Download Imaging superficial lymph nodes: Is there a clue for

Imaging superficial lymph nodes: Is there a clue for
malignancy?
Poster No.:
C-2477
Congress:
ECR 2013
Type:
Educational Exhibit
Authors:
H. Zaghouani Ben Alaya , N. Benzina , Z. Kmira , W. Kermani ,
1
1
1
1
2
1
3
1
1
M. Limeme , S. MAJDOUB , H. Amara , D. Bakir , C. Kraeim ;
1
Sousse, DEPARTMENT OF RADIOLOGY, FARHAT HACHED
2
HOSPITAL, SOUSSE/TN, Sousse, DEPARTMENT OF CLINICAL
HEMATOLOGY, FARHAT HACHED HOSPITAL, SOUSSE/TN/TN,
3
Sousse, Department of Ear, Nose, and Throat, Farhat Hached
University Hospital, Sousse, Tunisia/TN
Keywords:
Hematologic diseases, Cancer, Decision analysis, Education,
Diagnostic procedure, Ultrasound, MR, CT, Lymph nodes,
Hematologic, Head and neck, Lymphoma
DOI:
10.1594/ecr2013/C-2477
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Learning objectives
- To review superficial lymph nodes anatomy.
- To illustrate a wide spectrum of pathologic disorders affecting nodes.
- To analyse normal and pathologic nodes on US, Doppler correlated with histopathologic
findings when available.
- To emphasize pitfalls, diagnostic difficulties and differential diagnoses of the entities.
Background
-Anatomy and distribution of superficial nodes: neck, axille and inguinal region.
-Review of morphologic criteria in normal and pathologic nodes highlighting key imaging
features and pitfalls: size, internal architecture, necrosis, number, calcifications.
Imaging findings OR Procedure details
•
Normal lymph node (fig 1)
•
Why have we rewieved the head and neck lymph nodes?
- To review imaging findings of the large number of diseases that develop
superficial lymph nodes.
- To describe the radiologist's role
-To describe the management of superficial lymphadenopathy
-To correlate the radiologic features with pathologic appearance
•
Approach to lymphadenopathy (fig2, 3, 4)
I- CERVICAL LYMPH NODES (fig 5)
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1- Pyogenic adenitis
•
GENERAL :
- Staphylococcus aureus and beta hemolytic streptocci are the most common infectious
agents.
- Acute and unilateral
- Most often is submandibular region (50-60%)
•
US IMAGING FINDINGS: (fig6)
- Enlarged, hypoecoic and hyperemic nodes
- Round to lobulates
- Faint acoustic and septations
- Important inflammation of adjacent soft tissues
2- Infectious mononucleosis
•
General :
- Common infection in adolescent caused by the Epstein-Barr Virus
- Bilateral enlarged head and neck nodes with proeminent lymphoid tissue
- Associated with hepatosplenomegaly
•
Us IMAGING FINDINGS (fig7)
- Bilateral, large and hypervascular nodes
- Round to lobulates
- Symmetric radial pattern of vessels on Doppler imaging
3- Cat-scratch disease
•
GENERAL
-the most common cause of chronic lymphadenitis in children
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- Solitary enlarged node caused by Bartonellahenselae resulting in granulomatous
lymphadenitis
-nodal enlargement can occur 1 to 2 weeks after a cat scratch or bite.
•
US IMAGING FINDINGS: (fig8)
- Enlarged, mobile, hypoechoic and hypervascular nodes
- The appareance of nodes can change hypo to anechoic
- Minimal periadenitis is commonly seen.
4- Cervical TB adenopathy
Adenopathy is the most common sign of extrapulmonary tb in 30-50% of cases and
cervical location is a very often finding (60-80%).
Cervical TB adenopathies are multiple, unilateral, predominantly affecting deep channels
and generally between 1,5 and 5 cm in size.
Ultrasound demonstrates predominantly hypoechoic nodes with or without echogenic
hilus with a heterogenous echo pattern and intra-nodal cyctic area (necrosis)
Surrounding soft tissue edema appears and ill-defined echolucent perinodal, and abcess
formation
The borders of the nodes appear indistinct, and nodal matting and clumping is seen due
to periadenitis.
There is three stages of nodal involvement on CT and MRI.
•
GENERAL
The infection most frequently results in chronic lymphadenitis
Unilateral enlarged node caused
granulomatous lymphadenitis
by
Mycobacterium
avium
intracellulare
Sub mandibular is the most commonly involved region.
•
US IMAGING FINDINGS(fig9, 10, 11)
- Single hypoechoic lymph node surrounded by smaller satellite nodes
- Anechoic center indicates necrosis
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in
- Periadenitis is commonly seen
5- Castleman's disease
•
GENERAL
-Uncommon lymphoproliferative disorder that can involve single lymph node stations or
can be systemic
-also known as giant lymph node hyperplasia and angiofollicular lymph node hyperplasia
It must be distinguished from readtive lymph node hyperplasia and malignancies
-diagnosis of Castleman disease is based on microscopic examination of the tumor tissue
and blood tests.
•
IMAGING FINDINGS
- Enlarged lymph node or localized nodal masses that demonstrate homogenous intense
enhacement after contrast material administration
- US and CT appearance is nonspecific
- Three patterns of involvement have been described: solitary noninvasive mass,
infiltrative mass with associated lymphadenopathy and matted lymphoadenopathy
without a dominant mass.
6- Lymphoma
•
GENERAL
- Head and neck lymphadenopathy is presenting the majority of patients with Hodgkin
lymphoma
- An enlarging, painless, nontender lymph node should raise concern
- In NHL, involvement of the Waldeyer ring might be diffuse or localized.
•
IMAGING FINDINGS(fig12)
- Enlarged hypoechoic nodes show sharp borders withan absent or eccentric echogenic
helium and a tendency to form masses
- On color Doppler imaging, the nodes demonstrate hypervascularity with both peripheral
and central hyperemia
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- On CT the enlarged nodes are isodense to muscle with mild and homogeneous
enhacement after contrast material administration.
7- Metastatic disease
•
GENERAL
- Metastatic involvement of head and neck lymph nodes can be seen in neuroblastomas,
papillary thyroid carcinoma or nasopharyngeal carcinoma
- Firm, matted, nontender, more than 3 cm of short axis with systemic sympthoms are
the most important signs of malignancy.
•
US IMAGING FINDINGS: (fig13)
-most metatatic nodes are enlarged, hypoechoic nodes show sharp boders with an
absent or eccentric echogenic helium
The exception is hyperrchoic nodes with intranodal calcification seen in metastatic
papillary or medullary thyroid carcinoma or metastatic neuroblastoma
On color Doppler imaging, the nodes demonstrate hypervascularity with both peripheral
and central hyperemia.
II- axillary adenopathy
Unilateral vs bilateral axillary adenopathy : differential diagnosis
Unilateral
Bilateral
Benign
Begnin
•
•
•
Regional infections (e.g.
cat scratch disease,
toxoplasmosis, TB, ipsilateral
upper extremety cellulitis,
metastasis)
Dermatopathic
lymphadenopathy
Silicone-induced
granulomatous lymphadenitis
•
•
•
•
HIV
Autoimmune diseases
(rheumatoid arthritis,
scleroderma, dermatomyositis,
SLE, psoriasis)
Lymphoid hyperplasia from
acute or chronic infection/
inflammation (infectious
mononucleosis, cat scratch
disease)
Granulomatous lymphadenitis
(sarccoidosis, tuberculosis)
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Malignant
•
•
•
•
Malignant
Metastases from breast
malignancy
Metastases from non-breast
malignancies (melanoma is a
common cause)
Primary malignancy in
ipsilateral arm
Lymphoma occasionally
unilateral
•
•
•
•
Lymphoma
Leukemia
HIV associated malignancies
( Kaposi sarcoma)
Metastases (lung, melanoma,
uncommonly breast)
Spectrum of axillary lymph node disease: unilateral axillary lymphadenopathy
•
•
•
Primary breast cancer metastasis to the axilla (fig14)
Non-breast primary metastasis to the axilla (fig15)
Infectious and inflammatory conditions
Spectrum of axillary lymph node disease: bilateral axillary lymphadenopathy
•
•
•
•
Lymphoma (fig16)
Leukemia
HIV
toxoplasmosis
III- Inguinal lymphadenopathy (fig17)
Are common.
Enlarged nodes up to 1 to 2 cm in diameter in many healthy adults, particularly those
who spend time barefoot outdoors.
Benign reactive lymphadenopathy and infection are the most common etiologies, and
inguinal lymphadenopathy is of low suspicion for malignancy.
Infrequently, Hodgkin's lymphomas first present in this area, as do non-Hodgkin's
lymphomas.
Penile and vulvar squamous cell carcinomas, the lymphomas, and melanoma also can
occur with lymphadenopathy in this area.
When the overlying skin is involved, testicular carcinoma may lead to inguinal
lymphadenopathy, which is present in 58 percent of patients diagnosed with penile or
urethral carcinoma.
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Images for this section:
Fig. 1: fig1
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Fig. 2: fig2
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Fig. 3: fig
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Fig. 4: fig
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Fig. 5: fig
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Fig. 6: fig
Fig. 7: fig
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Fig. 8: fig
Fig. 9: fig
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Fig. 10: fig
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Fig. 11: fig
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Fig. 12: fig
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Fig. 13: FIG
Fig. 14: FIG
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Fig. 16: FIG
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Fig. 15: FIG
Fig. 17: FIG
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Conclusion
The majority of patients presenting with peripheral lymphadenopathy have easily
identifiable causes that are benign or self-limited.
The critical challenge for the primary care physician is to identify which cases are
secondary to malignancies or other serious conditions.
While modern imaging techniques have improved the diagnostic yields of nodes and
their management, a complete exposure history, review of associated symptoms, and a
thorough regional examination help determine whether lymphadenopathy is of benign or
malignant origin.
References
Lymphadenopathy and Malignancy
ANDREW W. BAZEMORE, M.D., and DOUGLAS R. SMUCKER, M.D., M.P.H.
University of Cincinnati College of Medicine, Cincinnati, Ohio
Personal Information
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