https://imcjms.com/public Ibrahim Medical College Journal of Medical Science https://imcjms.com/public/registration/journal_full_text/139 Wed, 09 Nov 2016 15:19:37 +0000 Abstract Address for Correspondence: Dr. Md. Mizanur Rahman, Assistant Professor, Department of Radiology and Imaging, Dhaka Medical College, Dhaka   Introduction FNAC (Fine needle aspiration cytology) has an important role in the diagnosis of diseases of enlarged cervical lymph nodes with good diagnostic yield. Procedure is easy, safe, simple, quick, inexpensive and reliable,8 but biopsy of the cervical lymph node is most important so far as diagnosis is concerned. However, both the procedures are invasive. Bruneton et al., Hajek et al. and Sakai et al.13-15 suggested nodal size to be a reliable indicator for differentiating benign from malignant nodes. Another group of authors suggested that L/S ratio is a reliable indicator of a metastatic node.9-11,15 Toriyabe et al.16 described different types of echopattern in lymph nodes. They concluded that homogeneous hypoechoic pattern was seen more in benign enlarged nodes whereas heterogeneous patterns of echo were more common in metastatic nodes. Sanders17 claimed that echogenic hilum in a large node is a good indicator that it is benign and is due to fat deposition. Rubaltelli et al.18 also concluded that echogenic hilum is a valid criterion for benignity. Some authors differed and opined that echogenic hilum is not specific for benignity or malignancy.10,19 The study was carried out in the Department of Radiology and Imaging, Bangabandhu Sheikh Mujib Medical University (BSMMU) and Dhaka Medical College Hospital (DMCH) from January 1998 to December 1998. Patients having enlarged cervical lymph nodes were scanned by high frequency (5.0 MHz) curvilinear probe. Lymph node size (measured by maximal short axis diameter), lymph node shape (expressed by dividing the long axis diameter by the short axis diameter or L/S Ratio), marginal clarity, internal echopattern and hilar echogenicity were the criteria that were individually brought into consideration for differentiating benign from malignant nodes (Table 1).   Table-1: Ultrasound criterion used in this study to differentiate benign from malignant.   After ultrasound evaluation, specimens were collected by excision biopsy. Gross and histopathological examinations were then done. Data collected from each individual was then analyzed using computer based statistical software. Chi-square test was used and a   p value of <0.05 was taken as significant.   Results Fig-1. Shows a maximal short axis diameter of  21.7 mm and a L/S Ratio of 1.46. The node was a metastatic carcinoma. Smooth margin is missing at places. Echo pattern is heterogeneous with no hilar echogenic line.   Among the 65 enlarged nodes, 39 had a maximal axial diameter <1 cm, of which 31 (79.5%) were histo-pathologically benign and the rest 8 (20.5%) were malignant. 26 (100%) nodes with maximal axial diameter of >1 cm were all histo-pathologically malignant and none were benign (2=39.5; df=1.0; p<0.001). Fig-2. Shows a maximal short axis diameter of 15 mm, a L/S ratio of 1.28 and was proved to be a metastatic enlarged cervical node. Margin in this node was regular with hypoechoic homogeneous echo pattern with absence of hilar echogenicity.   Sonographic Parameters used Number Benign Malignant Total 65 No % no % Maximal short axis diameter           <1 cm n=39 31 79.49 08 20.51 >1 cm n=26 0 0 26 100 L/S Ratio            2 n=31 27 87.10 04 12.90 < 2 n=34 04 11.76 30 88.24 Margin           Regular n=39 28 71.79 11 28.21 Irregular n=26 03 11.54 23 88.46 Echopattern           Homogeneous hypoechoic n=32 28 87.50 04 12.50 Heterogeneous n=33 03 9.09 30 90.91 Hilar Echogenicity           Echogenic n=43 31 72.10 12 27.90 No echogenicity n=22 0 0 22 100   All the individual parameters showed high statistical significance (p < 0.001).   Of the 32 enlarged nodes with homogeneous hypoechoic echo-pattern, 28 (87.5%) were benign and 4 (12.5%) were malignant. 33 nodes showed heterogeneous echopattern of which 30 (90.9%) were malignant and 03 (9.1%) were benign. (2=42.17; df=1.0; p<0.001). There are approximately 800 lymph nodes in the body of which 300 lie in the neck.1 In this prospective study, nodal size, shape, marginal clarity, internal echo-pattern and hilar echo-genicity were the criteria selected to differentiate benign from malignant group of enlarged cervical lymph nodes. As far as the L/S ratio was considered, among the nodes with L/S ratio <2, 30 (88.2%) were malignant and 4 (11.8%) were benign. Among the nodes with    L/S ratio  2, 27 (87.10%) were benign and 04 (12.90%) malignant. Steinkemp et al.20 found 90% of the enlarged nodes to be metastatic with L/S ratio <2. Vassallo et al.10 showed that 86% of primary nodal malignancies and 85% of nodal metastasis had L/S ratio <2. So, malignant nodes have larger axial diameter thus reducing the L/S ratio and the malignant nodes becoming more roundish. This was also found true in this series. In this study, 28 (87.5%) nodes were benign among 31 enlarged nodes with homogeneous hypoechoic internal echopattern. In contrast 30, (90.9%) were malignant among 34 enlarged nodes with heterogeneous echopattern. Toriyabe et al.16 showed 90.9% nodes with homogeneous hypoechoic pattern to be benign and 86.7% with heterogeneous echopattern to be malignant. These findings are also consistent with the findings of the present study. This study was performed using a 5.0 MHz high frequency probe. Probe with a larger frequency like 7.5 MHz might have shown the above signs more clearly, particularly the marginal clarity, internal echopattern and presence or absence of echogenic hilum. But this much can be concluded that when all the parameters are evaluated simultaneously, a better interpretation or differentiation between benign and malignant cervical nodes is possible with real time high resolution ultrasound.   References 1.   Mann CV, Russell RCG, Williams NS. Editors, Lymphatics and Lymph nodes and The Neck. 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