Journal of the Korean Radiological Society 1995; 33(4) : 521-525 Cervical Tuberculous Lymphadenitis: MR Features 1 So Yeon Cho , M.D. , Ho Chul Kim , M.D. , Sang Hoon Bae , M.D. , Yul Lee , M.D. , Kil Woo Lee , M.D. , Kyu Sun Kim , M.D. , Saang Joe Lee , M.D. Purpose: To characterize the magnetic resonance (MR) imaging features of cervical tuberculous Iymphadenitis. Materials and Methods: The cervical MR images of 14 patients with pathologi- cally or clinically proven cervical tuberculous Iymphadenitis were retrospec- tively analyzed. T1- and T2-weighted or proton density images and contrast enhanced MR imageswereobtained in all patients. Results: Most patient had multiple (n=12). unilaterallesions (n=1 0). 8 mm to 45 mm in size , round (n=46) or ovoid (n=46) in shape and all with smooth and well-defined margins mostly at internal jugular chain(N2: 41 , N3: 2 , N4: 21). The signal intensities of the most Iymph nodes were isointense or slightly hype- rintense on T1 -weighted images , and hyperintense (all) with variable homogen- eity on T2-weighted and/or proton density images. After contrast enhancement most showed characteristic thi n periphera I rim enhancement (n= 71). Conclusion: The characteristic MR features of cervical tuberculous Iymph- adenitis would be multiple , unilateral enlarged Iymph nodes which show iso or slightly increased signal intensity on T1-weighted image , high signal intensity on T2-weighted and/ or proton density image and peri pheral ri m enhancement. Index Words: Lymphatic system , infection Lymphatic system , MR Tuberculosis In recent years , although the prevalence of the tu- adenitis berculosis is declining , the importance of diagnosis of the tuberculosis is increasing as the incidence ofthetu- MATERIALS and METHODS berculosis related the immune - compromising status such as acquired immune deficiency syndrome is increased. As a common manifestation tuberculosis , cervical tuberculous Iymph- adenitis requires the differentiat ion from the other cer- vical masses such as the Iymphoma , the metastatic Iymphadenopathy and the reactive Iymph node hyper- plasia. The computed tomographic (CT) findings of cer- vical tuberculous Iymphadenitis have been well -docu- mented. According to our knowledge , however , there have been no descriptions concerning the magnetic resonance (MR) imaging features of cervical tubercu- lous Iymphadenitis. The purpose ofthis article is to de- scribe the MR features of cervical tuberculous Iymph- 1 Department olRadiology, Hallym Un iversity Co lI ege 01 Medicine Rece i ved May 27 , 1995 ; Accepted O ctober 4 , 1995 Address reprint requests to:80 Yeon Cho, M. D. , Department 01 Radiology, Kangdong Sacred Heart Hospital , # 445 , Gil.dong , Kangdong.ku , 8eoul , 134- 701 Korea. TeL 82- 2- 224. 2312 Fax. 82.2.473- 8101 The cervical MR im ages of 14 consecutive patients (eleven women , three men ; age range , 15 -55 years) with two cases of fOllow -up MR images were retro- spectively reviewed. The diagnoses were established by aspiration biopsy in seven and excisional biopsy in five patients and by clinical fOllow-up after anti-tu- berculous medications in two patients (Table 1). MR imaging was performed with 1.5T supercon- ducting MR unit (Siemens , Erlangen , Germany) , using spin -echo pulse sequences. Before contrast admini- stration , T1 -weighted (500 -800/15 repetition time / echo time msec) axial and coronal images and T2- weighted and/or proton density (2100 - 2500/20 -80 msec) axial and/or coronal images were obtained . After intravenous injection of gadopentetate dimeg- lumine (0.07-0.1 mmol/Kg body weight , Magnevist @ , Schering , Berlin , Germany) , T1-weighted axial , cor- onal and sometimes sagittal images were obtained 521 -
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Journal of the Korean Radiological Society 1995; 33(4) : 521-525
Cervical Tuberculous Lymphadenitis: MR Features1
So Yeon Cho, M.D., Ho Chul Kim, M.D. , Sang Hoon Bae, M.D. , Yul Lee, M.D.,
Kil Woo Lee, M.D., Kyu Sun Kim, M .D ., Saang Joe Lee, M.D.
Purpose: To characterize the magnetic resonance (MR) imaging features of cervical tuberculous Iymphadenitis.
Materials and Methods: The cervical MR images of 14 patients with pathologically or clinically proven cervical tuberculous Iymphadenitis were retrospectively analyzed. T1- and T2-weighted or proton density images and contrast enhanced MR imageswereobtained in all patients.
Results: Most patient had multiple (n=12). unilaterallesions (n=1 0). 8 mm to 45 mm in size, round (n=46) or ovoid (n=46) in shape and all with smooth and well-defined margins mostly at internal jugular chain(N2: 41 , N3: 2, N4: 21). The signal intensities of the most Iymph nodes were isointense or slightly hyperintense on T1 -weighted images, and hyperintense (all) with variable homogeneity on T2-weighted and/or proton density images. After contrast enhancement most showed characteristic thi n periphera I rim enhancement (n= 71).
Conclusion: The characteristic MR features of cervical tuberculous Iymphadenitis would be multiple, unilateral enlarged Iymph nodes which show iso or slightly increased signal intensity on T1-weighted image, high signal intensity on T2-weighted and/ or proton density image and peri pheral ri m enhancement.
Index Words: Lymphatic system , infection Lymphatic system , MR Tuberculosis
In recent years , although the prevalence of the tu- adenitis berculosis is declining , the importance of diagnosis of the tuberculosis is increasing as the incidence ofthetu- MATERIALS and METHODS berculosis related the immune -compromising status such as acquired immune deficiency syndrome is increased. As a common extrap비 monic manifestation ofp비monary tuberculosis , cervical tuberculous Iymphadenitis requires the differentiation from the other cervical masses such as the Iymphoma, the metastatic Iymphadenopathy and the reactive Iymph node hyperplasia. The computed tomographic (CT) findings of cervical tuberculous Iymphadenitis have been well - documented. According to our knowledge , however , there have been no descriptions concerning the magnetic resonance (MR) imaging features of cervical tuberculous Iymphadenitis. The purpose ofthis article is to describe the MR features of cervical tuberculous Iymph-
1 Department olRadiology, Hallym UniversityCo lI ege 01 Medicine Received May 27,1995 ; Accepted October 4,1995 Address reprint requests to:80 Yeon Cho, M. D. , Department 01 Radiology, Kangdong Sacred Heart Hospital , # 445, Gil.dong, Kangdong.ku , 8eoul , 134-701 Korea. TeL 82- 2- 224. 2312 Fax. 82.2.473- 8101
The cervical MR im ages of 14 consecutive patients (eleven women , three men ; age range , 15 -55 years) with two cases of fOllow - up MR images were retrospectively reviewed. The diagnoses were established by aspiration biopsy in seven and excisional biopsy in five patients and by clinical fOllow-up after anti-tuberculous medications in two patients (Table 1).
MR imaging was performed with 1.5T superconducting MR unit (Siemens , Erlangen , Germany) , using spin -echo pulse sequences. Before contrast administration , T1 -weighted (500 -800/15 repetition time/ echo time msec) axial and coronal images and T2 -weighted and/or proton density (2100 - 2500/20 -80 msec) axial and/or coronal images were obtained. After intravenous injection of gadopentetate dimeglumine (0.07-0.1 mmol/Kg body weight , Magnevist @, Schering , Berlin , Germany) , T1-weighted axial , coronal and sometimes sagittal images were obtained
521 -
Journal of the Korean Radiological Society 1995: 33(4) : 521-525
in all patients. Fat supression technique via inversion recovery was applied for more clear demonstration of high signal intensity of the lesion on T2 weighted or gadolinium - enhanced T1 -weighted images. The slice thickness was 4 mm. The matrix number was 192 -256 X 256, and the number of acq비 si
tion was two. The MR images were analyzed regarding the multi
plicity , location , size , shape , margin , signal intensity and enhancement pattern ofthe Iymph nodes.
The locations of Iymph node followed the classifi cation by Som (1).
The enhancement was defined as either homogeneous or peripheral in pattern. The peripheral pattern was subdivided as thin (Iess than 4 mm) and thick rim (equal or more than 4 mm) enhancements (2)
RESULTS
Ninety seven Iymph nodes were observed in 14 patients.
Most patients (n=12) had m비tiple nodes 2 to 24 in number while two patients had single nodal involvement. In multiple lesions, unilaterallymphadenitis was dominant(n=8) than bilateral (n=4) (Table 1).
The visible nodes were 8 mm t045 mm in size Most of the nodes were internal jugular group in 10-
Table 1. Summary ofRadiologic and Clinical Findings.
cation (N2 : 41 , N3 : 2, N4 : 21) and the others were posterior triangle (N5: 22) , submandibular and submental nodes (N1 : 7) , and mediastinal nodes (n=4)
The Iymph nodes were round (n=46) , ovoid (n=46) , or lobulated (n=5) in shape and showed the tendency of lobulation as the size increased.
AII nodes showed smooth and well - defined margin. The signal intensity of the Iymph nodes were either
homogeneously is이ntense or slightly hyperintense (n=84) than those of cervical muscles and some showed peripherally hyperintense ring - like pattern (n=13) on T1-weighted images. On T2 -weighted or proton density images, the signal intensity of Iymph nodes were hyperintense either homogeneously (n = 36) or inhomogeneously (n=25) (Fig. 1, 2)
On gadolinium-enhanced T1 -weighted images, peripheral thin rim enhancement pattern was dominant (n=71) (Fig. 1) than peripheral thick enhancement (n=14) (Fig. 2) or homogeneous enhancement(n=12).
The fOllow - up MR images in two patients showed constant characteristics of the affected Iymph nodes except for the decrease in size (Fig. 3) or increase in enhancing portion ofgranulation tissue
DISCUSSION
The CT features of cervical tuberculous Iymphaden-
No. Age/Sex Unilateral /Bilateral *
15/F B
2 281M U 3 55/F U 4 29/F U
5 261M U 6 18/F U
7 19/F B
8 18/F B
9 251M U 10 38/F U 11 23/F B
12 24/F U 13 36/F
14 53/F
* : U=unilateral. B=bilateral
Location Numbers of Lymph Nodes
N2 11
N2 2 N2 5
N2 2
N1 2
N4 3
N2 8
N5 4 N1 N2 8
N3 2
N4 3
N5 10 N2 2
N4 7 N5 5
N5 2
N2 3
N1 4
Mediastinum 4
N4 6
N4 N4
Pulmonary Tuberculosis Confirm
(-) Clinical
(+ ) Active Aspiration Biopsy (-) Aspi ration Biopsy (-) Clini cal
( +) Active Aspi ration Bi opsy (-) Aspiration Biopsy
(+ ) Active Aspiration Biopsy
(+ ) Inactive Aspiration Biopsy
(+) Active Excision Biopsy (+) Active Excision Biopsy ( - ) Excision Biopsy
(+) Active Excision Biopsy (+ ) Active Aspiration Biopsy ( -) Excision Biopsy
m
μ
So Yeon Cho, et al: Cervical Tuberculous Lymphadenitis
it is are well documented as multiple , bilateral , low
density , posterior triangular nodal enlargement with
thick and irregular rim enhancement (3, 4) , while the
MR features of which have not been described. Fur-
thermore , the MR criteria of the pathologic nodes are
only based on that the increase of the signal intensity
on long TR image and of the en~ancement after con
trast injection. Which was the reason that we included
a b c Fig . 1. a. T1 cweighted image shows a Iymph node (arrow) which shows homogeneously and slightly hyperintense signal intensity than
that 01 cervical muscle. And another small node shows the same MR features
b. On proton density image, the nodes show homogeneously hyperintense signal intensity (arrow).
c. Peripheral thin enhancement pattern is noted on contrast enhanced T1-weighted image (arrow) which is the most common MR fea
ture of tuberculous cerv icallym phadenitis
a b c Fig . 2 . a. T1-weighted image shows a Iymph node (arrow) which shows peripheral hyperintense ring-like pattern
b. On fat supression image, the node shows homogeneously hyperinternse signal intensity (arrow)
c. Peripheral thick enhancement pattern is noted on contrast enhanced T1-weighted image (arrow)
잉
Journal of the Korean Radiological Society 1995 ; 33(4): 521-525
a b
c d
all the visible Iymph nodes on long TR image regardless oftheir sizes.
Generally , it is well-known that a large portion of the cervical tuberculous Iymphadenitis patients have a history of previous tuberculosis or an active tuberculos is in lung and that the more inferior location of Iymphadenopathy suggest the higher likelihood of concomitant pulmonary tuberculosis (5). In our study , eight patients (57%) had p미 monary tuberculosis and showed higher incidence of lower neck (N4) involvement than those without P비 monary tuberculosis.
The most common site of the cervical tuberculous Iymphadenitis had been reported to be in posterior chain (3 , 6, 7) , while in our study, it was internal jugular
Fig . 3. a. Peripheral thin enhancement 01 the Iymph node (arrow) is noted on contrast enhanced T1-weighted i mage b. Follow up contrast enhanced T1-weighted image alter 3 months shows constant cha racteristics 01 affected Iymph node (arrow) except the decrease of the nodal size c. In the same patient, another peripheral thin enhancement 01 the Iymph node (arrow) is noted on contrast enhanced T1-weighted Image. d. Follow up image shows increase enahncing portion 01 allected Iymph node(arrow)
chain(N2 , N3, N4). The difference may be due to inclusion of many active pulmonary tuberculosis patients in this study
After contrast enhancement, the characteristic CT feature of tuberculous Iymphadenitis is described as a thick and irregular rim enhancement around the central necrotic area (3 , 4, 6). On contrast enhanced MR images, however, most of the tuberculous Iymph nodes showed thin per ipheral rim enhancement although the pathologic findings revealed caseation necrosis. The exact causes for the discrepancy have not been proved and further study maybe required
After anti - tuberculous medication , the necrotic form of tuberculous node converts into the solid form with
524 -
decrease of its size (8). In our study, fOllow-up MR images of two patients , 3 months and 10 months in in
terval each , showed constant MR features of periph
eral rim enhancement or increase of enhancing por
tion.
In conclusion , the characteristic MR features of cer
vical tuberculous Iymphadenitis would be multiple, unilateral , well - marginated Iymph nodes which show
homogeneous iso- or slightly high signal intensity on
T1 - weighted image, high signal intensity on T2-wei
ghted and/or proton density images, and thin periph
eral rim enhancement after contrast 미 ection.
REFERENCES
1. Som PM. Lymph nodes 01 the neck. Radiology 1987; 165: 593-
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So Yeon Cho, et al: Cervical Tuberculous Lymphadenitis
2. Kim SH, Lee Y, Park KS, etal. Computed tomographic cervical tuberculous Iymphadenitis. J Korean Radiol Soc 1992 ; 28 : 531-535
8. Moon WK , 1m JG, Kim HC, et al. Analysis olCT patterns and treatment response in patients with mediastinal tuberculous Iymphadenitis. J Korean RadiolSoc 1993; 29: 987-994