C. Metreweli

A practical approach to ultrasound of cervical lymph nodes

Although the role of high resolution ultrasound (US) in evaluating cervical nodes is well established, it is often combined with fine needle aspiration cytology (FNAC). As a result, US appearances that help in distinguishing the various causes of cervical adenopathy are often overlooked and not emphasized. The aim of this study is to re-emphasize to the sonologist the US clues that may help in differentiating the aetiology of abnormal cervical nodes. We, therefore, present the spectrum of US appearances of lymph nodes. One hundred and forty patients (702 abnormal nodes) with known pathology were compared with 100 normal subjects (1211 nodes). After identifying an abnormal nodes, US features that further help in distinguishing between the various pathologies are the distribution of lymphadenopathy, echogenicity, calcification, distal enhancement, intranodal cystic necrosis, matting and soft tissue oedema.

The use of sonography in differentiating cervical lymphomatous lymph nodes from cervical metastatic lymph nodes

Lymphoma and metastases are common causes of cervical lymphadenopathy. Clinical examination alone is unable to differentiate the two. Ultrasound (US) with its high sensitivity and specificity when combined with a find needle aspiration cytology (FNAC) is therefore the ideal initial investigation. We present the spectrum of findings in 19 patients with non Hodgkins lymphoma (NHL), 15 patients with pharyngeal, laryngeal and oesophageal (PLO) carcinomas, 22 patients with oral cavity tumours and 12 patients with infraclavicular carcinomas. The US features found consistently useful in differentiating NHL from other metastases were the distribution of the nodes, distal enhancement and lack of intranodal necrosis. Other US features of abnormal nodes helped identify abnormality but did not help in differentiation.

Retropharyngeal lymphadenopathy in nasopharyngeal carcinoma

Background This study was done to investigate the size of normal retropharyngeal lymph nodes (RLN) and the incidence of retropharyngeal lymph node involvement in patients with nasopharyngyngeal carcinoma (NPC). Methods Forty-four NPC patients who had not yet received treatment and 20 control subjects underwent MRI scanning. The number and the maximum diameter of the short axis of the cervical lymph nodes were measured. The number of nasopharyngeal walls involved and the maximum diameter of the tumor were recorded. Results In 5 of 20 control subjects lateral RLN were identified; none of these nodes was greater than 2.5 mm. In the NPC patients, taking 4 mm as the upper limit of normal RLN, 89% of the patients had enlarged RLN. The number of nasopharyngeal walls involved and the maximum diameter of the primary tumor showed no statistical relationship with the involvement of RLN. There was a statistical association between RLN and level II node involvement, but not with other groups of neck nodes. Conclusion Of all patients with NPC, 89% showed enlarged RLN. Its involvement was related to level II nodes but not to the number of nasopharyngeal sites involved nor with the maximum diameter of the tumor.

The application of ultrasound criteria for malignancy in differentiating tuberculous cervical adenitis from metastatic nasopharyngeal carcinoma

Tuberculous adenitis and metastatic nodes from Nasopharyngeal carcinoma may have a similar clinical presentation. Clinical examination and laboratory tests alone are unable to differentiate the two. However, ultrasound is a useful initial investigation in differentiating these two conditions. We present ultrasound appearances in 33 patients with proven tuberculous cervical adenitis and 32 patients with proven metastatic nasopharyngeal carcinoma. The ultrasound features we found useful were the distribution of the nodes, cystic change, matting and surrounding soft tissue oedema. The size, shape and internal architecture of the nodes, previously described criteria in differentiating benign from malignant nodes, did not help.

MR imaging in amyopathic dermatomyositis.

Purpose: Amyopathic dermatomyositis is a distinct clinical entity with cutaneous involvement but no myopathy. We conducted a prospective study to investigate the role of MR imaging in these patients. Material and Methods: Out of 40 Chinese patients presenting with dermatomyositis, based on clinical assessment and normal serum muscle enzymes 10 were diagnosed as having amyopathic dermatomyositis. These 10 patients underwent MR imaging for evaluation of any subclinical muscle involvement. Results: Three patients demonstrated abnormal signal intensity in muscles on both T2- and fat suppression sequences. Thus, one-third of patients with dermatomyositis and clinically normal muscles may have detectable muscle inflammation on MR images, indicating that MR has a potential role for locating the relevant biopsy site and for longitudinal follow up. Six of the 10 patients had malignant disease diagnosed before or after diagnosis of the cutaneous manifestation. Nasopharyngeal carcinoma was the most common malignant disease in this group of patients. Conclusion: MR imaging is recommended for demonstrating subclinical muscle involvement in patients with the clinical diagnosis of amyopathic dermatomyositis. We also recommend screening for malignancy, particularly nasopharyngeal carcinoma, in Southern Chinese patients with dermatomyositis.

The role of ultrasound and oesophagography in the management of acute suppurative thyroiditis in children associated with congenital pyriform fossa sinus

The thyroid is remarkably resistant to infection. Hence, when an infection does occur, the presence of a pyriform fossa sinus must be considered, particularly if it is recurrent and left sided. The aim of this paper is to alert radiologists to the existence, clinical presentation, and ultrasonographic and oesophagographic appearances of a pyriform fossa sinus. We present the role of ultrasound and oesophagography in five children with pyriform fossa sinus associated with suppurative thyroiditis. In four children the abnormality was on the left and on the right in one.

The role of hepatic arterial embolization in the management of ruptured hepatocellular carcinoma

Fifteen patients with ruptured hepatocellular carcinomas and intraperitoneal bleeding were considered for hepatic arterial embolization. Embolization was attempted in nine patients (60%) with patent or partially patent portal veins. Successful occlusion of the feeding tumour vessels was achieved in eight patients (53%) with six patients (40%) surviving more than 3 months compared to three survivors in the non-embolized group, all of whom had total occluded portal veins. Prognosis depends on the underlying liver function with total serum bilirubin levels of survivors significantly lower than those patients who died (P < 0.01). Embolization was tolerated well in those patients with partial portal vein occlusion. Selective tumour embolization should be the initial treatment of choice in these severely ill patients who have reasonable hepatic function.

Solitary cystic nodal metastasis from occult papillary carcinoma of the thyroid mimicking a branchial cyst: a potential pitfall

Thyroid carcinoma presenting as cervical lymph node metastasis with a clinically normal neck indicates an aggressive tumour of the thyroid. When the nodal metastasis is solitary and cystic, with no obvious suspicious thyroid mass on ultrasound (US) it may be mistaken for a branchial cyst. As the management of these two conditions is different, it is important to make a correct pre-operative diagnosis. We present the US features that help in distinguishing the two.

The sonographic appearance and significance of cervical metastatic nodes following radiotherapy for nasopharyngaeal carcinoma

Serial ultrasound (US) was performed on 36 patients with palpable malignant nodes in the neck who had radiotherapy for nasopharyngeal carcinoma (NPC). All patients had a preradiotherapy baseline US examination, and follow-up studies at least 8 weeks after radiotherapy (RT). After RT there was diminution in size and disappearance of some of the nodes. However, in the residual nodes, US criteria for malignant nodes were still present in many of the post RT nodes. i.e. 140/143 (97.9%) residual nodes had an absent hilus and all the nodes were poorly reflective, 122 (85.3%) nodes still had sharp borders, 53 (37.1%) had a short to long axis (S/L) ratio greater than 0.5 and 11 (7.7%) nodes were greater than 8 mm in size. These parameters therefore are not of value in determining the persistence or recurrence of disease in a previously abnormal node. Appreciation of this fact should prevent unnecessary fine needle aspiration of these nodes up to 3 months following radiotherapy.

Imaging of alveolar soft part sarcoma

The imaging investigations in six patients with alveolar soft part sarcoma (ASPS) are reviewed. Five patients presented with a pelvic or lower limb mass and one with haemoptysis from pulmonary metastases. Magnetic resonance imaging (MRI), CT, Doppler US and angiography studies demonstrated the highly vascular nature of this rare tumour and the frequent occurrence of pulmonary and intracranial metastases. Previously unreported Doppler US and MR evidence of multiple enlarged vessels and high blood flow within primary and secondary ASPS tumours is emphasized. Imaging is of considerable importance both for pre-operative localization and long term surveillance of this slow growing but invariably disseminating tumour.