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The value of qualitative and semiquantitative ultrasonographic findings in the differential diagnosis of lymphomatous superficial lymph node enlargements
Abstract
The value of the gray-scale (GSUSG), color Doppler (CDUSG), and power Doppler (PDUSG) ultrasonography in the differential diagnosis of lymphomatous superficial lymph node enlargements were evaluated. The study group consisted of 33 males and 16 females (5-74 yrs old, mean age 36.1 yrs) in whom physical examination had revealed superficial lymph node enlargements. All patients were investigated with Doppler USG (Sonoline Elegra Advanced, Siemens, Germany) using 7.5 Mhz linear transducer. Longitudinal/ transverse dimensions (L/T) and hilar echogenecity of lymph nodes were evaluated with GSUSG. During the CDUSG and PDUSG examination, we classified the nodes into 3 patterns: type I, "hilar normal"; type II, "hilar activated"; and type III, "peripheral". Pulsatility (PI) and resistivity (RI) indexes were calculated using CDUSG. Above parameters were analyzed to determine their differential diagnostic values using ANOVA based discriminant analysis, Student's-T test and ROC curve analysis. When clinical data and histopathological findings were combined, 27 subjects were diagnosed as lymphoma, and 22 cases were classified as lymphadenitis. Multiple comparison analysis of qualitative GSUSG and PDUSG features consisting of hilar echogenecity, L/T value and vascular type patterns was able to differentiate lymphomatous lymph nodes and lymphadenitis with 86.8% accuracy (p<0.001). On the contrary, semiquantitative features (RI, PI) were not able to classify lymph nodes (p>0.05). Semiquantitative RDUS parameters are not valuable in the differential diagnosis of lymphomatous superficial lymph node pathologies. Qualitative GSUSG and PDUSG features, on the other hand, may be used as an alternative work-up to cytological studies in patients in whom diagnostic surgical procedures cannot be performed.
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Steinkamp H-J, Teichgräber UKM, Mueffelmann M, Hosten N, Kenzel P, Felix R. Differential diagnosis of lymph node lesions: A semiquantitative approach with power Doppler sonography. Invest Radiol 1999;34:509–515. RATIONALE AND OBJECTIVES. To assess the value of power Doppler for distinguishing reactive from malignant lymph node disease. METHODS. In a prospective study, 48 untreated patients with palpable cervical lymph node enlargement (n = 211) underwent examination with power Doppler sonography. The perfusion sites were subdivided into three groups: central, peripheral, and hilar perfusion. In addition, the authors qualified the intensity of perfusion using a semiquantitative scale from 0 (no perfusion) to III (high perfusion). Finally, the overall perfused lymph node area was measured and the percentage of perfused nodal area was calculated. RESULTS. Power Doppler sonography showed perfusion in 183 of 211 lymph nodes. Histologic examination revealed 67 reactively enlarged lymph nodes, 72 metastases, and 44 lymphomas. Reactively enlarged lymph nodes showed characteristically intense hilar perfusion (82.1%), whereas nodal metastases exhibited mainly peripherally located flow (84.7%) of grade intensity I to III. Lymph nodes invaded by malignant lymphoma were highly perfused, displaying color signals in the center as well as in the nodal periphery (90.9%). CONCLUSIONS. The perfusion patterns of lymph nodes provide useful additional information in the differential diagnosis of cervical lymphadenopathy.
In einer prospektiven Studie wurde die Perfusion von 105 benignen und 115 malignen Lymphknotenvergrößerungen, die histologisch (n = 158) bzw. klinisch (n = 62) gesichert sind, mit der FD-Sonographie untersucht. Aus der Doppler-Spektralanalyse der benignen Lymphknoten wurden Normalwerte des Pulsatilitäts- und Resistance-Index bestimmt. Ein Pulsatilitätsindex > = 1,8 oder ein Resistance-Index > = 0,9 weisen auf Lymphknotenmetastasen hin mit einem positiven Vorhersagewert von 93 % und einer Spezifität von 97 %. Zusätzlich läßt sich durch die subjektive semiquantitative Klassifizierung der Lymphknotenperfusion im Vergleich zum umgebenden Fett- und Bindegewebe eine verbesserte Diagnostik von Lymphknotenmetastasen und malignen Lymphomen im farbkodierten B-Bild-Sonogramm erreichen.
Summary
Perfusion of enlarged lymph nodes by colour-coded sonography was studied prospectively in 105 benign and 115 malignant lymph nodes. The diagnosis was confirmed histologically in 158 and clinically in 62. Spectral analysis in the benign lymph nodes provided normal values for pulsatility and resistance indices. A pulsatility index > = 1.8, or a resistance > = 0.9 indicate lymph node metastases with positive prediction of 93 % and specificity of 97 %. In addition, subjective, semiquantitative classification of lymph node perfusion in relation to the surrounding fat or connective tissue improves the diagnosis of lymph node metastases and of malignant lymphomas.
The authors conducted a prospective study in D-galactose signal-enhanced Doppler sonography of lymph nodes to investigate new aspects in differentiating malignant from reactive lymph nodes of patients with suspected malignancy of the neck.
Twenty-one patients with suspected squamous epithelial cell carcinoma metastases of the neck were examined by Doppler sonography before and after administration of an ultrasound signal-enhancing agent, consisting of D-galactose microbubbles. Qualitative sonomorphology, peak flow rates, and pulsatility and resistive indices were assessed.
Compared with conventional Doppler, enhanced Doppler sonography gave detailed additional information about vascularization of metastases or reactive lymph nodes. Signal-enhanced Doppler of metastases showed a relatively characteristic pattern of vascularity, therefore facilitating differential diagnoses and allowing better discrimination from surrounding tissue, demonstrated by the infiltration of neighboring vessels in the neck. Concerning reactive lymph nodes, vascularization could be stated and measured in many cases only after signal enhancement. Evaluating peak velocities and pulsatility and resistive indices could not differentiate significantly malignant from reactive lymph nodes.
Administration of a D-galactose-based signal-enhancer helps to differentiate malignant from reactive lymph nodes of the neck. It is superior to conventional Doppler by improving evaluation of the vascularity and could be of use for staging procedures.
Although the role of gray-scale sonography for neck nodes is well documented, it plays a limited role in the evaluation of nodal response to treatment. This preliminary limited study sought to determine color duplex sonographic changes in successfully treated metastatic nodes from nasopharyngeal carcinoma.
Fourteen patients with nodal metastases from nasopharyngeal carcinoma were studied. A pretreatment sonogram was obtained for all patients. Patients were divided into two groups of seven: in one group, repeat sonograms were obtained 8 weeks after completion of treatment; in the second group, sonograms were obtained 16 weeks after treatment. The features studied included distribution of intranodal vascularity, resistive and pulsatility indexes, and peak systolic velocity. In 11 patients, follow-up sonograms were obtained 1 year after treatment.
The majority (90%) of malignant nodes from nasopharyngeal carcinoma have an increased central and peripheral vascularity, a high resistive index (0.8), and a high pulsatility index (1.8). After radiation therapy to the nodes, a reduction in intranodal vascularity and a statistically significant reduction in the resistive index (0.58 to 0.59) and pulsatility index (0.91 to 0.93) are found. Although a similar reduction in the peak systolic velocity is observed, it is not statistically significant.
Our preliminary findings suggest that after radiation therapy for malignant nodes in nasopharyngeal carcinoma, a reduction in intranodal vascularity is found, and the resistive and pulsatility indexes may return to benign parameters as early as 8 weeks after completion of treatment.
The aim of the study was to show whether it may be possible to characterize malignant nodes of different aetiologies with Doppler imaging. Non-Hodgkin's lymphoma (NHL) and nasopharyneal carcinoma (NPC) were used as the models.
A prospective study was undertaken using colour Doppler sonography in 60 enlarged peripheral lymph nodes of 34 patients with either lymphoma or NPC. The vascular distribution, peak systolic velocity (PSV), end diastolic velocity (EDV), resistivity index (RI) and the pulsatility index (PI) of the largest node on each side of the patient were investigated.
The vascular distribution was predominantly 'capsular and central' or 'capsular' in 57 nodes, consistent with previous descriptions, but there was no significant difference in the mean PSV (lymphoma: 20.0 cm/s; NPC: 21.86 cm/s;P > 0.05) and mean EDV (lymphoma: 5.95 cm/s; NPC: 5.07 cm/s;P > 0.05). However, significant differences were shown in the mean RI (lymphoma: 0.71; NPC: 0.81;P < 0.05) and mean PI (lymphoma: 1.43; NPC: 1.88;P < 0.05) of these two groups of lymph nodes.
There is significant difference in the Doppler waveform between malignant nodes affected by lymphoma or NPC, suggesting that further differentiation of malignant nodes may be possible.
Pathologic changes of the intranodal angioarchitecture, as displayed by colour Doppler sonography, were used in recent studies to predict malignant infiltration of superficial lymph nodes. We searched for the underlying histopathologic findings in a prospective study including 100 lymph nodes in 86 patients. In the histopathologic specimens, we evaluated tumour infiltration, distribution of intranodal vessels, hilar structures, thickness of the capsule and tissue alterations (necrosis, sclerosis, lipo-/fibromatosis). Using the only prospectively tested classification, a pathologic angioarchitecture was described as displacement, aberrant course, avascular foci or subcapsular vessels. Testing these four criteria by multivariate regression analysis, the most important correlations were found between the following pairs of sonographic and histopathologic findings: displacement with perinodal tumour spread, aberrant vessels with intranodal sclerosis, avascular foci with intranodal necroses and subcapsular vessels with intranodal necroses. In conclusion, the criteria describing a pathologic angioarchitecture correlate with histopathologic findings that are frequently seen in malignant lymph nodes.
The supraclavicular region is a common site for tuberculous and metastatic nodes from infraclavicular carcinomas. Grey scale sonographic features differentiating the two have been previously described. However, as power Doppler sonography is now frequently used in the assessment of neck nodes, power Doppler features that may help to differentiate the two are discussed.
In 78 patients, power Doppler sonograms of nodes involved by metastases from infraclavicular carcinomas (n = 24) and tuberculosis (n = 54) were evaluated. The intranodal distribution of vessels and the intranodal vascular resistance of vessels was assessed and compared. In addition, the power Doppler features of metastatic nodes from infraclavicular carcinomas were compared with metastatic nodes from a head and neck primary (n = 38) such as nasopharyngeal carcinoma (NPC).
Tuberculous nodes frequently demonstrated displaced hilar vascularity or avascularity and the intranodal vascular resistance was low. Metastatic nodes from infraclavicular primaries demonstrated capsular or mixed vascularity and their intranodal resistance was significantly (P < 0.05) higher. In general, metastatic nodes from infraclavicular primaries had a higher intranodal vascular resistance compared to metastatic nodes from NPC, but this was not statistically significant.
In the supraclavicular region, the presence of displaced low resistance hilar vascularity or avascularity in nodes is suggestive of tuberculous nodes. Metastatic nodes from infraclavicular primaries have a capsular or mixed vascularity with high resistance.