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Magnetic Resonance Appearance of Normal Popliteal Lymph Nodes

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Magnetic Resonance Appearance of Normal Popliteal Lymph Nodes J Korean Radiol Soc 2002;47:665-671 Magnetic Resonance Appearance of Normal Popliteal Lymph Nodes: Location and Relationship of Number, Fatty change, and Size of the Lymph nodes with Aging1 Hee Jung Moon, M.D., Jin-Suck Suh, M.D., Sang Hoon Lee, M.D. Purpose: To investigate the location of popliteal lymph nodes and the relationship be- tween patient age and their number, size, and the occurrence of fatty chang. Materials and Methods: We retrospectively evaluated the magnetic resonance (MR) images of 222 patients〔 age range, 8-79 (mean, 47.1) years〕who had undergone MRI of the knee after its internal derangement. Images were obtained in the axial, coronal, and sagittal planes. A lymph node was defined as‘ observed’if it was visible in at least two planes, such as axial and sagittal or axial and coronal. With regard to location, nodes were classified as anteromedial, anterolateral, posteromedial, or posterolateral, depending upon their relationship with the popliteal vein. To determine their size, the smallest diameter was measured. Results: Popliteal lymph nodes were present in 116 of 222 examinations (52.3%), and their total number was 158 (mean, 1.36). Patients’age correlated negatively with their presence (R square=0.826), and positively with the occurrence of fatty change (R square=0.840). Sixty- five of 158 lymph nodes (41.1%) were located anteromedially, 58 (36.7%) posterolaterally, 27 (17.1%) anterolaterally, and eight (5.1%) posteromedially. Their distance from the most distal femoral articular surface was 4.6±1.4 cm (mean ± SD), and their mean diameter was 4.96±2.4 mm (mean ±SD; range, 4-8 mm). Conclusion: The number of popliteal lymph nodes decreased with age, while the inci- dence of fatty change increased. Nodes were most frequently anteromedial or posteri- lateral to the popliteal vein. Index words : Lymph nodes Lymphatic system, MR Extremities, MR Peripheral lymph nodes, including the cubital, axil- throughout life, showing minor differences in size lary, inguinal and popliteal type, have been reported to change according to location. The replacement of lym- be largest in neonates and to become gradually smaller phatic parenchyma by fatty tissue (fatty change) is more characteristic of peripheral lymph nodes, which usually 1Department of Diagnostic Radiology, Yonsei University College of receive little antigenic stimulation (1). Medicine In clinical work-up involving MR imaging of the knee, Received August 16, 2002 ; Accepted November 6, 2002 Address reprint requests to : Jin-Suck Suh, M.D., Department of we have frequently noticed popliteal lymph nodes in pa- Diagnostic Radiology, Yonsei University College of Medicine, 134 tients with internal derangement, or rheumatoid or de- Shinchon-dong Seodaemun-gu, Seoul 120-752, Korea. Tel. 82-2-361 5840 Fax. 82-2-393-3035 E-mail: [email protected] generative arthritis. Several studies have reported the ─ 665 ─ Hee Jung Moon, et al : Magnetic Resonance Appearance of Normal Popliteal Lymph Nodes imaging findings of peripheral lymph nodes at axillary logic findings in one-third of the patients. Other findings and inguinal sites but not, to our knowledge, those of included ganglion cyst, fibrous cortical defect, bipartite popliteal lymph nodes. In this reports we describe patella, hemarthrosis, Baker’s cyst, bone infarction, os- popliteal lymph nodes in terms of their prevalence, loca- teochondral lesion, and medial patellar plicae syn- tion, and size, and the occurene of fatty change. drome. For all examinations, a 1.5-T MR imager (Signa; Materials and Methods General Electric Medical Systems, Milwaukee, Wis., U.S.A.) was used, together with a dedicated knee coil. Between January 2000 and February 2001, 249 MR The patients were placed in the magnet with the knee in imagings procedures were performed for the evaluation of arthralgia of the knee. The findings of 27 cases were Table 1. MR Imaging Interpretation Results of the 222 Patients excluded due to presence of metal artifact (n=19) or Meniscal tear or degeneration 141 rheumatoid arthritis (n=8); those remaining related to Ligament tear 43 115 females and 107 males〔mean age, 47.1 (range, 8- Contusion 19 79) years〕in their first (n=4), second (n=23), third Chondromalacia 42 Discoid meniscus 24 (n=42), fourth (n=34), fifth (n=40), sixth (n=40), sev- Normal 21 enth (n=28), or eighth (n=11) decade, and are described Others 20 in Table 1. The most common MR diagnosis was menis- ligament; anterior and posterior crucate, medial and lateral collat- cal tear or degeneration, revealed by two or more radio- eral ligaments Fig. 1. A 21 year-old-man with bipartite patella. The popliteal lymph node shows inter- mediate signal intensity on T1 weight- ed images (A), high signal intensity on T2 weighted axial and sagittal images (B, C), and low signal intensity on pro- ton weighted sagittal images (D). AB CD ─ 666 ─ J Korean Radiol Soc 2002;47:665-671 the neutral position, and the following sequences were Lee), who reached a consensus. Nodes were considered obtained: axial T1-weighted (TR/TE/number of excita- to be present if observed in at least two imaging planes, tions: 600/14/2; field of view, 14×14 cm; matrix, 256× such as axial and sagittal or axial and coronal. 192; slice thickness, 4mm; interslice gap, 0 mm); axial Lymph nodes appeared as discrete round or oval fat-suppressed T2-weighted (TR/TE/number of excita- structures which were, at T1- and T2-weighted imaging, tions: 4000/50/2; field of view, 14×14 cm; matrix, 256× respectively, of intermediate or high signal intensity 192; slice thickness, 4mm; interslice gap, 0 mm); sagittal (Fig. 1). Those which showed fatty change were also T2-weighted (TR/TE/number of excitations: 2000/80/1; seen as discrete round or oval structures. At T1-weight- field of view, 14×14 cm; matrix, 256×256; slice thick- ed imaging they were of high signal intensity (identical ness, 3 mm; interslice gap, 1 mm); sagittal proton densi- to fat) and were surrounded by a low signal intensity ty-weighted (TR/TE/number of excitations: 2000/20/1; rim, and at T2-weighted fat-supressed imaging, a central field of view, 14×14 cm; matrix, 256×192; slice thick- low signal intensity area with a peripheral high signal in- ness, 3 mm; interslice gap, 1 mm); and coronal fat-sup- tensity rim was observed (Fig. 2). Several lymph nodes pressed fast spin-echo T2-weighted (TR/TE/number of with fatty change had an incomplete peripheral low sig- excitations: 4000/50/2; field of view, 14×14 cm; matrix, nal intensity rim (Fig. 3). 256×256; slice thickness, 3 mm; interslice gap, 1 mm). On contiguous images, branching vessels could be eas- All images were reviewed for the presence of popliteal ily distinguished from lymph nodes by virtue of their lymph nodes by two of the authors (H.J. Moon, S.H. anatomical location, the presence of intraluminal signal Fig. 2. A 43 year-old-man with knee pain. A. On T1-weigthed axial images, the popliteal lymph node with fatty change is identified as discrete, round or oval structures, which were well-demarcat- ed high signal structures surrounded by a low signal rim. B, C. On T2-weighted axial and sagittal images, lymph nodes were identified as central low signal intensity with pe- ripheral high signal rim on fat-sup- pressed imaging. D. On proton weighted sagittal images, lymph nodes showed high signal inten- sity. AB CD ─ 667 ─ Hee Jung Moon, et al : Magnetic Resonance Appearance of Normal Popliteal Lymph Nodes void, and their tubular branching shape (2, 3). this study. Their number correlated negatively with age In terms of localization, lymph nodes were classified (R square=0.826): they were found in all four subjects as anteromedial, anterolateral, posteromedial or pos- in the 1st decade of life, (100%), 15 of 23 in the 2nd terolateral, depending upon their relationship with the (65.2%), 27 of 42 in the 3rd (64.3%), 22 of 34 in the 4th popliteal vein (Fig. 4). In addition, the precise location of (64.7%), 22 of 40 in the 5th (55%), 12 of 40 in the 6th a node was expressed as the shortest distance from the (30%), 11 of 28 in the 7th (39.3%), and 3 of 11 in the 8th line tangential to the most distal femoral articular sur- (27.3%) (Fig. 6). face to the center of the node (Fig. 5). The number of lymph nodes showing fatty change The size of a node was expressed as its shortest diame- correlated positively with age (R square=0.840). Fatty ter, as measured on an axial image (5-8). change was observed in none of the four subjects in the The relationship between number, fatty change, and 1st decade (0%), 4 of 15 in the 2nd (26.7%), 12 of 27 in the size of popliteal lymph nodes with aging was deter- the 3rd (44.4%), 17 of 22 in the 4th (77.3%), 21 of 22 in mined by statistical analysis employing univariate logis- the 5th (95.5%), 12 of 12 in the 6th (100%), 11 of 11 in tic regression. the 7th (100%), and 3 of 3 in the 8th (100%) (Fig. 7). The number of lymph nodes present in each of the Results four regions varied: they were most common in the an- teromedial region (65 of 222 cases, 29.3%), followed by A total of 158 (mean, 1.36) popliteal lymph nodes the posterolateral region (58 of 222, 26.1%), the antero- were present in 116 (52.3%) of 222 patients included in lateral region (27 of 222, 12.2%), and the posteromedial Fig.
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