Correlation of Sonographic Classification of Neck Adenopathy (A-RADS) and Malignancy

Original Article Iranian Journal of Otorhinolaryngology, Vol.35(1), Serial No.126, Jan-2023 Correlation of Sonographic Classification of Neck Adenopathy (A-RADS) and Malignancy Seyed Ali Alamdaran1, *Alieh Randian1, Bashir Rasoulian2, Amir Hossein Jafarian3, Behzad Aminzadeh1, Shabnam Niroumand4 Abstract Introduction: Cervical adenopathy can be involved in various pathological processes. This study aimed to evaluate the ultrasound classification of cervical adenopathy (A-RADS) to choose the appropriate approach. Materials and Methods: This cross-sectional study was conducted among 294 patients with cervical adenopathy at Mashhad University of Medical Sciences during 2020-2021. The data of the long axis diameter, short axis diameter, shape, border, vascular pattern, presence of calcification and changes in cyst/necrosis, cortical echogenicity, hilum visibility, and location of involved lymph nodes were extracted. Lymph nodes was classified into four normal, reactive, suspicious & lymphoid disorders, and metastatic groups, based on ultrasound appearance (Adenopathy-reporting and data system). Diagnostic methods included follow-up, core needle biopsy (CNB), and fine needle aspiration (FNA), and surgical results. After determining the final diagnosis, demographic, sonographic, and pathological data were analyzed at a significance level of p<0.05. Results: Of 294 patients, 185 were benign, and 109 were malignant. There were no significant differences in the location, long axis diameter, shape, cystic or necrotic changes, calcification, and margins of the lymph nodes between the benign and malignant groups. The enlarged short axis diameter, invisible hilum with isoechoic cortex, and non-hilar vascularity were significantly higher in the malignant group (p<0.001). The malignancy rate was 8.7% in reactive cases, 48.5% in lymphoid disorders , and 90% in metastatic nodes. Conclusion: The results of this study shows that cervical lymph nodes can be classified based on short axis diameter, cortex and hilum echo-texture and vascular pattern into normal, reactive, suspicious & lymphoid disorders, and metastatic, which have a high concordance with pathologic results. Keywords: Adenopathy, Cancer, Lymph node, Ultrasound Received date: 18 Aug 2022 Accepted date: 25 Dec 2022 *Please cite this article; Alamdaran SA,* Randian A, Rasoulian B, Jafarian AH, Aminzadeh B, Niroumand S. Correlation of Sonographic Classification of Neck Adenopathy and Malignancy. Iran J Otorhinolaryngol. 2022:35(1):39-47. Doi: 10.22038/IJORL.2022.67255.3299 1Department of Radiology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran. and Surgical Endoscopic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran. 3Pathology Cancer Molecular Research Center, Mashhad University of Medical Sciences, Mashhad, Iran. 4 Department of Community Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran. *Corresponding Author: Department of Radiology, Faculty of medicine, Mashhad University of Medical Sciences, Mashhad, Iran. E-mail: 2Sinus 39 Alamdaran SA, et al Introduction Approximately one-third of the body's lymph nodes are in the neck region (1). Cervical adenopathy can be seen in various pathological processes such as lymphoma, tuberculosis, and metastasis (2). The importance of adenopathy is that it reduces the 5-year survival of patients with metastatic lymph nodes. Therefore, accurate differentiation between these conditions is crucial to choosing the appropriate treatment and assessing the prognosis (3,4). Different imaging modalities such as CT, MRI, and ultrasound have been used to evaluate cervical lymph nodes (3,5). Although some studies have not reported any significant difference between these modalities in cervical lymph node assessment, other studies have mentioned ultrasonography as the most sensitive technique (4,6). Ultrasound can detect small lymph nodes (under 10 mm) better than other techniques. In addition, it can evaluate both internal and external anatomy, number, size, shape, and margins of cervical lymph nodes (6-8). Also, intra-nodal vascular patterns, blood flow velocity, and vascular resistance can be evaluated by Doppler ultrasound (9). Cervical ultrasound has been of interest more than other diagnostic approaches, especially as the first line. Ultrasound is associated with advantages such as safety, being fast, low cost, availability, no need for special medical facilities, and the possibility of performing diagnostic procedures. Numerous studies have been conducted on the relationship between sonographic parameters such as size, shape, margin condition, and vascularity of cervical lymph nodes and cervical adenopathy causes (10-12). However, different criteria have been proposed to distinguish malignant from benign lymph nodes. According to the different diagnostic approaches for various types of lymphadenopathies, their classification is valuable to choosing the appropriate diagnostic approach, reducing the costs and duration of diagnosis, and improving diagnostic-therapeutic outcomes. This study aimed to evaluate the ultrasound classification of cervical adenopathy to choose the appropriate diagnostic method and match the pathology results. Materials and Methods This study was conducted on 294 patients with cervical adenopathy who were referred to a clinic affiliated with Omid Hospital of Medical Sciences Mashhad University during 2020-2021 after obtaining the Code of Ethics Committee (IR. mums. medical. Rec. 1400.257). The patients with cervical adenopathy without known cancer or patients referred for the staging of known cancer were included in the study. Patients with reactive lymph nodes caused by thyroiditis and acute infections and patients whose follow-up, cytology, or pathology results were not available were excluded from the study. Gray scale and Doppler ultrasound were performed using an Esoate-class C machine with a 16-8 MHz probe by a single examiner experienced in head and neck sonography. Ultrasound variables such as location, short axis diameter, long axis diameter, shape, border, cortical echogenicity, visibility of the echogenic hilum, cortex echogenicity, existence of necrotic/cystic changes, calcification, and vascular pattern of lymph nodes were recorded. Normal cervical lymph nodes are oval with echogenic hilum and symmetrical cortex and hilar blood flow, the largest of which is one or two prominent lymph nodes in the jugulo-digastric area with a short axis diameter (SAD) about 1 centimeter and smaller. In other cervical levels, lymph nodes are not prominent. Sometimes one slightly larger lymph node is observed at the junction of the thoracic duct and subclavian vein in the left fourth level of the neck, although it is smaller than normal lymph nodes of the jugulo-digastric region. A prominent enlarged lymph node outside this pattern was considered adenopathy, especially in levels 3, (...truncated)