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192
Fig. 10.1 Patient’s position
for US of axillary lymph
nodes
10 Ultrasound Examination of Regional Lymph Nodes
Fig. 10.2 The graphic of lymph nodes affected at breast
pathology
Level 3 (apical axillary) lymph nodes are located •
medially from the medial edge of pectoralis
minor muscle including subclavian and apical.
Intramammary lymph nodes are coded as •
axillary.
US characterization of the lymph nodes
involves evaluating the following aspects:
Site, according to anatomical area •
Number •
Dimensions (in three planes) •
Short/long axis ratio in transverse view •
Similarity of changes •
Shape ( fl at, oval, spherical, or irregular) •
Echodensity of the lymph node in general •
(increased, medium, or decreased)
Differentiation of lymph node parts (present/•
absent)
Differentiation of the hilum (present/absent) •
Core echodensity (high, low, or isoechoic) •
Status of the cortex of the lymph node ( narrow/•
wide)
Mobility upon compression with the probe •
Vascularity •
Normal axillary lymph nodes demonstrate the
following sonographic features (Fig.
10.3 ):
Oval (or bean-like, tape-like) shape •
Length smaller than 10 mm •
Regular, well-de fi ned contours •
Hypo- or isoechoic peripheral part and hyper-•
echoic central part
Painless, moderately mobile upon compres-•
sion with the US probe
Avascular or hypovascular in CDI, PDI, and •
3DPD, with predominant vascularity of the
hilum
Soft- or mixed-type color pattern with sono-•
elastography comparable with the pattern of
the surrounding structures
19310.1 Normal and Benign Lymph Nodes
A normal lymph node has a width of up to
10 mm on transverse scan, although, according to
a number of authors, the dimensions of normal
lymph nodes vary signi fi cantly. The Solbiati
index (SI), which is the ratio of the largest to the
smallest diameter of a lymph node, is normally
2.9 ± 0.13 in adults and 2.4 ± 0.05 or above in
children ( Solbiati and Rissato 1995 ) .
The assessment of vascularity with CDI and
PDI supplies additional data for the differential
diagnosis of the origin of an enlarged lymph node
(Fig.
10.4 ). Vessels, if any are detected, are usu-
ally located within the hilum in normal or reactive
lymph nodes. Even in large benign hyperplastic
lymph nodes, the vascular pattern remains regular.
Vessels are normally observed along the capsule
and radially from the hilum to the periphery.
Abbasova et al. ( 2005 ) classify the vascular
pattern of lymph nodes into the following four
categories:
1. Hilar: individual arterial and/or venous fl ow
signals without diffusion to the parenchyma of
the lymph node and without branching
2. Activated hilar (central) type: venous and arte-
rial fl ow signals branching radially within the
hilum and medulla
Fig. 10.3 Normal axillary
lymph nodes. Grayscale US
194
Fig. 10.3 (continued)
10 Ultrasound Examination of Regional Lymph Nodes
3. Peripheral: fl ow signals along the periphery of
the lymph nodes without subcapsular branches
arising from the hilar vessels
4. Mixed: presence of hilar and peripheral fl ow
signals
(a) One large artery in the hilum with
individual dot-shaped color signals in the
periphery
(b) Fragments of afferent artery and chaotic
fl ow signals within the solid component of
the lymph node
According to Sinyukova et al. ( 2007 ) , normal
lymph nodes exhibit single vessels in 58 % of
cases. In the case of multiple vessels, their pattern is regular with branching from the hilum to
periphery.
Doppler data, according to Abbasova et al.
( 2005 ) , do not affect the differential diagnosis of
enlarged lymph nodes.
Enlargement of a lymph node may appear as a
manifestation of a variety of diseases, such as
speci fi c or nonspeci fi c in fl ammation of head and
19510.1 Normal and Benign Lymph Nodes
neck organs, metastases, and hemoblastoses (e.g.,
Hodgkin’s disease). Nonspeci fi c types of lymphadenitis are divided into the following groups
(Tro fi mova 2008 ):
1. According to disease severity
Acute •
Subacute •
Chronic •
Fig. 10.4 Normal axillary lymph nodes. CDI and PDI
196
Fig. 10.4 (continued)
10 Ultrasound Examination of Regional Lymph Nodes
2. According to dispersion
Isolated •
Regional (in groups) •
Extended •
Generalized •
Individual and multiple lymph nodes as well
as lymph node conglomerations can be also
described.
Reactive hyperplasia of lymph nodes may
result from different pathological processes (an
in fl ammatory process, vaccination, injections,
etc.). Lymph nodes that are close to a tumor can
also present a nonspeci fi c reaction of in fl ammatory
character ( Tro fi mova 2008 ).
Hyperplastic lymph nodes usually exhibit
the following US features (Sinyukova et al.
2007):
Size of >10 mm •
Roundish shape •
Decreased or normal general echodensity •
Heterogeneous echostructure with thick •
cortex
19710.1 Normal and Benign Lymph Nodes
Fig. 10.5 Reactive axillary lymph nodes. Grayscale US
198
Fig. 10.5 (continued)
10 Ultrasound Examination of Regional Lymph Nodes
Regular distinct margins •
Avascularity or hypovascularity in CDI, PDI, •
and 3DPD (Figs.
Low values of PSV, EDV, and RI in PW •
Doppler
No difference in color pattern as compared •
with the surrounding tissues in US elastography (Fig. 10.7 )
In fl ammatory lymph nodes show fast dynamics. Even without therapy, they often sonographically disappear after 5–7 days. Treatment speeds
up their involution, resulting in the restoration of
the oval shape of the node and sharpness of
10.5 and 10.6 )
margins, an increase in the general echodensity
with more accurate corticomedullary differentiation, and a decrease in blood fl ow intensity and
morbidity upon compression.
10.2 Ultrasound Examination of Lymph Nodes in Patients with Breast Cancer
The incidence of metastases of breast cancer
in regional lymph nodes is 19–75 % (Chissov
2003 ; Sinyukova et al. 2007 ; Trufanov et al.
19910.2 Ultrasound Examination of Lymph Nodes in Patients with Breast Cancer
Fig. 10.6 Reactive axillary lymph nodes. CDI, PDI, and 3D
200
10 Ultrasound Examination of Regional Lymph Nodes
Fig. 10.6 (continued)
20110.2 Ultrasound Examination of Lymph Nodes in Patients with Breast Cancer
Fig. 10.7 Reactive axillary lymph nodes. US elastography