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 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 tuberculosis is declining, the importance of diagnosis of the tuberculosis is increasing as the incidence ofthetuberculosis related the immune -compromising status such as acquired immune deficiency syndrome is increased. As a common extrap 비 monic manifestation ofp 비 monary 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 University Co 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 adenitis MATERIALS and METHODS 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 acq 비 sition was two. The MR images were analyzed regarding the multiplicity, location, size, shape, margin, signal intensity and enhancement pattern ofthe Iymph nodes. The locations of Iymph node followed the classification 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 m 비 tiple 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- 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 is이 ntense 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- Table 1. Summary ofradiologic and Clinical Findings. 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 μm 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
So Yeon Cho, et al: Cervical Tuberculous Lymphadenitis itis 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. Furthermore, 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 contrast 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 feature of tuberculous cervicallym 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 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-weig hted Image. d. Follow up image shows increase enahncing portion 01 allected Iymph node(arrow) 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 tuberculosis 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 p 미 monary tuberculosis and showed higher incidence of lower neck (N4) involvement than those without P 비 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 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 peripheral 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-
ιso Yeon Cho, et al: Cervical Tuberculous Lymphadenitis decrease of its size (8). In our study, follow-up MR images of two patients, 3 months and 10 months in interval each, showed constant MR features of peripheral rim enhancement or increase of enhancing portion. In conclusion, the characteristic MR features of cervical 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-weighted and/or proton density images, and thin peripheral rim enhancement after contrast REFERENCES 미 ection. 1. Som PM. Lymph nodes 01 the neck. Radiology 1987; 165: 593-600 2. Kim SH, Lee Y, Park KS, etal. Computed tomographic cervical tuberculous Iymphadenitis. J Korean Radiol Soc 1992 ; 28 : 531-535 3. Reed DR, Bergeron RT. Cervical tuberculous adenitis : CT manilestations. Radiology 1985; 154: 701-704 4. Lee Y, Park KS, Chung SY. Cervical tuberculous Iymphadenitis CTfindings. JComput AssistTomogr1994; 18: 370-375 5. Domb GH, Chole RA. The diagnosis and treatment 01 scopula (Mycobacterial cervicallymphadenitis). Otolaryngol Head Nedc Surg 1980 ; 88: 338-341 6. Reed DR, Som PM. The neck: Lymph nodes. In Som PM, Bergeron RT, eds. Head and neck imaging. 2nd ed. SI. Louis Mosby, 1991 : 572-574 7. Appling D, Miller RH. Mycobacterial cervicallymphadenopathy 1981 update. Laryngoscope 1981 ; 91 : 1259-1266 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 대한방사선의학회지 1995 ; 33( 4) : 521-525 경부결핵성럼프절염의자기공명영상소견 1 1 한림대학교의과대학진단방사선과학교실 조소연 김호철 배상훈 이 열 이길우 김큐선 이상조 목 적 : 경부에발생한결핵성림프절염의자기공명영상소견을제시함으로서전이암이나림프종과의감별에도움을주 고자하였다. 대상빛방법 : 경부종괴를주소로자기공명영상을시행한환자중결핵성림프절염으로확진된 14 명의환자를대상으로 스핀에코기법의 T1, T2 강조영상또는앙자밀도영상과조영증강영상의소견을후향적으로분석하였다. 결 과 : 경부결핵성림프절엽으로진단된 14 명의환자에서총 97 개의림프절이자기공명영상에서관찰되었다. 림프절은 대부분 8-45mm 의다발성 (n=12), 펀측성 (n =10) 으로주로내겸정맥을따라분포 (N2:41, N3:2, N4 : 2 1) 하였다. 자기공명영상에서의신호강도는 T1 강조영상에서주변근육과동일하거나약간증가된신호강도로 T2 강조영상또는양자밀도영상에서는고신호강도를보였으며, 조영증강영상에서는대부분변연부가앓고균일하게증강되는변연부조영증강형으로관찰되었다 (n=7 1) 결 론 : 경부걸핵성림프절엽의특징적인자기공명영상소견은 T1 강조영상에서주변근육과동일하거나약간증가된신 호강도와 T2 강조영상또는앙자밀도영상에서고신호강도의다발성, 편측성의립프절종대로조영증강영상에서는앓은주 변부조영증강을보이는것이다. m
1. 일정표 95. 11. 2( 목 ) -9( 목 ) 11. 1 3( 월 )- 1 1. 1 8( 토 ) 11. 20( 월 ) -11. 25( 토 ) 12. 5( 화 ) 12. 27( 수 ) -12. 29( 토 ) 96. 1. 11( 목 ) 1. 17( 수 ) 1. 22( 월 ) 1. 23( 화 ) 시험시행공고원서교부 ( 의협 ) 원서접수 ( 학회 ) 자격심사수험표교부 1 차시험 ( 장소미정 ) 1 차시험발표 ( 의협 ) 2차슬라이드시험 ( 장소미정 ) 2차구술시험 ( 장소미정 ) 2. 2( 금 2 차시험발표 ( 의협 ) * 문의처대한방사선의학회사무국전화 578-8003 2. 구비서류 1) 응시원서 ( 의협소정양식 ).............. 1 통 2) 수험표 ( 의협소정양식 )........ 1 통 3) 사진 ( 반명함판, 제출서류부착수량제외 )... 2 매 4) 합격자명부 ( 의협소정양식 )... 2 통 5) 응시료 ( 원서교부시의협에남부 )... 60,000 원 수험료 ( 원서접수시학회에납부 )..... 200,000 원 전문의제도개선사업비 )...... 10,000 원 입회비 )................................ 100,000 원 년회비 ( " ) ( 미납자에한함 )... 원 6) 수련과정이수또는예정증명서 ( 의협소정양식 )..... 2 통 ( 인턴, 레지던트수련병원이다를경우분리작성 ) 7) 해외수련자인경우수련과정이수증명서사본... 2 통 ( 해외공관장확인을필한것 ) 8) 외국의전문의자격증을취득한자의경우그자격증사본 ( 해외공관장확인을필한것 )......... 2 통 9) 의사면허증사본 ( 규격 B5 용지크기 ).............. 2 통 10) 파견수련확인서...... 분야별각 l 통 11) 전공의기록부........., ' "... 1 부 12) 논문별책 ( 원저제 1 저자 1 부, 공저 2 부 )... 3 부 κ씨