Sonographic Assessment of Peripheral Lymph Nodes In Early-Stage Mycosis Fungoides: Diagnostic Value And Prognostic Implications

Banu İsmail Mendi; Hatice Şanlı; Bökebatur Ahmet Raşit Mendi; Ahmet Taha Aydemir; İncilay Kalay Yıldızhan; Evren Üstüner; Bengü Nisa Akay

doi:10.5826/dpc.1601a7092

Sonographic Assessment of Peripheral Lymph Nodes In Early-Stage Mycosis Fungoides: Diagnostic Value And Prognostic Implications

Authors

Banu İsmail Mendi Niğde Ömer Halisdemir University Faculty of Medicine, Department of Dermatology https://orcid.org/0000-0003-4890-1484
Hatice Şanlı Ankara University Faculty of Medicine, Department of Dermatology
Bökebatur Ahmet Raşit Mendi Ankara Yıldırım Beyazıt University Faculty of Medicine, Department of Radiology https://orcid.org/0000-0002-6102-2188
Ahmet Taha Aydemir Yozgat City Hospital
İncilay Kalay Yıldızhan Ankara University Faculty of Medicine, Department of Dermatology
Evren Üstüner Ankara University Faculty of Medicine, Department of Radiology
Bengü Nisa Akay Ankara University Faculty of Medicine, Department of Dermatology https://orcid.org/0000-0002-4896-1666

Keywords:

Mycosis Fungoides, Peripheral Lymph Nodes, Ultrasound, Diagnostic Value, Prognostic Implications

Abstract

Introduction: Imaging studies are infrequently performed in patients with early-stage mycosis fungoides (MF), resulting in limited research on lymph nodes within this group.

Objectives: To determine which patient groups are more likely to have sonographically pathological lymph nodes and to assess the relationship between sonographic lymph node features and progression to advanced stage.

Methods: Characteristics of early-stage MF patients with lymphadenopathy were recorded retrospectively. Logistic regression analyses were performed to evaluate associations between patient characteristics and sonographic findings as well as to assess the relationship between sonographic features and progression to advanced disease stages.

Results: In the study, 70 patients were examined, revealing lymphadenopathy at a single site in 18.6% and multiple sites in 81.4%. The average long axis length was 23.4 mm, and the average short axis length was 8.4 mm. Diffuse cortical thickening was observed in 14.4%, asymmetric thickening in 3.8%, fatty hilum loss in 4.8%, heterogeneity in 1%, contour irregularity in 0.5%, and non-hilar, disorganized blood flow in 0.5% of the lymph nodes. Biopsies were performed on 13 lymph nodes post-ultrasound, with 195 nodes monitored subsequently. Of these, 42 nodes did not regress, while 153 regressed. A total of 30 lymph nodes were biopsied, identifying 28 as N1, one as N2, and one as N3. Younger age and elevated beta-2 microglobulin levels correlated with pathological features and persistent lymphadenopathy.

Conclusions: Considering the potential morbidities linked to lymph node biopsy, evaluating ultrasound features might be essential to patient selection. An earlier biopsy could be justified in younger patients with increased beta-2 microglobulin levels.

References

Maguire A, Puelles J, Raboisson P, Chavda R, Gabriel S, Thornton S. Early-stage mycosis fungoides: epidemiology and prognosis. Acta dermato-venereologica. 2020;100(1-2):1-6. DOI:10.2340/00015555-3367. PMID:31663598.

Olsen E, Vonderheid E, Pimpinelli N, et al. Revisions to the staging and classification of mycosis fungoides and Sezary syndrome: a proposal of the International Society for Cutaneous Lymphomas (ISCL) and the cutaneous lymphoma task force of the European Organization of Research and Treatment of Cancer (EORTC). Blood. Sep 15 2007;110(6):1713-22. DOI:10.1182/blood-2007-03-055749. PMID:17540844.

Rehell M, Atula T, Tapiovaara LK, et al. Complications in lymph node excision in the head and neck area. Acta Otolaryngol. Sep-Dec 2022;142(9-12):738-742. DOI:10.1080/00016489.2022.2115551. PMID:36107716.

Hodak E, Sherman S, Papadavid E, et al. Should we be imaging lymph nodes at initial diagnosis of early-stage mycosis fungoides? Results from the PROspective Cutaneous Lymphoma International Prognostic Index (PROCLIPI) international study. Br J Dermatol. Mar 2021;184(3):524-531. DOI:10.1111/bjd.19303. PMID:32574377.

Torabi M, Aquino SL, Harisinghani MG. Current concepts in lymph node imaging. Journal of nuclear medicine. 2004;45(9):1509-1518. PMID: 15347718.

Marchal G, Oyen R, Verschakelen J, Gelin J, Baert A, Stessens R. Sonographic appearance of normal lymph nodes. Journal of Ultrasound in Medicine. 1985;4(8):417-419. DOI: 10.7863/jum.1985.4.8.417. PMID: 3897564.

Ying M, Ahuja A. Sonography of neck lymph nodes. Part I: normal lymph nodes. Clinical radiology. 2003;58(5):351-358. DOI: 10.1016/s0009-9260(02)00584-6 PMID: 12727162.

Ahuja A, Ying M. Sonography of neck lymph nodes. Part II: abnormal lymph nodes. Clinical radiology. 2003;58(5):359-366. DOI: 10.1016/s0009-9260(02)00585-8. PMID: 12727163.

Griffith J, Chan A, Ahuja A, et al. Neck ultrasound in staging squamous oesophageal carcinoma—a high yield technique. Clinical radiology. 2000;55(9):696-701. DOI: 10.1053/crad.2000.0502. PMID: 10988048.

Olsen E, Vonderheid E, Pimpinelli N, et al. Revisions to the staging and classification of mycosis fungoides and Sezary syndrome: a proposal of the International Society for Cutaneous Lymphomas (ISCL) and the cutaneous lymphoma task force of the European Organization of Research and Treatment of Cancer (EORTC). Blood. 2007;110(6):1713-1722. DOI: 10.1182/blood-2007-03-055749. PMID: 17540844.

Esen G. Ultrasound of superficial lymph nodes. Eur J Radiol. Jun 2006;58(3):345-59. DOI:10.1016/j.ejrad.2005.12.039. PMID: 16480846

Doerken S, Avalos M, Lagarde E, Schumacher M. Penalized logistic regression with low prevalence exposures beyond high dimensional settings. PLoS One. 2019;14(5):e0217057. DOI:10.1371/journal.pone.0217057. PMID: 31107924.

Ogundimu EO, Altman DG, Collins GS. Adequate sample size for developing prediction models is not simply related to events per variable. Journal of Clinical Epidemiology. 2016/08/01/ 2016;76:175-182. DOI:10.1016/j.jclinepi.2016.02.031. PMID: 26964707.

Heinze G, Wallisch C, Dunkler D. Variable selection - A review and recommendations for the practicing statistician. Biom J. May 2018;60(3):431-449. DOI:10.1002/bimj.201700067. PMID: 29292533.

Harrell Jr FE. General aspects of fitting regression models. Regression modeling strategies: with applications to linear models, logistic regression, and survival analysis. Springer; 2001:11-40. DOI:10.1007/978-1-4757-3462-1_2.

Babyak MA. What you see may not be what you get: a brief, nontechnical introduction to overfitting in regression-type models. Psychosom Med. May-Jun 2004;66(3):411-21. DOI:10.1097/01.psy.0000127692.23278.a9. PMID: 15184705.

Olsen EA, Whittaker S, Willemze R, et al. Primary cutaneous lymphoma: recommendations for clinical trial design and staging update from the ISCL, USCLC, and EORTC. Blood. Aug 4 2022;140(5):419-437. DOI:10.1182/blood.2021012057. PMID: 34758074.

Olsen EA, Whittaker S, Kim YH, et al. Clinical end points and response criteria in mycosis fungoides and Sézary syndrome: a consensus statement of the International Society for Cutaneous Lymphomas, the United States Cutaneous Lymphoma Consortium, and the Cutaneous Lymphoma Task Force of the European Organisation for Research and Treatment of Cancer. J Clin Oncol. Jun 20 2011;29(18):2598-607. DOI:10.1200/jco.2010.32.0630. PMID: 21576639.

Ahuja AT, Ying M, Ho S, et al. Ultrasound of malignant cervical lymph nodes. Cancer Imaging. 2008;8(1):48. DOI: 10.1102/1470-7330.2008.0006. PMID: 18390388.

Ying M, Ahuja AT. Ultrasound of neck lymph nodes: how to do it and how do they look? Radiography. 2006;12(2):105-117. DOI:10.1016/j.radi.2005.04.004.

Gaddey HL, Riegel AM. Unexplained Lymphadenopathy: Evaluation and Differential Diagnosis. Am Fam Physician. Dec 1 2016;94(11):896-903. PMID: 27929264.

Hwang MK, Dua H, Mulligan AM, Escallon J. Seven-month persistence of COVID-19 vaccine-induced lymphadenopathy: a case report. J Med Case Rep. Mar 27 2025;19(1):143. DOI:10.1186/s13256-025-05188-0. PMID: 40148999.

Schwartz L, Bogaerts J, Ford R, et al. Evaluation of lymph nodes with RECIST 1.1. European journal of cancer. 2009;45(2):261-267. DOI: 10.1016/j.ejca.2008.10.028. PMID: 19091550.

Matsumoto F, Itoh S, Ohba S-i, Yokoi H, Furukawa M, Ikeda K. Biopsy of cervical lymph node. Auris Nasus Larynx. 2009;36(1):71-74. DOI: 10.1016/j.anl.2008.03.008. PMID: 18479855.

Aftab M, Hasan M, Samad L. Lymph node biopsy in children: Indications and etiology. Journal of Pediatric and Adolescent Surgery. 2020;1(1):28-31. DOI:10.46831/jpas.v1i1.18.

Locke R, Comfort R, Kubba H. When does an enlarged cervical lymph node in a child need excision? A systematic review. International journal of pediatric otorhinolaryngology. 2014;78(3):393-401. DOI: 10.1016/j.ijporl.2013.12.011. PMID: 24447684.

Slap GB, Brooks JS, Schwartz JS. When to perform biopsies of enlarged peripheral lymph nodes in young patients. Jama. 1984;252(10):1321-1326. DOI: 10.1001/jama.1984.03350100051031. PMID: 6471252.

Sun G, Berthelot C, Li Y, et al. Poor prognosis in non-Caucasian patients with early-onset mycosis fungoides. J Am Acad Dermatol. Feb 2009;60(2):231-5. DOI:10.1016/j.jaad.2008.09.063. PMID: 19026464.

Wang J, Liu J, Pan H, et al. Young age increases the risk of lymph node positivity in papillary thyroid cancer patients: a SEER data-based study. Cancer Manag Res. 2018;10:3867-3873. DOI:10.2147/cmar.S167774. PMID: 30288118

Meyer JE, Cohen SJ, Ruth KJ, Sigurdson ER, Hall MJ. Young Age Increases Risk of Lymph Node Positivity in Early-Stage Rectal Cancer. J Natl Cancer Inst. Jan 2016;108(1) DOI:10.1093/jnci/djv284. PMID: 26719881.

Xie X, Yin J, Zhou Z, Dang C, Zhang H, Zhang Y. Young age increases the risk for lymph node metastasis in patients with early Colon Cancer. BMC Cancer. Aug 14 2019;19(1):803. DOI:10.1186/s12885-019-5995-4. PMID: 31412872.

Xia W, Wang A, Jin M, et al. Young age increases risk for lymph node positivity but decreases risk for non-small cell lung cancer death. Cancer Manag Res. 2018;10:41-48. DOI:10.2147/cmar.S152017. PMID: 29386914.

Talpur R, Singh L, Daulat S, et al. Long-term outcomes of 1,263 patients with mycosis fungoides and Sézary syndrome from 1982 to 2009. Clin Cancer Res. Sep 15 2012;18(18):5051-60. DOI:10.1158/1078-0432.Ccr-12-0604. PMID: 22850569.

Nikolaou V, Papadavid E, Patsatsi A, et al. Prognostic indicators for mycosis fungoides in a Greek population. Br J Dermatol. May 2017;176(5):1321-1330. DOI:10.1111/bjd.15000. PMID: 27552962.

Suzuki SY, Ito K, Ito M, Kawai K. Prognosis of 100 Japanese patients with mycosis fungoides and Sézary syndrome. J Dermatol Sci. Jan 2010;57(1):37-43. DOI:10.1016/j.jdermsci.2009.10.010. PMID: 19931424.

Green SB, Byar DP, Lamberg SI. Prognostic variables in mycosis fungoides. Cancer. Jun 1 1981;47(11):2671-7. DOI:10.1002/1097-0142(19810601)47:11<2671::aid-cncr2820471125>3.0.co;2-x. PMID: 7260860.

Lamberg SI, Green SB, Byar DP, et al. Clinical staging for cutaneous T-cell lymphoma. Ann Intern Med. Feb 1984;100(2):187-92. DOI:10.7326/0003-4819-100-2-187. PMID: 6607008.