Presentation on theme: "Lumps and Bumps Anne Moore, MD Assistant Professor Radiology"— Presentation transcript:
1 Lumps and Bumps Anne Moore, MD Assistant Professor Radiology Children’s Mercy Hospital andUniversity of Missouri, Kansas City
2 Imaging Modalities Plain Xray imaging ULTRASOUND CT imaging MR imaging Common complaint in children and source of concern in parents.Differential diagnosis is broad. Can be found all over body. The lesions may be congenital or acquired. Rad evaluation is often requested.Radiography and especially ultrasound have been mainstays in evaluating masses in the pediatric population.RAD – possible osteochon, osteosarc, prevert STS, LCH(bone margins and location), CephalohematomaUS is first chioce esp. in head and neck and is fast and relatively inexpensive test and fits the imaging gently theme. US in particularly useful in evaluating cystic verus solid and vascular lesions.CT and MR imaging are useful in evaluating complex masses some of which may have connections with the central nervous system that may only be well eval withCT/MR. CT/MR provides greater anatomic detail and info on vascular anatomy. Which can be useful in therapeutic/surgical planning.
7 Head and Neck Dermoid/Epidermoid Branchial Cleft Cyst Thyroglossal Duct CystAccessory Parotid TissueFibromatosis ColiVascular AnomaliesHemangiomaLymphatic/Venous Malformation
8 Dermoid/EpidermoidFound in a variety of locations around the skull, midface and neckCommonly in midline and frontotemporal location, followed by parietal locationMidline or near midline lesion in neckDermoid contains ectoderm and skin elements. Epi ectoderm but no skin elementsThought as a result of of the persistence of ectodermal elements at sites of suture closure.Appearance depends on content.
10 Dermoid/Epidermoid Note Midline location Near sutures Often contains fatNegative Hounsfield Units
11 Branchial Cleft Cyst: Second Most common Branchial anomalyPresents acutely with mass at the angle of the mandibleCan occur anywhere along the potential tract of a second brach fistula from the tosillar fossa to the suprclavicular region. A sinus or fistula may open to the skin anywhere along this path.Diff would include vasc anomaly, paramedian thyrogl duct cyst, suppruative lymphadenopathyThe appearance of the cyst depends on the presence and extent of inflammatory changes.Sono-cystic or complex mass that often contains debrisCT – oval or round cystic mass. Wall thickness, enhancement, and surrounding soft tissue edema. Uncomplicated cyst is of low attenuation and has a thin smooth wall. Infected cyst is of higher attenuation with increased protein content and can have a thick irregular enhancing wall.MR- appearance varies with protein content.
12 Accessory Parotid Tissue Superficial and lateral to masseter muscle and anterior to superficial lobeRarely palpableSuperficial lobe main bulk of gland superficial and posterior to masseter muscle.Deep lobe—small extension of gland deep to angle of mandibleAccessory lobe (20%) superficial and lateral to masseter muscle and anterior to superficial lobe of parotid and drainage is directly into parotid duct
13 Fibromatosis Coli Idiopathic intramuscular hematoma Focal mass or fusiform enlargement of sternocleidomastoidPresents with torticollis < 8 weeks of ageDiff deliveryTorticollis often coexistsSuggested causes include birth trauma, in utero torticollisSecond to fourth week of lifeMale greater than femaleFirm nontenderPlagiocephaly can develop in untreated patients
14 Fibromatosis ColiNormal for comparisonFibromatosis Coli
15 In a 6 week old with torticollis, which imaging study is initially suggested? MRICTUltrasoundPlain Radiographs
16 Thyroglossal duct cyst Most common midline developmental lesion of the neck in childhoodAbuts hyoid bonePresents acutelyOften after URIArises from remnants of the thyroglossal duct.Occurs at any site from the base of the tongue to the suprasteranl regionOver 2/3rd are midlineDemonstration of a sinus tract extending cephalsd from the cyst supports the dx.Diff: for midline includes dermoid or teratoma, lymph node, vallecular cystOffmidline includes lymphatic mal, lymph node brachial anomaly
18 Hemangioma Most common tumor of infancy & childhood Female > Male Characteristic growth: proliferation, then regressionPresents 2weeks-2 months of ageOften skin changesLobulated mass with prominent color Doppler flow
19 Hemangioma MRI Parotid is most common salivary gland T2 bright EnhancingLobularFlow voidsParotid is most common salivary glandOccurring in 12% of infantsMost are asymptomaticMost hemangioma can be dx. On basis of physical appearance and temporal growth history and imaging not necessary.Imaging used if dx is in question or evaluating extent of diseaseCharactertically two stage process of growth and regressionAt birth the lesions are often small and inconspicous. 60% are not present at birthShortly after birth period of rapid proliferation that lasts several monthsTypically involuation begins approximately at 10 months of age50% of lesions completely resolved by 5 years of age
20 Hemangioma Proliferation Involution MR is the imaging test of choice for making dx and evaluating extent of disease.Ct is not typically used in dx of suspected hemangionma but may be obtained to work up nonspecific mass. On CT discrete lobualated mass with diffuse enhancement with prominent draining veins.
21 Venous and Lymphatic Malformations Present any age, but usually beyond infancyVenous Malformation:Dysplastic venous channels; Solid with phleboliths and venous Doppler wave formsLymphatic Malformation:Dysplastic lymphatic structures; Cystic with fluid levelsVM:Us Serpentine structure with no Doppler arterial flowMR is best imaging test for dx and evaluation of extent.Typically are present at birth and grow proportional to childLM: multicystic mass most commonly in neck and axillaTypically grow in proportion to child but may have a rapid increase in size if hemorrhage or infectionMR is best imaging choice for evaluation and extent.US: multicystic massCT/MR multi cystic mass with peripheral enhancement.
23 Lymphatic Malformation Note cystic and solid components
24 In a 1-month-old child with a hemangioma on the arm, what is the suggested imaging study? No imaging neededMRIBone scanPlain radiographs
25 RhabdomyosarcomaMost common soft tissue sarcoma of childhood Aggressive looking60% of cases1/3 of ped rhs occur in head/neckMR/CT need for evauation
26 Lymphoma Third most common childhood malignancy Asymptomatic lymphadenopathyStart US. CT scan to evaluate extent and likely go ahead and scan the CAP
27 Cervical Lymphadenopathy Common in childrenImaging studies will show size, number and location of enlarged lymph nodesOften follows tonsiller, pharyngeal or dental infectionAnd may indicate compositionUS multiple discrete oval relatively hypoechoic masses along the cervical chainCT and MR lymph nodes greater than 1.0 to 1.5 cm are considered abnormalBacterial infection may result in abscess formation
35 Baker’s/Popliteal Cyst Synovial cyst in posterior aspect of knee jointIntact cystDissected CystRuptured CystExtends b/w medial head of gastro and sm tendonIntact smooth contourDissected smooth contour extending along facial plane usually b/w gastro and soleusRuptured cyst with leakage into calf tissue
37 Ganglion Cyst Cystic lesion usually attached to a tendon sheath Location: hand, wrist, dorsum of footMucin containing cyst arising from tendon sheath/joint capsule/bursaCan be asymptomatic or painUni or multilocCan have bone reresorption or periosteal formation
38 Langerhan Cell Histiocystosis Idiopathic disorder that can manifest as focal or systemic diseaseInitial lesion often identified with radiographyRadiographic appearance is extremely variableMay presents with palpable lumpsEspecially on skull or ribsRadiographic skel survey with or without bone scintigraphy obtained to identify other bone lesionsChest radiograph or chest CT to evaluate for pulmonary involvementCommon sites of involvement are skull, ribs, femur, pelvis, spine mandibleRad appearance is extremely variable. Lucent or sclerotic, permeative or geographic, well-defined or poorly defeined.
39 LCH 15 month old Well difined lytic lesion without sclerotic rim Edge described as beveled with the inner table involved more than the outer tableSclerotic rim during healingSoft tissue mass overlying lytic process in calvarium
44 Osteochondroma Most common benign growth of the skeleton Usually painless massPainful=possible malignancy and need MRI1st to 3rd decadePainful with impingement of nerves and blood vesselsPedunculated form and broad based formLong bone metaphysis of femur, humerus, prosicmal radius, tibis abpit 50% about knee acapula rib pailvis spine in any bone that develops by enchondromal calcificaitonGrows at right angle toward the diaphysisCortial bone with cartilaginous capContinuity of bone cortex to host boneMalg transformation in to chondro/osteoscarcoma less than 1%
45 Sacral Dimple Classified as low or high risk Low risk does not require imagingHigh risk require imagingUltrasound if < 6 monthsMR imaging thereafterMR after 6 months due to the limitations of ultrasound with progressive ossifiction of the spineUltrasound is the screening modality of choice. Unless dimple is draining CSF(sinus tract) or an open dysraphisms which require immediate surgery and/or MR imaging.
46 Sacral dimple Low risk Midline Less than 5mm in diameter Located with the gluteal creaseNo cutaneous abnormalities or drainageCan see bottom of dimpleWithin 2.5cm of the anus
47 Sacral dimple High risk Greater than 5mm in diameter Located above the gluteal creaseCutaneous abnormalitiesDraining cerebrospinal fluidBottom of dimple cannot be seenCutaneous hemangiomas, cutis aplasia, hairy patches, skin tags