Contrast-enhanced color Doppler sonography for evaluation of enlarged cervical lymph nodes in head and neck tumors

Value of Assessing Peripheral Vascularization with Micro-Flow Imaging, Resistive Index and Absent Hilum Sign as Predictor for Malignancy in Lymph Nodes in Head and Neck Squamous Cell Carcinoma

Simple Summary

Ultrasound-guided fine needle aspiration cytology (USgFNAC) is commonly used for N-staging in head and neck squamous cell carcinoma (HNSCC). The specificity of USgFNAC is always in the order of 100% as false positive cytology is rare. The difference in sensitivity is mainly attributable to selection of the lymph nodes to aspirate and aspiration technique. The aim of this study was to improve the selection criteria of lymph nodes to aspirate. Ultrasound features of nodes such as a short axis diameter, S/L ratio, loss of a fatty hilum sign, resistive index, and peripheral or mixed hilar and peripheral vascularization, obtained by Micro-flow imaging (MFI), which is a new technique to obtain micro-vascularization, were evaluated. To calculate the sensitivity and PPV of each feature, data of sonographic findings and cytological results of all aspirated nodes were statistically analyzed. We found that next to size, peripheral vascularisation obtained by MFI and absent hilum sign have a high predictive value for malignancy and should be added as selection criteria for fine needle aspiration in lymph nodes.

Abstract

Ultrasound-guided fine needle aspiration cytology (USgFNAC) is commonly used for nodal staging in head and neck squamous cell cancer (HNSCC). Peripheral vascularity is a described feature for node metastasis. Micro-flow imaging (MFI) is a new sensitive technique to evaluate micro-vascularization. Our goal is to assess the additional value of MFI to detect malignancy in lymph nodes. A total of 102 patients with HNSCC were included prospectively. USgFNAC was performed with the Philips eL18–4 transducer. Cytological results served as a reference standard to evaluate the prediction of cytological malignancy depending on ultrasound features such as resistive index (RI), absence of fatty hilum sign, and peripheral vascularization. Results were obtained for all US examinations and for the subgroup of clinically node-negative neck (cN0). USgFNAC was performed in 211 nodes. Peripheral vascularization had a positive predictive value (PPV) of 83% (cN0: 50%) and the absence of a fatty hilum had a PPV of 82% (cN0 50%) The combination of peripheral vascularization and absent fatty hilum had a PPV of 94% (cN0: 72%). RI (threshold: 0.705) had a PPV of 61% (cN0: RI-threshold 0.615, PPV 20%), whereas the PPV of short axis diameter (threshold of 6.5mm) was 59% for all patients and 19% in cN0 necks (threshold of 4 mm). Peripheral vascularization assessed by MFI and absent hilum has a high predictive value for cytological malignancy in neck metastases. Next to size, both features should be used as additional selection criteria for USgFNAC.

Application of multimodal ultrasonography for differentiating benign and malignant cervical lymphadenopathy

OBJECTIVES

The purpose of this study was to evaluate the diagnostic value of multimodal ultrasonography, including SWE and CEUS, for the differentiation of benign and malignant cervical lymphadenopathy.

METHODS

A total of 103 patients with 109 enlarged neck lymph nodes underwent SWE and CEUS. There were 25 hyperplastic lymph nodes, 66 metastatic lymph nodes, and 18 cases of lymphoma.

RESULTS

Using 31.6 kPa as the Emax cutoff, the sensitivity, specificity and accuracy of measurements on both benign and malignant cervical lymph nodes were 55.95%, 96%, and 65.2%, respectively. CEUS showed that lymph nodes with reactive hyperplasia mainly exhibited uniform perfusion via the lymphatic hilum (18/25; 72%; P < 0.01). The main manifestation of lymphoma was uniform perfusion through the lymphatic hila (10/18; 55.6%; P < 0.01). Metastatic lymph nodes mainly exhibited uneven perfusion (57/66; 86.4%; P < 0.01). The sensitivity, specificity, and accuracy of multimodal ultrasonography for the diagnosis of benign and malignant cervical lymphadenopathies were 90.5%, 72%, and 86.2%, respectively.

CONCLUSIONS

Our findings suggest that multimodal ultrasonography can detect the stiffness (elasticity), perfusion pattern, and characteristics of lymph nodes and is a valuable tool for differentiating between benign and malignant lymphadenopathies.

Comparison of contrast-enhanced ultrasound and contrast-enhanced computed tomography for the diagnosis of cervical lymph node metastasis in squamous cell carcinoma of the oral cavity

Early detection of cervical lymph node metastasis (CLNM) from squamous cell carcinoma (SCC) of the oral cavity remains challenging. This prospective study was performed to evaluate the ability of contrast-enhanced ultrasound (CEUS) to detect CLNM from oral cavity SCC. Additionally, its diagnostic value was compared with that of contrast-enhanced computed tomography (CECT). Forty-eight consecutive patients with SCC of the oral cavity were enrolled. All subjects were examined preoperatively with both CEUS and CECT. Subsequently, neck dissections were performed for these patients, and cervical lymph nodes separated from the surgical specimens were assessed histologically. The diagnostic performance of these two examinations was compared based on the results of histopathology. The sensitivity, specificity, accuracy, positive predictive value, negative predictive value, and Youden index for CEUS and CECT were 69.39% vs. 44.90%, 94.71% vs. 97.12%, 89.88%% vs. 87.16%, 75.56% vs. 78.57%, 92.92% vs. 88.21%, and 64.10% vs. 42.02%, respectively. A significant difference was observed in terms of sensitivity (P=0.024) and Youden index (rate difference 22.08%, 95% confidence interval 2.72-41.44%). Therefore, CEUS appears to be a promising diagnostic tool that is superior to CECT for detecting CLNM from SCC of the oral cavity, with a higher sensitivity.

A decision analysis model for elective neck dissection in patients with cT1-2 cN0 oral squamous cell carcinoma

Neck metastasis from oral squamous cell carcinoma (OSCC) has a significant impact on disease-specific and overall survival. Physical examination and imaging exams are used to stage the neck, but preoperative neck staging cannot reliably differentiate between metastatic and non-metastatic nodes. The decision to perform elective neck dissection (END) should consider the probability of neck metastasis and the harm of unnecessary surgery. We evaluate if this model can be used to decide treatment and the net benefit with different strategies. We reviewed patients treated from January, 1985 to December, 2012. Inclusion criteria were histological diagnosis of OSCC, initial surgery and primary tumour in the oral cavity staged as cT1-2 cN0. Development of a predictive model for metastatic nodes used patients submitted to END. The probability of neck metastasis was calculated and decision curve analysis was performed. We considered two interventions: watchful waiting and END, and two outcomes, regional recurrence and disease-free survival. We developed the model using logistic regression after multiple inputs with neck metastasis as an outcome. The initial model included all demographic and pathological variables. This model has an area under the curve (AUC) of 0.8423, a positive predictive value (PPV) of 70.7% and a negative predictive value (NPV) of 80.2%. We used LASSO for coefficient reduction and variable selection. This model has an AUC of 0.8265 with PPV of 68.3% and NPV of 80.2%. For neck recurrence, the curves of “treat all by watchful waiting” and “treat none by watchful waiting” crossed at the prevalence of neck metastasis. When focusing on disease-free survival, the decision analysis curve shows a pattern where the predictive model provides a net benefit if used to choose treatment from a 20% until a 54% threshold.

Diagnostic Accuracy of Axillary Ultrasonography Compared with Intra-operative Pathological Findings in Patients with Breast Cancer

Objective:

Breast cancer is the most common cancer and leading cause of mortality in women worldwide. Diagnosis of axillary lymph node involvement, frequently by axillary ultrasonography (AUS), is an important step in patients with primary breast cancer, while the gold standard pathological examination is only applicable during surgery. Thus, we aimed to evaluate the predictive value of AUS in detection of lymph node involvement.

Methods:

A total of 56 patients with primary breast cancer, who were candidate of mastectomy were included in this study. A single radiologist performed pre-operative axillary sonography for all the patients and reported the results in a checklist. The results were then compared with intra-operative pathological results of lymph node dissection to evaluate the sensitivity, specificity, positive and negative predictive values of AUS in detection of the disease.

Result:

The results showed that pre-operative AUS had a sensitivity of 63.3%, specificity of 84.6%, positive predictive value of 82.6%, and negative predictive value of 66.6%. Correlation between axillary lymph node characteristics revealed that the absence of fatty hilum, cortical thickness, and loss of ovality of the lymph nodes were the most specific factors in detection of lymph nodes’ involvement.

Conclusion:

AUS has a low sensitivity and cannot determine the presence of micro-metastases and suspicious lymph nodes accurately in early stages of the disease, and it seems that defining new parameters may help for increasing the sensitivity and specificity of the axillary lymph node sonography. Apparently, pathological examination remains the gold standard diagnostic method.

Contrast-enhanced ultrasound for the differential diagnosis between benign and metastatic superficial lymph nodes: a meta-analysis

Purpose

Contrast-enhanced ultrasound (CEUS) is a new technique used to distinguish benign from metastatic superficial lymph nodes (LNs) with variable accuracy. The objective of this meta-analysis was to evaluate the accuracy of CEUS for the diagnosis of superficial metastatic LNs.

Methods

A comprehensive literature search of PubMed, Web of Science, Medline, Embase, and the Cochrane Library was performed until April 2018. Nine articles reporting the diagnosis of 436 LNs by CEUS were investigated. The Mantel–Haenszel and DerSimonian–Laird methods were used to analyze pooled sensitivity, specificity, diagnostic OR, positive likelihood ratio (LR), and negative LR, and a summary receiver operating characteristic (SROC) curve was also evaluated.

Results

The pooled sensitivity and specificity of CEUS for the differential diagnosis of benign and metastatic superficial LNs were 0.88 (95% CI, 0.83–0.92) and 0.80 (95% CI, 0.74–0.85), respectively. The pooled positive LR, negative LR, and diagnostic OR were 4.36 (95% CI, 2.38–7.99), 0.17 (95% CI, 0.10–0.31), and 32.75 (95% CI, 11.08–96.84), respectively. SROC area under the curve (AUC) was 0.9288. The subgroup analysis excluding outliers implied that the heterogeneity was almost eliminated, and the pooled sensitivity and specificity were 0.87 (95% CI, 0.81–0.92) and 0.79 (95% CI, 0.71–0.85), respectively. The SROC AUC was 0.8950.

Conclusion

CEUS, a novel imaging modality for the characterization of superficial LNs, shows a high sensitivity and specificity in the diagnosis of superficial metastatic LNs. The different diagnostic standards, contrast agents, and contrast modes contribute to a considerable level of heterogeneity among studies. A uniform standard for distinguishing between benign and metastatic LNs is needed for further clinical application.

Applications of 3-Dimensional Ultrasonography in the Neck, Excluding the Thyroid

Ultrasonography (US) of the neck is an accepted, useful imaging modality for many applications beyond its usefulness in thyroid disease. Two-dimensional US has been effectively used for evaluation of many types of neck conditions, and now, 3-dimensional US can be added to the imaging armamentaria. Three-dimensional US is useful in the evaluation of cervical lymph nodes, recurrent/residual thyroid neoplasia, parathyroid glands, parotid and submandibular glands, as well as thyroglossal duct cysts and other assorted palpable and visible abnormalities because of its unique capabilities, including multiplanar reconstruction, accessibility of the coronal view, volume calculation, and regularly spaced incremental slice evaluation.

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.

Monitoring of Blood Vessel Density Using Contrast-Enhanced High Frequency Ultrasound May Facilitate Early Diagnosis of Lymph Node Metastasis

Time-dependent alterations in the ultrasonography characteristics of lymph nodes during early-stage metastasis have not been compared with those of tumor-draining lymph nodes that do not develop tumor; this is partly due to the absence of an appropriate experimental model. In a previous study of lymph nodes with experimental early-stage metastasis, we used contrast-enhanced high-frequency ultrasound to demonstrate that an increase in lymph node blood vessel density preceded any changes in lymph node volume. In the present study, we used an experimental model of lymph node metastasis in which tumor cells metastasized from the subiliac lymph node to the proper axillary lymph node (the tumor-draining lymph node). We utilized contrast-enhanced high-frequency ultrasound to perform a longitudinal analysis of tumor-draining lymph nodes, comparing those at an early-stage of metastasis with those that did not develop detectable metastasis. We found that the normalized blood vessel density of an early-stage metastatic lymph node exhibited a progressive rise, whereas that of a tumor-draining lymph node not containing tumor began to increase later. For both types of lymph nodes, the normalized blood vessel density on the final day of experiments showed a trend towards being higher than that measured in controls. We further found that mice with an initially low value for lymph node blood vessel density subsequently showed a larger increase in the blood vessel density of the metastatic lymph node; this differed significantly from measurements in controls. The present study indicates that a longitudinal analysis of the blood vessel densities of tumor-draining lymph nodes, made using contrast-enhanced high-frequency ultrasound imaging, may be a potentially promising method for detecting early-stage lymph node metastasis in selected patients. Furthermore, our findings suggest that tumor in an upstream lymph node may induce alteration of the vascular structures in draining lymph nodes that do not contain tumor.

Contrast-enhanced endobronchial ultrasound: Potential value of a new method

Endobronchial ultrasound (EBUS) has gained importance for mediastinal lymph node staging. Contrast-enhanced EBUS is so far not a discussed technique including contrast-enhanced high mechanical index (MI)-EBUS and potentially contrast-enhanced low MI-EBUS. Possible use could include characterization of mediastinal lymph nodes for better selection of biopsies, differential diagnosis of the primary tumor, and evaluation of thrombosis or tumor in vein infiltration.

Role of contrast-enhanced endoscopic ultrasound in lymph nodes

Diagnosing unclear lymph node (LN) enlargements in the mediastinum and abdomen is the most important indication of endoscopic ultrasound (EUS)-fine needle aspiration (FNA) after the diagnosis and treatment of pancreatic diseases. Investigating LNs in these areas can happen in different clinical settings. Mostly, it is the first modality in general LN diseases without any peripheral LN enlargements. On the other hand, it can be the question of LN involvement in a known or suspected primary tumor. Due to EUS-FNA cytology, those questions can be answered highly, accurately. However, a primary discrimination of LNs might be helpful to increase the diagnostic value of the FNA cytology, especially in cases with multiple LN enlargements and hard to reach enlarged LNs for example by vessel interposition. Because of the unreliability of B-mode criteria, further diagnostic improvements such as elastography and contrast-enhanced EUS are investigated to increase the accuracy of the initial diagnosis.

Shear Wave Elastography in Head and Neck Lymph Node Assessment: Image Quality and Diagnostic Impact Compared with B-Mode and Doppler Ultrasonography

The aim of this study was to assess the diagnostic performance of shear wave elastography (SWE) in comparison to B-mode and Doppler ultrasonography in differentiating benign from malignant head and neck lymph nodes (HNLNs). Sixty-two HNLNs from 56 patients were prospectively examined using B-mode, Doppler and SWE. The standard of reference was histopathology or cytology and follow-up. Qualitative malignant criteria (hilum infiltration, cortical hypo-echogenicity, irregular margins, abnormal vessels) were assessed on a five-point scale. Four quantitative parameters were obtained: long axis length, short axis length, short axis/long axis ratio, resistive index and maximum shear elasticity modulus (μmax). Diagnostic performance was analyzed with special emphasis on the sub-centimeter HNLN subgroup. Thirty HNLNs were malignant (48%). μmax intra-observer reproducibility was 0.899 (0.728 in sub-centimeter subgroup). Malignant HNLNs were stiffer (μmax = 72.4 ± 59.0 kPa) compared with benign nodes (μmax = 23.3 ± 25.3 kPa) (p < 0.001). Among the quantitative criteria, μmax had the highest diagnostic accuracy (area under the curve = 0.903 ± 0.042), especially in the sub-centimeter subgroup (area under the curve = 0.929 ± 0.045; p < 0.001) in which the area under the curve was significantly higher compared with the other quantitative criteria (p < 0.05). The additional use of SWE combined with B-mode tended to improve diagnostic accuracy (p > 0.05). SWE is a promising reproducible quantitative tool with which to predict malignant HNLNs, especially sub-centimeter nodes.

Value of contrast-enhanced ultrasonography in the differential diagnosis of enlarged lymph nodes: a meta-analysis of diagnostic accuracy studies

OBJECTIVE

To evaluate the diagnostic accuracy of contrast-enhanced ultrasonography (CEUS) in differentiating between benign and malignant enlarged lymph nodes using meta-analysis.

MATERIALS AND METHODS

Pubmed, Embase, SCI and Cochrane databases were searched for studies (up to September 1, 2014) reporting the diagnostic performance of CEUS in discriminating between benign and malignant lymph nodes. Inclusion criteria were: prospective study; histopathology as the reference standard; and sufficient data to construct 2?2 contingency tables. Methodological quality was assessed using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). Patient clinical characteristics, sensitivity and specificity were extracted. The summary receiver operating characteristic curve was used to examine the accuracy of CEUS. A meta-analysis was performed to evaluate the clinical utility in identification of benign and malignant lymph nodes. Sensitivity analysis was performed after omitting outliers identified in a bivariate boxplot and publication bias was assessed with Egger testing.

RESULTS

The pooled sensitivity, specificity and AUROC were 0.92 (95%CI, 0.85-0.96), 0.91 (95%CI, 0.82-0.95) and 0.97 (95%CI, 0.95-0.98), respectively. After omitting 3 outlier studies, heterogeneity decreased. Sensitivity analysis demonstrated no disproportionate influences of individual studies. Publication bias was not significant.

CONCLUSIONS

CEUS is a promising diagnostic modality in differentiating between benign and malignant lymph nodes and can potentially reduce unnecessary fine-needle aspiration biopsies of benign nodes.

Contrast-Enhanced Color Doppler Ultrasonography for Preoperative Evaluation of Sentinel Lymph Node in Breast Cancer Patients

BACKGROUND

Sentinel lymph node (SLN) biopsy is the standard of care for breast cancer patients with non-palpable axillary lymph nodes. We evaluated the usefulness of contrast-enhanced ultrasonography in preoperative detection of malignant SLNs.

METHODS

50 patients with breast cancer (median age: 60 years) underwent a color power Doppler ultrasonography with intravenous contrast (Sonovue®) preoperatively, and findings suggestive of metastatic disease to the SLN were documented. The final histopathological report and the radiological preoperative record were compared. Finally, the sensitivity, specificity and diagnostic accuracy of this evolving diagnostic modality were calculated.

RESULTS

Contrast-enhanced ultrasound scan identified a negative SLN in the axilla of 27 patients and final histopathology was negative for 30 cases in total, so negative predictive value was calculated as 90% and positive predictive value was 75%. Overall sensitivity was 83.33% and specificity was 84.38%. Moreover, the ability of contrast-enhanced ultrasound to differentiate between SLN status was only statistically significantly correlated with the actual final histopathological report (p < 0.001), while successful ultrasound prediction was not correlated with any factor.

CONCLUSIONS

SLN status can be evaluated preoperatively using contrast-enhanced color Doppler ultrasonography with high accuracy.

Cervical lymphadenopathy: study of 251 patients

Correct diagnosis of cervical lymphadenopathy is often a great challenge. The objective of this case study is to describe the distribution of the most common causes of unclear neck swellings presented in an ENT-Department and to evaluate the clinical history, examination and laboratory findings. In a retrospective study at the Department of Otorhinolaryngology, University Medical Center Homburg/Saar, 251 patients were enrolled with clinical and ultrasound signs of cervical lymphadenopathy as well as lymph node extirpation for histopathological evaluation. 127 patients (50.6 %) had a histological malignant finding. The distribution of the most common pathological conditions was as follows: Non-specific reactive hyperplasia n = 89 (35.5 %), metastases n = 86 (34.3 %), lymphoma n = 41 (16.3 %), granulomatous lesions n = 15 (6 %), abscess formations n = 5 (2 %), necrotic lymphadenitis and Castleman's disease one case of each, lymph node with normal architecture n = 7 (2.8 %), and neck masses mimicking lymphadenopathy n = 6 cases (2.4 %). The following factors identified by multivariate logistic regression were significantly associated to malignant lymphadenopathy: increasing age, generalized lymphadenopathy and history of malignant disorder, fixed neck masses and increasing diameter in ENT examination, bulky lesion, absence of hilus, blurred outer contour, protective role of the long form and decreasing Solbiati-index values by ultrasound B-Mode gray scale examination. Level II contained more benign lymphatic lesions, while the malignancy rate in level IV and V was enhanced. Laboratory parameters significantly associated to malignancies were CRP, LDH and thrombocytopenia. Patients with persisting cervical lymphadenopathy and over 3 weeks of antibiotic treatment should be considered for early biopsy, especially if some of the risk factors, pointed out in this study, are present.

Contrast-enhanced ultrasound (CEUS) facilitated US in detecting lateral neck lymph node metastasis of thyroid cancer patients: diagnosis value and enhancement patterns of malignant lymph nodes

OBJECTIVES

To examine the value of CEUS as a non-invasive tool in detecting lateral neck metastasis (LNM) and the enhancement patterns of malignant lymph nodes (LN) for thyroid cancer patients.

METHODS

Eighty-two consecutive patients, who underwent both preoperative non-enhanced US and CEUS examinations, were retrospectively reviewed. All patients underwent lateral neck dissection (LND). Enhancement patterns of 102 collected LNs matching to CEUS findings were analyzed.

RESULTS

CEUS detected LNM in 53 of 65 patients, showing a higher sensitivity and accuracy than that of conventional US (p = 0.109 and p = 0.154, respectively). Thirteen patients' surgical procedures were altered by CEUS findings, including nine true positive and four false positive cases. Five patients' surgical procedures were altered by conventional US findings, including two true positive and three false positive cases. Heterogeneous enhancement, perfusion defects, microcalcification, and centripetal/hybrid enhancement were all specific criteria for malignant LNs in univariate analysis. In multivariate analysis, only heterogeneous enhancement and centripetal/hybrid enhancement were significantly related to LN metastasis (p = 0.000 and p = 0.037, respectively).

CONCLUSIONS

CEUS may be a potential tool to facilitate conventional US in detecting LNM. Heterogeneous enhancement and centripetal/hybrid enhancement are useful criteria to distinguish between malignant and benign LNs.

KEY POINTS

• CEUS findings facilitated conventional US in detecting LNM. • Heterogeneous, centripetal/hybrid enhancement, microcalcification and perfusion defects were specific criteria of malignant LNs. • Heterogeneous and centripetal/hybrid enhancement were significantly related to LN metastasis in multivariate analysis.

Diagnostic accuracy of sonography versus magnetic resonance imaging for primary nasopharyngeal carcinoma

OBJECTIVES

The purpose of this study was to prospectively assess the accuracy of sonography versus magnetic resonance imaging (MRI) for a diagnosis of primary nasopharyngeal carcinoma.

METHODS

A total of 150 patients suspected of having nasopharyngeal carcinoma underwent sonography and MRI. A diagnosis was obtained from an endoscopic biopsy that was collected from the suspected tumor or a normal nasopharynx. The diagnostic performance of sonography and MRI for nasopharyngeal carcinoma was evaluated by receiver operating characteristic curve analysis. The sensitivity and specificity of the two imaging methods were compared by the McNemar test.

RESULTS

Nasopharyngeal carcinoma was present in 71 of 150 patients (47.3%) and absent in 79 (52.7%). The sensitivity, specificity, and accuracy of sonography versus MRI for these cases were 90.1%, 84.8%, and 87.3% for sonography and 97.2%, 89.9%, and 93.3% for MRI, respectively. Both sonography and MRI had good diagnostic performance for nasopharyngeal carcinoma, with area under the curve values of 0.958 and 0.987, respectively. There was no significant difference in the rate of tumor detectability between sonography and MRI (P = .12), and the specificities of sonography and MRI were similar (P = .22).

CONCLUSIONS

Both sonography and MRI are useful tools for clinical screening of nasopharyngeal carcinoma. However, sonography is less expensive and easier to perform. The results of this study also suggest that nasopharyngeal sonography could be used for the initial investigation of primary cancer in patients suspected of having nasopharyngeal carcinoma.

Review of ultrasonography of malignant neck nodes: greyscale, Doppler, contrast enhancement and elastography

Assessment of neck lymph nodes is essential in patients with head and neck cancers for predicting the patient’s prognosis and selecting the appropriate treatment. Ultrasonography is a useful imaging tool in the assessment of neck lymph nodes. Greyscale ultrasonography assesses the size, distribution, and internal architecture of lymph nodes. Doppler ultrasonography evaluates the intranodal vascular pattern and resistance of lymph nodes. Contrast-enhanced ultrasonography provides information on lymph node parenchymal perfusion. Elastography allows qualitative and quantitative assessment of lymph node stiffness. This article reviews the value of greyscale, Doppler and contrast-enhanced ultrasonography as well as elastography in the assessment of malignant nodes in the neck.

Chronic cervical lymphadenopathy in children: Role of ultrasonography

Aim:

To assess the usefulness of ultrasonography in the differentiation of causes of chronic cervical lymphadenopathy in children.

Materials and Methods:

Children with palpable cervical lymph nodes were included. An ultrasonographic examination was performed to delineate multiple lymph nodes, irregular margins, tendency towards fusion, internal echos, the presence of strong echoes and echogenic thin layer.

Results:

The total number of patients was 120. Echogenic thin layer and strong internal echoes were specific for tuberculosis. Long axis to short axis (L/S) ratio was more than 2 in most of the tubercular nodes (85.71%). Hilus was present in 50 (73.53%) tubercular lymphadenitis, 12 (40%) lymphoma and 10 (62.5%) cases with metastatic lymph nodes. Hypoechoic center was present in 60 (88.24%) tubercular lymphadenitis cases followed by 62.5% metastatic and 60% malignant lymphoma cases.

Conclusions:

Ultrasonography is a non-invasive tool for lymph nodal evaluation in children. It may be used to differentiate cervical lymphadenopathy with different etiologies in children. When correlated clinically, it may avoid biopsy in a patient.

Efficiency of ultrasonography in assessing cervical lymph node metastasis in oral carcinoma

Objectives

The study was conducted to assess the value of ultrasonography (USG) for lymph node metastasis in patients with carcinoma of oral cavity.

Materials and Methods:

A total of 20 cases were selected with primary tumor of oral cavity. Ninety-two lymph nodes were detected by ultrasound of 5 mm or more in diameter. The patients were examined preoperatively for palpable lymph nodes clinically and ultrasonographic examination of bilateral neck. Ultrasonographic parameters, such as size, shape, boundaries (well-delineated/ poorly delineated) and internal echoes for the lymph nodes were recorded.

Results:

The histologic positive rate was 25%, 80% and 93% for nodes between 5 and 10 mm, 10 and 15 mm and for nodes 15 mm or more in size, respectively. Ultrasonographic findings showed a high significance as the size of nodes increases. The positive rate of 86% for the round nodes of 9 mm or more in size showed a high significance. The positive rate was 93% for well-delineated nodes and 68% for poorly delineated nodes. The most frequent echo pattern was homogenous followed by hypoechoic with positive rate for metastasis ranging from 83% to 88%.

Conclusion:

The diagnostic validity of USG as compared with histopathology showed sensitivity of 86% and specificity of 73% with overall efficiency of about 82% in detecting lymph node metastasis. USG 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.

Contrast-enhanced sonography in pediatrics

Microbubble US contrast agents are composed of an outer shell of protein, phospholipid or polymer that encase air or perfluorocarbon gas. These contrast agents have been widely used in adult cardiology patients to improve endocardial border delineation and have been proved safe and well tolerated in this patient population. There is also a growing body of literature elucidating the value of contrast-enhanced sonography to distinguish benign from malignant liver lesions in adults and to characterize non-hepatic adult malignancies. Because these agents have not been approved for pediatric use in many countries, less is known of the value of contrast-enhanced sonography in children. In this review I will discuss several proven and potential pediatric applications of contrast-enhanced sonography.

Contrast-enhanced ultrasound imaging of sentinel lymph nodes after peritumoral administration of Sonazoid in a melanoma tumor animal model

OBJECTIVES

The purpose of this study was to compare lymphosonography (ie, contrast-enhanced ultrasound imaging [US] after interstitial injection of a US contrast agent) for the detection of sentinel lymph nodes (SLNs) in swine with naturally occurring melanoma tumors to lymphoscintigraphy using blue dye-guided surgical dissection as the reference standard. Also, we sought to determine if lymphosonography can be used to characterize SLNs.

METHODS

Sixty-three swine with 104 melanomas were evaluated. Contrast-specific US was performed after peritumoral injection (1 mL dose) of Sonazoid (GE Healthcare, Oslo, Norway). Lymphoscintigraphy was performed after peritumoral injections of technetium Tc 99m sulfur colloid. Peritumoral injection of 1% Lymphazurin (Ben Venue Labs, Inc, Bedford, OH) was used to guide SLN resection. The accuracy of SLN detection with the two imaging modalities was compared using the McNemar test. The SLNs were qualitatively and quantitatively characterized as benign or malignant based on the lymphosonography results with histopathology and RNA analyses used as the reference standards.

RESULTS

Blue dye-guided surgery identified 351 SLNs. Lymphosonography detected 293 SLNs and 11 false-positives, while lymphoscintigraphy detected 231 SLNs and 20 false-positives. The accuracy of SLN detection was 81.8% for lymphosonography, which was significantly higher than the 63.2% achieved with lymphoscintigraphy (P < .0001). The accuracy of lymphosonography for SLN characterization was 80%. When the size of the enhanced SLN was taken into consideration to characterize SLNs, the accuracy was 86%.

CONCLUSIONS

Lymphosonography is statistically better than lymphoscintigraphy for the detection of SLNs in this animal model. The ability to use lymphosonography as a means to characterize SLNs as benign or malignant is limited.

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.

Sonographic management of mediastinal syndrome

INTRODUCTION

Mediastinal syndrome is suspected on the basis of clinical symptoms and is generally confirmed by chest radiography or computed tomography (CT). However, also grey scale ultrasound (US) and contrast enhanced US (CEUS) are useful in this hematologic emergency as they provide the possibility to perform US-guided biopsy and histological diagnosis.

MATERIALS AND METHODS

15 Patients affected by mediastinal syndrome were prospectively studied using B-mode US and CEUS; 13 of these patients, who had no other lesions, were proposed for US-guided biopsy of the mediastinal mass, but only in 12 patients biopsy was technically possible.

RESULTS

In this study, B-mode US reached an excellent sensitivity (100%) in evidencing the lesions but a low specificity which did not exceed 30-40%. CEUS reached an elevated specificity identifying neoplastic pathologies if both the early and the late phases are considered (90-86.6%). US-guided biopsy was possible in 92.3% of lesions showing a diagnostic adequacy of 91.66%.

CONCLUSIONS

B-mode US associated with CEUS and US-guided biopsy reached an elevated accuracy in the diagnosis of mediastinal masses. If these results are confirmed by further studies, this diagnostic procedure could be included in the routine management of mediastinal syndrome.

Neck masses: evaluation and diagnostic approach

Oral and maxillofacial surgeons frequently deal with patients who present with an unknown neck mass. Formulation of a differential diagnosis is essential and requires that the surgeon bring to bear a host of skills to systematically arrive at a definitive diagnosis and ensure that the correct treatment is rendered. This article highlights some of the skills needed in the workup of neck masses and reviews some of the available techniques that aid in achieving the correct diagnosis.

Ultrasound of malignant cervical lymph nodes

Malignant lymph nodes in the neck include metastases and lymphoma. Cervical nodal metastases are common in patients with head and neck cancers, and their assessment is important as it affects treatment planning and prognosis. Neck nodes are also a common site of lymphomatous involvement and an accurate diagnosis is essential as its treatment differs from other causes of neck lymphadenopathy. On ultrasound, grey scale sonography helps to evaluate nodal morphology, whilst power Doppler sonography is used to assess the vascular pattern. Grey scale sonographic features that help to identify metastatic and lymphomatous lymph nodes include size, shape and internal architecture (loss of hilar architecture, presence of intranodal necrosis and calcification). Soft tissue oedema and nodal matting are additional grey scale features seen in tuberculous nodes or in nodes that have been previously irradiated. Power Doppler sonography evaluates the vascular pattern of nodes and helps to identify the malignant nodes. In addition, serial monitoring of nodal size and vascularity are useful features in the assessment of treatment response.

The role of ultrasound in the detection of cervical lymph node metastases in clinically N0 squamous cell carcinoma of the head and neck

Nodal involvement is the most important prognostic factor in head and neck squamous cell carcinoma (HNSCC) of mucosal origin. The presence of a single ipsilateral or contralateral metastatic node reduces survival by 50% and bilateral disease by a further 50%. The management of N+ HNSCC is relatively clear-cut. By contrast, the investigation and treatment of patients with clinically N0 disease is controversial. Most institutions electively treat the neck with surgery or radiotherapy because the risk of occult metastases is over 20%, even though it will be unnecessary in the majority of cases. In this situation the main purpose of staging would be to assess those nodes that are not going to be removed. However, the optimal management of the clinically N0 neck remains controversial and there is growing interest in a more conservative approach. Research is now directed toward finding a method of staging sensitive enough to bring the risk of occult metastases below 20%. High spatial resolution, ease of multiplanar scanning, power Doppler and the ability to perform guided fine-needle aspiration for cytology give ultrasound (US) an advantage over other imaging techniques.

Tissue characterization of locoregionally advanced head-and-neck squamous cell carcinoma (HNSCC) using quantified ultrasonography: A prospective phase II study on prognostic relevance

BACKGROUND AND PURPOSE

Information on a patient's prognosis is important for the clinical decision-making process. This study explored the capacity of quantitative ultrasound imaging to increase prognostic information.

MATERIALS AND METHODS

High-resolution B-scan and colour-coded duplex-sonography of the neck was prospectively applied to 50 HNSCC-patients stage IVA-B 05/99-01/02 before definite radio-(chemo-)therapy. Every lymph node >1.5 cm was scored for the following Malignancy Criteria: Inhomogeneity, Surface-irregularity, Missing hilar sign, Spherical form, Matting, Aberrant intranodal vessels, Infiltration of surrounding tissue, Intranodal cystic necrosis.

RESULTS

Median Overall Survival (OS) was 1 year. High MMCC (Maximal Malignancy Criteria Count in a single node) predicted a poor outcome with a median OS of 8.1 months (MMCC=7-8, n=24) vs. 24.7 months for low MMCC (1-6, n=26, p=0.0004, logrank). Estimated 1- and 3-year-OS was 25% and 8% for high vs. 69% and 41% for low MMCC. Ten out of eleven living patients (follow-up 2.3-5.3 years) had a low MMCC. Of the clinical parameters determined, only pre-treatment hemoglobin levels <12 g/dl and treatment less radical than chemoradiation to 70 Gy predicted poor OS (univariate p=0.04 and 0.02, respectively). In multivariate Cox analysis, MMCC continued to significantly predict for OS (p=0.002) and Disease-Free Survival (p=0.002).

CONCLUSIONS

Quantification of nodal ultrasonography offers valuable prognostic information for the conservative management of HNSCC.

Imaging manifestations of neck masses in the immunocompromised host

Human immunodeficiency virus (HIV) infection, haematological malignancy, and immunosuppression for transplantation and autoimmune disorders have led to a large increase in immunocompromised patients. Neck masses are relatively common in this patient group and include both opportunistic and severe manifestations of common infections, benign hyperplasia, and primary or secondary malignancies. Although biopsy may be necessary for definitive diagnosis, features on cross-sectional imaging may suggest a specific diagnosis or limit the differential diagnosis and facilitate optimal patient management. This article will review critical aspects of neck anatomy, illustrate the spectrum of imaging features, and discuss the interpretative pearls and pitfalls when evaluating neck masses in immunocompromised patients.

Imaging of the lymphatic system: new horizons

The lymphatic system is a complex network of lymph vessels, lymphatic organs and lymph nodes. Traditionally, imaging of the lymphatic system has been based on conventional imaging methods like computed tomography (CT) and magnetic resonance imaging (MRI), whereby enlargement of lymph nodes is considered the primary diagnostic criterion for disease. This is particularly true in oncology, where nodal enlargement can be indicative of nodal metastases or lymphoma. CT and MRI on their own are, however, anatomical imaging methods. Newer imaging methods such as positron emission tomography (PET), dynamic contrast-enhanced MRI (DCE-MRI) and color Doppler ultrasound (CDUS) provide a functional assessment of node status. None of these techniques is capable of detecting flow within the lymphatics and, thus, several intra-lymphatic imaging methods have been developed. Direct lymphangiography is an all-but-extinct method of visualizing the lymphatic drainage from an extremity using oil-based iodine contrast agents. More recently, interstitially injected intra-lymphatic imaging, such as lymphoscintigraphy, has been used for lymphedema assessment and sentinel node detection. Nevertheless, radionuclide-based imaging has the disadvantage of poor resolution. This has lead to the development of novel systemic and interstitial imaging techniques which are minimally invasive and have the potential to provide both structural and functional information; this is a particular advantage for cancer imaging, where anatomical depiction alone often provides insufficient information. At present the respective role each modality plays remains to be determined. Indeed, multi-modal imaging may be more appropriate for certain lymphatic disorders. The field of lymphatic imaging is ever evolving, and technological advances, combined with the development of new contrast agents, continue to improve diagnostic accuracy.

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.

Neck lymph nodes: prediction by computer-assisted contrast medium analysis?

Several criteria in B-scan and colour-coded Doppler ultrasound have been shown to discriminate malignant transformation of cervical lymph nodes. All these parameters tend to be operator dependent. We describe the first use of computer-assisted analysis of contrast-enhanced ultrasound images evaluating cervical lymphadenopathy in differentiation between benign and malignant lesions. The results from sonography were compared with the histologic findings in 60 patients. Subjective sonomorphologic parameters were evaluated and compared with quantitative criteria obtained from computer analysis after intravenous contrast medium (SonoVue) application to estimate diagnostic impact. Our results confirm that malignant lymph nodes are round in shape (p < 0.001) and show peripheral perfusion (p = 0.0089). Dynamic parameters revealed that malignant nodes were characterized by contrast medium wash-in time (p = 0.0487). However, the contrast-related criteria did not improve the pretherapeutic prediction of malignancy. Although contrast medium kinetics provided statistically significant new criteria for identifying malignant lymph nodes, differentiating between malignant and inflammatory changes in lymph nodes remains a diagnostic challenge.

Modern imaging lymph node staging of the head and neck region

The aim of this paper is to describe the modern imaging methods, their techniques, ability, and performance in staging head and neck lymph nodes. Also, the imaging morphologies of benign and malignant lymph nodes according to the different imaging techniques will be delineated. The imaging techniques of ultrasound including contrast-enhanced ultrasound, computed tomography and magnetic resonance imaging (MRI) including diffusing weighted imaging and contrast-enhanced iron oxide MRI are explained. Imaging examples of the different modalities of benign and malignant transformed lymph nodes will be demonstrated. Furthermore, the diagnostic sensitivity of each modality will be delineated and further aspects of modern lymph node staging of the head and neck region such as those with special contrast agents will be described. These modern imaging modalities have sensitivity rates of 70-80% depending on the technical equipment and ability and on the experience of the investigator. The technique of near-infrared-imaging will be mentioned in another article in this journal. Also the value of biopsy techniques including recently developed ultrasonography guided needle biopsy with molecular analysis of the cells of about 97-100% accuracy in diagnosing benign from malignant lymph nodes will be mentioned. Overall, the reader will get an overview of the present imaging modalities to potentially stage correctly lymph nodes in the head and neck region to facilitate the therapeutic procedure.

Lymph node imaging: Basic principles

Lymph nodes are involved in a wide variety of diseases, particularly in cancer. In the latter, precise nodal staging is essential to guide therapeutic options and to determine prognosis. For long, imaging of the lymphatic system has been limited to lymph vessel,especially via the exclusive use of conventional lymphography, at the expense of invasive procedures and patient's discomfort. Three main technical advances, however, have recently completed the clinical armamentarium for lymph node imaging: first, the refinement of cross sectional imaging, i.e. CT and MRI, combined or not with dedicated contrast agents, has progressively replaced conventional lymphography in oncology situations; second, the development of intra-operative sentinel node mapping has profoundly modified the diagnostic and therapeutic procedures in several cancer situations, mostly melanoma and breast cancer; finally, the increased availability of functional imaging, especially through the use of FDG-PET, has greatly contributed to the accuracy improvement of nodal metastases identification. The aim of this review will thus be to briefly review the anatomy and physiology of the lymphatic systems and to overview the basic principles of up-to-date lymph node imaging.

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.

[Lymph node dissection in non-medullary differentiated thyroid carcinoma]

Papillary and follicular thyroid carcinomas are the most common form of endocrine carcinomas. Lymph node involvement seems to be a low risk factor for death, but it increases the risk for loco-regional recurrences and distant metastasis. The limits and the key points of the cervical lymph node dissection are described. The sentinel lymph node is used to rarely, so it could limit the lymph dissection. Node-picking has to be avoided. Central lymph node resection is recommended for high-risk patients, as male, patients more than 45 or less than 21 years old, papillary carcinomas greater than 1 cm or follicular carcinoma more than 2 cm in diameter. Lateral lymph node resection is performed when the lymph nodes of the central compartment are involved, more than 3 cm in diameter, and bulked. Prophylactic lymphadenectomy is useless. When thyroid carcinoma is known postoperatively, re-operation depends of the cervical mass and of the results of the radioactive iodine treatment.

What the clinician wants to know: surgical perspective and ultrasound for lymph node imaging of the neck

Imaging of lymph node metastases in the neck can have two major indications: (1) prognosis and assisting with choice of treatment; (2) staging and detection of clinically occult metastases in different levels of the neck. Both indications are discussed. The role and limitations of US and US-guided fine-needle aspiration cytology are also reviewed.

Imagerie dans le bilan d’extension ganglionnaire et métastatique du cancer du sein

Disease staging of patients with breast cancer is based on the probability of metastatic disease, the reliability of complementary examinations, and therapeutic possibilities, evaluated on a cost/benefit basis. For regional disease staging, nodal status can be assessed by ultrasound, and the value of this approach can be optimized by imaging-guided biopsies. Ultrasound examination of nodes upstream of the sentinel node allows determination of the utility of this node and the indications for axillary resection. Work-up of metastatic spread is performed only after evaluation of risk factors for metastasis. Prior to therapy, and in the absence of any clinical warning signs for resectable tumors, there are no indications for imaging, which is reserved solely for locally advanced tumors.

Ultrasonographic differentiation between metastatic and benign lymph nodes in patients with papillary thyroid carcinoma

OBJECTIVE

The purpose of this study was to evaluate the ultrasonographic characteristics of metastatic lymph nodes in patients with papillary thyroid carcinoma.

METHODS

The ultrasonographic characteristics of lymph nodes were analyzed in 112 consecutive patients who underwent thyroidectomy and lymph node dissection, with the diagnosis being confirmed by anatomopathologic examination.

RESULTS

A total of 198 lymph nodes were metastatic, and 152 were benign (normal or with nonspecific lymphadenitis). Minimum axial diameters of 7 mm for level II (upper internal jugular chain) and 6 mm for the rest of the neck were observed in 93% of metastatic lymph nodes, absence of an echogenic hilum in 88%, hyperechogenicity in relation to the adjacent muscles in 86%, a round shape in 80%, calcifications in 49.5%, and intranodal cystic necrosis in 20%. These ultrasonographic characteristics were observed in 17%, 10%, 4.5%, 29.5%, 0%, and 0% of benign lymph nodes, respectively.

CONCLUSIONS

Even basic ultrasonographic characteristics (shape, echogenicity and echogenic hilum, calcifications, and intranodal cystic necrosis) help in the differentiation between metastatic and nonmetastatic lymph nodes in patients with papillary thyroid carcinoma.

Metastatic and inflammatory cervical lymph nodes as analyzed by contrast-enhanced color-coded Doppler ultrasonography: quantitative dynamic perfusion patterns and histopathologic correlation

Use of contrast-enhanced color-coded Doppler (ultra)sonography (CCDS) in evaluating enlarged lymph nodes has been subject to numerous attempts to define criteria for differentiation between benign and malignant lesions. Evaluation of dynamic perfusion patterns with contrast-enhanced CCDS in cervical lymph nodes offers new possibilities of differential diagnosis. A total of 28 patients with clinically enlarged lymph nodes were included in this study. Contrast-enhanced CCDS was performed on each patient. The color signals from nodes <15 mm in diameter were analyzed with a specialized computer program. Each node was later examined through immunohistochemical staining. Vascularization as shown by unenhanced CCDS was significantly greater in metastatic lymph nodes than in reactively enlarged lymph nodes (8.66% versus 2.81%; p = .01). The maximum vascularization area after contrast injection did not show any significant change (26.61% versus 28.63%; p = .75). Comparison of values obtained before and after contrast enhancement showed the largest relative increase in vascularization in inflammatory lymph nodes, from a factor of 19.55 to a factor of 10.03 (p = .025). Dynamic values such as contrast enhancement, behavior of dynamic values referred to time, and the evaluated vascularized area did not show any significant difference. The metastatic lymph nodes (5.46 versus 3.33; p = .007) predominantly consisted of large blood vessels. The increased vascularization in the unenhanced CCDS examination of metastatic lymph nodes seems to be associated with the increased number of large blood vessels. An increased vessel density, due to a greater number of total vessels, is related to an inflammatory process. Color Doppler mapping has been proven to depict useful aspects distinguishing benign from malignant lymph nodes of the neck; however, a definitive differentiation between lymph nodes involved with malignancy and inflammatory changes remains difficult.