Characterisation of cervical lymph nodes by US and PET-CT

Characterisation of cervical lymph nodes by US and PET-CT Poster No.: C-1807 Congress: ECR 2010 Type: Educational Exhibit Topic: Head and Neck Authors: J. I. Garcia Gomez; Mexico City/MX Keywords: cervical Lymph nodes, lymph nodes, nodal classification DOI: 10.1594/ecr2010/C-1807 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 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. www.myesr.org Page 1 of 13

Learning objectives To describe and Illustrate the Nodal Classification of the neck by Ultrasound and PET -CT To help identify nodes features in order to differentiate their typical benign and malignant appearances To review the U.S. and PET- CT findings of different neck lymph nodes characteristics Background The cervical lymph nodes may represent one of the most challenging difficulties that a radiologist faces today; this is because many imagers are unfamiliar with the anatomy of the head and neck. Once a lymph node is identified on a diagnostic study, the radiologist must then determinate the most accurate nomenclature to use in describing the findings to the clinician and the criteria to be used in evaluating whether a node is pathologic or not. In this exhibits we will describe the most recent and commonly used classification for cervical lymph nodes as their appearance in different radiologic modalities. Images for this section: Page 2 of 13

Fig. 1: Anatomy nodal classification Page 3 of 13

Imaging findings OR Procedure details Between February 2009 and August 2009, we perform 598 FDG-18 PET-CT studies, of those, we select 20 patients with head and neck lymphadenopathy and perform high resolution ultrasonography of the neck with 7-13 MHz lineal probes, to compare their radiological appearances and show the differences between a malignant and non malignant lymph node. The imaging features and typical locations of lymph nodes of the neck are illustrated on axial and coronal PET - CT with their US. Images for this section: Fig. 1: Axial PET-CT Fusion, nodal levels IB, II A and II B Page 4 of 13

Fig. 2: Coronal PET-CT fusion, posterior view of lymph nodes levels III, IV And VII Fig. 3: Coronal PET-CT fusion, posterior view of lymph node levels VA and VB Page 5 of 13

Fig. 4: Axial PET-CT scan reveals Cervical lymph nodes located in levels I and Ib, in a patient diagnosed with diffuse small cell non-hodgkin's lymphoma. Same patient U.S. shows marked hypoechogenicity and vascular lymph node in this level Page 6 of 13

Fig. 5: U.S. shows hypoechoic and vascular cervical lymph nodes at level IIa and IIb, axial PET-CT scan shows increased uptake of FDG-18 at the same levels in 31 years male patient diagnosed with non-hodgkin's Lymphoma Page 7 of 13

Fig. 6: U.S. shows small, hypoechoic cervical lymph nodes at levels VA and VB in a patient with breast cancer. Axial PET-CT scan shows increased uptake at diferent levels, arrow shows same nodes seen in US Page 8 of 13

Fig. 7: PET-CT scan shows increased uptake of FDG-18 at different zones with more metabolism at left side. U.S. focused in left level IV, shows irregular, more than 2 cm, hypoechoic and vascular lymph node in a patient with metastatic lung cancer. Page 9 of 13

Fig. 8: Axial PET-CT scan shows hypermetabolic cervical nodule in Level VI. U.S. of the same patient shows heterogeneous lesion inside thyroid gland in 68 years old male, with papillary thyroid cancer. Page 10 of 13

Fig. 9: Axial PET-CT scan with increased uptake in multiple paratracheal nodes, located at level VII in a patient with B-cell lymphoma Fig. 10: PET-CT scan shows increased uptake of radiopharmaceutical FDG-18 at levels IIA, III, And IV. U.S. shows irregular, hypoechoic and vascular cervical lymph nodes at at the same levels in a patient diagnosed with non-hodgkin's Lymphoma Page 11 of 13

Fig. 11: Coronal view CT and U.S. shows example of microcalcifications inside a cervical lymph node at level III right, in a patient with papillary thyroid cancer Page 12 of 13

Conclusion The knowledge of the cervical lymph nodes classification it is of great importance for the evaluation of the pathology of neck. The diverse diagnostic modalities used in radiology, help to the characterization and differentiation of the cervical ganglions. The clinical palpation of the lymphatic nodes in the malignant disease is not very trustworthy and presents low levels of sensibility and precision, different image modalities can identify a significant number of patients with cancer of head and neck lymphadenopathy Personal Information References 1.- Peter M. Som, et al, Imaging Based Nodal Classification for evaluation of Neck Metastatic Adenopathy, AJR:174 March 2000 2.- Anil T. Ahuja, et al, Sonographic Evaluation of Cervical Lymph Nodes, Pictorial Essay, AJR : 184, May 2005 3.- Devang M. Gor, Técnicas de imagen de los ganglios linfáticos en el cáncer de cabeza y cuello: aspectos básicos, Clínicas radiológicas de Norteamérica. Radiol Clin N am 44 (2006) 101-110 4.- Rumak, Wilson, Diagnostico por ecografía Editorial Marban, 2da edición, 2005, 5.-American cancer society. Cancer facts and figures 2005. Atlanta 6.- Atula Ts, Varpula Mj, Kurji TJ et al. Assessment of cervical lymph node status in head and neck cancer patients: Palpation, CT, and low field magnetic resonance imaging compared with us, Eur J Radiology 1997 ; 25 : 152-61 Page 13 of 13