Disclosures Disclosures I have nothing to disclose Imaging Work-Up - - PowerPoint PPT Presentation

11/7/2014 1

Imaging Work-Up of a Neck Mass - Adults & Children Imaging Work-Up of a Neck Mass - 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

Disclosures Disclosures

• I have nothing to disclose

Plan & Summary Plan & Summary

• Modalities: P & C, I & CI
• Masses
• When in doubt start with CECT
• ? Thyroid mass – U/S, NECT, MR
• Pediatric case – U/S, MR, unless urgent

clinical problem

• Almost no utility of PET-CT for initial

mass evaluation

thyroid parotid adenopathy unknown primary pediatric

Modalities Modalities

• CT
• NECT
• CECT
• MRI
• PET-CT
• Ultrasound

CT (NECT/CECT) MRI PET-CT ULTRASOUND

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CT CT

• P: Fast, readily available, multiplanar,

bone detail, reproducible studies, relatively cheap,

• C: Limited ST characterization,

radiation

• I: Emergent situations, staging, bone...
• CI: ??
• Pediatric patients
• Thyroid carcinoma

CT (NECT/CECT) MRI PET-CT ULTRASOUND

MRI MRI

• P: Excellent soft tissue contrast, no

radiation, few contrast allergies

• C: 45min study, motion etc artifacts, $$
• I: Characterize mass, determine deep

extent, perineural tumor, avoid radiation

• CI: Pacemaker, shrapnel
• Claustrophobia,
• No gad if renal failure

CT (NECT/CECT) MRI PET-CT ULTRASOUND

PET-CT PET-CT

• P: Physiological information, localize

sites of active disease

• C: Inflammation FDG-avid, tumor may

not be!, radiation, $$

• Many different PET-CT flavors….
• Many different readers of PET-CT
• I: Staging, Tx response, surveillance?
• CI: Tumor not FDG-avid

CT (NECT/CECT) MRI PET-CT ULTRASOUND

U/S U/S

• P: Real time, see flow, may

characterize masses, guide FNA, rapidly obtained, no ionizing radiation

• C: Limited FOV, user dependant
• I: Thyroid mass, superficial lesions,

nodal evaluation, pediatric patients

• CI: ?
• Large masses, deep extension, RPN…

CT (NECT/CECT) MRI PET-CT ULTRASOUND

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Indications Indications

• ?Thyroid mass
• Parotid mass
• Adenopathy
• Unknown primary
• Pediatric mass

thyroid parotid adenopathy unknown primary pediatric

Thyroid mass Thyroid mass

• Multinodular goiter
• Benign thyroid lesion
• Thyroid malignancy
• Invasion of adjacent tissues
• Nodal disease

thyroid parotid adenopathy unknown primary pediatric

31yF 55yM

“Enlarging neck masses”

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Thyroid mass Thyroid mass

• U/S
• Excellent first line, FNA guidance
• MR & CT
• Good anatomic , limited morphologic info
• Extent of MNG, invasion of tissues
• Avoid iodine contrast if suspect malignancy
• FDG-PET
• Negative ¹³¹I scan + ↑TG, NHL, Hürthle

thyroid parotid adenopathy unknown primary pediatric

Parotid mass Parotid mass

• Inflammatory disease
• Calculi, symmetrical changes
• Neoplasms
• May be invisible on CT
• Need MRI for PNT
• Benign and malignant may be FDG-avid
• TMJ masses
• CT or MRI

thyroid parotid adenopathy unknown primary pediatric

55yM. Palpable left neck mass

CECT T1 MR T2 MR

Acinic cell ca

*Parotid masses may be occult

• n CT

Oropharyngeal mass Parotid deep lobe mass

Deep lobe pleomorphic adenoma

*MR allows better characterization of parotid masses

thyroid parotid adenopathy unknown primary pediatric

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Parotid mass Parotid mass

• MRI preferred imaging method
• Localize and characterize
• Perineural & deep extension
• CT for inflammatory disease
• U/S may help to localize, guide FNA
• No role for FDG-PET in assessing mass

thyroid parotid adenopathy unknown primary pediatric

Adenopathy Adenopathy

• CT and MR probably equivalent for

detection of neoplastic nodes

• Easier with MR to see RPN
• U/S difficult for evaluating entire neck for

nodes (or RPN)

• Excellent for ‘suspicious node’, guiding FNA
• FDG-PET not taken up by cystic nodes

thyroid parotid adenopathy unknown primary pediatric

Unknown Primary Unknown Primary

• 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

thyroid parotid adenopathy unknown primary pediatric

• 59yM. Left neck mass

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• 63yM. Left neck masses

FNA = SCCa

• 55yM. Right neck masses

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Pediatric Neck Mass Pediatric Neck Mass

• Thyroglossal duct cyst (53%)
• Branchial cleft fistula /cyst (22%)
• 85% Second
• Dermoid cyst (11%)
• Hemangioma (7%)
• Venous /lymphatic malformation (6%)

thyroid parotid adenopathy unknown primary pediatric

Al-Khateeb TH. J Oral Maxillofacial Surg 2007;65:2247-7

Congenital Neck Mass Congenital Neck Mass

T1+C FS MR T2 FS MR T1 MR T1+C FS MR T2 FS MR

*MR allows better evaluation of extent and characterization of mass

Pediatric Neck Mass Pediatric Neck Mass

• Image gently
• Avoid ionizing radiation when possible
• U/S, MRI as first line whenever possible
• Minimize radiation dose when CT is

necessary

thyroid parotid adenopathy unknown primary pediatric

11 wk old with right neck dimple draining mucoid material

Second branchial cleft fistula

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Which test?

Indications

• Thyroid mass
• Parotid mass
• Adenopathy
• Unknown primary
• Pediatric

Modalities

• Ultrasound
• NECT or MRI if suspect

malignancy

• MRI
• CECT
• MRI, PET/CT
• Acute infections – CECT
• Congenital malf – MRI
• Superficial -?U/S

thyroid parotid adenopathy unknown primary pediatric

Summary Summary

• When in doubt start with CECT
• ? Thyroid mass – U/S, NECT, MR
• Pediatric case – U/S, MR, unless urgent

clinical problem

• U/S may be excellent additional tool
• FNA guidance
• PET/CT largely reserved for evaluation
• f known malignant (metastatic)

disease

thyroid parotid adenopathy unknown primary pediatric

christine.glastonbury@ucsf.edu