Evaluation of Peripheral Lymphadenopathies in Children in a Single Center: Predictive Factors for Malignancy.

BACKGROUND: Lymphadenopathy (LAP) is a common finding in pediatric patients. It was aimed to determine predictive factors in distinguishing cases with malignant or benign lymphadenopathy in this study. SUBJECTS AND METHODS: Between January 2022 and January 2023, 101 patients (1-16 years old) with lymphadenopathy were retrospectively examined. RESULTS: LAP was localized in 80.2% (n=81) cases and generalized in 19.8% (n=20) cases. In 60 cases (59.4%), lymph node sizes were found to be greater than 20×20 mm in width and length. The most common infectious causative agent was Epstein Barr Virus (EBV). Seven (6.9%) patients underwent biopsy and all were diagnosed with malignancy. When the benign and malignant groups were compared, age, lymph node length, and width on physical examination, anteroposterior and longitudinal diameter of the lymph node on ultrasonography (USG) were statistically significantly higher in the malignant group (p<0.05). The presence of supraclavicular lymphadenopathy was found to be an important factor in differentiating the malignant group (p<0.003). The most important factors in distinguishing the groups are respectively were the anteroposterior diameter of the lymph node on ultrasonography and the presence supraclavicular lymph node in multivariate logistic regression analysis. CONCLUSION: It is not always easy to distinguish benign and malignant etiologies in patients with lymphadenopathy. A detailed history, a careful physical examination, laboratory studies, and excisional biopsy are guiding.

Unicentric Castleman's disease in the parotid gland associated with psoriasis: a case report.

BACKGROUND: Castleman's disease is a rare lymphoproliferative disorder that is often misdiagnosed because of its untypical clinical or imaging features except for a painless mass. Besides, it is also difficult to cure Castleman's disease due to its unclear pathogenesis. CASE PRESENTATION: We present a Castleman's disease case with diagnostic significance regarding a 54-year-old Chinese male who has a painless mass in his left parotid gland for 18 months with a 30-years history of autoimmune disease psoriasis. Computed tomography scan showed a high-density nodule with clear boundaries in the left parotid and multiple enlarged lymph nodes in the left submandibular and neck region. General checkup, the extremely elevated serum interleukin-6 and lymph node biopsy in the left submandibular region gave us an initial suspicion of Castleman's disease. Then the patient underwent a left superficial parotidectomy. Based on histopathologic analysis, we made a certain diagnosis of Castleman's disease and gave corresponding treatments. In 18 months of follow-up, the patient showed no evidence of recurrence, with the level of serum interleukin-6 decreased. CONCLUSIONS: Clinicians should be aware of the possibility of Castleman's disease when faced with masses or enlarged lymph nodes in the parotid gland to avoid misdiagnosis, especially in patients with autoimmune diseases and elevated serum interleukin-6.

Plasmacytoma and Amyloid Lymphadenopathy, FDG, and Fluorocholine.

ABSTRACT: A 56-year-old man with thoracal mass suspected of solitary plasmacytoma was referred for 18 F-FDG PET-CT scan. His PET-CT revealed FDG-avid rib mass and cervical lesion at level 2. He also underwent 18 F-fluorocholine (FCH) PET-CT to evaluate possible metastatic spread of the disease. FCH PET-CT showed increased uptake at the rib mass, while the cervical lesion was not FCH-avid. Biopsies confirmed rib lesion was a solitary plasmacytoma; however, the cervical lesion was an amyloid deposited lymph node. This case showed FCH PET-CT is a valuable companion of FDG scan for the evaluation of plasma cell dyscrasias with a better specificity.

Development of a Novel Contrast-Enhanced Ultrasound-Based Nomogram for Superficial Lymphadenopathy Differentiation: Postvascular Phase Value.

OBJECTIVE: The aim of this study was to develop and prospectively validate a prediction model for superficial lymphadenopathy differentiation using Sonazoid contrast-enhanced ultrasound (CEUS) combined with ultrasound (US) and clinical data. METHODS: The training cohort comprised 260 retrospectively enrolled patients with 260 pathological lymph nodes imaged between January and December 2020. Two clinical US-CEUS models were created using multivariable logistic regression analysis and compared using receiver operating characteristic curve analysis: Model 1 included clinical and US characteristics; Model 2 included all confirmed predictors, including CEUS characteristics. Feature contributions were evaluated using the SHapley Additive exPlanations (SHAP) algorithm. Data from 172 patients were prospectively collected between January and May 2021 for model validation. RESULTS: Age, tumor history, long-axis diameter of lymph node, blood flow distribution, echogenic hilus, and the mean postvascular phase intensity (MPI) were identified as independent predictors for malignant lymphadenopathy. The area under the curve (AUC), sensitivity, specificity, and accuracy of MPI alone was 0.858 (95% confidence interval [CI], 0.817-0.891), 86.47%, 74.55%, and 81.2%, respectively. Model 2 had an AUC of 0.919 (95% CI, 0.879-0.949) and good calibration in training and validation cohorts. The incorporation of MPI significantly enhanced diagnostic capability (p < 0.0001 and p = 0.002 for training and validation cohorts, respectively). Decision curve analysis indicated Model 2 as the superior diagnostic tool. SHAP analysis highlighted MPI as the most pivotal feature in the diagnostic process. CONCLUSION: The employment of our straightforward prediction model has the potential to enhance clinical decision-making and mitigate the need for unwarranted biopsies.

Quantitative evaluation of endobronchial ultrasound elastography in the diagnosis of benign and malignant mediastinal and hilar lymph nodes.

OBJECTIVE: To compare the diagnostic value of different quantitative methods of endobronchial ultrasound elastography in benign and malignant mediastinal and hilar lymph nodes. METHODS: This retrospective study included patients who underwent endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for mediastinal and hilar lymph node enlargement in our hospital between January 2019 and August 2022. We compared different quantitative elastography parameters [red area ratio (RAR, lymph node red area/lymph node area), green area ratio (GAR, lymph node green area/lymph node area), blue area ratio (SAR, lymph node blue area/lymph node area), mixed area ratio (MAR, lymph node green area/lymph node area), blue-green lymph node area/lymph node area), strain rate ratio (SR), strain rate in the target lymph node (LPA), ratio of blue area to total lymph node area outside the center of the target lymph node (PAR), and average grey value (MGV)], in order to find the best quantitative evaluation method. RESULTS: A total of 244 patients (346 lymph nodes) were included in this study. All quantitative elastography parameters were statistically significant for the differentiation of benign and malignant lesions except the average grey value of the target lymph nodes. The area under the receiver operating characteristic curve of SAR was 0.872 (95% confidence interval: 0.83-0.91), the cutoff value was 0.409, and the sensitivity, specificity, positive and negative predictive values were 85.4%, 78.0%, 80.4%, and 83.4%, respectively. CONCLUSION: Compared with other types of quantitative analysis, SAR has a higher predictive significance for benign and malignant lymph nodes.

Differential diagnosis of cervical lymphadenopathy: Integration of postvascular phase of contrast-enhanced ultrasound and predictive nomogram model.

BACKGROUND: Distinguishing benign from malignant cervical lymph nodes is critical yet challenging. This study evaluates the postvascular phase of contrast-enhanced ultrasound (CEUS) and develops a user-friendly nomogram integrating demographic, conventional ultrasound, and CEUS features for accurate differentiation. METHODS: We retrospectively analyzed 395 cervical lymph nodes from 395 patients between January 2020 and December 2022. The cohort was divided into training and validation sets using stratified random sampling. A predictive model, based on demographic, ultrasound, and CEUS features, was created and internally validated. RESULTS: The training set included 280 patients (130 benign, 150 malignant nodes) and the validation set 115 patients (46 benign, 69 malignant). Relative hypoenhancement in the postvascular phase emerged as a promising indicator for MLN, with sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 96.7 %,52.3 %, 70.0 %, 93.2 %, and 76.1 %, respectively in the training set and 95.7 %, 52.2 %, 75.0 %, 88.9 %, and 74.8 % in the validation set. Age over 50 years, history of malignancy, short-axis diameter greater than 1.00 cm, focal hyperechogenicity, ill-defined borders, and centripetal perfusion were also identified as independent MLN indicators. The nomogram prediction model showed outstanding accuracy, with an area under the curve (AUC) of 0.922 (95 % CI: 0.892-0.953) in the training set and 0.914 (95 % CI: 0.864-0.963) in the validation set. CONCLUSION: Relative hypoenhancement in the postvascular phase of CEUS, combined with demographics and ultrasound features, is effective for identifying MLNs. The developed prediction model, with a user-friendly nomogram, can facilitate clinical decision-making.

Utility of 18F-FDG PET/CT for differential diagnosis between IgG4-related lymphadenopathy and angioimmunoblastic T-cell lymphoma.

AIM: To explore the utility of the 2-[18F]-fluoro-2-deoxy-d-glucose (18F-FDG) positron-emission tomography (PET)/computed tomography (CT) in the differential diagnosis of IgG4-related lymphadenopathy (IgG4-RLAD) and angioimmunoblastic T-cell lymphoma (AITL). MATERIALS AND METHODS: Retrospective analysis of 18F-FDG PET/CT imaging findings in clinically diagnosed IgG4-RLAD and AITL cases was undertaken to record the distribution, morphological characteristics, and imaging features of the affected lymph nodes, as well as FDG uptake of the spleen and bone marrow. Standardised uptake values normalised to lean body mass were evaluated for maximum (SULmax), average (SULavg), and peak values (SULpeak). Univariate and multivariate logistic regression was used to screen for statistically significant imaging findings to discriminate IgG4-RLAD from AITL. RESULTS: Twenty-two cases of IgG4-RLAD (17 men, five women, median age 49.5 years) and 22 cases of AITL (16 men, six women, median age 55 years) were finally included in the analysis. There were no AITL patients with involvement of a single lymph node region. AITL patients had more involvement of the different nodal regions except cervical and pelvic nodal regions. A practical assessment method based on a combination of SULpeak-LN/SULavg-liver, SULpeak-spleen, and the number of involved nodal regions, improved the performance for differential diagnosis between both groups with an overall classification accuracy of 90.9%. CONCLUSIONS: 18F-FDG PET/CT is a useful tool for distinguishing AITL from IgG4-RLAD, and it can also help determine the optimal biopsy site for suspected cases of IgG4-RLAD or AITL, reduce the need for re-biopsy procedures, and enable physicians to develop timely treatment strategies.

Hypermetabolic Axillary Lymphadenopathy After Shingrix Vaccination for Varicella Zoster Virus.

ABSTRACT: A 67-year-old woman underwent staging 18 F-FDG PET/CT scan for recently diagnosed breast cancer. Her scan showed a highly hypermetabolic right breast mass, with ipsilateral hypermetabolic axillary lymph nodes. The contralateral axillary lymph nodes were also enlarged with avid FDG uptake, alongside focal increased uptake in the left deltoid muscle. Upon investigation, the patient reported receiving the new zoster recombinant adjuvanted varicella zoster vaccine (Shingrix, GlaxoSmithKline) 4 days before the scan. The lymph node uptake could be potential pitfall for cancer staging.

Comparison of Axillary Lymph Nodes on Breast MRI Before and After COVID-19 Booster Vaccination.

RATIONALE AND OBJECTIVES: Vaccine-related lymphadenopathy is a frequent finding following initial coronavirus disease 2019 (COVID-19) vaccination, but the frequency after COVID-19 booster vaccination is still unknown. In this study we compare axillary lymph node morphology on breast MRI before and after COVID-19 booster vaccination. MATERIALS AND METHODS: This retrospective, single-center, IRB-approved study included patients who underwent breast MRI between October 2021 and December 2021 after the COVID-19 booster vaccination. The axillary lymph node with the greatest cortical thickness ipsilateral to the side of vaccination was measured on MRI after booster vaccination and before initial COVID-19 vaccination. Comparisons were made between patients with and without increase in cortical thickness of ≥ 0.2 cm. Continuous covariates were compared using Wilcoxon rank-sum test and categorical covariates were compared using Fisher's exact test. Multiple comparison adjustment was made using the Benjamini-Hochberg procedure. RESULTS: All 128 patients were included. Twenty-four of 128 (19%) displayed an increase in lymph node cortical thickness of ≥ 0.2 cm. Patients who received the booster more recently were more likely to present cortical thickening, with a median of 9 days (IQR 5, 20) vs. 36 days (IQR 18, 59) (p < 0.001). Age (p = 0.5) and type of vaccine (p = 0.7) were not associated with thickening. No ipsilateral breast cancer or malignant lymphadenopathy were diagnosed on follow-up. CONCLUSION: Axillary lymphadenopathy on breast MRI following COVID-19 booster vaccination is a frequent finding, especially in the first 3 weeks after vaccination. Additional evaluation or follow-up may be omitted in patients with low concern for malignancy.

Management of Pediatric Persistent Asymptomatic Cervical Lymphadenopathy.

OBJECTIVE: Persistent asymptomatic cervical lymphadenopathy (PACL) is a common outpatient referral diagnosis for pediatric otolaryngologists. Historically, excisional biopsy under general anesthesia has been the gold standard for diagnosis but is associated with some risks. Current literature provides little guidance on less invasive monitoring. Our hypothesis is that the majority of children who present with PACL can be safely monitored with ultrasound and avoid the risks of excisional biopsy. STUDY DESIGN: A retrospective review was performed of patients <18 years of age, referred to a tertiary care children's hospital for PACL who also underwent at least 1 neck ultrasound from 2007 to 2021. Patients with acute neck infections, congenital masses, or known rheumatologic, immunologic, or malignant conditions were excluded. A multivariate logistic regression model was used to determine patient and nodal factors associated with the decision for operative management. SETTING: University of California, San Francisco Pediatric Otolaryngology Department. RESULTS: Among the 197 patients meeting inclusion criteria, 30 (15.2%) underwent surgical biopsy. Overall, 26% underwent repeat ultrasound with a mean interval of 6.6 months, and a mean decrease in nodal size of 0.34 cm. Of the 30 surgical cases, 27 (90%) patients had benign pathology. Multivariate regression analysis revealed pain (p = .04), firmness (p < .001), and lack of a normal fatty hilum on ultrasound (p = .04) as statistically significantly correlated with decisions for surgical management. CONCLUSION: The majority of pediatric PACL is benign and does not require an excisional biopsy to rule out lymphoma. Serial clinical follow-up with neck ultrasound can be used to safely monitor patients.

Can deep learning replace histopathological examinations in the differential diagnosis of cervical lymphadenopathy?

INTRODUCTION: We aimed to develop a diagnostic deep learning model using contrast-enhanced CT images and to investigate whether cervical lymphadenopathies can be diagnosed with these deep learning methods without radiologist interpretations and histopathological examinations. MATERIAL METHOD: A total of 400 patients who underwent surgery for lymphadenopathy in the neck between 2010 and 2022 were retrospectively analyzed. They were examined in four groups of 100 patients: the granulomatous diseases group, the lymphoma group, the squamous cell tumor group, and the reactive hyperplasia group. The diagnoses of the patients were confirmed histopathologically. Two CT images from all the patients in each group were used in the study. The CT images were classified using ResNet50, NASNetMobile, and DenseNet121 architecture input. RESULTS: The classification accuracies obtained with ResNet50, DenseNet121, and NASNetMobile were 92.5%, 90.62, and 87.5, respectively. CONCLUSION: Deep learning is a useful diagnostic tool in diagnosing cervical lymphadenopathy. In the near future, many diseases could be diagnosed with deep learning models without radiologist interpretations and invasive examinations such as histopathological examinations. However, further studies with much larger case series are needed to develop accurate deep-learning models.

Chest CT findings in community-acquired pneumonia due to Coxiella burnetii (Q fever) compared to Streptococcus pneumoniae, a cross sectional study in French Guiana, 2013-2017.

OBJECTIVES: Few and small studies previously examined chest CT-scan characteristics of Coxiella burnetii (Cb) community-acquired pneumonia (CAP). Larger studies are needed to guide physicians towards diagnosis of Q fever in case of pneumonia. METHODS: We conducted a single-center retrospective observational study between 2013 and 2017. All patients with Cb or Streptococcus pneumoniae (Sp) CAP who had a chest CT-scan on admission at Cayenne Hospital (French Guiana) were included. Chest CT-scan were all analyzed by the same expert radiologist. RESULTS: We included 75 patients with Cb CAP and 36 with Sp CAP. Fifty-nine percent of all patients were men (n = 66) and median age was 52 [IQR = 38-62]. Chest CT-scans of Cb CAP patients revealed 67 alveolar condensations (89 %), 52 ground-glass opacities (69 %), 30 cases of lymphadenopathy(ies) (40 %) and 25 pleural effusions (33 %). Parenchyma lesions caused by Cb were predominantly unilateral (67 %). We found high numbers of alveolar condensations in both Cb and Sp CAP (89 % and 75 %; respectively), but the presence of ground-glass opacities was significantly associated with Cb CAP (69 % versus 30 %; p < 0.01). Cb CAP were associated with more lymphadenopathies (40 % vs 17 %; p = 0.01) while Sp CAP showed more bronchial thickening (19 % versus 3 %; p < 0.01) and (micro)nodule(s) ≤1 cm (25 % vs 3 %, p < 0.01). CONCLUSIONS: This large study shows that the most typical aspect of chest CT-scan in case of Cb CAP in French Guiana is a unilateral alveolar consolidation associated with ground glass opacities and lymphadenopathies. C. burnetti and S. pneumoniae both most often cause alveolar consolidations, but present some significantly different CT-scan patterns. This could help physicians through therapeutic choices.

CT-based diagnosis in patients presenting with throat pain: A single institutional review.

RATIONALE AND OBJECTIVE: To determine if patient demographic data, medical history, physical examination, and laboratory tests will help predict likelihood of imaging-based diagnosis using CT of the neck performed in the ED for a chief complaint of throat pain. MATERIAL AND METHODS: Single institutional, retrospective review of 367 CT scans of the neck performed for the evaluation of throat pain in the ED from August 2013 to September 2019. Patients' clinical history, physical exams, lab findings, and imaging results were recorded. RESULTS: A total of 367 CT scans of the neck performed for the evaluation of throat pain included a recorded exam and clinical history. Of these cases, we noted that the presence of cervical lymphadenopathy (OR = 2.69; 95% CI, 1.37-5.49), tonsillar findings (OR = 2.94; 95% CI, 1.4-6.57), increased white blood cell count (OR = 1.08; 95% CI, 1.02-1.15), and temperature (OR = 1.94; 95% CI, 1.1-3.6) were associated with increased likelihood of obtaining a diagnostic CT scan. CONCLUSION: Consideration of tonsillar abnormalities, lymphadenopathy, body temperature, and measured leukocyte count prior to ordering CT scans of the neck for throat pain may increase the diagnostic yield of such exams and decrease CT utilization in the ED.

Analysis of clinical factors and ultrasound features associated with COVID-19 vaccine-related axillary lymphadenopathy: A large group study.

PURPOSE: To investigate factors that distinguish COVID-19 vaccine-related axillary lymphadenopathy from malignancy or other etiologies. METHODS: From June 2021 to April 2022, 3859 consecutive female patients had breast and axillary ultrasound (US) at our institution. After exclusions, 592 patients were included in the study. We retrospectively reviewed clinical history and US features of enlarged axillary lymph nodes. Assessed clinical factors included age, vaccination type, dose and vaccination date, and ultrasound features included cortical thickness, shape, marginal irregularity, focal cortical thickening, fatty hilum, and number and anatomic location of enlarged lymph nodes. The seven US features were used to score the severity of lymphadenopathy. Binary logistic models and independent two-sample t-tests were used for statistical analysis. RESULTS: Among 592 patients (mean age 49.3 ± 10.3 years), 406(68.6%), 90(15.2%), 42(7.1), 4(0.7%) and 50(8.4%) patients received Pfizer, AstraZeneca, Moderna, Janssen and cross inoculation of more than one type, respectively. 185(31.3%), 376(63.5%) and 31(5.2%) patients received a first, second and third dose, respectively. The interval between vaccination and US was 30.9 ± 21.5 days. US showed axillary lymphadenopathy (LAP) in 113 patients (19.1%). Clinical factors associated with LAP were age younger than 50 years, mRNA vaccine, first dose and shorter interval(P < 0.05). US features associated with LAP were mean cortical thickness of 4.6 ± 1.63 mm, oval shape (70.8%), smooth margin (53.1%), focal cortical thickening (62.8%) and preserved fatty hilum (84.1%). Using our scoring method, the mean overall score for vaccine-related LAP was 2.45 ± 1.51 points. CONCLUSION: Awareness of influencing factors and sonographic features can help differentiate COVID-19 vaccine-related adenopathy from other etiologies.

Adenopatías gigantes en paciente con diagnóstico de linfoma no Hodking / Giant Lymphadenopathy in a Patient Diagnosed with Non-Hodgkin's Lymphoma

El linfoma se encuentra en el área de los ganglios linfáticos a ambos lados (superior e inferior) del diafragma, así como en el bazo(AU)

Comparison of post-COVID-19 vaccination hypermetabolic lymphadenopathy on 18F-fluorodeoxyglucose PET/CT between virus-vector vaccine and mRNA vaccine.

PURPOSE: We compared hypermetabolic lymphadenopathy (HLN) on 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) after virus-vector and mRNA vaccines for coronavirus disease 2019 (COVID-19). METHODS: This retrospective study included 573 participants who underwent FDG PET/CT after receiving a virus-vector vaccine (ChAdOx1, AstraZeneca [AZ] group) or an mRNA vaccine (mRNA-1273, Moderna [M] group) from July 2021 to October 2021. The incidence and avidity of HLN were evaluated and correlated with clinical features and vaccine type. The final analysis was conducted with 263 participants in the AZ group and 310 participants in the M group. RESULTS: The HLN incidence was significantly lower in the AZ group than in the M group (38/263 [14%] vs. 74/310 [24%], p = 0.006). The FDG avidity of HLN was comparable between the two groups. The HLN incidence in both groups was significantly higher within 4 weeks after the vaccination compared with more than 4 weeks. The HLN incidence within 4 weeks of the vaccination was significantly higher in the M group than in the AZ group (p = 0.008), whereas a difference in HLN incidence between the two groups was not observed after the same duration (p = 0.11). CONCLUSIONS: The mRNA mRNA-1273 COVID-19 vaccine was found to be associated with higher glucose hypermetabolism in regional lymph nodes within the first 4 weeks compared with the virus-vector vaccine, as indicated by the presence of HLN on FDG PET/CT. The degree of glucose hypermetabolism was comparable between the two vaccines.

Coexistence of Rosai-Dorfman disease and Hodgkin's lymphoma in a patient with cervical lymphadenopathy.

A man in his 40s, with no tobacco or alcohol habit, was referred to the otorhinolaryngology department presenting with a 2-month history of enlarged left cervical lymphadenopathy with no other signs or symptoms. The ear, nose and throat examination showed no abnormalities apart from the described lymphadenopathy. An ultrasound scan suggested these nodes to be part of either an inflammatory or a malignant process. Subsequent positron emission tomography-CT proved those lymph nodes to be metabolically active, as well as others within the thorax. Cervicotomy was performed and the histopathological analysis showed dilated sinuses and histiocytes with emperipolesis. Suspecting Rosai-Dorfman disease (RDD), high-dose steroid therapy was started; but given no improvement was observed, a second cervicotomy was performed, with the histopathological diagnosis of the latter of Hodgkin's lymphoma. The present article aims to emphasise the need to exclude haematological disorders whenever RDD histology is observed, given their possible coexistence, and a worse outcome and clinical and histopathological semblance.