Solid Neck Mass in Neonate

Solid Neck Mass in Neonate
Bernadette L. Koch, MD
DIFFERENTIAL DIAGNOSIS
Common
  • Fibromatosis Colli
  • Reactive Lymph Nodes
  • Infantile Hemangioma
Less Common
  • Neurofibromatosis Type 1
  • Teratoma
Rare but Important
  • Langerhans Cell Histiocytosis, General
  • Metastatic Neuroblastoma
  • Fibromatosis
  • Primary Cervical Neuroblastoma
  • Cervical Thymus
ESSENTIAL INFORMATION
Helpful Clues for Common Diagnoses
  • Fibromatosis Colli
    • Key facts
      • Synonyms: Sternocleidomastoid (SCM) tumor of infancy, congenital muscular torticollis
      • Increased incidence in breech presentation and difficult deliveries
      • Present with neck mass ± torticollis, usually within 1st 2 weeks of life
      • Ultrasound preferred imaging modality
    • Imaging
      • Large SCM muscle, focal or diffuse
      • Almost always unilateral
      • Variable echogenicity, attenuation, signal intensity; heterogeneous contrast enhancement on MR
      • No associated adenopathy
      • No extramuscular extension of mass
  • Reactive Lymph Nodes
    • Key facts
      • “Reactive” implies benign etiology
      • Acute or chronic
      • Any H&N nodal group
      • Response to infection/inflammation
    • Imaging
      • Enlarged oval-shaped lymph nodes
      • Variable enhancement, usually mild
      • ± enlargement of lingual, faucial, or adenoid hypertrophy
      • ± stranding of adjacent fat (cellulitis)
      • ± edema in adjacent muscles (myositis)
      • ± suppurative nodes or abscess
  • Infantile Hemangioma
    • Key facts
      • Vacular neoplasm, NOT malformation
      • Usually not well seen at birth, more apparent within 1st few weeks of life
      • Proliferative phase: 1st year of life
      • Involuting phase: 1-5 years
      • Involuted usually by 5-7 years
      • GLUT-1: Specific immunohistochemical marker expressed in all 3 phases of infantile hemangioma; also expressed in placenta, fetal, and embryonic tissue
      • Congenital hemangioma: Rare variant, present at birth or on prenatal imaging (fetal hemangioma); 2 subtypes, rapidly involuting (RICH) shows involution by 8-14 months, noninvoluting (NICH)
    • Imaging
      • Proliferative: Solid, intensely enhancing mass with intralesional high-flow vessels
      • Involutional: Fatty infiltration, ↓ size
      • PHACES syndrome: Posterior fossa abnormalities, hemangiomas, arterial anomalies, cardiovascular defects, eye abnormalities, sternal clefts
Helpful Clues for Less Common Diagnoses
  • Neurofibromatosis Type 1
    • Key facts
      • Carotid space, perivertebral space (brachial plexus) common
      • Localized, diffuse, or plexiform
      • Single or multiple
    • Imaging
      • Localized: Well-circumscribed, smooth, solid masses with variable enhancement
      • Diffuse: Plaque-like thickening of skin with poorly defined linear branching lesion in subcutaneous fat
      • Plexiform: Lobulated, tortuous, rope-like expansion in major nerve distribution; “tangle of worms” appearance
  • Teratoma
    • Key facts
      • Contains all 3 germ layers
      • Mature or immature, rarely malignant in neonate
    • Imaging
      • Large, heterogeneous mass
      • Frequently with fat and calcium
      • Solid and cystic components
Helpful Clues for Rare Diagnoses
  • Langerhans Cell Histiocytosis, General
    • Key facts
      • Acute disseminated form (Letterer-Siwe) occurs in children < 1 year
      • Acute onset of hepatosplenomegaly, rash, lymphadenopathy, marrow failure
      • Skeletal involvement may be absent
    • Imaging
      • Large nonspecific cervical lymph nodes
      • Hepatosplenomegaly
  • Metastatic Neuroblastoma
    • Key facts
      • Most cervical disease is metastatic from retroperitoneal primary lesion
      • Metastatic cervical disease more common in older children
    • Imaging
      • Large metastatic lymph nodes
      • Bilateral skull base metastasis common
      • Skull base metastases: Enhancing masses with osseous erosion ± intracranial or intraorbital extension
  • Fibromatosis
    • Key facts
      • Synonyms: Desmoid or aggressive fibromatosis, infantile fibromatosis, extraabdominal desmoid tumor
      • Benign soft tissue tumor arising from musculoaponeurotic structures
      • Tendency to infiltrate adjacent tissues
      • Recurrence common
      • Does not metastasize
      • Identified at all ages
      • In infants, more common in retroperitoneum and extremity
    • Imaging
      • Well-defined or poorly marginated, infiltrative mass
      • Often trans-spatial enhancing mass
      • ± erosion of adjacent bone
  • Primary Cervical Neuroblastoma
    • Key facts
      • < 5% are primary cervical lesions
      • In general, < 1 year = better prognosis
      • Young children may present with opsoclonus-myoclonus
    • Imaging findings
      • Solid mass closely associated with carotid sheath space
      • Calcifications common
      • Foraminal or intraspinal extension
  • Cervical Thymus
Aug 10, 2016 | Posted by in PEDIATRICS | Comments Off on Solid Neck Mass in Neonate

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