Classification of Ultrasound Features of Superficially Located Lymph Nodes

Assessment of lymphatic drainage areas is a critical task in ultrasound (US) examination of organs and tissues involved in various pathological processes. Superficially located lymph nodes (LNs) are more accessible for US evaluation. The numerous LN changes identified in ultrasound often are challenging for interpretation. The proposed classification provides grading of the detected ultrasound features in superficial LNs into groups, facilitating a risk stratification system for LN malignancy.

Objective. To stratify LN ultrasound features according to the degree of deviation from the normal pattern – from loss of benign features to appearance of signs of malignancy – and to establish a classification of changes in superficially located LN based on US findings.

Results. The classification comprises six levels: normal/unchanged LNs; probably benign LN changes; indeterminate/uncertain LN changes; suspicious LN changes; highly suspicious LN changes; morphologically confirmed malignant LN.

Conclusion. The presented Russian classification for risk stratification of malignancy in superficial LNs will enable a more accurate US assessment of superficial lymph nodes, allowing identification of distinct types of ultrasound structure and selection of suspicious lymph nodes for biopsy.

1. Clinical guidelines. Acute lymphoblastic leukemia. Year of approval 2025. https://cr.minzdrav.gov.ru/view-cr/496_2 (In Russian)

2. Clinical Guidelines. Peritonsillar abscess. Year of approval 2024. https://cr.minzdrav.gov.ru/view-cr/664_2 (In Russian)

3. Clinical guidelines. Cervical cancer. Year of approval 2025. https://cr.minzdrav.gov.ru/view-cr/537_3 (In Russian)

4. Clinical guidelines. Oropharyngeal cancer. Year of approval 2024. https://cr.minzdrav.gov.ru/view-cr/ 4_2 (In Russian)

5. Clinical guidelines. Melanoma of the skin and mucous membranes. Year of approval 2023. https://cr.minzdrav.gov.ru/view-cr/546_3 (In Russian)

6. Fisenko E.P., Allahverdieva G.F., Bulanov M.N. et al. Standardization of the protocol of superficial lymph node ultrasound. Consensus of experts of the Russian association of specialists of ultrasound in medicine (RASUDM). Ultrasound & Functional Diagnostics. 2024; 4: 115–131. (In Russ.) https://doi.org/10.24835/1607-0771-294 (In Russian)

7. Davydova L.A., Chaika L.D. Anatomy of the lymphatic system. Study guide. Minsk: Belorussian State Medical University, 2013. 48 p. (In Russian)

8. Fisenko E.P., Postnova N.A. Vetsheva N.N., Batukhtina E.V. Application of the ВI-RADS classification in ultrasound multiparametric assessment of breast formations. Moscow: STROM, 2023. 125 p. (In Russian)

9. Katrich A. N., Fisenko E. P., Vetsheva N. N. Application of the TI-RADS classification in ultrasound multiparametric assessment of thyroid nodules. M.: STROM, 2023. 86 p. (In Russian)

10. Gazhonova V.E. A new standard system for ultrasound examination of ovarian formations to predict the risk of tumor malignancy. Obstetrics and Gynecology. 2020; 10: 28–40. https://dx.doi.org/10.18565/aig.2020.10.28-40 (In Russian)

11. Elsholtz F.H.J., Asbach P., Haas M. et al. Introducing the Node Reporting and Data System 1.0 (Node-RADS): a concept for standardized assessment of lymph nodes in cancer. Eur. Radiol. 2021; 31 (8): 6116–6124. https://doi.org/10.1007/s00330-020-07572-4

12. Bedi D.G., Krishnamurthy R., Krishnamurthy S. et al. Cortical morphologic features of axillary lymph nodes as a predictor of metastasis in breast cancer: in vitro sonographic study. Am. J. Roentgenol. 2008; 191 (3): 646–652. https://doi.org/10.2214/AJR.07.2460

13. Ryu K.H., Lee K.H., Ryu J. et al. Cervical Lymph Node Imaging Reporting and Data System for Ultrasound of Cervical Lymphadenopathy: A Pilot Study. Am. J. Roentgenol. 2016; 206 (6): 1286–1291. https://doi.org/10.2214/AJR.15.15381

14. Zhang M., Ahn R.W., Hayes J.C. et al. Axillary Lymphadenopathy in the COVID-19 Era: What the Radiologist Needs to Know. Radiographics. 2022; 42 (7): 1897–1911. https://doi.org/10.1148/rg.220045

15. Alamdaran S.A., Randian A., Rasoulian B. et al. Correlation of Sonographic Classification of Neck Adenopathy (A-RADS) and Malignancy. Iran J. Otorhinolaryngol. 2023; 35 (126): 39–47. https://doi.org/10.22038/IJORL.2022.67255.3299

16. Allahverdieva G.F., Danzanova T.Yu., Mudunov A.M. et al. Ultrasound Assessment of the Condition of Peripheral Lymph Nodes (Literature Review). Ultrasound Classification Node-RADS (US). Journal of Oncology: Diagnostic Radiology and Radiotherapy. 2023; 6 (4): 42–52. https://doi.org/10.37174/2587-7593-2023-6-4-42-52 (In Russian)

17. Fischerova D., Garganese G., Reina H. et al. Terms, definitions and measurements to describe sonographic features of lymph nodes: consensus opinion from the Vulvar International Tumor Analysis (VITA) group. Ultrasound Obstet. Gynecol. 2021; 57 (6): 861–879. https://doi.org/10.1002/uog.23617

18. Zabolotskaya N.V. Ultrasound diagnostics of diseases of the lymphatic system. In: Practical guide to ultrasound diagnostics. General ultrasound diagnostics. 3rd ed / Ed. V.V. Mitkov. Moscow: VIDAR-M, 2019: 557–590. (In Russian)

19. Sencha A.N. Lymph nodes. Ultrasound examination. NODE-RADS. In: Ultrasound examination of superficially located organs. Atlas. Under the general editorship of A.N., Sencha. Moscow: MEDpress-inform, 2026: 257–298 (In Russian)

20. Clinical Guidelines. Differentiated thyroid cancer. Year of approval 2024. https://cr.minzdrav.gov.ru/view-cr/329_2 (In Russian)

21. Baskin-sr. G.D., Dwik D.S., Levin R.E. Ultrasound examination and mapping of the lymph nodes of the neck. In: Ultrasound examination of the thyroid gland. Moscow: GEOTAR-Media, 2018: 181–213. (In Russian)

22. Ahuja A.T., Ying M. Sonographic evaluation of cervical lymph nodes. Am. J. Roentgenol. 2005; 184 (5): 1691–1699. https://doi.org/10.2214/ajr.184.5.01841691

23. Vassallo P., Wernecke K., Roos N., Peters P.E. Differentiation of benign from malignant superficial lymphadenopathy: the role of high-resolution US. Radiology. 1992; 183 (1): 215–220. https://doi.org/10.1148/radiology.183.1.1549675

24. Normal ultrasound anatomy of internal organs and superficial structures: Practical guide. Eds by V.A. Sandrikov, E.P. Fisenko. Moscow: STROM, 2012. 192 p. (In Russian)

25. Robbins K.T., Shaha A.R., Medina J.E. et al.; Committee for Neck Dissection Classification, American Head and Neck Society. Consensus statement on the classification and terminology of neck dissection. Arch. Otolaryngol. Head Neck Surg. 2008; 134 (5): 536–538. https://doi.org/10.1001/archotol.134.5.536

26. Durante C., Hegedüs L., Czarniecka A. et al. 2023 European Thyroid Association Clinical Practice Guidelines for thyroid nodule management. Eur. Thyroid J. 2023; 12 (5): e230067. https://doi.org/10.1530/ETJ-23-0067

27. Mainiero M.B., Cinelli C.M., Koelliker S.L. et al. Axillary ultrasound and fine-needle aspiration in the preoperative evaluation of the breast cancer patient: an algorithm based on tumor size and lymph node appearance. Am. J. Roentgenol. 2010; 195 (5): 1261–1267. https://doi.org/10.2214/AJR.10.44

28. Gazhonova V.E. Ultrasound diagnostics and multimodal approach in mammology. Moscow: GEOTAR-Media, 2025.400 p. (In Russian)

29. Tsunodo-Shimizu H., Saida Y. Ultrasonographic visibility of supraclavicular lymph nodes in normal subjects. J. Ultrasound Med. 1997; 16 (7): 481–483. https://doi.org/10.7863/jum.1997.16.7.481

30. Fultz P.J., Harrow A.R., Elvey S.P. et al. Sonographically guided biopsy of supraclavicular lymph nodes: a simple alternative to lung biopsy and other more invasive procedures. Am. J. Roentgenol. 2003; 180 (5): 1403–1409. https://doi.org/10.2214/ajr.180.5.1801403

31. Fisenko E.P., Pankova E.A., Shinakova K.A. et al. Features of ultrasonic picture of unchanged inguinal lymph nodes. 2025; 15 (1):167–176. https://doi.org/10.21569/2222-7415-2025-15-1-167-176 (In Russian)

32. Mäkelä P.J., Leminen A., Kääriäinen M., Lehtovirta P. Pretreatment sonographic evaluation of inguinal lymph nodes in patients with vulvar malignancy. J. Ultrasound Med. 1993; 12 (5): 255–258. https://doi.org/10.7863/jum.1993.12.5.255

33. Krishna R.P., Sistla S., Smile R., Krishnan R. Sonography: An Underutilized Diagnostic Tool in the Assessment of Metastatic Groin Nodes. Clin. Ultrasound. 2008, 36: 212–217. https://doi.org/10.1002/jcu.20420

34. Ahuja A.T., Ying M., Ho S.Y. et al. Ultrasound of malignant cervical lymph nodes. Cancer Imaging. 2008; 8 (1): 48–56. https://doi.org/10.1102/1470-7330.2008.0006

35. Esen G. Ultrasound of superficial lymph nodes. Eur. J. Radiol. 2006; 58 (3): 345–359. https://doi.org/10.1016/j.ejrad.2005.12.039

36. Allahverdyan G.S., Chekalova M.A. Ultrasound Diagnostics in Superficial Lymph Nodes Pathology. Ultrasound & Functional Diagnostics. 2011 (1): 77–84. (In Russian)

37. Gupta A., Rahman K., Shahid M. et al. Sonographic assessment of cervical lymphadenopathy: role of high-resolution and color Doppler imaging. Head Neck. 2011; 33 (3): 297–302. https://doi.org/10.1002/hed.21448

38. Xing Z., Qiu Y., Yang Q. et al. Thyroid cancer neck lymph nodes metastasis: Meta-analysis of US and CT diagnosis. Eur. J. Radiol. 2020; 129: 109103. https://doi.org/10.1016/j.ejrad.2020.109103

39. Savelyeva N.A. Ultrasound diagnostics of malignant lesions of peripheral lymph nodes. Practical Medicine. 2014; 3: 135–138. (In Russian)

40. Zabolotskaya N.V. Ultrasound examination in mammology. Moscow: Strom, 2019. 208 p. (In Russian)

41. Chung H.L., Le-Petross H.T., Leung J.W.T. Imaging Updates to Breast Cancer Lymph Node Management. Radiographics. 2021; 41 (5): 1283–1299. https://doi.org/10.1148/rg.2021210053

42. Białek E.J., Jakubowski W., Szczepanik A.B. et al. Superficial lymph nodes involved by lymphoma in modern gray-scale ultrasound imaging. Pol. J. Radiol. 2007; 72 (4): 30–34. https://inis.iaea.org/records/et6z7-bnv74

43. Kovaleva E.V., Danzanova T.Yu., Sinyukova G.T. et al. Multiparametric ultrasound diagnostics of altered lymph nodes in primary multiple malignant tumors, including breast cancer and lymphoma. Malignant Tumors. 2018; 8 (4): 37–44. https://doi.org/10.18027/2224-5057-2018-8-4-37-44 (In Russian)

44. Kapustin V.V., Kabin, Yu. V., Kostash O. V. Ultrasound visualization of superficial lymph nodes. Differential diagnostics in oncological practice: Guide for doctors. Moscow: OOO Firma STROM, 2024. 180 p. (In Russian)

45. Kolyadina IV, Danzanova TY, Khokhlova SV, Trofimova OP, Kovaleva EV, Rodionov VV, Poddubnaya IV. Modern view on the issues of diagnosis and verification of axillary lymph nodes involvement in early breast cancer. Journal of Modern Oncology. 2020; 22 (1): 46–52. (In Russian)

46. Guidelines. Breast cancer. 2023. https://cr.minzdrav.gov.ru/view-cr/379_4 (In Russian)

47. Clinical Guidelines. Hodgkin's lymphoma. 2024. https://cr.minzdrav.gov.ru/view-cr/139_2 (In Russian)

48. Standards of ultrasound, CT, MRI, SPECT, PET/CT and AG studies in oncology / Eds by B.I. Dolgushin and I.E. Tyurin. Moscow, 2024, 9th Suppl. ed. 304 p. ISBN 978-5-4253-0770-5 (In Russian)

49. Kovaleva E.V., Danzanova T.Yu., Sinyukova G.T. et al. Current state of diagnostics and evaluation of the effectiveness of treatment of lymphomas with damage to peripheral lymph nodes. Ultrasound and Functional Diagnostics. 2019; 4: 70–90. https://doi.org/10.24835/1607-0771-2019-4-70-90 (In Russian)

50. You S., Kang D.K., Jung Y.S. et al. Evaluation of lymph node status after neoadjuvant chemotherapy in breast cancer patients: comparison of diagnostic performance of ultrasound, MRI and 18F-FDG PET/CT. Br. J. Radiol. 2015; 88 (1052): 20150143. https://doi.org/10.1259/bjr.20150143

51. Ha S.M., Cha J.H., Kim H.H. et al. Diagnostic performance of breast ultrasonography and MRI in the prediction of lymph node status after neoadjuvant chemotherapy for breast cancer. Acta Radiol. 2017; 58 (10): 1198–1205. https://doi.org/10.1177/0284185117690421

52. Kovaleva E.V., Gudilina E.A., Danzanova T.Yu. et al. Evaluation of the effectiveness of treatment of lymphoma with damage to peripheral lymph nodes using ultrasound with contrast enhancement. Journal of Oncology: Diagnostic Radiology and Radiotherapy. 2020; 3 (3): 35–43. https://doi.org/10.37174/2587-7593-2020-3-3-35-43 (In Russian)

53. Dialani V., Dogan B., Dodelzon K. et al. Axillary Imaging Following a New Invasive Breast Cancer Diagnosis-A Radiologist's Dilemma. J. Breast Imaging. 2021; 3 (6): 645–658. https://doi.org/10.1093/jbi/wbab082

54. Li Z., Tong Y., Chen X., Shen K. Accuracy of ultrasonographic changes during neoadjuvant chemotherapy to predict axillary lymph node response in clinical node-positive breast cancer patients. Front. Oncol. 2022; 12: 845823. https://doi.org/10.3389/fonc.2022.845823

55. Zhou T., Yang M., Wang M. et al. Prediction of axillary lymph node pathological complete response to neoadjuvant therapy using nomogram and machine learning methods. Front. Oncol. 2022; 12: 1046039. https://doi.org/10.3389/fonc.2022.1046039

56. Sych Yu.P., Fisenko E.Р., Katrich A.N., Bulanov M.N. Assessment of inter-expert agreement among ultrasound diagnostic physicians using the Russian classification of lymphatic nodules ultrasound characteristics LN-RADS. Medical Visualization. 2026; 30 (1): 61–67. https://doi.org/10.24835/1607-0763-1569 (In Russian)