Neck lymphadenopathy and

solid masses: benign or

malignant

Bogdana TILEA , A. Ntorkou, M, Alison, M. Elmaleh Bergès

Pediatric Radiology departement , Hopital R. Debré , Paris

Pediatric neck masses

▪Frequently encountered situation

▪Clinical approach varies from that of adults

▪Diagnostic challenge

▪80-90 % is benign in children

▪Variety of possible etiologies ranging from

congenital anomalies to malignancies

History and clinical examination

Diagnostic hypothesis

Appropriate serological exams

IMAGING EXAMINATIONS

DIAGNOSIS OR NOT

BIOPSY or SURGICAL EXCISION

Diagnosis hypothesis

▪ HISTORY

▪ Present at birth → congenital

▪ Fever, pain → inflammatory

▪ Rapidly growing mass → inflammatory, malignancy

▪ PHYSICAL EXAMINATION

▪ Midline location → thyroid

▪ Supraclavicular location → malignancy

▪ Shotty lymphadenopathy → reactive lymph nodes

▪ Hard, immobile, firm → malignancy

History and clinical examination

Meier : Evaluation and management of neck masses in children

Imaging

ULTRASONOGRAPHY

▪ Initial imaging

▪Palpable neck mass

▪Location , size, shape, internal contents

▪ Vascularity - Colour Doppler

▪Guidance

CLINICS

US

Observation

Follow –up US

Radiography

CT

MRI

Tissue sampling

Imaging

▪CT

▪ ALARA principle

▪ Pediatric protocols +IV

contrast

▪ High resolution anatomy,

bony structures ,

airspaces, fat,

calcifications

▪MR imaging

▪ T1, fat - supressed T2,

Stir sequences, DWI,

post contrast fat-

supressed T1

▪ Mass too large

▪ Too deep

▪ Malignancy features

▪ Extent of the disease

ULTRASOUND

Lymphadenopathy

NO Lymphadenopathy

NORMAL ANATOMY LYMPH NODES

Lymphadenopathy

▪ Size < 1 cm

▪ Shape long/ oval , S/ L < 0. 5

▪ Echogenic hilus – hyperechoic

linear structure

▪ Borders- well defined

▪ Vascular pattern –hilar vascularity

▪ Low vascular resistance

▪ Low pulsatility index

▪ Sonoelastography

Ying 2009 HK J Paeditr Ultrasound of neck lumph nodes in children

Restrepo 2009 Pediatr Radiol : Head and neck lymph nodes in children : the spectrum from normal

to abnormal

CTMRI

Lymphadenopathy

NORMAL LYMPH NODES

T1 T1Gd

T2TSE FLAIR

PATHOLOGICAL NODES

▪Round shape

▪Absent /eccentric hilum

▪ Irregular borders

▪Necrosis

▪Chaotic blood flow

pattern

Lymphadenopathy

Restrepo 2009 Pediatr Radiol : Head and neck lymph nodes in children : the spectrum from normal to

abnormal

Causes of pediatric cervical lymphadenopathy

▪ Infectious

▪ Viral

▪ Bacteries

▪ Mycobacterieum tuberculosis and atypical mycobacterial

▪Malignancies

▪Metastasis

▪Miscellaneous

▪ Histiocytosis

▪ Kawasaki disease

▪ Castelman diseaseWeinstock 2018 Pediatric Cervical

Lymphadenopathy

LOCATION CONGENITAL INFLAMMATORY MALIGNANT

Anterior SCM Cysts, vascular Lymphadenitis,

reactive LN

Lymphoma

Midline Tyreoglossal cyst

Dermoid cyst

Tyroid tumor

Occipital Vascular malf Reactive LN,

lymphadenitis

Metastatic

Preauricular

submandibular

Branchial cyst,vascular malf Reactive LN,

lymphadenitis

mycobacterium

Salivary gland

Submental Tyroglossal cyst, dermoid

cystReactive LN,

lyphadenitis

Supraclavicular Vascular malformation Lymphoma,

MTS

Meier- Evaluation and management of neck masses in children

6 years old

Painful right cervical mass

Fever

Torticollis

Suppurative cervical adenopathy

Ponction → infectious agent ?

CT if retropharyngeal abcess suspected

8 years old girl, right cervical

mass for 4 months increasing

in size the last week

MYCOBACTERIUM AVIUM

MYCOBACTERIAL INFECTION

▪ Mycobacterium tuberculosis

▪ Intra nodal abcess , lack of periadenitis

▪ Chest RX if suspicion

▪ Nontuberculous mycobacterial infection – mycobacterium

avium- intracellulare

▪ Isolated enlarged neck mass + skin discoloration

▪ Central necrotic mass in the parotid or submandibular

region

▪ Minimal periadenitis

3 years old girl, since 1 year right submandibular painless , soft adenopathy

No inflammatory syndrome

CASTELMAN Disease

Asymptomatic cervical nodal mass

Marked nodal enlargement with doppler hypervascularity

Nodal calcifications

MRI – central T2 hypointensity ( fibrosis )

7 years old girl presenting painless bilateral neck swelling

Rosai Dorfman HISTIOCYTOSIS

HISTIOCYTOSIS

Langerhans cell histiocytosis

Non LCH- chronic , massive,

painless lymphadenopathy

MALIGNANCIES ET METASTASIS

▪ Hard , painless lymph nodes with

progressive nodal enlargement

▪ Lack of respose to antibiotic therapy

▪ Systemic symptoms

▪ US : round shape, hypoechoic

parenchyma , absent / eccentric

hilum, intranodal necrosis , color

doppler

▪ CT, MRI : nodal enlargement ,

enhancement , intranodal necrosis

without periadenitis

▪ DWI: decreased ADC values

LYMPHOMA

LEUKEMIA

METASTASIS

10 years old girl with painful bilateral adenopathies for 5 months increasing in

size. No general symptoms

HODGKIN LYMPHOMA

BURKITT LYMPHOMA

2 subtypes : non –Hodgkin lymphoma,

Hodgkin lymphoma

HL : enlarged, painless, non tender lymph

node

12 years old boy, mass in the left thyroid

When biopsy ?

▪ Suspicion of malignancy

▪ Lymphadenopathy of unknown cause that persists for greater

than 4 to 6 weeks , despite a trial of antibiotics

▪ Lymphadenopathy increasing in size over 2 weeks

▪ Lymphadenopathy greater than 2 cm

▪ Supraclavicular lymphadenopathy

▪ Abnormal chest radiograph

▪ Systemic signs / symptoms suggesting malignancy : weight

loss, hepatosplenomegaly, fever and arthralgia

Nodler AR. Pediatric cervical lymphadenopathy : when biopsy . Curr Opin Otolaryngol Head Neck

Surg 2013

Rajasekaran K, Krakovitz P. Enlarged neck lymp nodes in children .Pediatr Clin North Am 2013

Nield LS, Kamat D. Lymphadenopathy in children : when and how to evaluate .Clin Pediatr 2004

14 years old boy , right sholder pain for 15 days and susclavicular adenopathy, no

night sweats, no fever ,no weight loss

▪ Fine needle aspiration

biopsy

▪ US –guided core needle

biopsy

▪ Well trained radiologist

▪ Sufficient and high-

quality sample volume

▪ Open biopsy

Feng Han and all ( 2018) Efficacy of ultrasound- guided core needle biopsy in cervical

lymphadenopathy : a retrospective study 6695 cases ; Eur Radiol 28

NO Lymphadenopathy

▪CONGENITAL MALFORMATIONS

▪TUMORS

▪Benign

▪Malignant

US

CT

MRI

ULTRASOUND

Lymphadenopathy

NO Lymphadenopathy

AGE LOCATION ETIOLOGY

MIDLINE Thyroglossal

duct cyst

Dermoid cyst

LATERAL Branchial cleft

cyst

Fibromatosis coli

Lymphangioma Ectopic Thymus

ADP

Tumor

PAROTID 1 st brachial cleft

cyst

Hemangioma

Lymphangioma Parotiditis

CONGENITAL MALFORMATIONS

▪NON VASCULAR

▪ Thyroglossal duct cyst

▪ Branchial cleft cyst

▪ Teratoma

▪ Dermoid cyst

▪ Ectopic thymus

▪VASCULAR

▪ Tumors – infantile

hemangioma

▪ Malformations

5 years old girl

ECTOPIC THYMUS

6 month old girl

Compressible bluish mass in the region of the right parotid gland

INFANTILE HEMANGIOMA

TUMORS

▪BENIGN

▪Sternocleidomastoidien

tumor

▪Pilomatrixoma

▪Neurofibroma

▪MALIGNANT

▪Lymphoma

▪Rhabdomyosarcoma

▪Neuroblastoma

▪Metastasis

▪Desmoid

fibromatosis

12 days old boy, firm right laterocervical mass

FIBROMATOSIS COLI

Boy with neurofibromatosis type I

PLEXIFORM NEUROFIBROMA

8 years old boy ; dysphonia since december 2016 and swallowing ploblems

Rhabdomyosarcoma

▪ Most common soft tissue sarcoma in children younger than

15 years old

▪ 3 histologic subtypes : embryonal, alveolar, pleomorphic

▪ CT: soft tissue mass , bone involvement

▪ MRI :

▪ Iso T1, hyper T2, variable enhancement

▪ Intracranial and meningeal spread

▪ Postoperative restaging

▪ Positron emission tomography – evaluation of bone

metastasis ,staging

5 months old boy with hard , painless left neck mass; no fever , good

general state

Neuroblastoma

▪ 5% of primary NB in the neck

▪ Dysphagia,hoarseness, airway obstruction , Horner’ s

syndrome, cranial nerve palsies

▪US : initial detection

▪CT and MRI : confirmation ,characterization , staging

▪ CT: calcifications, hemorrhage or necrosis

▪ MRI :

▪ Iso/hypointense to muscle on T1

▪ mildly hyper T2 with intense enhancement , internal restricted

diffusion

▪ relationship to the carotid space

▪ Epidural extension !!!

▪ MIBG scintygraphy : primary and metastatic NB

CONCLUSION

▪Neck masses are a common finding and can

present a difficult diagnostic challenge

▪ Infection is the most common cause in children

▪Clinical examination and imaging are

complementary and the first step to differentiate

benign from malignant diseases

▪US the first imaging study

▪Cross sectional imaging (MRI , CT)

▪Characterisation of large et deep masses

▪Staging

▪Follow up