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Presentation on theme: "Financial Disclosures But first… Please direct your smart phone, tablet, or laptops browser to:"— Presentation transcript:

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2 Financial Disclosures

3 But first… Please direct your smart phone, tablet, or laptops browser to:

4 Objectives Review Infrahyoid Neck Anatomy – Deep Spaces – Nodal Stations Cases, Cases, Cases – Tackle challenging cases – Develop an appropriate differential diagnosis – Identify useful discriminators Multiple choice questions

5 Anatomy

6 Anatomic Spaces of Infrahyoid Neck Posterior Cervical Space Visceral Space Retropharyngeal Space Perivertebral Space Carotid Space

7 Infrahyoid Lymph Node Stations

8 Cases

9 Case 1 65 year-old woman with neck pain, palpable lump

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13 Differential Diagnosis Differentiated Thyroid Ca Medullary Thyroid Ca Anaplastic Thyroid Ca Thyroid NHL Multinodular Goiter

14 Most Likely Diagnosis Differentiated Thyroid Ca (DTCa) Age & Sex Ill-defined Infiltrating, invasive Mixed solid/cystic Intra-thyroidal Calcs Intra-thyroidal Intra-nodal Adenopathy Some solid Some cystic Punctate calcs

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16 Question 1 Which of the following is a TRUE statement? – A. Follicular is the most common subtype of DTCa – B. Hematogenous spread is more commonly associated with Papillary carcinoma – C. The peak incidence of DTCa is seen in women in the third or fourth decade – D. Rising free T4 is a clinical marker for disease recurrence

17 Question 1 Which of the following is a TRUE statement? – A. Follicular is the most common subtype of DTCa – B. Hematogenous spread is more commonly associated with Papillary carcinoma – C. The peak incidence of DTCa is seen in women in the third or fourth decade – D. Rising free T4 is a clinical marker for disease recurrence

18 DTCa Companion Cases

19 1) 75 year-old-woman, neck lump

20 2) 48 year-old-woman, enlarging mass

21 3) Nodal Manifestations of DTCa

22 4) 30 year-old-woman, adenoma Magnified Cor CECT of LN

23 Case 2 55 year-old-woman with right neck mass, cough

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25 Differential Diagnosis H&N SCCa Metastatic Nodes Systemic Nodal Metastases Thyroid Ca Metastatic Nodes HL or NHL Nodes Granulomatous Lymph Nodes Reactive Adenopathy

26 Most Likely Diagnosis Systemic Nodal Mets Infrahyoid (level IV) location H&N primary SCCa more commonly levels II & III Non-calcified Sarcoid, DTCa often Ca++ Central low-density/necrosis HL, NHL, & reactive nodes usually solid, but can be low-density

27 Use Everything at Your Disposal Ill tell you right now – that aint normal. -- Rick Wiggins

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30 Question 2 Which of the following is MOST suggestive of systemic nodal metastases in the neck? – A. Enlarged suprahyoid (level I or II) node – B. Enlarged left supraclavicular lymph node – C. Centrally necrotic lymph node – D. Calcification within an enlarged cervical node

31 Question 2 Which of the following is MOST suggestive of systemic nodal metastases in the neck? – A. Enlarged suprahyoid (level I or II) node – B. Enlarged left supraclavicular lymph node – C. Centrally necrotic lymph node – D. Calcification within an enlarged cervical node

32 Companion Case

33 25-year-old man with neck mass

34 HL with Signal Node AKA Virchow node Isolated left supraclavicular adenopathy look to the chest & abdomen for primary Most HL patients present with neck nodes Concurrent mediastinal nodes common Rarely extranodal H&N disease M > F Peak incidence in mid-20s

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36 Question 3 Which of the following is a TRUE statement? – A. HL is more common than NHL – B. Extranodal disease favors HL over NHL – C. Imaging can reliably differentiate NHL from HL – D. HL has an earlier peak incidence than NHL

37 Question 3 Which of the following is a TRUE statement? – A. HL is more common than NHL – B. Extranodal disease favors HL over NHL – C. Imaging can reliably differentiate NHL from HL – D. HL has an earlier peak incidence than NHL

38 Case 4 55-year-old woman with known thyroid nodules, reportedly benign – surveillance US

39 LongitudinalTransverse Power Doppler

40 Prior biopsy reported benign

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42 Differential Diagnosis Congenital lesion Lymphatic malformation Venolymphatic malformation Venous malformation 3 rd Branchial cleft cyst Neurofibroma Schwannoma Malignant Lymph node Carotid artery Pseudoaneurysm

43 Most Likely Diagnosis Congenital lesion Lymphatic malformation Benign, circumscribed No flow on US Demonstrably separate from IJV and CCA Venolymphatic malformation Possible, but would have essentially no venous component Why not a NST?

44 Carotid Space Nerve Sheath Tumor Pros Location Size Morphology Low Density Cons Echogenicity Lack of vascularity Image c/o Lauren Ladd, M.D.

45 CS Nerve Sheath Tumor Comparison CS SchwannomaCS Neurofibroma ShapeFusiformOvoid or fusiform (***unless plexiform) MarginsCircumscribedCircumscribed (***unless plexiform) Size2 - 8 cm2 - 5 cm M:FMale predominanceFemale Predominance NECTIsodense to muscleHypodense CECTUniform enhancement, rare low densityPoorly enhancing T1WI -CVariable, no flow voidsIsointense to muscle T1WI +CMarked uniform enhancementHomogeneous or patchy enhancement T2WIHyperintense to muscle, +/- intratumoral cystsVery hyperintense, "target sign"

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47 Question 4 Which of the following is a FALSE statement? – A. Most lymphatic malformations are diagnosed before age 2 – B. Lymphatic malformations can be acquired – C. Lymphatic malformations have no malignant potential – D. Microcystic lymphatic malformations are less likely to recur than macrocystic malformations

48 Question 4 Which of the following is a FALSE statement? – A. Most lymphatic malformations are diagnosed before age 2 – B. Lymphatic malformations can be acquired – C. Lymphatic malformations have no malignant potential – D. Microcystic lymphatic malformations are less likely to recur than macrocystic malformations

49 Case 5 25-year-old man with enlarging neck mass, recent URI

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53 Same patient, 3 days prior

54 Differential Diagnosis Thyroglossal Duct Cyst Lymphatic Malformation Mixed Laryngocele Necrotic Lymph Node Abscess Thyroid Ca

55 Most Likely Diagnosis Infected Thyroglossal Duct Cyst with associated FOM Abscess Classic history Midline/paramidline infrahyoid Wall enhancement infected Round or ovoid Cyst No calcs or solid component

56 Thyroglossal Duct Cyst Key Points Cystic remnant of TGD Lesion of the young Location 20-25% = Suprahyoid 50% = Hyoid 25% = Infrahyoid Infrahyoid typically embedded in strap muscles claw sign Wall enhancement if infected < 1% will develop Thyroid Ca

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58 Question 5 Which of the following is a TRUE statement? – A. Thyroglossal duct cyst is the most common congenital neck mass – B. Thyroglossal duct cysts are always midline structures – C. The most common malignancy to develop in a thyroglossal duct cyst is medullary thyroid Ca – D. Treatment of thyroglossal duct cyst is typically needle aspiration

59 Question 5 Which of the following is a TRUE statement? – A. Thyroglossal duct cyst is the most common congenital neck mass – B. Thyroglossal duct cysts are always midline structures – C. The most common malignancy to develop in a thyroglossal duct cyst is medullary thyroid Ca – D. Treatment of thyroglossal duct cyst is typically needle aspiration

60 TGD Cyst Companion Cases

61 1) 50-year-old man with neck mass TGD Cyst. High density = heme, protein.

62 2) Young girl, dysphagia TGD Cyst. Suprahyoid/BOT.

63 3) Enlarging neck mass TGD Cyst Thyroid Ca. Enhancing nodule. Coarse calc. Nodal Met.

64 4) Ectopic Thyroid

65 Case 6 31-year-old woman with difficult intubation during elective surgery

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67 Ill tell you right now – that aint normal. -- Rick Wiggins

68 Ax T1WI +C FS Cor T1WI +C FS Ax T2WI FS

69 Differential Diagnosis NF1 NF2 Schwannomatosis Laryngeal SCCa with Mets Chondrosarcoma with Mets

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71 Ax T1WI +C FS Ax T2WI FS

72 Most Likely Diagnosis Schwannomatosis Morphology & Margins SCCa infiltrative/invasive Distribution CS + Brachial plexus NST NORMAL IACs NF2 less likely Age NF1 = 1 st decade NF2 = 2 nd decade Schwannomatosis = 3-4 th decades No matrix calcification MR signal NST

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74 Question 6 Which of the following is a TRUE statement? – A. Schwannomas grow centrally within an involved nerve – B. Schwannomatosis patients demonstrate a normal life expectancy – C. Schwannomas arise from pericytes in the nerve sheath – D. Schwannomatosis is more common than NF1

75 Question 6 Which of the following is a TRUE statement? – A. Schwannomas grow centrally within an involved nerve – B. Schwannomatosis patients demonstrate a normal life expectancy – C. Schwannomas arise from pericytes in the nerve sheath – D. Schwannomatosis is more common than NF1

76 Schwannomatosis Key Points Multiple nonintradermal schwannomas WITHOUT vestibular nerve involvement Separate disease entity from NF2 – Different gene mutation SMARCB1 vs. NF2 – Later onset 4 th decade vs. 2 nd decade – Normal life expectancy (unlike NF2) – Pain >> neurologic deficits (unlike NF2) Similar incidence to NF2 (~ 1/40,000)

77 Infrahyoid Neck Conclusion Several deep spaces & nodal stations – Wide variety of pathology Look for useful discriminators: – Age – History – Deep space of origin

78 Thanks


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