Ultrasound-based Node-RADS: Introducing a new Scoring System for Ultrasound-based Classification of Lymphadenopathy

Original Article Iranian Journal of Otorhinolaryngology, Vol.37(4), Serial No.141, Jul-2025 Ultrasound-based Node-RADS: Introducing a new Scoring System for Ultrasound-based Classification of Lymphadenopathy Amir Mohammad Heravi1, Fatemeh Hataminia2, Bashir Rasoulian3, Maryam Tavakoli1, Narjes Sadat Yaghobi 1, Amir Hossein Jafarian4, *Seyed Ali Alamdaran1 Abstract Introduction: Lymphadenopathy often causes anxiety due to its association with malignancy or serious infections. This study investigates the role of ultrasound features in distinguishing benign from malignant neck lymphadenopathy and proposes a quantitative scoring system (Node-RADS). Materials and Methods: This cross-sectional study was conducted at Omid Hospital, Mashhad University of Medical Sciences, Iran. Seven hundred ninety-one patients with neck lymphadenopathy underwent gray-scale and Doppler ultrasound, followed by fine needle aspiration (FNA) or core needle biopsy (CNB) for cytopathological confirmation. Key ultrasound features assessed included Short-Axis Diameter (SAD), Cortical/Hilar Echotexture, and Vascular patterns. A scoring system was developed by assigning malignancy coefficients to each variable. Malignancy coefficients (Wi) were assigned based on the prevalence of malignancy for each feature, and a quantitative Node-RADS score was derived. Diagnostic accuracy was evaluated using ROC analysis. Results: Of 791 patients, 68.5% (542) had malignant lymphadenopathy, predominantly metastases (57.1%, 452). Malignancy coefficients (Wi = 9) were extracted to high-risk features: SAD >16 mm (82% malignancy), Isoechoic cortex with compressed hilum (89%), and non-hilar vascularity (91%). The proposed Node-RADS system achieved an AUC of 0.85 (95% CI: 0.817–0.889), demonstrating strong diagnostic performance. Conclusion: The proposed ultrasound-based Node-RADS scoring system correlates significantly with pathologic results, offering an appropriate tool for evaluating cervical superficial lymphadenopathy. Keywords: Lymphadenopathy classification, Ultrasound, Node- Reporting and Data System (NodeRADS). Received date: 05 Feb 2025 Accepted date: 26 May 2025 *Please cite this article; Heravi AM, Hataminia F, Rasoulian B, Tavakoli M, Yaghobi al N, Jafarian AH, Alamdaran SA. Ultrasound-based classification of Lymphadenopathy: Introducing a new scoring system for Ultrasound-based Node-RADS Iran J Otorhinolaryngol. 2025:37(4):169-177. Doi: 10.22038/ijorl.2025.85674.3883 1Department of Radiology, Mashhad University of Medical Sciences, Mashhad, Iran. of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran. 3 Department of ENT, Mashhad University of Medical Sciences, Mashhad, Iran. 4Department of Pathology, Mashhad University of Medical Sciences, Mashhad, Iran. Corresponding Author: Department of Radiology, Mashhad University of Medical Sciences, Mashhad, Iran. E-mail: 2Faculty Copyright©2025 Mashhad University of Medical Sciences. This work is licensed under a Creative Commons Attribution-Noncommercial 4.0 International License https://creativecommons.org/licenses/by-nc/4.0/deed.en 169 Heravi AM, et al Introduction Lymphadenopathy is a common clinical finding. Its importance is due to its association with malignancy or severe infections. While most cases are benign, accurate differentiation is critical for cancer staging (TNM; Tumor, Node, Metastasis) and management. Clinicians must carefully determine whether immediate invasive intervention is necessary or whether clinical observation and follow-up are sufficient (1,2). In addition to history-taking and physical examination, patients typically undergo complementary diagnostic evaluations, including laboratory tests and imaging studies such as ultrasound, chest X-ray, CT scans, Fine Needle Aspiration, and Core Needle Biopsy (3– 5). While a definitive diagnosis requires histopathological examination, invasive procedures such as biopsies can place significant physical and emotional burdens on patients. Imaging modalities, particularly ultrasound, play a key role in non-invasive evaluation due to their accessibility and high resolution in superficial regions like the neck (3-7). In recent years, in many organs, lesions have been classified based on the risk of malignancy using standardized classification systems such as the ACR-RADS series. These systems help improve diagnostic accuracy, guide treatment decisions, facilitate better physician communication, prevent overtreatment, and support more rigorous scientific research (8). Given the high prevalence and varied causes of lymphadenopathy, a standardized classification system - such as the NodeReporting and Data System (Node-RADS) would be beneficial. However, most existing Node-RADS classification is based on CT and MRI findings, using "size" and "configuration" as key criteria to classify nodes from 1 ("very low probability") to 5 ("very high probability"). Similar to other classifications, these systems categorize lymph nodes based on their likelihood of malignancy (9-17). However, existing research on ultrasound-based NodeRADS has limited support and requires further research, particularly in ultrasound-based applications. Since the neck is a common site for both malignant and inflammatory lymphadenopathy and the use of highresolution ultrasound (>10 MHz) in this area, a standardized ultrasound-based Node-RADS system could be especially valuable. To date, only three ultrasound-based lymph node classification systems have been reported in the literature: the Cervical Lymph Node Imaging Reporting and Data System (CLN-RADS), the Adenopathy Reporting and Data System (ARADS), and the Lymph Node Reporting and Data System (LN-RADS) (2,18,19). CLNRADS is considered outdated, and A-RADS is primarily qualitative. The A-RADS study showed that features such as increased short axis, absence of a hilum with isoechoic cortex, and presence of non-hilar vessels were significantly more common in malignant lymph nodes than benign ones. This study classified cervical lymph nodes into four groups: normal, reactive, suspicious/lymphatic abnormalities, and metastatic (19). This study aimed to evaluate the diagnostic value of specific ultrasound features in differentiating types of cervical lymphadenopathy and propose a quantitative, ultrasound-based scoring system. Materials and Methods This study investigated neck lymphadenopathy in patients referred to the radiology Clinic at Omid Hospital, Mashhad University of Medical Sciences. The institution’s Ethics Committee approved the study protocol (IR. MUMS.IRH. REC.1403.070). Informed consent was obtained from all participants. All patient information was anonymized using coded identifiers for data analysis, and results were reported in aggregate to preserve confidentiality. Initially, demographic information of 791 patients, such as age and gender, was recorded. Participants underwent gray-scale and Doppler ultrasound imaging using an Esaote Class C ultrasound s (...truncated)