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

Transcription

1 Disclosures Imaging Work-Up of a Neck Mass - Adults & Children I have nothing to disclose Christine M Glastonbury MBBS Professor of Radiology & Biomedical Imaging Otolaryngology-Head & Neck Surgery and Radiation Oncology University of California, San Francisco November 7, 2014 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 CT (NECT/CECT) MRI PET-CT ULTRASOUND CT NECT CECT MRI PET-CT Ultrasound Modalities 1

2 CT (NECT/CECT) MRI PET-CT ULTRASOUND CT CT (NECT/CECT) MRI MRI PET-CT ULTRASOUND 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 P: Excellent soft tissue contrast, no radiation, few contrast allergies C: 45min study, motion etc artifacts, $$ I: Characterize mass, determine deep extent, perineural tumor, avoid radiation CI: Pacemaker, shrapnel Claustrophobia, No gad if renal failure CT (NECT/CECT) MRI PET-CT PET-CT ULTRASOUND CT (NECT/CECT) MRI PET-CT ULTRASOUND U/S P: Physiological information, localize sites of active disease C: Inflammation FDG-avid, tumor may not be!, radiation, $$ Many different PET-CT flavors. Many different readers of PET-CT I: Staging, Tx response, surveillance? CI: Tumor not FDG-avid 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 2

3 Indications thyroid parotid adenopathy unknown primary pediatric Thyroid mass?thyroid mass Parotid mass Adenopathy Unknown primary Pediatric mass Multinodular goiter Benign thyroid lesion Thyroid malignancy Invasion of adjacent tissues Nodal disease 31yF Enlarging neck masses 55yM 3

4 thyroid parotid adenopathy unknown primary pediatric thyroid parotid adenopathy unknown primary pediatric Thyroid mass Parotid 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 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 CECT Acinic cell ca *Parotid masses may be occult on CT thyroid parotid adenopathy unknown primary pediatric Deep Parotid lobe Oropharyngeal pleomorphic deep lobe adenoma mass *MR allows better characterization of parotid masses 55yM. Palpable left neck mass T1 MR T2 MR 4

5 thyroid parotid adenopathy unknown primary pediatric thyroid parotid adenopathy unknown primary pediatric Parotid mass Adenopathy 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 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 Unknown Primary pediatric 59yM. Left neck mass 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 5

6 63yM. Left neck masses FNA = SCCa 55yM. Right neck masses 6

7 Congenital Pediatric Neck Mass Thyroglossal duct cyst (53%) Branchial cleft fistula /cyst (22%) 85% Second Dermoid cyst (11%) Hemangioma (7%) Venous /lymphatic malformation (6%) *MR allows better evaluation T2 FS MR of extent T1+C FS and MR characterization of mass Al-Khateeb TH. J Oral Maxillofacial Surg 2007;65: T1 MR T2 FS MR T1+C FS MR Pediatric Neck Mass Image gently Second branchial cleft fistula Avoid ionizing radiation when possible U/S, MRI as first line whenever possible Minimize radiation dose when CT is necessary 11 wk old with right neck dimple draining mucoid material 7

8 Which test? Summary 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 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 of known malignant (metastatic) disease 8