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Imaging of cervical lymph nodes

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Imaging of cervical lymph nodes

  1. 1. IMAGING OF CERVICAL LYMPH NODES Mohamed Wasel M.Sc, EDIR , EDiNR Alharda Armed Forces Hospital 2019
  2. 2. Outlines –Cervical lymph nodes classification developed by Som. et al, which groups lymph nodes in levels . –Ultrasonic features of cervical lymph node . –CT features of cervical lymph nodes. –MRI feasures of cervical lymph nodes . – PET scan feasures of cervical lymph nodes .
  3. 3. To use the imaging-based nodal classification developed by Som its essential to know the anatomic landmarks of the classification: 1. The skull base at the jugular fossa, 2. The bottom of the body of the hyoid bone 3. The bottom of the cricoid arch . 4. The top of the manubrium . 5. The back edge of the submandibular gland . 6. the back edge of the sternocleidomastoid muscle . 7. The lateral posterior edge of the anterior scalene muscle, 8. The anterior edge of the trapezius muscle, 9. Both the internal carotid and common carotid arteries, the internal jugular vein, 10. The clavicle, the medial margin of the anterior belly of the digastric muscle, and 11. The mylohyoid muscle.
  4. 4. Fig. 1 References: Imagiologia Geral, Centro Hospitalar Lisboa Norte, Hospital de Santa Maria - Vila Nova De Gaia/PT
  5. 5. Fig. 2 References: Imagiologia Geral, Centro Hospitalar Lisboa Norte, Hospital de Santa Maria - Vila Nova De Gaia/PT
  6. 6. - Level I includes all nodes above the hyoid bone, below the mylohyoid muscle, and anterior to the posterior edge of the sub- mandibular gland..
  7. 7. - Level IA represents the nodes that lie between the medial margins of the anterior bellies of the digastric muscles. - Level IB represents the nodes that lie posterior and lateral to the medial edge of the anterior belly of the digastric muscle.
  8. 8. Level II is limited cranially by the skull base and extends caudally to the the lower body of the hyoid bone. Level II nodes lie anterior to the posterior edge of the sternocleidomastoid muscle and lie posterior to the posterior edge of the submandibular gland.
  9. 9. •Level II nodes can be subclassified into levels IIA and IIB. •Level IIA nodes are level II nodes that lie posterior to the internal jugular vein and are inseparable from the vein or that lie anterior, lateral, or medial to the vein. •Level IIB nodes lie posterior to the internal jugular vein and have a fat plane separating the nodes and the vein .
  10. 10. Level III nodes lie between the of the lower body of the hyoid bone and the level of the lower margin of the cricoid cartilage arch, anterior to the posterior edge of the sternocleidomastoid muscle and lateral to the medial margin of either the common carotid artery or the internal carotid artery.
  11. 11. Level III nodes lie between the of the lower body of the hyoid bone and the level of the lower margin of the cricoid cartilage arch, anterior to the posterior edge of the sternocleidomastoid muscle and lateral to the medial margin of either the common carotid artery or the internal carotid artery.
  12. 12. Level IV nodes lie between the level of the lower margin of the cricoid cartilage arch the level of the clavicle, anterior and medial to an oblique line drawn through the posterior edge of the sternocleidomastoid muscle and the posterolateral edge of the anterior scalene muscle
  13. 13. . The medial aspect of the common carotid artery is the landmark that separates level IV nodes (lateral to this artery) from level VI nodes (medial to this artery).
  14. 14. Level V nodes extend from the skull base, at the posterior border of the attachment of the stermocleidomastoid muscle, to the level of the clavicle
  15. 15. . Level V nodes all lie anterior to the anterior edge of the trapezius muscle. Between the levels of the skull base and the bottom of the cricoid arch, these nodes are situated posterior to the posterior edge of the sternocleidomastoid muscle. Between the axial level of the bottom of the cricoid arch and the level of the clavicle,
  16. 16. level V nodes lie posterior and lateral to an oblique line through the posterior edge of the sternocleidomastoid muscle and the posterolateral edge of the anterior scalene muscle. The level V nodes can be subdivided into VA and VB nodes. The lower margin of the cricoid is the landmark that separates level VA (superior to the cartilage) and level VB (inferior to the cartilage)
  17. 17. Level VI nodes lie inferior to the lower body of the hyoid bone, superior to the top of the manubrium, and
  18. 18. Level VI nodes lie between the medial margins of the left and right common carotid arteries or the internal carotid arteries.
  19. 19. Level VII nodes lie caudal to the top of the manubrium in the superior mediastinum, between the medial margins of the left and right common carotid arteries.
  20. 20. These superior mediastinal nodes extend caudally to the level of the innominate vein.
  21. 21.  Size:  The size of LN cannot be used as the sole criterion in DD.  An increase in LN size on serial examinations.  Changes in the size of malignant nodes.
  22. 22.  Nodal Borders& margins:  Metastatic nodes have sharp borders. Due to tumor infiltration and reduced fatty deposition within LN leads to Increased acoustic impedance difference between LN and the surrounding tissues.
  23. 23.  Reactive nodes usually show un- sharp borders.  Un-sharp borders due to edema & inflammation of surrounding soft tissue.
  24. 24. Shape Feature:  Malignant and TB nodes round.  Reactive and normal nodes usually oval.  The L/S ratio was used to characterize this feature.
  25. 25.  Echogeneity:  Homogeneous hypo- echoic pattern with preserved echo- genic hilum mainly observed in benign nodes.  Heterogeneous and anechoic patterns with loss echogenic hilum are observed in metastatic nodes.
  26. 26.  Normal and reactive nodes predo- minantly hypo- echoic.  Metastatic nodes may be hypo or mixed hypo and eccenteric hyper- echoic component.
  27. 27.  Vascular Pattern: Normal and reactive lymph nodes tend to have central hilar vascular pattern.  club- or Y-shaped and extended from the extra-nodal area into deep portion of the node.  May be appear as apparently a-vascular lesion.
  28. 28.  Metastatic and lympho-matous nodes usually show peripheral or mixed vascularity.  The presence of peripheral vascularity strongly suggesting of a pathologic process.
  29. 29. •Intranodal calcification is rarely found in cervical lymphadenopathy. However, about 50-69% of metastatic nodes from papillary carcinoma of the thyroid show calcification which is punctuate, peripherally located and may show acoustic shadowing . •Intranodal calcification may be found in lymphomatous and tuberculous nodes after treatment but the calcification is usually dense and shows acoustic shadowing. Calcification
  30. 30.  Nodal parenchyma exhibited homogeneous and low echogenicity.  Regular margin and oval or flattened in shape.  The hilum was identified as a highly echogenic structure in the central part of the node.  On power Doppler, usually hypovascular or has hilar vascular pattern.
  31. 31.  Ill defined margin of enlarged LN.  Central decreased echogenicity.  Loss hilum.  On power Doppler, increase peripheral vascularity.
  32. 32.  Nodal parenchyma exhibited inhomogeneous low or mixed echogenicity.  Irregular margin with round shape.  Sharp borders.  Loss of normal hilar echogenicity.  On power Doppler sonograms, has peripheral or mixed vascular pattern.
  33. 33.  CT SCAN:  scanning orientation was parallel to the Frankfurt horizontal line.  Start point at skull base down to the level of aortic arch.  3 mm in thickness.  A collimation of 3 mm, a pitch of 1:1, a matrix of 512x512, a display field of view of 23 cm, 120 kVp, and 200 mA.
  34. 34.  Was carried out after an IV bolus injection of contrast material 100 mL (2 mL/kg of body weight), at a rate of 1.0 mL/sec.  Started scanning 80 sec after the start of contrast medium injection.  Completed in 50–60 sec after the start of scanning.  The scanning period (80–140 sec after the start of contrast medium injection) was confirmed to be the time when the lymph node showed appropriate contrast enhancement against neck muscles.
  35. 35.  A. short- and long-axis diameters of the node:  Short-axis diameter: was used as a size criterion.  Average short-axis lengths of nodes at level I: 7 (reactive) and 11 mm (metastatic).  Level II: 7 (reactive) and 13 mm (metastatic).  Level III, IV , V ,VI and VII : 6 (reactive) and 10 mm (metastatic).  A long axis diameter of more than 10 mm plus a long-to-short-axis ratio of less than 1.6, suggesting metastatic node.
  36. 36.  B. Assessment of changes in the internal architecture:  The presence or absence of necrosis, We considered an area of low attenuation (10–18 HU) to be evidence of nodal necrosis.  The margin, categorized as well or ill defined.  Enhancement pattern, described as homogeneous or heterogeneous .
  37. 37.  Discrete, smooth and well-defined kidney or cigar shaped soft-tissue structures .  The hilum composed of fat tissue attenuation.  No necrosis.  Homogenous and uniform, enhancing criteria and attenuation.
  38. 38.  Rounded shape with ill defined margin.  The long-to-short axis ratio decreases.  Eccentric cortical hypertrophy.  Central necrotic content.  Heterogeneous enhancing pattern.
  39. 39.  Ill defined peripheral enhancing thick wall.  Intra-nodal septation.  Central hypo-dense non enhancing fluid collection.  Marked stranding of adjacent fat ?cellulitis.
  40. 40.  Conventional MRI criteria used in clinical imaging studies are morphologic criteria including: A. Maximum short axial diameter. B. Presence of necrosis and loss of LN hilum. C.Heterogeneous enhancement and peri-nodal infiltration.  A size criterion and presence of necrosis are relatively objective.  But the other criteria are less objective and dependent on the interpretation of the radiologist.
  41. 41.  2D-Single-Shot Diffusion-Weighted Echo Planer Imaging (ss DWEPI ) has been applied to head and neck imaging.  DWEPI provides a quantitative measurement of the ADC of water protons in tissue.  ADC value can be used to differentiate malignant LNs from benign LNs.  Can be a marker for prediction and early detection of chemo-radiation therapy response.  DWEPI also can be used for the early detection of recurrence.
  42. 42.  Axial DW images of cervical lymph nodes were obtained by using a neurovascular array coil.  The sequence was repeated for two different values of gradients (b = 500 and 1000 s/mm2).  The section thickness was 5 mm.  Was performed with a matrix of 128 /128, field of view of 24 cm, and an intersection gap of 1 mm.  Toincrease the signal-to-noise ratio, the sequence was repeated four times for each imaging.
  43. 43.  Hilum Structure of the Nodes:  The hilar fat, has high- intensity area on T1WIs and a low-intensity area on fat suppressedT2WIs.  The vessels may be evident in the hilum on T1WIs and fat suppressed T2WIs.
  44. 44.  Was lost at a metastatic nodes.  Narrowed or also lost in nodal lymphomas.  Preserved hilum was noted on benign LN.
  45. 45.  Margins of the Nodes: T1-weighted and fat suppression imaging was good for the depiction of nodal margins.  Nodal margins blending into surrounding tissue were found in metastatic nodes.  Irregular margins were found in lymphomas.  Regular borders were found on benign nodes.
  46. 46.  Parenchymal architecture: •  Metastatic nodes frequently exhibited heterogeneous architecture of the parenchyma on T1- or fat-suppressed T2-weighted. •  Metastatic nodes contained hypo to intermediately intense areas indicative of cancer cell nests and interstitial fibrous tissue. •  With or without central hyper-intense areas indicative of liquefaction necrosis on fat-suppressed T2.
  47. 47.  Basically lymphomasexhibited homogeneous architecture.  Heterogeneous architecture of the nodal ymphomas was significantly low comparedwith metastatic nodes.  heterogeneity in the nodal architecture may be due tothe presence of necrotic areas.  Associated with narrowed hilum and blood vessels inside, which were depicted as so- called small-vessel sign.
  48. 48.  The ADC of metastatic nodes equal to or greater than 0.73 × 10–3 mm2/sec.
  49. 49.  On lymphoma, it had an ADC equal to or less than 0.51 × 10–3 mm2/sec.  Due to increased nuclear-to- cytoplasmic ratio and hyper- cellularity.
  50. 50.  PET using the radio-labeled glucose analog 18F-FDG has great importance in lymph node imaging.  PET supplies a semi-quantitative metabolic characterization of tissues that may help to predict tumor behavior.  The sensitivity and specificity of 18F-FDG PET for identification of lymph node metastases on a neck level-by-level basis were higher than those of CT/MRI.  The incorporation of functional information derived from PET has the potential factor to improve prognostic stratification and treatment planning for patients.
  51. 51.  Patients were instructed to fast for 6 h before the PET study.  18F-FDG was administered intravenously.  For PET/CT scans, oral contrast was administered to patients during the uptake time.  No IV contrast material was administered for CT scans.  Head to mid thigh scans were obtained for all patients.  PET and CT images were acquired 50 min after the injection of 18F-FDG.  PET, CT,and fused PET/CT images were available for review and were displayed in axial, coronal, and sagittal planes.  PET data were displayed as non-corrected and attenuation- corrected images as well as in a rotating MIP.
  52. 52.  Area of increased 18F-FDG uptake with intensity higher than that of surrounding tissues and did not correspond to the physiologic bio- distribution of the radiotracer, were defined as positive.  18F-FDG activity only in areas of the physiologic tracer bio- distribution or no sites of increased uptake were considered negative.  The highest activity within a region of interest was measured.  The standardized uptake value (SUV) was determined as the highest activity concentration per injected dose per body weight (kg).
  53. 53. •  Area of increased 18F-FDG uptake with intensity higher than that of surrounding tissues and did not correspond to the physiologic bio-distribution of the radiotracer, were defined as positive.
  54. 54. •  18F-FDG activity only in areas of the physiologic tracer bio- distribution or no sites of increased uptake were considered negative. •  The highest activity within a region of interest was measured. •  The standardized uptake value (SUV) was determined as the highest activity concentration per injected dose per body weight (kg).
  55. 55.  18F-FDG uptake was graded visually on the following 5-point scale:  0-definitely benign, no uptake.  1-probably benign, 2.3 (range, 1.4–4.0).  2-equivocal, 2.6 (range, 1.4–4.4).  3-probablymalignant, 3.5 (range, 2.1–7.9).  4-definitely malignant, 6.6 (range, 2.6–24.5).  SUV of 3.1 was used as the cutoff for positive PET results.

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