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