The Child With a Neck Mass

Bernadette L. Koch, MD

Disclosures

Appl Radiol. 2005;34(8):8-22. 

In This Article

Malignant Solid Masses

Lymphoma. Malignant lymphoma accounts for approximately 50% of head and neck malignancies in children. Approximately 50% of cervical involvement with lymphoma is due to Hodgkin's disease and 50% due to non-Hodgkin's lymphoma. Imaging characteristics cannot distinguish between the two. Patients may present with unilateral or bilateral disease in both Hodgkin's and non-Hodgkin's lymphoma. Lymphomatous nodes have a similar appearance to inflammatory and metastatic nodes from other primary malignancies. However, lymphomatous nodes are frequently larger and more extensive than inflammatory adenopathy. The differential diagnosis in children with bulky cervical adenopathy includes mononucleosis (particularly if there is associated enlargement of the adenoids and palatine tonsil), metastatic disease (rarely, from primary malignancy such as nasopharyngeal carcinoma, rhabdomyosarcoma, or neuroblastoma), and lymphoproliferative disease (particularly in the posttransplant patients). Imaging of patients with head and neck lymphoma should include CT of the involved area and adjacent lymph nodes as well as the chest, abdomen, and pelvis. In addition, gallium-67 citrate scintigraphy is frequently used for initial staging and follow-up (Figure 22). Increasingly, FDG-PET is being used in evaluation of these patients (Figure 23).

Lymphoma. (A) Axial postcontrast CT image of the neck shows bulky left anterior and posterior cervical chain lymph nodes, as well as conglomerate nodes posterior to the trachea deviating the trachea and thyroid anteriorly and to the right. (B) Gallium-67 citrate scintigraphy shows uptake in the left supraclavicular region and anterior neck in this child with Hodgkin's disease.

Lymphoma. (A) Axial postcontrast CT image of the neck shows bulky left anterior and posterior cervical chain lymph nodes, as well as conglomerate nodes posterior to the trachea deviating the trachea and thyroid anteriorly and to the right. (B) Gallium-67 citrate scintigraphy shows uptake in the left supraclavicular region and anterior neck in this child with Hodgkin's disease.

Lymphoma. (A) Axial postcontrast CT image shows conglomerate lymph nodes compressing the jugular vein in the left lower neck. (B) Corresponding fluorodeoxyglucose positron emission tomographic image shows abnormal uptake in the left supraclavicular region, as well as in the left mediastinum.

Lymphoma. (A) Axial postcontrast CT image shows conglomerate lymph nodes compressing the jugular vein in the left lower neck. (B) Corresponding fluorodeoxyglucose positron emission tomographic image shows abnormal uptake in the left supraclavicular region, as well as in the left mediastinum.

Rhabdomyosarcoma is the most common childhood soft-tissue sarcoma and involves the head and neck in up to 40% of patients.[34,35] Rhabdomyosarcoma is divided by sites of origin into orbit, parameningeal (middle ear, paranasal sinus, nasopharynx), and all other sites. Up to 55% of parameningeal rhabdomyosarcomas have intra-cranial extension. In these patients, CT is helpful to assess bony destruction and MRI is complimentary to evaluate for intracranial extension. Rhabdomyosarcoma is typically heterogeneous on all imaging modalities (Figure 24), with or without osseous erosion.[34]

Rhabdomyosarcoma. Axial postcontrast CT image of the neck shows a large heterogeneous right neck mass. This mass surrounds the carotid artery and deviates it anteriorly and medially. The jugular vein is not identified.

Neuroblastoma is the most common malignant tumor in children <1 year of age; primary lesions are usually located in the adrenal gland and retroperitoneum. Cervical lymphadenopathy from neuroblastoma is most often metastatic disease. Less than 5% of primary lesions are located in the neck. In addition to presenting with a palpable neck mass, patients may present with feeding difficulties, airway symptoms, or opsomyoclonus (opsoclonus, myoclonus, and cerebellar ataxia), which is thought to be a paraneoplastic syndrome. Most patients with cervical primary lesions present with a well- defined mass posterior to the carotid sheath vessels with or without intraspinal extension and with or without calcification.[36,37,38] CT and MRI nicely show the primary mass (Figure 25), occasionally with intraspinal extension. In addition to CT or MRI, I-123-metaiodobenzylguanidine (MIBG) is indicated in the workup of these children to assess for metastatic disease (Figure 26).

Neuroblastoma. Axial proton-density-weighted image of the neck shows a well-defined right neck mass in the carotid sheath deviating the carotid artery and jugular vein anteriorly and mildly deviating the trachea to the left.

Neuroblastoma. Posterior I- 123-metaiodobenzylguanidine image of the chest reveals focal areas of abnormal increased radiopharmaceutical uptake in the left shoulder and midthoracic spine in this patient with known neuroblastoma. Note normal uptake in the salivary glands.

Metastatic cervical adenopathy unrelated to lymphoma is very uncommon in children. Potential etiologies include neuroblastoma, rhabdomyosarcoma, nasopharyngeal carcinoma, and thyroid carcinoma (Figure 27).

Metastatic adenopathy. (A) Axial postcontrast CT of the neck shows a heterogeneous left supraclavicular mass deviating the trachea to the right in a patient with metastatic hepatoblastoma. (B) Axial postcontrast CT image of the neck shows large heterogeneous left neck mass deviating and compressing the jugular vein in a teenager with metastatic testicular carcinoma. (C) Axial postcontrast CT image of the neck shows a heterogeneous low-attenuation left lower neck mass with an irregular enhancing wall in a teenager with metastatic nasopharyngeal carcinoma.

Metastatic adenopathy. (A) Axial postcontrast CT of the neck shows a heterogeneous left supraclavicular mass deviating the trachea to the right in a patient with metastatic hepatoblastoma. (B) Axial postcontrast CT image of the neck shows large heterogeneous left neck mass deviating and compressing the jugular vein in a teenager with metastatic testicular carcinoma. (C) Axial postcontrast CT image of the neck shows a heterogeneous low-attenuation left lower neck mass with an irregular enhancing wall in a teenager with metastatic nasopharyngeal carcinoma.

Metastatic adenopathy. (A) Axial postcontrast CT of the neck shows a heterogeneous left supraclavicular mass deviating the trachea to the right in a patient with metastatic hepatoblastoma. (B) Axial postcontrast CT image of the neck shows large heterogeneous left neck mass deviating and compressing the jugular vein in a teenager with metastatic testicular carcinoma. (C) Axial postcontrast CT image of the neck shows a heterogeneous low-attenuation left lower neck mass with an irregular enhancing wall in a teenager with metastatic nasopharyngeal carcinoma.

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