Lumps and Bumps Anne Moore, MD Assistant Professor Radiology Children’s Mercy Hospital and University of Missouri, Kansas City

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), Cephalohematoma US 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 with CT/MR. CT/MR provides greater anatomic detail and info on vascular anatomy. Which can be useful in therapeutic/surgical planning.

Lumps and Bumps Congenital Lesions Vascular Anomalies Acquired Lesions Infectious Lesions Traumatic Lesions

Head, Shoulders, Knees and Toes

Eyes and ears and mouth and nose

Head and neck Start with Ultrasound!

Head and Neck Dermoid/Epidermoid Branchial Cleft Cyst Thyroglossal Duct Cyst Accessory Parotid Tissue Fibromatosis Coli Vascular Anomalies Hemangioma Lymphatic/Venous Malformation

Dermoid/Epidermoid Found in a variety of locations around the skull, midface and neck Commonly in midline and frontotemporal location, followed by parietal location Midline or near midline lesion in neck Dermoid contains ectoderm and skin elements. Epi ectoderm but no skin elements Thought as a result of of the persistence of ectodermal elements at sites of suture closure. Appearance depends on content.

Dermoid Cystic or solid Hypovascular

Dermoid/Epidermoid Note Midline location Near sutures Often contains fat Negative Hounsfield Units

Branchial Cleft Cyst: Second Most common Branchial anomaly Presents acutely with mass at the angle of the mandible Can 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 lymphadenopathy The appearance of the cyst depends on the presence and extent of inflammatory changes. Sono-cystic or complex mass that often contains debris CT – 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.

Accessory Parotid Tissue Superficial and lateral to masseter muscle and anterior to superficial lobe Rarely palpable Superficial lobe main bulk of gland superficial and posterior to masseter muscle. Deep lobe—small extension of gland deep to angle of mandible Accessory lobe (20%) superficial and lateral to masseter muscle and anterior to superficial lobe of parotid and drainage is directly into parotid duct

Fibromatosis Coli Idiopathic intramuscular hematoma Focal mass or fusiform enlargement of sternocleidomastoid Presents with torticollis < 8 weeks of age Diff delivery Torticollis often coexists Suggested causes include birth trauma, in utero torticollis Second to fourth week of life Male greater than female Firm nontender Plagiocephaly can develop in untreated patients

Fibromatosis Coli Normal for comparison Fibromatosis Coli

In a 6 week old with torticollis, which imaging study is initially suggested? MRI CT Ultrasound Plain Radiographs

Thyroglossal duct cyst Most common midline developmental lesion of the neck in childhood Abuts hyoid bone Presents acutely Often after URI Arises from remnants of the thyroglossal duct. Occurs at any site from the base of the tongue to the suprasteranl region Over 2/3rd are midline Demonstration of a sinus tract extending cephalsd from the cyst supports the dx. Diff: for midline includes dermoid or teratoma, lymph node, vallecular cyst Offmidline includes lymphatic mal, lymph node brachial anomaly

Thyroglossal Duct Cyst

Hemangioma Most common tumor of infancy & childhood Female > Male Characteristic growth: proliferation, then regression Presents 2weeks-2 months of age Often skin changes Lobulated mass with prominent color Doppler flow

Hemangioma MRI Parotid is most common salivary gland T2 bright Enhancing Lobular Flow voids Parotid is most common salivary gland Occurring in 12% of infants Most are asymptomatic Most 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 disease Charactertically two stage process of growth and regression At birth the lesions are often small and inconspicous. 60% are not present at birth Shortly after birth period of rapid proliferation that lasts several months Typically involuation begins approximately at 10 months of age 50% of lesions completely resolved by 5 years of age

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.

Venous and Lymphatic Malformations Present any age, but usually beyond infancy Venous Malformation: Dysplastic venous channels; Solid with phleboliths and venous Doppler wave forms Lymphatic Malformation: Dysplastic lymphatic structures; Cystic with fluid levels VM:Us Serpentine structure with no Doppler arterial flow MR is best imaging test for dx and evaluation of extent. Typically are present at birth and grow proportional to child LM: multicystic mass most commonly in neck and axilla Typically grow in proportion to child but may have a rapid increase in size if hemorrhage or infection MR is best imaging choice for evaluation and extent. US: multicystic mass CT/MR multi cystic mass with peripheral enhancement.

Venous Malformation Venous wave forms Solid

Lymphatic Malformation Note cystic and solid components

In a 1-month-old child with a hemangioma on the arm, what is the suggested imaging study? No imaging needed MRI Bone scan Plain radiographs

Rhabdomyosarcoma Most common soft tissue sarcoma of childhood Aggressive looking 60% of cases 1/3 of ped rhs occur in head/neck MR/CT need for evauation

Lymphoma Third most common childhood malignancy Asymptomatic lymphadenopathy Start US. CT scan to evaluate extent and likely go ahead and scan the CAP

Cervical Lymphadenopathy Common in children Imaging studies will show size, number and location of enlarged lymph nodes Often follows tonsiller, pharyngeal or dental infection And may indicate composition US multiple discrete oval relatively hypoechoic masses along the cervical chain CT and MR lymph nodes greater than 1.0 to 1.5 cm are considered abnormal Bacterial infection may result in abscess formation

Cervical Lymphadenopathy

Suppurative Lymphadenitis Bacterial infection may result in abscess formation

Suppurative Lymphadenitis Nodes with central necrosis/fluid May take weeks to resolve

Cephalohematoma Subperiosteal accumulation of blood Confined by sutures Most commonly parietal No imaging usually needed ? ultrasound

Cephalohematoma

In a newborn male with unilateral parietal swelling since birth, which imaging study is indicated? MRI CT Plain radiographs No imaging indicated

Shoulder, Knees and Toes aka Below the Neck

Baker’s/Popliteal Cyst Synovial cyst in posterior aspect of knee joint Intact cyst Dissected Cyst Ruptured Cyst Extends b/w medial head of gastro and sm tendon Intact smooth contour Dissected smooth contour extending along facial plane usually b/w gastro and soleus Ruptured cyst with leakage into calf tissue

Baker’s/popliteal cyst

Ganglion Cyst Cystic lesion usually attached to a tendon sheath Location: hand, wrist, dorsum of foot Mucin containing cyst arising from tendon sheath/joint capsule/bursa Can be asymptomatic or pain Uni or multiloc Can have bone reresorption or periosteal formation

Langerhan Cell Histiocystosis Idiopathic disorder that can manifest as focal or systemic disease Initial lesion often identified with radiography Radiographic appearance is extremely variable May presents with palpable lumps Especially on skull or ribs Radiographic skel survey with or without bone scintigraphy obtained to identify other bone lesions Chest radiograph or chest CT to evaluate for pulmonary involvement Common sites of involvement are skull, ribs, femur, pelvis, spine mandible Rad appearance is extremely variable. Lucent or sclerotic, permeative or geographic, well-defined or poorly defeined.

LCH 15 month old Well difined lytic lesion without sclerotic rim Edge described as beveled with the inner table involved more than the outer table Sclerotic rim during healing Soft tissue mass overlying lytic process in calvarium

LCH 15 month old

LCH 15 month old clavicle/chest wall mass 11 year old female left chest wall mass

Inguinal Hernia Patent processus vaginalis Imaging not usually needed Ultrasound if unsure about etiology PPV becomes an indirect hernia when bowel enters or ovary/bowel in girls Boys more than girls

Inguinal Hernia

Osteochondroma Most common benign growth of the skeleton Usually painless mass Painful=possible malignancy and need MRI 1st to 3rd decade Painful with impingement of nerves and blood vessels Pedunculated form and broad based form Long bone metaphysis of femur, humerus, prosicmal radius, tibis abpit 50% about knee acapula rib pailvis spine in any bone that develops by enchondromal calcificaiton Grows at right angle toward the diaphysis Cortial bone with cartilaginous cap Continuity of bone cortex to host bone Malg transformation in to chondro/osteoscarcoma less than 1%

Sacral Dimple Classified as low or high risk Low risk does not require imaging High risk require imaging Ultrasound if < 6 months MR imaging thereafter MR after 6 months due to the limitations of ultrasound with progressive ossifiction of the spine Ultrasound 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.

Sacral dimple Low risk Midline Less than 5mm in diameter Located with the gluteal crease No cutaneous abnormalities or drainage Can see bottom of dimple Within 2.5cm of the anus

Sacral dimple High risk Greater than 5mm in diameter Located above the gluteal crease Cutaneous abnormalities Draining cerebrospinal fluid Bottom of dimple cannot be seen Cutaneous hemangiomas, cutis aplasia, hairy patches, skin tags

Sacral Dimple Tethered Cord Normal

Sacral Dimple Dermal sinus tract

Sacral Dimple

Lumps and bumps Ultrasound First Use Ultrasound and Clinical Setting to Determine Next Best Step in Evaluation and Treatment

In a 4-mo-old with skin lesion. Which imaging study is indicated? MRI Ultrasound No imaging needed Plain radiographs