Imaging superficial lymph nodes: Is there a clue for malignancy?

Transcription

1 Imaging superficial lymph nodes: Is there a clue for malignancy? Poster No.: C-2477 Congress: ECR 2013 Type: Educational Exhibit Authors: H. Zaghouani Ben Alaya, N. Benzina, Z. Kmira, W. Kermani, M. Limeme, S. MAJDOUB, H. Amara, D. Bakir, C. Kraeim ; 1 Sousse, DEPARTMENT OF RADIOLOGY, FARHAT HACHED 2 HOSPITAL, SOUSSE/TN, Sousse, DEPARTMENT OF CLINICAL HEMATOLOGY, FARHAT HACHED HOSPITAL, SOUSSE/TN/TN, 3 Sousse, Department of Ear, Nose, and Throat, Farhat Hached University Hospital, Sousse, Tunisia/TN Keywords: Haematologic diseases, Cancer, Decision analysis, Education, Diagnostic procedure, Ultrasound, MR, CT, Lymph nodes, Haematologic, Head and neck, Lymphoma DOI: /ecr2013/C-2477 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related Page 1 of 25

2 to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 2 of 25

3 Learning objectives - To review superficial lymph nodes anatomy. - To illustrate a wide spectrum of pathologic disorders affecting nodes. - To analyse normal and pathologic nodes on US, Doppler correlated with histopathologic findings when available. - To emphasize pitfalls, diagnostic difficulties and differential diagnoses of the entities. Page 3 of 25

4 Background -Anatomy and distribution of superficial nodes: neck, axille and inguinal region. -Review of morphologic criteria in normal and pathologic nodes highlighting key imaging features and pitfalls: size, internal architecture, necrosis, number, calcifications. Page 4 of 25

5 Imaging findings OR Procedure details Normal lymph node (fig 1) Why have we rewieved the head and neck lymph nodes? - To review imaging findings of the large number of diseases that develop superficial lymph nodes. - To describe the radiologist's role -To describe the management of superficial lymphadenopathy -To correlate the radiologic features with pathologic appearance Approach to lymphadenopathy (fig2, 3, 4) I- CERVICAL LYMPH NODES (fig 5) 1- Pyogenic adenitis GENERAL : - Staphylococcus aureus and beta hemolytic streptocci are the most common infectious agents. - Acute and unilateral - Most often is submandibular region (50-60%) US IMAGING FINDINGS: (fig6) - Enlarged, hypoecoic and hyperemic nodes - Round to lobulates - Faint acoustic and septations - Important inflammation of adjacent soft tissues Page 5 of 25

6 2- Infectious mononucleosis General : - Common infection in adolescent caused by the Epstein-Barr Virus - Bilateral enlarged head and neck nodes with proeminent lymphoid tissue - Associated with hepatosplenomegaly Us IMAGING FINDINGS (fig7) - Bilateral, large and hypervascular nodes - Round to lobulates - Symmetric radial pattern of vessels on Doppler imaging 3- Cat-scratch disease GENERAL -the most common cause of chronic lymphadenitis in children - Solitary enlarged node caused by Bartonellahenselae resulting in granulomatous lymphadenitis -nodal enlargement can occur 1 to 2 weeks after a cat scratch or bite. US IMAGING FINDINGS: (fig8) - Enlarged, mobile, hypoechoic and hypervascular nodes - The appareance of nodes can change hypo to anechoic - Minimal periadenitis is commonly seen. 4- Cervical TB adenopathy Adenopathy is the most common sign of extrapulmonary tb in 30-50% of cases and cervical location is a very often finding (60-80%). Cervical TB adenopathies are multiple, unilateral, predominantly affecting deep channels and generally between 1,5 and 5 cm in size. Page 6 of 25

7 Ultrasound demonstrates predominantly hypoechoic nodes with or without echogenic hilus with a heterogenous echo pattern and intra-nodal cyctic area (necrosis) Surrounding soft tissue edema appears and ill-defined echolucent perinodal, and abcess formation The borders of the nodes appear indistinct, and nodal matting and clumping is seen due to periadenitis. There is three stages of nodal involvement on CT and MRI. GENERAL The infection most frequently results in chronic lymphadenitis Unilateral enlarged node caused granulomatous lymphadenitis by Mycobacterium avium intracellulare in Sub mandibular is the most commonly involved region. US IMAGING FINDINGS(fig9, 10, 11) - Single hypoechoic lymph node surrounded by smaller satellite nodes - Anechoic center indicates necrosis - Periadenitis is commonly seen 5- Castleman's disease GENERAL -Uncommon lymphoproliferative disorder that can involve single lymph node stations or can be systemic -also known as giant lymph node hyperplasia and angiofollicular lymph node hyperplasia It must be distinguished from readtive lymph node hyperplasia and malignancies -diagnosis of Castleman disease is based on microscopic examination of the tumor tissue and blood tests. IMAGING FINDINGS - Enlarged lymph node or localized nodal masses that demonstrate homogenous intense enhacement after contrast material administration Page 7 of 25

8 - US and CT appearance is nonspecific - Three patterns of involvement have been described: solitary noninvasive mass, infiltrative mass with associated lymphadenopathy and matted lymphoadenopathy without a dominant mass. 6- Lymphoma GENERAL - Head and neck lymphadenopathy is presenting the majority of patients with Hodgkin lymphoma - An enlarging, painless, nontender lymph node should raise concern - In NHL, involvement of the Waldeyer ring might be diffuse or localized. IMAGING FINDINGS(fig12) - Enlarged hypoechoic nodes show sharp borders withan absent or eccentric echogenic helium and a tendency to form masses - On color Doppler imaging, the nodes demonstrate hypervascularity with both peripheral and central hyperemia - On CT the enlarged nodes are isodense to muscle with mild and homogeneous enhacement after contrast material administration. 7- Metastatic disease GENERAL - Metastatic involvement of head and neck lymph nodes can be seen in neuroblastomas, papillary thyroid carcinoma or nasopharyngeal carcinoma - Firm, matted, nontender, more than 3 cm of short axis with systemic sympthoms are the most important signs of malignancy. US IMAGING FINDINGS: (fig13) -most metatatic nodes are enlarged, hypoechoic nodes show sharp boders with an absent or eccentric echogenic helium The exception is hyperrchoic nodes with intranodal calcification seen in metastatic papillary or medullary thyroid carcinoma or metastatic neuroblastoma Page 8 of 25

9 On color Doppler imaging, the nodes demonstrate hypervascularity with both peripheral and central hyperemia. II- axillary adenopathy Unilateral vs bilateral axillary adenopathy : differential diagnosis Unilateral Bilateral Benign Begnin Regional infections (e.g. cat scratch disease, toxoplasmosis, TB, ipsilateral upper extremety cellulitis, metastasis) Dermatopathic lymphadenopathy Silicone-induced granulomatous lymphadenitis Malignant HIV Autoimmune diseases (rheumatoid arthritis, scleroderma, dermatomyositis, SLE, psoriasis) Lymphoid hyperplasia from acute or chronic infection/ inflammation (infectious mononucleosis, cat scratch disease) Granulomatous lymphadenitis (sarccoidosis, tuberculosis) Malignant Metastases from breast malignancy Metastases from non-breast malignancies (melanoma is a common cause) Primary malignancy in ipsilateral arm Lymphoma occasionally unilateral Lymphoma Leukemia HIV associated malignancies ( Kaposi sarcoma) Metastases (lung, melanoma, uncommonly breast) Spectrum of axillary lymph node disease: unilateral axillary lymphadenopathy Primary breast cancer metastasis to the axilla (fig14) Non-breast primary metastasis to the axilla (fig15) Infectious and inflammatory conditions Spectrum of axillary lymph node disease: bilateral axillary lymphadenopathy Lymphoma (fig16) Page 9 of 25

10 Leukemia HIV toxoplasmosis III- Inguinal lymphadenopathy (fig17) Are common. Enlarged nodes up to 1 to 2 cm in diameter in many healthy adults, particularly those who spend time barefoot outdoors. Benign reactive lymphadenopathy and infection are the most common etiologies, and inguinal lymphadenopathy is of low suspicion for malignancy. Infrequently, Hodgkin's lymphomas first present in this area, as do non-hodgkin's lymphomas. Penile and vulvar squamous cell carcinomas, the lymphomas, and melanoma also can occur with lymphadenopathy in this area. When the overlying skin is involved, testicular carcinoma may lead to inguinal lymphadenopathy, which is present in 58 percent of patients diagnosed with penile or urethral carcinoma. Page 10 of 25

11 Images for this section: Fig. 1: fig1 Page 11 of 25

12 Fig. 2: fig2 Page 12 of 25

13 Fig. 3: fig Page 13 of 25

14 Fig. 4: fig Page 14 of 25

15 Fig. 5: fig Page 15 of 25

16 Fig. 6: fig Fig. 7: fig Page 16 of 25

17 Fig. 8: fig Fig. 9: fig Page 17 of 25

18 Fig. 10: fig Page 18 of 25

19 Fig. 11: fig Page 19 of 25

20 Fig. 12: fig Page 20 of 25

21 Fig. 13: FIG Fig. 14: FIG Page 21 of 25

22 Fig. 16: FIG Page 22 of 25

23 Fig. 15: FIG Fig. 17: FIG Page 23 of 25

24 Conclusion The majority of patients presenting with peripheral lymphadenopathy have easily identifiable causes that are benign or self-limited. The critical challenge for the primary care physician is to identify which cases are secondary to malignancies or other serious conditions. While modern imaging techniques have improved the diagnostic yields of nodes and their management, a complete exposure history, review of associated symptoms, and a thorough regional examination help determine whether lymphadenopathy is of benign or malignant origin. Page 24 of 25

25 References Lymphadenopathy and Malignancy ANDREW W. BAZEMORE, M.D., and DOUGLAS R. SMUCKER, M.D., M.P.H. University of Cincinnati College of Medicine, Cincinnati, Ohio Page 25 of 25