AJR 2005; 184:1691-1699
© American Roentgen Ray Society
Sonographic Evaluation of Cervical Lymph Nodes
Anil T. Ahuja1 and
Michael Ying2
1 Department of Diagnostic Radiology and Organ Imaging, The Chinese University
of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China.
2 Department of Optometry and Radiography, The Hong Kong Polytechnic University,
Hung Hom, Kowloon, Hong Kong SAR, China.
Received August 4, 2004;
accepted after revision September 30, 2004.
Address correspondence to M. Ying.
Abstract
OBJECTIVE. Sonography is a useful imaging tool in the evaluation of
cervical lymph nodes. Gray-scale sonography and color and power Doppler
sonography are commonly used in clinical practice. This article documents the
common sonographic appearances of different causes of cervical
lymphadenopathy.
CONCLUSION. The sonographic appearances of normal nodes differ from
those of abnormal nodes. Sonographic features that help to identify abnormal
nodes include shape (round), absent hilus, intranodal necrosis, reticulation,
calcification, matting, soft-tissue edema, and peripheral vascularity.
Introduction
Metastatic cervical lymph nodes are common in patients with head and neck
[1] and non–head and neck
[2] cancers. In patients with
squamous cell carcinoma in the head and neck, the presence of a metastatic
node reduces the 5-year survival rate to 50%, and the presence of another
metastatic node on the contralateral side further reduces the 5-year survival
rate to 25% [3]. Therefore,
evaluation of cervical lymph nodes is important in patients with cancers
because it aids in the assessment of patient prognosis and helps in planning
treatment. Cervical lymph nodes are also common sites of involvement of
lymphoma; tuberculous lymphadenitis; and other benign lymphadenitis such as
Kikuchi's disease, Kimura's disease, and Rosai-Dorfman disease
[4,
5].
Sonography is a useful imaging tool in the assessment of cervical lymph
nodes. Gray-scale sonography is widely used in the evaluation of the number,
size, site, shape, borders, matting, adjacent soft-tissue edema, and internal
architectures of cervical lymph nodes. Although both color and power Doppler
sonography are routine, 3D sonography is not commonly used to assess the
intranodal vascular distribution. With the use of spectral Doppler sonography,
the vascular resistance of lymph nodes can also be measured. The purpose of
this article is to briefly reiterate and illustrate the sonographic features
of normal and abnormal cervical lymph nodes.
Normal and Reactive Lymph Nodes
In sonography examinations, cervical lymph nodes are usually classified
into eight regions (Fig. 1).
Normal and reactive lymph nodes are usually found in submandibular, parotid,
upper cervical, and posterior triangle regions. On gray-scale sonography,
normal and reactive nodes tend to be hypoechoic compared with adjacent muscles
and oval (short axis–to–long axis ratio [S/L] < 0.5) except for
submandibular and parotid nodes, which are usually round (S/L 
0.5), and
to have an echogenic hilus [6]
(Fig. 2A,
2B). The upper limit in minimal
axial diameter of normal and reactive nodes is 9 mm for subdigastric and
submandibular nodes and 8 mm for other cervical nodes
[7].
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Fig. 2A. —Gray-scale sonograms of lymph nodes in healthy subjects.
Image of 45-year-old man shows normal intraparotid lymph node is hypoechoic
and oval. Lymph node shows echogenic hilus (arrows), which is
continuous with adjacent soft tissues (arrowheads).
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Fig. 2B. —Gray-scale sonograms of lymph nodes in healthy subjects.
Image of 20-year-old man shows normal posterior triangle lymph node is
hypoechoic, elliptic, and elongated (arrows). Arrowheads indicate
echogenic hilus that is continuous with adjacent soft tissues.
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On color Doppler, power Doppler, and 3D sonography, normal cervical nodes
show hilar vascularity or appear avascular, and reactive nodes predominantly
show hilar vascularity [6]
(Fig. 3A,
3B,
3C). On spectral Doppler
sonography, normal and reactive nodes usually show low vascular resistance
(resistive index [RI] and pulsatility index [PI])
[6] (Fig.
4A,
4B). Inflammation causes
vasodilatation, which increases blood flow velocity in reactive lymph nodes.
It may explain the low vascular resistance in reactive lymph nodes given that
high blood flow velocity is always associated with a lower vascular
resistance.
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Fig. 3A. —42-year-old man with palpable submandibular lymph nodes.
Color Doppler sonogram shows extensive vascularity originating in hilus and
branching radially toward periphery of lymph node (arrows).
Subsequent fine-needle aspiration cytology confirmed reactive node.
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Fig. 3C. —42-year-old man with palpable submandibular lymph nodes.
Three-dimensional power Doppler sonogram of same lymph node as in A and
B shows hilar vascularity of reactive lymph node (arrows).
More extensive vascularity is shown on 3D power Doppler sonography than power
Doppler sonography.
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Fig. 4A. —53-year-old man with confirmed reactive lymph nodes in neck.
Spectral Doppler sonogram shows low vascular resistance of lymph node with
resistive index (RI) of 0.59 and pulsatility index (PI) of 0.94, which are
lower than cutoff values commonly used to differentiate benign and malignant
nodes (RI, 0.7; PI, 1.5).
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Fig. 4B. —53-year-old man with confirmed reactive lymph nodes in neck.
Longitudinal gray-scale sonogram of same lymph node as in A shows lymph
node is hypoechoic and oval (arrows). Arrowheads indicate echogenic
hilus where blood vessels enter and leave lymph node.
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Malignant Lymph Nodes
Malignant lymph nodes include metastatic and lymphomatous nodes. On
grayscale sonography, metastatic nodes are usually hypoechoic, round, and
without echogenic hilus (Fig.
5A). Coagulation necrosis, which appears as a demarcated echogenic
focus, may be found in metastatic nodes
(Fig. 5A). Eccentric cortical
hypertrophy is a useful sign to indicate focal tumor infiltration
(Fig. 5B). Lymph nodes with
cystic necrosis are suggestive of malignancy, and intranodal cystic necrosis
is common in metastatic nodes from squamous cell carcinomas
(Fig. 5C).
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Fig. 5A. —Gray-scale sonograms of patients with metastatic nodes. Image
of 63-year-old man with lung carcinoma and proven metastatic lymph nodes in
lower cervical and supraclavicular regions shows lower cervical node is
hypoechoic, round, and without echogenic hilus (arrows). Note
intranodal coagulation necrosis that appears as demarcated echogenic focus and
is not continuous with adjacent soft tissues (arrowheads).
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Fig. 5B. —Gray-scale sonograms of patients with metastatic nodes. Image
of 60-year-old woman with carcinoma of breast and proven metastatic nodes in
supraclavicular region and internal jugular chain shows eccentric cortical
hypertrophy of upper cervical lymph node due to focal tumor infiltration
(arrowheads).
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Fig. 5C. —Gray-scale sonograms of patients with metastatic nodes. Image
of 70-year-old man with carcinoma of tongue and with bilateral metastatic
upper cervical lymph nodes shows one of metastatic upper cervical nodes is
hypoechoic, round, and without echogenic hilus (arrows). Lymph node
also shows multiple areas of intranodal cystic necrosis
(arrowheads).
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A proven metastatic lymph node with illdefined borders may suggest
extracapsular spread and patients may have a poor prognosis
(Fig. 5D). Metastatic nodes
from papillary carcinoma of the thyroid may be hyperechoic compared with
adjacent muscles and have punctate calcifications
[8]
(Fig. 5E). In Hodgkin's
lymphoma and non-Hodgkin's lymphoma, lymph nodes tend to be round, hypoechoic,
and without echogenic hilus and tend to show intranodal reticulation
[9]
(Fig. 6).
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Fig. 5D. —Gray-scale sonograms of patients with metastatic nodes. Image
of 25-year-old man with nasopharyngeal carcinoma and proven metastatic nodes
in posterior triangle shows metastatic node in posterior triangle with
ill-defined nodal borders (arrows), which indicates extracapsular
spread.
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Fig. 5E. —Gray-scale sonograms of patients with metastatic nodes. Image
of 44-year-old woman with papillary carcinoma of thyroid and associated
metastatic node in right upper cervical region shows metastatic node appears
hyperechoic (arrowheads) when compared with adjacent muscle and has
intranodal punctate calcification (arrow). These sonographic features
are common in metastatic nodes from papillary carcinoma of thyroid.
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Fig. 6. —68-year-old man with proven bilateral non-Hodgkin's
lymphomatous nodes in submandibular region. High-resolution gray-scale
sonogram shows lymphomatous node appears hypoechoic, round, and without
echogenic hilus and shows intranodal reticulation—that is, micronodular
appearance (arrows). (Reprinted with permission from
[8])
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On color Doppler, power Doppler, and 3D sonography, metastatic and
lymphomatous nodes usually show peripheral (Fig.
7A,
7B,
7C) or mixed (Fig.
8A,
8B) vascularity. On spectral
Doppler sonography, malignant lymph nodes tend to have high RI and PI values
[8]
(Fig. 9). In metastatic nodes,
blood vessels within the nodes are compressed by tumor cells, which grow and
spread and replace a large portion of the lymph node, resulting in an increase
in vascular resistance.
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Fig. 7A. —43-year-old woman with nasopharyngeal carcinoma and proven
metastatic nodes in posterior triangle. Color Doppler sonogram shows
metastatic node with peripheral vascularity (arrows) that runs along
periphery of nodes, with perforating branches into lymph nodes.
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Fig. 7B. —43-year-old woman with nasopharyngeal carcinoma and proven
metastatic nodes in posterior triangle. Power Doppler sonogram of same lymph
node as in A shows peripheral vascularity (arrows) similar to
that seen in A.
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Fig. 7C. —43-year-old woman with nasopharyngeal carcinoma and proven
metastatic nodes in posterior triangle. Three-dimensional power Doppler
sonogram of same lymph node as in A and B shows peripheral
vascularity of lymph node (arrows) is better depicted on 3D power
Doppler sonography.
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Fig. 8A. —43-year-old man with proven non-Hodgkin's lymphomatous nodes in
posterior triangle. Color Doppler sonogram shows lymphomatous node with both
hilar (arrows) and peripheral (arrowhead) vascularity.
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Fig. 8B. —43-year-old man with proven non-Hodgkin's lymphomatous nodes in
posterior triangle. Power Doppler sonogram of same lymph node as in A
shows hilar (arrows) and peripheral (arrowheads) vascularity
similar to that seen in A.
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Fig. 9. —41-year-old man with nasopharyngeal carcinoma and metastatic
lymph nodes in posterior triangle. Spectral Doppler sonogram shows high
vascular resistance of lymph node with resistive index (RI) of 0.85 and
pulsatility index (PI) of 2.18, which are higher than cutoff values commonly
used to differentiate benign and malignant nodes (RI, 0.7; PI, 1.5).
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Gray-scale sonography has a sensitivity of 95% and a specificity of 83% in
differentiating metastatic and reactive nodes
[10]. Color or power Doppler
sonography is essential and useful to patients when gray-scale sonography is
equivocal. In one study, power Doppler sonography aided in the diagnosis of 5%
of patients with metastatic nodes and 17% of patients with reactive nodes
[10].
Tuberculous Lymph Nodes
On gray-scale sonography, tuberculous nodes tend to be hypoechoic, round,
and without echogenic hilus and tend to show intranodal cystic necrosis, nodal
matting, and adjacent soft-tissue edema
[8] (Fig.
10A,
10B). On color Doppler, power
Doppler, and 3D sonography, the vascular distribution of tuberculous nodes is
varied and simulates benign and malignant nodes. However, displacement of
hilar vascularity is common in tuberculous nodes and is due to the high
incidence of intranodal cystic necrosis, which displaces the vessels, in
tuberculous nodes [11] (Fig.
11A,
11B,
11C).
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Fig. 10A. —Gray-scale sonograms of two patients with proven tuberculous
lymphadenitis. Image of 59-year-old woman shows two tuberculous nodes
(arrows) matted together without normal intervening soft tissues.
Note cystic necrosis within lymph nodes (arrowheads), which is common
in tuberculous lymphadenitis.
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Fig. 10B. —Gray-scale sonograms of two patients with proven tuberculous
lymphadenitis. Image of 31-year-old woman shows hypoechoic and round
tuberculous node in posterior triangle (arrows) with adjacent
soft-tissue edema (arrowheads), which is common in tuberculous
lymphadenitis.
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Fig. 11A. —20-year-old man with proven tuberculous lymphadenitis. Color
Doppler sonogram shows tuberculous node in posterior triangle with hilar
vascularity (arrows) is being displaced by intranodal cystic necrosis
(arrowheads).
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Fig. 11B. —20-year-old man with proven tuberculous lymphadenitis. Power
Doppler sonogram of same lymph node as in A shows displaced hilar
vascularity (arrows) and intranodal cystic necrosis
(arrowheads).
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Fig. 11C. —20-year-old man with proven tuberculous lymphadenitis.
Three-dimensional power Doppler sonogram of same lymph node as in A and
B shows displaced vascularity (arrows); however, intranodal
cystic necrosis (arrowheads) is not shown because 3D power Doppler
sonography did not provide superimposed gray-scale image.
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Unusual Lymphadenopathy
Diseases such as Kikuchi's disease (histiocytic necrotizing lymphadenitis),
Kimura's disease (eosinophilic hyperplastic lymphogranuloma), and
Rosai-Dorfman disease (sinus histiocytosis with massive lymphadenopathy) may
show benign and inflammatory lymphadenopathy in the neck. Kikuchi's disease is
a self-limiting and benign lymphadenitis in which cervical nodes are usually
affected. Kimura's disease is an autoimmune eosinophilic granulomatous
disorder with generalized lymphadenopathy. Rosai-Dorfman disease is a rare
idiopathic benign histiocytic proliferation, and massive lymphadenopathy is
usually found in the neck region with predominant sinusoidal histiocyte
infiltration.
On sonography, lymph nodes involved with Kikuchi's and Kimura's diseases
have an appearance similar to that of reactive nodes, which tend to be
hypoechoic, and have an echogenic hilus. In patients with Kikuchi's disease,
lymph nodes are usually oval (Fig.
12A), whereas lymph nodes in patients with Kimura's disease are
usually round (Fig. 13A). On
power Doppler sonography [12,
13], lymph nodes in patients
with Kikuchi's disease and Kimura's disease tend to show hilar vascularity
[12,
13] (Figs.
12B and
13B). In patients with
Rosai-Dorfman disease, involved lymph nodes appear similar to malignant nodes,
which are hypoechoic, round, and without echogenic hilus
(Fig. 14A). On power Doppler
sonography, involved lymph nodes in Rosai-Dorfman disease also have an
appearance similar to that of malignant nodes and show peripheral or mixed
vascularity [12]
(Fig. 14B). Because the
sonographic appearance of these unusual lymphadenopathies is similar to that
of reactive or malignant nodes, the diagnosis is still based on histology.
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Fig. 12A. —30-year-old woman with palpable nodes in upper cervical
region proven to be Kikuchi's disease. (Reprinted with permission from
[12]) Gray-scale sonogram of
upper cervical node (small arrows) shows node is hypoechoic and
elliptic and has echogenic hilus (arrowheads). Large arrows indicate
common carotid artery, and asterisk indicates internal jugular vein. Note
gray-scale sonographic appearance of lymph nodes in Kikuchi's disease is
similar to that of reactive nodes.
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Fig. 13A. —42-year-old man with palpable nodes in submandibular area
that were subsequently proven to be Kimura's disease. Gray-scale sonogram
shows submandibular lymph node (arrows) is hypoechoic, is round, and
has echogenic hilus (arrowheads). Gray-scale sonographic appearance
is similar to that of reactive nodes except that lymph nodes in Kimura's
disease tend to be round and are located in the vicinity of the salivary
glands.
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Fig. 12B. —30-year-old woman with palpable nodes in upper cervical
region proven to be Kikuchi's disease. (Reprinted with permission from
[12]) Power Doppler sonogram
of same lymph node as in A (arrows) reveals that lymph node
involved with Kikuchi's disease shows hilar vascularity (arrowheads)
that is similar to vascular pattern of reactive lymph nodes.
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Fig. 13B. —42-year-old man with palpable nodes in submandibular area
that were subsequently proven to be Kimura's disease. Power Doppler sonogram
of same lymph node as in A (arrows) shows extensive hilar
vascularity (arrowheads), which is similar to vascular pattern of
reactive lymph nodes.
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Fig. 14A. —13-year-old boy with palpable nodes in submental and
submandibular areas that were subsequently proven to be Rosai-Dorfman disease.
Gray-scale sonogram shows two submental nodes that are hypoechoic, round, and
without echogenic hilus (arrows). Sonographic appearance is similar
to that of malignant nodes.
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Fig. 14B. —13-year-old boy with palpable nodes in submental and
submandibular areas that were subsequently proven to be Rosai-Dorfman disease.
Power Doppler sonogram of same submental node as in A shows peripheral
vascularity (arrows), which is similar to malignant lymph nodes.
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Top
Abstract
Introduction
