CEUS showed 55 (54.5%) cases of "peripheral" enhancement in group A and 47 (83.9%) cases of "hilar normal or activated" in group B. Inhomogeneous "spotted or cycle-like" enhancement in the equilibrium phase was seen in 80 (79.2%) cases of group A and only 11 (19.6%) cases of group B. The specificity, sensitivity and accuracy of CEUS examination result as an indication for puncture biopsy were 80.4%, 81.2% and 80.9%, respectively.

Conclusions

Centripetal perfusion in the early arterial phase or inhomogeneous spotted or cycle-like enhancement in the equilibrium phase of the cervical lymph nodes during CEUS can be used as an indication for core-needle biopsy with a high degree of accuracy. Conversely, for lymph nodes with more variable appearances, surgical removal or closely followed-up of nodes may be more appropriate.

Intranodal Palisaded Myofibroblastoma: Radiological and Cytological Overview

Background

Intranodal palisaded myofibroblastoma is a benign and very rare mesenchymal neoplasm of the lymph nodes originating from differentiated smooth muscle cells and myofibroblasts.

Case Report

We report a case of intranodal palisaded myofibroblastoma in an 84-year-old woman with Parkinson’s disease that presented as a left inguinal mass. The diagnosis was made using ultrasound-guided fine needle aspiration biopsy and consequent cytopathological examination that included immunohistochemical analysis. Herein, we discuss the presentation of a rare intranodal palisaded myofibroblastoma with emphasis on its ultrasonographic and cytopathologic features.

Conclusions

Intranodal palisaded myofibroblastoma should be considered in the differential diagnosis of inguinal lymphadenopathy and the diagnosis is possible with cytopathologic exam and immunohistochemical analysis using ultrasound-guided FNA biopsy, guiding the clinician to nodal excision rather than aggressive measures.

[Interpretation of ultrasound findings in otorhinolaryngology : Skin, soft tissue of the neck, lymph nodes, and oncologic follow-up]

A major advantage of head and neck sonography over other imaging methods is that the attending physician performs the examination himself/herself and can directly compare the imaging findings with other clinical and endoscopic findings. Given the "big picture," the physician is thus able to interpret the sonographic findings correctly. The first part of this article gives an exemplary overview of lesions of the skin, neck, and lymph nodes as well as the ensuing oncologic follow-up with ultrasound. In the second part the focus lies on salivary glands, paragangliomas, the esophagus, and vascular pathologies.

Cervical lymph node diseases in children

The lymph nodes are an essential part of the body’s immune system and as such are affected in many infectious, autoimmune, metabolic and malignant diseases. The cervical lymph nodes are particularly important because they are the first drainage stations for key points of contact with the outside world (mouth/throat/nose/eyes/ears/respiratory system) – a critical aspect especially among children – and can represent an early clinical sign in their exposed position on a child’s slim neck.

Involvement of the lymph nodes in multiple conditions is accompanied by a correspondingly large number of available diagnostic procedures. In the interests of time, patient wellbeing and cost, a careful choice of these must be made to permit appropriate treatment. The basis of diagnostic decisions is a detailed anamnesis and clinical examination. Sonography also plays an important role in differential diagnosis of lymph node swelling in children and is useful in answering one of the critical diagnostic questions: is there a suspicion of malignancy? If so, full dissection of the most conspicuous lymph node may be necessary to obtain histological confirmation.

Diagnosis and treatment of childhood cervical lymph node disorders present the attending pediatric and ENT physicians with some particular challenges. The spectrum of differential diagnoses and the varying degrees of clinical relevance – from banal infections to malignant diseases – demand a clear and considered approach to the child’s individual clinical presentation. Such an approach is described in the following paper.

Can contrast-enhanced ultrasound distinguish malignant from reactive lymph nodes in patients with head and neck cancers?

The purpose of this study was to investigate the utility of contrast-enhanced ultrasound in differentiating benign from malignant cervical lymph nodes in patients with squamous cell carcinoma of the head and neck. A consecutive series of 17 patients with known head and neck malignancy scheduled for neck surgery and lymph node clearance were recruited for contrast-enhanced ultrasound evaluation. Sonographic signal intensity as a function of time, comparing features of time to peak, time to arrival and time to wash-out, was quantified. The selected node was removed surgically and submitted for histology. Contrast-enhanced ultrasound examination had 100% sensitivity and 85.7% specificity for lymph node involvement. Functional analysis revealed contrast peaks significantly earlier in the malignant nodes (mean ± standard deviation) of 24.14 ± 2.7 s compared with 29.33 ± 3.4 s (p = 0.0128). Contrast-enhanced ultrasound holds promise in the detection and characterization of metastatic nodes that would not be diagnosed as abnormal on the basis of conventional ultrasound criteria.

Sonographic findings of axillary masses: what can be imaged in this space?

The diagnosis of axillary masses can be challenging because various tumors can develop in parts of the axilla other than lymph nodes, even though we frequently encounter axillary masses in daily practice. These lesions include soft tissue masses associated with nontumorous conditions (accessory breast tissue and chronic granulomatous inflammation) and benign and malignant tumorous conditions (lipomas, epidermal inclusion cysts, lymphangiomas, fibroadenomas, schwannomas, malignant neuroendocrine tumors, and lymph node-associated diseases). In this pictorial essay, we display commonly encountered sonographic findings of various axillary lesions to assist in the differential diagnosis of axillary masses.

Enlarged lymph nodes in head and neck cancer: Analysis with triplex ultrasonography

BACKGROUND

Presence of cervical metastasis is one of the factors influencing the outcome of patients with carcinoma of the head and neck, its early detection is potentially very important. Triplex ultrasonography technology have definitive role in detecting clinically undetectable involvement of lymph nodes (LNs). The purpose of this study was to evaluate, whether triplex ultrasonography characterization of cervical LNs could, with an acceptable degree of certainty, differentiate malignant from benign/reactive LNs, in order to prevent invasive diagnostic procedures.

MATERIALS AND METHODS

A total of 50 patients with oral cancer, were subjected to ultrasonographic investigation of the neck for grayscale, color flow imaging, and pulsed Doppler. All the parameters were compared with histopathologic examination. Correlation was then made between ultrasound and Doppler investigation and histopathology results to evaluate the sensitivity specificity, positive predictive value (PPV) and negative predictive value (NPV) of color Doppler ultrasonography in detecting metastatic neck nodes.

RESULTS

Study results showed that malignant LNs, especially metastatic nodes, are accompanied with significantly high resistive index (RI) and pulsatility index (PI) values, rounded shape, size, loss of central hilar echogenicity and peripheral vascularity. Among these sonographic findings, nodal shape (longitudinal nodal diameter to transverse diameter ratio or L/T ratio), RI and PI values were more accurate for differentiating benign from malignant LNs.

CONCLUSION

In this study, triplex sonographic findings had relatively high accuracy in differentiating benign from malignant cervical LNs. Ultrasound hence can be recommended for initial non-invasive evaluation of the neck in patients with oral cancers with or without palpable cervical lymph nodes.

Efficacy of colour Doppler ultrasound in diagnosis of cervical lymphadenopathy

OBJECTIVES

The purpose of the study was to evaluate the efficacy of colour doppler ultrasound (CDUS) in diagnosis of cervical lymphadenopathy.

MATERIALS AND METHODS

The study group consisted of 30 patients with clinical evidence of cervical lymphadenopathy (19 patients with clinically suspected reactive/benign cervical lymphadenopathy and 11 patients with clinically suspected malignant/metastatic cervical lymphadenopathy). CDUS examinations were carried out for one lymph node (LN) in each patient and fine needle aspiration cytology of the same LN was obtained. To evaluate the efficacy of CDUS, comparison between clinical features, CDUS features and cytological features of enlarged cervical LNs were then done.

RESULTS

Clinical examination evaluated 54 cervical LNs. CDUS evaluation discovered an additional 55 LNs (54 + 55 = 109). Accuracy of the CDUS examination was higher than clinical evaluation. Patterns of colour doppler flow signals when correlated with cytological diagnosis showed central flow for benign nodes and peripheral flow for malignant nodes. The mean pulsatility index (PI) was 1.977 ± 0.669 in LNs involved with metastases and 0.839 ± 0.135in LNs affected by benign processes. LNs involved with metastases showed a characteristic high resistive index (RI) and a high pulsatility index than the lymph nodes affected by benign processes. The RI and PI were significantly different between LNs affected by benign versus malignant disease.

CONCLUSION

Nodal vascularity of the LNs can be used to differentiate benign from malignant lymphadenopathy. CDUS can be trusted upon as a reliable marker for the diagnosis of cervical lymphadenopathy.

Role of Structural Imaging in Lymphoma

The lymphomas, Hodgkin lymphoma and non-Hodgkin lymphoma, are among the most common types of cancer in the United States. Imaging plays an important role in the evaluation of patients with lymphoma, because it aids in treatment planning and in the determination of prognosis. Structural imaging entails the assessment of morphologic features of normal tissues and organs of the body and of malignant lesions within these structures, and plays a major role in the noninvasive assessment of lymphoma. This article reviews cross-sectional structural imaging modalities with an emphasis on computed tomography and magnetic resonance imaging, with some mention of ultrasonography.

Quantitative evaluation of vascularity within cervical lymph nodes using Doppler ultrasound in patients with oral cancer: relation to lymph node size

OBJECTIVES

The aim of this study was to quantitatively evaluate the relationship between vascularity within lymph nodes and lymph node size on Doppler ultrasound images of patients with oral cancer.

METHODS

A total of 310 lymph nodes (86 metastatic, 224 benign) from 63 patients with oral cancer were classified into 4 groups according to their short axis diameters: Group 1, short axis diameters of 4-5 mm; Group 2, 6-7 mm; Group 3, 8-9 mm; and Group 4, ≥ 10 mm. Vascular and scattering indices of lymph nodes on Doppler ultrasound images were analysed quantitatively. The vascular index was defined as the ratio of blood flow area to the whole lymph node area and the scattering index was defined as the number of isolated blood flow signal units.

RESULTS

For metastatic lymph nodes, the vascular index was highest in Group 1 and decreased as lymph node size increased. The vascular index of benign lymph nodes did not differ significantly among the four groups. The vascular index of metastatic lymph nodes was significantly higher than that of benign lymph nodes in Group 1. For metastatic lymph nodes, the scattering index increased as lymph node size increased and was significantly higher than that of benign lymph nodes in Groups 2-4.

CONCLUSIONS

An increase in vascularity is a characteristic of Doppler ultrasound findings in small metastatic lymph nodes. As the metastatic lymph node size increases, blood flow signals become scattered, and the scattering index increases.

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.

Contrast-enhanced ultrasound for characterizing lymph nodes with focal cortical thickening in patients with cutaneous melanoma

OBJECTIVE

The aim of this study was to ascertain the utility of contrast-enhanced ultrasound in assessing the significance of focal cortical thickening in the lymph nodes of patients followed up after surgery for cutaneous melanoma.

MATERIALS AND METHODS

Ultrasound was used to examine 460 consecutive patients to identify nodes with focal hypoechoic cortical thickening. Patients whose nodes revealed these features underwent contrast-enhanced ultrasound and ultrasound-guided fine-needle aspiration cytology (FNAC) focusing on the area of cortical thickening. Enhancement in the arterial and parenchymal phases was evaluated: A generalized homogeneous or intense enhancement was considered benign and the presence of a perfusion defect was considered metastatic.

RESULTS

After exclusion of 24 patients with frank signs of malignancy at gray-scale ultrasound, the study included 436 patients. Focal hypoechoic cortical thickening was seen in 44 of 436 nodes in as many patients. In 29 nodes, the area of focal thickening showed contrast enhancement similar to that of the remaining cortex on contrast-enhanced ultrasound. In 15 nodes, the area of cortical thickening was less well vascularized than the adjacent parenchyma in the arterial phase and there were areas with perfusion defects that were more evident in the parenchymal phase. FNAC focusing on the areas of focal cortical thickening identified 13 metastatic nodes and 31 nodes with benign features. Contrast-enhanced ultrasound compared with FNAC correctly classified 42 of 44 nodes, showing a sensitivity of 100% and a specificity of 99.5%.

CONCLUSION

Although our findings need to be confirmed in larger series, they indicate that contrast-enhanced ultrasound can be useful in clinical practice for characterizing focal cortical thickening in lymph nodes. The exclusion or identification of regional lymph node metastases is of fundamental importance in oncologic staging because this issue directly influences both the prognosis and the choice of therapeutic strategy.

The role of contrast-enhanced gray-scale ultrasonography in the differential diagnosis of superficial lymph nodes

Lymph node micrometastases are common, but too often in clinical practice lack the tools for their accurate prebiopsy detection. The gray-scale contrast-enhanced ultrasonography technique permits high-resolution imaging of both the arterial and parenchymal phase and allows visualization of diffuse and partial alterations of nodal perfusion even in lymph nodes with a maximum diameter smaller than 1 cm. The gray-scale contrast-enhanced ultrasonography can supply further useful information in case where doubt has arisen with conventional techniques. The results obtained show that it affords highly accurate differentiation between benign and metastatic lymph nodes.

Clinical application of contrast-enhanced ultrasonography in diagnosis of superficial lymphadenopathy

OBJECTIVE

The purpose of this study was to evaluate the value of contrast-enhanced ultrasonography (CEUS) in differential diagnosis of superficial lymphadenopathy.

METHODS

Ninety-four superficial enlarged lymph nodes in 94 patients were studied by conventional ultrasonography (gray scale and color Doppler) and CEUS. Contrast-enhanced sonograms were analyzed using contrast-specific quantification software. All of the results were compared with pathologic diagnoses.

RESULTS

Of the 94 lymph nodes examined, 44 were benign and 50 were malignant (33 metastases and 17 lymphomas). The sensitivity, specificity, and accuracy of conventional ultrasonography in differential diagnosis between benign and malignant nodes were 51%, 47%, and 55%, respectively. Contrast-enhanced ultrasonography showed intense homogeneous enhancement in 39 of 44 benign lymph nodes, inhomogeneous enhancement in 32 of 33 metastases, and intense homogeneous enhancement and absence of perfusion in 9 of 17 and 6 of 17 lymphomas, respectively. The sensitivity specificity, and accuracy of CEUS were 84%, 79%, and 80%. After time-intensity curve gamma variates were calculated, the area under the curve of the benign lymph nodes was greater than those of the metastatic lymph nodes and lymphomas (P < .01).

CONCLUSIONS

These results indicate that the use of CEUS and contrast-specific software has a higher degree of diagnostic accuracy than conventional ultrasonography for evaluations of superficial lymphadenopathy. The contrast enhancement patterns and time-intensity curves provide valuable diagnostic information for differential diagnosis of benign and malignant lymph nodes.

Evaluation of the efficacy of colour Doppler ultrasound in diagnosis of cervical lymphadenopathy

OBJECTIVES

The purpose of the study was to evaluate the efficacy of colour Doppler ultrasound (CDUS) to differentiate between benign and malignant cervical lymph nodes.

METHODS

During a period of 12 months, 100 untreated patients with clinical evidence of cervical lymphadenopathy (50 patients with clinically suspected malignant/metastatic cervical lymphadenopathy and 50 patients with clinically suspected reactive/benign cervical lymphadenopathy) were prospectively evaluated with CDUS. CDUS was performed for 168 cervical lymph nodes in these 100 patients. Histopathological confirmations were obtained by fine needle aspiration biopsy and/or excisional biopsy. To evaluate the efficacy of CDUS, comparison between clinical features, CDUS features and cytological/histological features of enlarged cervical lymph nodes was then done.

RESULTS

Initially, clinical examination evaluated 143 cervical lymph nodes. CDUS evaluation discovered additional 25 lymph nodes (143+25 = 168). Correlation of patterns of colour Doppler flow signals with pathological diagnosis showed that central flow for benign nodes and peripheral flow for malignant nodes were highly significant parameters (P < 0.01). CDUS has a higher specificity than clinical evaluation, being 94.28% and 58.76%, respectively. Accuracy of the CDUS examination was also definitely higher than clinical evaluation at 92.85% and 63.67%, respectively.

CONCLUSIONS

Nodal vascularity can be used to differentiate benign from malignant lymphadenopathy. Proper judicious CDUS examination provides an opportunity to eliminate the need for biopsy/FNAC in reactive nodes.

Detection of small inflammatory and metastatic lymph nodes in rabbits by sonography: evaluation with the resistive index ratio

OBJECTIVE

The aim of this prospective study was to determine whether the resistive index (RI) ratio based on high-resolution spectral Doppler sonography would be useful in the differential diagnosis of small inflammatory and metastatic lymph nodes in rabbit models.

METHODS

The infected and metastatic lymph node models we used were created by subcutaneously inoculating methicillin-susceptible Staphylococcus aureus and VX2 tumor cells respectively into the left hind limbs of 10 New Zealand White rabbits. High-resolution sonography was performed to investigate the popliteal fossa lymph nodes 2 weeks after the inoculation. The sizes, long-/short-axis ratios, and RI ratios (defined as the value of the peripheral RI relative to the central RI) of the nodes were evaluated with sonography and then compared with the histopathologic findings.

RESULTS

No statistical differences were found between the volumes (mean +/- SD, 104 +/- 41 versus 87 +/- 24 mm(3); P > .05) and the long-/short-axis ratios (1.97 +/- 0.28 versus 2.03 +/- 0.26; P > .05) of 15 inflammatory and 14 metastatic lymph nodes. On spectral Doppler sonography, the RI ratio was higher in the metastatic lymph nodes than in the inflammatory lymph nodes. With an RI ratio higher than 1.2 as a diagnostic criterion for a metastatic lymph node, the sensitivity, specificity, and positive and negative predictive values of sonography were 71% (10/14), 80% (12/15), 76% (10/13), and 75% (12/16), respectively, with an area under the receiver operating characteristic curve value of 0.824.

CONCLUSIONS

This experimental study confirms that RI ratio changes based on high-resolution spectral Doppler sonography are associated with histopathologic changes of metastatic and inflammatory lymph nodes during the initial stage in rabbits.

Contrast-enhanced endoscopic ultrasound in discrimination between benign and malignant mediastinal and abdominal lymph nodes

BACKGROUND

Enlarged lymph nodes in the mediastinum reflect neoplastic, infectious or other diseases. The classification of these nodes is crucial in the management of the patient. Currently, only invasive measures obtaining tissue samples reach satisfying specificity. Contrast-enhanced endoscopic ultrasound (EUS) may offer a non-invasive alternative.

MATERIALS AND METHODS

A total of 122 patients (age: 63 +/- 15 years, 92 males, 30 females) with enlarged mediastinal and/or paraaortic lymph nodes diagnosed by CT scan were included in the study. EUS-guided fine needle aspiration was performed and cytologic specimens were diagnosed as representing a malignant or benign process in case of Papanicolau IV and V, or Papanicolau I and II, respectively.

RESULTS

Based on cytology results, the investigated lymph nodes were classified as neoplastic (n = 48) or non-neoplastic lymph nodes. Using the B-mode criteria the preliminary diagnosis was confirmed in 64 out of 74 benign lymph nodes (specificity 86%). Regarding malignant lymph nodes 33 of 48 were confirmed (sensitivity 68%). Using the advanced contrast-enhanced EUS criteria the diagnosis was confirmed in 68 of 74 benign lymph nodes (specificity 91%). However, in case of malignant lymph nodes the number of correct diagnoses dropped to 29 of 48 lymph nodes (sensitivity 60%). The contrast-enhanced EUS criteria to identify benign lymph nodes and node enlargement in malignant lymphoma do not differ. If those ten patients with malignant lymphoma are excluded, the sensitivity of the contrast enhanced EUS for malignant lymph nodes rises to 73%.

CONCLUSION

Contrast-enhanced EUS improves the specificity in diagnosing benign lymph nodes as compared to B-mode EUS. It does not improve the correct identification of malignant lymph nodes and cannot replace EUS-guided fine-needle aspiration.

Vascular patterns in superficial lymphomatous lymph nodes: A detailed sonographic analysis()

PURPOSE

To identify the vascular patterns found in superficial lymph nodes with histologically confirmed lymphomatous involvement and to determine their value in the sonographic diagnosis of lymphadenopathy.

METHODS AND MATERIALS

The study involved the prospective classification of vascular patterns observed during power Doppler and/or color Doppler studies of superficial lymph nodes scheduled for resection. Forty patients (27 men and 13 women, aged 22-84 years; mean age: 58 years) with pathologically proven lymphoma were selected for this study (26 cervical, 13 axillary and 1 inguinal).

RESULTS

A longitudinal vessel with or without branches (pattern I) was found in 14 lymphomatous nodes. Six contained short vessel segments distributed in the hilum area or centrally (pattern II), five had multiple vessels, partially branching, entering the node in a few rows from its longitudinal side (pattern III), seven presented multiple vessels that branched irregularly or chaotically with avascular areas (pattern IV), and eight had a peripheral vessel distribution (pattern V). Therefore, 50% of the lymphomatous nodes had vascular patterns regarded as characteristic of reactive lymph nodes (patterns I and II), and 37.5% had patterns normally described in lymph nodes with metastatic involvement (patterns IV and V); other lymphomatous lymph nodes had ambiguous vascular patterns that have not been previously classified (pattern III).

CONCLUSION

The angioarchitecture of superficial lymphomatous lymph nodes varies widely and is difficult to classify. It may resemble that reported in normal or reactive lymph nodes or patterns that are associated with metastases. The finding of a normal or benign vascular pattern in a lymph node with suspected lymphomatous involvement does not eliminate the need for a diagnostic biopsy.

Automated quantitative evaluation of lymph node perfusion on contrast-enhanced sonography

OBJECTIVE

The aim of this study was to assess the performance of experimental software (Qontraxt) intended to provide automated quantification of sonographic signal intensity, which is related to the contrast enhancement of lymph node tissue, to differentiate benign from malignant lymph nodes.

SUBJECTS AND METHODS

In 31 patients (age range, 24-86 years; mean age +/- SD, 53.6 +/- 14.4 years) a single lymph node per patient was evaluated on sonography after the administration of sulfur hexafluoride-filled microbubbles. The stored sonographic images were analyzed and processed into chromatic maps that had numeric values related to the amount of contrast. The lymph node regions in which the increase of signal intensity values with respect to baseline were highest (maximum signal intensity value [SImax]) and lowest (minimum signal intensity value [SImin]) were identified, and the corresponding numeric data were stored. Statistical analyses were performed by means of the Student's t test; a p value of less than 0.05 was considered to be statistically significant.

RESULTS

Histopathologic analysis revealed metastatic lesions in 12 of the 31 lymph nodes; the remaining 19 were benign (16 reactive lymph nodes, two cases of granulomatous lymphadenitis, and one case of tubercular lymphadenitis). Values obtained from the SImax regions showed no consistent difference between benign and malignant lymph nodes; on the other hand, values from the SImin regions comparing baseline and maximal contrast-enhanced values were significantly different in the two groups (p < 0.001). Confidence for characterization of malignancy was significant using the difference between values from SImax and SImin regions, with the higher diagnostic value from 24 to 31 inclusive: sensitivity, 92% (11/12); specificity, 89% (17/19); positive predictive value, 85% (11/13); and accuracy, 90% (28/31).

CONCLUSION

The software being tested proved to be useful in differentiating benign from metastatic lymph nodes on the basis of the quantitative data it provided.

US of the major salivary glands: anatomy and spatial relationships, pathologic conditions, and pitfalls

Ultrasonography (US) is useful for differential diagnosis of diseases of the salivary glands. In acute inflammation, salivary glands are enlarged and hypoechoic with increased blood flow; they may contain multiple small, oval, hypoechoic areas. In chronic inflammation, salivary glands are normal sized or smaller, hypoechoic, and inhomogeneous. Sialolithiasis appears as markedly hyperechoic lines or points with distal acoustic shadowing. Sialosis appears as enlarged hyperechoic glands without focal lesions or increased blood flow. The US features of advanced Sjögren syndrome include inhomogeneous salivary glands with scattered small, oval, hypoechoic or anechoic areas, usually well defined, and increased parenchymal blood flow. Pleomorphic adenomas are usually hypoechoic, well-defined, lobulated lesions with posterior acoustic enhancement that may contain calcifications; Warthin tumors are usually oval, hypoechoic, well-defined lesions that often contain anechoic areas and are often hypervascularized. Malignant neoplasms of the salivary glands may have irregular shapes, irregular borders, blurred margins, and a hypoechoic inhomogeneous structure or may have a benign appearance. Salivary gland cysts have well-defined margins, anechoic contents, posterior acoustic enhancement, and no internal blood flow. However, US appearances of some diseases may overlap, thus producing diagnostic pitfalls.

Ultrasound of superficial lymph nodes

US is a powerful tool for characterization of superficial lymph nodes. Unlike other imaging techniques like CT and MRI, which mainly depend on size for differential diagnosis, US can evaluate important parameters such as shape, margins, internal structure and abnormal vascularization. It has the advantage of showing early subtle findings of neoplastic involvement like asymmetric thickening and focal lobulations in the cortex, as well as late findings such as diffuse cortical thickening and absence of hilum. It is possible to evaluate the heterogeneous inner structure due to necrosis, unsharp or irregular borders due to extracapsular spread and abnormal vascularization with multiple subcapsular feeding vessels due to tumor angiogenesis. The advances in US technology like high-resolution transducers, power Doppler function and contrast agents have all contributed to the well established role of US in the evaluation of lymph nodes. This article mainly focuses on the sonographic criteria for differential diagnosis of normal, reactive, inflammatous and neoplastic lymph nodes as well as examination techniques in the neck, axilla, internal mammary and inguinal regions and indications in various clinical settings.

Contrast-enhanced ultrasound examination of lymph nodes in different types of lymphoma

BACKGROUND

Since the tumor growth depends on the formation of feeding vessels, color/power Doppler ultrasonography (US) has been used to evaluate the vascular flow images of lymph nodes (LNs) in order to differentiate benign LNs from malignant LNs or lymphoma from metastatic carcinoma.

METHODS

We performed color/power Doppler ultrasonography (US) using Levovist (LV) to evaluate the vascular patterns in the LNs of 10 patients with different types of lymphoma. The patterns were classified as central, peripheral, or avascular type.

RESULTS

Vascular flow was identified in 9 of 10 LNs and it was enhanced with LV in all cases. The vascular pattern of the LNs was of the central type in all seven B-cell lymphoma patients and one of two T-cell lymphoma patients and of the peripheral type in the remaining T-cell lymphoma patient. The avascular type pattern was observed in one Hodgkin lymphoma patient even with LV.

DISCUSSION

Typical vascular patterns might be associated with certain subtypes of lymphoma, and LV appears to improve the diagnostic value of Doppler US.

CHARACTERIZATION OF LYMPHOMATOUS LYMPH NODES IN DOGS USING CONTRAST HARMONIC AND POWER DOPPLER ULTRASOUND

Doppler ultrasound has been used in humans to determine angioarchitecture of lymph nodes as the criterion for the determination of malignancy. We hypothesized that the vascular and perfusion patterns of a canine malignant lymph node could be characterized with intravenous microbubble ultrasound contrast media and that contrast harmonic ultrasound could provide better conspicuity of the angioarchitecture when compared with Power Doppler ultrasound. In this study, 11 peripheral lymph nodes in dogs with histologically verified malignant lymphoma were imaged with fundamental ultrasound, Power Doppler ultrasound, and three contrast harmonic pulse sequences to characterize the vascular pattern and perfusion. Vascular imaging was greatly enhanced in these nodes with 2.13 times more vessels seen with contrast harmonic ultrasound compared with Power Doppler ultrasound (P < 0.01). The angioarchitecture of lymphomatous lymph nodes of dogs in this study were similar to those previously described in malignant superficial lymph nodes in human patients; 45.5% of the nodes had displacement of the central hilar vessel, 45.5% had aberrant vessels, 63.6% had pericapsular vessels, 36.4% had subcapsular vessels, and 81.8% had loss of the central hyperechoic band in fundamental sonography. Poor perfusion, indicated by a lower mean pixel intensity increase between pre- and postcontrast administration images, was seen in 36.4% of the lymph nodes while 63.6% had fair to good perfusion. The perfusion patterns in nine of the 11 lymph nodes were homogenous and two showed focal hypoperfused regions. We conclude that Power Doppler and contrast harmonic ultrasound are beneficial in accurately depicting angioarchitechture and can provide additional information in determining the presence of malignant vascular characteristics within lymphomatous nodes in dogs.

High-resolution ultrasonography of primary peripheral soft tissue lymphoma

OBJECTIVE

The purpose of this study was to evaluate the appearance of primary peripheral soft tissue lymphoma on high-resolution ultrasonography.

METHODS

We retrospectively studied the sonograms of 12 patients (5 female and 7 male; age range, 12-90 years; mean, 55 years) with soft tissue lymphoma. All lesions were palpable and in the salivary glands, trunk, upper limb, or lower limb, and the diagnosis was proved by biopsy or open surgery. For each lesion, sonograms were obtained by gray scale and color Doppler ultrasonography.

RESULTS

The gray scale imaging showed relatively homogeneous hypoechogenicity in 11 patients and homogeneous hyperechogenicity in 1 patient. The tumors appeared as big masses in 5 patients, nodal or confluent nodes in 3, small disseminated nodules in 2, a myositis type in 1, and a panniculitis type (homogeneous echogenic infiltrate in a subcutaneous fat layer) in 1.

CONCLUSIONS

In patients with a soft-tissue mass, routine plain radiography and high-resolution ultrasonography including color Doppler ultrasonography are recommended before further evaluation with ultrasonographically guided biopsy.

Evaluation of lymph node perfusion using continuous mode harmonic ultrasonography with a second-generation contrast agent

OBJECTIVE

To evaluate the contribution of continuous mode contrast-enhanced harmonic ultrasonography (CE-HUS) with a second-generation contrast agent to the characterization of superficial lymphadenopathies with respect to conventional ultrasonographic techniques (B-mode and power Doppler).

METHODS

Fifty-six lymph nodes from 45 patients were studied both by conventional techniques and by CE-HUS. The dimensions, intranodal architecture, margins, and location of vessels were evaluated. Subsequently, all the lymph nodes were examined by CE-HUS, and enhancement of echogenicity was evaluated. The diagnoses obtained by means of fine-needle aspiration cytologic examination, surgical biopsy, or both were compared with those obtained by ultrasonography.

RESULTS

Of the lymph nodes examined, 30 were benign and 26 were malignant (18 metastases and 8 non-Hodgkin lymphomas). The study using CE-HUS showed intense homogeneous enhancement in 28 of 30 reactive lymph nodes; perfusion defects in 17, of which 15 were neoplastic and 2 were inflammatory; intense but inhomogeneous speckled enhancement in the early arterial phase in 5 cases of lymphoma; and, last, scarce or absent intranodal enhancement in 4 metastases. The specificity, sensitivity, and accuracy of conventional techniques in differentiation between benign and malignant lymph nodes were 76%, 80%, and 78% versus 93%, 92%, and 92.8% for CE-HUS. The increase in correct diagnoses was significant (P = .05) when conventional ultrasonography was tested against CE-HUS.

CONCLUSIONS

Superficial lymph nodes can be characterized as being neoplastic or benign with a high degree of diagnostic accuracy on the basis of the perfusion characteristics evaluated by CE-HUS. This technique has been shown to afford a higher degree of accuracy than currently obtainable by any other ultrasonographic technique.

Diagnostic value of high-resolution B-mode and power-mode sonography in the follow-up of thyroid cancer

OBJECTIVE

Ultrasonography is an established diagnostic modality in the follow-up of thyroid cancer. Color flow Doppler has been proposed by some authors as an additional tool for differentiating benign from malignant cervical lesions in various types of head and neck cancer. Over the last few years, a new generation of high-resolution ultrasound platforms with the "power-mode" feature has become available, that also enables the imaging of small vessel blood flow. The objective of our study was to find ways of optimizing the differentiation of benign and malignant cervical tumors in thyroid cancer follow-up by means of sonography.

METHODS

Hundred and twelve cervical lesions in 90 patients with thyroid cancer were evaluated by high-end ultrasonography (Sonoline Elegra, Siemens) using a small-part transducer (7.5 L 40, Siemens). B-mode sonography was performed at a frequency of 8 MHz. The Solbiati index (SI= ratio of largest to smallest diameter), configuration, echogenicity, intranodular structures, and margins were assessed. Perinodular and intranodular blood flow was evaluated by color flow Doppler (PRF 1250 Hz for conventional color flow Doppler, 868 Hz for power-mode Doppler). Possible malignancy was validated by histology, cytology, scintigraphy, and follow-up. Thirty five lesions were benign (diameter 0.4-3.0 cm) and 77 were malignant (0.4-5.4 cm). The patients were randomized into a test group and a learning group to determine the diagnostic value of various ultrasound criteria by means of statistical analysis. In the learning group, decision rules based on the dichotomized criteria were developed using a logistic regression model. Sensitivity and specificity of these decision rules were then evaluated in the test group.

RESULTS

The presence of an echocomplex pattern or irregular hyperechoic small intranodular structures (criterion A) and the presence of an irregular diffuse intranodular blood flow (criterion B) are the best indicators of malignancy, whereas an SI >>2 is highly indicative of benign changes. Color flow Doppler is a useful addition to B-mode scanning for distinguishing benign and malignant neoplasms in the follow-up of thyroid cancer. Power-mode Doppler sonography significantly improves imaging of perinodular and intranodular blood flow when compared with conventional color flow Doppler.

CONCLUSION

We propose the following decision rules based on a combination of the criteria above: (A) and (B) fulfilled: malignant, if SI< or =4; (B) but not (A) fulfilled: malignant, if SI< or =3; (A) but not (B) fulfilled: malignant, if SI< or =2; neither (A) nor (B) fulfilled: malignant, if SI approximately equal to 1 (sensitivity: 90%; specificity: 82%; accuracy 88%).