The Diagnostic Performance of Magnetic Resonance Imaging in the Categorization of Pediatric Neck Lymph Nodes: Radiologic and Pathologic Correlations.

BACKGROUND/AIM: To present MRI features of neck lymph nodes in benign and malignant conditions in the pediatric population. MATERIALS AND METHODS: MRIs of the neck of 51 patients 1 to 18 years old (40 boys, 11 girls [10.08±4.73]) with lymph node biopsy were retrospectively analyzed. Those were grouped as benign including reactive (27 [52.9%]) and lymphadenitis (11 [21.6%]), and malignant (13 [25.5%]). The groups were evaluated multiparametrically in terms of quantitative and qualitative variables. RESULTS: The long axis, short axis, area, and apparent diffusion coefficient (ADC) values of the largest lymph node were 21 (17 to 24) mm, 14 (12 to 18) mm, 228.60 (144.79 to 351.82) mm 2 , 2531 (2457 to 2714) mm 2 /s for reactive, 24 (19 to 27) mm, 15 (11 to 20) mm, 271.80 (231.43 to 412.20) mm 2 , 2534 (2425 to 2594) mm 2 /s for lymphadenitis, 27 (23.50 to 31.50) mm, 20 (15 to 22) mm, 377.08 (260.47 to 530.94) mm 2 , 2337 (2254 to 2466) mm 2 /s for malignant, respectively. Statistical analysis of our data suggests that the following parameters are associated with a higher likelihood of malignancy: long axis >22 mm, short axis >16 mm, area >319 cm 2 , ADC value <2367 mm 2 /s, and supraclavicular location. Perinodal and nodal heterogeneity, posterior cervical triangle location are common in lymphadenitis ( P <0.001). Reactive lymph nodes are distributed symmetrically in both neck halves ( P <0.001). CONCLUSION: In the MRI-based approach to lymph nodes, not only long axis, short axis, surface area, and ADC, but also location, distribution, perinodal, and nodal heterogeneity should be used.

An assessment of radiology resident competency in identifying suppurative retropharyngeal lymphadenitis: an examination using the WIDI SIM platform.

BACKGROUND AND PURPOSE: Suppurative retropharyngeal lymphadenitis is a retropharyngeal space infection almost exclusively seen in the young (4-8 years old) pediatric population. It can be misdiagnosed as a retropharyngeal abscess, leading to unnecessary invasive treatment procedures. This retrospective study aims to assess radiology residents' ability to independently identify CT imaging findings and make a definitive diagnosis of suppurative retropharyngeal lymphadenitis in a simulated call environment. MATERIALS AND METHODS: The Wisdom in Diagnostic Imaging Emergent/Critical Care Radiology Simulation (WIDI SIM) is a computer-aided emergency imaging simulation proven to be a reliable method for assessing resident preparedness for independent radiology call. The simulation included 65 cases across various imaging modalities of varying complexity, including normal studies, with one case specifically targeting suppurative retropharyngeal adenitis identification. Residents' free text responses were manually scored by faculty members using a standardized grading rubric, with errors subsequently classified by type. RESULTS: A total of 543 radiology residents were tested in three separate years on the imaging findings of suppurative retropharyngeal lymphadenitis using the Wisdom in Diagnostic Imaging simulation web-based testing platform. Suppurative retropharyngeal lymphadenitis was consistently underdiagnosed by radiology residents being tested for call readiness irrespective of the numbers of years in training. On average, only 3.5% of radiology residents were able to correctly identify suppurative retropharyngeal lymphadenitis on a contrast-enhanced computed tomography (CT). CONCLUSIONS: Our findings underscore a potential gap in radiology residency training related to the accurate identification of suppurative retropharyngeal lymphadenitis, highlighting the potential need for enhanced educational efforts in this area.

A comparison of ultrasound-guided aspiration with open surgical drainage in the management of pediatric acute suppurative cervical lymphadenitis.

OBJECTIVES: Image-guided aspiration has been proposed as an alternative to the traditional open drainage in acute suppurative cervical lymphadenitis, although little evidence comparing these approaches exists. The aim of this study was to compare ultrasound-guided aspiration and open surgical drainage in the management of pediatric acute suppurative cervical lymphadenitis. METHODS: Patients treated for acute suppurative cervical lymphadenitis at a tertiary referral pediatric hospital over a three-year period were retrospectively analyzed. RESULTS: Of eighteen patients included, 9 (50 %) underwent aspiration and 9 (50 %) underwent open surgical drainage. None required repeat intervention or readmission over a median follow up of 10.5 weeks. Those undergoing aspiration had a shorter post-operative length of stay (1.67 vs 4.33 days, p = 0.001) compared with open surgical drainage. CONCLUSION: Ultrasound-guided aspiration of pediatric acute suppurative cervical lymphadenitis is a safe and effective alternative to open drainage.

Observer- and radiomics model-based computed tomography classification of suppurative versus tuberculous lymphadenitis complicated with nodal necrosis of the neck in children.

BACKGROUND: Computed tomography (CT) can be used for the early detection of lymphadenitis. Radiomics is able to identify a large amount of hidden information from images. However, few CT-based radiomics studies on cervical lymphadenitis in children have been published. OBJECTIVE: This study aimed to investigate the role of visual CT analysis and CT radiomics in differentiating cervical suppurative node necrosis from tuberculous node necrosis in pediatric patients. MATERIALS AND METHODS: A total of 101 patients with cervical suppurative lymphadenitis (n=52) or cervical tuberculous lymphadenitis (n=49) were included. Clinical data and CT images were retrieved for analysis. For visual observation, 11 major CT features were identified for univariate and multivariate analyses. For radiomics analysis, image segmentation, feature value extraction, and dimension reduction, feature selection and the construction of radiomics-based models were performed through the RadCloud platform. RESULTS: For the visual observation, significant differences were found between the two groups, including the short diameter of the largest necrotic lymph node (P=0.03), sharp border of the node (P=0.02), fusion of nodes (P=0.02), regular silhouette of the necrotic area (P=0.001), multilocular necrotic area (P=0.02), node calcification (P=0.004), and enhancement degree of the nodal nonnecrotic area (P=0.01). No feature was found to be an independent predictor for suppurative or tuberculous lymphadenitis (P>0.05 for all features). Concerning the radiomics analysis, after feature value extraction and dimension reduction, nine related features were selected. The support vector machine classifier achieved high diagnostic performance in distinguishing suppurative from tuberculous lymphadenitis. The area under the curve, accuracy, sensitivity, and specificity of the support vector machine model test set were 0.89 (95% confidence interval: 0.72-1.00), 0.88, 0.78, and 0.90, respectively. CONCLUSION: Compared to observer-based CT image analyses, radiomics model-based CT image analyses exhibit better performance in the differential diagnosis of cervical suppurative and tuberculous lymphadenitis complicated with nodal necrosis in children.

The benefit of superb microvascular imaging and shear wave elastography in differentiating metastatic axillary lymphadenopathy from lymphadenitis.

PURPOSE: The purpose of this study is to detect and compare the diagnostic performances of vascularity index (VI) via superb microvascular imaging (SMI) and shear wave elastography (SWE) in metastatic axillary lymphadenopathy and lymphadenitis. MATERIALS AND METHODS: The study is based on 45 female patients who were ultrasonographed due to swelling in the axilla and underwent SWE and SMI before tru-cut biopsy, between August 2019 and February 2021. The patients had a total of 53 lymph nodes (LNs), 38 of these were metastatic and 15 were lymphadenitis. RESULTS: The results showed that mean volumes, value of cortex thickness, elasticity and velocity values, and mean VI values were significantly higher in metastatic LAP group compared to lymphadenitis group. Correlation analysis showed that both VI (r: 0.44) and elastography (r: 0.52) values were positively correlated with the cortex thickness, while elastography values were strongly correlated with volume (r: 0.42) and short diameter (r: 0.40). For differentiating lymphadenitis and metastatic LAP, the optimal cut-off VI value was 8.55 while the optimal cut-off elastography value was 31.8 kPa. CONCLUSION: In conclusion, combined grayscale ultrasonography evaluation of lymph nodes with SWE and SMI increase the diagnostic performance in distinguishing lymphadenitis-metastatic LAP.

Severe Fever with Thrombocytopenia Syndrome with Necrotizing Lymphadenitis in a Patient who Underwent 18F-FDG PET/CT: A Case Report.

Severe fever with thrombocytopenia syndrome (SFTS), also known as fever, thrombocytopenia, and leukopenia syndrome, is an emerging tick-borne infectious disease in Asian countries. SFTS should be suspected in patients presenting with fever, thrombocytopenia, and leukopenia and have a history of tick exposure in an endemic area. Since SFTS can be accompanied by lymphadenopathy, particularly generalized lymphadenopathy, it can be confused with a primary malignancy, such as lymphoma. The study reports a case of SFTS accompanied by multiple lymphadenopathies, which mimicked malignant lymphoma on F-18 fluorodeoxyglucose positron emission tomography/computed tomography.

Angioimmunoblastic T-cell lymphoma masquerading as granulomatous lymphadenitis: Fine needle aspiration cytology, clinical and radiology correlation.

Fine needle aspiration (FNA) is a minimally invasive technique used in the initial diagnosis of superficial lesions, including lymphadenopathy. Its benefit in lymph node pathology, however, is highly variable, especially in heterogeneous lymphoproliferative disorders like angioimmunoblastic T-cell lymphoma (AITL). AITL is an aggressive hematopoietic malignancy, histologically characterized by medium-sized neoplastic cells, high endothelial venule proliferations, and a heterogeneous hematolymphoid background. Diagnostic difficulty arises at lymph node FNA, where cytology yields nonspecific polymorphous collections of medium-sized lymphocytes, hematolymphoid cells, dendritic cell-lymphoid complexes, and lymphoid tissue fragments with transgressing blood vessels; findings mimicking reactive lymphadenopathy. We present a case of a 62-year-old male who presented with cervical lymphadenopathy. Neck level II lymph node FNA revealed granulomatous inflammation. A cell block was prepared for additional infectious studies but was non-contributory due to lack of material. Flow cytometry showed no evidence of non-Hodgkin lymphoma. Excisional biopsy revealed lymph node effacement by a T-cell lymphoproliferative disorder consistent with AITL. This case contributes to the paucity of literature regarding the cytologic features of AITL observed at FNA, and becomes the premier case to emphasize the addition of granulomatous features. Despite the aggressive nature of this entity, cases are frequently misdiagnosed as reactive on initial evaluation resulting in delay of treatment. This report serves to raise suspicion of AITL and other polymorphic cellular lymphomas in the setting of reactive granulomatous cytomorphology, thus prompting histological examination of tissue biopsy, expediting treatment, and ultimately providing potential improvement to the current prognosis.

Kikuchi Cervical Lymphadenitis in Children: Ultrasound Differentiation From Common Infectious Lymphadenitis.

OBJECTIVES: To investigate ultrasound (US) features of enlarged cervical lymph nodes (LNs) to differentiate between Kikuchi disease (KD) and other common types of infectious lymphadenitis in an East Asian pediatric patient population. METHODS: A total of 142 pediatric patients with KD and 45 patients with infectious lymphadenitis (suppurative lymphadenitis [n = 29], nontuberculous mycobacterial lymphadenitis [n = 9], and tuberculous lymphadenitis [n = 7]) were included. The clinical characteristics, laboratory results, and US features of LNs were reviewed. The area under the curve (AUC) from a receiver operating characteristic curve analysis was used as a diagnostic accuracy measure. RESULTS: A multiple clustered adjacent pattern, bilaterality, an even size, posterior neck involvement, no enlargement, an elongated-to-ovoid shape, homogeneous hypoechogenicity, a well-defined margin, presence of an echogenic fatty hilum, no intranodal gross necrosis, increased perinodal fat echogenicity, and no increased echogenicity of the adjacent sternocleidomastoid muscle were significant US features of the affected LNs to discriminate KD from infectious lymphadenitis (P < .05). Homogeneous hypoechogenicity in KD showed the highest AUC (0.930) as a single variable (95% confidence interval, 0.88-0.96). The AUCs were increased in 3 combination models with 2 US features: homogeneous echogenicity and 1 of 3 other US features (increased perinodal fat echogenicity, 0.935; number of affected LNs, 0.947; and LN shape, 0.949). CONCLUSIONS: Homogeneous hypoechogenicity of LNs was a significant US feature with the highest diagnostic accuracy in differentiating KD from common infectious lymphadenitis on a univariate analysis. In the combination model, US features of an elongated-to-ovoid shape and homogeneous hypoechogenicity showed the highest diagnostic accuracy.

A febrile child with a 'bunch of grapes' appearance on neck ultrasonography.

Kawasaki disease is a common childhood vasculitis. Fever and lymphadenopathy, at times, are the only clinical presentation of Kawasaki disease, which mimics infectious lymphadenitis, especially, when other features are yet to evolve. In such a scenario, ultrasonography of cervical lymph nodes can help to differentiate Kawasaki disease lymphadenitis from infectious lymphadenitis. We present one such patient who was initially diagnosed as having bacterial lymphadenitis; however, ultrasonography of the neck lymph nodes showed typical imaging features described with Kawasaki disease lymphadenitis.

Diagnostic performance of EBUS-TBNA and its interrelation with PET-CT in patients with extra-thoracic malignancies.

INTRODUCTION: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a well-established diagnostic tool for lung cancer, sarcoidosis, and suspected metastatic extra-thoracic malignancy (ETM). Patients with primary ETM often have hypermetabolic mediastinal/hilar lymph node enlargement in the PET-scan done for initial staging or post treatment followup. We aimed to determine the diagnostic performance of EBUS-TBNA and the relationship between PET-SUV values and diagnosis of malignancy metastasis in patients with ETM. MATERIALS AND METHODS: Results of EBUS-TBNA in ETM patients with suspected MLN metastasis were retrospectively analysed (May 2016 to July 2019). Non-malign results were confirmed for surgery or clinical/radiological followup. Lymph nodes with a high FDG-uptake (SUV > 2.5, MLN) were reported as suspicious for metastasis. RESULT: Of the 588 EBUS procedures, 109 were included in the analysis. Patient' mean age was 62.5 ± 10.1 years; there were 35 men and 74 women. Primary malignancies were breast cancer in 33, gastrointestinal in 23, female genital tract in 17, head and neck in 14, genitourinary cancer in 13, malignant melanoma in 6, sarcoma in 2 and kaposi sarcoma in 1. According to EBUS-TBNA smear and cell block histopathologic evaluations, 16 patients' results (14.7%) were malignant compatible with metastasis of ETM. Among the 93 patients with non-malignant diagnosis, EBUS-TBNA revealed a granulomatous lympadenitis compatible with sarcoid reaction in 7 and tuberculosis in 2. A total of 9 patients underwent surgical procedures after EBUSTBNA, with a definitive histological diagnosis of granulomatous lymphadenitis in 2, malignancy in 5 and, reactive lymph node in 2. Overall sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of EBUS-TBNA were 76.19% (95% CI 52.83-91.78), 100% (95% CI 95.89-100.00), 100%, 94.62% (95% CI 89.12-97.12) and 95.4%, respectively. CONCLUSIONS: EBUS-TBNA sampling has high diagnostic performance. Histopathological confirmation requirement for MLN should be kept in mind in patients with ETM, even they have negative EBUS results.

Cervicofacial non-tuberculous mycobacterial lymphadenitis: clinical determinants of incomplete surgical removal.

In patients with non-tuberculous mycobacterial cervicofacial lymphadenitis, incomplete surgical removal of infected lymph nodes leads to delayed healing and a higher recurrence rate, with eventual spontaneous drainage through the skin. However, complete surgical removal is not always achievable due to the extent of the infected tissue and proximity to vulnerable structures, such as the facial or accessory nerve. The aim of this study was to identify the clinical determinants of the (in)ability to perform complete surgical removal. The electronic health records of patients aged 0-15 years with bacteriologically proven non-tuberculous mycobacterial cervicofacial lymphadenitis, who underwent surgical treatment and preoperative sonographic imaging, were analysed. This was a case-control study. A total of 103 patients met the inclusion criteria. Most of the infections were unilateral, submandibular, and caused by Mycobacterium avium. Multiple logistic regression analysis revealed that higher age (odds ratio 1.24, 95% confidence interval 1.04-1.47) and fistulization (odds ratio 3.15, 95% confidence interval 1.13-8.75) were significantly associated with a limited ability to surgically remove all infected tissue. However, a larger sonographic lymph node size was not significantly associated. These findings could aid clinicians when informing the parent(s)/guardian(s) of the patient preoperatively and in properly estimating the intraoperative and postoperative course.

[Cervical lymphadenitis caused by non-tuberculous mycobacteria in children with different residence]. / Zervikale Lymphadenitis durch atypische Mykobakterien bei Kindern mit unterschiedlichem Wohnsitz.

OBJECTIVE: Atypical mycobacteria form a heterogeneous group. Although more than 140 species have been identified, only 25 of them are considered responsible for infection in humans. The most frequent manifestation of the disease in immunocompetent children is the cervical lymphadenitis. Aims of this study were to identify a correlation of the location of residence with patients' demographics and disease characteristics, to evaluate the ultrasonographic findings and the different operative treatments modalities and to develop an algorithm for the diagnosis and treatment. MATERIALS AND METHODS: Cases were identified by using the hospital's correspondence, microbiology and pathology databases. Demographic and clinical data were collected. A statistical analysis of the results was performed. RESULTS: 32 patients were included. Our data revealed no significant correlation between area of residence and disease characteristics. Hypoechoic lymph nodes with intraglandular necrosis and low vascularity were observed in the majority of patients. Surgical treatment included abscess incision with biopsy, lymphadenectomy, selective neck dissection and partial parotidectomy. A recurrent disease was significantly more frequent after abscess incision. CONCLUSIONS: Further studies with prospective design are required, in order to confidently identify the correlation between area of residence and disease characteristics. Similar ultrasonographic findings suggest a constant constellation of changes that facilitate diagnostic evaluation. Complete surgical excision offers an effective management option as it combines definitive treatment and histological confirmation with low risk of complications.

Cervical lymphadenopathy in children: a diagnostic tree analysis model based on ultrasonographic and clinical findings.

OBJECTIVES: To establish a diagnostic tree analysis (DTA) model based on ultrasonography (US) findings and clinical characteristics for differential diagnosis of common causes of cervical lymphadenopathy in children. METHODS: A total of 242 patients (131 boys, 111 girls; mean age, 11.2 ± 0.3 years; range, 1 month-18 years) with pathologically confirmed Kikuchi disease (n = 127), reactive hyperplasia (n = 64), lymphoma (n = 24), or suppurative lymphadenitis (n = 27) who underwent neck US were included. US images were retrospectively reviewed to assess lymph node (LN) characteristics, and clinical information was collected from patient records. DTA models were created using a classification and regression tree algorithm on the basis of US imaging and clinical findings. The patients were randomly divided into training (70%, 170/242) and validation (30%, 72/242) datasets to assess the diagnostic performance of the DTA models. RESULTS: In the DTA model based on all predictors, perinodal fat hyperechogenicity, LN echogenicity, and short diameter of the largest LN were significant predictors for differential diagnosis of cervical lymphadenopathy (overall accuracy, 85.3% and 83.3% in the training and validation datasets). In the model based on categorical parameters alone, perinodal fat hyperechogenicity, LN echogenicity, and loss of fatty hilum were significant predictors (overall accuracy, 84.7% and 86.1% in the training and validation datasets). CONCLUSIONS: Perinodal fat hyperechogenicity, heterogeneous echotexture, short diameter of the largest LN, and loss of fatty hilum were significant US findings in the DTA for differential diagnosis of cervical lymphadenopathy in children. KEY POINTS: • Diagnostic tree analysis model based on ultrasonography and clinical findings would be helpful in differential diagnosis of pediatric cervical lymphadenopathy. • Significant predictors were perinodal fat hyperechogenicity, heterogeneous echotexture, short diameter of the largest LN, and loss of fatty hilum.

Using Point-of-Care Ultrasound to Characterize Acute Inguinal Swelling of Young Children in the Pediatric Emergency Department.

Acute inguinal swelling in young children is frequently assumed to be an inguinal hernia, often prompting a bedside reduction attempt. We report 3 cases of inguinal swelling where the use of point-of-care ultrasound changed the patients' management by identifying an alternate diagnosis, thus avoiding unnecessary and painful procedures as well as their associated sedation risks.

Imaging Strategies and Outcomes in Children Hospitalized with Cervical Lymphadenitis.

OBJECTIVES: This study aimed to describe variation in imaging practices and examine the association between early imaging and outcomes in children hospitalized with cervical lymphadenitis. METHODS: This multicenter cross-sectional study included children between two months and 18 years hospitalized with cervical lymphadenitis between 2013 and 2017. Children with complex chronic conditions, transferred from another institution, and with prior hospitalizations for lymphadenitis were excluded. To examine hospital-level variation, we calculated the proportion of children at each hospital who received any imaging study, early imaging (conducted on day 0 of hospitalization), multiple imaging studies, and CT imaging. Generalized linear or logistic mixed effects models examined the association between early imaging and outcomes (ie, multiple imaging studies, surgical drainage, 30-day readmission, and length of stay) while accounting for patient demographics, markers of illness duration and severity, and clustering by hospital. RESULTS: Among 10,014 children with cervical lymphadenitis, 61% received early imaging. There was hospital-level variation in imaging practices. Compared with children who did not receive early imaging, children who received early imaging presented increased odds of having multiple imaging studies (adjusted odds ratio [aOR] 3.0; 95% CI: 2.6-3.6), surgical drainage (aOR 1.3, 95%CI: 1.1-1.4), and 30-day readmission for lymphadenitis (aOR 1.5, 95%CI: 1.2-1.9), as well as longer lengths of stay (adjusted rate ratio 1.2, 95%CI: 1.1-1.2). CONCLUSIONS: Children receiving early imaging had more resource utilization and intervention than those without early imaging. Our findings may represent a cascade effect, in which routinely conducted early imaging prompts clinicians to pursue additional testing and interventions in this population.

Radiographic and computed tomographic appearance of caseous lymphadenitis in a goat.

A 2-year-old Boer doe was presented with respiratory distress and severe inspiratory dyspnea. Cervical and thoracic radiographs revealed a marked retropharyngeal soft tissue mass effect, several mineralized pharyngeal and retropharyngeal structures, and a pulmonary mass. Computed tomography (CT) revealed a severely enlarged right medial retropharyngeal lymph node, which caused laryngeal compression, leading to upper airway obstruction. Multiple cervical and thoracic lymph nodes, and the pulmonary mass had an irregular layered/laminated pattern of mineralization. Imaging findings were consistent with caseous lymphadenitis, and further confirmed with culture, necropsy, and histopathology. This is the first report of CT appearance of caseous lymphadenitis in a goat.