1. Lumps and Bumps Anne Moore, MD Assistant Professor Radiology
Children’s Mercy Hospital and
University of Missouri, Kansas City

2. Imaging Modalities Plain Xray imaging ULTRASOUND CT imaging MR imaging
Common complaint in children and source of concern in parents.
Differential diagnosis is broad. Can be found all over body. The lesions may be congenital or acquired. Rad evaluation is often requested.
Radiography and especially ultrasound have been mainstays in evaluating masses in the pediatric population.
RAD – possible osteochon, osteosarc, prevert STS, LCH(bone margins and location), Cephalohematoma
US is first chioce esp. in head and neck and is fast and relatively inexpensive test and fits the imaging gently theme. US in particularly useful in evaluating cystic verus solid and vascular lesions.
CT and MR imaging are useful in evaluating complex masses some of which may have connections with the central nervous system that may only be well eval with
CT/MR. CT/MR provides greater anatomic detail and info on vascular anatomy. Which can be useful in therapeutic/surgical planning.

3. Lumps and Bumps
Congenital Lesions Vascular Anomalies Acquired Lesions Infectious Lesions Traumatic Lesions

4. Head, Shoulders, Knees and Toes

5. Eyes and ears and mouth and nose

6. Head and neck
Start with Ultrasound!

7. Head and Neck Dermoid/Epidermoid Branchial Cleft Cyst
Thyroglossal Duct Cyst
Accessory Parotid Tissue
Fibromatosis Coli
Vascular Anomalies
Hemangioma
Lymphatic/Venous Malformation

8. Dermoid/Epidermoid
Found in a variety of locations around the skull, midface and neck
Commonly in midline and frontotemporal location, followed by parietal location
Midline or near midline lesion in neck
Dermoid contains ectoderm and skin elements. Epi ectoderm but no skin elements
Thought as a result of of the persistence of ectodermal elements at sites of suture closure.
Appearance depends on content.

9. Dermoid
Cystic or solid
Hypovascular

10. Dermoid/Epidermoid Note Midline location Near sutures
Often contains fat
Negative Hounsfield Units

11. Branchial Cleft Cyst: Second
Most common Branchial anomaly
Presents acutely with mass at the angle of the mandible
Can occur anywhere along the potential tract of a second brach fistula from the tosillar fossa to the suprclavicular region. A sinus or fistula may open to the skin anywhere along this path.
Diff would include vasc anomaly, paramedian thyrogl duct cyst, suppruative lymphadenopathy
The appearance of the cyst depends on the presence and extent of inflammatory changes.
Sono-cystic or complex mass that often contains debris
CT – oval or round cystic mass. Wall thickness, enhancement, and surrounding soft tissue edema. Uncomplicated cyst is of low attenuation and has a thin smooth wall. Infected cyst is of higher attenuation with increased protein content and can have a thick irregular enhancing wall.
MR- appearance varies with protein content.

12. Accessory Parotid Tissue
Superficial and lateral to masseter muscle and anterior to superficial lobe
Rarely palpable
Superficial lobe main bulk of gland superficial and posterior to masseter muscle.
Deep lobe—small extension of gland deep to angle of mandible
Accessory lobe (20%) superficial and lateral to masseter muscle and anterior to superficial lobe of parotid and drainage is directly into parotid duct

13. Fibromatosis Coli Idiopathic intramuscular hematoma
Focal mass or fusiform enlargement of sternocleidomastoid
Presents with torticollis < 8 weeks of age
Diff delivery
Torticollis often coexists
Suggested causes include birth trauma, in utero torticollis
Second to fourth week of life
Male greater than female
Firm nontender
Plagiocephaly can develop in untreated patients

14. Fibromatosis Coli
Normal for comparison
Fibromatosis Coli

15. In a 6 week old with torticollis, which imaging study is initially suggested?
MRI CT
Ultrasound
Plain Radiographs

16. Thyroglossal duct cyst
Most common midline developmental lesion of the neck in childhood
Abuts hyoid bone
Presents acutely
Often after URI
Arises from remnants of the thyroglossal duct.
Occurs at any site from the base of the tongue to the suprasteranl region
Over 2/3rd are midline
Demonstration of a sinus tract extending cephalsd from the cyst supports the dx.
Diff: for midline includes dermoid or teratoma, lymph node, vallecular cyst
Offmidline includes lymphatic mal, lymph node brachial anomaly

17. Thyroglossal Duct Cyst

18. Hemangioma Most common tumor of infancy & childhood Female > Male
Characteristic growth: proliferation, then regression
Presents 2weeks-2 months of age
Often skin changes
Lobulated mass with prominent color Doppler flow

19. Hemangioma MRI Parotid is most common salivary gland T2 bright
Enhancing
Lobular
Flow voids
Parotid is most common salivary gland
Occurring in 12% of infants
Most are asymptomatic
Most hemangioma can be dx. On basis of physical appearance and temporal growth history and imaging not necessary.
Imaging used if dx is in question or evaluating extent of disease
Charactertically two stage process of growth and regression
At birth the lesions are often small and inconspicous. 60% are not present at birth
Shortly after birth period of rapid proliferation that lasts several months
Typically involuation begins approximately at 10 months of age
50% of lesions completely resolved by 5 years of age

20. Hemangioma Proliferation Involution
MR is the imaging test of choice for making dx and evaluating extent of disease.
Ct is not typically used in dx of suspected hemangionma but may be obtained to work up nonspecific mass. On CT discrete lobualated mass with diffuse enhancement with prominent draining veins.

21. Venous and Lymphatic Malformations
Present any age, but usually beyond infancy
Venous Malformation:
Dysplastic venous channels; Solid with phleboliths and venous Doppler wave forms
Lymphatic Malformation:
Dysplastic lymphatic structures; Cystic with fluid levels
VM:Us Serpentine structure with no Doppler arterial flow
MR is best imaging test for dx and evaluation of extent.
Typically are present at birth and grow proportional to child
LM: multicystic mass most commonly in neck and axilla
Typically grow in proportion to child but may have a rapid increase in size if hemorrhage or infection
MR is best imaging choice for evaluation and extent.
US: multicystic mass
CT/MR multi cystic mass with peripheral enhancement.

22. Venous Malformation
Venous wave forms
Solid

23. Lymphatic Malformation
Note cystic and solid components

24. In a 1-month-old child with a hemangioma on the arm, what is the suggested imaging study?
No imaging needed
MRI
Bone scan
Plain radiographs

25. Rhabdomyosarcoma
Most common soft tissue sarcoma of childhood Aggressive looking
60% of cases
1/3 of ped rhs occur in head/neck
MR/CT need for evauation

26. Lymphoma Third most common childhood malignancy
Asymptomatic lymphadenopathy
Start US. CT scan to evaluate extent and likely go ahead and scan the CAP

27. Cervical Lymphadenopathy
Common in children
Imaging studies will show size, number and location of enlarged lymph nodes
Often follows tonsiller, pharyngeal or dental infection
And may indicate composition
US multiple discrete oval relatively hypoechoic masses along the cervical chain
CT and MR lymph nodes greater than 1.0 to 1.5 cm are considered abnormal
Bacterial infection may result in abscess formation

28. Cervical Lymphadenopathy

29. Suppurative Lymphadenitis
Bacterial infection may result in abscess formation

30. Suppurative Lymphadenitis
Nodes with central necrosis/fluid
May take weeks to resolve

31. Cephalohematoma Subperiosteal accumulation of blood
Confined by sutures
Most commonly parietal
No imaging usually needed
? ultrasound

32. Cephalohematoma

33. In a newborn male with unilateral parietal swelling since birth, which imaging study is indicated?
MRI CT
Plain radiographs
No imaging indicated

34. Shoulder, Knees and Toes aka Below the Neck

35. Baker’s/Popliteal Cyst
Synovial cyst in posterior aspect of knee joint
Intact cyst
Dissected Cyst
Ruptured Cyst
Extends b/w medial head of gastro and sm tendon
Intact smooth contour
Dissected smooth contour extending along facial plane usually b/w gastro and soleus
Ruptured cyst with leakage into calf tissue

36. Baker’s/popliteal cyst

37. Ganglion Cyst Cystic lesion usually attached to a tendon sheath
Location: hand, wrist, dorsum of foot
Mucin containing cyst arising from tendon sheath/joint capsule/bursa
Can be asymptomatic or pain
Uni or multiloc
Can have bone reresorption or periosteal formation

38. Langerhan Cell Histiocystosis
Idiopathic disorder that can manifest as focal or systemic disease
Initial lesion often identified with radiography
Radiographic appearance is extremely variable
May presents with palpable lumps
Especially on skull or ribs
Radiographic skel survey with or without bone scintigraphy obtained to identify other bone lesions
Chest radiograph or chest CT to evaluate for pulmonary involvement
Common sites of involvement are skull, ribs, femur, pelvis, spine mandible
Rad appearance is extremely variable. Lucent or sclerotic, permeative or geographic, well-defined or poorly defeined.

39. LCH 15 month old Well difined lytic lesion without sclerotic rim
Edge described as beveled with the inner table involved more than the outer table
Sclerotic rim during healing
Soft tissue mass overlying lytic process in calvarium

40. LCH
15 month old

41. LCH 15 month old clavicle/chest wall mass
11 year old female left chest wall mass

42. Inguinal Hernia Patent processus vaginalis Imaging not usually needed
Ultrasound if unsure about etiology
PPV becomes an indirect hernia when bowel enters or ovary/bowel in girls
Boys more than girls

43. Inguinal Hernia

44. Osteochondroma Most common benign growth of the skeleton
Usually painless mass
Painful=possible malignancy and need MRI
1st to 3rd decade
Painful with impingement of nerves and blood vessels
Pedunculated form and broad based form
Long bone metaphysis of femur, humerus, prosicmal radius, tibis abpit 50% about knee acapula rib pailvis spine in any bone that develops by enchondromal calcificaiton
Grows at right angle toward the diaphysis
Cortial bone with cartilaginous cap
Continuity of bone cortex to host bone
Malg transformation in to chondro/osteoscarcoma less than 1%

45. Sacral Dimple Classified as low or high risk
Low risk does not require imaging
High risk require imaging
Ultrasound if < 6 months
MR imaging thereafter
MR after 6 months due to the limitations of ultrasound with progressive ossifiction of the spine
Ultrasound is the screening modality of choice. Unless dimple is draining CSF(sinus tract) or an open dysraphisms which require immediate surgery and/or MR imaging.

46. Sacral dimple Low risk Midline Less than 5mm in diameter
Located with the gluteal crease
No cutaneous abnormalities or drainage
Can see bottom of dimple
Within 2.5cm of the anus

47. Sacral dimple High risk Greater than 5mm in diameter
Located above the gluteal crease
Cutaneous abnormalities
Draining cerebrospinal fluid
Bottom of dimple cannot be seen
Cutaneous hemangiomas, cutis aplasia, hairy patches, skin tags

48. Sacral Dimple
Tethered Cord
Normal

49. Sacral Dimple
Dermal sinus tract

50. Sacral Dimple

51. Lumps and bumps Ultrasound First
Use Ultrasound and Clinical Setting to Determine Next Best Step in Evaluation and Treatment

52. In a 4-mo-old with skin lesion. Which imaging study is indicated?
MRI
Ultrasound
No imaging needed
Plain radiographs