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Radiology- Pathology Conference 4/29/2012 Lymph Nodes John McGrath Presentation material is for education purposes only. All rights reserved. ©2012 URMC Radiology Page 1 of 24

Radiology- Pathology Conference 4/29/2012 Lymph Nodes · Pathology Conference 4/29/2012 Lymph Nodes John McGrath ... •!Drains into systemic circulation at left brachiocephalic vein

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Page 1: Radiology- Pathology Conference 4/29/2012 Lymph Nodes · Pathology Conference 4/29/2012 Lymph Nodes John McGrath ... •!Drains into systemic circulation at left brachiocephalic vein

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Radiology-Pathology

Conference 4/29/2012

Lymph Nodes

John McGrath

Presentation material is for education purposes only. All rights reserved. ©2012 URMC Radiology Page 1 of 24

Page 2: Radiology- Pathology Conference 4/29/2012 Lymph Nodes · Pathology Conference 4/29/2012 Lymph Nodes John McGrath ... •!Drains into systemic circulation at left brachiocephalic vein

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

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Page 3: Radiology- Pathology Conference 4/29/2012 Lymph Nodes · Pathology Conference 4/29/2012 Lymph Nodes John McGrath ... •!Drains into systemic circulation at left brachiocephalic vein

3 years prior!

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Page 4: Radiology- Pathology Conference 4/29/2012 Lymph Nodes · Pathology Conference 4/29/2012 Lymph Nodes John McGrath ... •!Drains into systemic circulation at left brachiocephalic vein

Diagnosis?

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Page 5: Radiology- Pathology Conference 4/29/2012 Lymph Nodes · Pathology Conference 4/29/2012 Lymph Nodes John McGrath ... •!Drains into systemic circulation at left brachiocephalic vein

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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Page 6: Radiology- Pathology Conference 4/29/2012 Lymph Nodes · Pathology Conference 4/29/2012 Lymph Nodes John McGrath ... •!Drains into systemic circulation at left brachiocephalic vein

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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Page 7: Radiology- Pathology Conference 4/29/2012 Lymph Nodes · Pathology Conference 4/29/2012 Lymph Nodes John McGrath ... •!Drains into systemic circulation at left brachiocephalic vein

Case 2: 24 year old male status post assault

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Page 8: Radiology- Pathology Conference 4/29/2012 Lymph Nodes · Pathology Conference 4/29/2012 Lymph Nodes John McGrath ... •!Drains into systemic circulation at left brachiocephalic vein

Normal or Abnormal?

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Page 9: Radiology- Pathology Conference 4/29/2012 Lymph Nodes · Pathology Conference 4/29/2012 Lymph Nodes John McGrath ... •!Drains into systemic circulation at left brachiocephalic vein

Neck Classification- Adenopathy

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

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Page 10: Radiology- Pathology Conference 4/29/2012 Lymph Nodes · Pathology Conference 4/29/2012 Lymph Nodes John McGrath ... •!Drains into systemic circulation at left brachiocephalic vein

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

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Page 11: Radiology- Pathology Conference 4/29/2012 Lymph Nodes · Pathology Conference 4/29/2012 Lymph Nodes John McGrath ... •!Drains into systemic circulation at left brachiocephalic vein

CT Neck, same date!

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Page 12: Radiology- Pathology Conference 4/29/2012 Lymph Nodes · Pathology Conference 4/29/2012 Lymph Nodes John McGrath ... •!Drains into systemic circulation at left brachiocephalic vein

Left supraclavicular and cervical lymphadenopathy, plus!

Differential Diagnosis?

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Page 13: Radiology- Pathology Conference 4/29/2012 Lymph Nodes · Pathology Conference 4/29/2012 Lymph Nodes John McGrath ... •!Drains into systemic circulation at left brachiocephalic vein

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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Page 14: Radiology- Pathology Conference 4/29/2012 Lymph Nodes · Pathology Conference 4/29/2012 Lymph Nodes John McGrath ... •!Drains into systemic circulation at left brachiocephalic vein

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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Page 15: Radiology- Pathology Conference 4/29/2012 Lymph Nodes · Pathology Conference 4/29/2012 Lymph Nodes John McGrath ... •!Drains into systemic circulation at left brachiocephalic vein

Lytic Metastases

•! Renal cell carcinoma –! expansile

•! Thyroid carcinoma •! Lung •! Breast

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Page 16: Radiology- Pathology Conference 4/29/2012 Lymph Nodes · Pathology Conference 4/29/2012 Lymph Nodes John McGrath ... •!Drains into systemic circulation at left brachiocephalic vein

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

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Page 17: Radiology- Pathology Conference 4/29/2012 Lymph Nodes · Pathology Conference 4/29/2012 Lymph Nodes John McGrath ... •!Drains into systemic circulation at left brachiocephalic vein

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Page 18: Radiology- Pathology Conference 4/29/2012 Lymph Nodes · Pathology Conference 4/29/2012 Lymph Nodes John McGrath ... •!Drains into systemic circulation at left brachiocephalic vein

Post Chemoradiation!

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Page 19: Radiology- Pathology Conference 4/29/2012 Lymph Nodes · Pathology Conference 4/29/2012 Lymph Nodes John McGrath ... •!Drains into systemic circulation at left brachiocephalic vein

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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Page 20: Radiology- Pathology Conference 4/29/2012 Lymph Nodes · Pathology Conference 4/29/2012 Lymph Nodes John McGrath ... •!Drains into systemic circulation at left brachiocephalic vein

26 year-old female presents with neck swelling!

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Page 21: Radiology- Pathology Conference 4/29/2012 Lymph Nodes · Pathology Conference 4/29/2012 Lymph Nodes John McGrath ... •!Drains into systemic circulation at left brachiocephalic vein

Normal or Abnormal?

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Page 22: Radiology- Pathology Conference 4/29/2012 Lymph Nodes · Pathology Conference 4/29/2012 Lymph Nodes John McGrath ... •!Drains into systemic circulation at left brachiocephalic vein

Normal or Abnormal?

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Page 23: Radiology- Pathology Conference 4/29/2012 Lymph Nodes · Pathology Conference 4/29/2012 Lymph Nodes John McGrath ... •!Drains into systemic circulation at left brachiocephalic vein

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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Page 24: Radiology- Pathology Conference 4/29/2012 Lymph Nodes · Pathology Conference 4/29/2012 Lymph Nodes John McGrath ... •!Drains into systemic circulation at left brachiocephalic vein

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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