Imaging of cervico-thoracic lymphangiomas in children

Ultrasonography findings of pediatric head and neck lymphatic malformations: A 10-year experience of 140 surgical cases

OBJECTIVE

To discuss the usefulness of ultrasonography (US) in the diagnosis and management of pediatric head and neck lymphatic malformations (HNLMs).

METHODS

We conducted a retrospective analysis of 140 children who were referred to our hospital for the treatment of HNLMs.

RESULTS

The median age at presentation was 12 months (1 day-171 months; 66.4% under 2 years old; 35.7% neonatus). The majority clinical presentations were asymptomatic mass (65.7%, 92/140) and cosmetic deformity (25.7%, 36/140). HNLMs involved the neck accounting for 65.7% (92/140), especially posterior cervical trigone (22.1%, 31/140), and submandibular (20.0%, 28/140). The US diagnostic accuracy was 91.4% (128/140). Their boundary with the surrounding tissues was usually clear (87.9%, 123/140), whereas the shape was mostly irregular (97.1%, 136/140). Based on surgical findings, there were 67 pure HNLMs and 73 intracystic hemorrhage. Between the two groups, there were statistical differences in capsule contents (χ2 = 7.8299, p = 0.0051), flocculent echo floating (χ2 = 21.2964, p < 0.0001), overlying skin (χ2 = 9.0498, p = 0.0026), and palpation (χ2 = 13.4058, p = 0.0003).

CONCLUSIONS

US typically reveals the lesion with clear boundary, irregular morphology, anechoic contents, no blood flow signal, and echoic intracapsular septum with blood flow signal. In contrast, bluish appearance, tensional palpation, and capsule contents with low/mixed echo or flocculent echo floating may indicate intracystic hemorrhage.

Risk factors for sequelae after surgery for lymphatic malformations in children

OBJECTIVE

The first-line treatment of lymphatic malformations (LMs) is pharmacological or interventional; however, surgery is still necessary in selected cases. Our aim was to identify factors associated with the occurrence of permanent postoperative complications.

METHODS

This was a case series study of children operated on for LMs between 2001 and 2021 and followed-up in our institution. Patients who presented sequelae derived from surgical treatment (cases) and those who did not (controls) were compared.

RESULTS

We included 112 children who underwent surgery for LMs in different centers. Forty-nine cases and 63 controls were included (58% male), with a mean age of 34 months. Patients younger than 1 year presented more complications than older children, 59% (n = 29/49) vs 41% (n = 24/49), respectively (P = .02). LMs were in the cervicofacial region in seven patients in the control group compared with 30 of the cases (P ≤ .001), with microcystic malformations the most associated with sequelae (n = 11/15; P = .019). Concerning permanent complications, 88% were neurological (n = 43/49), mainly peripheral facial palsy (n = 17). There was greater postoperative residual disease in controls compared with cases (65% vs 14%, respectively; P ≤ .0001). However, following a second procedure in the control group, there was no significant difference in long-term cure rates (P = .38).

CONCLUSIONS

The risk of sequelae following surgery for LM increases significantly in patients younger than 12 months in cervicofacial and microcystic malformations. Because non-radical resections are associated with fewer complications and an optimal long-term cure rate, we consider that aggressive surgical approaches should be avoided if the absence of sequelae is not guaranteed.

Prenatal MRI of neck masses with special focus on the evaluation of foetal airway

BACKGROUND

Prenatal magnetic resonance imaging is the best tool to visualize foetal airway.

OBJECTIVE

To evaluate the performance of MRI in the assessment of foetal airway status in the presence of a neck mass.

MATERIALS AND METHODS

Two paediatric radiologists with 12- and 2-year experience in foetal imaging retrospectively analysed 23 foetal MRI examinations, performed between 2001 and 2016, after a second-level ultrasound suspicious for presence of a neck mass. Postnatal imaging, postoperative report, histology, autopsy, and clinical outcomes were the reference standard to calculate sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of prenatal MRI in detecting airway patency. We used the Cohen к statistics to estimate the interobserver agreement. We also assessed MRI performance in the diagnosis of the mass nature.

RESULTS

We obtained data about postnatal airway status in 19 of 23 patients; prenatal MRI demonstrated a sensitivity of 9/9 [100%, 95% confidence interval (CI) 66-100%], specificity 8/10 (80%, 44-98%), accuracy 17/19 (89%, 67-99%), PPV 9/11 (82%, 48-98%), and NPV 8/8 (100%, 63-100%); the interobserver agreement was perfect. Prenatal MRI correctly identified 21 of 23 masses (к = 0.858); the interobserver agreement was almost perfect (к = 0.851).

CONCLUSION

Prenatal MRI demonstrated high accuracy in assessing foetal airway status and diagnosing mass nature, allowing proper delivery planning.

[Giant mesocolic cystic lymphangioma: A treacherous prenatal presentation. Case report]

Cystic lymphangiomas are usually located in the neck region. Less frequently, they can be found in the abdomen. In those cases, pre- and neonatal diagnosis is extremely difficult. We report on the case of a giant mesocolic cystic lymphangioma, diagnosed at birth, in a child who had been monitored during the prenatal period for what was believed to be a digestive dilatation. The progression was marked by excellent tolerance despite a complete lack of regression in the first 10 months of life. The authors discuss the prenatal signs that should suggest this diagnosis and an MRI, as well as management during the 1st year of life.

An 8-year population description from a national treatment centre on lymphatic malformations

INTRODUCTION

Lymphatic malformations are rare developmental non-malignant abnormalities that present as masses consisting of abnormal growth of fluid filled channels or spaces in the skin or deep tissue that result in abnormalities of lymphatic flow. They may cause symptoms like pain, recurrent lymphorrea, abnormal bone growth, and disturbance of bodily functions. They may also be a cosmetic problem. The study aims to describe the population with lymphatic malformations (LM) treated at a national referral centre.

MATERIALS AND METHODS

This is a retrospective review of patients with the diagnosis lymphatic malformation seen at the centre between 2006-2013. The authors performed a systematic review of the hospital records and a reevaluation of the radiological findings. Eighty-five patients with 102 lymphatic malformations were included.

RESULTS

The majority of the patients (67%) were diagnosed before the age of 2 years. Lesions were located mainly to the head and neck (64%) and half (52%) were macrocystic. Treatment was: sclerotherapy (69%), surgery (49%), laser therapy (19%), or a combination of these treatment modalities (33%). The best outcome was found in the patients with macrocystic lesions (p = .029), and 76% of the patients reported a good or very good outcome.

CONCLUSION

Most patients presented before the age of 2 years with complex lesions which required unique, often multimodal treatment plans and in general they experienced good outcome.

[Iconographic imaging (ultrasound/MRI) in prenatal evaluation of cervical cystic lymphatic malformations]

OBJECTIVES

Assess imaging (ultrasound±MRI) in the diagnosis of cervical cystic lymphangioma.

METHODS

Retrospective, descriptive study of the patients who underwent reference ultrasound screening for fetal anterior cervival masses in multidisciplinary prenatal diagnosis center of the Lille Regional University Hospital from 1997 to 2014.

RESULTS

Seventeen lymphangiomas were identified. Seventy-three percent of lymphangiomas (n=12) were diagnosed in the baseline ultrasound and 85% (n=11) in MRI. An extra-cervical extension was identified in 10 (62%) with ultrasound and 11 (85%) with MRI. Main sites of mass extension objectived by ultrasound and MRI were respectively the face (4,23%/6,46%), the base of tongue (3, 18%/2, 15%) and buccal floor (3, 18%/3, 15%). Pharyngeal disease (5,38%) and mandible (4,31%) were detected by MRI and not found on ultrasound. Associated malformations detected with ultrasound were 2 (12%) urogenital malformation, 1 (6%) heart defect and 1 (6%) facial anomalies. Lymphangiomas remained stable in volume in 12 (71%) cases and disappeared before birth in 2 (12%) cases.

CONCLUSION

MRI and ultrasound seem inseparable to assess and optimally manage fetal cervical masses. Detection of associated lesions seems to help in the final lymphangioma diagnosis. Most of the time, lymphangiomas seem to be stable lesion during pregnancy and a good prognosis in cases of uncomplicated cervical lymphatic mass and without pejorative extension.

Sclerotherapy for cervical cystic lymphatic malformations in children. Our experience with computed tomography-guided 98% sterile ethanol insertion and a review of the literature

PURPOSE

The treatment of cystic lymphatic malformations of the neck and mediastinum is controversial. Surgical management may be limited by the invasiveness of the procedure, the complex anatomy of this region, and the high recurrence rate. An alternative therapeutic method is sclerotherapy. We report our experience in the treatment of cystic lymphatic malformations of the neck by computed tomography (CT)-guided instillation of 98% sterile ethanol in children.

METHODS

Eight children with clinical suspicion of cervical cystic lymphatic malformation were assessed by ultrasonography (US) and magnetic resonance imaging (MRI) to define the location, size, and number of cystic cavities. The CT-guided instillation of 98% sterile ethanol was performed. Cystic fluid was analyzed by fine-needle aspiration cytology. Clinical and US or MRI follow-up was performed after 1 and 3 months and at 1 and 2 years.

RESULTS

The results were excellent with complete disappearance of the lesion in 7 (87.5%) of 8 patients. One patient (12.5%) with satisfactory results required a second alcohol injection with an excellent outcome. No allergic reactions or complications were observed.

CONCLUSIONS

The CT-guided 98% sterile ethanol sclerotherapy is a good alternative to surgical therapy. This procedure seems accurate, minimally invasive, safe, low cost, and reliable without untoward complications. Moreover, it does not exclude later surgical treatment.

Lymphatic malformations: review of current treatment

OBJECTIVE

Summarize current knowledge of lymphatic malformation medical, sclerotherapy, and surgical treatment; and highlight areas of treatment controversy and treatment difficulty that need improvement.

METHODS

Panel presentation of various aspects of lymphatic malformation treatment.

RESULTS

The mainstay of lymphatic malformation treatment has been surgical resection, which has been refined through lesion staging and radiographic characterization. Intralesional sclerotherapy in macrocystic lymphatic malformations is effective. Suprahyoid microcystic lymphatic malformations are more difficult to treat than macrocystic lymphatic malformations in the infrahyoid and posterior cervical regions. Bilateral suprahyoid lymphatic malformations require staged treatment to prevent complications. Lymphatic malformation treatment planning is primarily determined by the presence or possibility of functional compromise. Problematic areas include chronic lymphatic malformation inflammation, dental health maintenance, macroglossia, airway obstruction, and dental malocclusion.

CONCLUSIONS

Lymphatic malformation treatment improvements have been made through radiographic characterization and staging of lymphatic malformations. Direct malformation involvement of the upper aerodigestive tract can cause significant functional compromise that is difficult to treat.

Misleading presentation of an orbital lymphangioma

We describe a 2-year-old patient with an orbital lymphangioma who presented with massive proptosis. We highlight the importance of magnetic resonance imaging in evaluating such patients, because physical examination can be misleading. We also demonstrate the difficulties of managing recurrent hemorrhages when only subtotal excision is possible, as is frequently the case.

Cystic hygroma: characterization by computerized tomography

Lymphangiomas are benign nonencapsulated lesions composed of sequestered noncommunicating lymphoid tissue lined by lymphatic endothelium and are thought to be caused by congenital obstruction of lymphatic drainage. They are subclassified by vessel size, such as the capillary, which is rare and located in subcutaneous tissue, cavernous (located about the mouth and tongue), and cystic (cystic hygromas). The cystic hygromas show a predilection for the neck (75%) and maxilla (20%), and the remaining 5% arise in rare locations such as the mediastinum, retroperitoneum, bone, kidney, colon, liver, spleen and scrotum. Only 3%-10% of neck lesions extend into the mediastinum. In this paper, we report a rare case of cystic hygroma with a huge dimension discussing the use of computed tomography scanning for diagnosis.

[A gigant cystic lymphangioma of the neck]

The cystic lymphangiomas are congenital pathology of lymphatic system which concern 90% of children population, adults suffer very seldom. The authors present the case of giant cystic lymphangioma of the neck in the 37-year-old man with symptoms of tumor of the neck. The USG, CT and MRI confirm the presence of polycystic tumour with feature of bleeding into one of the cavities. Surgical treatment was performed. The patient is controlled without any relaps. The authors remind this rare pathology that should be considered in case of neck tumours.

Rapid Development of an Axillary Mass in an Adult: A Case of Cystic Hygroma

Cystic hygroma is a congenital anomaly of lymphatic origin, which mainly develops during childhood. Its development in adulthood, however, has been proposed to be related to several predisposing factors such as trauma, infection, tumor growth or iatrogenic stimuli. The development of cystic hygroma in the extremities of adults is extremely rare and moreover, its development in the axillary region has, to our knowledge, been reported only once in the literature. We describe an unusual case of a cystic hygroma which developed rapidly in the axillary region of a female patient in the absence of any predisposing factor. The diagnostic workup and the need for surgical excision of the mass to obtain an accurate, histologic diagnosis is presented.

Multimodality imaging evaluation of the pediatric neck: techniques and spectrum of findings

Neck masses are a common finding in children and can present a difficult diagnostic challenge. These masses may represent a variety of conditions having a congenital, acquired inflammatory, neoplastic, or vascular origin. The fascial spaces and compartments of the neck provide an approach to differential diagnosis, and extensive knowledge of the anatomy and contents of each cervical compartment is mandatory in the diagnosis of pediatric neck lesions. Several imaging techniques, including radiography, gray-scale and Doppler ultrasonography, conventional and three-dimensional computed tomography, magnetic resonance (MR) imaging, and MR angiography, have been proposed for the evaluation of such lesions, and each has its own advantages and limitations. The imaging findings in 120 children who had been referred or treated for cervical lesions were retrospectively reviewed, and a systematic multimodality imaging approach to pediatric neck lesions based on the involvement of anatomic compartments of the cervical region was developed to increase diagnostic efficiency. Careful attention to clinical history and physical examination findings, along with knowledge of the embryologic features and anatomy of the cervical region and a multimodality imaging approach, is very helpful in the diagnosis and management of pediatric neck lesions.

[Emergency pediatric thoracic radiology]

Pediatric thoracic emergencies are frequent and may be due to a large spectrum of lesions including traumatic and non traumatic pathologies, such as foreign bodies, mediastinal tumors, pulmonary infections, asthma, pneumothorax and delayed manifestations of congenital chest malformations. Emergencies require rapid diagnosis to make a treatment plan and in most cases, radiology plays an essential role. Plain chest radiographs remain the initial study with inspiratory films. In certain circumstances, the use of expiratory films is absolutely necessary. Ultrasonogragraphy is the primary modality for evaluation of pleural effusions. Computed tomography (CT), with volume acquisition and more rapid scanning, is a technique capable of imaging the lungs and mediastinum with excellent spatial resolution in the pediatric population. CT provides more information than chest radiographs. This explains the increasing indications of CT in the evaluation of pediatric thoracic emergencies, more particularly traumatic emergencies.

Lymphatic Malformation of the Lingual Base and Oral Floor

BACKGROUND

Lymphatic malformation of the tongue and floor of the mouth is associated with chronic airway problems, recurrent infection, and functional issues related to speech, oral hygiene, and malocclusion. There are no accepted anatomic guidelines or treatment protocols.

METHODS

This retrospective review focused on anatomic extent, treatment, complications, and airway management in 31 patients with lymphatic malformation of the lingual base and oral floor.

RESULTS

Involved adjacent structures included the neck (77 percent), mandible (41 percent), face (42 percent), lips (10 percent), pharynx (45 percent), and larynx (26 percent). Fifty-eight percent of patients required tracheostomy during infancy; decannulation was possible in two-thirds of these patients. Management included resection alone (42 percent), resection and sclerotherapy (26 percent), resection and laser coagulation (16 percent), sclerotherapy and laser coagulation (16 percent), and resection and radiofrequency ablation (3 percent). Resection involved the neck (58 percent), floor of the mouth (52 percent), and tongue (42 percent); there were often multiple procedures. Aspiration was tried with little success in 10 percent of patients. Virtually all patients had residual abnormal lymphatic tissue. Complications and posttherapeutic problems included infection (81 percent), neural damage (27 percent), difficulty in speech (23 percent), feeding problems (10 percent), and seroma or hematoma (6 percent). Associated dental/orthognathic conditions, particularly prognathism and anterior open bite, were documented in one-third of patients.

CONCLUSIONS

The initial step in the protocol is control of the neonatal airway. Staged cervical resection is undertaken in late infancy to early childhood; resection should also include abnormal tissue in the oral floor. Sclerotherapy is primarily for macrocystic disease or secondarily for recurrent cysts following partial extirpation. Vesicles of the mucous membranes and dorsal tongue are treated either by sclerotherapy, laser (carbon dioxide, yttrium-aluminum-garnet, or potassium-titanyl-phosphate), or radiofrequency ablation. Reduction for macroglossia is indicated for persistent protrusion or to allow correction of malocclusion. Embolization controls lingual bleeding. Orthognathic procedures are undertaken at the appropriate age, only after lingual size and position are acceptable.

New treatment options for lymphangioma in infants and children

Lymphangiomas are congenital malformations of the lymphatic system. These lesions occur most often in the head and neck area, and their treatment continues to be a challenge. Fortunately, a number of advances have occurred in the diagnosis and management of lymphatic malformations in the past decade. The purpose of this article is to clarify the embryology, pathogenesis, histopathology, and classification of these lesions, as well as to describe their various forms of clinical presentation. We provide a complete review of the diagnostic measures available and thoroughly discuss new therapeutic interventions proposed to treat lymphangiomas.

Lymphatic malformations of the head and neck: a retrospective review and a support for staging

BACKGROUND

Lymphatic malformations (LM) are rare benign congenital tumors appearing mainly in the head and neck with a considerably variable outcome. A need exists to validate a staging system, taking into account the prognosis of the malformation, including preoperative and postoperative complications, long-term sequelae, and persistence of the disease to improve parental counseling and evaluate the outcome of a surgical treatment of such tumors.

METHODS

Twenty-two patients treated for LM were selected from a series of 129 patients operated on for congenital malformations of the head and neck between 1986 and 1997 at St-Luc University Hospital, Brussels, Belgium. Their charts were reviewed retrospectively, with a special focus on the anatomic location of the lesions and all the complications reported. According to de Serres et al, LM up to now have been divided into six possible categories according to their unilateral or bilateral infrahyoid and/or suprahyoid locations.

RESULTS

Stage I (unilateral infrahyoid): nine patients, 11% of complications (without mediastinal extension: 0%, with mediastinal extension: 50%); stage II (unilateral suprahyoid): three patients, 33% of complications; stage III (unilateral suprahyoid and infrahyoid): eight patients, 75% of complications; stage V (bilateral suprahyoid and infrahyoid): two patients, 100% of complications. None of the children was initially seen with stage IV (bilateral suprahyoid) or stage VI (bilateral infrahyoid) LM. Overall complications, preoperative complications, postoperative com- plications, and long-term morbidity showed a significant in- crease from stage I to V (p <.01, p =.002, p =.02, and p =.03, respectively).

CONCLUSIONS

A staging system of cervicofacial LM based on the anatomic location can be reliably used for prognostic purposes, allowing a more accurate assessment of the global risk of complications and determination of surgical outcome. Mediastinal extension in stage I patients seems to be associated with a higher rate of complications. Such information can be used to inform parents more appropriately regarding the management and long-term prognosis of their children's malformation.

Imaging of cystic lesions

Cystic neck masses are varied in their histology and embryogenesis. Because neural, vascular, and lipomatous lesions may all appear cystic, a multimodality imaging approach can help identify these potential mimics. Developmental neck cysts include thyroglossal duct, thymic, and branchial cleft cysts, and teratomatous lesions or lymphangiomas. Although laryngoceles are acquired lesions, congenital anomalies (e.g., abnormally long saccules) may play a role in their formation. Lesion location is at least as important a determinant as morphology in formulating the differential diagnosis of a cystic neck mass. Midline cystic lesions are most commonly thyroglossal duct cysts, although dermoid tumors are also frequently midline. Squamous cell carcinoma metastatic to anterior triangle lymph nodes (Fig. 17), and cystic, necrotic schwanommas, can mimic the typical appearance of an infected second branchial cleft cyst. Posterior triangle lymphadenopathy and lipomatous lesions may resemble cystic hygromas. Cystic-appearing masses in the carotid space include neurogenic tumors, vascular thromboses, and carotid chain lymphadenopathy. Neural-based lesions typically occur posterolateral to the carotid artery. Necrotic lymphadenopathy may be suggested by lesion multiplicity, or by the presence of ancillary features, such as systemic symptoms, or the existence of a primary tumor. It must be emphasized that the primary role of the radiologist in head and neck imaging is to help stage disease and guide surgery. Despite clinical and radiographic analysis, the diagnosis of many lesions ultimately depends on image-guided or excisional biopsy.

Cystic hygroma in the fetus and newborn

Cystic hygromas are developmental abnormalities of the lymphoid system that occur at sites of lymphatic-venous connection, most commonly in the posterior neck. They are frequently associated with karyotypic abnormalities, various malformation syndromes, and several teratogenic agents. The disease course of an infant with cystic hygroma is unpredictable. When diagnosed prenatally, the overall prognosis is poor. Cystic hygroma diagnosed after birth is usually associated with a good prognosis. This article reviews the embryologic, genetic, and pathologic correlates of these lymphatic system abnormalities, as well as the clinical course and outcome of the fetus and newborn with a cystic hygroma. Management strategies are reviewed, including newer nonsurgical therapies for the neonate with a cystic hygroma.

Cervicothoracic lesions in infants and children

Cervicothoracic lesions are not uncommon in children. All cervicothoracic lesions except superficial lesions extend from the neck to the thorax through the thoracic inlet. Evaluation of this area involves multiple imaging modalities: plain radiography, ultrasonography, nuclear medicine, computed tomography, and magnetic resonance (MR) imaging. However, MR imaging is the method of choice for assessing the full extents of cervicothoracic lesions and their relationships to neurovascular structures. Cervicothoracic lesions can be classified as congenital lesions, inflammatory lesions, benign tumors, malignant tumors, and traumatic lesions. Lymphangioma is the most common cervicothoracic mass in children; other congenital lesions include hemangioma, thymic cyst, and vascular anomalies. Inflammatory adenopathy reactive to tuberculosis, mononucleosis, tularemia, cat-scratch fever, infection with human immunodeficiency virus, or other upper respiratory tract infections can manifest as cervicothoracic lesions; tuberculous abscesses and abscesses of other origins can also be seen. Lipoma, lipoblastoma, aggressive fibromatosis, and nerve sheath tumors (either isolated lesions or those associated with neurofibromatosis) can also occur as cervicothoracic masses. Malignant cervicothoracic tumors include lymphoma, thyroid carcinoma, neuroblastoma, and chest wall tumors (rhabdomyosarcoma, Ewing sarcoma, and neuroectodermal tumor). Traumatic cervicothoracic lesions include pneumomediastinum of traumatic origin, traumatic pharyngeal pseudodiverticulum, esophageal foreign-body granuloma, and cervicothoracic hematoma.

Impact of magnetic resonance imaging on the surgical management of cystic hygromas

BACKGROUND

The surgical management of cystic hygromas can be challenging, and accurate diagnosis and anatomic localization is essential. The literature on the use of magnetic resonance imaging (MRI) in pediatric cystic hygromas is sparse and mostly limited to radiological descriptions.

METHODS

The authors present five cases of cystic hygromas in children ranging in age from 1 to 13 years. The preoperative MRI scans and patient charts were reviewed with attention to the clinical, radiological, surgical, and histological findings.

RESULTS

MRI produced highly detailed multiplanar renderings of the cystic hygromas that were both diagnostic and predictive of the subsequent intraoperative findings. This modality helped specifically in some cases to identify lesion extensions that required specific surgical attention. There were no recurrences or complications at a mean follow-up of 18 months.

CONCLUSION

The use of MRI in cystic hygromas can facilitate accurate diagnosis and assist in the preoperative planning, thereby contributing to the successful treatment of these lesions.