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Radiology-Pathology

Conference 4/29/2012

Lymph Nodes

John McGrath

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Case 1: 51 year-old male presents with palpable right axillary lump

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3 years prior!

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Diagnosis?

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Lymphatics •! 500-700 lymph nodes

scattered throughout the body

•! Common drainage pathways via the right and (left) thoracic duct, into the venous system

•! Assess size, morphology, and interval change on imaging

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Abnormal Lymph Nodes CT

•! > 1 cm (short axis) generally considered abnormal –! Inguinal: > 1.5 cm –! Epitrochlear: > 0.5 cm –! Subcarinal: > 1.5 cm

•! May see necrosis, calcifications, etc.

US

•! Obliteration of echogenic hilum

•! Long-axis to short-axis ratio < 1.5

•! Cystic changes •! Microcalcifications

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Case 2: 24 year old male status post assault

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Normal or Abnormal?

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Neck Classification- Adenopathy

Som P M et al. AJR 2000;174:837-844

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•! 27 year-old male with left-sided neck swelling for 6 months, worsening!

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CT Neck, same date!

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Left supraclavicular and cervical lymphadenopathy, plus!

Differential Diagnosis?

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Thoracic Duct Right Thoracic Duct

•! Drains: –! Right arm and right

side of chest –! Neck and head –! Left lower lobe

(Left) Thoracic Duct

•! Drains into systemic circulation at left brachiocephalic vein

•! Virchow s node- left supraclavicular node, vicinity of entrance of thoracic duct into circulation

•! Drains much of the remainder of the body

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Virchow s Node

•! Left supraclavicular lymphadenopathy •! Especially concerning for malginancy •! Differential considerations (especially if

unilateral): –!Lymphoma –!Thoracic or retroperitoneal cancer –!Bacterial or fungal infections

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Lytic Metastases

•! Renal cell carcinoma –! expansile

•! Thyroid carcinoma •! Lung •! Breast

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60 year-old with right neck pain and fullness for several months!

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Post Chemoradiation!

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Regional Nodal Metastases

•! NX- regional lymph nodes cannot be assessed •! N0- no regional node metastasis •! N1- single ipsilateral node < 3 cm •! N2a- single ipsilateral node (3-6 cm) •! N2b- multiple ipsilateral nodes, all < 6 cm •! N2c- bilateral or contralateral nodes, < 6 cm •! N3- metastasis in a lymph node > 6 cm

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26 year-old female presents with neck swelling!

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Normal or Abnormal?

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Normal or Abnormal?

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Thyroid Cancer Benign Characteristic

•! Cystic Elements •! Hyper/isoechoic •! Eggshell calcification •! Inspissated colloid

Malignant Characteristics

•! Entirely solid •! Hypoechoic •! Microcalcifications •! Associated cervical

adenopathy

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Thyroid Cancer Metastasis

Papillary •! Lymphatic dissemination more

common than hematogenous spread

•! Cervical nodal metastases often present at diagnosis –! Cystic degeneration –! microcalcifications

•! Metastatic cervical nodes does not affect prognosis

•! Distant metastases rare

Follicular •! Hematogenous spread

–! Bone, brain lung, liver •! Metastases to cervical nodes

uncommon •! Distanat metastases in 20-40%

of widely invasive variant

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