Pediatric Head and Neck Malignancies

Using T2-weighted magnetic resonance imaging-derived radiomics to classify cervical lymphadenopathy in children

BACKGROUND

Cervical lymphadenopathy is common in children and has diverse causes varying from benign to malignant, their similar manifestations making differential diagnosis difficult.

OBJECTIVE

This study aimed to investigate whether radiomic models using conventional magnetic resonance imaging (MRI) could classify pediatric cervical lymphadenopathy.

METHODS

A total of 419 cervical lymph nodes from 146 patients, and encompassing four common etiologies (Kikuchi disease, reactive hyperplasia, suppurative lymphadenitis and malignancy), were randomly divided into training and testing sets in a ratio of 7:3. For each lymph node, 1,218 features were extracted from T2-weighted images. Then, the least absolute shrinkage and selection operator (LASSO) models were used to select the most relevant ones. Two models were built using a support vector machine classifier, one was to classify benign and malignant lymph nodes and the other further distinguished four different diseases. The performance was assessed by receiver operating characteristic curves and decision curve analysis.

RESULTS

By LASSO, 20 features were selected to construct a model to distinguish benign and malignant lymph nodes, which achieved an area under the curve (AUC) of 0.89 and 0.80 in the training and testing sets, respectively. Sixteen features were selected to construct a model to distinguish four different cervical lymphadenopathies. For each etiology, Kikuchi disease, reactive hyperplasia, suppurative lymphadenitis, and malignancy, an AUC of 0.97, 0.91, 0.88, and 0.87 was achieved in the training set, and an AUC of 0.96, 0.80, 0.82, and 0.82 was achieved in the testing set, respectively.

CONCLUSION

MRI-derived radiomic analysis provides a promising non-invasive approach for distinguishing causes of cervical lymphadenopathy in children.

Quality Improvement Methodology to Improve Standardized Reporting of Pediatric Thyroid Ultrasounds Using TI-RADS

BACKGROUND/PURPOSE

The process of evaluating pediatric thyroid nodules at our institution was inconsistent with a high rate of negative biopsies raising concern of appropriate patient selection for biopsy. Our aim was to institute a standardized risk stratification reporting system for thyroid nodules to increase utilization and agreement of TI-RADS reporting at our institution.

METHODS

Radiology report data were collected and analyzed as part of a quality improvement project. A standardized TI-RADS dictation template was created, ultrasound technicians were trained, a multi-disciplinary conference initiated, and education provided for radiologists and clinicians. Control charts were used to track utilization and agreement of scoring of TI-RADS reporting based upon review by a radiologist trained in TI-RADS scoring.

RESULTS

From January 2019 to January 2021, 218 patients with a thyroid nodule had a thyroid ultrasound performed at our institution. TI-RADS was utilized in 0 % (0 of 57) of children in the four months prior to project initiation. Following creation of the template, utilization increased to 65 % (39 of 60) over 5 months. Utilization further increased after the first training conference and was maintained above 90 % for 13 months. Ultrasound reports were in agreement in 46.7 % (28 of 60) of children initially. Agreement in reporting improved to 71.4 % (10 of 14) in the 3 months following the first training and to 78.4 % (58 of 74) over 12 months. Agreement in reporting was maintained at 80 % in the following 6 months.

CONCLUSIONS

A quality improvement initiative can improve utilization and agreement of scoring using the TI-RADS system in pediatrics. This may ultimately reduce unnecessary biopsies and sedation in children.

LEVEL OF EVIDENCE

Level III.

TYPE OF STUDY

Quality Improvement.

A Rare Case of Pediatric Nasopharyngeal Rhabdomyosarcoma With Parameningeal Extension Presenting as a Thornwaldt Cyst

Rhabdomyosarcoma (RMS) is a common soft tissue malignancy of the pediatric age group, frequently involving the head and neck region; however, nasopharyngeal RMS is a rare entity. By virtue of its parameningeal involvement and nonspecific presentations, nasopharyngeal RMS has become a clinical challenge to diagnose. We present a case of an eight-year-old boy presenting with signs and symptoms of nasal obstruction who was initially being treated for tonsillitis. Recurrent episodes led to detailed examination and radiologic imaging, and a diagnosis of Thornwaldt cyst was made. For the relief of symptoms, a debulking surgery was performed followed by a biopsy which revealed the mass to be a nasopharyngeal RMS. Our case highlights the importance of including nasopharyngeal RMS into the differentials of midline nasal masses along with the role of biopsy for confirming its diagnosis as treatment modalities for it are strikingly different than the other more common group of conditions, i.e., benign nasal masses. While surgery is usually delayed in the latter group, it can be of prime importance while treating nasal RMS, along with chemotherapy and radiotherapy.

Diagnostic performance of adult-based ultrasound risk stratification systems in pediatric thyroid nodules: a systematic review and meta-analysis

Purpose

Ultrasound (US) is the first choice in the detection of thyroid nodules in pediatric and adult patients. The purpose of this study was to evaluate the diagnostic performance of adult-based US risk stratification systems (RSSs) when applied to the pediatric population.

Methods

Medline, Embase, and Cochrane Library (CENTRAL) were searched up to 5 March 2023 for studies about the diagnostic performance of adult-based US RSS in pediatric patients. The pooled sensitivity, specificity, positive likelihood ratio (LR), negative LR, and diagnostic odds ratio (DOR) were calculated. The summary receiver operating characteristic (SROC) curves and area under the curve (AUC) were also analyzed.

Results

The sensitivity was highest in American College of Radiology-Thyroid Imaging Reporting and Data System (ACR-TIRADS) category 4-5 and American Thyroid Association RSS high-intermediate risk (ATA), which was 0.84 [0.79, 0.88] and 0.84 [0.75, 0.90], respectively. The specificity was highest in ACR-TIRADS category 5 and Europe-TIRADS (EU-TIRADS) category 5, which was 0.93 [0.83, 0.97] and 0.93 [0.88, 0.98], respectively. The ACR-TIRADS, ATA, and EU-TIRADS showed moderate diagnostic performance in pediatric thyroid nodule patients. For Korea-TIRADS (K-TRADS) category 5, the summary sensitivity and specificity with a 95% CI were 0.64 [0.40, 0.83] and 0.84 [0.38, 0.99], respectively.

Conclusions

In conclusion, the ACR-TIRADS, ATA, and EU-TIRADS have moderate diagnostic performance in pediatric thyroid nodule patients. The diagnostic efficacy of the K-TIRADS was not as high as expected. However, the diagnostic performance of Kwak-TIRADS was uncertain because of the small sample size and small number of studies included. More studies are needed to evaluate these adult-based RSSs in pediatric patients with thyroid nodules. RSSs specific for pediatric thyroid nodules and thyroid malignancies were necessary.

Radiologic diagnosis of non-traumatic paediatric head and neck emergencies

Imaging plays a crucial role in evaluating paediatric patients with non-traumatic head and neck lesions in an emergency setting because clinical manifestations of these entities can overlap. For this reason, radiologists must be familiar with the clinical and imaging findings of prevalent paediatric head and neck emergencies. In this review, we present techniques and imaging clues for common complications of pathological processes in the paediatric head and neck, with a focus on the clinical scenario as a starting point for the radiologic approach.

Long-Term Outcome and Quality of Life in Patients Treated for Head and Neck Sarcoma during Pediatric Age: Considerations from a Series of 4 Cases

Pediatric sarcomas are rare malignancies accounting for about 10% of solid tumors in childhood. Sarcomas represent a heterogeneous group of malignancies, especially they include Rhabdomyosarcoma (RMS) and Non-Rhabdomyosarcoma Type Sarcomas (STSNR). Therapeutic management of pediatric sarcomas is challenging. Multidisciplinary approach including chemotherapy, surgery and radiotherapy is the treatment of choice. The correct management of affected patients can be demanding, especially in terms of preserving a good quality of life (QoL). In the present study we described our experience with a series of patients diagnosed with head and neck non-metastatic sarcoma between January 1995 and December 2020, referred to Pediatric Oncology or to Maxillo-Facial Surgery of University Hospital of Modena and Reggio Emilia.The survivors were asked to complete questionnaires on health-related quality of life (HRQoL; PedsQL and EORTC QLQ-H&N 43). We found satisfactory results in terms of global HRQoL; although outstanding issues persist, such as deterioration in masticatory function, and speech. Long-term sequelae of multimodality treatment may lead to both significant aesthetic-functional and psychosocial implications that need to be further investigate during the whole the care pathway.

Diagnosis difficulty of histiocytosis in the thyroid region of a child: a rare case report with literature review of differential diagnoses

Background

Isolated histiocytosis of thyroid region is very rare; clinical history, exam, and radiological aspects are non-specific, and etiological reasoning is quite difficult considering the tremendous number of differential diagnoses.

Case presentation

This is the case of a 6-year-old girl who came to the emergency room with an acute presentation bulging of the anterior and left lateral regions of the neck. The palpation of the mass showed tenderness; there was no sign of inflammation, nor was there any fistula to the anterior border of the sternocleidomastoid muscle.

The patient was stable. She did not have any signs of compression. The initial blood showed anemia and inflammatory syndrome. She underwent cervical ultrasound exam that showed a mass at the expense of the left thyroid lobe; the mass extends through the sub-hyoid muscles to the lateral cervical region.

A CT scan with and without contrast injection was performed. It showed a heterogenous mass, which seemed centered in the anterior compartment, and from which it extended to the left lateral compartment, as well as the posterior compartment, invading the prevertebral muscles and englobing the carotid and the internal jugular vein.

The patient underwent surgical biopsy. A basal cervical incision was made, dissection with the myo-cutaneous plane. Per-operative observation established that the mass breeched the infrahyoid muscles, as well as the sternocleidomastoid muscle. A biopsy was performed without opening the middle line.

The pathological exam showed an eosinophilic granulomatosis, associated with Stembergoid cells. The immune-histochemical exam concluded that the lesion is histiocytosis. The patient underwent a cervicothoracic and pelvic CT scan to rule out systemic forms. The diagnosis of isolated histiocytosis of thyroid region was confirmed.

The patient underwent hemithyroidectomy, associated with careful dissection of extension of the mass to lateral compartment of the neck. Postoperative exam showed no abnormalities. No dysphonia and no hypocalcemia were observed.

The 8-month follow-up showed satisfactory results, no cervical swelling, and no signs of inflammation or compression. Postoperative naso-fibroscopy was normal.

Conclusions

The most important takeaway message of this work is that methodical approach of neck masses allows to rule out the most aggressive lesions frequently encountered, which allows clinicians to establish thorough diagnosis and management without further delay.

Pediatric Neck Masses: Imaging Guidelines and Recommendations

Neck masses commonly present in children and several potential diagnostic and management pathways exist, though with a paucity of evidence-based recommendations. The purpose of this article is to evaluate the current literature and utilization of various diagnostic imaging modalities , with a review of imaging features and management pearls for pediatric neck masses. A comprehensive understanding and practical imaging workflow will guide optimal patient workup and management.

Pediatric adaptions are needed to improve the diagnostic accuracy of thyroid ultrasound using TI-RADS

BACKGROUND/PURPOSE

Thyroid Imaging Reporting and Data System (TI-RADS) is validated in adults but not yet in children. The purpose of this study was to determine the sensitivity, specificity, and accuracy of TI-RADS in predicting thyroid malignancy for pediatric nodules, and to compare the diagnostic accuracy to the current American Thyroid Association (ATA) guidelines.

METHODS

A single institution retrospective review was performed of patients younger than 21 years who underwent thyroid nodule fine needle aspiration biopsy (FNAB). Two radiologists were blinded to the pathology and independently classified all biopsied thyroid nodules based on TI-RADS. ATA and TI-RADS guidelines were analyzed to determine the diagnostic sensitivity and specificity of both scoring systems.

RESULTS

115 patients (median age 15.5 years, 90 females) with 138 nodules were scored using TI-RADS. There was moderate inter-rater agreement between radiologists (Kappa = 0.51; p < 0.0001). Evaluating several potential TI-RADS criteria, 23.2%-68.1% of nodules were recommended for FNAB, compared to 82.6% of nodules using ATA guidelines. Using TI-RADS ≥ 3 (without size cutoff) as an indication for FNAB had 100% sensitivity with no missed suspicious or malignant nodules on cytology or pathology.

CONCLUSIONS

Using TI-RADS for diagnostic management of pediatric thyroid nodules improves accuracy in predicting malignancy.

Sarcomas of the paranasal sinuses: An analysis of the SEER database

Objective

To determine the demographics, treatment modalities, and overall survival of patients with sinonasal sarcoma.

Methods

All cases of primary sinonasal sarcomas diagnosed between the years of 2009 and 2014 were extracted from the National Cancer Institute's Surveillance, Epidemiology, and End Results database. Additional variables collected included age, gender, ethnicity, tumor histological subtype, tumor size, treatment modality, vitality status, and follow-up time. Kaplan-Meier survival curves were generated and overall survival was calculated.

Results

One hundred and four cases of sinonasal sarcoma were identified. The majority of patients were female (55%), white (76%), and non-Hispanic (84%), and the mean age was 47 ± 22 years. The most common tumor sites were the maxillary sinus, followed by the ethmoid, sphenoid, and frontal sinus. Forty six percent of tumors were rhabdomyosarcoma type. Most patients (66%) had some type of surgery, 64% received radiation, and 58% received chemotherapy as part of their treatment. Overall 1- and 5-year survival was 79% and 31%, respectively. There was no significant difference in survival based on patient gender, age, ethnicity, radiation, or chemotherapy treatment.

Conclusions

This study adds to the current literature of sinonasal sarcomas and is the first to report in detail the surgical interventions performed as well as characteristics about lymph node spread, tumor histology, and treatment outcomes since the advent of radiation and chemotherapy. As these tumors are so rare, continued study of the demographics, tumor characteristics, and long-term outcomes of this population is necessary to guide treatment modalities and strategies for otolaryngologists.

Level of Evidence

2b.

A Survival Analysis of Pediatric Tonsillar Malignancies and Review of a Rare Case

OBJECTIVE

To examine the survival of pediatric tonsillar cancer patients and review a rare case of pediatric tonsillar cancer.

METHODS

Pediatric patients in the Surveillance, Epidemiology, and End Results (SEER) database were included from 1973 to 2014 based on a diagnosis of tonsillar malignancy using the ICD O-3 tonsil primary site codes of: C09.0, C09.1, C09.8, and C09.9. Patients were included from birth-18 years. Survival analysis was performed using Kaplan-Meier analysis. Additionally, a case of pediatric natural killer (NK) cell tonsillar lymphoma diagnosed and treated at the Nemours Children's hospital in Orlando, Florida is presented.

RESULTS

One hundred forty-one cases of tonsil cancer were identified. The mean age at diagnosis was 9.9 years (SD: 5.1, range: 0.0 (months)-18.0). Ninety five (67.4%) patients were male and 116 (82.3%) had unilateral malignancies. Burkitt lymphoma (32.6%) followed by diffuse large B-cell lymphoma (DLBCL) (27.0%) were the two most common histological types of tonsillar cancers. 79.4% of patients received chemotherapy and 81.6% received surgery as a part of their care. The 5-year disease-specific survival rate was >90% for patient cohorts diagnosed from 1984 to 1993, 1994-2003, and 2004-2014 as compared to 64% for patients diagnosed from 1973 to 1983 (p = 0.01).

CONCLUSIONS

Survival rates for pediatric patients with tonsillar cancer are excellent. Pediatric primary tonsil cancer occurred most commonly in adolescent males and usually presents as a unilateral mass. Lymphoma remains the predominant histological type of cancer. Most patients are likely to receive surgery and chemotherapy.

Surgical management of follicular thyroid carcinoma in children and adolescents: A study of 30 cases

BACKGROUND/PURPOSE

The purpose of the study is to describe the anatomoclinical, diagnostic, therapeutic and prognostic aspects of pediatric follicular thyroid carcinoma (FTC) in order to choose the best therapeutic strategy.

METHODS

Our study includes patients ≤18 years old surgically treated for FTC in four Italian Pediatric Surgery Centers from January 2000 to March 2017. The collected data were compared with those of 132 patients matched for age with a histological diagnosis of papillary thyroid carcinoma (PTC) surgically treated in the same institutions during the same period and with the data of patients diagnosed with FTC found in the literature; p-values <0.05 were considered significant.

RESULTS

21 (70%) of the 30 patients with a histological diagnosis of FTC underwent hemithyroidectomy while 9 (30%) underwent total thyroidectomy. 11 (55%) out of 21 patients were subjected to a completion of thyroidectomy. All patients are alive (OS = 100%) without recurrence or relapse of the disease. Compared with PTC, FTC is significant for capsule infiltration (p < 0.0001), vascular invasion (p = 0.0014) and T-stage T3-T4 (p = 0.013). However, multifocality (p < 0.001), extrathyroid extension (p < 0.0001) and lymph node metastasis (p < 0.0001) are more evident in PTC.

CONCLUSION

The conservative approach seems to be a valid surgical treatment for pediatric patients diagnosed with MI-FTC. For patients with wide vascular invasion and/or a tumor >4 cm, especially with high after-surgery Tg rate, a completion of thyroidectomy is recommended. In patients with multifocal neoplasia, and/or tumor size ≥4 cm, and/or extrathyroid extension, and/or lymph node metastasis, and/or distant metastasis, total thyroidectomy followed by radioiodine therapy is generally indicated.

LEVELS OF EVIDENCE

II.

Pediatric Ewing sarcoma of the head and neck: A retrospective survival analysis

OBJECTIVE

To determine the demographics, treatment modalities, and overall survival of pediatric Ewing sarcoma of the head and neck.

METHODS

The National Cancer Institute's Surveillance, Epidemiology, and End Results database was used to identify cases of pediatric Ewing sarcoma of the head and neck between 1973 and 2015. Additional variables collected included age, gender, ethnicity, tumor grade, staging, treatment modality, and follow-up time. Kaplan-Meier survival curves were generated and overall survival was calculated.

RESULTS

One hundred and twenty-seven cases of pediatric Ewing sarcoma were identified. The majority of patients were male (52.8%), white (88.2%), and non-Hispanic (75.6%), and the mean age at diagnosis was 10.5 years. The most common tumor sites were bones and joints of the skull and face (45.5%), followed by soft tissue of the head, face, and neck (25.2%), followed by the mandible (13.4%). Most patients (69.2%) had some type of surgery, 70.0% received radiation, and 92.1% received chemotherapy as part of their treatment. Overall 1-, 5-, and 10-year survival was 91.1%, 72.9%, and 68.2%, respectively. There was no significant difference in survival based on patient gender, age, tumor location, radiation, or chemotherapy treatment.

CONCLUSION

This study demonstrates that pediatric patients with Ewing sarcoma of the head and neck most commonly have stage II disease, no distant metastasis, and are treated with chemotherapy, with or without radiation. One, five, and ten-year survival are 91.1%, 72.9%, and 68.2%, respectively, and age, gender, and radiation do not seem to affect prognosis.

Metastasis of Ewing's sarcoma to the thyroid gland: A case report

Ewing's sarcoma (ES) is an aggressive pediatric malignancy. We present a case of ES with thyroid metastasis. The patient was diagnosed with ES at age 8. Despite aggressive treatment, she suffered disease progression. Surveillance demonstrated a left thyroid lesion. This grew rapidly within 2 months, causing tracheal compression. She underwent hemi-thyroidectomy to prevent airway compromise. Due to her refractory ES, she was enrolled in the Vigil immunotherapy vaccine trial; thus, the specimen was used for vaccine development. This is the first reported case of skeletal ES with metastasis to the thyroid, requiring hemithyroidectomy to prevent airway compromise.

Benign and Malignant Oral Lesions in Children and Adolescents: An Organized Approach to Diagnosis and Management

Oral lesions in children encompass a wide range of etiologies, including idiopathic entities as well as those related to an underlying systemic illness. In addition, oral masses include benign entities harboring locally destructive behavior and even malignancies in rare cases. Thorough patient history and detailed and efficient physical examination are critical for determining which lesions can be closely observed versus those require further diagnostic work-up. Understanding normal oral cavity anatomy is crucial for performing appropriate evaluation. This review describes the appropriate diagnostic and therapeutic strategies for oral cavity lesions and reviews the broad differential diagnosis of oral cavity masses.

Pediatric thyroid cancer: An update from the SEER database 2007-2012

OBJECTIVE

To update the medical literature regarding the incidence, disease specific survival, and treatment modalities utilized in pediatric patients diagnosed with thyroid carcinomas.

STUDY DESIGN

Cross Sectional Analysis of a National Database.

STUDY SETTING

SEER Database.

METHODS

The National Cancer Institute's Surveillance Epidemiology and End Results (SEER) Database was queried for all cases of pediatric thyroid cancer between the years 2007 and 2012. Patients ages 0-19 were grouped by histological subtypes and demographic data, overall incidence rate, and disease specific survival after surgery and surgery with radiation therapy. Fifteen-Year Disease Specific Survival Curves were generated and treatment modalities were compared to assess for statistical differences at each yearly interval.

RESULTS

A total of 1723 pediatric patients were identified and the average age-adjusted rate of malignancy was determined to be 0.59 per 100,000 patients. The incidence of pediatric thyroid cancer was approximately 4.4:1 when comparing females to males, respectively. Papillary subtype was the most common (n = 1014, 58.8%), followed by follicular variant subtype (n = 397, 23%), follicular subtype (n = 173, 10.1%) and medullary subtype (n = 139, 8.1%). As pediatric patients reached fifteen to nineteen years of age, the incidence of papillary and follicular variant subtypes increased. Analysis of medullary thyroid cancer data revealed that incidence was highest in the zero to four age group and declined at later years. Pediatric patients presenting with metastatic medullary thyroid carcinoma maintained significantly poorer fifteen-year disease specific survival when compared to other histologic subtypes (p < 0.05). Intervention with surgery and radiation therapy provided significant benefit across all histologic subtypes when evaluating disease specific survival at fifteen-years past the initial diagnoses (p < 0.05).

CONCLUSIONS

Pediatric thyroid carcinoma remains an uncommon diagnosis despite an annual increase in incidence of approximately one percent since the development of the SEER database. Overall, pediatric thyroid carcinomas demonstrate an excellent prognosis if identified early and appropriate management is available. Caucasian female patients have higher incidence of carcinoma diagnoses when compared to males. Medullary histologic subtype, especially when metastatic at initial diagnoses, demonstrates statistically poorer outcomes when compared to other subtypes.