1 Presented by Intern郭婉吟Lymph Nodes Differential Diagnosis in Ultrasound Imaging p Presented by Intern郭婉吟
2 Outline Introduction Topography Sonographic parameter for assessmentPeripheral lymph nodes Abdominal lymph nodes
3 Introduction Essential barrier of the secondary immune systemDiameter：0.2 cm ~ 2.5 cm Functional state Age of the patient Assessment of possible malignancy： Clinical picture Ultrasound findings Differential diagnosis of LAP
4 Differential diagnosis of LAPInfectious disease ► Viral infection Infectious mononucleosis (EBV), cytomegalic inclusion disease, infectious hepatitis, AIDS, rubella, human herpesvirus 3 (varicella-zoster) ► Bacterial infection Streptococci, staphylococci, salmonellae, Tropheryma whippelii (Whipple disease), Francisella tularensis (tularemia) ► Mycotic infection Histoplasmosis, coccidioidomycosis, blastomycosis * Chlamydial infection Lymphogranuloma venereum, cat-scratch disease, trachoma Mycobacterial infection Toxoplasmosis, trypanosomosis, microfilariae Spirochetosis Syphilis, leptospirosis Malignancy Hodgkin disease, non-Hodgkin lymphoma, chronic lymphocytic leukemia, acute lympho- cytic leukemia Myelogenous leukemia (chloromas = extramedullary manifestation of myelogenous leu- kosis): acute myelogenous leukemia, blast crisis in chronic myelogenous leukemia Metastasis of epithelial or mesenchymal tumors Immunological disease Rheumatoid arthritis Systemic lupus erythematosus Dermatomyositis Allergic reaction to drugs such as phenytoin, hydralazine, allopurinol Other Sarcoidosis Lipid storage disease (Caucher disease, Niemann-Pick disease)
5 Anatomy
6 Topography Peripheral lymph nodesHead/ Neck Axilla/ Groin Nonperipheral lymph nodes (Abdominal) Intraperitoneal (splanchnic) lymph nodes hepatic hilum, splenic hilum, mesentery Retroperitoneal (parietal) lymph nodes para-aortic, iliac
7 Lymph nodes in the head and neckRelations： Cervical lymph nodes along the jugular vein and carotid artery Submandibular lymph nodes along the muscles of the root of the tongue Landmark structure in ultrasound： Jugular vein Carotid artery Subclavian atery and vein Submental, submandibular Nuchal +supraclavicular
8 Abdominal lymph nodes Relations： Landmark structure in ultrasound：Intraperitoneal along the blood vessels leading to liver and spleen Along the mesenteric blood vessels Along the retroperitoneal iliac blood vessels Landmark structure in ultrasound： Arteries and vein Celiac group Hilum of spleen Heptic portal Upper and lower mesenteric group Para-aortic group Iliac group
9 Axillary lymph nodes Relations： Landmark structure in ultrasound：Lymph nodes along the axillary vessels Lymph nodes anterior, along, and posterior to the pectoralis major muscle Landmark structure in ultrasound： Axillary vessels Pectoralis major muscle Upper + infraclavicular lymph nodes Lower central
10 Lymph nodes Usualy, only enlarged lymph nodes will be visualizedDetected normal lymph nodes： down to 2-3mm Head and neck： >10mm pathologically enlarged Central hyperechoic ovoid hilum and peripheral hypoechoic concentric cortex 8mm
12 Sonographic parameters for lymph node assessmentLocation Region involved Pattern of involvement Morphology Size Shape Delineation from adjacent tissue Structural parameters Hilar sign Echogenicity Homogeneity Vascularization Concentration of blood vessels Pattern of vascularization Flow parameters
13 Location-Region Supraclavicular sentineal (Virchow’s sentineal node) in gastric cancer Painful inguinal LAP in erysipelas (alarm-bell sign) Unilateral axillary LAP in breast cancer Malignancy Reactive LAP
14 Location-Pattern Localized or generally spreadRelation with the blood vessels Vascular invasion： Contact between the tumor and the vascular wall > 3.5 cm or >1/2 the circumference
15 Morphological criteriaSize Shape Length/Width ratio： >2 reactive changes <2 malignancy Delimitation Lung ca Malignant lymphoma Hodgkin disease
16 Structural parametersHilar sign：indicative of malignant LAP Echogenicity： Malignant lymphoma hypoechoic Cancer metastasis, chronic inflammation or regression scars hyperechoic Malignant lymphoma Ovarian cancer CLL
17 Structural parametersHomogeneity Anechoic Necrosis：granulomatous or suppurating inflammation Colliquation：cancer metastasis Hypoechoic： beginnig malignant lymph node invasion Hyperechoic： low-grade malignant lymphoma Calcification： lymph node scarring cancer metastasis：medullary thyroid carcinoma Bacterial lymphadenitis Esophagus cancer metastasis
18 Vascularization-ConcentrationColor-flow Doppler scanning Increased vascularization： Acute inflammation Malignant lymphoma Focal lack： Metastasis Post therapy Infectious mononucleosis Hodgkin disease /p chemotherapy
19 Vascularization-Vascular patternsLongitudinal hilar vessel (LHV) LHV with multiple branches LHV with spurious branching Malignant LAP Reactive lymph nodes：more horizontal hilar or longitudinal parenchyma vessels and treelike branching Complete lack of vessels Paint spots Vascular displacement Focal lack of vessels Subcapsular vessels Aberrant vessels
20 For example Gastric cancer 1 subcapsular vessels 2 aberrant vessels
21 Vascularization-Flow parametersResistance index (RI) Pulsatility index (PI) RI > 85：lymph node invaded by metastasis
22 Abdominal lymph nodes Sonographic parameters of the vascularization are difficult to obtain. Differential diagnosis： location and morphology In most cases, impossible to demonstrate the hilum.
23 Four basic patterns in the invasion of abdominal lymph nodesDiffuse micronodular invasion Focal micronodular invasion Focal macronodular invasion Bulky formation
24 individual Plaquelike micronocular Displacing the splenic artery and hepatic artery
25 Disadvantages Only enlarged lymph nodes will be detected.Specificity is rather low in lumbar and iliac lymph nodes. Intestinal gas can limit the usefulness of the study. Misdiagnosis is possible in solitary lympho mas. It requires substantial experience of the operator in terms of technique and assessment.
26 Peripheral lymph nodesHead / Neck Extremities (Axilla, Groin) Inflammatory lymph nodes Metastases Malignant lymphoma Other structures
27 Head/Neck-inflammatory300 lymph nodes are located in the cervical region During childhood/adolescence, >80 % are reactive Posterocervical nuchal lymph nodes：benign ; supraclavicular fossa often are malignant. Reactive LAP Horizontal hilar vessels Longitudinal branches Homogenous vascular branching Autoimmune vasculitis
28 Acute inflammation Small (<1.5 cm) Hilar sign L/W >2Not caked together Homogenous parenchyma Acute lymphadenitis：homogenous hyperperfusion
29 Chronic inflammation(regressive)Parechymal calcification A lack of flow Calcified cervical lymph node as end stage of tuberculous lymphadenitis
30 Head/Neck-metastasesSize is not a typical parameter and the hilar sign is usually missing Round and hyperechoic Necrosis Calcification of the parenchyma The concentration of blood vessels varies Vascular patterns： Vascular displacement Aberrant vessels Regions lacks any vascularization Capsular vessels Prostate cancer
31 Head/Neck-metastasesMetastases exhibiting rapid growth ： pathologic vascularization with corkscrew-like vessels Vascular invasion： Contact between tumor and vessel wall >3.5cm or >1/2 circumference Malignant lymphom with cervical lymph node ENT tumor
32 Head/Neck-malignant lymphomaLarge, hypoechoic and multiples L/W <2 Homogeneous Clustered like grapes or in festoonlike fashion Homogeneous increase in the vascular images During treatment： Size decrease Flow diminish End stage： echogenic lymph node varying in size with hyperechoic capsule and no discernible flow signals
33 Head/Neck-other structuresBrachial cyst
35 Extremities-metastasesMore common in the axilla than in the groin Breast cancer：homogenous, hypoechoic and size differs widely Malignant melanoma：very small lymph nodes metastases Breast cancer Malignant melanoma Rectal cancer
36 Extremities-malignant lymphomaSimilar to that of the head/neck Invasive growth into the soft tissue particularly in T-cell lymphoma of the groin hyperechoic and ill defined to the adjacent soft tissues Hodgkin disease
37 Extremities-other structuresFalse aneurysm
38 Abdominal lymph nodes Hepatic portal Splenic hilumMesentery (Celiac, upper and lower mesenteric station) Retroperitoneum (para-aortic, paracaval, aortointercaval and iliac station) Inflammatory lymph nodes Metastases Malignant lymphoma Other structures
39 Hepatic portal-inflammatorySmall (<2 cm) Ovoid or elongated Likely echogenic Found in acute hepatitis, concomitant hepatitis (EBV, chickenpox, HIV….) autoimmune hepatitis, primary biliary cirrhosis, primary sclerosisng cholangitis, bacterial cholangitis
40 Hepatic portal-metastasesNo definite ultrasound criteria for ruling out possible malignancy The probability of malignant invasion will increase with increasing size of the lymph node Enlarged lymph node in pancreatic cancer (TU)
41 Hepatic portal-malignant lymphomaParticularly in systemic low-grade lymphoma Different invasion patterns： individual multiple extensive Bulky tumor formation
42 Hepatic portal-other structuresHepatic artery aneurysm Hypoechoic mass with anechoic center
43 Splenic hilum-inflammatoryReactive lymphadenitis of lymph nodes is almost never seen
44 Splenic hilum-metastasesAdenocarcinoma of the pancreatic tail, neuroendocrine tumors of the pancreas, gastric cancer and in peritoneal metastasis Ovarian cancer
45 Splenic hilum-malignant lymphomaIndividual lymph nodes in CLL Numerous confluent lymph nodes in CLL Extensive lymph nodes in mantle cell lymphoma Perisplenic invasion by follicular center lymphoma
46 Splenic hilum-other structuresAccessory spleen Pancreatic mass (tumor, cyst, necrosis) Pseudocyst
47 Mesentery Sometimes difficult to visualizeMesenteric lipomatosis- homogeneous echogenic thickening of the mesentery
48 Mesentery-inflammatorySituated in the mesenteric fat along the unpaired branches of the aorta (celiac axis, superior and inferior mesenteric artery) Dirty pattern Dirty pattern Mesenteric lymphadenitis No aberrant vessels
49 Mesentery-metastasesCarcinoma of the stomach, pancreas, esophagus, colon, etc. Definite diagnosis：pathology Mesenteric lymphadenitis Gastric cancer
50 Mesentery-malignant lymphomaAll various lymphomas Morphology diverse Ultrasound-guided needle biopsy or laparotomy
51 Mesentery-other structuresDifferential diagnosis of an isolated mesenteric mass： Intestinal loop, mesenteric cyst, necrosis in pancreatitis, abscess Mesenteric varicosities in portal hypertension, thrombosis of the mesenteric vessels, mesenteric artery aneurysms, hematoma Inflammatory pseudotumor, lipoma, primary mesenchymal tumor
52 Cyst Inflammatory pseudotumor
53 Retroperitoneum-inflammtoryPara-aortic lymph nodes with reactive enlargement are rare Iliac region：local inflammation (appendicitis, diverticulitis, adnexitis) Tuberculosis
54 Retroperitoneum-metastasesCancer of the kidney, testis, esophagus, prostate, colon and rectum Sonographic patterns of invasion cannot be distinguished from malignant lymphoma Testicular cancer Colon cancer Esophageal cancer Malignant melanoma Ovarian cancer Bladder cancer
55 Retroperitoneum-malignant lymphomaVaried sonographic patterns Isolated retroperitoneal manifestation of lymphoma is rare Para-aortic iliac
56 Retroperitoneum-other structuresLocal retroperitoneal tumor formations： Para-aortic region：crura of diaphragm,abscess, aortic aneurysm, horseshoe kidney, horizontal part of the duodenum, hematoma, primarily retroperitoneal tumors Iliac region：ovary, undescended testis, lymphocele, hematoma, abscess
57 Para-aortic masses Duodenum Horseshoe kidney HematomaPartially thrombosed aortic aneurysm
58 Parailiac masses Ovary Testicle Varicosity? Inguinal hernia
59 Thank you for your attention
60 Staging in abdominal lymph node involvementSolid gastrointestinal tumors Cannot differentiate reliably Endosonography Diffuse, micronodular and focal LAP Malignant lymphoma Focal LAP, bulky formations with concomitant displacement Regional lymph node ：stage 2e1 Pariental involvement：stage 2e2 Low-grade and high-grade non-Hodgkin lymphoma Low-grade：systemic LAP High-grade： localized LAP Ultrasound-guided fine-needle aspiration biopsy
61 Splanchnic and Parietal lymph nodesSplanchnic (regional) lymph nodes Parietal (nonregional) lymph nodes