Enlarged Lymph Nodes

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6.7 Enlarged Lymph Nodes

Lipoma, Fibroma (Fig. 142)

..............................................................................................................

Clinical manifestations : swelling, no systemic manifestations

Diagnosis:

History

Palpation: doughy, mobile, nontender

Gradual enlargement may occur; doubts are resolved by FNAB.

Sonographic findings :

Round or elliptical mass

Smooth, well-defined margin s

Hypoechoic rim may form as a result of tumor expansion

Mobile

Fibroma tends to be hypoechoic.

Lipoma tends to be echogenic.

Accuracy of sonographic diagnosis: Sonography can clearly demonstrate the

individual features of these tumors, but it is prudent to evaluate the lesion by FNAB. If the findings are equivocal, a local excision is indicated.

Principal Signs and Symptoms

Fig. 142 Lipoma (cursors): rubbery, mobile mass that is hyperechoic to the neck muscles (M)

6.7 Enlarged Lymph Nodes

Basic Principles

..............................................................................................................

Note: The evaluation of enlarged lymph nodes relies on the history, physical

examination, and serologic findings. A definitive diagnosis requires histologic examination.

Criteria for evaluating findings: See Table 16

107

6.7 Enlarged Lymph Nodes

Table 16.Sonographic criteria for the differentiation of lymph nodes

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Location (Fig. 143) Superficial or deep, visceral or parietal

Size, shape, cortical widening, hilar sign (Fig. 144)

Echogenicity (Fig. 145) Echogenic hilum, hypoechoic cortex

Vascularity Absent, branching, aberrant vessels

Differential diagnosis of benign-malignant lymph nodes: See Table 17.

Table 17.Differential diagnosis of enlarged lymph nodes

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Principal Signs and Symptoms

Diagnosis Sonographic signs

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Inflamed lymph nodes (p. 110)

Lymph node metastases (p. 112) Variable size, L/W ratio I 2, absent hilar sign, aberrant

Malignant lymphoma (p. 113) Variable size, L/W ratio often I 2, absent hilar sign,

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

Length/width ratio I 2, length/width ratio j 2

Variable size, L/W ratio j 2, prominent echogenic hilum

vessels

variable pattern of involvement, variable echogenicity,

increased vascularity on CDS

Fig. 143 Localization: abdominal lymph node groups

108

6.7 Enlarged Lymph Nodes

Fig. 144 Sonographic morphology of peripheral lymph nodes (after Vasallo et al.)

Principal Signs and Symptoms

Fig. 145a, b Echogenicity. a Enlarged lymph node with an

echogenic hilum and hypoechoic cortical parenchyma. b The hilar vessels course within the echogenic hilum

109

6.7 Enlarged Lymph Nodes

Causes: Table 18 reviews the most frequent causes of enlarged lymph nodes.

Ultrasound examination contributes significantly to benign–malignant differentiation.

Table 18.Most frequent causes of enlarged lymph nodes

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Inflamed lymph nodes Metastatic lymph nodes Malignant lymphoma

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

Tonsillitis

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

ENT carcinoma

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Low-grade NHL

Pharyngitis Bronchial carcinoma High-grade NHL

Mononucleosis Thyroid carcinoma Hodgkin disease

Toxoplasmosis Breast carcinoma

Rubella Esophageal carcinoma

Principal Signs and Symptoms

Tuberculosis Gastric carcinoma

Mesenteric lymphadenitis Gallbladder carcinoma

Ileitis Colon carcinoma

Appendicitis Malignant melanoma

Diverticulitis Sarcoma, etc.

Hepatitis

Cholecystitis, etc.

Inflamed Lymph Nodes

..............................................................................................................

Most frequent causes : see Table 18.

Clinical manifestations: The clinical findings often suggest the correct diagnosis

(local infection with regional lymphadenopathy) and may include inflammatory signs, tenderness to palpation, and positive serology.

Sonographic diagnosis: The sonographic criteria for benign–malignant differen-

tiation are helpful in the evaluation of peripheral lymphadenopathy (Figs. and 145).

Variable size, L/W ratio j 2

Prominent echogenic hilum; occasional concentric or eccentric cortical widening

Frequent visualization of hilar vessels or a branched vascular pattern

144

110

Sonographic findings : See Figs. 146–149.

Fig. 146 Multiple paracolic lymph nodes (L) in a patient with ileocecal tuberculosis. CE = cecum

6.7 Enlarged Lymph Nodes

Fig. 147 Solitary hypoechoic lymph node (L) at the porta hepatis in infectious hepatitis. HA = hepatic artery, SA = splenic artery, CT = celiac trunk

Principal Signs and Symptoms

Fig. 148 Multiple large lymph nodes (L) along the right psoas muscle in a patient with mesenteric lymphadenitis

Further studies :

In cases with a typical clinical presentation, it is sufficient to provide sonographic follow-up and treatment as needed.

Asymptomatic cases that do not regress and show rapid growth p lymphadenectomy. There are no definite ultrasound criteria for benign–malignant differentiation.

Fig. 149 Small lymph nodes (arrows) produce a speckled echo texture in the mesentery of a patient with gastroenteritis. VC = vena cava, AO = aorta

111

6.7 Enlarged Lymph Nodes

Lymph Node Metastases

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Most frequent causes : see Table 18, p. 110.

Clinical manifestations: frequently suggest the correct diagnosis. Lymph node

enlargement has major prognostic implications for tumor staging (TNM), especially in terms of operability (Fig.

Principal Signs and Symptoms

150).

Fig. 150 Schematic representation of regional and “super”-regional lymph node groups that are significant in tumors of the gastrointestinal tract. K = kidney, VC = vena cava, CT = celiac trunk, AO = aorta, S = spleen, SMA = superior mesenteric artery, IMA = inferior mesenteric artery

Sonographic diagnosis:

Ultrasound cannot positively differentiate metastatic lymph nodes from benign lymphadenopathy.

Variable size (Figs. 151 and 152). The L/W ratio is often I 2.

Fig. 151 Multiple enlarged lymph nodes (L) clustered around the celiac trunk in a patient with gastric carcinoma (TU)

112

Fig. 152 Speckled pattern of micronodular infiltration (arrows) about the celiac trunk due to regional lymph node metastasis and gastric carcinoma (TU). AO = aorta

6.7 Enlarged Lymph Nodes

Fig. 153 Small regional lymph node (arrow) bordering the sigmoid colon and intraluminal tumor growth (TU) in a patient with colon carcinoma

Echogenic hilum is frequently absent (“absent hilum ” sign, often found in the lymphatic region draining the primary tumor, Fig.

CDS frequently shows aberrant vessels in peripheral lymph nodes.

Further studies :

With a primary malignancy of confirmed histology, it is likely that a nodal dia-

153)

meter i 2 cm signifies metastasis. Doubtful cases require histologic confirmation (if there are therapeutic implications), and a pathology specimen is usually necessary for accurate staging.

CT is often superior to sonography in the detection of mediastinal, hilar, paraaortic. and iliac nodal metastases. Endosonography is the method of choice for staging gastrointestinal tumors outside the colon and small intestine.

Malignant Lymphoma

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Most frequent causes : see Table 18, p. 110.

Principal Signs and Symptoms

Table 19.Modified Ann Arbor system for staging malignant lymphoma

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Stage Involvement

yyyyyyyIyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyy

II1 Involvement of two adjacent lymph node regions above or below the diaphragm (II1)

II2 Involvement of two nonadjacent lymph node regions or more than two adjacent

III Involvement of lymph nodes above or below the diaphragm (III)

IV Lymph node involvement with diffuse or disseminated involvement of one or more

with primary nodal involvement

Involvement of a single lymph node region (I)

or a single extralymphatic organ or site (IE)

or of a single lymph node region with localized involvement of an extralymphatic organ or site (II1E)

lymph node regions above or below the diaphragm (II2)

accompanied by localized involvement of extralymphatic organ or site (II2E)

accompanied by localized involvement of an extralymphatic organ or site (IIIE)

or by involvement of the spleen (IIIS)

or both (IIISE)

extralymphatic organs or tissues

113

6.7 Enlarged Lymph Nodes

Principal Signs and Symptoms

Fig. 154 Marked involvement of the para-aortic lymph nodes (L) and mesentery (MES) by non-Hodgkin lymphoma. SC = spinal column

Clinical manifestations: frequently suggest the correct diagnosis (fever, night

sweats, weight loss, generalized lymphadenopathy, blood count, elevated LDH). Staging has major prognostic importance and therapeutic implications (Table

19, Figs. 154 and 155).

Sonographic diagnosis:

Benign and metastatic lymph nodes cannot be positively distinguished on the basis of their sonographic features alone

Variable size (Figs. 156 and 157); L/W ratio often I 2

Fig. 155 Confluent hilar lymphomas (L) distributed around the splenic artery in a patient with non-Hodgkin lymphoma. S = spleen

Fig. 156 Multiple small para-aortic and mesenteric lymph nodes (L) in Hodgkin disease. VC = vena cava, AO = aorta, SC = spinal column

Echogenic hilum is usually absent; variable patterns of involvement with occasional extreme size, often confluent (Fig. genicity, varying infiltration patterns (see Fig.

CDS frequently shows increased vascularity.

Fig. 157 Large solitary para-aortic lymphoma (L) in a patient with malignant non-Hodgkin lymphoma. AO = aorta, SC = spinal column

158); multiple foci of variable echo-

159)

114

Fig. 158 Confluent, matted

lymphomas (L) encasing the aorta (AO) in a patient with malignant non-Hodgkin lymphoma. SC = spinal column

6.7 Enlarged Lymph Nodes

Principal Signs and Symptoms

Fig. 159 Sonographic infiltration patterns of abdominal lymph nodes, illustrated in an upper abdominal transverse scan through the origin of the celiac trunk

Further studies: With a confirmed malignant lymphoma, a nodal diameter i 2cm

probably signifies metastasis. Abdominal CT is necessary only if the lesions cannot be evaluated sonographically. A staging laparotomy (Hodgkin disease) is indicated only if it would have therapeutic implications. Response to treatment should be evaluated in sonographic follow-ups.

Possible Errors of Interpretation

..............................................................................................................

These errors are numerous and location-dependent:

Neck p cysts, abscesses

Abdomen p bowel structures (usually recognized by peristaltic motion,

160), cysts, abscesses, hematomas (typical clinical presentation)

Fig.

Groin p hematomas, hernias, aneurysms

115

6.8 Edema

Fig. 160a, b Hypoechoic mesenteric masses suspicious for lymphoma, identified

Principal Signs and Symptoms

as bowel loops by their peristaltic size changes

Further studies in patients with equivocal findings:

Doubtful cases should be investigated by FNAB, especially in patients with a suspected abscess or pancreatogenic pseudocysts.

Aneurysms can be identified by their features on CDS.

6.8 Edema

Basic Principles

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Principal signs and symptoms: swollen extremities, dyspnea with pulmonary

edema, possible pleural effusion, ascites, and anasarca.

Differential diagnosis: Table 20 lists the possible diagnoses in order of their fre-

quency in the general hospital setting.

Table 20.Differential diagnosis of edema

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Diagnosis Sonographic signs