Clinical value of imaging for lymph nodes evaluation with particular emphasis on ultrasonography

L. Chiorean; X. W. Cui; S. A. Klein; J. Budjan; Z. Sparchez; M. Radzina; C. Jenssen; Y. Dong; C. F. Dietrich

doi:10.1055/s-0042-108656

Zeitschrift für Gastroenterologie, Table of Contents

Z Gastroenterol 2016; 54(08): 774-790
DOI: 10.1055/s-0042-108656

Übersicht

Clinical value of imaging for lymph nodes evaluation with particular emphasis on ultrasonography

Klinische Wertigkeit der Bildgebung bei der Abklärung von Lymphknotenerkrankungen unter besonderer Berücksichtigung der Sonografie

L. Chiorean

¹Medizinische Klinik 2, Caritas-Krankenhaus, Bad Mergentheim, Germany

²Département d’imagerie médicale, Clinique des Cévennes, France

,

X. W. Cui

¹Medizinische Klinik 2, Caritas-Krankenhaus, Bad Mergentheim, Germany

³Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China

,

S. A. Klein

⁴III. Medizinische Klinik, Universitätsmedizin Mannheim

,

J. Budjan

⁵Department of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University

,

Z. Sparchez

⁶3rd Medical Department, Institute for Gastroenterology and Hepatology, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania

,

M. Radzina

⁷Diagnostic Radiology Institute, Paula Stradina Clinical University Hospital, Riga, Latvia

,

C. Jenssen

⁸Medical Department, Krankenhaus Märkisch Oderland, Strausberg, Germany

,

Y. Dong

¹Medizinische Klinik 2, Caritas-Krankenhaus, Bad Mergentheim, Germany

,

C. F. Dietrich

¹Medizinische Klinik 2, Caritas-Krankenhaus, Bad Mergentheim, Germany

› Author Affiliations

Abstract

Enlarged or irregular lymph nodes (LNs) are clinical and imaging findings in a large variety of malignant and non-malignant diseases. A comprehensive diagnostic work up is usually necessary in order to differentiate the benign or the malignant nature of the altered LNs. The diagnosis has to be made using all clinical information and, if necessary, assessed LNs need to be biopsied and further, histologically or microbiologically characterized. However, imaging techniques, and particularly ultrasonography (US), are essential on the way to the final diagnosis, from initial detection and characterization to follow-up of biopsy guidance. Computed-tomography (CT) and/or magnetic resonance imaging (MRI) are of great value for oncological diseases staging and treatment monitoring. Imaging techniques are helpful in distinguishing between benign and malignant LNs disease as well as between LNs metastases and lymphoma in most cases. Furthermore, imaging can define the extent and distribution of malignant diseases. It may assist, through the use of particular techniques such as elastography, to identify the most suspicious LN to be biopsied and to guide targeted biopsies from the most suspicious areas. It also serves as the main tool for the evaluation of treatment response in malignant diseases. The quality of LNs imaging has remarkably improved in recent years. New methods, such as contrast-enhanced ultrasonography (CEUS), elastography, positron emission tomography (PET)/PET-CT, as well as diffusion weighted imaging (DWI) in MRI, have already led to substantial changes in clinical practice. This review describes the most recent imaging techniques for LNs assessment, and their particular clinical value, with a special emphasis on the role of US techniques. Strengths and weaknesses of different imaging tools are discussed comprehensively, highlighting the importance of a corroborative attitude for successful management of each particular case.

Zusammenfassung

Vergrößerte oder abnorme Lymphknoten (LK) finden sich bildgebend bei einer Vielzahl maligner und nicht-maligner Krankheitsbilder. Zur Klärung der Dignität ist regelhaft eine umfassende diagnostische Aufarbeitung erforderlich, die neben einer gründlichen Anamnese und klinischen Untersuchung in vielen Fällen auch eine mikrobiologische und histologische Untersuchung von Biopsaten einschließen wird. Bildgebende Verfahren und insbesondere die Sonografie sind essenzielle Bestandteile des diagnostischen Vorgehens – von der Detektion über die Charakterisierung bis hin zur gezielten Durchführung der Biopsie. Computertomografie (CT) und/oder Magnetresonanztomografie (MRT) haben einen großen Stellenwert für das Staging und die Therapieüberwachung. Bildgebende Methoden werden auch mit dem Ziel eingesetzt, zwischen benignen und malignen Lymphknoten sowie zwischen Karzinommetastasen und malignem Lymphombefall zu differenzieren. Bei malignen Erkrankungen können darüber hinaus Ausmaß und Verteilungmuster evaluiert werden. Elastografische Methoden können diejenigen Lymphknoten oder Lymphknotenareale definieren, aus denen eine bildgebend gestützte Biopsie am Erfolg versprechendsten ist. Bildgebung ist auch die wichtigste Grundlage für die Bewertung des Therapieansprechens. Die Qualität der LK-Bildgebung hat sich in den letzten Jahren deutlich verbessert. Neue Methoden wie kontrastverstärkte Sonografie (CEUS), Elastografie, Positronenemissionstomografie (PET) und PET-CT sowie diffusionsgewichtete MRT-Bildgebung haben bereits in der klinischen Praxis Gewicht erlangt. Unter besonderer Berücksichtigung sonografischer Verfahren beschreibt diese Übersicht die aktuellen Methoden der LK-Bildgebung sowie ihren Stellenwert in der klinischen Praxis und empfiehlt unter Berücksichtigung der spezifischen Stärken und Schwächen der verfügbaren Methoden ihren komplementären Einsatz.

Schlüsselworter

Bildgebung - kontrastverstärkte Sonografie - Elastografie - Computertomografie - Magnetresonanztomografie - diffusionsgewichtete Bildgebung - Positronenemissionstomografie

Key words

imaging - contrast-enhanced ultrasound - elastography - computed tomography - magnetic resonance imaging - diffusion weighted imaging - positron emission tomography

Full Text

References

References
1 Sidhu PS. Multiparametric Ultrasound (MPUS) Imaging: Terminology describing the many aspects of ultrasonography. Ultraschall in Med 2015; 36: 315-317
2 Cui XW, Hocke M, Jenssen C et al. Conventional ultrasound for lymph node evaluation, update 2013. Z Gastroenterol 2014; 52: 212-221
3 Rettenbacher T. Sonography of peripheral lymph nodes part 2: Doppler criteria and typical findings of distinct entities. Ultraschall in Med 2014 ; 35: 10-27
4 Bruneton JN, Balu-Maestro C, Marcy PY et al. Very high frequency (13 MHz) ultrasonographic examination of the normal neck: Detection of normal lymph nodes and thyroid nodules. J Ultrasound Med 1994; 13: 87-90
5 Schwartz LH, Bogaerts J, Ford R et al. Evaluation of lymph nodes with RECIST 1.1. Eur J Cancer 2009; 45: 261-267
6 Furukawa MK, Furukawa M. Diagnosis of lymph node metastases of head and neck cancer and evaluation of effects of chemoradiotherapy using ultrasonography. Int J Clin Oncol 2010 ; 15: 23-32
7 Wunderbaldinger P, Harisinghani MG, Hahn PF et al. Cystic lymph node metastases in papillary thyroid carcinoma. Am J Roentgenol 2002 ; 178: 693-697
8 Yang WT, Lam WW, Yu MY et al. Comparison of dynamic helical CT and dynamic MR imaging in the evaluation of pelvic lymph nodes in cervical carcinoma. Am J Roentgenol 2000 ; 175: 759-766
9 Scatarige JC, Fishman EK, Kuhajda FP et al. Low attenuation nodal metastases in testicular carcinoma. J Comput Assist Tomogr 1983 ; 7: 682-687
10 Brown G, Richards CJ, Bourne MW et al. Morphologic predictors of lymph node status in rectal cancer with use of high-spatial-resolution MR imaging with histopathologic comparison. Radiology 2003 ; 227: 371-377
11 Ganeshalingam S, Koh DM. Nodal staging. Cancer Imaging 2009; 9: 104-111
12 Cui XW, Jenssen C, Saftoiu A et al. New ultrasound techniques for lymph node evaluation. World J Gastroenterol 2013; 19: 4850-4860
13 Steinkamp HJ, Cornehl M, Hosten N et al. Cervical lymphadenopathy: Ratio of long- to short-axis diameter as a predictor of malignancy. Br J Radiol 1995 ; 68 (807) 266-270
14 Griffith JF, Chan AC, Ahuja AT et al. Neck ultrasound in staging squamous oesophageal carcinoma—a high yield technique. Clin Radiol 2000 ; 55: 696-701
15 Einstein DM, Singer AA, Chilcote WA et al. Abdominal lymphadenopathy: Spectrum of CT findings. Radiographics 1991 ; 11: 457-472
16 Glazer GM, Gross BH, Quint LE et al. Normal mediastinal lymph nodes: Number and size according to American Thoracic Society mapping. Am J Roentgenol 1985 ; 144: 261-265
17 Eisenhauer EA, Therasse P, Bogaerts J et al. New response evaluation criteria in solid tumours: Revised RECIST guideline (version 1.1). Eur J Cancer 2009; 45: 228-247
18 Dietrich CF. Endoscopic Ultrasound. An Introductory Manual and Atlas. Stuttgart: Thieme Verlag; 2008
19 Hocke M, Menges M, Topalidis T et al. Contrast-enhanced endoscopic ultrasound in discrimination between benign and malignant mediastinal and abdominal lymph nodes. J Cancer Res Clin Oncol 2008 ; 134: 473-480
20 Ying M, Ahuja A. Sonography of neck lymph nodes. Part I: normal lymph nodes. Clin Radiol 2003; 58: 351-358
21 Sakaguchi T, Yamashita Y, Katahira K et al. Differential diagnosis of small round cervical lymph nodes: Comparison of power Doppler US with contrast-enhanced CT and pathologic results. Radiat Med 2001 ; 19: 119-125
22 Na DG, Lim HK, Byun HS et al. Differential diagnosis of cervical lymphadenopathy: Usefulness of color Doppler sonography. Am J Roentgenol 1997 ; 168: 1311-1316
23 Ying M, Ahuja A, Brook F et al. Power Doppler sonography of normal cervical lymph nodes. J Ultrasound Med 2000 ; 19: 511-517
24 Steinkamp HJ, Teichgraber UK, Mueffelmann M et al. Differential diagnosis of lymph node lesions. A semiquantitative approach with power Doppler sonography. Invest Radiol 1999; 34: 509-515
25 Wu CH, Chang YL, Hsu WC et al. Usefulness of Doppler spectral analysis and power Doppler sonography in the differentiation of cervical lymphadenopathies. Am J Roentgenol 1998 ; 171: 503-509
26 Wu CH, Shih JC, Chang YL et al. Two-dimensional and three-dimensional power Doppler sonographic classification of vascular patterns in cervical lymphadenopathies. J Ultrasound Med 1998 ; 17: 459-464
27 Wu CH, Hsu MM, Chang YL et al. Vascular pathology of malignant cervical lymphadenopathy: Qualitative and quantitative assessment with power Doppler ultrasound. Cancer 1998; 83: 1189-1196
28 Jenssen C, Dietrich CF. Endoscopic ultrasound-guided fine-needle aspiration biopsy and trucut biopsy in gastroenterology—an overview. Best Pract Res Clin Gastroenterol 2009; 23: 743-759
29 Dietrich CF, Cui XW, Schreiber-Dietrich DG et al. EFSUMB guidelines 2011: Comments and illustrations. Ultraschall in Med 2012 ; 33: S11-S21
30 Cui XW, Ignee A, Bachmann NM et al. Contrast enhanced ultrasound of sentinel lymph nodes. J Ultrason 2013; 13: 73-81
31 Paterson S, Duthie F, Stanley AJ. Endoscopic ultrasound-guided elastography in the nodal staging of oesophageal cancer. World J Gastroenterol 2012; 18: 889-895
32 Bhatia KS, Lee YY, Yuen EH et al. Ultrasound elastography in the head and neck. Part II. Accuracy for malignancy. Cancer Imaging 2013; 13: 260-276
33 Lo WC, Cheng PW, Wang CT et al. Real-time ultrasound elastography: An assessment of enlarged cervical lymph nodes. Eur Radiol 2013 ; 23: 2351-2357
34 Dietrich CF, Saftoiu A, Jenssen C. Real time elastography endoscopic ultrasound (RTE-EUS), a comprehensive review. Eur J Radiol 2014 ; 83: 405-414
35 Edge SB, Compton CC. The American Joint Committee on Cancer: The 7th edition of the AJCC cancer staging manual and the future of TNM. Ann Surg Oncol 2010 ; 17: 1471-1474
36 Ahuja A, Ying M. An overview of neck node sonography. Invest Radiol 2002 ; 37: 333-342
37 Jank S, Robatscher P, Emshoff R et al. The diagnostic value of ultrasonography to detect occult lymph node involvement at different levels in patients with squamous cell carcinoma in the maxillofacial region. Int J Oral Maxillofac Surg 2003 ; 32: 39-42
38 Yarbro JW, Page DL, Fielding LP et al. American Joint Committee on Cancer prognostic factors consensus conference. Cancer 1999; 86: 2436-2446
39 Yang WT, Goldberg BB. Microbubble contrast-enhanced ultrasound for sentinel lymph node detection: Ready for prime time?. Am J Roentgenol 2011 ; 196: 249-250
40 Xing Y, Bronstein Y, Ross MI et al. Contemporary diagnostic imaging modalities for the staging and surveillance of melanoma patients: A meta-analysis. J Natl Cancer Inst 2011; 103: 129-142
41 Torabi M, Aquino SL, Harisinghani MG. Current concepts in lymph node imaging. J Nucl Med 2004 ; 45: 1509-1518
42 Sakai F, Kiyono K, Sone S et al. Ultrasonic evaluation of cervical metastatic lymphadenopathy. J Ultrasound Med 1988 ; 7: 305-310
43 Roberts SA, Mahon BS, Evans R. Coagulation necrosis in malignant mediastinal nodes on endoscopic ultrasound: A new endosonographic sign. Clin Radiol 2005 ; 60: 587-591
44 Ying M, Ahuja AT, Evans R et al. Cervical lymphadenopathy: Sonographic differentiation between tuberculous nodes and nodal metastases from non-head and neck carcinomas. J Clin Ultrasound 1998 ; 26: 383-389
45 Bhutani MS, Saftoiu A, Chaya C et al. Irregular echogenic foci representing coagulation necrosis: A useful but perhaps under-recognized EUS echo feature of malignant lymph node invasion. J Gastrointestin Liver Dis 2009 ; 18: 181-184
46 Fujiwara T, Yasufuku K, Nakajima T et al. The utility of sonographic features during endobronchial ultrasound-guided transbronchial needle aspiration for lymph node staging in patients with lung cancer: A standard endobronchial ultrasound image classification system. Chest 2010 ; 138: 641-647
47 Bipat S, Glas AS, van der Velden J et al. Computed tomography and magnetic resonance imaging in staging of uterine cervical carcinoma: A systematic review. Gynecol Oncol 2003; 91: 59-66
48 Yoshimura G, Sakurai T, Oura S et al. Evaluation of Axillary Lymph Node Status in Breast Cancer with MRI. Breast Cancer 1999; 6: 249-258
49 Dietrich CF, Bojunga J. Ultrasound of the Thyroid. Laryngorhinootologie 2016 ; 95: 87-104
50 Friedrich-Rust M, Vorlaender C, Dietrich CF et al. Evaluation of Strain Elastography for Differentiation of Thyroid Nodules: Results of a Prospective DEGUM Multicenter Study. Ultraschall in Med 2016; epub in advance
51 Eichenauer DA, Engert A, Dreyling M. Hodgkin's lymphoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2011 ; 22: vi55-vi58
52 Guermazi A, Brice P, Hennequin C et al. Lymphography: An old technique retains its usefulness. Radiographics 2003 ; 23: 1541-1558
53 Sohn KM, Lee JM, Lee SY et al. Comparing MR imaging and CT in the staging of gastric carcinoma. Am J Roentgenol 2000 ; 174: 1551-1557
54 Curtin HD, Ishwaran H, Mancuso AA et al. Comparison of CT and MR imaging in staging of neck metastases. Radiology 1998 ; 207: 123-130
55 Matsukuma K, Tsukamoto N, Matsuyama T et al. Preoperative CT study of lymph nodes in cervical cancer—Its correlation with histological findings. Gynecol Oncol 1989 ; 33: 168-171
56 De Leyn P, Lardinois D, Van Schil PE et al. ESTS guidelines for preoperative lymph node staging for non-small cell lung cancer. Eur J Cardiothorac Surg 2007 ; 32: 1-8
57 Kim SH, Choi BI, Lee HP et al. Uterine cervical carcinoma: Comparison of CT and MR findings. Radiology 1990 ; 175: 45-51
58 Davis GL. Sensitivity of frozen section examination of pelvic lymph nodes for metastatic prostate carcinoma. Cancer 1995; 76: 661-668
59 Brnic Z, Hebrang A. Usefulness of Doppler waveform analysis in differential diagnosis of cervical lymphadenopathy. Eur Radiol 2003 ; 13: 175-180
60 Choi MY, Lee JW, Jang KJ. Distinction between benign and malignant causes of cervical, axillary, and inguinal lymphadenopathy: Value of Doppler spectral waveform analysis. Am J Roentgenol 1995 ; 165: 981-984
61 Ignee A, Boerner N, Bruening A et al. Duplexsonography of the mesenteric vessels—A critical evaluation of inter observer variability. Z Gastroenterol 2016 ; 54: 304-311
62 Magarelli N, Guglielmi G, Savastano M et al. Superficial inflammatory and primary neoplastic lymphadenopathy: Diagnostic accuracy of power-Doppler sonography. Eur J Radiol 2004 ; 52: 257-263
63 Ho SS, Metreweli C, Ahuja AT. Does anybody know how we should measure Doppler parameters in lymph nodes?. Clin Radiol 2001 ; 56: 124-126
64 Ahuja AT, Ying M. Sonographic evaluation of cervical lymph nodes. Am J Roentgenol 2005 ; 184: 1691-1699
65 Steinkamp HJ, Beck A, Werk M et al. Extracapsular spread of cervical lymph node metastases: diagnostic relevance of ultrasound examinations. Ultraschall in Med 2003; 24: 323-330
66 Barentsz JO, Jager GJ, van Vierzen PB et al. Staging urinary bladder cancer after transurethral biopsy: Value of fast dynamic contrast-enhanced MR imaging. Radiology 1996; 201: 185-193
67 Noworolski SM, Fischbein NJ, Kaplan MJ et al. Challenges in dynamic contrast-enhanced MRI imaging of cervical lymph nodes to detect metastatic disease. J Magn Reson Imaging 2003; 17: 455-462
68 Husband JE, Koh DM. Bladder cancer. In: Husband JE, Reznek RH, eds. Imaging in Oncology. London: Martin Dunitz Ltd; 2004: 343-374
69 Marone U, Catalano O, Caraco C et al. Can high-resolution ultrasound avoid the sentinel lymph-node biopsy procedure in the staging process of patients with stage I-II cutaneous melanoma?. Ultraschall in Med 2012; 33: E179-E185
70 Som PM. Lymph nodes of the neck. Radiology 1987; 165: 593-600
71 Sumi M, Sakihama N, Sumi T et al. Discrimination of metastatic cervical lymph nodes with diffusion-weighted MR imaging in patients with head and neck cancer. Am J Neuroradiol 2003; 24: 1627-1634
72 Martinez Barbero JP, Rodriquez JI, Martin NT et al. Utility of MRI diffusion techniques in the evaluation of tumors of the head and neck. Cancers (Basel) 2013; 5: 875-889
73 Abdel Razek AA, Soliman NY, Elkhamary S et al. Role of diffusion-weighted MR imaging in cervical lymphadenopathy. Eur Radiol 2006; 16: 1468-1477
74 Koh DM, Brown G, Temple L et al. Rectal cancer: Mesorectal lymph nodes at MR imaging with USPIO versus histopathologic findings—initial observations. Radiology 2004; 231: 91-99
75 Koh DM, George C, Temple L et al. Diagnostic accuracy of nodal enhancement pattern of rectal cancer at MRI enhanced with ultrasmall superparamagnetic iron oxide: Findings in pathologically matched mesorectal lymph nodes. Am J Roentgenol 2010; 194: W505-W513
76 Lahaye MJ, Engelen SM, Kessels AG et al. USPIO-enhanced MR imaging for nodal staging in patients with primary rectal cancer: Predictive criteria. Radiology 2008; 246: 804-811
77 Memarsadeghi M, Riedl CC, Kaneider A et al. Axillary lymph node metastases in patients with breast carcinomas: Assessment with nonenhanced versus uspio-enhanced MR imaging. Radiology 2006; 241: 367-377
78 Esen G. Ultrasound of superficial lymph nodes. Eur J Radiol 2006; 58: 345-359
79 Hajek PC, Salomonowitz E, Turk R et al. Lymph nodes of the neck: Evaluation with US. Radiology 1986; 158: 739-742
80 Ahuja A, Ying M. Sonography of neck lymph nodes. Part II: Abnormal lymph nodes. Clin Radiol 2003; 58: 359-366
81 Sumi M, Ohki M, Nakamura T. Comparison of sonography and CT for differentiating benign from malignant cervical lymph nodes in patients with squamous cell carcinoma of the head and neck. Am J Roentgenol 2001; 176: 1019-1024
82 Sharma A, Fidias P, Hayman LA et al. Patterns of lymphadenopathy in thoracic malignancies. Radiographics 2004; 24: 419-434
83 Yu M, Liu Q, Song HP et al. Clinical application of contrast-enhanced ultrasonography in diagnosis of superficial lymphadenopathy. J Ultrasound Med 2010; 29: 735-740
84 Rettenbacher T. Sonography of peripheral lymph nodes part 1: Normal findings and B-image criteria. Ultraschall in Med 2010; 31: 344-362
85 Piscaglia F, Nolsoe C, Dietrich CF et al. The EFSUMB Guidelines and Recommendations on the Clinical Practice of Contrast Enhanced Ultrasound (CEUS): Update 2011 on non-hepatic applications. Ultraschall in Med 2012; 33: 33-59
86 Ahuja AT, Ying M, Ho SY et al. Ultrasound of malignant cervical lymph nodes. Cancer Imaging 2008; 8: 48-56
87 Solbiati L, Rizalto G, Belotti E. High resolution sonography of cervical lymph nodes in head and neck cancer: Criteria for differentiation of reactive versus malignant nodes. Radiology 1988; 169: P113
88 Vassallo P, Wernecke K, Roos N et al. Differentiation of benign from malignant superficial lymphadenopathy: The role of high-resolution US. Radiology 1992; 183: 215-220
89 Prenzel KL, Holscher AH, Drebber U et al. Prognostic impact of nodal micrometastasis in early esophageal cancer. Eur J Surg Oncol 2012; 38: 314-318
90 Prenzel KL, Monig SP, Sinning JM et al. Lymph node size and metastatic infiltration in non-small cell lung cancer. Chest 2003; 123: 463-467
91 Prenzel KL, Holscher AH, Vallbohmer D et al. Lymph node size and metastatic infiltration in adenocarcinoma of the pancreatic head. Eur J Surg Oncol 2010; 36: 993-996
92 Jenssen C, Dietrich CF, Burmester E. Malignant neoplasias of the gastrointestinal tract—Endosonographic staging revisited. Z Gastroenterol 2011; 49: 357-368
93 Moehler M, Al Batran SE, Andus T et al. German S3-guideline “Diagnosis and treatment of esophagogastric cancer”. Z Gastroenterol 2011; 49: 461-531
94 Jurgensen C, Dietrich CF. Role of endoscopic ultrasound (EUS) in the staging of rectal cancer. Z Gastroenterol 2008; 46: 580-589
95 Ahuja A, Ying M. Sonographic evaluation of cervical lymphadenopathy: Is power Doppler sonography routinely indicated?. Ultrasound Med Biol 2003; 29: 353-359
96 Tschammler A, Heuser B, Ott G et al. Pathological angioarchitecture in lymph nodes: Underlying histopathologic findings. Ultrasound Med Biol 2000; 26: 1089-1097
97 Hocke M, Schulze E, Gottschalk P et al. Contrast-enhanced endoscopic ultrasound in discrimination between focal pancreatitis and pancreatic cancer. World J Gastroenterol 2006; 12: 246-250
98 Tschammler A, Wirkner H, Ott G et al. Vascular patterns in reactive and malignant lymphadenopathy. Eur Radiol 1996; 6: 473-480
99 Moore A, Hester M, Nam MW et al. Distinct lymph nodal sonographic characteristics in breast cancer patients at high risk for axillary metastases correlate with the final axillary stage. Br J Radiol 2008; 81: 630-636
100 Esen G, Gurses B, Yilmaz MH et al. Gray scale and power Doppler US in the preoperative evaluation of axillary metastases in breast cancer patients with no palpable lymph nodes. Eur Radiol 2005; 15: 1215-1223
101 Giovagnorio F, Caiazzo R, Avitto A. Evaluation of vascular patterns of cervical lymph nodes with power Doppler sonography. J Clin Ultrasound 1997; 25: 71-76
102 Tschammler A, Gunzer U, Reinhart E et al. The diagnostic assessment of enlarged lymph nodes by the qualitative and semiquantitative evaluation of lymph node perfusion with color-coded duplex sonography. Rofo 1991; 154: 414-418
103 Matsuoka H, Masaki T, Sugiyama M et al. Morphological characteristics of lateral pelvic lymph nodes in rectal carcinoma. Langenbecks Arch Surg 2007; 392: 543-547
104 Anzai Y, Piccoli CW, Outwater EK et al. Evaluation of neck and body metastases to nodes with ferumoxtran 10-enhanced MR imaging: Phase III safety and efficacy study. Radiology 2003; 228: 777-788
105 Antoch G, Stattaus J, Nemat AT et al. Non-small cell lung cancer: Dual-modality PET/CT in preoperative staging. Radiology 2003; 229: 526-533
106 Jager GJ, Barentsz JO, Oosterhof GO et al. Pelvic adenopathy in prostatic and urinary bladder carcinoma: MR imaging with a three-dimensional TI-weighted magnetization-prepared-rapid gradient-echo sequence. Am J Roentgenol 1996; 167: 1503-1507
107 Gross BH, Glazer GM, Orringer MB et al. Bronchogenic carcinoma metastatic to normal-sized lymph nodes: Frequency and significance. Radiology 1988; 166: 71-74
108 Kayser K, Bach S, Bulzebruck H et al. Site, size, and tumour involvement of resected extrapulmonary lymph nodes in lung cancer. J Surg Oncol 1990; 43: 45-49
109 Staples CA, Muller NL, Miller RR et al. Mediastinal nodes in bronchogenic carcinoma: Comparison between CT and mediastinoscopy. Radiology 1988; 167: 367-372
110 McLoud TC, Bourgouin PM, Greenberg RW et al. Bronchogenic carcinoma: Analysis of staging in the mediastinum with CT by correlative lymph node mapping and sampling. Radiology 1992; 182: 319-323
111 Barchetti F, Pranno N, Giraldi G et al. The role of 3 Tesla diffusion-weighted imaging in the differential diagnosis of benign versus malignant cervical lymph nodes in patients with head and neck squamous cell carcinoma. Biomed Res Int 2014; 2014: 532095
112 Lin G, Ho KC, Wang JJ et al. Detection of lymph node metastasis in cervical and uterine cancers by diffusion-weighted magnetic resonance imaging at 3T. J Magn Reson Imaging 2008; 28: 128-135
113 Kwee TC, Takahara T, Luijten PR et al. ADC measurements of lymph nodes: Inter- and intra-observer reproducibility study and an overview of the literature. Eur J Radiol 2010; 75: 215-220
114 Giannarini G, Petralia G, Thoeny HC. Potential and limitations of diffusion-weighted magnetic resonance imaging in kidney, prostate, and bladder cancer including pelvic lymph node staging: A critical analysis of the literature. Eur Urol 2012; 61: 326-340
115 Akduman EI, Momtahen AJ, Balci NC et al. Comparison between malignant and benign abdominal lymph nodes on diffusion-weighted imaging. Acad Radiol 2008; 15: 641-646
116 Grueneisen J, Schaarschmidt BM, Beiderwellen K et al. Diagnostic value of diffusion-weighted imaging in simultaneous 18F-FDG PET/MR imaging for whole-body staging of women with pelvic malignancies. J Nucl Med 2014; 55: 1930-1935
117 Dietrich CF, Lorentzen T, Sidhu PS et al. An introduction to the EFSUMB guidelines on Interventional Ultrasound (INVUS). Ultraschall in Med 2015; 36: 460-463
118 Dietrich CF. EFSUMB guidelines 2015 on interventional ultrasound. Med Ultrason 2015; 17: 521-527
119 Lorentzen T, Nolsoe CP, Ewertsen C et al. EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part I. General Aspects (Long Version). Ultraschall in Med 2015; 36: E1-E14
120 Lorentzen T, Nolsoe CP, Ewertsen C et al. EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part I. General Aspects (Short Version). Ultraschall in Med 2015; 36: 464-472
121 Sidhu PS, Brabrand K, Cantisani V et al. EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part II. Ultraschall in Med 2015; 36: E15-E35
122 Sidhu PS, Brabrand K, Cantisani V et al. EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part II. Ultraschall in Med 2015; 36: 566-580
123 Dietrich CF, Lorentzen T, Appelbaum L et al. EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part III. Ultraschall in Med 2016; 37: 27-45
124 Dietrich CF, Lorentzen T, Appelbaum L et al. EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part III. Ultraschall in Med 2016; 37: E1-E32
125 Fusaroli P, Jenssen C, Hocke M et al. EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part V. Ultraschall in Med 2015; 6 , In press
126 Jenssen C, Hocke M, Fusaroli P et al. EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part IV—EUS-guided interventions: General Aspects and EUS-guided Sampling (Short Version). Ultraschall in Med 2016; 37: 157-169
127 Jenssen C, Hocke M, Fusaroli P et al. EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part IV—EUS-guided interventions: General aspects and EUS-guided sampling (Long Version). Ultraschall in Med 2016; 37: E33-E76
128 Jenssen C, Brkljacic B, Hocke M et al. EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part VI—Ultrasound-guided vascular interventions. Ultraschall in Med 2015; 6 , In press
129 Dietrich CF, Cui XW, Chiorean L et al. Local ablative procedures of the liver. Z Gastroenterol 2015; 53: 579-590
130 Dietrich CF, Chiorean L, Potthoff A et al. Percutaneous sclerotherapy of liver and renal cysts, comments on the EFSUMB guidelines. Z Gastroenterol 2016; 54: 155-166
131 Albrecht T, Blomley M, Bolondi L et al. Guidelines for the use of contrast agents in ultrasound. January 2004. Ultraschall in Med 2004; 25: 249-256
132 Claudon M, Cosgrove D, Albrecht T et al. Guidelines and good clinical practice recommendations for contrast enhanced ultrasound (CEUS)—Update 2008. Ultraschall in Med 2008; 29: 28-44
133 Claudon M, Dietrich CF, Choi BI et al. Guidelines and good clinical practice recommendations for Contrast Enhanced Ultrasound (CEUS) in the liver—Update 2012: A WFUMB-EFSUMB initiative in cooperation with representatives of AFSUMB, AIUM, ASUM, FLAUS and ICUS. Ultrasound Med Biol 2013; 39: 187-210
134 Claudon M, Dietrich CF, Choi BI et al. Guidelines and good clinical practice recommendations for contrast enhanced ultrasound (CEUS) in the liver—Update 2012: A WFUMB-EFSUMB initiative in cooperation with representatives of AFSUMB, AIUM, ASUM, FLAUS and ICUS. Ultraschall in Med 2013; 34: 11-29
135 Schmid-Wendtner MH, Partscht K, Korting HC et al. Improved differentiation of benign and malignant lymphadenopathy in patients with cutaneous melanoma by contrast-enhanced color Doppler sonography. Arch Dermatol 2002; 138: 491-497
136 Yang WT, Metreweli C, Lam PK et al. Benign and malignant breast masses and axillary nodes: Evaluation with echo-enhanced color power Doppler US. Radiology 2001; 220: 795-802
137 Rubaltelli L, Beltrame V, Tregnaghi A et al. Contrast-enhanced ultrasound for characterizing lymph nodes with focal cortical thickening in patients with cutaneous melanoma. Am J Roentgenol 2011; 196: W8-W12
138 Ouyang Q, Chen L, Zhao H et al. Detecting metastasis of lymph nodes and predicting aggressiveness in patients with breast carcinomas. J Ultrasound Med 2010; 29: 343-352
139 Schulte-Altedorneburg G, Demharter J, Linne R et al. Does ultrasound contrast agent improve the diagnostic value of colour and power Doppler sonography in superficial lymph node enlargement?. Eur J Radiol 2003; 48: 252-257
140 Schmid-Wendtner MH, Dill-Muller D, Baumert J et al. Lymph node metastases in patients with cutaneous melanoma: Improvements in diagnosis by signal-enhanced color Doppler sonography. Melanoma Res 2004; 14: 269-276
141 Zenk J, Bozzato A, Steinhart H et al. Metastatic and inflammatory cervical lymph nodes as analyzed by contrast-enhanced color-coded Doppler ultrasonography: Quantitative dynamic perfusion patterns and histopathologic correlation. Ann Otol Rhinol Laryngol 2005; 114: 43-47
142 Stoeckelhuber BM, Wiesmann M, Berg SA et al. Sonography of enlarged lymph nodes: Pathogenetic categorization using contrast enhanced power Doppler sonography. Hautarzt 2006; 57: 610-617
143 Weskott HP. Emerging roles for contrast-enhanced ultrasound. Clin Hemorheol Microcirc 2008; 40: 51-71
144 Steppan I, Reimer D, Muller-Holzner E et al. Breast cancer in women: Evaluation of benign and malignant axillary lymph nodes with contrast-enhanced ultrasound. Ultraschall in Med 2010; 31: 63-67
145 Stramare R, Scagliori E, Mannucci M et al. The role of contrast-enhanced gray-scale ultrasonography in the differential diagnosis of superficial lymph nodes. Ultrasound Q 2010; 26: 45-51
146 Rubaltelli L, Beltrame V, Scagliori E et al. Potential use of contrast-enhanced ultrasound (CEUS) in the detection of metastatic superficial lymph nodes in melanoma patients. Ultraschall in Med 2014; 35: 67-71
147 Dietrich CF, Lembcke B, Jenssen C et al. Intestinal ultrasound in rare gastrointestinal diseases, Update, Part 1. Ultraschall in Med 2014; 35: 400-421
148 Dietrich CF, Lembcke B, Jenssen C et al. Intestinal Ultrasound in Rare Gastrointestinal Diseases, Update, Part 2. Ultraschall in Med 2015; 36: 428-456
149 Goldberg BB, Merton DA, Liu JB et al. Sentinel lymph nodes in a swine model with melanoma: Contrast-enhanced lymphatic US. Radiology 2004; 230: 727-734
150 Goldberg BB, Merton DA, Liu JB et al. Contrast-enhanced ultrasound imaging of sentinel lymph nodes after peritumoral administration of Sonazoid in a melanoma tumor animal model. J Ultrasound Med 2011; 30: 441-453
151 Sever A, Jones S, Cox K et al. Preoperative localization of sentinel lymph nodes using intradermal microbubbles and contrast-enhanced ultrasonography in patients with breast cancer. Br J Surg 2009; 96: 1295-1299
152 Omoto K, Matsunaga H, Take N et al. Sentinel node detection method using contrast-enhanced ultrasonography with sonazoid in breast cancer: Preliminary clinical study. Ultrasound Med Biol 2009; 35: 1249-1256
153 Sever AR, Mills P, Jones SE et al. Preoperative sentinel node identification with ultrasound using microbubbles in patients with breast cancer. Am J Roentgenol 2011; 196: 251-256
154 Nielsen KR. Studies on radionuclide imaging and contrast ultrasound for sentinel node diagnostics in breast cancer and melanoma. Dan Med Bull 2011; 58: B4225
155 Rue NK, Klyver H, Hougaard CA et al. Sentinel node detection in melanomas using contrast-enhanced ultrasound. Acta Radiol 2009; 50: 412-417
156 Wang Y, Wang W, Li J et al. Gray-scale contrast-enhanced ultrasonography of sentinel lymph nodes in a metastatic breast cancer model. Acad Radiol 2009; 16: 957-962
157 Sever AR, Mills P, Weeks J et al. Preoperative needle biopsy of sentinel lymph nodes using intradermal microbubbles and contrast-enhanced ultrasound in patients with breast cancer. Am J Roentgenol 2012; 199: 465-470
158 Cox K, Sever A, Jones S et al. Validation of a technique using microbubbles and contrast enhanced ultrasound (CEUS) to biopsy sentinel lymph nodes (SLN) in pre-operative breast cancer patients with a normal grey-scale axillary ultrasound. Eur J Surg Oncol 2013; 39: 760-765
159 Cox K, Weeks J, Mills P et al. Contrast-Enhanced Ultrasound Biopsy of Sentinel Lymph Nodes in Patients with Breast Cancer: Implications for Axillary Metastases and Conservation. Ann Surg Oncol 2016; 23: 58-64
160 Liu JB, Merton DA, Berger AC et al. Contrast-enhanced sonography for detection of secondary lymph nodes in a melanoma tumor animal model. J Ultrasound Med 2014; 33: 939-947
161 Gkegkes ID, Iavazzo C. Contrast Enhanced Ultrasound (CEU) Using microbubbles for sentinel lymph node biopsy in breast cancer: A systematic review. Acta Chir Belg 2015; 115: 212-218
162 Lyshchik A, Higashi T, Asato R et al. Cervical lymph node metastases: Diagnosis at sonoelastography—Initial experience. Radiology 2007; 243: 258-267
163 Giovannini M, Thomas B, Erwan B et al. Endoscopic ultrasound elastography for evaluation of lymph nodes and pancreatic masses: A multicenter study. World J Gastroenterol 2009; 15: 1587-1593
164 Cui XW, Chang JM, Kan QC et al. Endoscopic ultrasound elastography: Current status and future perspectives. World J Gastroenterol 2015; 21: 13212-13224
165 Dietrich CF, Cantisani V. Current status and perspectives of elastography. Eur J Radiol 2014; 83: 403-404
166 Dietrich CF. Elastography applications. Endo heute 2011; 24: 177-212
167 Chiorean L, Barr RG, Braden B et al. Transcutaneous ultrasound: Elastographic lymph node evaluation. Current clinical applications and literature review. Ultrasound Med Biol 2016; 42: 16-30
168 Dietrich CF, Jenssen C, Arcidiacono PG et al. Endoscopic ultrasound: Elastographic lymph node evaluation. Endosc Ultrasound 2015; 4: 176-190
169 Schreiber-Dietrich D, Pohl M, Cui XW et al. Perihepatic lymphadenopathy in children with chronic viral hepatitis. J Ultrason 2015; 15: 137-150
170 Schreiber-Dietrich D, Chiorean L, Cui XW et al. Particularities of Crohn's disease in pediatric patients: Current status and perspectives regarding imaging modalities. Expert Rev Gastroenterol Hepatol 2015; 9: 1313-1325
171 Cosgrove D, Piscaglia F, Bamber J et al. EFSUMB guidelines and recommendations on the clinical use of ultrasound elastography. Part 2: Clinical applications. Ultraschall in Med 2013; 34: 238-253
172 Bhatia KS, Tong CS, Cho CC et al. Shear wave elastography of thyroid nodules in routine clinical practice: Preliminary observations and utility for detecting malignancy. Eur Radiol 2012; 22: 2397-2406
173 Weskott HP. Ultrasound in the diagnostic management of malignant lymphomas. Radiologe 2012; 52: 347-359
174 Nakase K, Yamamoto K, Hiasa A et al. Contrast-enhanced ultrasound examination of lymph nodes in different types of lymphoma. Cancer Detect Prev 2006; 30: 188-191
175 Wei X, Li Y, Zhang S et al. The role of contrast-enhanced ultrasound (CEUS) in the early assessment of microvascularization in patients with aggressive B-cell lymphoma treated by rituximab-CHOP: A preliminary study. Clin Hemorheol Microcirc 2014; 58: 363-376
176 Kouvaraki MA, Shapiro SE, Fornage BD et al. Role of preoperative ultrasonography in the surgical management of patients with thyroid cancer. Surgery 2003; 134: 946-954
177 Cheng L, Zincke H, Blute ML et al. Risk of prostate carcinoma death in patients with lymph node metastasis. Cancer 2001; 91: 66-73
178 Chaudhry A, Williams S, Cook J et al. The real-time intra-operative evaluation of sentinel lymph nodes in breast cancer patients using One Step Nucleic Acid Amplification (OSNA) and implications for clinical decision-making. Eur J Surg Oncol 2014; 40: 150-157
179 Baatenburg de Jong RJ, Rongen RJ, De Jong PC et al. Screening for lymph nodes in the neck with ultrasound. Clin Otolaryngol Allied Sci 1988; 13: 5-9
180 Vassallo P, Edel G, Roos N et al. In-vitro high-resolution ultrasonography of benign and malignant lymph nodes. A sonographic-pathologic correlation. Invest Radiol 1993; 28: 698-705
181 Schroder W, Baldus SE, Monig SP et al. Lymph node staging of esophageal squamous cell carcinoma in patients with and without neoadjuvant radiochemotherapy: Histomorphologic analysis. World J Surg 2002; 26: 584-587
182 Monig SP, Zirbes TK, Schroder W et al. Staging of gastric cancer: Correlation of lymph node size and metastatic infiltration. Am J Roentgenol 1999; 173: 365-367
183 Monig SP, Baldus SE, Zirbes TK et al. Lymph node size and metastatic infiltration in colon cancer. Ann Surg Oncol 1999; 6: 579-581
184 Majer MC, Hess CF, Kolbel G et al. Small arteries in peripheral lymph nodes: A specific US sign of lymphomatous involvement. Radiology 1988; 168: 241-243
185 Cheson BD, Pfistner B, Juweid ME et al. Revised response criteria for malignant lymphoma. J Clin Oncol 2007; 25: 579-586
186 Juweid ME, Wiseman GA, Vose JM et al. Response assessment of aggressive non-Hodgkin's lymphoma by integrated International Workshop Criteria and fluorine-18-fluorodeoxyglucose positron emission tomography. J Clin Oncol 2005; 23: 4652-4661
187 Haioun C, Itti E, Rahmouni A et al. [18F]fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) in aggressive lymphoma: An early prognostic tool for predicting patient outcome. Blood 2005; 106: 1376-1381
188 Hutchings M, Loft A, Hansen M et al. Position emission tomography with or without computed tomography in the primary staging of Hodgkin's lymphoma. Haematologica 2006; 91: 482-489
189 Wirth A, Seymour JF, Hicks RJ et al. Fluorine-18 fluorodeoxyglucose positron emission tomography, gallium-67 scintigraphy, and conventional staging for Hodgkin's disease and non-Hodgkin's lymphoma. Am J Med 2002; 112: 262-268
190 Jerusalem G, Beguin Y, Fassotte MF et al. Whole-body positron emission tomography using 18F-fluorodeoxyglucose for posttreatment evaluation in Hodgkin's disease and non-Hodgkin's lymphoma has higher diagnostic and prognostic value than classical computed tomography scan imaging. Blood 1999; 94: 429-433
191 Jerusalem G, Warland V, Najjar F et al. Whole-body 18F-FDG PET for the evaluation of patients with Hodgkin's disease and non-Hodgkin's lymphoma. Nucl Med Commun 1999; 20: 13-20
192 Juweid ME, Stroobants S, Hoekstra OS et al. Use of positron emission tomography for response assessment of lymphoma: consensus of the Imaging Subcommittee of International Harmonization Project in Lymphoma. J Clin Oncol 2007; 25: 571-578
193 Jerusalem G, Beguin Y, Najjar F et al. Positron emission tomography (PET) with 18F-fluorodeoxyglucose (18F-FDG) for the staging of low-grade non-Hodgkin's lymphoma (NHL). Ann Oncol 2001; 12: 825-830
194 Karam M, Novak L, Cyriac J et al. Role of fluorine-18 fluoro-deoxyglucose positron emission tomography scan in the evaluation and follow-up of patients with low-grade lymphomas. Cancer 2006; 107: 175-183
195 Elstrom R, Guan L, Baker G et al. Utility of FDG-PET scanning in lymphoma by WHO classification. Blood 2003; 101: 3875-3876
196 Lewis E, Bernardino ME, Salvador PG et al. Post-therapy CT-detected mass in lymphoma patients: Is it viable tissue?. J Comput Assist Tomogr 1982; 6: 792-795
197 Dietrich CF. Editorial on the contribution “Challenges for the German Health Care System”. Z Gastroenterol 2012; 50: 555-556
198 Castellino RA, Marglin SI. Imaging of abdominal and pelvic lymph nodes: lymphography or computed tomography?. Invest Radiol 1982; 17: 433-443
199 Williams AD, Cousins C, Soutter WP et al. Detection of pelvic lymph node metastases in gynecologic malignancy: A comparison of CT, MR imaging, and positron emission tomography. Am J Roentgenol 2001; 177: 343-348
200 Fukuda H, Nakagawa T, Shibuya H. Metastases to pelvic lymph nodes from carcinoma in the pelvic cavity: Diagnosis using thin-section CT. Clin Radiol 1999; 54: 237-242
201 Oyen RH, Van Poppel HP, Ameye FE et al. Lymph node staging of localized prostatic carcinoma with CT and CT-guided fine-needle aspiration biopsy: Prospective study of 285 patients. Radiology 1994; 190: 315-322
202 Kim SH, Choi BI, Han JK et al. Preoperative staging of uterine cervical carcinoma: Comparison of CT and MRI in 99 patients. J Comput Assist Tomogr 1993; 17: 633-640
203 Dietrich CF, Annema JT, Clementsen P et al. Ultrasound techniques in the evaluation of the mediastinum, Part I: Endoscopic ultrasound (EUS), endobronchial ultrasound (EBUS) and transcutaneous mediastinal ultrasound (TMUS), introduction into ultrasound techniques. J Thorac Dis 2015; 7: E311-E325
204 Jenssen C, Annema JT, Clementsen P et al. Ultrasound techniques in the evaluation of the mediastinum, Part 2: Mediastinal lymph node anatomy and diagnostic reach of ultrasound techniques, clinical work up of neoplastic and inflammatory mediastinal lymphadenopathy using ultrasound techniques and how to learn mediastinal endosonography. J Thorac Dis 2015; 7: E439-E458
205 Dietrich CF, Mathis G, Cui XW et al. Ultrasound of the pleurae and lungs. Ultrasound Med Biol 2015; 41: 351-365
206 Szabo BK, Aspelin P, Kristoffersen WM et al. Invasive breast cancer: Correlation of dynamic MR features with prognostic factors. Eur Radiol 2003; 13: 2425-2435
207 Fischbein NJ, Noworolski SM, Henry RG et al. Assessment of metastatic cervical adenopathy using dynamic contrast-enhanced MR imaging. Am J Neuroradiol 2003; 24: 301-311
208 Kostakoglu L, Leonard JP, Coleman M et al. The role of FDG-PET imaging in the management of lymphoma. Clin Adv Hematol Oncol 2004; 2: 115-121
209 Dietrich CF, Hocke M, Jenssen C. Ultrasound for abdominal lymphadenopathy. Dtsch Med Wochenschr 2013; 138: 1001-1018
210 Dietrich CF, Jenssen C. Evidence based endoscopic ultrasound. Z Gastroenterol 2011; 49: 599-621
211 Dietrich CF, Hocke M, Jenssen C. Interventional endosonography. Ultraschall in Med 2011; 32: 8-22 , quiz
212 Dietrich CF, Sharma M, Hocke M. Contrast enhanced endoscopic ultrasound. Endosc Ultrasound 2014; 1: 130-136
213 Bamber J, Cosgrove D, Dietrich CF et al. EFSUMB guidelines and recommendations on the clinical use of ultrasound elastography. Part 1: Basic principles and technology. Ultraschall in Med 2013; 34: 169-184