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Advanced Thyroid and Parathyroid Ultrasound pp 215–225Cite as

Sonographic Appearance of Abnormal Cervical Lymph Nodes in the Preoperative and Reoperative/“Empty” Neck: A Surgeon’s Perspective

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Abstract

Thyroid cancer frequently metastasizes to the cervical lymph nodes. Identifying initial metastatic disease or recurrent thyroid cancer is imperative in proper operative management. Cervical lymph nodes have distinct sonographic features when benign and malignant. Utilizing ultrasound to evaluate the neck in patients with thyroid cancer or thyroid nodules is helpful in stratifying the malignant potential of individual lymph nodes. Though no single ultrasound finding can accurately diagnose metastasis, specific features of lymph node morphology can help identify lymph nodes that warrant further work-up. This chapter focuses on the sonographic features that allow differentiation between benign and malignant lymph nodes and specifically centers on the criteria that most reliably suggest metastasis.

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Author information

Authors and Affiliations

  1. Department of Surgery, Banner - University Medical Center, Tucson Campus, University of Arizona, 1501 N. Campbell Avenue, Tucson, AZ, 85724, USA

    Marlon A. Guerrero M.D., F.A.C.S.

Authors
  1. Marlon A. Guerrero M.D., F.A.C.S.
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Corresponding author

Correspondence to Marlon A. Guerrero M.D., F.A.C.S. .

Editor information

Editors and Affiliations

  1. Department of Surgery and the Endocrinology & Metabolism Institute, University of Arizona College of Medicine - Phoenix, Banner - University Medical Center Phoenix, Phoenix, Arizona, USA

    Mira Milas

  2. Department of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA

    Susan J. Mandel

  3. Department of Radiology, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA

    Jill E. Langer

1 Electronic Supplementary Material

ALL lymph nodes illustrated in the following cine-clips represent proven thyroid cancer metastases, either via cytology or surgical histology.

Central neck lymph nodes adjacent to the esophagus in longitudinal plane (MP4 1514 kb)

Large lymph node metastasis between the carotid artery and jugular vein (MP4 2138 kb)

Central neck lymph node adjacent to the trachea (MP4 1703 kb)

Longitudinal view of the thyroid lobe with central neck lymph node at the tip of the lobe (MP4 1784 kb)

Subtle, small hypoechoic lymph nodes above the esophagus in the central neck 2 years following thyroidectomy, proven papillary thyroid cancer (MP4 6074 kb)

The same lymph node from 6E seen with greater transducer pressure and slower scanning (MP4 6068 kb)

Cystic lymph nodes in the lateral neck (MP4 5314 kb)

Large lymph node with microcalcifications in lateral neck deep to the pulsating carotid artery, longitudinal view (MP4 1755 kb)

Small lymph node deep to the carotid artery in a patient with prior thyroidectomy for papillary thyroid cancer. The location of the lymph node was in level 6 (central neck) as determined by surgery. Some sonographers may interpret this location as level 4, but it is actually level 6 because of the proximity to the trachea. In a postoperative neck, the carotid sinks medially toward the trachea, making lymph nodes like this appear to belong to the lateral neck. However, they remain outside of the fascial sheath and plane of the carotid artery, and this anatomical tissue boundary is too thick to be imaged by ultrasound (MP4 6111 kb)

Small central neck lymph node imaged longitudinally between strap muscles and esophagus (MP4 1601 kb)

Several small left lateral neck lymph nodes with microcalcifications, including one just deep to the sternocleidomastoid muscle (MP4 1898 kb)

Fine needle aspiration biopsy, ultrasound guided, of lateral neck lymph node (MP4 1717 kb)

Hypoechoic, small dark lymph nodes in the right lateral neck that might benefit from additional imaging with CT scan to determine if additional nodes are present and not as visible by ultrasound due to the location adjacent to hypoechoic vascular structures. When intravenous CT contrast is used, the distinction between lymph nodes and blood vessels is significantly helpful (MP4 6197 kb)

Another example of dense central neck (not Level 4) lymphadenopathy from papillary thyroid carcinoma (MP4 1716 kb)

Central neck lymph nodes in inferior aspect close to sternal notch (MP4 1702 kb)

Hypoechoic lymph nodes in the left lateral neck (MP4 6027 kb)

Vascularity within lymph node shown on Video 21.16 (MP4 6029 kb)

Disordered vascularity in lymph node (MP4 5865 kb)

Lymph nodes that require ultrasound probe to be angled toward the upper mediastinum (level 7) to be detected. The major thoracic vessels, including innominate artery, are seen at the end of the clip. Lymph nodes of small to large size are shown (MP4 6063 kb)

Lymph nodes that require ultrasound probe to be angled toward the upper mediastinum (level 7) to be detected. The major thoracic vessels, including innominate artery, are seen at the end of the clip. Lymph nodes of small to large size are shown (MP4 6040 kb)

Lymph nodes that require ultrasound probe to be angled toward the upper mediastinum (level 7) to be detected. The major thoracic vessels, including innominate artery, are seen at the end of the clip. Lymph nodes of small to large size are shown (MP4 6215 kb)

Series of videos depicting thyroid cancer metastases in the lateral neck shown in relation to the internal jugular vein, some being close to it and some distant. This video: lymph node deep to IJ (MP4 4177 kb)

Series of videos depicting thyroid cancer metastases in lateral neck shown in relation to the internal jugular vein, some being close to it and some distant. This video: lymph node lateral to IJ (MP4 9601 kb)

Series of videos depicting thyroid cancer metastases in lateral neck shown in relation to the internal jugular vein, some being close to it and some distant. This video: lymph node below IJ (MP4 5619 kb)

Series of videos depicting thyroid cancer metastases in lateral neck shown in relation to the internal jugular vein, some being close to it and some distant. This video: lymph nodes next to IJ (MP4 9222 kb)

From the same patient are seen diseased central neck lymph nodes in sagittal view (MP4 17,309 kb)

From the same patient are seen diseased central neck lymph nodes in transverse view (MP4 8623 kb)

Large lymph node in level 4 of the right neck. Note how low in the neck it is located, in proximity to junction between subclavian and jugular veins (MP4 1904 kb)

Chain of abnormal right lateral neck lymph nodes from papillary thyroid cancer which appear more hyperechoic than usual (MP4 6142 kb)

Brachial plexus is seen as a bundle of small circles that are avascular on color Doppler imaging and nestled between the scalene muscles (MP4 1140 kb)

Transverse spinous process of cervical spine is seen at the center of the video as the most hyperechoic linear structure, with shadowing (MP4 1709 kb)

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Guerrero, M.A. (2017). Sonographic Appearance of Abnormal Cervical Lymph Nodes in the Preoperative and Reoperative/“Empty” Neck: A Surgeon’s Perspective. In: Milas, M., Mandel, S.J., Langer, J.E. (eds) Advanced Thyroid and Parathyroid Ultrasound. Springer, Cham. https://doi.org/10.1007/978-3-319-44100-9_21

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  • DOI: https://doi.org/10.1007/978-3-319-44100-9_21

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-44098-9

  • Online ISBN: 978-3-319-44100-9

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