11/7/2014 Disclosures Disclosures • I have nothing to disclose Imaging Work-Up of a Neck Imaging Work-Up of a Neck Mass - Mass - Adults & Children Adults & Children Christine M Glastonbury MBBS Professor of Radiology & Biomedical Imaging Otolaryngology-Head & Neck Surgery and Radiation Oncology University of California, San Francisco November 7, 2014 thyroid parotid adenopathy unknown primary pediatric CT (NECT/CECT) MRI PET-CT ULTRASOUND Plan & Summary Plan & Summary Modalities Modalities • Modalities: P & C, I & CI • CT • Masses • NECT • When in doubt start with CECT • CECT • ? Thyroid mass – U/S, NECT, MR • MRI • Pediatric case – U/S, MR, unless urgent • PET-CT clinical problem • Ultrasound • Almost no utility of PET-CT for initial mass evaluation 1
11/7/2014 CT (NECT/CECT) MRI PET-CT ULTRASOUND CT (NECT/CECT) MRI PET-CT ULTRASOUND CT CT MRI MRI • P: Fast, readily available, multiplanar, • P: Excellent soft tissue contrast, no bone detail, reproducible studies, radiation, few contrast allergies relatively cheap, • C: 45min study, motion etc artifacts, $$ • C: Limited ST characterization, • I: Characterize mass, determine deep radiation extent, perineural tumor, avoid • I: Emergent situations, staging, bone... radiation • CI: ?? • CI: Pacemaker, shrapnel • Pediatric patients • Claustrophobia, • Thyroid carcinoma • No gad if renal failure CT (NECT/CECT) MRI PET-CT ULTRASOUND CT (NECT/CECT) MRI PET-CT ULTRASOUND PET-CT PET-CT U/S U/S • P: Physiological information, localize • P: Real time, see flow, may sites of active disease characterize masses, guide FNA, rapidly obtained, no ionizing radiation • C: Inflammation FDG-avid, tumor may • C: Limited FOV, user dependant not be!, radiation, $$ • Many different PET-CT flavors…. • I: Thyroid mass, superficial lesions, • Many different readers of PET-CT nodal evaluation, pediatric patients • I: Staging, Tx response, surveillance? • CI: ? • CI: Tumor not FDG-avid • Large masses, deep extension, RPN… 2
11/7/2014 thyroid parotid adenopathy unknown primary pediatric thyroid parotid adenopathy unknown primary pediatric Indications Indications Thyroid mass Thyroid mass • ?Thyroid mass • Multinodular goiter • Parotid mass • Benign thyroid lesion • Adenopathy • Thyroid malignancy • Invasion of adjacent tissues • Unknown primary • Nodal disease • Pediatric mass 31yF “Enlarging neck masses” 55yM 3
11/7/2014 thyroid parotid adenopathy unknown primary pediatric thyroid parotid adenopathy unknown primary pediatric Thyroid mass Thyroid mass Parotid mass Parotid mass • U/S • Inflammatory disease • Excellent first line, FNA guidance • Calculi, symmetrical changes • MR & CT • Neoplasms • Good anatomic , limited morphologic info • May be invisible on CT • Extent of MNG, invasion of tissues • Need MRI for PNT • Avoid iodine contrast if suspect malignancy • Benign and malignant may be FDG-avid • FDG-PET • TMJ masses • Negative ¹³¹I scan + ↑TG, NHL, Hürthle • CT or MRI thyroid parotid adenopathy unknown primary pediatric CECT Oropharyngeal mass Deep lobe pleomorphic adenoma Parotid deep lobe mass Acinic cell ca *MR allows better characterization of *Parotid masses parotid masses may be occult on CT 55yM. Palpable left neck mass T1 MR T2 MR 4
11/7/2014 thyroid parotid adenopathy unknown primary pediatric thyroid parotid adenopathy unknown primary pediatric Parotid mass Parotid mass Adenopathy Adenopathy • MRI preferred imaging method • CT and MR probably equivalent for detection of neoplastic nodes • Localize and characterize • Easier with MR to see RPN • Perineural & deep extension • CT for inflammatory disease • U/S difficult for evaluating entire neck for nodes (or RPN) • U/S may help to localize, guide FNA • Excellent for ‘suspicious node’, guiding FNA • No role for FDG-PET in assessing mass • FDG-PET not taken up by cystic nodes thyroid parotid adenopathy unknown primary pediatric Unknown Primary Unknown Primary 59yM. Left neck mass • CECT often first line study • PET/CT used if primary not seen on CECT • We prefer MRI • Better soft tissue characterization • Unless adenopathy is supraclavicular • No real role for U/S 5
11/7/2014 63yM. Left neck masses FNA = SCCa 55yM. Right neck masses 6
11/7/2014 thyroid parotid adenopathy unknown primary pediatric Congenital Neck Mass Congenital Neck Mass Pediatric Neck Mass Pediatric Neck Mass • Thyroglossal duct cyst (53%) • Branchial cleft fistula /cyst (22%) • 85% Second *MR allows better evaluation of extent and T2 FS MR T1+C FS MR characterization of mass • Dermoid cyst (11%) • Hemangioma (7%) • Venous /lymphatic malformation (6%) Al-Khateeb TH. J Oral Maxillofacial Surg 2007;65:2247-7 T1 MR T2 FS MR T1+C FS MR thyroid parotid adenopathy unknown primary pediatric Pediatric Neck Mass Pediatric Neck Mass • Image gently Second branchial cleft fistula • Avoid ionizing radiation when possible • U/S, MRI as first line whenever possible • Minimize radiation dose when CT is necessary 11 wk old with right neck dimple draining mucoid material 7
11/7/2014 thyroid parotid adenopathy unknown primary pediatric thyroid parotid adenopathy unknown primary pediatric Which test? Summary Summary • When in doubt start with CECT Indications Modalities • Thyroid mass • Ultrasound • ? Thyroid mass – U/S, NECT, MR • NECT or MRI if suspect • Pediatric case – U/S, MR, unless urgent malignancy clinical problem • MRI • Parotid mass • U/S may be excellent additional tool • CECT • Adenopathy • FNA guidance • MRI, PET/CT • Unknown primary • Acute infections – CECT • PET/CT largely reserved for evaluation • Pediatric • Congenital malf – MRI of known malignant (metastatic) • Superficial -?U/S disease christine.glastonbury@ucsf.edu 8
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