Cervical lymph nodes: a pictorial review of ultrasound

findings.

Poster No.: C-3455

Congress: ECR 2019
Type: Educational Exhibit
Authors: A. V. Altamirano S. , E. F. Altamirano Carcache, C. C. Zamora G.,
Y. P. Medrano; Managua/NI
Keywords: Cancer, Staging, Education, Ultrasound-Power Doppler,
Ultrasound-Colour Doppler, Ultrasound, Lymph nodes, Head and
neck, Anatomy
DOI: 10.26044/ecr2019/C-3455

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Learning objectives

1. To review the most important neck echographic landmarks using a visual

and practical approach in order to classify nodes according to the levels of
the AJCC.
2. To know the echographic characteristics of normal and pathological lymph
nodes.
3. To illustrate a wide spectrum of differential diagnoses affecting neck lymph
nodes.

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Background

Ultrasound is the first modality used in the assessment of neck adenopathies, it provides
a great detail of the morphology and internal structure of nodes that allows a proper
evaluation, these characteristics help to differentiate reactive or pathological lymph
nodes. It is crucial to know the cervical lymph node staging especially in oncological
patients. Several imaging-based classification for cervical lymph nodes of the neck
are applied considering theoretical limits using anatomical landmarks such as muscles,
bones, nerves and cervical vessels. The American Joint Committee on Cancer (AJCC)
classification is the most used and optimized to predict survival in patients with thyroid
cancer.

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Findings and procedure details

It's essential to know and be able to identify the anatomic landmarks, like the skull
base at the jugular fossa, the bottom of the hyoid bone, the bottom of the cricoid
arch, the manubrium, the back edge of the submandibular gland, the back edge of the
sternocleidomastoid muscle, the lateral posterior edge of the anterior scalene muscle,
the anterior edge of the trapezius muscle, both the internal carotid and common carotid
arteries, the internal jugular vein, the clavicle, medial margin of the anterior belly of the
digastric muscle, and the mylohyoid muscle.

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Fig. 1: Nodal classification, anatomical landmarks.
References: Instituto radiodiagnóstico / Managua, Nicaragua 2018

Imaginary lines are used to define the boundaries of the levels in each side of the neck.
With time and practice the radiologist will become familiar with the classification and will
be able to locate the lymph node instantaneously. The main horizontal lines are across
the lower border of hyoid bone and across the lower margin of the cricoid cartilage, a third
line is depicted by the superior border of the clavicle. Other lines of separation will be
explain in each level. The term central neck usually refers to levels VI and VII, whereas
the lateral neck includes levels I. II. III, IV, and V.

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Fig. 2: Nodal classification, imaginary lines are used to define the boundaries of the
levels in each side of the neck.
References: Instituto radiodiagnóstico / Managua, Nicaragua 2018

Level I includes all nodes above the hyoid bone, below the mylohyoid muscle, and anterior
to the posterior edge of the submandibular gland. The anterior belly of the digastric
muscle divides this space into A and B.

• Level IA: nodes that lie between the medial margins of the anterior bellies of
the digastric muscles. Previously classified as submental nodes.
• Level IB: nodes that lie posterolateral to the medial edge of the anterior belly
of the digastric muscle Previously classified as submandibular nodes.

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Level II extends from the skull base to the hyoid bone, between the submandibular gland
and the posterior edge of sternocleidomastoid muscle.

• Level IIA nodes that lie anterior, lateral, or medial to the vein. Previously
classified as upper internal jugular nodes.
• Level IIB nodes that lie posterior to the internal jugular vein and have a fat
plane separating the nodes and the vein.

Level III nodes lie between the hyoid bone and the lower margin of the cricoid cartilage
and extend between either the common carotid artery or the internal carotid artery and
the posterior edge of sternocleidomastoid muscle.

Level IV includes nodes that lie between the level of the lower margin of the cricoid
cartilage and the level of the clavicle on each side, with the same anterior and posterior
landmark than level III. 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).

Level V represents the nodes of the posterior cervical triangle, which extends from skull
base to the clavicle and from the posterior edge of sternocleidomastoid muscle to the
anterior edge of the trapezius muscle.

• Level VA: extends from the skull base and the level of the lower
margin of the cricoid cartilage arch, behind the posterior edge of the
sternocleidomastoid muscle.
• Level VB: nodes lie between the level of the lower margin of the cricoid
cartilage arch and the level of the clavicle. They are behind an oblique
line through the posterior edge of the sternocleidomastoid muscle and the
posterolateral edge of the anterior scalene muscle.

Level VI covers the space defined between the hyoid bone and the top of the manubrium
and between both common carotid arteries and internal carotid artery. They are the
visceral nodes.

Level VII this are the superior mediastinal nodes, framed between the upper margin of
the manubrium, the innominate vein, and the left and right common carotid arteries.

MORPHOLOGICAL CRITERIA

Normal reactive lymph nodes are:

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- Presence of hilus: This appearance is due to the abutment of multiple medullar sinuses
acting as interfaces. No hilus visualization is usual in smaller nodes.

- Morphology: Benign nodes are described as oval or elongated while malignant nodes
as rounded. As an exception, the normal submandibular, submental and parotid nodes
may be rounded.

- Short axis less than 8 mm (except submandibular and upper jugular nodes, which can
be up to 9 mm). The ratio between the longitudinal axis (L) of the node and the nodal
transverse or short axis (S), is used to define the nodal shape. The long axis of an oval
benign node will be at least two times greater than the axial diameter, situation that may
be described as L/S > 2 or S/L < 0.5. In malignant, rounded nodules, the value of L/S is
less that 2 or even < 1.5 or S/L > 0.5.

Pathological lymph nodes are:

-The eccentric cortical hypertrophy or asymmetrical cortical nodular focus should be

considered suspicious. May indicates partial tumor infiltration.

- Absence of identifiable echogenic hilus. The majority of malignant lymph nodes have no
visible hilum, due to tumor infiltration and effacement of the normal nodal tissue. Although
metastatic, lymphomatous and tuberculous nodes tend to not show central hilus, they
may present an echogenic hilus in their early stage of involvement in which the medullary
sinuses have not been sufficiently disrupted to eradicate it. Therefore, the presence or
absence of echogenic hilus should not be absolute criteria in the diagnosis.

- Shape: Rounded morphology, regarding long-short axis ratio less than 2, as described
previously. The shape index has proven to be an excellent criterion for differentiation
between benign and malignant cervical lymph nodes Fig. 4 on page 15

- Echogenicity: Metastatic nodes are usually hypoechoic, nevertheless the presence

of additional suspicious features increases the confidence for differentiating them from
benign reactive lymphadenopathy. The exception of this rule are metastases from PTC,
that tend to be hyperechoic.

- Necrosis usually is central and proportional to the node size, but it is considered
a pathological finding regardless of size. The first area invaded by tumor cells is the
subcapsular zone. Necrosis is more typical of the cervical region and the most common
causes are infection and metastasis of head and neck cancers, this finding can also occur

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in other malignancies. Necrosis can be anechoic (cystic necrosis), which is more frequent
or hyperechoic (coagulation necrosis). Fig. 3 on page 14

- Borders: Benign reactive nodes typically have blurred borders, thought to be related to
surrounding tissue inflammation. It indicates extracapsular spread of tumor. Also some
unsharp borders are common in tuberculous nodes and these are due to the edema and
inflammation of the surrounding soft tissue (periadenitis).

- Calcification: Its presence is a marker of nodal disease, whether active or a sequela

of previous illness. Coarse calcification are related to a prior inflammatory disease like
tuberculosis Fig. 8 on page 18 or lymphoma treated with chemotherapy/radiotherapy
and punctate microcalcifications can be found in metastases from PTC. Fig. 5 on page
16

-Vascularity: The color Doppler shows a radial vascular distribution from the centred
hilum. A non-hilar peripheral flow (subcapsular vessels) is a clear sign of pathology,
probably related to metastatic disorder or reactive nodes, as a result of angiogenesis.

There are four types of vascular distribution:

1. Hilar flow: Flow signal is seen branching radially from the hilum, which can
originate from the cortical region or from the periphery.
2. Capsular/Peripheral flow: Flow signal is seen along the periphery of the
node, with flow perforating the periphery (not arising from the hilum).
3. Mixed-Hilar and Peripheral flow: Flow signal is in both the hilum and
periphery;
4. Avascular: No flow signal.

NODAL PATHOLOGY

Thyroid cancer metastases: Adenopathies are found in the lower neck. All the
usual characteristic of malignant nodes are present, such as echogenic cortex,
microcalcifications and cystic changes. Fig. 10 on page 19 Approximately 40% of all
lymph node metastases from PTC makes cystic degeneration.

The best predictor of metastatic nodes is increase of short axis diameter while the
presence of normal hilar blood flow, hilar echoes, or both is the best predictor for reactive
nodes.

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A metastatic adenopathy with ill defined margins suggest extracapsular spread and
patients may have a poor prognosis. Metastatic nodes from PTC may be hyperechoic
and have punctate calcifications. Fig. 12 on page 21

The definition of the central neck compartment (N1a) was expanded to include both
level VI and level VII (upper mediastinal) lymph nodes compartments in the eighth
edition of the AJCC. It is a diagnostic challenge to identify adenopathies in the central
compartment, this is due to the anatomical location. US has a low sensitivity (9.5%-61%)
for central compartment metastasis and a high sensitivity (64%-93.9%) for lateral
compartment metastasis. The first echelon of nodal meta#stasis most commonly includes
the paralaryngeal, paratracheal, and prelaryngeal (Delphian) nodes adjacent to the
thyroid gland. Metastases also may involve level IIA, III, IV and the supraclavicular (level
V). Lymph node metastasis to submandibular and submental lymph nodes (level I) is
rare. Upper mediastinal (level VII) nodal spread occurs frequently.

Definition of the N categories for thyroid carcinoma in the eighth edition of the AJCC
Cancer Staging Manual is the following:

Regional lymph node (pN):

NX: Regional lymph nodes cannot be assessed

N0: No evidence of regional lymph node metastases Fig. 15 on page 23

• N0a*: One or more cytologic or histologically confirmed benign lymph nodes

• N0b*: No radiologic or clinical evidence of locoregional lymph node
metastasis

N1*: Metastasis to regional nodes

• N1a*: Metastasis to level VI or VII (pretracheal, paratracheal, prelaryngeal /

Delphian or upper mediastinal) lymph nodes; this can be unilateral or
bilateral disease Fig. 16 on page 24
• N1b*: Metastasis to unilateral, bilateral or contralateral lateral neck lymph
nodes (levels I, II, III, IV or V) or retropharyngeal lymph nodes. Fig. 17 on
page 25

Melanoma metastases: Approximately 70% of melanoma metastases imply the regional

lymph nodes, the first draining lymph node being the sentinel lymph node. Therefore the
evaluation of regional lymph nodes status is fundamental in the initial staging. Superficial
lymph nodes appear as oval/rounded nodes without echogenic hilum and focal cortical
thickening or irregular margins (suspicious nodes). Melanoma nodes are hypervascular
even at small size. An early sign of lymph node alteration, is the appearance of accessory
blood vessels in the periphery, known as peripheral perfusion.

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Satellite and in-transit metastases are common in melanoma. They appear between
the site of the primary tumor and regional lymph nodes, in the skin lymphatics and
subcutaneous tissue. Metastases within 2 cm of the primary tumor are known as satellites
lesions. Those in the cutaneous or subcutaneous tissue and more than 2 cm from the
main lesion are called in-transit metastases.

Lymphoma: Involved lymph nodes are usually found in the submandibular, upper
cervical chain and posterior triangle region. The classical presentation are rounded, large,
homogeneous (hypoechoic on US) and bilateral nodes, some of them confluent. Necrosis
is rare, suggesting high grade non-Hodgkin´s lymphoma. Some of them present sharp
margins and nodal reticulation present mixed, peripheral and hilar vessels. Fig. 9 on page
18

Pseudo-cystic appearance and posterior acoustic enhancement are features of

lymphoproliferative processes. Intranodal reticulation (micronodular echopattern) is also
commonly found. Fig. 13 on page 21 Color or power Doppler is useful in monitoring
response as quick reduction of vessel signal demonstrates not only favorable response
but also prolonged remission.

Quervain's thyroiditis: Often show certain sonographic malignancy criteria as rounded

shapes and facet formation. In early stages small infracentrimetrical LN in pre and
paratracheal situations are seen. Usually they are round, hypoechogenic, with loss of
central hilium and vascularized. Serres-Cre#ixams et al. first described an involvement of
paratracheal LN in thyroiditis and suggested a connection to the inflammatory process.
Fig. 6 on page 17

Cervical tuberculous lymphadenitis: Tuberculous nodes are rounded, hypoechoic, no

visible hilum, with blurred margins or matting , thickening of the cortex and perinodal
edema. If chronic some nodes with cystic necrosis and internal echoes are identify. The
Doppler appearance may mimic malignancy due to vessel dislocation by necrosis. The
posterior cervical triangle and supraclavicular levels are mostly affected.

In early fases homogeneous, hypoechogenic nodes are found, as the illness progress
the nodes become coalescence (nodal matting) with an irregular thickness and calcified
appearance once the process is healed. Sometimes complications occur such as
inflammation of soft tissue or abscesses. Fig. 14 on page 22

Silicone adenopathy: The silicone adenopathy or siliconoma is a recognized

complication of breast implants (rupture or leakage). Although siliconomas first appear
closest to the implant, because of the proximity with the internal mammary chain, the

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lower cervical levels are also affected. The local swelling of the involved lymph nodes, can
be misdiagnosed as metastasis or malignant lymphadenopathy upon initial presentation.

Ultrasound depicts "snowstorm" or scattered hyperechoic images with reverberating

artefact. Hypoechoic masses with posterior acoustic shadowing or resembling dense
cysts may also be found. The color and power Doppler don´t provide valid additional
information. Fig. 7 on page 17

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Images for this section:

Fig. 1: Nodal classification, anatomical landmarks.

© Instituto radiodiagnóstico / Managua, Nicaragua 2018

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Fig. 2: Nodal classification, imaginary lines are used to define the boundaries of the levels
in each side of the neck.

© Instituto radiodiagnóstico / Managua, Nicaragua 2018

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Fig. 3: Coagulation necrosis in the subcapsular zone.

© Instituto radiodiagnóstico / Managua, Nicaragua 2018

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Fig. 4: Rounded morphology of an adenopathy

© Instituto radiodiagnóstico / Managua, Nicaragua 2018

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Fig. 5: Punctate microcalcifications found in metastases from PTC

© Instituto radiodiagnóstico / Managua, Nicaragua 2018

Fig. 6: Round, hypoechogenic nodes with loss of central hilium in Quervains's thyroiditis.

© Instituto radiodiagnóstico / Managua, Nicaragua 2018

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Fig. 7: "snowstorm" in a lymph node.

© Instituto radiodiagnóstico / Managua, Nicaragua 2018

Fig. 8: Coarse calcification found in a 8 year old with a prior tuberculosis.

© Instituto radiodiagnóstico / Managua, Nicaragua 2018

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Fig. 9: Rounded, large, homogeneous nodes, with sharp margins and nodal reticulation
found in a 14 years old with Lymphoma

© Instituto radiodiagnóstico / Managua, Nicaragua 2018

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Fig. 10: Thyroid cancer metastases: microcalcifications (punctate echogenic foci)

© Instituto radiodiagnóstico / Managua, Nicaragua 2018

Fig. 11: coarse calcifications in chronic tuberculosis

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© Instituto radiodiagnóstico / Managua, Nicaragua 2018

Fig. 12: Metastatic node from PTC, with coagulation necrosis

© Instituto radiodiagnóstico / Managua, Nicaragua 2018

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Fig. 13: Rounded, hypoechogenic nodes in lymphoma with intranodal reticulation
(micronodular echopattern).

© Instituto radiodiagnóstico / Managua, Nicaragua 2018

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Fig. 14: An scrofula in cervical tuberculous lymphadenitis.

© Instituto radiodiagnóstico / Managua, Nicaragua 2018

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Fig. 15: Definition of the N categories for thyroid carcinoma in the eighth edition of the
AJCC Cancer Staging Manual: N0: No evidence of regional lymph node metastases

© Instituto radiodiagnóstico / Managua, Nicaragua 2018

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Fig. 16: Definition of the N categories for thyroid carcinoma in the eighth edition of
the AJCC Cancer Staging Manual: N1a*: Metastasis to level VI or VII (pretracheal,
paratracheal, prelaryngeal / Delphian or upper mediastinal) lymph nodes; this can be
unilateral or bilateral disease

© Instituto radiodiagnóstico / Managua, Nicaragua 2018

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Fig. 17: Definition of the N categories for thyroid carcinoma in the eighth edition of the
AJCC Cancer Staging Manual: N1b*: Metastasis to unilateral, bilateral or contralateral
lateral neck lymph nodes (levels I, II, III, IV or V) or retropharyngeal lymph nodes.

© Instituto radiodiagnóstico / Managua, Nicaragua 2018

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Conclusion

Ultrasound is an accurate, sensitive and specific modality to differentiate benign from

malignant cervical lymph nodes. Distribution of nodes, morphology, necrosis, calcification
and power Doppler are the main sonographic features that help in distinguishing the
nodes. It is crucial to know the cervical lymph node staging especially in oncological
patients. The AJCC classification is the most used and optimized to predict survival in
patients with thyroid cancer.

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Personal information

Dr. Aleen Altamirano, Radiology / Breast imaging - INSTITUTO RADIODIAGNOSTICO

- Managua, Nicaragua.

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References

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