Location: Levels I-VI

Head and neck squamous cell cancers: Most common in upper neck, at level II

Thyroid cancers: Most common at levels VI, III, and IV

Supraclavicular nodes are usually from distant primary tumor (e.g., lung, gastrointestinal tract, breast)

Size less important than morphology

Malignant nodes are round with sharp borders, (long = short axis < 2)

Irregular borders suggest extracapsular extension; ± invasion of adjacent structures (e.g., vessels, muscles)

Loss of fatty hilum

Eccentric cortical thickening

Most hypoechoic but can be hyperechoic in papillary thyroid cancer

Cystic component: Consider necrosis in squamous cell carcinoma or cystic metastasis from papillary thyroid cancer

Punctate calcifications: Consider papillary thyroid cancer or medullary thyroid carcinoma

Color Doppler: Chaotic/disorganized intranodal vascularity, peripheral vascularity

Reactive lymphadenopathy

Non-Hodgkin lymphoma

Tuberculosis

Patients may present with painless, firm neck mass

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  Nodes may be asymptomatic and found during staging

Nodes more likely with larger primary, initially ipsilateral then contralateral to primary tumor

Even when nodes are sonographically suspicious, fine-needle aspiration may be required to confirm tumor involvement