Lymph Nodes on Ultrasound
Many of you have experienced pain under the arms or felt "swollen" lymph nodes and have had reports that were just short of complete in describing them in my opinion.
The overall size of a lymph node is more often less important than their internal architecture in breast cancer. The key is the thickness of the cortex and the appearance of the fat that lives in the center of the lymph node. When cancer cells enter a node the collect in the cortex making it thick. The increased volume of the cortex enlarges the node and compresses the fat in the center. An abnormal lymph node can be small with a thick cortex and completely effaced fatty center. A normal lymph node can be very large but have a very thin cortex and nice plump fatty center. If the cortical thickness in not included in a report that indicates an enlarged node, I would ask them to revise the report.
The images below are US images and corresponding line drawings of the progression from normal node to abnormal node on ultrasound. (From "the bible" 'Breast Ultrasound' a text book by A. Thomas Stavros, MD, the world's foremost authority on the subject)
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Thank you for this!
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That is SO informative! Thanks DJMammo!
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This is great information. As a breast sonographer I would note that our radiologists do not include the measurement of the cortex in their reports. They will describe the node, i.e. abnormal cortical thickening, loss of fatty hilum etc. and recommend biopsy if abnormal.
Also nodes can appear abnormal in the presence of infection and/or autoimmune disorders such as lupus, RA, or Sarcoidosis.
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This is just what I was wondering about. Thank you
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Thank you - that is quite enlightening.
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Thank you! This is very helpful!
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Thank you so much for this amazing resource.
I am 30 years old and I too have "mystery" pain, tenderness, and inflammation in my L axillary lymph nodes. It's like a painful thin mishapen sponge-web that's not hard but also definitely not normal under my skin. The pain and sick feeling seems to start during my ovulation but it hurts all month long to some degree and has been for about a year and a half. The sick feeling I get from it (I'm developing a hunch like a wounded animal over this "thing") coupled with serous/bloody, unilateral, single-duct nipple discharge that began >6 months ago, coupled with finding a mass in my right breast caused me to finally wake up from what I can only describe as a mental block or willful ignorance brought on by my own Mother being dx with Inflammatory BC when I was 19. I was her sole patient-advocate and caregiver from age 19-25 and she ultimately passed away with Mets to bone and blood. She was 46 at dx and passed away at 51.
I got a referral for an ultrasound from Planned Parenthood. At the US today a person who I think was a radiologist came in for 5 mins at the end and said in the right breast it looked like a cyst. Luckily I spent time memorizing what the expected indicators would be for various results and I was relieved to come to the same conclusion during the ultrasound with the technician. Cyst had been my guess from palpation beforehand and was the least of my worries. He also said they found several cysts in the left breast. When I specifically asked "But how did my lymph nodes look?" He said "I did not see any masses".
When I asked about the bloody nipple discharge, which was the primary reason on my referral for my being there, he said if it continued to "bother me" I should see a surgeon. He was rude and dismissive and literally kept one hand on the doorknob during the conversation.
I was really overwhelmed mentally/socially at this point so I just said okay and he left. The technician and I think someone she was training stayed behind and technician told me her Mom died from BC in her 40s and she strongly recommended that I keep pursuing this but did not mention what tests or what type of doctor I should go to for more information.
I do know in my heart and in my mind from studying medical journals and case studies that what I am presenting with does exactly match the criteria for being suspicious. It's spontaneous, persistent, it's orange-ish clear-ish (like you think of lymph if you skinned your knee) somewhat sticky when it comes out and on my bra it's blood stained in dots. I sometimes get a tiny fleck of dried blood but not a scab per say. And now in the spot on my nipple that it comes out of it looks kind of shiny and it's a slightly different color than anywhere else.
So according to this diagnostic his opinion was if it bothers me see a surgeon or just do nothing.
I don't know what to do..Is it common for DCIS to present with lymphadenopathy?
The practitioner at Planned Parenthood is who they will send my results to but she already told me she could only order them and cannot interpret them. I plan to get a copy of my diagnostic results and look to see for myself what my lymph nodes look like. I feel like I will at least be able to differentiate whether they appear simply inflamed/reactive to something systemic or idk what. When I reviewed the graphic you posted here after returning home I felt D most matched what my lymph nodes appeared to me during the quick and stressful US but that one says metastatic or severe inflammation so still no clear indicator one way or another there.
And now several hours later the whole area is sore and tender. I can feel it and it hurts just from my arm being down.
I was hoping to leave this appointment with a more clear picture and action plan or possible relief but I feel more worried than ever.0 -
Bloody nipple discharge is never normal. Sometimes US will show an intraductal mass but not always. A ductogram will show the inside of the duct more clearly. Cyclical pain in the axilla is often due to ectopic breast tissue located there. It will cycle with the rest of the breast tissue. PM me the US report here when you get it. Look for the measurement of the cortical thickness. If they don't mention it, ask that an addendum to the report be issued.
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After all that they did not even take still shots of my lymph nodes during the sono or mention them in the report whatsoever and when I asked about it I was told I would need another referral.. It took me quite a while to get in to see my primary doctor and in the month that has passed my lymph nodes changed from tender to painless but hard and rubbery. I just now had another ultrasound today which I will very gladly send over the results as soon as I receive them. I have lost over 20% of my body weight in the past 6 months and I very much get the impression my doctor thinks the problem is "anxiety" which I do not have. Thank you for being so respectful and kind and sharing your knowledge.
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RoamingNomad never came back, I guess she’s ok. I had three nodes US’d today and they said they were normal. But I saw white specks in two of them? And little red arrows. Came here to check the pics. They don’t feel normal. The fishbowl waiting room was full up too. The tech said she could recognize them by their appearnce. Really dj?
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marijen
Recognizing things by their appearance is kinda the basis of the entire specialty of radiology so yes, really. ;-)
The white in the middle of a lymph node is fat. The “red arrows” were probably the node’s arterial supply being demonstrated with Doppler.
Do you have the final report you can post
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Thanks DJ. No report yet but I will get one. The Dr. rdaiologist did not look at the pics in the exam room, so I’m assuming they are networked to his office? Not sure about what you mean -I saw the doppler as the tech worked, but the saved pics were gray, two with a the white speck and the red arrows. She reduced the size to 80% when sheleft the room. It was hard to read.
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Well I’m not a tech but it looked normal except when she turned on the doppler, then I didn’t know what to think. They don’t want to say if it’s normal or not. The biggest one was 2.2 cm. The same size as my positive node removedon the other side. One was .7 x 1.something cm. I’ll send the report when I get it. Why are you up so late? I can’t sleep.
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Djmammo, the nurse called this morning and posted my reports. There is nothing to question. Mammo is benign and US is benign. They did give the size of the nodes as per my request. And it says no suspicious calcifications, masses, or architectural distortions and no abnormal appearing lymph nodes, masses, or fluid collections were seen. Thanks so much for your help and for starting this topic! It's time to stop worrying, oh what will I do : )
Oh oh I missed something, it also says continue clinical monitoring of left breast. DJ, does that mean they still aren’t 100% sure the nodes are normal? I think so...
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Oh the things we think when we have nothing to do but wait and think. I had a CT scan in April that discovered "several prominent and borderline enlarged right axillary lymph nodes measuring up to 12 mm in short axis diameter". Nothing else was noted. This led my breast specialist to call me in for a screening mammogram and ultrasound, as I have had issues with the right axillary and breast for years, and also have the ATM mutation. However, all my US report said was benign lymph nodes, with no other information at all. But, the mammogram found "an asymmetry in the right breast posterior depth outer region
seen on the craniocaudal view only"...There is no sonographic abnormality seen in the right breast to
correspond with the mammographic density.
A follow-up right mammogram in 6 months is recommended to demonstrate
stability. BIRADS 3It is being explained as possible residual bruising to my breast from a car accident that occurred February 12. I am not so sure I want to wait 6 months to see if that is the case. I am almost 39. Both my grandmothers had BC in early 40s. Two of my father's sisters were diagnosed with BC TWICE...one in early 40s, and then again in 70s. The other in early and late 60s...and lost to mets to bone and blood. I have 3 young kids. How do I proceed and at least get the peace of mind I need that I will be healthy for my children for years to come?!
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US is more accurate at assessing individual lymph nodes than CT. It can show the internal architecture which is more reliable than size in calling a node abnormal. 12mm is not large for a lymph node though for some reason they reported the "short axis" rather than the "long axis" of the node, odd.
US is also very good for assessing asymmetric tissue density. If there is nothing seen on US, a short-term follow up is pretty standard. Did you have compression views of that area on the day you had the US? MRI would be the next step but if the US is completely negative there may not be anything big enough to easily biopsy.
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Thank you for your reply. I did have several mammogram views the same day, though I can't speak to whether that is considered compression views. I am waiting for a response from my breast specialist..she had suggested doing a repeat u/s in 3 months if that would reassure me, instead of waiting 6 months for the diagnostic mammogram. I am scheduled for the diagnostic in early November, and my regularly scheduled MRI in January, as I am on a 6 month mammo/MRI rotation due to my genetic risk factors. I am just concerned about the wait-factor. I feel like waiting 6 months to check stability is too long when you consider the possibilities. We are going on a hunch that is just residual bruising...after 4 months...and if it isn't, then I have lost 6 months.
Also, I should note that my breast specialist did inform me that they had noted the lymph nodes on my previous MRI and mammo but that they were not the sizes noted on the CT, I guess. She literally said, "We had noted lymph nodes." but didn't go into detail about WHAT they noted. I am not sure why the CT reported one axis vs. another...it was in a different hospital system that I am not to happy with for other reasons right now. Specifically, they told me my CT was normal but I am literally waiting to see the cardiologist right now because it in fact was NOT normal. Just too much going on at once.
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This is so amazing! Thank you for posting this! My MRI 6 months ago and the one completed in May discussed "probable intramammary lymph nodes" in November and then suddenly in the same positions that these nodes were seen were the areas they wanted to biopsy. I asked the radiologist what causes the changes if they were lymph nodes to something different and he basically told me lots of different things so I didn't get a warm fuzzy about his answer but this def helps! I watched during my core needle biopsies and the most strange looking area looked like a mix between g & f. Still thinking it'll be benign but there's nothing I can do to change the course, so whatever happens will happen. Really appreciate this info and thread, thank you!
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djmammo--thank you so much for your generous input here. You're providing information that's reassuring and enlightening.
I thought I would mention a fact about lymph nodes I learned from my own experience. My initial presentation was a 3-inch "umbrella" of pink, peau d'orange skin--dermal lymphatic invasion, we now know--over a 0.8 cm lump. No palpable lymph nodes. Everyone concentrated on the small lump--not the skin--and when a lumpectomy with sentinel node biopsy was done, the nodes were so chock-full of tumor that there was no uptake of either the radioactive tracer or the blue dye. Fortunately my surgeon manually explored the axilla until she found a hard node, and when that was biopsied and proven malignant, completed the axillary dissection.
Since then I've learned that with dermal lymphatic invasion, lymph node uptake during sentinel node hunts is very unreliable. My axilla was never imaged with ultrasound, probably since we all got tunnel vision on that 0.8 cm lump, but if we had looked, I bet the nodes would have been small but abnormal.
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DJMammo; I was just dx with IDC; the report stated "Targeted ultrasound of the right axilla demonstrates a borderline lymph node with a cortex measuring up to 3mm in thickness. Several other benign appearing lymph nodes with thin cortices are present".
I'm wondering if I should be concerned about "borderline" and request that it be further investigated? It's a bit unnerving, to be honest....
Kim.
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The cortical thickness is the important measurement and it’s normal. They should monitor the overall size periodically if they are concerned to make sure it is stable.
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thank you!!
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Hi, I noticed you mentioned that you have the ATM gene mutation. I have it also. Did you know we shouldn't be having CT's or x-rays, only MRI's? I just want to save you from any other problems.
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I am on a schedule of MRIs alternating with mammograms so that I have some imaging every 6 months, although I did not know about not having CTs or xrays. Should I tell my primary care physician, then, as well as other medical professionals I encounter? I had a CT due to car accident, then because of chest pain and risk of blood clots... Most recently, I had a mammogram to follow up on my area of asymmetry. It was unchanged and they decided it was bi-rads 4 and did stereotactic biopsy taking 6 samples 3 weeks ago...all benign! I followed directions and felt better after a few days but lately I am experiencing considerable pain in my breast and a lot of aching in the axilla. I had thought maybe I had an infection brewing 2 weeks ago from it as I was extremely run down but no fever, heat, redness or swelling. Just pain.
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Hello, I had mammograms for two years with enlarged lymph nodes and the radiologist did not refer me to get them looked at more closely. A new (female) radiologist did the review of the mammogram this year and immediately referred me to ultrasound. I got it done and she said the cortices and fat etc looked normal and marked it as such on her ultrasound report, but she orally told me that I should follow up on the enlarged lymph nodes since while they looked normal in structure, they were enlarged/larger and had been for three years now. I was floored the last radiologist did not mention the lymph nodes AT ALL or refer me for an ultrasound for TWO YEARS. Now, my question is: I went to the primary doctor for CBC/blood work since there must be some reason they are enlarged. She said get a second opinion from an actual breast care center. I had to go through the former primary care doctor where the breast care center is, and that doctor totally poo-poo'ed my even wanting to go to the breast care center since the ultrasound for breast cancer purposes said "normal" in structure. She acted cold and annoyed that I was asking to be seen when the report said normal in structure but enlarged. I at least want to establish care at a specialty care center again since my mother had breast cancer three times, two different cancers and one recurrence, and got a double mastectomy. I am negative for BRCA genes they tested me for, but have a lot of family cancer. My question is: is it reasonable to bring these findings and take myself to an appointment to at least get into the system for next time with an actual breast care center?? If I get my records there, I will feel better since this last place did not even note the findings to me, but just sent me that page they have to by law stating all was benign, follow up in a year, for two years despite the actual written report stating that the axillary lymph nodes were enlarged in 2016 and 2017. Also, is it reasonable to get a second opinion despite there not being abnormally structured lymph nodes?? Thank you for any assistance. I'm pretty mad I had that for two years and no one even ultrasounded me until the third year, even if they look normal in structure on further screening. They could not tell that from the diagnostic mammograms they did.
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I'm just another patient out here but if I were having pain, I would make an appointment and talk with someone. My mother had various issues and did not go to the doctor and it caused her more problems later on, for postponing going to the doctor.... That's just my own personal two cents, to be more on the cautious side than not, from what I saw my mother experience.
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Again the overall size of the node, length x width, is less relevant than the width of the cortex + appearance of the central fat. They can be several centimeters in length and still be ok if the cortex is normal. If they measure large on both sides it is less worrisome for a breast abnormality than if they are "enlarged" unilaterally. The number of nodes that can be seen on mammo varies from patient to patient. If they can be seen on 2-4 past mammograms one should be able to tell if they are getting larger. Cortical thickness is best seen and measured on US as is the condition of the central fat. Do you have a report with these measurements?
The significance of truly abnormal lymph nodes varies with concomitant findings. If there are abnormal nodes only on one side, and there is a breast abnormality on that side, one can suspect breast cancer. If the big nodes are on both sides and there is no breast abnormality then the problem may be systemic like lymphoma. If the big nodes are unilateral and there is no breast abnormality then perhaps there is an infection in that upper extremity and so on.
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hello,
I recently had an abnormal mammo and ultrasound a few days ago and i am very concerned about the wording and descriptions on the report. This was my first mammo and ultrasound both diagnostic since my gyn thought she felt bilateral breast masses.
They found an enlarged lymph node in right breast 3x5x7 with a thickened vascular cortex. No mass noted. Fna is scheduled. In my left breast they found a microlobulated hypoechoic mass 5x7x10 and also subcentimeter asymmetry in lower central region. Bx scheduled.
My question is should i be worried they missed a mass in my right breast? Or if my left breast mass is malignant could it spread to a right breast lymph node? Could this enlarged lymph node just be nothing at all and just worried for nothing. Im 40 and healthy. The radiologist made me do a second mammo on left breast because i have heterogenously dense breasts and they wanted better pics of mass. Result was birads 4.
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