Nodal shape (S/L) and its combination with size for assessment of cervical lymphadenopathy: which cut-off should be used?

Comparative analysis of diagnostic ultrasound and histopathology for detecting cervical lymph node metastases in head and neck cancer

PURPOSE

We evaluated the current performance of diagnostic ultrasound (US) for detecting cervical lymph node (LN) metastases based on objective measures and subjective findings in comparison to the gold standard, histopathological evaluation.

PATIENTS AND METHODS

From 2007 to 2016, we prospectively included patients with head and neck cancer who were scheduled for surgical therapy including neck dissection. LNs were examined by multimodal US by a level III head and neck sonologist and individually assigned to a map containing six AAO-HNS neck LN levels preoperatively. During the operation, LNs were dissected and then assessed by routine histopathology, with 86% of them examined individually and the remaining LNs (14%) per AAO-HNS neck LN level. The optimal cutoff points (OCPs) of four defined LN diameters and 2D and 3D roundness indices per AAO-HNS neck LN level were determined.

RESULTS

In total, 235 patients were included, and 4539 LNs were analyzed by US, 7237 by histopathology and 2684 by both methods. Of these, 259 (9.65%) were classified as suspicious for metastasis by US, whereas 299 (11.14%) were found to be positive by histopathology. Subjective US sensitivity and specificity were 0.79 and 0.99, respectively. The OCPs of the individual LN diameters and the 2D and 3D roundness index were determined individually for all AAO-HNS neck LN levels. Across all levels, the OCP for the 2D index was 1.79 and the 3D index was 14.97. The predictive performance of all distances, indices, and subjective findings improved with increasing metastasis size. Anticipation of pN stage was best achieved with subjective US findings and the smallest diameter (Cohen's κ = 0.713 and 0.438, respectively).

CONCLUSION

Our LN mapping and meticulous 1:1 node-by-node comparison reveals the usefulness of US for detecting metastatic involvement of neck LNs in head and neck carcinomas as compared to histopathology. The predictive ability for small tumor deposits less than 8 mm in size remains weak and urgently needs improvement.

Virtual touch tissue imaging quantification shear wave elastography for determining benign versus malignant cervical lymph nodes: a comparison with conventional ultrasound

PURPOSE

We aimed to prospectively examine virtual touch tissue imaging quantification (VTIQ) shear wave elastography (SWE) and conventional (B-mode and Doppler) ultrasonography (US), individually and combined, for their ability to differentiate benign and malignant cervical lymph nodes (CLNs).

METHODS

One hundred enlarged lymph nodes (LNs) from 72 patients, confirmed by histopathologic diagnoses, were included in the present study. B-mode US, Doppler US, and SWE were performed before histopathologic sampling of the LNs. The LN shear wave velocity (SWV, m/s) was assessed by VTIQ.

RESULTS

Using a 3.03 m/s cutoff value, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of SWVmax for differentiating benign and malignant CLNs were 93%, 59%, 68%, 91%, and 75%, respectively. B-mode and Doppler had a sensitivity, specificity, PPV, NPV, and accuracy of 79.2%, 71.2%, 71.6%, 78.7%, and 75%, respectively. B-mode, Doppler, and VTIQ SWE combined had 87.5%, 75%, 76.3%, 86.6%, and 81% for the same parameters, respectively.

CONCLUSION

VTIQ SWE is a promising noninvasive diagnostic imaging technique for differentiating benign and malignant CLNs. VTIQ SWV can improve the diagnostic performance of conventional US for differentiating benign and malignant CLNs.

Diagnosis of cervical lymph node metastases in head and neck cancer with ultrasonic measurement of lymph node volume

OBJECTIVE

The purpose of this study was to evaluate the usefulness of ultrasound (US) volume measurement of the cervical lymph nodes for diagnosing nodal metastasis in patients with head and neck cancer using a node-by-node comparison.

METHODS

Thirty-four consecutive patients with head and neck cancer from one tertiary university hospital were prospectively enrolled from 2012 to 2017. Patients with histologically proven squamous cell primary tumors in the head and neck region scheduled to undergo a therapeutic neck dissection were eligible. For each patient, 1-4 target lymph nodes were selected from the planned neck dissection levels. Lymph nodes with thickness >20 mm or in a cluster were excluded. Node-by-node comparisons between the pre-operative US assessment, the post-operative actual measurements and histopathological results were performed for all target lymph nodes. Quantitative measurements, such as three diameters, ratios of the three diameters and volume were analyzed in this study. Lymph node volume was calculated using the ellipsoid formula.

RESULTS

Patients comprised 28 men and 6 women with a mean age of 60.0 years (range, 29-80 years) at the time of surgery. In total, 67 target lymph nodes were analyzed in this study and the thickness ranged from 3.9 to 20.0 mm (mean 8.0 mm). There was a strong correlation between the US volume and post-operative actual volume (ρ = 0.87, p < 0.01). The US volume measured 2156 ± 2156 mm³ for the tumor positive nodes, which was significantly greater than the US volume of 512 ± 315 mm³ for tumor negative nodes (p < 0.01). Significant differences between tumor positive and tumor negative nodes were found in five variables (volume, thickness, major axis, minor axis and ratio of minor axis to thickness) for total lymph nodes. To identify predictors of lymph node metastasis, ROC curves of the US variables of target lymph nodes were compared, of which 4 variables were considered acceptable for predicting the lymph node metastasis: volume (AUC 0.86), thickness (AUC 0.86), major axis (AUC 0.79), and minor axis (AUC 0.79) for total lymph nodes. The optimal cut-off level for US volume in total lymph nodes was found to be 1242 mm³, whereby a 62% sensitivity and 98% specificity was reached (likelihood ratio: 25.2).

CONCLUSION

Pre-operative ultrasonic volume measurement of the cervical lymph nodes was useful for early detection of cervical nodal metastasis in head and neck cancer.

[Influence of external and endogenous factors on cervical lymph nodes : Sonographic study of size and morphology]

BACKGROUND

Sonographic evaluation of the dignity of cervical lymph nodes is essential for further diagnostics and treatment concepts in various diseases. The aim of this prospective monocenter study was to determine the sonomorphology and size of benign changes of lymph nodes in healthy subjects and patients who had undergone surgery, in order to examine the influence of various factors.

MATERIALS AND METHODS

Data from 205 healthy subjects and 15 patients before and after surgery were analyzed. Sonographically representative lymph nodes were measured in diameter and volumes were calculated; margins, the recognizability of a hilus, and vascularization were documented. A detailed medical history was taken using a standardized questionnaire.

RESULTS

In 20-39-year-olds, lymph node diameters were larger than in 40-59- and over 60-year-olds, and in 40-59-year-olds, the lymph nodes were larger than over 60-year-old subjects. Individuals with consumption of less than 10 and 10-20 cigarettes per day showed larger cervical lymph nodes compared to subjects with a consumption of more than 20 cigarettes per day. Smokers who additionally exercised routinely showed larger lymph nodes than those who never smoked or exercised. In addition, we observed that both the size and the number of cervical lymph nodes increased postoperatively compared to preoperative.

CONCLUSION

The recorded lymph nodes corresponded to the established sonographic criteria of benign lymph nodes. Our results show that age, smoking intensity, combination of smoking with sporting activity, and surgery influence the size of sonographically measured cervical lymph nodes.

Sonographic appearances of cervical lymph nodes in healthy young Japanese adults: Association with age, sex, and body mass index

PURPOSE

We investigated whether there was any association between age, sex, and body mass index (BMI) and nodal morphology and vascular pattern in healthy young Japanese adults.

METHODS

Three neck regions in 100 healthy subjects, 19-40 years old, were examined by gray-scale and color Doppler sonography. Vascular pattern was classified into three groups: avascular, hilar, or scattered. A linear mixed-effect model was used to identify associations of age, sex, or BMI with the short-axis diameter and the short-to-long axis diameter ratio (S/L). A cumulative link mixed model was used to identify any association between age, sex, BMI, and vascular pattern.

RESULTS

In the upper cervical region, a decrease in the short-axis diameter was statistically significantly associated with aging (p = 0.04), and an increase in the short-axis diameter was significantly associated with greater BMI (p < 0.001). An increase in short-axis diameter was significantly associated with female sex (p = 0.02) and higher BMI (p = 0.002) in the submandibular region, whereas it was associated with higher BMI (p = 0.001) in the submental region. A greater S/L was significantly associated with higher BMI and female sex in all regions. The scattered vascular pattern tended to be associated with lower BMI (p = 0.051) in the upper cervical region, but it was significantly associated with higher BMI (p = 0.01) in the submental region.

CONCLUSIONS

Nodal morphology and vascular pattern may be associated with age, sex, and BMI.

Modified sonoelastographic scale score for lymph node assessment in lymphoma - a preliminary report

Elastography is a new method of assessment of lymph node consistency. The majority of papers focus on metastases detection of head and neck or breast tumors. The typical desmoplastic reaction in connective tissue stroma in cancer, which is responsible for tissue's hardening, is seen in lymphoma less frequently.

Predictive factors for detecting malignancy in central and lateral cervical lymph nodes in papillary carcinoma of the thyroid

AIM

To determine the factors for predicting malignant diagnosis and limitations in ultrasonography guided fine-needle aspiration cytology of central and lateral cervical lymph nodes in patients with primary differentiated thyroid papillary carcinoma.

METHODS

Biopsies of cervical lymph nodes were performed in 120 patients, 31 of whom had subsequent surgical diagnoses. Factors examined were patient's age and gender of the patients, location (central and lateral compartments), hypoechogenicity with loss of hilum, microcalcification, cystic feature, minimum and maximum diameters and index value (minimum/maximum diameter).

RESULTS

The mean minimum diameter and index value of the lymph nodes were 9.9 ± 4.9 mm and 0.60 ± 0.19, respectively. Microcalcifications and cystic parts were specific findings with rates of 93.9% and 95.1%, respectively. Microcalcification, cystic feature, minimum diameter and index value were poor predictors of malignancy. The predictors were central location (P = 0.031) and hypoechogenicity with loss of hilum in lateral neck (P = 0.019). Central nodes led to a major problem for biopsy success due to postoperative changes and anatomic position. Nondiagnostic (30%) nodes were therefore mostly central.

CONCLUSION

The involvement of the central neck should be a major indication of lymph node biopsy and pathological diagnosis regardless of the imaging findings. In the lateral compartment, hypoechogenicity with loss of hilum, microcalcifications, cystic parts and an index value ≥ 0.51 are indications of a lymph node biopsy to rule out malignancy.

Ultrasound criteria of malignancy for cervical lymph nodes in patients followed up for differentiated thyroid cancer

CONTEXT

Neck ultrasonography (US) has become a keystone in the follow-up of patients with differentiated thyroid cancer.

OBJECTIVE

The aim of this study was to determine specificity and sensitivity of ultrasound criteria of malignancy for cervical lymph nodes (LNs) in patients with differentiated thyroid cancer.

DESIGN

We prospectively studied 19 patients referred to the Institut Gustave Roussy for neck LN dissection. All patients underwent a neck US within 4 d prior to surgery. Only LNs that were unequivocally matched between US and pathology were taken into account for the analysis.

RESULTS

One hundred three LNs were detected on US, 578 LNs were surgically removed, and 56 LNs were analyzed (28 benign and 28 malignant). Sensitivity and specificity were 68 and 75% for the long axis (> or =1 cm), 61 and 96% for the short axis (>5 mm), 46 and 64% for the round shape (long to short axis ratio < 2), 100 and 29% for the loss of fatty hyperechoic hilum, 39 and 18% for hypoechogenicity, 11 and 100% for cystic appearance, 46 and 100% for hyperechoic punctuations, and 86 and 82% for peripheral vascularization.

CONCLUSION

Cystic appearance, hyperechoic punctuations, loss of hilum, and peripheral vascularization can be considered as major ultrasound criteria of LN malignancy. LNs with cystic appearance or hyperechoic punctuations are highly suspicious of malignancy. LNs with a hyperechoic hilum should be considered as benign. Peripheral vascularization has the best sensitivity-specificity compromise. Round shape, hypoechogenicity, and the loss of hilum taken as single criteria are not specific enough to suspect malignancy.

Ultrasonography of Abnormal Neck Lymph Nodes

Ultrasonography is a useful imaging modality for assessing cervical lymphadenopathy in patients with head and neck carcinomas. Features of cervical lymph nodes using gray-scale and color and power Doppler ultrasonography can help to distinguish normal and reactive lymph nodes from potentially metastatic lymph nodes. The distinguishing features that separate abnormal from normal cervical lymph nodes include peripheral vascularity, shape, overall lymph node echogenicity, absence of hilus, presence of nodal microcalcifications, and cystic changes. Often, a combination of these features is needed to assign a cervical lymph node as being abnormal.

What is important for ultrasound evaluation of occult metastatic lymph nodes in laryngeal cancer: size, shape, vascularity or cytological findings?

The assessment of the status of the cervical lymph nodes in patients with a squamous cell carcinoma of the head and neck is still one of the most challenging diagnostic problems. We evaluated ultrasonography criteria with respect to their value for comparative determination of occult metastatic lymph nodes in laryngeal carcinoma. A prospective study was performed in 60 patients with laryngeal squamous cell carcinoma without enlarged neck nodes on CT scan. We used recommended sonography criteria for size, shape and vascularity for distinguishing metastatic and nonmetastatic nodes preoperatively and compared them with cytological and histopathological investigations. Fifty-two of 144 lymph nodes were involved with metastasis on histopathological examination. Respective values for ultrasound-guided fine needle aspiration cytology (USg FNAC) showed high sensitivity, specificity, positive and negative predictive values and accuracy (92, 100, 100, 96, and 97%, respectively). The size, shape and vascularity showed significantly lower values of these statistic parameters. USg FNAC is useful for preoperative evaluation of the neck, as the most reliable, inexpensive and easily available method. It is essential for diagnosis, staging and therapy choices.

[Significance of ultrasound and ultrasound-guided fine-needle aspiration for the detection of laryngeal occult metastases]

BACKGROUND/AIM

To evaluate ultrasound criteria based on a node size, shape, vascularity and cytology findings with respect to their value for the comparative determination of metastatic lymph nodes in laryngeal carcinoma.

METHODS

A prospective study included 30 patients with laryngeal squamous cell carcinoma without node enlargement on computerized tomography, at the Department of Otorhinolaryngology, the University Hospital, Zemun. Thirty-six neck lymph nodes were evaluated sonographically and aspirated with an ultrasound-guided fine-needle. They were examined cytologically and/or histopathologically and compared to the sonographic assessment of their malignancy.

RESULTS

Of the 36 neck lymph nodes evaluated cytologically, the 13 were found to be with a metastatic deposit. The assessment of a lymph node malignancy using the parameter of size had the senzitivity of 84%, the specificity of 70%, and the reliability of 75%. Using the criteria of a lymph node shape for the assessment of malignancy, the sensitivity of 61%, specificity of 65%, and the reliability of 64% were achieved. The evaluation of a lymph node vascularity by the use of the effect of Doppler showed the sensitivity of 69%, the specificity of 95%, and the reliability of 86%.

CONCLUSION

Ultrasound and ultrasound-guided fine-needle aspiration citology should be always used for the preoperative staging and for the postoperative follow-up of the status of the neck with cancer of the larynx becouse of their high accuracy, availability and semiinvasivity, and in order to enhance the reliability of the evaluation of the malignant disease progression.

Ultrasound in head and neck surgery: thyroid, parathyroid, and cervical lymph nodes

Ultrasound (US) of the neck is extremely sensitive in detecting thyroid, parathyroid, and cervical lymph node pathology, and is regarded as the most complete and cost-effective imaging method for evaluating the thyroid and parathyroid glands, as well as for the diagnostic evaluation of the cervical lymph node basin. US is widely used in screening high-risk individuals, evaluation of palpable and nonpalpable thyroid nodules, needle guidance for biopsy of nonpalpable and suspicious nodules, and preoperative evaluation of the extent of thyroid neoplasms, as well as in the detection of residual, recurrent, or metastatic thyroid tumors, and in observing nonsurgical cases. It has thus become an important adjunct to the practice of head and neck surgery.

Sonography of neck lymph nodes. Part I: normal lymph nodes

Grey scale and power Doppler sonography play an important role in assessment of cervical lymphadenopathy. However, before examination of pathological nodes, a clear understanding of the anatomy of cervical nodes, scanning technique and sonographic appearances of normal cervical nodes is essential. This article reviews these topics in order to provide a baseline for sonographic examination of cervical lymphadenopathy.

B-mode sonographic criteria for differential diagnosis of cervicofacial lymphadenopathy in cat-scratch disease and toxoplasmosis

BACKGROUND

Our purpose was to evaluate different sonographic parameters of cervicofacial lymphadenopathy caused by cat-scratch disease (CSD) and toxoplasmosis.

METHODS

By use of high-resolution B-mode sonography a total of 552 lymph nodes in the head and neck were detected between January 1997 and December 2001. There were 71 patients (422 lymph nodes) with CSD and 19 patients (130 lymph nodes) with toxoplasmosis. Sonographic variables, including 20 sonomorphologic features along with age and gender, were analyzed with multivariate logistic regression.

RESULTS

Heterogenous lymph nodes were more often found in CSD (p =.003), and nonsharp nodal borders showed a significant association with CSD (p =.0005). Multivariate analysis identified sharpness of borders (p =.0001), S/L ratio (p =.0006), and type of lymphadenopathy (acute, abscessed, chronic) (p =.0006) as most significant for differentiating between CSD and toxoplasmosis.

CONCLUSIONS

These results provide significant and useful criteria for ultrasonographic differentiation between CSD and toxoplasmosis.

Sonographic appearances of cervical lymph nodes: variations by age and sex

PURPOSE

The purpose of this study was to evaluate the age- and sex-related variations in the numbers and sonographic appearances of normal cervical lymph nodes.

METHODS

One hundred thirty-three healthy subjects (67 men and 66 women) underwent sonographic examinations of the neck, during which 1,299 lymph nodes were detected. The lymph nodes were assessed for their size, shape (short-to-long-axis ratio), and border sharpness, as well as for the presence of an echogenic hilum. The subjects were categorized by age (20-29, 30-39, 40-49, and > or = 50 years) and subcategorized by sex. The differences between the groups in the number of nodes and in their appearance were evaluated.

RESULTS

The mean number of nodes visualized on sonography was significantly higher (p < 0.05) in subjects aged 20-29 and 30-39 years than in subjects aged 40-49 and 50 years or older. The difference in the mean sizes of the cervical nodes between men and women was not statistically significant. The lymph nodes in subjects aged 20-29 and 30-39 years were commonly smaller than those in subjects aged 40-49 and 50 years or older, but the differences were not statistically significant. Neither the shape nor the border sharpness of the cervical lymph nodes varied significantly by age or sex. The incidence of an echogenic hilum within the lymph nodes increased significantly with age in both sexes (p < 0.05).

CONCLUSIONS

This study provides information about the sonographic appearances of and variations between normal cervical lymph nodes. The presence of an increased number of cervical lymph nodes and the absence of an echogenic hilum within the nodes may help to identify an abnormality more in older patients than in younger patients.

Gray-scale sonographic evaluation of cervical lymphadenopathy in cat-scratch disease

PURPOSE

The aim of this study was to characterize the gray-scale sonographic findings in the lymph nodes of patients with cat-scratch disease (CSD).

METHODS

We analyzed the sonograms of cervical lymph nodes in 41 patients with proven CSD between January 1997 and October 1999.

RESULTS

A total of 222 involved lymph nodes were detected. Involved nodes were most commonly found in the middle cervical (58%), parotid (37%), upper cervical (37%), and submandibular (17%) regions. We found acute, chronic, or abscessed lymphadenopathy in 63%, 12%, and 24% of patients, respectively. The size of involved lymph nodes ranged from 12 x 4 mm to 35 x 26 mm. The largest involved node had a short axis/long axis ratio of 0.5 or more in 61% of patients. Useful features for the differential diagnosis included markedly decreased echogenicity (100%), normal surrounding tissues (100%), and the presence of an echogenic hilum (76%). Posterior sound enhancement was significantly associated with larger and abscessed lymph nodes.

CONCLUSIONS

Despite the absence of a specific sonographic finding for CSD, gray-scale sonography can provide clues to the diagnosis of CSD in the proper clinical setting.