The Diagnostic Performance of Multiparametric Ultrasound in the Qualitative Assessment of Inconclusive Cervical Lymph Nodes

SIMPLE SUMMARY: Enlarged cervical lymph nodes (CLNs) are routinely evaluated for distinction between benign infectious enlargements and malignant diseases. Ultrasound (US) is the first-line imaging modality for the assessment of CLNs. The aim was to investigate the diagnostic performance of the addition of the multiparametric applications shear wave elastography (SWE) and contrast-enhanced US (CEUS) to B-mode US and color-coded duplex sonography (CCDS). Our results show that the diagnostic performance of multiparametric US (mpUS) is significantly higher than that of B-mode US and CCDS. MpUS may help to distinguish between malignant and benign CLNs and might aid the decision of choosing between the watch-and-scan strategy and surgery in primary cases as well as between repeated surgery and short-term follow-up in oncological patients. ABSTRACT: Background: Enlarged cervical lymph nodes (CLNs) can result from infection or malignancies, and a definitive diagnosis requires histological examination. Ultrasound (US) remains the first-line imaging modality for detection, and new US techniques may improve characterization. The aim of our study was to investigate whether the qualitative assessment of multiparametric US (mpUS) can improve diagnostic performance in the differentiation of benign and malignant CLNs. Methods: 107 CLNs in 105 patients were examined by preoperative mpUS consisting of B-mode US, color-coded duplex sonography (CCDS), shear wave elastography (SWE) and contrast-enhanced US (CEUS). US images were evaluated in consensus by two experienced US operators. Histopathological examination was used as reference standard. Results: SWE and CEUS combined showed the highest overall diagnostic performance (91% sensitivity, 77% specificity, 87% positive predictive value (PPV), 83% negative predictive value (NPV), 90% accuracy, χ(2) (1) = 51.485, p < 0.001) compared to B-mode US and CCDS (87% sensitivity, 44% specificity, 73% PPV, 65% NPV, 73% accuracy χ(2) (1) = 12.415, p < 0.001). In terms of individual techniques, SWE had higher specificity than B-mode and CCDS (71% sensitivity, 90% specificity, 92% PPV, 64% NPV, 78% accuracy, χ(2) (1) = 36.115, p < 0.001), while qualitative CEUS showed the best diagnostic performance of all investigated US techniques (93% sensitivity, 85% specificity, 91% PPV, 87% NPV, 90% accuracy, χ(2) (1) = 13.219, p < 0.001). Perfusion patterns, homogeneity, presence of necrosis, and malignancy differed significantly between malignant and benign CLNs (p < 0.001). Conclusions: SWE and CEUS can facilitate the differentiation of inconclusive CLNs when performed to supplement B-mode US and CCDS. MpUS may thus aid the decision between surgery and a watch-and-scan strategy in enlarged CLNs.