Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5791_Библиотеки_им_академика_М_И_Перельмана.pdf
202
10 Ultrasound Examination of Regional Lymph Nodes
2009 ) . The sensitivity of US in detection and
differentiation of malignant lymph nodes in
patients with breast carcinoma ranges from 70 to
99 % with the speci fi city of 83–97 %. Both mentioned depend on the quality of equipment and
skills and experience of the operator (Cosgrove
et al. 1990 ; Svensson et al. 2000 ; Drincovic
2002 ) . Several authors report high diagnostic
value of other imaging techniques, such as CT,
PET, MRI, and scintigraphy in the evaluation of
affected lymph nodes in breast carcinoma.
Our own data based on 1150 US examinations
of patients with breast carcinoma revealed metastases in axillary lymph nodes in 37.5 % of cases.
Lymph nodes of other groups ( fi rst of all supraclavicular, subclavian, jugular, and parasternal)
in addition to axillary were affected in 13.6 %.
Some US features that are suspicious for a
malignant process in a neck lymph node are listed
below (Figs.
10.8 , 10.9 , 10.10 , and 10.11 ):
Size of >10 mm (the average size 19 ± 2 cm). •
Oval (50 %) or irregular (46 %) shape. •
Irregular margins (55 %), blurred (15 %) •
contours.
Decreased general echodensity (94 %). •
Heterogeneous echostructure (88 %). •
Pathological echogenic inclusions (5 %). •
Anechoic component (34 %). •
Dislocation or deformation of the hilum, indis-•
tinct image of the hilum of the lymph node up
to its full disappearance (39 %).
Local thickening of the cortex of the lymph •
node in combination with dislocation of the
hilar vessels.
Conglomerations of lymph nodes. •
Immobility or limited mobility against the •
surrounding tissues.
Pathological vascular patterns in CDI, PDI, •
and 3DPD with general hypovascularity
(58 %) or hypervascularity (28 %).
No difference from the surrounding tissues in •
compression elastography mode in 76 %. Only
12 % of cases exhibited intense hard (blue)
color pattern.
The site of metastases does not always corre-
spond to the location of the primary breast
tumor.
Grayscale US remains the principal method
for diagnosis of the pathology in the axillary area.
B -mode US signi fi cantly surpasses the possibilities of palpation and mammography in de fi ning
the nature of enlarged lymph nodes. Up to 55 %
of sonographically detected abnormal lymph
nodes are impalpable.
According to Trufanov et al. ( 2009 ) , local
metastases are characterized with multiple (more
than 2) abnormal lymph nodes with roundish
shape, heterogeneous echostructure, rough margins, and irregular cortical thickening located on
the side of breast carcinoma (Figs. 10.8 , 10.9 ,
10.10 , and 10.11 ).
Rough indistinct margins of a lymph node are,
as a rule, a consequence of capsule invasion.
Heterogeneity of echostructure, fl uid collections,
and calci fi cations characterize necrosis and
fi brosis within the affected lymph node. The
echodensity of a malignant lymph node is associated with morphological structure of the primary
tumor and the ratio of lymphoid and tumoral tissues. Along with the decrease of normal elements
within a lymph node, its structure becomes more
homogeneous and hypoechoic.
Many authors consider narrow or absent
hilum in combination with thickened cortex suspicious for malignant nature of a lymph node
( Allahverdyan and Chekalova 2011 ) .
The risk of regional metastases depends on the
size of the primary tumor. The breast carcinoma of
stages T1, T2, and T3 metastasizes in axillary lymph
nodes in 3, 7, and 15 % of cases, accordingly.
The growth of secondary tumors leads to extracapsular invasion and merging into surrounding adipose tissue. That often results in shapeless
conglomerations of lymph nodes with involvement of surrounding organs and structures in
malignant process. Sixty to eighty-seven percent
of breast carcinoma metastases in axillary lymph
nodes can be detected with the use of only grayscale US ( Tro fi mova 2000a ) .
CDI is used in addition to grayscale US. It
permits assessment of both vascular pattern and
functional features of blood supply. Sinyukova
and Sholokhov ( 2010 ) reports that CDI detects
blood vessels in metastatic lymph nodes in 93 %
20310.2 Ultrasound Examination of Lymph Nodes in Patients with Breast Cancer
of cases. Vascular pattern is usually disorganized
with irregular distribution and nonuniform caliber and shape of vessels. The average indexes of
blood fl ow with PW Doppler are the following:
PSV, 42.8 ± 2.5 cm/s; EDV, 10.5 ± 0.8 cm/s; RI,
0.75 ± 0.01; and PI, 1.6 ± 0.06.
Some explorers consider that pulsed Doppler
criterion of lymph node malignancy is RI > 0.9;
some, RI > 0.73; and others, decrease of RI.
Dif fi culties in PW Doppler of lymph nodes result
a1
from irregular wavy course of vessels with wide
range of velocities.
Comparison of the vascular patterns of breasts
and lymph nodes on the normal and affected sides
with CDI and PDI is also necessary. The status of
incoming arteries and smaller vessels may be
obviously assessed with 3D reconstruction in
vascular mode. That permits the targeted study of
maximally changed vessels with PW Doppler.
Visual parameters of vascular structures, which
Fig. 10.8 Grayscale US of
breast carcinoma metastases.
( a ) Axillary lymph nodes.
( b ) Subclavian lymph nodes.
( c ) Supraclavicular lymph
nodes
a2
204
Fig. 10.8 (continued)
10 Ultrasound Examination of Regional Lymph Nodes
a3
a4
a5
20510.2 Ultrasound Examination of Lymph Nodes in Patients with Breast Cancer
a6
Fig. 10.8 (continued)
206
10 Ultrasound Examination of Regional Lymph Nodes
Fig. 10.8 (continued)
a7
a8
Fig. 10.8 (continued)
20710.2 Ultrasound Examination of Lymph Nodes in Patients with Breast Cancer
b1
b2
208
Fig. 10.8 (continued)
10 Ultrasound Examination of Regional Lymph Nodes
b3
b4
Fig. 10.8 (continued)
20910.2 Ultrasound Examination of Lymph Nodes in Patients with Breast Cancer
c1
c2
210
Fig. 10.9 Metastases of
breast carcinoma in axillary
lymph nodes. CDI and PDI
10 Ultrasound Examination of Regional Lymph Nodes
21110.2 Ultrasound Examination of Lymph Nodes in Patients with Breast Cancer
Fig. 10.9 (continued)