Ultrasound Evaluation of Lumps, Bumps and Small Parts of ... · –754 studies head, neck, torso...
Transcript of Ultrasound Evaluation of Lumps, Bumps and Small Parts of ... · –754 studies head, neck, torso...
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Ultrasound Evaluation
of Lumps, Bumps and
Small Parts of the
Extremities
Michael J. Callahan, M.D.
Department of Radiology
Boston Children’s Hospital
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No disclosures
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Learning Objectives
• Background information
• BCH experiences
• Clinical perspectives
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Learning Objectives
• Background information
• BCH experiences
• Clinical perspectives
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Pediatric superficial
soft tissue masses
– Common
– Variable pathology
– Most can be treated
conservatively
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Pediatric superficial
soft tissue masses
Benign >>> malignant
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– 1% of all pediatric soft tissue
tumors are malignant
– up to 25% malignant if small
superficial lesions are excluded
Brisse et al. Imaging and Diagnostic Strategy of soft tissue tumors in children
Eur Radiol (2006) 16: 1147-1164
Pediatric superficial
soft tissue masses
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Clinical Evaluation
• Radiologist & Sonographer
– Direct examination & discussion
– Facilitates accurate report
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Clinical Evaluation
• Where?
• Does it hurt?
• Mobile or fixed?
• Skin Changes?
• Systemic Symptoms?
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Clinical Evaluation
• Age of patient ?
• Lesion Duration ?
• Congenital ?
• Growth pattern ?
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Ultrasound Examination
• Location
– Anatomic location
– Depth
• Shape / Margins
• Echotexture / Internal
Characteristics
• Vascularity
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Ultrasound Examination
• Comparison views of
contralateral side
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Ultrasound Examination
• High frequency
Linear Transducer
• Gel
• Standoff Pad
• Waterbath
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Standoff Pad
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Waterbath
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Anatomy
• Dermis
• Subcutaneous
tissues
• Fascia
• Muscle
• Bone, Joint
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Learning Objectives
• Background information
• BCH experiences
• Clinical perspectives
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BCH experiences
Ultrasound evaluation of
superficial lumps and bumps
of the extremities in children:
a 5-year retrospective review
Shah S, Callahan MJ. Pediatric Radiology
MSK supplement, In press
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BCH experiences
• IRB approval
• Extremity US
– CPT codes 5 - year period (2007-
2012)
– “Mass, lump, bump, nodule”
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BCH experiences
• 1052 results from search
– 754 studies head, neck, torso
– 298 studies of extremities
(272 patients)
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BCH experiences
• Male = 131 (48%)
• Female = 141 (52%)
• Mean age = 8.7 years
• Range = 2 wks – 24.8 years
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BCH experiences
• Upper extremity = 109 (40%)
• Lower extremity = 163 (60%)
• Mass = 208
• Focal abnormality = 35
• No abnormality = 29
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BCH experiences
• SQ = 191
• Deep fascia= 7
• Muscle = 21
• Joint = 3
• SQ w tail to joint = 12
• Bone = 3
• Other (skin, inguinal
canal, tendon) = 5
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BCH experiences
• 54 (20%) no clinical or imaging
follow-up
– excluded
• Remaining patients
– Pathologic confirmation
42 (21%)
– MRI evaluation 49 (24%)
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BCH experiences
• Impression
– Benign Dx = 142
– Narrow Ddx (all benign dx) = 19
– Non – Specific = 27
– Non – Specific vascular lesion = 5
– Wide Ddx (including malignancy) = 5
– Highly concerning for malignancy = 5
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BCH experiences
• None of the “benign” diagnoses
were found to be malignant
• None of the sonographically “non-
specific” lesions were malignant
• Many of our cases had “benign”
clinical follow up, but no
pathologic or MR diagnoses
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10
• Pilomatricoma = 3
• Giant Cell Tumor of the TS = 3
• Foreign Body = 3
• Granuloma Annulare = 3
• Axillary Breast Tissue = 3
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Pilomatricoma
• Benign tumor
• Hair follicle
• < 20 yr
• Head & Neck, upper
extremity
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Pilomatricoma
• Firm
• Often dx clinically
• Surgical excision
• Dermis, grows into
SQ tissues
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Pilomatricoma
• Well-defined
• Heterogeneous
• Hypoechoic rim
• Homgeneous
hyperechoic
• Ca 2+
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Granuloma Annulare
• Asymptomatic
• Benign
inflammatory
process
• SQ form children
• Peak 2-5 yrs
• Pre-tibial location
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Granuloma Annulare
• Hypoechoic
• Ill-defined or
nodular
• SQ tissues
• Vascular
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Granuloma Annulare
4 yo male, left forearm mass
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Granuloma Annulare
22 mo female,“cysts” on the hands / fingers
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8 & 9
• Epidermal Inclusion Cyst = 4
• Herniae = 4
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Epidermal Inclusion Cyst
• Most commonly excised SQ cyst
• Dx usually clinical / excisional
• < 10 % occur in extremities
• Keratin
8 year old male with left heel nodule
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Epidermal Inclusion Cyst
• Well-circumscribed
• Relatively homogenous internally
• Hypoechoic rim
• No color
Doppler flow
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7
• Lipoma = 6
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Lipoma
• More common in
adults
• 2/3 of adipocytic
tumors
• Variable US
appearance
– Hypoechoic to
echogenic
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Lipoma
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Lipoblastoma
10 month old with
painless knee mass
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5 & 6
• Infection = 13
– Abscess (6)
– Cellulitis (5)
– Phelgmon (2)
• Baker’s cyst = 13
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Infection
• Cellulitis
• Phlegmon
• Abscess
• Exclusion of abscess
Overlap
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Infection
• Sonographic findings mirror the
clinical picture
– Skin thickening
– Hyperemia
– SQ edema
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Abscess
7 y.o. female
with right
thigh mass &
fever
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Baker’s Cyst
• 2%
asymptomatic
children
• 6% w knee pain
• Semimemb. &
medial head of
gastroc. tendons
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4
• Trauma = 18
– Hematoma (6)
– Fat Necrosis (3)
– SQ injury (4)
– Muscle injury (2)
– Muscle Hernia (3)
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Hematoma
3 y.o. male with leg pain
and swelling
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Rectus Femoris Strain
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2 & 3
• Ganglion = 19
• LN = 19
– Normal (9), reactive (4),
lymphadenitis (4), dermatopathic
(1), Hodgkin’s disease (1)
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Ganglion Cyst
• Periarticular
• +/- Pain
• 2nd
– 4th
decades
• Hand / Wrist
• No synovial lining
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Ganglion Cyst
• Simple
• Septated
• Tail
• Debris / Solid
• Vascularity
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Ganglion Cyst
6 y.o. female w mass
near great toe MTP joint
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Lymph Nodes
• Very common adults and
children
• Vast majority have benign
etiology
• Ultrasound often provides
reassurance
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Lymph Nodes
• Benign
– Oval shape
– Fatty Hilum
– Central
Vascularity
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Lymph Nodes
• Malignant
– Enlargement
– Round
– Loss of fatty hilum
– Heterogeneity
– Necrosis
– Peripheral
hypervascularity
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Reactive
Lymphadenopathy
Shape &
vascularity
can mimic
malignancy
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1
Vascular Anomalies = 36
Venous Malformation = 16
Lymphatic Malformation = 9
Infantile Hemangioma = 8
Vascular Lesion NOS = 2
AVM (post traumatic) = 1
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Vascular Anomalies
• Vascular Malformations
– VM
– LM
– VLM
– AVM
• Infantile Hemangioma
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17 year old HIV + girl
with arm mass
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VLM
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Infantile hemangioma
3 month old female with
thigh mass & cutaneous
hemangioma on eyelid
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Top Ten List
• Vasc malf
• Ganglion
• Lymph nodes
• Trauma
– Hematoma, Fat
necrosis
• Baker’s cyst
• Infection
• Lipoma
• Hernia
• Epidermal Inc Cyst
• Misc
– Pilomatricoma, GCell
Tumor TS, Foreign Body,
Granuloma Annulare,
Axillary Breast Tissue
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Malignancy
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Malignancy
• > 5 cm
• Pain
• Increase in size and depth
beneath the deep fascia
• Significant displacement of
surrounding tissues
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14 y.o. girl w/ palpable
lymphadenopathy
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Nodular Sclerosing
Hodgkin’s Disease
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16 year old girl with
painless palmar mass
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Rhabdomyosarcoma
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17 y.o. male,
enlarging thigh mass
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Dermatofibrosarcoma
protuberans
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17 y.o. male, new left
shoulder mass
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Malignant peripheral
nerve sheath tumor
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2 mo female with enlarging
forearm mass
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Undifferentiated Sarcoma
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Learning Objectives
• Background information
• BCH experiences
• Clinical perspectives
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Surgical perspective
• Imaging may be avoided
– Pilomatricoma
– Cutaneous infantile hemangioma
– Subcutaneous infection
– Post traumatic hematoma
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Surgical perspective
• Imaging should be performed
if biopsy or surgical procedure
is planned
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Lesion Characteristics
• Cystic components
– Pure cysts nearly pathognomonic
of benign lesions (cyst, hematoma,
abscess, LM)
– Some malignant tumors can have
cystic components (necrosis)
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Lesion Characteristics
• Fat
– Fatty component suggests a
benign lesion (lipoblastoma,
fibrolipomatous hamartoma,
lipoma, dermoid cyst)
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Lesion Characteristics
• Vacularity
– Poor predictor benign vs.
malignant
– Complete absence of vascular
flow indicates benignity
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Pitfalls
Spindle Cell CA
< 5 cm
HIV +
Past Med
History
Reactive Lymphadenopathy
Vascular
Lesions
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Objectives of Imaging
• Primary objectives:
– Confirm solid mass
– Define precise location and
characteristics
– Guide the decision of whether to
perform biopsy, excise or observe
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Objectives of Imaging
• Know your limitations:
– Frequently ultrasound cannot
determine the exact nature of
a soft tissue lesion
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Further imaging
• MRI
– Superior contrast resolution
– Deep extent of lesion
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Absence of definite
signs of benignity
– Short term f/u
– MRI
– Biopsy
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Ultrasound Evaluation
of Lumps, Bumps and
Small Parts of the
Extremities
Michael J. Callahan, M.D.
Department of Radiology
Boston Children’s Hospital