British Journal of Radiology (2008) 81, 165-167
© 2008 British Institute of Radiology
doi: 10.1259/bjr/94831745
Cystic neck mass in a young man
O BUCKLEY, MB BCh, BAO, MRCP, FFR (RCSI)
and
S HAMILTON, MD, FRCR
Tallaght, Dublin 24, Ireland
Correspondence: Dr Orla Buckley, Tallaght, Dublin 24, Ireland. E-mail: orla.buckley{at}amnch.ie
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Case history
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A 20-year-old man presented to his general practitioner with rapid onset, over a few days, of a swelling in the left side of his neck. The swelling was not tender and he was otherwise well. Ultrasound was performed (Figure 1
). Subsequently CT and MR imaging were performed (Figures 2 and 3). What are the findings and what is the likely diagnosis?
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Figure 1. Transverse ultrasound image of the left side of the neck demonstrates a mixed cystic(large arrow) and solid mass (small arrow), which was part of a larger complex multiseptated mass that extended from the submandibular area to the supraclavicular area.
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Figure 2. Transverse CT scan of the neck following intravenous contrast confirmed the mixed nature of the mass(small arrows) and showed moderate enhancement of the solid portions. The left internal jugular vein has been compressed by the mass and the external jugular vein on the left has increased in size to compensate (large arrow).
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Figure 3. CoronalT2 weighted MRI of the neck showed the mass in the left side of the neck containing solid and cystic elements (arrows) and extending into the mediastinum, as well as a small mass of similar nature in the right lower neck (arrowhead).
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Discussion
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The ultrasound examination (Figure 1
) showed a mixed cystic and solid mass in the left side of the neck. It was well defined and the solid components were homogeneous. CT (Figure 2) confirmed the mixed nature of the mass and showed moderate enhancement of the solid portions. MRI gave better detail of the mass as shown in the coronal T2 weighted image (Figure 3), which showed a small mass of similar nature in the right lower neck. CT and MR confirmed that the mass extended into the upper mediastinum. A fine-needle aspiration was inconclusive, but showed no evidence of malignant cells. The masses were resected by a combined neck and chest approach and were thought to have been completely removed. Pathology showed metastatic lymph nodes from papillary thyroid carcinoma. The thyroid gland had appeared normal on all investigations. The thyroid was subsequently removed and was found on histological analysis to contain a tiny focus of papillary thyroid carcinoma.
The patient's age, the location and characteristics of the neck mass are important features in the history and clinical examination of any patient with a neck mass. Three main age groups need to be considered: paediatric (<15 years), young adult (<40 years) and older adult (>40 years) [1]. In the paediatric patient, congenital or inflammatory causes are most likely. In the young adult, inflammatory conditions are most likely. In the older age group, an asymmetric enlarged lymph node is highly suspicious for malignancy: up to 50% of adults with such a mass are found to have a malignancy [2, 3].
This young man presented with a non-tender, cystic, lateral neck mass for which the differential diagnosis would include benign entities such as branchial cysts (remnants of the second branchial cleft are usually found in the anterior triangle of the neck in the submandibular area) or cystic hygroma. Metastatic papillary thyroid carcinoma should also be considered even if the thyroid gland appears normal clinically and radiologically. Papillary thyroid carcinoma accounts for 80% of thyroid cancers and is the most common thyroid cancer to occur in children and young adults [4, 5]. In up to 40% of cases of papillary thyroid cancer the initial presentation may be the development of enlarged cervical lymph nodes (usually in the lower jugular chain) [6]. Papillary thyroid cancer can usually be palpated when >1.5 cm and detected ultrasonographically when >0.5 cm [5]. Cystic degeneration of papillary thyroid carcinoma metastatic nodes occurs in 40% of cases and is more common in younger adults [7]. Cystic degeneration of neck nodes can also occur in cases of metastatic squamous cell carcinoma or mycobacterial infection [8]. When solitary cystic masses are seen in the lateral aspect of the neck, they can often be mistaken clinically for benign entities [9] but there are key sonographic features that should raise suspicions for a metastatic node. If the mass appears to have a thick irregular wall, with internal septations and nodules, it is most likely a malignant node. Branchial cysts are usually well-defined solitary masses that are hypoechogenic with a smooth wall, although multiple or echogenic branchial cysts can occur [6, 10]. Infected or multiloculated branchial cysts can have a more complex appearance. Branchial cysts are usually low density on CT with a well-circumscribed rim [11].
Cystic hygromas are benign, non-encapsulated lesions derived from lymphoid tissue. They appear as multilocated cystic masses with or without septatations. Branchial cysts and cystic hygromas have similar soft tissue characteristics on CT and MRI. However, unlike branchial cleft cysts, cystic hygroma does not cause any displacement of structures in the neck. Only 3–10% of cystic hygromas extend into the mediastinum [11]. Haemorrhage into the cyst may result in a fluid level on ultrasound, CT and MRI. Fine-needle aspiration of neck nodes is a rapid minimally invasive tool that can differentiate between inflammatory and malignant conditions. Fine-needle aspiration has been shown to have sensitivity and negative predictive value in the diagnosis of cancer of 95% and 96% respectively [12]. The false-negative value in this case may be attributed to sampling of a cystic component of the mass as the yield in cystic lesions is often less than from solid lesions [7]. Histologically, papillary thyroid cancers and their metastatic nodes often contain microcalcifications (50%) [13, 14].
This patient was young and had an acute onset of a cystic neck mass which was confirmed histologically to represent lymph node metastasis from a papillary thyroid carcinoma. In any young patient with a cystic neck mass, the possibility of lymph node metastasis from papillary thyroid carcinoma should be considered, even if there is no clinically or radiologically detectable thyroid abnormality [15].
Received for publication March 20, 2006.
Revision received June 8, 2006.
Accepted for publication June 23, 2006.
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References
|
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- McGuirt WF. The neck mass. Med Clin N America 1999;83:219–33.[CrossRef][Medline]
- Mayo CW, Lee M Jr. Significance of tumours of the neck. Lancet 1950;70:420
- Slaughter DP, Majarakis JD, Southwick HW. Clinical evaluation of swellings in the neck. Surg Clin N America 1956;36:3
- De Lellis RA. Endocrine system. In: Cotron RS, Kumar V, Robbins SL, editors. Robbins pathologic basis of disease, 4th edn. Philadelphia, PA: WB Saunders, 1989:1205–76
- Ahuja AT, Chow L, Chick W, King W, Metreweli C. Metastatic cervical nodes in papillary carcinoma of the thyroid: ultrasound and histological correlation. Clin Radiol 1995;50:229–31.[CrossRef][Medline]
- Loughran CF. Case report: cystic lymph node metastasis from occult thyroid carcinoma: a sonographic mimic of a branchial cleft cyst. Clin Radiol 1991;43:213–14.[CrossRef][Medline]
- Wunderbaldinger P, Harisinghani MG, Hahn PF, Daniels GH, Turetschek K, Simeone J, et al. Cystic lymph node metastases in papillary thyroid carcinoma. AJR Am J Roentgenol 2002;178:693–7.[Abstract/Free Full Text]
- Muraki AS, Mancuso AA, Harnsberger HR. Metastatic cervical adenopathy from tumours of unknown primary: the role of CT. Radiology 1984;152:749–8.[Abstract/Free Full Text]
- Singh S, Baboo ML, Pathak LC. Cystic lymphangioma in children: report of 32 cases including lesions at rare sites. Surgery 1971;69:947[Medline]
- Howie AJ, Proops DW. The definition of branchial cyst sinuses and fistulae. Clin Otolaryngol 1982;7:51–7.[CrossRef][Medline]
- Som PM, Curtin HD. Head and neck imaging, 3rd edn. Mosby; 1996.
- El Hag IA, Chiedozi LC, al Reyees FA, Kollur SM. Fine needle aspiration cytology of head and neck masses. Seven years' experience in a secondary care hospital. Acta Cytol 2003;47:387–92.[Medline]
- Rosario PW, de Faria S, Bicalho L, Alves MF, Borges MA, Purisch S, et al. Ultrasonographic differentiation between metastatic and benign lymph nodes in patients with papillary thyroid carcinoma. J Ultrasound Med 2005;24:1385–9.[Abstract/Free Full Text]
- Chan BK, Desser TS, McDougall IR, Weigel RJ, Jeffrey RB Jr. Common and uncommon sonographic features of papillary thyroid carcinoma. J Ultrasound Med 2004;23:572[Free Full Text]
- Ric Harnsberger H. Handbook of head and neck imaging, 2nd edn. St. Louis: Mosby, 1990; 199–223.
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Case history
Discussion
