Epitrochlear lymph nodes: Anatomical basis, clinical aspects

Epitrochlear lymph nodes: Anatomical basis, clinical
aspects, sonography findings, and cross-sectional imaging
correlation
Poster No.:
C-2431
Congress:
ECR 2010
Type:
Educational Exhibit
Topic:
Musculoskeletal
Authors:
O. Catalano, A. Nunziata, F. Laghi, A. Siani; Naples/IT
Keywords:
Epitroclear lymph nodes, Ultrasound, Colour-Doppler ultrasound
DOI:
10.1594/ecr2010/C-2431
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Page 1 of 17
Learning objectives
The objective of this exhibit is to illustrate, through a wide spectrum of drawings and
illustrations, the normal and abnormal US and colour-Doppler findings encountered when
imaging the lymph nodes of the epitrochlear region.
Images for this section:
Fig. 1: Drawing 1
Page 2 of 17
Background
The normal and abnormal aspects of the epitrochlear lymphatic station are not much well
known by the radiologists. The axillary lymph node basin is commonly regarded as the
primary lymphatic target of upper limb disorders but this is not always true.
In this exhibit we illustrate, through a number of drawings and illustrations, the normal and
abnormal sonography (US) and colour-Doppler US findings encountered when imaging
the lymph nodes of the epitrochlear region.
Images for this section:
Fig. 1: Drawing 2
Page 3 of 17
Imaging findings OR Procedure details
Normal Findings
The epitrochlear lymph nodes (called also sovraepitrochlear or cubital lymph nodes)
are part of the upper extremity lymphatic system. These lymph nodes range in number
between 1 and 3 (very rarely 4) and are located within the subcutaneous layer, along the
medial aspect of the elbow, 4 to 5 cm proximal to the epitrochlear (Drawing 1 on page
). The epitrochlear collect the fluid from the last two or three fingers and from the
medial aspect of the hand.
Nevertheless, it should be remembered that there is a relevant interindividual variation
among the drainage area. Consequently any disorder of the elbow, forearm, wrist, or
hand could involve the epitrochlear lymph nodes and the radiologist must explore this
station aside from the medial or lateral location of the primary disease.
The lymphatics originating from the epitrochlear lymph nodes reach the axillary station.
In some instance both stations are jointly involved by inflammatory or tumour processes.
Fig.: Drawing 1
References: Antonio Nunziata, tonikus@libero.it
Clinical Findings
The data from patient history and physical examination include: location, extension,
colour of the overlying skin, size, consistence, pain, mobility, adhesion between the
various nodes, and presence of other abnormalities in other body districts. This
Page 4 of 17
information is important prior to an US exploration and should be merged with the US
and colour-Doppler findings to achieve a definitive diagnosis.
Imaging Findings
The morphologic, echostructural, and vascular findings are the same of all superficial
lymphadenopaties. The most relevant aspects include: number, size and shape of the
lymph nodes, border and appearance of the fat around the lymph node, measure and
ratio of the longitudinal and transverse diameter, appearance of the echoic hilum (large,
reduced, displaced, inhomogeneous, and disappeared), thickness and texture of the
cortex, angioarchitecture (hilar or capsular, normal or increased, etc.) (Drawing 2 on page
).
Fig.: Drawing 2
References: Antonio Nunziata, tonikus@libero.it
We show a number of cases, including lymphadenitis of the IV drug abuser (Fig.1 on
page 6), cat-scratch disease (Fig.2 on page 7); Hodgkin disease (Fig.3 on page
8); metastasis from upper limb cutaneous melanoma (Fig.4 on page 9), (Fig.5
on page 10).
Page 5 of 17
In subjects with lymphomas, elbow lymphadenopaties can be the presentation site of the
haematological malignancy. In some case this is a solitary localization while in other the
subsequent work-up allows the detection of other superficial and deep lesions.
In melanoma patients the axillary lymph nodes are regarded as the regional basin of the
upper limb. The epitrochlear lymph nodes (as well as the popliteal lymph nodes for the
lower limb) are considered as "interval" lymph nodes, along the route from the primary
skin tumour and the axilla. Cutaneous melanoma is known to spread mostly along the
lymphatic ducts, with the development of so-called in-transit metastasis and, as we said
before, of interval lymphadenopaties. Intriguingly, in one of our cases the patient had
already undergone radical axillary lymphadenectomy from a shoulder melanoma and
subsequently developed an epitrochlear lymphadenectomy with an unusual descending
path of the tumour cells.
Clearly, a differential diagnosis is needed with the other possible causes of epitrochlear
and elbow swelling (Table 1 on page
).
Fig.: Table 1
References: Dept of Radiology, National Cancer Institute, Naples, Italy
Images for this section:
Page 6 of 17
Fig. 1: Acute lymphadenitis in a subject with history of IV drug abuse. Palpable, painful
swelling. Single inflammatory lymphadenomegaly.
Page 7 of 17
Fig. 2: Acute lymphadenitis in a veterinary (cat-scratch disease, subsequently proven
at serology). Palpable, painful swelling. Single inflammatory lymphadenomegaly with
intense hyperaemia.
Page 8 of 17
Fig. 3: Hodgkin disease presenting as palpable epitrochlear mass. Multiple
lymphadenopaties. Consequently, a brachial vein thrombosis is apparent.
Page 9 of 17
Fig. 4: Single, partial, lymph node metastasis in a patient having undergone excision of
a cutaneous melanoma of the wrist one year before. Palpable, painless mass found by
the patient herself.
Page 10 of 17
Fig. 5: Single lymph node metastasis in a patient with previous excision of shoulder
melanoma and previous axillary lymphadenectomy. Probably this explains the unusual
lymphatic spread to the elbow. US demonstrated the lymph node metastasis after the
PET-CT detection o fan occult elbow lesion.
Page 11 of 17
Conclusion
In conclusion, epitrochlear lymphadenopaties are uncommon but possible. Consequently
this occurrence requires an adequate knowledge of the key points for recognition and
differential diagnosis.
Images for this section:
Fig. 1
Page 12 of 17
Personal Information
Orlando Catalano, MD, Dept of Radiology, National Cancer Institute "G.Pascale",
Naples, Italy. orlandcat@tin.it
Antonio Nunziata, MD, Dept of Radiology, P. "S.Bellone", DSB 30, ASL Napoli 1 Centro,
Naples, Italy. tonikus@libero.it
Francesca Laghi, MD, Dept of Radiology, Second University, Naples, Italy.
Alfredo Siani, MD, Dept of Radiology, National Cancer Institute "G.Pascale", Naples,
Italy.
Images for this section:
Fig. 1
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Fig. 2
Page 14 of 17
References
1.
2.
3.
4.
5.
Catalano O, Nunziata A, Siani A. Fundamental in oncologic ultrasound on
page 15. Sonographic Imaging and Intervention in the Cancer Patient
Springer Italia, Milan 2009.
Hunt JA, Thompson JF, Uren RF et al. Epitrochlear lymph nodes as a site
of melanoma metastasis. Ann Surg Oncol 1998;5:248-252.
McMasters KM, Chao C, Wong SL et al. Sunbelt Melanoma Trial Group.
Interval sentinel lymph nodes in melanoma. Arch Surg 2002;137:543-547.
Uren RF, Howman-Giles RB, Thompson JF. Failure to detect drainage to
the popliteal and epitrochlear lymph nodes on cutaneous lymphoscintigraphy
in melanoma patients. J Nucl Med 1998;39:2195.
Uren RF, Howman-Giles R, Thompson JF et al. Interval nodes:
the forgotten sentinel nodes in patients with melanoma. Arch Surg
2000;135:1168-1172.
Images for this section:
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Fig. 1
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