Ultrasound

Pierre Vassallo, MD Karl

#{149} Wernecke, MD Nikolaus
#{149} Roos, MD Peter
#{149} E. Peters, MD

Differentiation ofBenign from Malignant

Superficial Lymphadenopathy: The Role
of High-Resolution US’

Ultrasonography has proved a valu- T HE diagnosis of superficial lymph- ferentiation from reactive nodal dis-
able tool for the detection of enlarged adenopathy (in cervical, axiltary, ease in patients with head and neck
lymph nodes; however, differentia- and inguinal regions) is crucial for malignancies (2,8-iO). It has been sug-
tion between benign and malignant therapeutic planning in patients with gested that depiction of lymph node
nodal disease remains a problem. suspected malignancy. Several studies shape altered from flat oval to broad
High-frequency probes with im- have shown that sonography has a oval or round (longitudinat-trans-
proved spatial and contrast resolu- markedly higher sensitivity than pal- verse diameter ratio [LIT] < 2) and
tion display superficial nodes to ad- pation for the detection of enlarged loss of the central echogenic hilus in-
vantage and also show the internal lymph nodes in patients with sus- dicate the presence of metastasis. In
structure of the nodes. Ninety-four pected regional lymph node metasta- contrast, a wide hyperechoic central
superficial nodes in patients with ses, particularly in the presence of hilus and a narrow cortex were seen
suspected nodal disease were exam- severe postoperative scarring (1-6). mostly in reactive nodes. Nodal size
med by using 7.5-MHz probes to Use of sonography also allows assess- atone has been shown to be an unreli-
evaluate longitudinal-transverse di- ment of infiltration of blood vessels able criterion for differentiation of
ameter ratio (LIT), the central hilus, and organs, such as the thyroid gland, reactive from malignant disease (2,8).
cortical widening, and size. Histo- by adjacent nodal metastases (6) and The purpose of our study was to
logic diagnosis was obtained after an accurate follow-up of patients re- assess these US findings in a series of
sonographic examination in 73 nodes ceiving chemotherapy or radiation patients with lymphadenopathy prior
(five reactive nodes, 35 primary nodal therapy. to biopsy and retrospectively to catcu-
malignancies, and 33 nodal metasta- The use of higher frequency sonic late the frequency with which each
ses). The remaining 21 nodes re- waves (7.5 MHz and above) in ultra- finding was depicted in the benign
gressed after either antibiotic or no sonography (US) results in an im- and malignant lymph node groups.
therapy. Marked differences were provement in spatial resolution. With
observed among the proportions of higher frequency, however, a sharp
MATERIALS AND METHODS
benign and malignant nodes in terms reduction in the depth of view occurs
of L/T, hilus, and cortex; the latter as a result of absorption, which limits Patient Population
two structures, however, must be in- the use of such probes to only very
Over a period of 18 months, a total of
terpreted together. Eccentric cortical superficial structures. US probes with
204 consecutive patients with clinically
widening was seen in only malignant very high frequencies ( > 10 MHz) are suspected lymphadenopathy in the cervi-
nodes. The distribution of nodal size essentially of value only for visualiza- cal, axillary, or inguinal regions were re-
was not significantly (P > .1) differ- tion of cutaneous and other very su- ferred for US scanning. In 85 cases, no
ent for benign and malignant nodes. perficial lesions. nodes were detected on initial and fol-
No differences were observed be- High-resolution US probes enable low-up US scans. Forty-one patients were
tween primary and secondary nodal differentiation between the central lost to further follow-up. The remaining
malignancies. The sonographic crite- echogenic oval hilus and the penph- 78 patients (mean age, 35 years), in whom
superficial lymph nodes were detected at
na evaluated in this study assist in erat concentric hypoechoic cortex of
US, were included in the study.
the differentiation of benign from the lymph node. Changes in shape of
Seventeen patients showed clinical evi-
malignant superficial lymph nodes. both components may suggest the
dence of inflammatory disease (sialoadeni-
presence of disease (benign or matig- tis [n = 7] and acute and chronic dermato-
Index terms: Lymphatic system, diseases,
nant), even in the absence of minimal logic disease, including paronychia
99.24 #{149}
Lymphatic system, neoplasms, 99.33, nodal enlargement. Even normal [n = 4], periodontitis [n = 4], and chronic
99.34 a Lymphatic system, US, 99.12981 lymph nodes may occasionally be de- sinusitis [n = 1]). In 30 patients, a primary
Lymphoma, 99.34 #{149}Melanoma, 99.33 tected with high-resolution US (7). tumor (malignant melanoma [n = 22] or
Other authors have evaluated high- carcinoma of the oral or pharyngeal re-
Radiology 1992; 183:215-220 gions [n = 8]) had been resected previ-
resolution US for the detection of
ously. Of the remaining 31 patients, 19
lymph node metastases and their dif-
had suspected recurrence of primary lym-
phatic disease (Hodgkin [n = 6] or non-

I From the Institute of Clinical Radiology, University of Muenster, Albert-Schweitzer-Strasse 33,

D-4400 Muenster, Germany. Received luly 25, 1991; revision requested September 3; revision re-
ceived October 18; accepted November 4. Address reprint requests to P.V. Abbreviation: L/T = longitudinal-transverse
C RSNA, 1992 diameter ratio.

215
Hodgkin [n = 10] lymphoma) or hemato- NORMAL
logic disease (chronic lymphatic leukemia
SHAPE
[n = 3]), and 12 who were referred for US (L/T>2) I (L/T <2)
prior to open biopsy had lymph node en-
largement
nodal groups
of unknown
(cervical,
cause in several
axillary, and/or
I
inguinal).

Lymph Nodes HILUS CORTEX

A total of 94 lymph nodes (cervical

[n = 54], axillary [n = 17], and inguinal concentric widening
[n = 23]) were evaluated. The decision to,
perform a biopsy, to excise, or to observe a
node was made by the referring physician
on the basis of all clinical and imaging
data.
Seventy
therefore
examination.
nodes
available
were excised
for detailed
The locations
and were
pathologic
of these nodes,
:i .itlli1
__
which were detected at the first US exami-
nation, were marked on the skin at the Figure 1. Sonomorphologic features in superficial lymph node disease.
time a second US examination was per-
formed immediately prior to surgery to
facilitate resection. In those patients in
whom metastatic disease was suspected, Number of Nodes in Each Pathologic Group with Each Sonographic Feature
all nodes (n = 33) were mapped, whereas Pathologic Nodal Group
in those patients with primary lymphatic
or hematologic malignancy or multifocal Primary Metastatic
lymphadenopathy of unknown origin, the Benign Malignancy Malignancy
locations of one to three readily accessible Sonographic Feature (a = 26) (n = 35) (n = 33)
nodes were indicated (total, n = 37).
Shape
Pathologic examination of these 70 nodes LIT < 2 4 (15) 30 (86) 28(85)
revealed two benign nodes (reactive), 35 LIT 2 22 (85) 5 (14) 5(15)
nodes with primary lymphatic malignan- Hilus
cies (13 Hodgkin lymphomas, 19 non- Wide 15 (58) 3 (9) 2(6)
Hodgkin lymphomas, and three chronic Narrow 9 (35) 18 (51) 15(46)
lymphatic leukemias) and 33 metastatic Absent 2 (8) 14(40) 16(48)
nodes (23 malignant melanomas and 10 Cortex
squamous cell carcinomas). Narrow 7 (27) 2 (6) 2 (6)
Concentrically wide 17 (65) 8 (23) 7(21)
Three nodes were evaluated with per-
Eccentrically wide 0 (0) 11 (31) 8(25)
cutaneous biopsy with US guidance, and
no malignant tissue was obtained. Note-Numbers in parentheses are percentages.
The remaining 21 lymph nodes (all in
patients with clinical evidence of inflam-
matory disease) were followed up cmi-
cally and sonographically over a period of ters of the node. These scans allowed cally wide, or eccentrically wide. The cor-
12-18 months. During this period, in evaluation of all sonomorphologic fea- tex was considered narrow when the
which only antibiotic or no therapy was tures described below. thickness at its broadest point was less
administered, these nodes either disap- The three sonomorphologic features than one-half the transverse diameter of
peared completely (n = 13) and were not evaluated are shown schematically in Fig- the hilus in the longitudinal plane. Thus,
detectable at repeat US and clinical exami- ure 1: lymph node shape, central all those nodes with a narrow hilus ac-
nations or showed marked shrinkage in echogenic hilus, and peripheral hypo- cording to the criteria described above also
size ( > 25% reduction in initial short di- echoic cortex. The largest diameter of the had a wide cortex. Those nodes that
ameter) and increase in echogenicity node was also recorded. showed a focal cortical widening of at
(making them barely discernible from sur- Lymph node shape was assessed by least 100% (ie, the thickness of the cortex
rounding connective tissue) (n = 8). These measuring the largest and smallest diame- at one site was at least double that at its
nodes were considered to be reactive. ters on the same scan and by calculating narrowest point) were classified as having
the LIT. Lymph nodes were separated an eccentrically wide cortex. If the nodal
according to their LIT into two classes: hilus-the reference structure-was ab-
LIT 2 and LIT < 2. sent, cortical width could not be assessed.
US Evaluation
The central hilus was also assessed, and All lymph nodes were grouped for size
US examinations were studied by one the nodes were separated into three hilar according to the integer value of their
radiologist (P.V.), who was not provided classes: wide, narrow, and absent. When largest nodal diameter (ie, according to
with any clinical data. All examinations the hilus appeared effiptical in the longitu- the value to the left of the decimal point).
were conducted with model LSC 9500 US dinal nodal plane, generally conforming All data were collected prior to biopsy
scanners (Picker International, Munich) by with the shape of the whole node, it was and, hence, with no knowledge of the
using 7.5-MHz probes with an attached classified as wide. A flat slitlike hilus was findings at pathologic examination. Subse-
short-water path system (1.0 cm thick). All considered narrowed. Those nodes that quently, the lymph nodes were separated
nodes were documented with a multifor- showed no central zone of hyperechoge- into three groups according to findings in
mat laser camera (Ektascan Laser Printer; nicity were classified as having no hilus. the pathology reports-benign, primary
Eastman Kodak, Rochester, NY) in a longi- The peripheral cortex was then evalu- malignant, and metastatic-and the distri-
tudinal nodal plane, the plane that dem- ated, and the nodes were separated into bution of each US finding within the three
onstrated the largest and smallest diame- three cortical classes: narrow, concentri- groups of nodes was analyzed.

216 Radiology
#{149} April 1992
 one-half the cases (35%) and coex-
isted with a wide hilus in the remain-
ing 30% of nodes. None of the benign
: nodes showed an eccentric cortical
widening. Of the primary nodal ma-
lignancies, 6% showed a narrow cor-
tex, 23% a concentrically wide cortex,
and 31% an eccentrically wide cortex.
Cortical widening, which occurred in
54% of these nodes, was a conse-

:: quence
all cases
of hilar
(53%).
narrowing
Of the nodal
in almost
metasta-
ses, 6% displayed a narrow cortex,

- T /T ‘‘i.E narrow Absent

21% a concentrically
25% an eccentrically
wide
wide
cortex,
cortex.
and
In
Figure 2. Histogram depicts changes in LIT Figure 3. Histogram depicts changes in the
this group of nodes, cortical widen-
in benign and malignant lymph nodes. Black nodal hilus in benign and malignant disease.
columns indicates benign nodes; dark gray ing, which occurred in 46% of cases,
Black columns indicate benign nodes; dark
columns indicate primary malignancy; gray gray columns indicate primary malignancy; was a consequence of hitar narrowing
columns indicate metastases. gray columns indicate metastases. in alt cases. The results obtained from
cortical assessment are shown in Fig-
ure 4.
In those nodes with a narrow hitus
Statistical Evaluation hilus, 51 % of primary nodal malig- (benign [n = 9] and malignant
nancies and 46% of nodal metastases [n = 33]), concomitant cortical widen-
The percentage of nodes in each of the
a narrow hitus, and 40% of primary ing was observed in only five benign
three groups was calculated. The signifi-
nodal malignancies and 48% of me- nodes (55%) but in 30 malignant
cance of the differences between the re-
sults obtained for the three groups was
tastases exhibited no hilus. These re- nodes (90%). The differences in the
assessed by using the 2 test. The signifi- sults are shown graphically in Figure distribution of benign and malignant
cance of differences in size was assessed 3. nodes in the three cortical classes
by using the Student t test. Pathologic assessment of excised were statistically significant (P < .001).
nodes with a hilus visualized at US No significant difference was noted
showed central arteries, veins, and between the distribution of primary
RESULTS
lymphatic sinuses, with no particular nodal malignancies and metastases
The Table lists the number of abundance of fatty tissue in the hilus. regarding appearance of nodal cortex
lymph nodes in each group that ex- One node from a patient with centro- (.5 > P > .1).
hibited each finding. The results for cytic, centroblastic tymphoma (non-
each finding at US wilt be presented Hodgkin lymphoma) showed central
Nodal Size
separately. anechoic zones suggesting necrosis
with loss of the hitus: Central necrosis The difference in distribution of
was confirmed at subsequent patho- benign and malignant nodes accord-
Lymph Node Shape
logic examination. ing to nodal size (Fig 5) was not statis-
L/T was easily evaluated in alt The differences in the distribution ticalty significantf,P > .i).
nodes. Of the 26 benign nodes, 85% of benign and malignant nodes in the
showed an L/T 2 and 15%, an three hitar classes were statistically
DISCUSSION
L/T < 2. Of the 68 malignant nodes, significant (P < .001). No significant
86% of primary nodal malignancies differences were observed among the For the evaluation of lymph nodes,
and 85% of nodal metastases showed distributions of primary nodal malig- US scanning has one particular ad-
an L/T < 2, white only 14% of pri- nancies and nodal metastases accord- vantage over alt other axial imaging
mary nodal malignancies and 15% of ing to appearance of the nodal hilus methods in that it allows free rotation
nodal metastases exhibited an L/T (P > .5). of the scanning plane and easy identi-
2. These results are shown graphically fication of the largest diameter of a
in Figure 2. node, which has been suggested to be
Nodal Cortex
The differences in distribution of an objective criterion for characteriz-
malignant and benign nodes in the In 31 nodes (two benign, i4 pri- ing lymphadenopathy (ii). Our re-
two L/T classes were statistically sig- mary malignancies, and 15 metasta- sults showed no significant differ-
nificant (P < .001); however, the dif- ses), the hilus-the reference struc- ences between benign and malignant
ferences in distribution of primary ture for assessing the cortex-was nodes in terms of their largest diame-
and secondary nodal malignancies absent. We were therefore unable to ter, but there were marked differences
were not significant (P > .5). classify these nodes according to their in terms of their L/T (or shape),
cortex. Of the remaining 62 nodes which can be assessed without limita-
(66%), 24 were benign and 38 malig- tion only with US. The tendency of
Nodal Hilus
nant (21 primary malignancies and 17 benign nodes to be “oval” (L/T 2)
Of the 26 benign lymph nodes, 58% metastases). (Fig 6a) and malignant nodes to be
showed a wide central hitus, 35% a In the benign group of nodes, 27% “round” (LIT < 2) (Fig 6b) has also
narrow hilus, and 8% no hitus. Of 68 exhibited a narrow cortex. The con- been reported by other observers
malignant nodes, 9% of primary centrically wide cortex in 65% of be- (3,8,9,12,13). One such study evaluat-
nodal malignancies and 6% of nodal nign nodes was a consequence of hi- ing 291 tymph nodes in 143 patients
metastases exhibited a wide central tar narrowing in slightly more than prior to neck dissection for thyroid

Volume 183 #{149}Number 1 Radiology 217

#{149}
cancer noted an L/T < 1.5 in 62% of
metastatic nodes and an LIT > 2 in
79% of reactive nodes (8). These re- . L

sults and the ease of assessment of

this finding make it a valuable crite-
rion for differentiating benign from
malignant nodes.
High-resolution US also depicts the
central echogenic nodal hitus and en-
ables assessment of its relation to the
peripheral hypoechoic cortex, which
may allow further characterization of
the lymph node (7,8,10,13). The main
problem with these two structures is
that their widths
reciprocal; in other
are to some extent
words, a narrow- Figure 4. Histogram depicts changes in the
: . , 2-2b 3-3A .:

nodal cortex in benign and malignant dis- Figure 5. Histogram depicts distribution of
ing of the hilus results in an apparent ease. Black columns indicate benign nodes; nodal size in benign and malignant disease.
widening of the cortex and vice versa, dark gray columns indicate primary malig- Black columns indicate benign nodes; dark
with use of our criteria. Thus, changes nancy; gray columns indicate metastases. gray columns indicate primary malignancy;
in one structure must be interpreted Conc. concentrically, Ecc. = eccentrically. gray columns indicate metastases.
with consideration of changes in the
other.
The assessment of nodes with a
narrow hilus showed concomitant
cortical widening in only 54% of be-
nign nodes but in 90% of malignant
nodes. Thus, the presence of hitar
narrowing accompanied by cortical
widening should be regarded with
suspicion for malignancy. In our se-
ries, an elliptical (wide) hilus (Fig 7a)
was seen more frequently in benign
nodes (15 of 26, 58%) than in malig-
nant nodes (5 of 68, 8%). Other stud-
ies have shown a hyperechoic hilus in
a. b.
48% of benign nodes but in only 4%
Figure 6. (a) Large reactive node (arrows) with an L/T > 2 was seen in a patient with fungal
of malignant nodes (8). In contrast, a
paronychia. (b) Nodal metastasis (arrows) from a malignant melanoma had an L/T < 2.
slittike narrow hilus (Fig 7b) was seen
more frequently in malignant nodes
(33 of 68, 49%) than in benign nodes
(9 of 26, 35%) in our study. The echogenic texture of the hilus has with the development of collateral
In the absence of a hilus (Fig 7c) (32 been attributed to an abundance of lymphatic drainage pathways, lym-
of 94, 33% of all nodes), we were un- lipocytes (13,i4). In our study, those phatic-venous shunts, and reversal of
able to classify the cortex, which fur- nodes with a hilus did not show any the direction of lymphatic flow (16).
ther reflects the reciprocity of these particular abundance of central fatty In reactive nodal disease, the
two structures. Absence of the hilus, tissue. We believe that the echogenic- pathogen (microorganism or cellular
however, was seen more frequently ity of the hilus is mainly the result of debris) initially reaches the nodal cor-
in malignant (36 of 68, 44%) than in an abundance of fluid-filled sinuses, tex and induces lymphocyte protifera-
benign (2 of 26, 8%) nodes, making it each of which acts as an acoustic in- tion within the lymphoid follicles and
a strong criterion for malignancy. terface, partially reflecting incident sinusoidal enlargement and margin-
In our series, focal doubling in cor- sound waves and imparting its ation with macrophages, which lead
tical thickness was observed in only echogenic texture. Sonographic-histo- to widening of the cortex (Fig 8b).
malignant nodes: We therefore sug- logic correlation by Rubattelli et at This feature was observed in 65% of
gest that its presence be regarded (i5) support this view. The focal benign nodes in our study. If the in-
with a high degree of suspicion for punctate areas described by Gorman flammatory stimulus persists, the cen-
malignancy. In contrast, no significant et at (4) represented amytoid or cal- tral hilus, which normally consists
difference was observed between cium deposition and should not be mainly of draining sinusoids and lym-
nodes involved with primary malig- confused with the nodal hilus. phatic vessels supported by a frame-
nant and metastatic disease with re- Both inflammatory and malignant work of loose connective tissue, de-
spect to focal doubling in cortical diseases reach the lymph node via velops new germinal centers, forming
thickness. afferent lymphatic vessels that drain new lymphoid follicles. These factors
The histologic basis of nodal texture into the peripheral sinuses located in may account for the change in
at US has not been fully evaluated. the subcapsutar regions of the node. echogenicity of the hitus at US. Thus,
The nodal cortex consists predomi- Thus, early malignant and benign le- in inflammatory conditions, changes
nantly of solid tissue with few lymph sions primarily involve the cortex; in the hitus may suggest a later stage
sinuses, and this homogeneity may they may spread into the hilus in later of disease. The diffuse nature of the
account for its low echogenicity (pau- stages (12). Occasionally, obstruction processes occurring within the reac-
city of internal reflective surfaces). of draining lymphatic vessels occurs tive node is also more likely to pre-

218 Radiology
#{149} April 1992
Figure 7. (a) Reactive node (solid arrows) with a wide hilus (open arrow) was seen in a patient with noncalculous parotitis, which disap-
peared 8 weeks after treatment with antibiotics. (b) Hilar narrowing (open arrows) in a malignant node (solid arrows) indicates recurrence of
non-Hodgkin lymphoma. (c) Multiple nodes (arrows) with no central hilus were involved with Hodgkin disease.

Figure 9. Lymph nodes (solid arrows) show

central necrosis (open arrows) with loss of
the central hilus in a patient with centrocytic,
centroblastic lymphoma (non-Hodgkin lym-
phoma).

reactive changes in all parts of the

node simultaneously. In contrast, ma-
tignant disease (metastatic or pri-
mary) may originate in or reach only
part of a node, may block the drain-
ing lymphatic channels, and may
manifest as focal cortical widening
(Fig 8c, d). All nodes showing this fea-
C. d.
ture in our study were malignant.
Figure 8. (a) Reactive lymph node (arrows) with a narrow cortex was seen in a patient with
Central necrosis leading to loss of
erysipelas. (b) Nodal metastasis with concentric cortical widening (arrows) was seen in a pa-
tient with squamous cell carcinoma of the floor of the mouth. (c) Malignant node (small ar- the hilus was observed in only one of
rows) shows eccentric cortical widening (large arrow) in a patient with Hodgkin disease. our patients, who had centrocytic,
(d) Node (small arrows) with eccentric cortical widening (large arrow) contains metastases centroblastic lymphoma (Fig 9). Cen-
from a malignant melanoma. tral necrosis has been reported to be
characteristic of this type of lym-
phoma (17). Inflammatory conditions,
serve nodal shape (LIT) despite a pos- of the hilus. In addition, the mass ef- such as tuberculosis, and metastases,
sible increase in size. fect of infiltrating tumor, which may however, may also lead to nodal ne-
In malignant disease, however, the not be equal at all points within the crosis (9,il,i3).
changes occurring within the lymph node, may lead to a change in nodal Other studies have suggested that
node are somewhat different in na- shape (LIT). nodal size may be a reliable criterion
ture. The process involves infiltration Eccentric cortical widening may for differentiating benign from matig-
of the node by malignant tissue, indicate focal intranodal disease. In nant nodes (5,ii,i8-24). In fact, the
which is more likely to result in early inflammatory disease, noxious agents impact of increasing size on the likeli-
distortion of internal nodal architec- would be expected to reach the whole hood of a node being malignant is the
ture with invasion (narrowing or loss) node in the early stages and to induce only criterion implemented in the as-

Volume 183 Number

#{149} 1 Radiology 219
#{149}
sessment of lymph nodes with com- are most likely to provide useful diag- 11. Som PM. Lymph nodes of the neck. Radi-
ology 1987; 165:593-600.
puted tomography. The distribution nostic data are facilitated by using the
12. Shozushima M, Suzuki M, Nakasima T, et
of nodal size in benign and malignant sonographic criteria described herein. al. Ultrasound diagnosis of lymph node
nodes in our study showed no signifi- Although nodal size is not a reliable metastasis in head and neck cancer. Den-
cant differences. Other authors have criterion for differentiating benign tomaxillofac Radiol 1990; 19:165-170.
from malignant lymph nodes, it may 13. Sakai F, Kiyono K, Sone 5, et al. Ultra-
reported similar results (2,8). One
sonic evaluation of cervical metastatic
study in patients with thyroid cancer be of value in monitoring response to lymphadenopathy. I Ultrasound Med 1988;
showed that 18% of lymph nodes therapy. U 7:305-310.
with a short-axis diameter less than 5 14. Marchal G, Oyen R, Verschakelen I et al.
References Sonographic appearance of normal lymph
mm contained metastases; however,
nodes. I Ultrasound Med 1985; 4:417-419.
the high rate of metastases in small 1. Hajek PC, Salomonowitz E, Turk R, et al.
15. Rubaltelli L, Proto E, Salmase R, et
Lymph nodes of the neck: evaluation with
lymph nodes may be attributed to the Sonography of abnormal lymph nodes in
US. Radiology 1986; 158:739-742.
fact that the patients included in the vitro: correlation of sonographic and histo-
2. Sutton RT, Reading CC, Charboneau JW, et
study were at high risk for metastatic logic findings. AIR 1990; 155:1241-1244.
al. US-guided biopsy of neck masses in
16. Threefoot SA. Gross and microscopic
disease (8). Another study in 300 pa- postoperative management of patients
anatomy of the lymphatic vessels and lym-
with thyroid cancer. Radiology 1988; 168:
tients with thyroid cancer showed phaticovenous communications. Cancer
769-772.
malignant nodes as small as 8 mm 3. Bruneton IN, Roux P, Caramella E, et Chemother 1968; 52:1-20.
and benign nodes as large as 3 cm in 17. Lennert K. Malignes
Ear, nose and throat cancer: ultrasound
trocytisches lymphom. In: Lennert K, ed.
long-axis diameter (2). diagnosis of metastasis to cervical lymph
Histopathologie der non-Hodgkin lym-
The sonographic changes in inter- nodes. Radiology 1984; 152:771-773.
phome. Berlin: Springer-Verlag, 1990; 63-
4. Gorman B, Charboneau JW, lames EM, et
nat architecture of lymph nodes de- al. Medullary thyroid carcinoma: role of
71.
scribed herein pertain to superficial 18. Lindberg R. Distribution of cervical
high-resolution US. Radiology 1987; 162:
lymph node metastases from squamous
nodes and probably cannot be recog- 147-150.
cell carcinoma of the upper respiratory and
nized in deeper nodes. The two possi- 5. Sako K, Pradier RN, Marchetta FC, et
digestive tracts. Cancer 1972; 29:1446-1449.
Fallibility of palpation in the diagnosis of
ble explanations for this difference are 19. Shah IP, Tollefsen HR. Epidermoid carci-
metastasis to cervical nodes. Surg Gynecol
decreasing contrast resolution be- noma of the supraglottic larynx: role of
Obstet 1964; 118:989-990.
neck dissection in initial surgical treatment.
cause of signal attenuation with in- 6. Greitzmann N, Taxler M, Grasl M, et al.
Am J Surg 1974; 128:494-499.
creasing distance of the object of in- Advanced laryngeal cancer: sonographic
20. Martis C, Karabouta I, Lazandis N.
assessment. Radiology 1989; 171:171-175.
terest from the US probe and the dence of lymph node metastases in elective
7. Vassallo P, Wernecke K, Roos N, et al. Di-
poorer spatial resolution of US probes agnostik der oberfl#{228}chlichen lymphknoten:
(prophylactic) neck dissections for oral car-
(eg, 3.5 MHz) used for analyzing cinoma. I Maxillofac Surg 1979; 7:182-191.
neue sonomorphologische befunde. In:
21. Ogura JH, Biller HF, Wette R. Elective
deeper structures. Gebhardt I, ed. Ultraschalldiagnostik ‘89
neck dissection for pharyngeal and laryn-
The changes in shape and internal Berlin. Berlin: Springer-Verlag, 1989; 162-
geal cancers. Ann Otol 1971; 80:646-651.
165.
structure of nodes depicted at US are 8. Solbiati L, Rizzatto G, Bellotti E, et al.
22. Ogura IH, Biller HF. Head and neck: sur-
valuable for the differentiation of be- gical management. JAMA 1972; 221 :77-79.
High-resolution sonography of cervical
23. Biller HF, Davis WH, Ogura IH. Delayed
nign from malignant nodes and are lymph nodes in head and neck cancer: cci-
contralateral cervical metastases with la-
regularly employed at our institution tena for differentiation of reactive versus
ryngeal and laryngopharyngeal cancers.
malignant nodes (abstr). Radiology 1988;
for this purpose. Repeatedly negative Laryngoscope 1971; 81:1499-1502.
169(P):113.
findings at percutaneous biopsy 24. Simeone JF, Daniels GH, Hall DA, et al.
9. Ishii J, Amagasa T, Tachibana T, et al. Ul-
Sonography in the follow-up of 100 pa-
should not delay open biopsy in pa- trasonic evaluation of cervical lymph node
tients with thyroid carcinoma. AIR 1987;
tients with nodal findings that are metastasis of squamous cell carcinoma in
148:45-49.
the oral cavity. Bull Tokyo Med Dent Univ
suspicious for malignancy at US. The
1989; 36:63-67.
decisions concerning whether nodal 10. Penn B, Gardellin G, Nisi E, et al. Ultra-
biopsy is required and which nodes sonic diagnosis of the central echogenic
area in lymph nodes: a sign of benign
lymphadenopathy [Italian]. Radiol Med
1987; 74:535-538.

220 #{149}Radiology April 1992