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Lymph node imaging: multidetector CT (MDCT)

Cancer Imaging. 2005; 5(Spec No A): S57–S67.

Monday 3 October 2005, 14:00–16:00

Paul M Silverman

*Department of Radiology, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA

*Department of Radiology, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA

Corresponding address: Paul M Silverman, MD, Department of Radiology, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA. Email: [email protected] © 2005 International Cancer Imaging SocietyThis article has been cited by other articles in PMC.

Abstract

Advances in cross-sectional imaging, including conventional and helical (spiral) CT and multidetector (MDCT) and MR imaging, now allow detailed evaluation of the anatomy and pathology of the neck and thoracic inlet. The major structures are identified by their appearance and that of contrasting fatty tissue planes surrounding the soft tissues. These structures include the larynx, trachea, thyroid, and parathyroid glands as well as the vessels, lymph node chains, nerves, and supporting muscles. A thorough understanding of the normal cross-sectional anatomy is fundamental to properly interpret pathologic processes. Pathologic processes include both solid and cystic masses. Most solid masses are enlarged lymph nodes. In contrast, cystic masses are of variable pathology, and their characteristic appearances and locations with respect to normal neck anatomy allow a confident diagnosis to be made from a brief differential diagnostic spectrum.

Keywords: Neck, computed tomography (CT), lymph nodes

Technique

Computed tomography (CT) is performed with the patient supine in quiet respiration [1–4]. A pad placed beneath the patient’s scapulae produces mild hyperextension of the neck and provides consistent images perpendicular to the long axis of the neck, minimizing dental artifacts. Scans are obtained using 3–5 mm or thinner contiguous slices. Multidetector CT (MDCT) affords optimal imaging in a single breath-hold, maximizing contrast enhancement and minimizing misregistration which improves visualization of small anatomic structures without rescanning or additional radiation. Intravenous contrast material is a prerequisite for enhancement of vascular structures. Its use facilitates differentiation of vessels from lymph nodes and the characterization of pathology.

Normal anatomy

The classic surgical approach divides the neck into two spaces, the anterior and posterior triangles (Fig. 1). The anterior triangle contains the major structures of the neck: hypopharynx, larynx, trachea, esophagus, thyroid, parathyroid, and salivary glands as well as the carotid sheath, nerves, and lymph nodes. Each anterior triangle is bordered posterolaterally by the sternocleidomastoid muscle and superiorly by the mandible. The anterior triangle is subdivided by the hyoid bone into suprahyoid and infrahyoid portions. The suprahyoid provides support for the floor of the mouth and contains sublingual, submandibular salivary glands and associated nodes. The infrahyoid portion contains the remaining components (Fig. 2). The posterior triangle is bounded anteriorly by the sternocleidomastoid muscle and posteriorly by the trapezius and is subdivided by the posterior belly of the omohyoid muscle. The space is primarily filled with fat and includes the hypoglossal nerve, vessels, and nodes.

Normal lymph nodes of the neck

The location of the various lymph node groups of the neck is most succinctly understood using a simplification of the Rouviere classification [5]. Nodal classification is critical for staging tumor extent [6–18]. Lymph nodes of the neck may be divided into 10 major groups [7–18].

The first six groups (I–VI) form a lymphoid collar at the junction of the head and neck (Fig. 2). These nodes are quite superficial, are usually accessible to palpation on physical examination and are commonly referred to as collar nodes: occipital, mastoid, parotid, submandibular, and facial submental.

Two groups of nodes lie deep within this lymphoid collar and are not accessible to clinical examination. Pathologic enlargement (>1.5 cm) allows detection. These nodes—groups VII, sublingual, and VIII, retropharyngeal—are often the site of metastases from carcinoma of the nasopharynx, the base of the tongue, and the tonsils (Fig. 3).

The anterior cervical group (IX) consists of superficial (Fig. 4B) and deep components (Fig. 4C). These nodes may be the site of metastases from primary tumors in the thyroid, larynx, and lung.

The lateral cervical nodes (group X) are also composed of superficial and deep chains (Fig. 5). This important deep group of nodes consists of three chains that form a triangle. The anterior portion is the internal jugular chain, the posterior portion is the spinal accessory chain, and the inferior component is the transverse cervical chain. Of these groups, the most important in staging head and neck tumors are the nodes along the internal jugular chain. A classification used by our surgical colleagues is shown in . Although the table is useful, the classification can easily be integrated into our system by carefully describing in reports the anatomic location of the nodes.

Table 1

1997 AJCC nodal (N) staging systems for cervical lymph nodes

Level Classification criteria
NX The regional lymph nodes cannot be assessed (clinically)
N0 There are no regional metastatic lymph nodes present
N1 There is metastasis to a single ipsilateral lymph node that is 3 cm or less in greatest dimension
N2 There is metastasis in a single ipsilateral lymph node that is between 3 and 6 cm in greatest dimension; there are multiple ipsilateral
lymph nodes, none of which are greater than 6 cm in greatest dimension; or there are bilateral or contralateral lymph nodes, none of
which are greater than 6 cm in greatest dimension
N2a There is metastasis in a single ipsilateral lymph node that is between 3 and 6 cm in greatest dimension
N2b There are multiple ipsilateral lymph nodes, none of which are greater than 6 cm in greatest dimension
N2c There are bilateral or contralateral lymph nodes, none of which are greater than 6 cm in greatest dimension
N3 There is metastasis in lymph nodes that are more than 6 cm in greatest dimension

A new imaging-based classification for abnormal nodes

Recently, the results of a study produced an imaging-based nodal classification for the evaluation of metastatic neck adenopathy. Imaging landmarks were identified to create a nodal classification similar to that of the American Joint Committee on Cancer and the American Academy of Otolaryngology—Head and Neck Surgery [9–11, 18–24] (). This system was defined to ensure a more consistent nodal classification and to eliminate confusion with existing clinically based classifications. Imaging was chosen as a pivotal study because it identifies clinically silent nodes. summarizes this new imaging-based classification (Figs. 6–19). A roman numeral is used to define the levels referenced to anatomic names, such as supraclavicular, retropharyngeal, carotid, facial, occipital, postauricular, and other superficial nodes; these anatomic terms are still widely used. This classification brings some improved precision and reproducibility to the staging of head and neck diseases.

Table 2

Clinical classification of neck nodes

t Definition of nodes
I Above hyoid bone
Below mylohyoid muscle
Anterior to back of submandibular gland
IA Between medial margins of anterior bellies of digastric muscles
Previously classified as submental nodes
IB Posterolateral to level IA nodes
Previously classified as submandibular nodes
II From Skull base to level of lower body of hyoid bone
Posterior to back of submandibular gland
Anterior to back of sternocleidomastoid muscle
IIA Anterior, lateral, medial, or posterior to internal jugular vein
Inseparable from internal jugular vein (if posterior to vein)
Previously classified as upper internal jugular nodes
IIB Posterior to internal jugular vein with pat plane separating nodes and vein
Previously classified as upper spinal accessory nodes
III From level of lower body of hyoid bone to level of lower cricoid cartilage arch
Anterior to back of sternocleidomastoid muscle
Previously known as mid jugular nodes
IV From level of lower cricoid cartilage arch to level of clavicle
Anterior to line connecting back of sternocleidomastoid muscle and posterolateral margin of anterior scalene muscle
Lateral to carotid arteries
Previously known as low jugular nodes
V Posterior to back of sternocleidomastoid muscle from skull base to level of lower cricoid arch
From level of lower cricoid arch to level of clavicle as seen on each axial scan
Posterior to line connecting back of sternocleidomastoid muscle and posterolateral margin of anterior scalene muscle
Anterior to anterior edge of trapezius muscle
VA From skull base to level of bottom of cricoid cartilage arch
Posterior to back of sternocleidomastoid muscle
Previously known as upper level V nodes
VB From level of lower cricoid arch to level of clavicle as seen on each axial scan
Posterior to line connecting back of sternocleidomastoid muscle and posterolateral margin of anterior scalene muscle
Previously known as lower level V nodes
VI Between carotid arteries from level of lower body of hyoid bone to level superior to top of manubrium
Previously known as visceral nodes
VII Between carotid arteries below level of top of manubrium
Caudal to level of innominate vein
Previously known as superior mediastinal nodes
Supraclavicular At or caudal to level of clavicle as seen on each axial scan
Above and medial to ribs
Retropharyngeal Within 2 cm of skull base and medial to internal carotid arteries

Nodal disease

Clinical examination alone is highly inaccurate in staging nodal disease in patients with head and neck tumors. Therefore, prophylactic X-ray therapy can be used to treat patients with occult metastases, which are estimated to occur in 15%–20% of these individuals.

Because normal nodes in the neck may be identified on high-quality scans, criteria have been established to define lymphadenopathy: (1) a discrete mass great than 1.0–1.5 cm; (2) an ill-defined mass in a lymph node area; (3) multiple nodes of 6–15 mm; and (4) obliteration of tissue planes around vessels in a nonirradiated neck. A nodal mass with central low density is specifically indicative of tumor necrosis [5–8].

Less common, nonnodal solid masses include neurovascular tumors (paraganglioma, neurofibroma, hemangioma), primary neoplasms (fibroma, sarcoma), congenital lesions (teratoma, ectopic thyroid), trauma (hematoma), lesions of the bone (plasmacytoma, aneurysmal bone cyst), and infection. Specific imaging features aid the differential diagnosis. Paragangliomas (carotid body tumor) occur in the carotid space and consistently show early and persistently dense enhancement after the administration of contrast material. Acute hematomas are characterized by an intrinsically high CT attenuation and high intensity on T1-weighted magnetic resonance (MR) imaging. Metastases are located in the expected site of the major lymph node chains of the neck. Many investigators now use 1.0 cm as an effective size criteria for positive nodes in a patient population at high risk. Nodes in the upper neck tend to be large because of repeated respiratory infections; therefore, more liberal size criteria should be accepted. With the use of more liberal criteria, 80% of nodes will be metastatic and 20% will be benign hyperplastic. Important caveats include the follow: (1) regardless of primary site, a single ipsilateral node decreases survival by 50% and a contralateral node halves survival again; (2) extranodal extension is the best indicator of treatment failure and decreases survival by 50%; (3) posterior triangle nodes, with the exception of lymphoma, indicate a poor prognosis; and (4) nodes in the low internal jugular chain have a poor prognosis because proximal spread has often occurred. These caveats are helpful when dealing with the assessment of lymphadenopathy in this region.

In summary, careful analysis of nodes in the neck and knowledge of the various compartments is critical in the assessment and staging of primary head and neck malignancies.

(1) Cross-sectional diagram. Anterior and posterior triangle of the neck. (2) (A) Collar nodes. There are six (I–VI) major nodal groups at the junction of the head and neck. The posterior group consists of the carotid, occipital, and mastoid group while the anterior group consists of the facial, submental, and submandibular nodes. They form a collar of rather superficial nodes. (B) CT scan at the level of the hyoid. Multiple non-specific submental nodes (arrow) deep to the platysmal muscle (arrowhead). (C) Scattered submandibular sub-centimeter nonspecific nodes seen lateral to the submandibular glands (arrows).

(3) (A) Groups VII and VIII are the sublingual and retropharyngeal nodes. The sublingual nodes are not specifically accessible by cross-sectional imaging but the retropharyngeal nodes are blind to clinical assessment and dependent on radiologic imaging. Diagram at the level of the posterior pharynx demonstrates retropharyngeal nodes in light blue. (B) CT scan showing low attenuation, necrotic node in the right retropharyngeal region (arrow). (4) (A) Anterior cervical nodes (IX). This consists of superficial and deep components. The superficial group is along the anterior jugular vein and the deep group consists of the pre-laryngeal, pre-tracheal, pre-thyroid, and paratracheal nodes. (B) CT scan showing lymphadenopathy including the anterior jugular region (arrow) in a patient with lymphoma. (C) CT scan demonstrating numerous deep nodes along the thyroid gland from metastatic disease.

(A) Lateral cervical nodes (X). The lateral cervical nodes are composed of three chains: the spinal accessory chain in the posterior triangle of the neck, the internal jugular chain along the internal jugular vein, and transverse cervical chain along the base of this triangle. The internal jugular chain represents the major site of metastatic disease for head and neck primary tumors. JD, jugulodigastric node; JO, juguloomohyoid node. (B) CT scan showing node (arrow) seen just lateral to the right internal jugular vein within the right internal jugular group. (C) Small node seen in the distribution of the spinal accessory group (arrow). (D) Enlarged nodes in the transverse cervical chain at the base of the neck (arrows).

(6) Imaging-based classification of neck nodes as defined in . These nodes are labeled I–VII with an additional notation of supraclavicular and retropharyngeal nodes. Adapted from: Som and Brandwein [24]. (7) Diagrammatic representation showing the distribution of nodes and their levels. Adapted from: Som and Brandwein [24]. (8) Internal jugular chain nodes. Diagrammatic demonstration of the superior and inferior extents of the internal jugular chain. The largest node superiorly in the internal jugular chain is the jugulodigastric node just posterior to the posterior belly of the digastric muscle. The largest inferior node is the jugulo-omohyoid node which lies along the intersection of the sternocleidomastoid muscle and the omohyoid muscle. Adapted from: Som and Brandwein [24].

(9) Level IA, submental nodes. CT scan at the level of the hyoid bone showing multiple nodes superficially (arrows). (10) Level IB, submandibular nodes. CT scan at the level of the body of the hyoid demonstrates nodes just lateral to the hyoid bone (arrow). (11) Level IIA, upper internal jugular chain. CT scan at the level of the hyoid bone. Necrotic node in the area of the high internal jugular chain (arrow). Necrotic node is the result of metastasis from pyriform sinus cancer (arrowheads). (12) Level IIB, upper spinal accessory chain. CT scan at the level of the upper neck demonstrating nodes (arrow) which were previously classified as upper spinal accessory nodes in the posterior triangle.

(13) Level III. Nodes previously described as mid-internal jugular chain nodes. CT scan at the level of the mid-internal jugular (arrows). (14) Level IV. Low internal jugular chain. CT scan demonstrating adenopathy in the low internal jugular chain (arrows). (15) Level V. Low spinal accessory chain. CT scan demonstrating node in the low posterior triangle region on right (arrow). (16) Level VI. Nodes previously described as juxtavisceral nodes. CT scan demonstrating small nodes (arrow) along the area of the thyroid gland.

(17) Level VII. Superior mediastinal nodes. CT scan demonstrating nodes in the superior mediastinum from head and neck primary (arrow). (18) Supraclavicular nodes. CT scan at the level of the medial aspect of the clavicles demonstrates an enlarged node in the right paratracheal region (arrowhead) and right supraclavicular node (arrow). (19) Retropharyngeal nodes. CT scan at the level of the base of the tongue demonstrates a small enhancing node in the right retropharyngeal area (arrow), a region blinded to clinical examination because of its location deep to the mucosa.

References

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Swollen lymph nodes in armpit: Symptoms, causes, and treatment

Lymph nodes are part of the body’s immune system. They act as filters, removing potentially harmful substances from the body. A swollen lymph node in the armpit may be a sign of an infection or injury.

The possible causes of lymph node swelling range in severity from common infections that typically resolve on their own to more serious conditions, such as lymphoma.

In this article, we look at why lymph nodes swell, the most common causes of this symptom, and when to see a doctor.

When a person has an infection or injury, the lymph nodes may swell as they start to filter unwanted cells from the lymph.

Lymph is a watery fluid that carries oxygen to the cells and transports waste products away from them. It also contains white blood cells, which help fight infections.

As the lymph nodes begin to work harder to remove waste, they can enlarge. This enlargement is more common in certain areas of the body, including the neck, armpit, and groin.

A swollen lymph node may be visibly enlarged, painful, and tender to the touch.

Many viruses can cause swollen lymph nodes. These include:

These viruses usually produce other visible symptoms, such as a rash.

However, other viral conditions can cause swollen lymph nodes with no other visible symptoms. These include:

Influenza (flu)

The flu is a respiratory infection that can also cause the lymph nodes to swell. The symptoms of flu are similar to those of other respiratory viruses, but they tend to be more severe. They also often develop suddenly rather than gradually.

Other symptoms of the flu include:

  • fatigue
  • sore throat
  • cough
  • runny or stuffy nose
  • body aches
  • headaches
  • fever or chills

Some people also experience vomiting and diarrhea, but these symptoms are more common in children.

While a person has the flu, they should stay at home and rest, avoiding contact with others. Most people recover from the flu without treatment, but it can cause complications.

People who are most at risk for complications include:

  • young children
  • adults over 65 years of age
  • pregnant people
  • people with underlying health conditions

People in these groups may need antiviral medication to prevent severe symptoms. Getting a flu vaccine each year is the best way to prevent the flu.

Infectious mononucleosis

Infectious mononucleosis, also known as mono or glandular fever, is the result of a viral infection. It can cause lymph nodes in the neck and armpits to swell. Mono also causes symptoms such as:

Mono will eventually go away on its own. Most people recover in 2–4 weeks, but some experience symptoms for longer. Resting, drinking fluids, and taking over-the-counter (OTC) pain relievers can help during recovery.

Bacterial infections can also cause the lymph nodes to swell. Some examples of infections that could affect the nodes in the armpit include:

Cellulitis

Cellulitis is a skin infection. It occurs when bacteria penetrate the skin and infect the middle layer, potentially as a result of an injury that led to an area of broken skin.

Cellulitis may cause nearby lymph nodes to swell. For example, an infection in the arm may cause the lymph nodes in the armpit to enlarge. The other symptoms of cellulitis include:

  • pain and swelling at the infection site
  • skin sores
  • fever or chills
  • body aches
  • muscle and joint pain
  • skin that is warm to the touch
  • vomiting and nausea
  • fatigue

Doctors treat cellulitis with antibiotics. A person may need to stay in the hospital if the infection is severe, or they require intravenous antibiotics.

Lyme disease

Lyme disease spreads through the saliva of certain species of tick, which are small insects that can bite humans. One of the early symptoms of Lyme disease is swollen lymph nodes, which may appear 3–30 days after the tick bite occurred.

Other early symptoms include:

  • a circular rash resembling a bull’s-eye at the site of the bite
  • fever
  • chills
  • joint or muscle aches
  • fatigue
  • headaches

To treat Lyme disease, a doctor will typically prescribe antibiotics. Anyone who suspects that they have this condition should seek medical attention promptly.

Other bacterial infections that can cause swollen lymph nodes include:

Bacteria and viruses are not always responsible for swollen lymph nodes in the armpit. Other possible causes include:

Rheumatoid arthritis

Some autoimmune conditions can cause swollen lymph nodes. These include rheumatoid arthritis (RA).

RA occurs when the body’s immune system mistakenly attacks the lining of the joints, causing stiffness, pain, and warmth.

A 2019 review article states that RA affects the lymph nodes, reducing their capacity to drain fluid from nearby inflamed joints. This impairment may lead to local lymph node enlargement.

Doctors treat RA with medications that reduce inflammation and relieve pain. Physical therapy may also help. In some cases, a doctor may recommend surgery to replace or repair affected joints.

Cancer

Rarely, swollen lymph nodes are a symptom of cancer.

Cancer that begins in the lymphatic system is known as lymphoma. There are several types of lymphoma, including:

  • Hodgkin lymphoma
  • non-Hodgkin lymphoma
  • non-Hodgkin lymphoma in children
  • Waldenstrom macroglobulinemia
  • lymphoma of the skin

In addition to swollen lymph nodes, the symptoms of lymphoma can include:

  • unintentional weight loss
  • feeling tired
  • fever
  • night sweats

Leukemia can also cause swollen lymph nodes, as can other types of cancer that have spread to the lymph nodes, such as breast cancer.

The type and stage of the cancer, as well as a person’s age and overall health, will affect what treatment doctors recommend.

However, it is worth remembering that there are many causes of swollen lymph nodes that are not related to cancer.

A doctor can determine the cause of swollen lymph nodes in the armpit and recommend the best treatment. They may ask about the person’s symptoms, review their medical history, and perform a physical examination.

In some cases, a doctor may also carry out diagnostic tests, such as blood tests or medical imaging.

Swollen lymph nodes can be painful. While a person receives medical treatment, there are things they can try at home to ease any tenderness.

A person can apply a warm compress to reduce pain. They can run warm or hot water over a washcloth and wring it mostly dry before placing it on the swollen lymph node.

People can take OTC pain medications, such as acetaminophen or ibuprofen, to relieve pain. A person should talk to their doctor if they are not sure what medications are best for them.

Anyone with swollen lymph nodes in their armpit should talk with a doctor. Swollen lymph nodes have many potential causes, and a doctor can rule out possibilities that require prompt treatment, such as Lyme disease.

A person should also consult their doctor about swollen lymph nodes if multiple lymph nodes become swollen or they have previously had cancer treatment.

Swollen lymph nodes in the armpit can be a sign of common viral infections, such as the flu or mono. They can also occur as a result of a bacterial infection or RA. In rare cases, swollen lymph nodes are a symptom of cancer.

Warm compresses and OTC pain medication can ease any pain or tenderness. However, a person should talk to their doctor if they have swollen lymph nodes with no clear cause.

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Lymph Node Disease and Advanced Head and Neck Imaging: A Review of the 2013 Literature

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  • Lymph nodes in the head and neck cancer: would diffusion-weighted magnetic resonance imaging solve the diagnostic dilemma? | Egyptian Journal of Radiology and Nuclear Medicine

    DW-MRI (diffusion-weighted magnetic resonance imaging) is an effective non-invasive imaging technique for tissue characterization. DWI has been considered as a cancer biomarker and could distinguish benign from malignant tumors [13]. Our research aimed to establish the diagnostic validity of the diffusion-weighted magnetic resonance imaging for the distinction between benign and malignant lymph nodes via comparing the ADC values, as solving out this diagnostic problem is mandatory for the management of the patients.

    Our study revealed that the prevalence of tumors in the head and neck was higher in males (55%) than females (45%) without significant differences, in agreement with Lambert et al. [14] who reported that males are highly affected than females, but with a significant difference, with a ratio ranging from 2 to 4 folds. Our study results showed that Hodgkin disease incidence is higher in young age groups, although the prevalence of non-Hodgkin disease among the elderly population was higher, with no significant difference. Our study findings are in line with previous studies which reported that Hodgkin lymphoma is higher in younger age groups [15,16,17].

    Our analysis included 9 nodes less than 1 cm in their shortest axis diameter; 3/9 were metastatic and showed a pattern of restriction on DWIs and opposing low ADC value. On the other hand, these 9 nodes displayed no definite morphological characteristics of malignancy, such as necrosis and ill-defined margins in the conventional MRI sequences, and classification of metastatic nodes would have been very unlikely, in agreement with ElSaid et al. [18] who reported that all metastatic lymph nodes less than 1 cm were missed due to anatomical MR imaging criteria based on size.

    In the present study, on the contralateral side of the primary tumor, 1/3 metastatic differentiated squamous cell carcinoma lymph nodes (< 1 cm) were found, in agreement with Vandecaveye et al. [19] and ElSaid et al. [18] who reported the degree to which DWI changes nodal differentiation efficacy via depicting subcentimetric nodal metastases may affect the clinical management. Our study showed that the pathologically proven malignant lymph nodes (29 out of 30 cases) showed increased signal in b 1000, and low signal in the corresponding ADC maps, the inflammatory diseases (5 out of 6 cases), and reactive lymphoid hyperplasia (4 out of 4 cases) showed signal intensity reduction for increased b values (b = 1000) and intermediate signal intensity on ADC maps representing facilitated diffusion. Our study findings agreeing with Youssef et al. [20] and Abou khadrah and Imam [12] that the DWI with ADC mapping were useful as non-invasive tools for distinguishing between the benign and malignant solid head and neck lesions by using b values 800 and 1000. The malignant lymph nodes in our sample had significantly lower ADCs than benign lymph nodes. The ADC measurements of benign and malignant lymph nodes varied considerably with a P < 0.001, these results agree with Youssef et al. [20]. In our research, the mean ADC value of the 30 malignant lymph nodes was 0.971 ± 0.305 × 10−3 mm2/s, while on the other hand, the mean ADC value of the 10 benign lymph nodes was 1.98 ± 0.33 ± 3 mm2/s with the threshold ADC value for separating malignant from benign nodes obtained from the receiver characteristic analysis being 1.30 × 10−3 mm2/s with 94% sensitivity and 100% specificity. In agreement with Abou khadrah and Imam [12] who recorded 94% accuracy in characterizing the metastatic lymph nodes using a threshold of 1. 0210−3 mm2/s. The mean ADC values recorded for benign and metastatic lymph nodes were 1. 24 ± 0.1610−3 mm2/s and 0.78 ± 0.0910−3 mm2/s respectively.

    In our research, malignant lymph nodes had been subdivided into subgroups of metastatic carcinoma and lymphoma based upon the histopathology. An attempt was made to distinguish between them according to their ADC values. The mean ADC value for metastatic carcinoma (1.079 × 10−3 mm2/s) was a little higher than that of the lymphoma (0.781 × 10−3 mm2/s). The ADC threshold value for metastatic differentiation from lymphomatous lymph nodes obtained from receiver operating characteristic (ROC) analysis was 0.9 × 10−3 mm2/s with 90% sensitivity and 75% specificity,

    Thirty-four true-positives and 6 false-positives were shown via statistical data, providing a sensitivity of 100%, and specificity of 85%; these results agree with Usama and Ahmed [21] who reported the same results of the present study.

    Limitations of this study

    First, our analysis has some drawbacks, such as being a small cohort study. Also, our statistical tests were carried out on the number of nodes involved, not the number of patients. Second, for several reasons, we did not provide standardized ADCs: (1) As far as we know, the value of using standardized, rather than absolute, ADCs in head and neck imaging at DW was never reported. Unlike the brain, the region of the head and neck is distinguished by an extremely heterogeneous diffusivity of the tissues due to the presence of tissues of distinctly different histological origins. The spine is also the most appropriate reference tissue for normalization. However, echo-planar imaging of the spinal cord is hampered by strong susceptibility influences caused mainly by the osseous elements of the spinal column, which induce additional variability in ADC calculations. (2) The promising results of the current study, obtained using absolute ADCs, may suggest that normalization is not necessary, thus facilitating the implementation of DW imaging into routine clinical practice.

    Description of a Neck Dissection (Removal of the Lymph Nodes in the Neck)

    EVMS Ear, Nose & Throat Surgeons

    Head & Neck

     

    Surgeons must be very careful
    When they take the knife!
    Underneath their fine incisions
    Stirs the culprit,-Life!

    Emily Dickenson

     

    A neck dissection is an operation that is done for individuals with cancer of the head and neck. The purpose of this web page is to describe the reasons for this surgery, how it is done, and what to expect during and after the surgery.

     

    PURPOSE OF A NECK DISSECTION

    The purpose of a neck dissection is to remove the lymph nodes in the neck. The surgery is almost always done for individuals with certain types of head and neck cancer. (Head and neck cancer is often described as throat cancer, but it can also include cancer of the mouth, the tongue, the thyroid gland, the saliva glands, etc. ) Cancer in this region can spread through the lymphatic system to adjacent lymph nodes. If there is concern that this type of spread may have occurred, a neck dissection can be done to remove the suspicious lymph nodes. There approximately 600 lymph nodes in the body, and 200 of this are located in the neck. A neck dissection is useful not only to remove the cancer, but also so that the nodes can be examined by a pathologist. If the microscopic examination by the pathologist shows extensive spread of cancer, additional treatment such as radiation therapy may be recommended.

    This image shows the various regions of the neck where the lymph nodes are located. The neck is typically divided into zones (zones I through VI are shown on this diagram). Research has shown that tumors tend to follow certain trends in the manner in which the spread. For example, tumors of the mouth tend to spread first to the upper neck zone ( e.g. zones I, II, and III). Tumors lower in the neck, for example laryngeal cancer, tend to spread to lower zones (zones III or IV).  

     

    HOW A NECK DISSECTION IS DONE

     

    A neck dissection is done through an incision in the neck. There are many important anatomical structures, such as nerves and blood vessels, that run through the neck, and these structures are carefully identified and preserved in the course of the operation. If the original (also called primary) tumor is going to be treated with surgery, this tumor resection is usually done at the same time as the neck dissection. For example, if the primary site of tumor is the larynx (voicebox), a part or all of the larynx will be removed at the same time as the neck dissection.

     

     

    OTHER STRUCTURES INVOLVED IN A NECK DISSECTION

    There are three other important structures in the neck that are closely involved in a neck dissection. These are the internal jugular vein, the spinal accessory nerve, and the sternocleidomastoid muscle. The internal jugular vein is a major blood vessel through which blood returns from the head to the heart. The spinal accessory nerve controls movement of some of the major shoulder muscles. The sternocleidomastoid muscle is a large muscle in the neck.

    During a neck dissection the surgeon will try to save the structures. However, if the tumor invades into one or all of these structures, one or all of them will have to be removed. The consequences of their removal is discussed below.

     

    DIFFERENT TYPES OF NECK DISSECTION

    Neck dissection are classified by the zones from which the lymph nodes are removed, and whether or not the three structures described above are preserved. If all the nodes are removed (zones I through V) and the three structures (internal jugular vein, accessory nerve, and sternocleidomastoid muscle) are removed it is called a radical neck dissection (radical is a misleading term; it just means that a complete neck dissection has been done). A radical neck dissection would be done if the tumor spread to the neck is quite extensive. If the nodes from zones I through V are removed and one of these three structures is preserved, it is called a modified radical neck dissection. And if the operation does not involve all five zones, it is called a selective neck dissection. 

     

    ‌The image to the left shows the appearance of the neck after a radical neck dissection. The sternocleidomastoid muscle, the internal jugular vein, and the spinal accessory nerve have been removed. The surgeon has saved the vagus nerve (which supplies the muscles in the throat and the larynx) and the hypoglossal nerve (which supplies the muscles that move the tongue). Also preserved is the carotid artery, which is extremely important for providing oxygen to the brain. The strap muscles are strap-shaped muscles that help raise and lower structures in the neck. Note that skin “flaps” have been elevated, which allows very good exposure to all the structures in the neck. Exposure is very important in surgery. The important structures to be saved must first be identified, and exposure is key to finding and protecting these nerves and blood vessels.

     

     

    WHAT TO EXPECT AFTER A NECK DISSECTION

    Recovery time from a neck dissection alone is quite quick. If a patient has only had a neck dissection, the total hospital stay may only be several days. However, the surgery is also done along with resection of the primary tumor site, and this can take longer. Considering only the neck dissection, there usually will be drains placed under the skin at the time of surgery to collect any serous fluid or blood that accumulates at the operative site. These drains will be removed after a couple days. Once they are out, and if the incision looks to be healing well, the patient can usually go home.

    It is not unusual to develop some numbness in the neck skin and ear after a neck dissection. Much of the numbness goes away after several months, but some may be permanent. The nerve supplying sensation to the ear often must be cut during the surgery, and some of this sensation never returns. If you live in a cold climate, you will have to be careful since a numb ear can develop frostbite without first feeling cold or painful. The remaining numbness can be bothersome but seldom causes any major problems.

     

    EFFECT OF REMOVING THE INTERNAL JUGULAR VEIN, THE SPINAL ACCESSORY NERVE, OR THE STERNOCLEIDOMASTOID (SCM) MUSCLE

    As mentioned above, one or more of these structures may need to be removed in a neck dissection. Removal of one jugular vein usually causes minimal or no problems. There are many other veins in the neck and the blood can flow back through them. There may be some temporary swelling, but this usually decreases after a couple weeks. If a neck dissection is being done on both sides of the neck, the surgeon will try to save at least one jugular vein. Both veins can be removed at the same time, but the consequences of the swelling can be quite severe. Removal of the spinal accessory nerve limits the upward movement of the shoulder. In particular, it will be more difficult to move the arm from the horizontal position to directly overhead. There also may be some shoulder droop on the side of surgery, and there can be some mild pain due inflammation at the shoulder joint. If the spinal nerve is removed, post-operative physical therapy will be crucial to maintain good shoulder function.

    Removal of one sternocleidomastoid muscle generally causes no problems. The neck may look a little sunken due to its removal. The muscle also provides some coverage of the carotid artery, so this will be reduced if the muscle is resected. This can cause a problem if there is a post-operative infection, but otherwise is not that important. If both sternocleidomastoid muscles are removed, one’s strength in flexing the head forward will be reduced.

     

    OTHER POSSIBLE COMPLICATIONS OF A NECK DISSECTION

    As mentioned earlier, there are many important structures running through the neck, and any one of these can be injured during a neck dissection. Nerves to the lower lip and the tongue are in the operative field, and if they are injured there can be reduced movement of the tongue. If this weakness occurs, it usually is temporary. Another nerve supplies some of the muscles in the lower lip, and these can become weak after the surgery.

    As with any surgery, there are risks of bleeding or infection after surgery. If the bleeding or infection is severe, it may be necessary to go back to the operating room to treat the problem. The operation is done under a general anesthetic, and if there are pre-existing lung or heart problems this can increase the risk of a pneumonia or heart attack.

    But the risk of a major complication after a neck dissection is relatively small, and almost always far outweighed by the benefits of the operation.

    Magnetic resonance techniques in lymph node imaging

    By Sanjay K. Shetty, MD and Mukesh G. Harisinghani, MD



    Dr. Shetty

    is a Resident in Radiology and
    Dr. Harisinghani

    is an Assistant Professor and a Co-Director of Abdominal MR in
    the Department of Radiology, Massachusetts General Hospital,
    Harvard Medical School, Boston, MA.

    Superior soft-tissue contrast and resolution has made magnetic
    resonance imaging (MRI) an important tool in the armamentarium of
    the oncologic imager, providing staging information that predicts
    prognosis, guides selection of therapy, and evaluates response to
    treatment. Several modalities have been employed to attempt
    accurate assessment of tumor stage (T stage), nodal status (N
    stage), and the existence of distant metastasis (M stage),
    including computed tomography (CT), MRI, and positron emission
    tomography (PET). Each modality has its own strengths and
    weaknesses: thanks to excellent soft-tissue contrast and
    resolution, MRI has been particularly useful in the evaluation of
    the primary tumor and detection of distant metastasis.

    This review details the historic challenges and current
    approaches to the application of MRI to the third domain of
    oncologic imaging, lymph nodes. MRI has traditionally relied on
    size criteria and morphology as a predictor of malignancy in lymph
    nodes, limiting accuracy of the modality and potentially providing
    inaccurate staging information. This understaging of nodal status
    has important clinical implications, because failure to diagnose
    nodal metastasis may prevent a patient from receiving appropriate
    or even curative treatment. Similarly, there are also implications
    of misdiagnosing metastasis in a normal lymph node, as reduced
    specificity for nodal metastasis will result in unnecessary
    treatment or exclusion of treatment options. Surgical methods, even
    less invasive methods such as laparoscopy, confer procedural risk
    and morbidity. While considered the gold standard, surgical
    exploration itself suffers from false-negative findings resulting
    from the fallibility of intraoperative frozen section.
    1

    This article will review the traditional methods of lymph node
    characterization by MRI and will discuss newer imaging approaches
    that attempt to address the modality’s historic shortcomings; these
    approaches include the evaluation of signal intensity, dynamic
    gadolinium contrast enhancement, the use of ultrasmall
    superparamagnetic iron oxides (USPIO), MR spectroscopy, and
    interstitial application of contrast. Particular attention will be
    paid to the mechanisms and oncologic applications of USPIO (also
    known as lymphotrophic superparamagnetic nanoparticles), a contrast
    agent with exciting potential supported by a growing body of
    clinical literature.


    Size and morphologic criteria

    The traditional approach to MRI of lymph nodes has relied on
    size criteria to distinguish metastatic from uninvolved nodes. The
    efficacy of this approach depends heavily on the selection of a
    threshold size, necessitating a tradeoff between setting a low size
    threshold (highly sensitive but poorly specific) and a high size
    threshold (increased specificity at a cost of diminished
    sensitivity). A range of acceptable threshold sizes has been
    proposed, which vary in the use of different aspects of nodal
    measurement, such as long-axis or short-axis diameter, and the
    application to specific nodal groups.
    2-4

    Studies using sizes derived from imaging
    5-11

    and gross specimens
    12-14

    show that although size criteria can be applied with some success,
    the approach frequently overlooks metastasis, particularly when the
    metastasis involves only microscopic or partial infiltration of the
    lymph node. The specificity of size criteria also deteriorates
    because of benign inflammatory or infectious lymph node
    enlargement, leading to incorrect characterization of a benign
    lymph node as malignant. MR is no different
    15

    or slightly worse,
    5

    basing the judgment on size criteria alone, compared with CT in the
    assessment of regional lymph node metastasis.

    The addition of morphologic criteria to the evaluation of lymph
    nodes seeks to exploit changes to the normal ovoid lymph node shape
    that arise from tumor infiltration. These changes could include
    either a more rounded shape, in which the long-to-short axis ratio
    decreases, or eccentric cortical hypertrophy. A commonly used size
    threshold in the pelvis accounts for this change in morphology,
    using 10 mm in short axis diameter for ovoid lymph nodes, while
    using a smaller threshold (8 mm) as a cutoff in rounded lymph
    nodes.
    3

    In a study of 4043 axillary lymph nodes in the setting of breast
    cancer,
    16

    the use of either eccentric cortical hypertrophy or a long axis
    diameter >10 mm plus a long-to-short axis ratio of <1.6
    resulted in a sensitivity of 79% and a specificity of 93% for the
    detection of lymph node metastasis, with nearly all false-negative
    findings in the axillae showing metastatic lymph nodes measuring
    <10 mm.

    Application of these size criteria requires detection of lymph
    nodes, a task that is complicated by motion, the presence of
    adjacent structures, and limitations in resolution and
    signal-to-noise ratio. Using a three-dimensional (3D)
    magnetization-prepared rapid gradient-echo (MPRAGE) T1-weighted
    sequence, Jager et al
    3

    reported a sensitivity and specificity of 75% and 98%,
    re-spectively, for lymph node metastasis in patients with prostate
    and bladder cancer. However, because their method was dependent on
    a size threshold for nodal characterization, they failed to detect
    microscopic metastases in 11 of 134 patients. Using a 3D-fast
    low-angle shot (FLASH) sequence performed after bolus injection of
    gadolinium, Hasegawa et al
    17

    reported 92% sensitivity and 78% specificity for the detection for
    hilar lymph node enlargement, results similar to those from CT and
    PET techniques. Continued evolution in MR hardware and development
    of innovative pulse sequences will improve detection of lymph nodes
    in increasingly efficient ways; however, even improved detection
    may not be sufficient to optimize the performance of MRI without a
    better means of lymph node characterization.


    T2 signal intensity

    The improved soft-tissue contrast and fluid sensitivity of MRI
    suggest an additional approach to the evaluation of lymph nodes for
    metastasis: using signal characteristics of lymph nodes in the
    absence of contrast media as a means of differentiating benign from
    malignant. However, results with these techniques have been mixed.
    Brown et al
    10

    evaluated 437 lymph nodes with high-resolution MR techniques, using
    a T2-weight-ed fast spin-echo (FSE) sequence with a relatively long
    acquisition time that took advantage of 4 averaged signals to
    maintain signal despite the high resolution. They saw no
    significant difference in size between benign and malignant lymph
    nodes and achieved a sensitivity of 81% and a specificity of 68%
    with a size threshold of 5 mm. Adding evaluation of heterogeneous
    nodal signal intensity or an irregular border improved these
    parameters such that the sensitivity and specificity for nodal
    metastasis were 85% and 97%, respectively. However, these results
    excluded lymph nodes <3 mm and metastatic lymph nodes outside of
    the field-of-view, a particular concern given the high-resolution
    techniques employed.

    In a study evaluating 140 mediastinal lymph nodes in patients
    with non-small-cell lung cancer,
    18

    the use of a T2-weighted respiratory-trig-gered short tau inversion
    recovery (STIR) turbo spin-echo (TSE) sequence allowed
    differentiation of metastatic lymph nodes with a sensitivity,
    specificity, and accuracy of 100%, 96%, and 96%, respectively; this
    technique relied on comparing the signal intensity of a lymph node
    with a 0.9% saline phantom and compared favorably with T1-weighted
    spin-echo (SE) imaging and CT (Figure 1).

    The presence or absence of central necrosis is another
    predictive feature of malignancy that can be exploited in the
    analysis of lymph node metastasis. In a study of 949 lymph nodes in
    43 women with cervical carcinoma,
    19

    MRI had a sensitivity and specificity of 70.6% and 89.8%,
    respectively, using a size threshold of 10 mm in long-axis diameter
    or the presence of central necrosis. Similarly, the presence of
    central necrosis is the single most accurate indicator of
    malignancy in the head and neck in the presence of squamous cell
    carcinoma.
    20,21

    However, the presence of central necrosis is very nonspecific when
    applied to other areas of the body, such as the mesentery,
    retroperitoneum, and pelvis, where infection or inflammation can
    result in a similar appearance.
    22


    Dynamic gadolinium enhancement

    Several investigators have attempted to use the enhancement
    characteristics of lymph nodes after bolus administration of
    intravenous gadolinium as a discriminant between malignant and
    benign lymph nodes. Simple comparison of signal intensity after
    intravenous gadolinium administration has not been effective in
    differentiating benign from malignant lymph nodes.
    23

    A more complex approach relies on a dynamic analysis of enhancement
    kinetics, based on alterations in tumor microcirculation: flow
    characteristics and blood volume, microvascular permeability, and
    increased fractional volume of the extravascular extracellular
    space.
    24

    In a study of mediastinal lymph nodes in 9 patients with
    bronchogenic carcinoma, Laissy et al
    25

    found peak enhancement in metastatic lymph nodes within 60 to 80
    seconds after gadolinium enhancement, with a slow washout
    thereafter. In contrast, reactive lymph nodes showed gradual
    increase in contrast enhancement without a peak value in the first
    6 to 8 minutes.

    Using a T1-weighted 3D FLASH sequence with a 44-second
    acquisition time, Murray et al
    26

    compared axillary lymph node enhancement to adjacent fat; it was
    concluded that using the presence of at least 1 lymph node with an
    enhancement index of >21% and nodal area of >0.4 cm
    2

    would allow discrimination of patients with axillary lymph node
    metastasis with a sensitivity of 100% and specificity of 56%. The
    relatively low specificity was deemed acceptable, because the high
    sensitivity for metastasis would ensure that all patients with
    metastasis would undergo surgical axillary lymph node dissection.
    Using a threshold of more than 100% increase in signal intensity in
    axillary lymph nodes on initial postcontrast images in 65 patients
    with invasive breast cancer, Kvistad and colleagues
    27

    showed an 83% sensitivity and a 90% specificity for correct
    diagnosis of axillary lymph node metastases per patient.
    Interestingly, their results showed no improvement in accuracy when
    additional size or appearance characteristics were added to the
    evaluation. However, a limitation of both studies was that a
    node-by-node correlation was not performed, raising the possibility
    that the abnormalities seen on MR did not correlate specifically
    with foci of metastasis.

    Fischbein and colleages
    24

    evaluated squamous cell cancer of the head and neck using a
    two-dimensional fast spoiled gradient-recalled sequence after a
    single bolus of intravenous gadolinium. Their results are almost
    opposite from those achieved in other neoplasms: correlating
    enhancement characteristics with pathologic specimens showed
    significantly longer time to peak enhancement, lower peak
    enhancement, lower maximum slope, and slower washout of contrast
    material in metastatic lymph nodes (Figure 2). Of note, the
    technical constraints of this dynamic imaging, as well as artifacts
    related to motion, precluded complete coverage of the entire area
    of interest and limited the radiologic evaluation to 68 of the 129
    pathologically identified lymph nodes. It was hypothesized that, in
    the specific case of squamous cell carcinoma, tumor tissue may
    actually have decreased blood flow relative to normal or
    hyperplastic lymphoid tissue and that squamous cell carcinoma of
    the head and neck may not have increased microvessel density.


    Ultrasmall superparamagnetic iron oxide
    particles

    A particularly promising technique for the evaluation of lymph
    nodes in the setting of malignancy relies on the use of USPIO
    particles.
    28,29

    These particles were developed as an alternative to larger
    superparamagnetic iron oxide particles (SPIO), which are rapidly
    cleared by the mononuclear phagocytic systems of the liver and
    spleen, allowing little uptake in other tissues. Ultrasmall
    superparamagnetic iron oxide particles have a longer blood
    half-life and accumulate in the normal reticuloendothelial
    structure of lymph nodes, providing a means to distinguish
    malignant and benign lymph nodes without reliance solely on size or
    morphologic criteria.
    30

    Ultrasmall superparamagnetic iron oxide particles belong to a
    larger family of the SPIO, in which particle size influences very
    different chemical and kinetic properties and therefore produces
    different clinical applications.
    31

    Each bio degradable particle of the USPIO ferumoxtran-10 (AMI-227;
    Combidex, Advanced Magnetics, Cambridge, MA; Sinerem, Laboratoire
    Guerbet, Aulnay-sous-Bois, France) is composed of a
    monocrystalline, inverse spinel, SPIO core (2 to 3 nm
    32

    or 4.3 to 6.0 nm
    33

    ) coated with polymers (low molecular weight dextran) to prevent
    uncontrolled aggregation. The method of particle preparation
    determines the final mean particle size (approximately 17 to 21 nm
    34

    or 20 to 40 nm
    31,33

    ) and composition
    22

    (Figures 3A through 3D). The agent is provided as a lyophilized
    powder that is reconstituted and administered over approximately 30
    minutes in an intravenous dose of 2.6 mg/kg, an amount that has
    been found to optimize signal decrease in normal lymph nodes.
    35

    Clinical trials have documented the safety of this agent,
    34-36

    with the most common side effect being back pain, occurring in
    about 3% to 6% of patients; this is of uncertain cause and usually
    resolves with temporary cessation of the infusion. Other less
    commonly reported minor side effects are rash, transient mild
    hypotension, and headache.
    22,34,37

    After administration of contrast material, the agent is
    distributed into lymph nodes throughout the body and is usually
    imaged 24 hours later. The contrast agent distributes symmetrically
    throughout the body after intravenous administration, which aids in
    a comprehensive nodal evaluation that does not depend on the site
    of injection.
    38

    Entrance into lymph nodes is via 2 mechanisms: first, direct
    transcapillary passage from venules into the medullary sinuses of
    lymph nodes and, second, nonselective endothelial transcytosis into
    the interstitial space, from where the particles drain into lymph
    nodes via the lymphatic system.
    28,29,39

    Once within the lymph node, the particles are phagocytosed and
    subsequently accumulate within macrophages (Figure 3E). This
    accumulation of the USPIO particles has 2 major effects: a
    predominant susceptibility effect, as well as T2 shortening,
    resulting in decreased signal on T2- and T2*-weighted images.
    40

    The susceptibility effect is most important, with microscopic field
    gradients that lead to diffusion and loss of phase coherence. There
    is also a T2-shortening effect caused by local field
    inhomogeneities that promotes transverse relaxation.

    The end result is that USPIO is a “negative” contrast agent, one
    which is taken up by benign lymph nodes with preserved nodal
    architecture; this “negative enhancement” appears as decreased
    signal intensity on T2- and T2*-weighted images.
    36,41

    This accumulation of USPIO in these normal lymph nodes corresponds
    to the macrophages in the medullary sinuses rather than the
    lymphocyte-rich follicles of the lymph nodes, as shown on 9.4T
    imaging.
    30

    In contrast, areas of metastatic nodal infiltration lack
    reticuloendothelial structure and macrophages and therefore do not
    accumulate USPIO, resulting in a lack of uptake in all or part of a
    malignant lymph node
    36

    (Figure 4). Metastasis is therefore identified in lymph nodes that
    are either entirely or partially unchanged in signal intensity on
    T2- and T2*-weighted scans.

    Analysis of USPIO-enhanced MR is most often performed with
    direct comparison of scans obtained before and after USPIO
    administration. While both T2- and T2*-weighted images show
    de-creased signal in benign lymph nodes, T2-weighted fast spin-echo
    techniques are generally favored for their superior resolution,
    despite the increased sensi-tivity to susceptibility achieved on
    gradient-echo sequences. In fact, the “blooming artifact” due to
    susceptibility on gradient-recalled echo (GRE) can actually hinder
    analysis, resulting in overestimated lymph node size and obscured
    areas of micrometastasis (which are surrounded by UPSIO-enhanced
    normal lymph node tissue).
    42,43

    Quantitative determination of changes in T2* from dual echo time
    (TE) images in lymph nodes may permit a more objective analysis of
    signal changes with significant differences seen between benign and
    malignant lymph nodes, even in the case of partial infiltration;
    this may have future application in partial automation of image
    analysis.
    44

    In lower concentrations, USPIO agents also cause T1- shortening,
    manifesting as increased signal on T1-weighted sequences; this
    effect has been shown in neoplasms with associated leakage of USPIO
    particles into the interstitium.
    40

    Interpretation of USPIO-enhanced images requires careful
    attention to MRI technique and experience in identification of even
    small lymph nodes. The results of USPIO-enhanced MRI have also been
    used successfully to direct image-guided lymph node biopsy,
    allowing pathologic correlation without a more invasive surgical
    procedure.
    45

    Several patterns of USPIO uptake have been identified. Malignant
    patterns in-clude complete lack of enhancement with USPIO,
    heterogeneous enhancement, discrete focal defects (representing
    small focal metastatic deposits), and peripheral signal loss with
    maintained signal centrally (in the absence of a fatty hilum).
    32,34

    False-positive results can be generated by focal nodal lipomatosis
    or prominent fatty hila,
    22

    and inclusion of T1-weighted images may help reduce these
    false-positive interpretations by increasing conspicuity and
    recognition of fat.
    46

    False-negative results most commonly relate to the presence of
    micro-metastasis below the spatial resolution of the imaging
    sequence. False-positive results have been seen in benign lymph
    nodes with reactive lymphoid follicular hyperplasia; the relative
    scarcity of macrophages results in decreased USPIO uptake and
    incorrect categorization of lymph nodes as malignant.
    36

    Similarly, granulomatous disease or other infection can reduce
    phagocytic activity and reduce uptake of UPSIO in normal nodes, a
    particular problem in the chest and mediastinum.
    47

    Heterogeneous uptake in normal lymph nodes may relate to a
    heterogeneous distribution of macrophages
    30

    or to areas of focal lymphoid hyperplasia.
    48

    Uptake of USPIO agents is not limited to the lymph nodes alone:
    decreases in signal intensity on T2- and T2*-weighted images have
    been seen in liver, spleen, bone marrow, and kidneys after USPIO
    administration. The long half-life of USPIO agents in the vascular
    system has prompted use of the agent for MR angiography; this
    application depends on the long imaging window and the
    T1-shortening effects of the contrast agent.
    22

    The use of USPIO agents for lymph node applications requires
    evaluation in the context of particular primary neoplasms and body
    regions, because the challenges encountered in the MR imaging of
    various body parts are unique. Direct comparison of the many
    clinical trials of USPIO is hindered by marked variations in MR
    technique and different methods of statistical analysis.
    Differences in MR technique and operator experience alter the
    ability to detect and analyze signal changes in lymph nodes.
    Published statistics are usually based only upon nodes with
    radiologic and pathologic correlation, often excluding very small
    nodes (1 to 3 mm) that are seen at pathologic analysis only; this
    precludes direct comparison with gold standard surgical techniques
    and somewhat undermines the confidence in staging based only on
    noninvasive methods. These studies also use different benchmarks,
    including performing analyses at a patient, nodal group, or
    individual lymph node level, complicating direct comparisons.
    Despite these limitations, however, a growing body of literature
    allows us to evaluate trends in the results of USPIO-enhanced MR
    and to highlight the promise of the technique.

    The largest single trial evaluating ferumoxtran-10 to date is a
    phase III trial of Combidex, which evaluated 152 patients with
    primary neoplasms of the head and neck, breast, chest, abdomen, and
    pelvis.
    34

    Using a node-by-node analysis with histopathologic correlation, the
    sensitivity, specificity, and accuracy of USPIO-enhanced MR was
    83%, 77%, and 80%, respectively, using both pre- and postcontrast
    images and 85%, 85%, and 85%, respectively, with the postcontrast
    images alone. This study highlighted one of the major benefits of
    USPIO relative to traditional size criteria: the potential for
    USPIO to reveal micrometastasis that does not grossly alter the
    size or shape of the metastatic lymph node.
    34

    Ultrasmall superparamagnetic iron oxide agents have been
    particularly successful in the analysis of the head and neck, where
    there is a complex distribution of normally visualized lymph nodes;
    previous studies have shown poor performance of traditional size
    criteria on both MR and
    5,8

    An accurate noninvasive method of nodal assessment is particularly
    important because of the morbidity and potential cosmetic deformity
    conferred by a surgical procedure. The use of USPIO-enhanced MR for
    differentiation of benign and malignant lymph nodes in the head and
    neck has revealed a range of sensitivities between 84% and 95% and
    a range of specificities between 77% and 97%.
    34,41,49-51

    Patients with neoplasms of the head and neck were the most
    accurately assessed subset of patients in the larger phase III
    trial of Combidex.
    34

    The low end of the range in sensitivity (77%) is based on a
    European phase III trial of Sinerem focusing on 81 patients with
    head and neck malignancies
    51

    and has been partially attributed to higher rates of artifact
    related to patient motion and susceptibility; in this trial,
    specificity was improved with USPIO, while no significant
    improvement in sensitivity was seen compared with precontrast
    imaging (which showed an unusually high sensitivity). A smaller
    study of USPIO in head and neck cancer showed that USPIO-enhanced
    MRI resulted in changed surgical management in 7 of 27 patients and
    a correct diagnosis of metastatic nodal level in 26 of 27 patients.
    52

    The performance of UPSIO-enhanced MRI in the evaluation of the
    axilla in patients with breast cancer has also been favorable;
    initial reported sensitivities of USPIO-enhanced MR (in 9 patients
    53

    and 20 patients
    54

    ) have ranged between 73% to 83% and specificities have ranged
    between 92% to 97% for the detection of lymph node metastasis.
    53,54

    Specific correlation of imaging to pathologic features was not
    performed in these cases due to the absence of anatomic landmarks
    in the axilla. When analyzed at a patient level, the sensitivity
    and specificity for detection of nodal metastasis in one study
    increased to 82% and 100%, respectively.
    54

    Looking at the subset of patients with breast cancer from the
    larger phase III trial, USPIO-enhanced MR had a sensitivity of 83%,
    a specificity of 78%, and an accuracy of 80%.
    34

    More recent work has documented improved performance of the
    technique: 25 patients with breast cancer were enrolled in another
    phase III trial, in which node-by-node pathologic correlation was
    achieved in 136 lymph nodes.
    55

    In this group, USPIO-enhanced MR resulted in a sensitivity,
    specificity, and accuracy of 92%, 99%, and 98%, respectively, for
    detection of nodal metastasis, improving on traditional MR size
    criteria, which had a sensitivity and specificity, respectively, of
    58% and 56%.
    55

    In non-small-cell cancer, PET and mediastinoscopy have
    traditionally been used to stage mediastinal lymph nodes, an
    important determinant in clinical staging and the differentiation
    between resectable versus unresectable disease. The chest is a
    particularly challenging location for the application of
    UPSIO-enhanced MR, given the high prevalence of benign lymph node
    enlargement and the specific challenges of MR imaging that include
    motion and susceptibility artifact from air-soft tissue interfaces.
    An investigation of USPIO-enhanced MR in 18 patients with known
    lung cancer showed a sensitivity of 92% and a specificity of 80%.
    56

    A study of 12 patients, 6 of whom had cancer, revealed that
    USPIO-enhanced MR had a sensitivity of 100% but a specificity of
    only 37.5%.
    47

    The high rate of false-positive results was attributed to the
    prevalence of granulomatous infection in the mediastinum, leading
    to decreased USPIO uptake in benign lymph nodes. One study
    comparing PET with CT included a small sample of USPIO-enhanced MR
    57

    (9 patients) and showed an overall sensitivity and specificity of
    86% and 82%, respectively; this was not significantly different
    from the results obtained with PET in the entire study population
    (64 patients), which had a sensitivity and specificity of 70% and
    86%. A low specificity of UPSIO in the chest and mediastinum was
    also seen in the phase III study of Combidex, presumably also
    because of the higher prevalence of granulomatous infection in the
    mediastinum; use of the approach in this population for detection
    of nodal metastasis showed a sensitivity, specificity, and accuracy
    of 89%, 47%, and 63%, respectively.
    34

    The use of USPIO-enhanced MR in the abdomen and pelvis has been
    quite successful; the improved differentiation of benign versus
    malignant lymph nodes plays an important role in staging and
    surgical planning in this population. Initial experience in this
    area correlated partial uptake of USPIO to partial metastatic nodal
    infiltration
    58

    and revealed a subset of lymph nodes with increased signal on
    T1-weighted images due to the T1-shortening effects of USPIO and
    increased capillary permeability.
    36

    Early experience in 2 studies, which enrolled 3036 and 1958
    patients with a variety of abdominal and pelvic malignancies,
    showed sensitivities of 100% and 93% and specificities of 80% and
    100%, respectively. This early experience showed the possibility of
    detecting partial metastatic infiltration in lymph nodes: in one
    study, the false-negative signal drop in 2 malignant lymph nodes
    was deemed a subjectively different, more heterogeneous pattern
    that correlated with heterogeneous lymph node infiltration.
    58

    At the same time, in the other study, 20 of 80 lymph nodes
    available at pathologic analysis were not seen at MRI, either due
    to small size or partial volume effects, and, of these, nearly a
    third harbored metastasis.
    36

    A study of 39 patients with gynecologic malignancies showed an
    improvement of sensitivity from 53% to 86% to 88% without loss of
    specificity in metastatic lymph node detection using USPIO.
    46

    A more recent, smaller study of 18 patients with testicular cancer
    also showed the value of USPIO-enhanced MR, which showed a
    sensitivity, specificity, and accuracy of 86.6%, 96.9%, and 95.8%,
    respectively, in the detection of lymph node metastasis. The use of
    USPIO in patients with malignancies of the abdomen and pelvis in
    the larger phase III clinical trial resulted in a sensitivity,
    specificity, and accuracy of 80%, 83%, and 81%, respectively.
    34

    Harisinghani and colleagues
    32

    reported on a large population (80 patients) with prostate cancer,
    where USPIO-enhanced MRI significantly increased sensitivity for
    detection of lymph nodes, from 35.4% to 90.5%. Specificity was also
    increased, from 90.4% to 97.8%. These results were particularly
    notable for the 45 of 63 metastatic lymph nodes that did not
    achieve traditional size criteria for malignancy but which were
    identified with USPIO. Careful attention to lymph node
    identification relative to anatomic landmarks allowed precise
    correlation with MR images (Figure 4 and Figure 5).

    In summary, the benefits of USPIO-enhanced MR imaging seem to be
    greatest with certain areas of the body, including the head and
    neck, axilla, retroperitoneum, and pelvis. Evaluation of
    mediastinal lymph nodes suffers from the prevalence of
    granulomatous and other infections, decreasing specificity of the
    UPSIO-enhanced technique, as well as from technical limitations
    imposed by motion and susceptibility. Several areas of
    investigation are critical: correlation of USPIO staging results
    with outcomes and treatment, evaluation of the cost effectiveness
    of the technique particularly given the logistical considerations
    of a 24-hour delay between contrast administration and imaging, and
    specific delineation of methodologies and MRI protocols for optimal
    use. Increasing clinical experience will permit more accurate
    comparison of USPIO approaches as applied to different neoplasms
    and clinical situations. Continued improvements in MR imaging will
    also further improve the technique, particularly through improved
    spatial and contrast resolution that will allow identification of
    smaller lymph nodes and micro-metastases without overly detrimental
    loss in coverage or noise.


    MR spectroscopy

    Applying the techniques of MR spectroscopy (MRS) to the
    evaluation of lymph nodes is another possible approach to
    differentiation of benign versus malignant lymph nodes; similar to
    USPIO and dynamic gadolinium approaches, the technique attempts to
    extend MRI beyond simple anatomic mapping. In a study of 39
    patients with a combination of ductal carcinoma in situ and
    invasive ductal carcinoma,
    59

    axillary lymph node MRS had a sensitivity of 82% and specificity of
    100% (correlating with pathologic results obtained from
    ultrasound-guided lymph node biopsy). These results were based on
    the presence or absence of choline (at 3.2 ppm). Of note, the
    targeted lymph nodes ranged in diameter between 1 and 5 cm, and 2
    patients with negative biopsies and MRS were subsequently found to
    have metastasis in small axillary nodes measuring 4 mm, too small
    to be targeted by either method. A preliminary study in cervical
    lymph node metastases showed abnormal MR spectra, including
    elevation in choline to creatine ratio and elevated lactate, when
    compared with normal muscle tissue.
    60


    Interstitial contrast administration

    The interstitial administration of MR lymphangiographic contrast
    agents represents a different approach to visualization of the
    lymphatic system on MR. The enhancement of the lymphatic system
    (including both lymphatic vessels and nodes) permits identification
    of the drainage pathway and possibly a sentinel lymph node that can
    be targeted for biopsy. Alterations or abnormalities in lymphatic
    flow can also be used to directly diagnose lymphatic metastasis, in
    a manner similar to conventional lymphangiography. However, these
    techniques sacrifice the more global lymph node evaluation afforded
    by, for example, intravenous administration of USPIO agents. The
    technique is also susceptible to concerns that arise from
    conventional interstitial sentinel node detection techniques,
    including radiolabeled sulfur colloid and methylene blue, in that
    the sites of injection may not truly reflect all potential drainage
    pathways of the primary tumor under study. A benefit of these
    agents is that they work primarily to promote T1-shorten-ing and
    therefore increase signal intensity on T1-weighted sequences,
    creating “positive contrast” images of lymph nodes and lymphatic
    vessels. There are also potential benefits of lower contrast dose
    and reduced systemic side effects of contrast. Preliminary work has
    shown experimental success of this technique with several agents,
    including MS-325 (a paramagnetic agent with novel chemical groups
    that promote reversible binding to albumin, increasing
    intravascular half-life),
    61

    conventional gadolinium agents,
    62-64

    and macromolecular gadolinium polymers and aggregates
    65-70

    (Figure 6).


    Conclusion

    The field of MR oncologic imaging represents an exciting
    application for current imaging techniques, offering important
    information with definite clinical implications, including
    prognosis and treatment selection. The traditional strengths of
    MRI, with improved soft-tissue contrast and delineation of tissue
    planes, are related to staging of the primary tumor or detection of
    metastasis. Extending its value as a modality for the evaluation of
    nodal status may increase accuracy of staging or even allow for a
    single imaging evaluation that includes the primary tumor and
    adjacent lymph nodes. As detailed in this review, several
    approaches have been developed that seek to improve on the results
    obtained with traditional size criteria alone; each of these has
    shown promising results in attempts to image the function and
    physiology of lymph nodes to increase accuracy. Unfortunately,
    direct comparison between different approaches (or even between
    different studies using the same approach, as in the case of USPIO)
    is hindered by marked differences in technique and methods of
    analysis employed in various investigations. As the experience with
    each approach grows, it will be easier to draw more accurate direct
    comparisons and identify the appropriate role of each. With
    inevitable continued technologic improvements, lymph node imaging
    will no doubt continue to represent an exciting frontier in MR,
    with the potential to have a large impact on future clinical
    practice.

    Back To Top
    90,000 Enlargement of lymph nodes – causes of appearance, under what diseases it occurs, diagnosis and treatment methods

    IMPORTANT!

    The information in this section cannot be used for self-diagnosis and self-medication. In case of pain or other exacerbation of the disease, only the attending physician should prescribe diagnostic tests. For a diagnosis and correct treatment, you should contact your doctor.

    Enlargement of lymph nodes – the reasons for the appearance, for what diseases it occurs, the diagnosis and methods of treatment.

    Lymph nodes are small biological filters related to the lymphatic system. Their main function is to protect the body. Lymph nodes let the flow of lymph through themselves and in their structures trap pathogens, which are destroyed by protective cells – lymphocytes.

    The lymph nodes target bacteria, tumor cells and toxic substances.

    What are lymph nodes? These are small accumulations of lymphoid tissue located on the connective tissue frame.

    Lymphoid tissue is a pool of cells that are involved in the destruction of damaged and tumor cells and microorganisms.

    Swollen lymph nodes can be a symptom of both a mild infectious disease and a serious pathology that can lead to a serious outcome. Therefore, in all cases of enlarged lymph nodes, you should consult a doctor for diagnostics and finding out the cause.

    Classification

    Depending on the localization, the following groups of lymph nodes are distinguished:

    • occipital;
    • cervical;
    • 90,026 submandibular;

      90,026 chin;

    • supraclavicular and subclavian;
    • axillary;
    • elbows;
    • inguinal;
    • popliteal.

    During the examination, the doctor palpates (feels) the lymph nodes and determines their size, structure, soreness, changes in the skin over the lymph node.

    Causes of swollen lymph nodes

    An increase in lymph nodes indicates a pathological process. Isolated lymph node enlargement, or generalized lymphadenopathy, directly depends on the underlying cause of the disease.

    Most cases of swollen lymph nodes are temporary.

    The reasons for the increase in lymph nodes are:

    • infectious processes;
    • autoimmune diseases;
    • tumor pathologies;
    • storage diseases (a group of diseases accompanied by metabolic disorders).

    Lymph nodes are involved in the formation of immunity, and during any infectious process, the division of cells that protect the body is activated in them.

    So, with brucellosis, tuberculosis, syphilis, diphtheria bacteria can settle in the lymph nodes, causing their inflammation. In this case, the lymph nodes increase in size due to the increased flow of lymph and blood.

    Most often, lymph nodes enlarge in acute upper respiratory tract infections. Among them, the largest size of the lymph nodes is acquired with tonsillitis (angina).

    Painful enlargement of lymph nodes can be a sign of cat scratch disease (from the name it is clear that the disease occurs in persons scratched by a cat).The cause of the inflammatory process is the bacterium Bartonella henselae.

    One of the striking examples of a viral disease accompanied by a significant increase in lymph nodes is infectious mononucleosis . The disease is caused by the Epstein-Barr virus and cytomegalovirus.

    Infectious mononucleosis is more common in childhood and young age. In addition to enlarged lymph nodes, it is characterized by an increase in body temperature, weakness and sore throat.

    In children, generalized lymphadenopathy occurs in childhood infectious diseases , such as measles, rubella, mumps, chickenpox.

    Among other viral diseases accompanied by lymphadenopathy, it is worth noting HIV infection .

    Lymphadenopathy in HIV infection is accompanied by a number of symptoms: weight loss, unexplained fever, night sweats, fatigue, and later infectious diseases (herpes, cytomegalovirus infection, candidiasis).

    Systemic (autoimmune) connective tissue diseases , such as rheumatoid arthritis, systemic lupus erythematosus, may be accompanied by swollen lymph nodes. In these conditions, there is a violation of the recognition of “foreign” and “own” proteins, as a result of which the body begins to attack its cells. If the process is active, then the lymph nodes increase in size due to the increasing load.

    Often autoimmune diseases are accompanied by an enlarged spleen and additional symptoms.

    With systemic lupus erythematosus, the skin, kidneys and serous membranes of internal organs are affected (lupus pleurisy, serositis occur). In rheumatoid arthritis, the articular cartilage is predominantly affected.

    Swollen lymph nodes can be a symptom of progression of the tumor process in the body. Atypical (tumor) cells migrate to the lymph nodes, get stuck in them, multiply and stretch the node with their mass.

    Separately, it is worth highlighting a group of malignant neoplasms that directly affect the lymphatic system.

    • Hodgkin’s lymphoma , or lymphogranulomatosis proceeds with the formation of conglomerates of affected immature lymphocytes in the lymph nodes and spleen.
    • Non-Hodgkin’s lymphomas – a group of lymphoproliferative diseases.

    Swollen lymph nodes can be a symptom of storage disease : as a result of metabolic disturbances, some substance accumulates in organs and tissues, including lymph nodes.Among these diseases: hemochromatosis (iron accumulation), Wilson-Konovalov disease (copper accumulation) and other hereditary metabolic disorders.

    Allergic reactions sometimes lead to swollen lymph nodes. Hypersensitivity to some drugs leads to generalized lymphadenopathy.

    Among endocrinological diseases , hyperthyroidism can be characterized by lymphadenopathy, enlarged spleen and increased lymphocyte count in the blood.During treatment, all indicators return to normal.

    It is worth remembering that all the lymph flowing from the organs passes through the lymph nodes, and if a person is engaged in heavy physical labor, then the elbow and popliteal lymph nodes can be enlarged due to the heavy load .

    Also, lymph nodes in rare cases enlarge after vaccination on the corresponding side.

    Which doctor should i contact if my lymph nodes are swollen?

    An adult should turn to
    a therapist, and examines a child and a teenager
    pediatrician.Depending on the accompanying symptoms, the following specialists may need to be consulted:

    Diagnostics and examination with enlarged lymph nodes

    • Clinical blood test;

    Ultrasound of the lymph nodes of the neck: indications for conduct, features, price | Make an ultrasound in Moscow

    9017 9017 Ultrasound of the bladder and determination of residual urine volume

    175 9017 translogues

    9017

    9017 apples with dopplerography of the vessels of the eyes and orbit (1 eye)

    Functional diagnostic

    9017 heart rate monitoring (HM-ECG) + ECG

    Electroencephalography

    75.00

    Ultrasound diagnostics
    Ultrasound of the hepatobiliary zone 2800.00
    Complex ultrasound of internal organs 3300.00
    Ultrasound of the liver 1400.00
    Ultrasound of the gallbladder 1250.00
    Ultrasound of the gallbladder with determination of its contractility 1400.00 Ultrasound

    veins and perforators of the lower extremity 1210.00
    Spleen ultrasound 1250.00
    Ultrasound determination of fluid in the abdominal cavity 1250.00
    Ultrasound of the kidneys and adrenal glands 2300.00
    Ultrasound of the kidneys and adrenal glands (1st kidney) 1300.00
    Ultrasound of the urinary bladder
    Ultrasound of the prostate and bladder with determination of residual urine 2900.00
    Transrectal ultrasound of the prostate 2400.00
    Ultrasound of the scrotal organs 2300.00
    Determination of residual urine volume 900.00
    Ultrasound of the bladder (determination of urine output from the orifice of the ureter in case of suspected obstruction
    1900.00
    Ultrasound of the thyroid and parathyroid glands 2400.00
    Ultrasound examination during puncture 2310.00
    Ultrasound of the lymph nodes (one anatomical zone) 2100.00
    Ultrasound of the salivary glands 1400.00

    1400.00
    Breast ultrasound + regional lymph node ultrasound 2800.00
    Breast ultrasound (control ultrasound of one breast at a second visit) 1900.00
    Ultrasound of the joint 1800.00
    Ultrasound of the pleural cavity 1280.00
    Ultrasound of the uterus and appendages transvaginal 2500.00
    2500.00
    Fetal ultrasound (up to 10 weeks) 2400.00
    Fetal ultrasound at 11-14 weeks 4100.00
    Fetal ultrasound (in 2-3 trimesters of pregnancy) 4500.00
    3D ultrasound (ultrasound after 15 weeks of pregnancy) 5700.00
    3D ultrasound (Doppler ultrasound after 15 weeks of pregnancy) 6800.00
    Fetal ultrasound (in 2-3 trimesters) pregnancy multiple 5500.00
    3D ultrasound (ultrasound after 15 weeks of pregnancy) multiple 7000.00
    3D ultrasound (Doppler ultrasound after 15 weeks of pregnancy) multiple 8000.00
    Fetal ultrasound (up to 10 weeks) multiple 3000.00
    fetal ultrasound (at 11 weeks) multiple 4900.00
    Doppler ultrasound of the arteries by monitoring (in obstetrics and gynecology) 1900.00
    Fetal cardiotocography 1910.00
    Echocardiography (ECHO KG) 3500.00
    Duplex scanning of brachiocephalic arteries with color Doppler blood flow mapping 3500.00
    Triraceflex bleeding color scan

    scanning of the vessels (arteries and veins) of the upper limbs 4710.00
    Triplex scanning of the vessels (arteries and veins) of the upper limbs 4710.00
    Duplex scanning of arteries (1st upper or lower limb) 2000.00
    Duplex scanning of vessels (arteries and veins of the 1st upper or lower limb) 3100.00
    Duplex scanning arteries and veins) of the lower extremities 5800.00
    Triplex scanning of the vessels (arteries and veins) of the lower extremities 5800.00
    Duplex scanning of transcranial arteries and veins 3500.00
    Triplex scanning of transcranial arteries and veins 3500.00
    Triplex scanning of veins (upper or lower extremities) 4100.00
    Triplex scanning (
    Triplex scanning (9017)
    Duplex scanning of arteries (upper or lower extremities) 3600.00
    Triplex scanning of arteries (upper or lower extremities) 3600.00
    Duplex scanning of renal arteries 3500.00
    Triplex scanning of renal arteries 3500.00
    Duplex scanning of the aorta 3300.00 2400.00
    Ultrasound examination of the eyeball with triplex scanning of the vessels of the eyes and orbits (1 eye) 2400.00
    Ultrasound examination of the eyeball with dopplerography of the vessels of the eyes and orbit (2 eyes) 4100.00
    Ultrasound examination of the eyeball with triplex scanning of the vessels of the eyes and orbits (2 eyes)
    Electrocardiography (ECG) 1530.00
    Electrocardiography with exercise (20 squats) 2740.00
    Study of unprovoked tidal volumes and flows (FVD) 1530.00
    Study of tidal volumes using drugs 2000.00
    Holter blood pressure monitoring (ABPM) 4800.00
    Holter heart rate monitoring (HM-ECG) 4000.00
    Holter heart rate monitoring (HM-ECG) + ECG 48 hours 6000.00
    Holter heart rate monitoring (HM-ECG) + ECG 72 hours 7500.00
    3500.00
    Rheoencephalography (REG) 1900.00
    Rheovasography (RVG) 1900.00
    Echoencephalography (ECHO EG) 16
    Treadmill test 6060.00

    Lymphadenopathy in children | Children’s Clinical Diagnostic Center in Domodedovo

    07.10.2014


    Bolshakov Igor Viktorovich, orthopedic surgeon

    Surgical aspects of lymphadenopathy in children

    Lymphadenopathy is an enlargement of lymph nodes, both single and several groups with various diseases. Usually, parents come to the pediatric surgeon with complaints that the child has some “bumps” on the back of the head, in the submandibular region, cervical, axillary, inguinal and other areas.These formations periodically increase, which causes fair concern for the mother. At the first examination by the doctor, it turns out that these are lymph nodes of different localization. The main task of a pediatrician and pediatric surgeon is to explain that in a child’s lymph nodes are the organs of the immune system, where, along with other organs (spleen, thymus, palatine tonsils), immune cells – lymphocytes are produced. The purpose of the latter is to protect the body from pathogens of various infections, allergens.

    When examining healthy children, individual groups of lymph nodes can be palpated, which are usually located in the submandibular, cervical, axillary and inguinal regions. Their sizes vary from 0.3 – 0.5 cm during the neonatal period to 1.5 cm at an older age. Normally, the lymph nodes are soft-elastic consistency, mobile, painless.

    The enlargement of the lymph nodes occurs due to the activation of lymphocytes in the node in response to an external factor that leads to lymphadenopathy.Among the causes of lymphadenopathy, local and widespread infections, connective tissue diseases and an oncological component can be distinguished. Usually, lymphadenopathies are observed against the background of staphylococcal and streptococcal infections (bacterial component) in diseases such as tonsillitis, tonsillitis, rhinosinitis, otitis media. There is lymphadenopathy of tuberculous etiology. An increase in lymph nodes against the background of a viral infection is observed in ARVI, chickenpox, rubella, cat scratch disease, infectious mononucleosis.In diseases of the connective tissue (arthritis, systemic lupus erythematosus), lymph node reactions are not uncommon. Oncological diseases (lymphogranulomatosis, lymphoma), which are much less common in children than in adults, also cause lymphadenopathy.

    To identify the cause of lymphadenopathy by a pediatrician and a surgeon, a thorough history taking is necessary (identification of diseases of the ENT organs, oral cavity, skin, contacts with patients, as well as contacts with insects, pets).

    Along with a general examination, it is necessary to pay attention to the condition of the peripheral lymph nodes, their size, localization, consistency, mobility, soreness, skin color over the lymph node, the presence of fluctuations. In addition, patients with lymphadenopathy are recommended to carry out laboratory research methods: a detailed general blood test, a general urine test, a biochemical blood test, serological tests for CMV, toxoplasmosis, HIV. Skin tests for tuberculosis, nasal and pharyngeal culture for flora and antibiotic sensitivity, abdominal X-ray, ultrasound or CT scan of the abdominal organs to detect spleno-hepatomegaly, lymph node puncture or biopsy.

    The examination described above is not required for all children with lymphadenopathy. In 90 – 95% of cases, the latter is the result of a nonspecific process (against the background of a banal bacterial or viral component). Competent treatment (elimination of the cause of lymphadenopathy) leads to the normalization of the lymph nodes within 1.5 – 2 months. A long course of lymphadenopathy, especially after sanitation of foci of infection, is an indication for the use of an extended examination.

    Pediatric surgeons have to deal with lymphadenopathies in the presence of an acute purulent process that occurs in one or more lymph nodes. The presence of manifestations of intoxication of the child’s body, local signs in the form of pain, edema, hyperemia, fluctuation is an indication for surgical intervention. The purulent lymph node is opened and drained for sanitation, followed by the appointment of antibiotics, desensitizing and immunostimulating agents, which leads to the child’s recovery.In the presence of a chronic process and if a lymphoproliferative process is suspected, the interested lymph node is removed for biopsy.

    As a result, we can conclude that in most cases, lymphadenopathies are caused by nonspecific (benign) processes. Timely identification of the causes of lymphadenopathy at all levels of diagnosis will help to identify the risk group of sick children who need the help of an oncologist.

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    90,000 ultrasound of the lymph nodes in Minka, ultrasound of the lymph nodes of the neck

    Lymph nodes are an important component of the lymphatic system.Their function is to separate harmful and foreign agents dangerous to the body, such as cancer cells, hostile microorganisms or other infections from the lymph flow. Lymph nodes make it possible to avoid the transportation of hazardous components to all tissues and organs, participate in the formation of immunity, in protein, fat and carbohydrate metabolism. For diagnostic purposes, the lymph nodes are usually examined using ultrasound.

    Prices for ultrasound of lymph nodes

    Indications for research

    Most often, you will notice an increase in the lymph nodes in the neck.Inflamed nodules indicate that the body’s immune defenses have been activated. In a normal state, the lymph nodes are visually invisible and hardly palpable. The following factors may indicate inflammation:

    • lymph nodes have increased in size;
    • lymph nodes are painful on palpation;
    • there were pains in the chest, neck or abdomen.

    Having these symptoms is a good reason to see a specialist. The doctor will prescribe the necessary examinations and direct you to do an ultrasound of the lymph nodes.

    Research Areas

    Lymph nodes are grouped according to their location:

    • thoracic, retroperitoneal, abdominal;
    • 90,026 popliteal;

    • inguinal;
    • cervical;
    • axillary;
    • occipital and aural;
    • 90,026 submandibular.

    Sometimes, if necessary, a comprehensive study is prescribed ultrasound of peripheral lymph nodes. This is the name for those lymph nodes that are located close to the surface (in the groin, in the cervical region, on the elbows and in the armpits).Depending on what the diagnostics show, a deeper examination of certain organs and tissues is possible in order to prescribe the necessary treatment.

    Ultrasound of the lymph nodes of the neck is prescribed at:

    • suspicion of benign or malignant neoplasms of the neck organs: soft tissues, pharynx, larynx, oral cavity, as well as the thyroid gland;
    • 90,026 chronic inflammatory processes of the oral cavity and neck organs;

      90,026 infectious diseases;

    Ultrasound of axillary lymph nodes is prescribed at:

    • changing their size and shape;
    • elevated body temperature;
    • 90,026 suspected cancer;

    Ultrasound of the submandibular lymph nodes is prescribed at:

    • diseases of the organs of the neck and oral cavity;
    • on the eve of dental prosthetics, including before the installation of implants;

    Ultrasound of the inguinal lymph nodes is prescribed if there is a suspicion of:

    90 025 90 026 sexually transmitted infections;

  • oncological pathology, including tumor metastases;
  • inflammatory diseases of the pelvic organs, skin of the perineum and thigh;
  • Ultrasound of the retroperitoneal lymph nodes is prescribed at:

    • vague abdominal pain;
    • 90,026 heat and chills;

    • looking for cancer or metastases.

    How is the study going

    The procedure is absolutely painless and safe even for a child. The sensors, treated with a special gel, are applied to the skin in the projection of the lymph nodes being examined. An image is displayed on the screen, which is deciphered by the ultrasound doctor. During the procedure, the shape and size of the lymph nodes, their structure, blood supply disturbances, the degree of tissue echo density, and location relative to each other are assessed.

    Preparation for ultrasound and procedure duration

    No preliminary preparation required.An exception is ultrasound of the lymph nodes of the abdominal cavity. A light diet is recommended 2-3 days before the examination. Dinner before the procedure should be light.

    The examination takes from 10 minutes to half an hour, depending on the zone and the complexity of the diagnosis.

    Cost of ultrasound of lymph nodes

    Ultrasound of peripheral lymph nodes (+ color and power Doppler + duplex scanning of blood vessels) from 25.30 BYN

    Advantages of the medical center “MedClinic”

    • examination on the Aloka Prosound Alpha 7 premium device, which allows the use of color Doppler ultrasonography to visualize structural changes and assess blood flow, as well as to study the structure of lymph nodes.
    • ultrasound doctors of the highest category;
    • speed of processing results;
    • no queues;
    • pre-registration at a convenient time;
    • working hours Mon-Fri from 9.00 to 21.00, Sat from 9.00 to 16.00.

    If you need to carry out an effective and accurate ultrasound of the lymph nodes in Minsk, contact the medical center “MedKlinik”. Highly qualified specialists will help you to carry out diagnostics in a timely and quick manner in a comfortable environment without waiting in queues.The cost of the procedure depends on the area of ​​interest.

    90,000 ultrasound of lymph nodes (group 1) in Izhevsk, prices, descriptions, doctors

    Ultrasound of lymph nodes is a high-precision diagnostic study that allows you to determine the location and number of lymph nodes, their size and shape, structure, changes in surrounding tissues. The study is of great diagnostic value for determining the nature of metastasis, dynamic observation of a number of diseases and timely detection of acute infectious conditions.

    Ultrasound examination of lymph nodes in the clinic “Medservice”

    The patient is in the supine position. A special sensor is processed with a gel and tightly pressed against the exposed area to be diagnosed. Under the influence of ultrasonic waves arising from the difference in the acoustic impedance of tissues, an image appears on the monitor screen, which allows a specialist to assess changes in any organ parameters or to detect the development of a pathological process.

    During the procedure, the size, shape, location of the lymph nodes relative to each other, structure, disturbances in blood supply and location, the degree of tissue echo density are visualized.

    Lymph nodes in the groin or abdomen are examined while holding the breath or during a deep breath. The lymph nodes of the neck and armpits are examined while the patient is calm.

    Ultrasound of lymph nodes using Siemens-Acuson S2000 apparatus in Izhevsk

    Patients of the Medservice clinic have an excellent opportunity to undergo high-quality ultrasound using the Acuson S2000 device.The Siemens Acuson S2000 ultrasound machine is a premium ultrasound system that allows you to obtain images of the analyzed organs of exceptionally high quality. A wide selection of different modes in combination with high-sensitivity transducers allows for virtually any ultrasound examination.

    Research quality assurance

    The technical equipment of the Medservice clinic allows for ultrasound diagnostics of various levels of complexity with high accuracy.The experience of doctors excludes mistakes when conducting ultrasound of the lymph nodes and decoding the results obtained. If pathologies of the lymph nodes are detected, the patient will be referred to specialized specialists to clarify the diagnosis and prescribe effective treatment.

    Indication

    Ultrasound of the lymph nodes is prescribed in the presence of the following indications:

    • enlargement of lymph nodes in size after infection and after recovery or for no apparent reason;
    • soreness and swelling of the lymph nodes;
    • oncological diseases;
    • identification of acute infectious conditions;
    • dynamic observation of a number of diseases.

    Contraindications

    Ultrasound of the lymph nodes has no contraindications and side effects. Does not cause radiation and is used to diagnose diseases in patients of any age.

    Preparation for procedure

    Depending on the indications, ultrasound diagnostics is performed for external (cervical, submandibular, axillary, inguinal) and internal lymph nodes (abdominal cavity, retroperitoneal space, small pelvis).

    To study the external nodes, special preparation of the patient is not required. The study can be carried out at any time of the day.

    When preparing for ultrasound of the internal lymph nodes of the abdominal cavity and retroperitoneal space, approximately 2 – 3 days before the study, it is necessary to cleanse the intestines and maintain a preliminary diet to reduce gas formation processes.

    Study results

    The specialists of the clinic “Medservice” will give out the results of the ultrasound immediately after the procedure.

    It should be noted that ultrasound of the lymph nodes is of a diagnostic nature and for the completeness of the clinical picture requires additional studies and analyzes, which you can do in the Medservice clinic.

    ultrasound of lymph nodes in Yekaterinburg. Medical center “URO-PRO”

    Indications for ultrasound of lymph nodes

    Ultrasound examination is indicated in case of enlargement of single or a whole group of lymph nodes, the appearance of pain when palpating or reddening of the skin.These symptoms are included in the definition of lymphadenopathy – local or generalized enlargement of the lymph nodes. The cause of its development is many infectious diseases, including STIs, ARVI and purulent infections of soft tissues, as well as malignant neoplasms of any localization.
    The attending physician may prescribe a control ultrasound examination of the lymph nodes after the transferred lymphadenitis and a course of antibacterial and anti-inflammatory therapy. In this case, the effect of the treatment, the size and condition of the nodes after an infectious disease is assessed.

    What diseases can be diagnosed by ultrasound of the lymph nodes?

    Ultrasound diagnostics detects changes in the size and structure of lymph nodes and helps in the diagnosis of the following pathological conditions:

    • Cystic, fatty and connective tissue degeneration of the lymph node.
    • Lymphogranulomatosis – a malignant neoplasm of the lymphatic tissue Lymphadenitis is an inflammatory process initially localized in the tissues of the node.
    • Lymphadenopathy associated with infectious diseases of various localizations.
    • Metastases in the lymph nodes.

    A change in the size of a certain group of lymph nodes indicates the likelihood of a particular disease. So, the inguinal nodes most often increase against the background of genital infections, cervical – with viral and bacterial infections of the respiratory tract, axillary and supraclavicular – with malignant processes.

    In controversial situations, an ultrasound examination of the lymph nodes of the groin area helps in the differential diagnosis of direct or oblique inguinal hernias with lymphadenitis and subcutaneous lipomas (benign neoplasm from adipose tissue).Lymph nodes that are enlarged and painful to touch can mimic a strangulated inguinal hernia. In this case, an ultrasound examination of the area of ​​interest is assigned to make the correct diagnosis.

    If there is a suspicion of malignant processes in the lymph node, a biopsy is performed under ultrasound control. Ultrasound allows you to determine the exact localization of both the node itself and the optimal place for sampling, which minimizes the risk of injury to healthy tissues.

    Preparation for the study and the procedure for conducting it

    Ultrasound diagnostics does not require special training.The hair in the study area does not interfere with the procedure and does not affect the image quality, but when examining a group of inguinal and axillary lymph nodes, it is recommended to adhere to generally accepted rules of personal hygiene.

    During the examination, the patient is placed on the couch. An echogel is applied to the transducer for close contact with the body surface and to improve the transmission of ultrasonic waves. The area of ​​investigation depends on the clinical presentation and the presumptive diagnosis. The doctor examines the groups of enlarged lymph nodes in stages, evaluates their structure and size.Lymph nodes in the neck, occiput, armpits and groin are usually visualized. In case of enlargement of other lymph nodes (for example, supraclavicular or popliteal), their purposeful study is carried out. The duration of the procedure depends on the number of examined areas and lasts from 10 to 25 minutes.

    Are there any contraindications for ultrasound examination of lymph nodes?

    Ultrasound is not always recommended for an active infectious and inflammatory process in the lymph node or nearby healthy tissue (the formation of fistulas with purulent discharge against the background of a disease, infection of the skin and subcutaneous tissue).Otherwise, the method of ultrasound diagnostics has no contraindications and is absolutely harmless to the body.

    Benefits of ultrasound diagnostics

    Lymph nodes are soft tissues, therefore, ultrasound examination is the main non-invasive method for diagnosing pathological processes occurring in them. They are also visualized on contrast-enhanced radiography, computed tomography and magnetic resonance imaging. X-ray examination methods imply radiation exposure to the body, therefore they are rarely used in everyday practice and have a narrow spectrum of indications.MRI is used only after ultrasound due to the high cost and less availability of the method.

    Ultrasound is the main method for detecting changes in the lymphatic system. Due to the high accuracy and information content of the method, the correct diagnosis can be established in the vast majority of patients.

    Advantages of the URO-PRO clinic

    Ultrasound examination is carried out on modern expert-class equipment.Our specialists are highly qualified and have extensive practical experience. Professional interpretation of the results allows the attending physician to make the correct diagnosis and prescribe a course of effective treatment.

    Enlarged lymph nodes | Prima Medica

    When lymph nodes are involved in the painful process, most often:
    Swollen lymph nodes You may feel an enlarged lymph node the size of a pea or bean, or even larger.Both single and multiple lymph nodes throughout the body can be enlarged.
    Single lymph nodes in the submandibular, cervical and occipital regions are enlarged to the size of a bean, elastic, moderately painful Runny nose, sore throat, headache, fever, muscle pain, and other signs of an upper respiratory infection SARS or colds
    Few lymph nodes in the submandibular region, the parotid region or the upper third of the neck, varying degrees of density and soreness, up to 1-1.5 cm in size, long-existing, increasing in size against the background of ARVI Frequent SARS, tonsillitis, pharyngitis, dental problems Chronic infection of the oral cavity and ENT organs: chronic tonsillitis, pharyngitis, dental caries, chronic inflammatory odontogenic processes, odontogenic cysts
    Multiple lymph nodes in the submandibular, cervical, occipital, inguinal, etc.areas enlarged to the size of a bean, soft, more often painless Weakness, fever, possibly an enlarged liver and / or spleen, and a skin rash Acute and chronic viral infections, toxoplasmosis, severe parasitic infestations
    Various symptoms depending on the specific disease – joint pain, fever, skin rashes, abdominal pain, increased pressure, etc. Autoimmune diseases such as lupus, periarteritis nodosa or rheumatoid arthritis, etc.
    Symptoms are absent, or not associated with the fact of enlarged lymph nodes Long-term use of certain medications, such as allopurinol, atenolol, captopril, enalopril (less often), carbamazepine, some antibiotics; sulfonamides; phenytoin, etc.
    A single dense, painful lymph node, most often in the submandibular region, upper third of the neck, axillary region Symptoms of the inflammatory process of varying severity – from diffuse edema and redness of the skin over the lymph node, fever, various severity of local pain.More often – the source of inflammation is obvious. Regional lymphadenitis, the presence of an entrance gate of infection in the form of damage to the skin of the hands with axillary lymphadenitis, carious teeth with submandibular lymphadenitis, inflammation of the tonsils with cervical lymphadenitis.
    An enlarged single lymph node or several nearby lymph nodes. The nodes are dense, often completely painless, inactive due to the fact that they are soldered to the surrounding tissue or to each other.The localization of the enlarged lymph nodes can be any, in particular – the axillary region, the lower third of the neck, the supraclavicular region. Additional symptoms may be absent, or be represented by general clinical symptoms such as weight loss, fever, weakness, itching, excessive sweating, or local symptoms such as pain, induration and deformation of the affected organ, swelling of the limb, etc. Often, such an increase in lymph nodes is a sign of a tumor of the lymphatic system, such as lymphoma (in particular, Hodgkin’s lymphoma), or tumors of internal organs (stomach, intestines, reproductive sphere, etc.).).
    Compaction of lymph nodes You can feel a lymph node or multiple nodes, which can be of varying degrees of density: both soft and barely visible to the touch, or as dense as wood or stone.
    Dense, most often painless, non-displaceable lymph nodes of any location, especially in unusual places such as the lower neck, armpits Additional complaints may either be completely absent or be presented by general symptoms (weakness, sweating, fever, weight loss, itching of the skin, rash), or local signs (soreness when squeezing, swelling of surrounding tissues and limbs; changes in the skin over the lymph nodes and etc.). First of all, it is necessary to exclude the presence of a tumor, the localization of which can be removed from the enlarged lymph nodes. Also, the diagnostic search includes infections such as tuberculosis and syphilis.
    Soreness of lymph nodes The enlarged lymph nodes may or may not be painful. Soreness of the lymph nodes can be associated with both inflammation and rapid growth due to stretching of the node capsule, as well as squeezing of the surrounding tissues and nerve endings.
    A single dense lymph node, sharply painful when touched, the skin over the node is reddened and hot to the touch. Most often, the entrance gate of infection is obvious: a sore throat with an enlarged lymph node in the neck, damage to the skin on an arm or leg, felon, etc. Infectious lymphadenitis, if you do not seek immediate medical attention, may require surgical treatment.
    One or more dense lymph nodes, painless or slightly painful when palpated, often soldered together and inactive, or completely not displaced when palpating, the skin over the nodes is not changed. Additional complaints may be completely absent or present as general symptoms (weakness, sweating, fever, weight loss, itching of the skin, rash). Local symptoms are not common, but can be caused by compression of the surrounding tissue (soreness, swelling). Often – such an increase in lymph nodes is a sign of a tumor of the lymphatic system, such as lymphoma (in particular – Hodgkin’s lymphoma), or tumors of internal organs (stomach, intestines, reproductive sphere, etc.).
    Several dense lymph nodes, painless or slightly painful when palpating, unsoldered to each other, mobile, which are sometimes compared to “potatoes in a bag”. Additional complaints may be either completely absent or present as general symptoms (weakness, fever, cough, weight loss, etc.).The skin over the nodes may not be changed, or have a bluish tint, be fused with the lymph nodes, external fistulas with cheesy discharge may form. A rare condition in our time – tuberculosis of the lymph nodes. However, in connection with the massive refusals of vaccination and uncontrolled migration from regions unfavorable for tuberculosis, one should not forget about the likelihood of this disease.
    A single painless densely elastic lymph node, movable on palpation, ranging in size from 1 to 3 and even 5 cm, the skin above it is not changed. The most common localization is in the groin, cervical or submandibular region, which depends on the entrance gate of the infection. The entrance gate of infection can most often be localized on the genitals, in the anus, in the mouth, on the tonsils and represent a dense painless ulcer with a whitish bottom. Sometimes, on examination, the ulcer is in the healing phase and is difficult to notice. Primary syphilis. Unfortunately, this situation is not uncommon in our time.Urgently see a doctor! At this stage, the disease is easily cured.
    Additional Features Additional signs may be changes in the skin over the lymph nodes, the presence of additional symptoms, both local and general, as well as the characteristics of the patient’s life, his age, heredity, professional activity and travel. An experienced physician should evaluate a holistic picture of changes in the body of a patient who has complained of enlarged lymph nodes.Most often, you need to see a therapist, pediatrician, or general practitioner. After examination and initial examination, the patient is assigned dynamic observation, treatment, or additional consultations of narrow specialists.

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