Background: Large number of patients with superficial lymphadenopathy 
undergo biopsy to differentiate benign and malignant lymph nodes (LNs). 
Although high accuracy of high-resolution sonography approaches 
differentiating benign and malignant lymph nodes, Ultrasound elastography 
(USE) explains that pathological changes are linked to changes in tissue 
stiffness or elasticity. We suggest the application of elastography may decrease 
using of invasive maneuvers for low-risk LN and improve the selection of LN 
with high malignant probability. The aim of our study is to evaluate the 
diagnostic accuracy of B-mode Ultrasound, color Doppler, elastography, and 
their combination to differentiate benign and malignant LNs. 
Methods: This was a prospective study included 70 patients with enlarged 
superficial LNs ranging in age from 3 to 82 years old. Using high frequency 
probes at 9L / ML6-15 MHz from GE Medical Systems, all patients underwent 
ultrasound, color Doppler scans, and elastography. Patients were subjected to 
fine needle aspiration cytology, core biopsy, or excisional biopsy according to 
patient's condition, with histopathological examination. 
Results: Based on strain elastography (SE); malignant lesions had strain 
elastography score 3 and 4 compared to benign lesions (92.3%) had strain 
elastography score 1 and 2, the difference was statistically significant (p-value <
0.001). The mean strain ratio ± standard deviation (SD) of benign lesions was 
0.84 ± 0.34, the mean strain ratio ± SD of malignant lesions was 2.91±1.05. The 
difference was statistically significant (p-value < 0.001). Based on shear wave 
elastography (SWE), 79.5% of malignant lesions had rim and undetermined 
shear wave color pattern compared to all benign lesions had homogenous and 
nodular shear wave color pattern, the association was statistically significant (p-
value < 0.001). The mean maximum stiffness and maximum velocity were 
statistically significantly higher among the malignant lesions (p-value < 0.001). 
Conclusion: Elastography is a non-invasive technique that provides a great 
promise in distinguishing reactive from malignant lymphadenopathy. Sensitivity 
can be enhanced when used in conjunction with Doppler and grayscale US. In 
comparison to greyscale ultrasonography, strain and shear wave elastography 
provides quantitative and quantitative information on LNs with good diagnostic 
accuracy differentiating benign and malignant ones.