CASE 16970 Published on 12.08.2020
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Carotid body tumour mimicking cervical lymph node in FDG PET/CT

Section

Head & neck imaging

Case Type

Clinical Cases

Authors

Teck Jian Choo1,2, James Birchall1,2, James Kirk1

  1. Department of Radiology. Royal Derby Hospital. University Hospitals of Derby and Burton NHS Trust Uttoxeter Rd, Derby DE22 3NE
  2. Department of Nuclear Medicine. Royal Derby Hospital. University Hospitals of Derby and Burton NHS Trust Uttoxeter Rd, Derby DE22 3NE
Connected authors
Teck Jian Choo UNITED KINGDOM
James D. Birchall UNITED KINGDOM
Patient

62 years, female

Categories
Area of Interest Head and neck, Nuclear medicine ; Imaging Technique CT, MR, PET-CT, Ultrasound
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Clinical History

A 62-year-old female patient presented with abdominal lump. CT chest, abdomen and pelvis shows multiple abdominal nodal masses. Biopsy revealed B Cell lymphoma. Current investigation is a 18-F FDG PET/CT performed for response post-R-CHOP chemotherapy showing a 2cm hyper-metabolic right neck mass and multiple avid abdominal masses.

Imaging Findings

18F-FDG PET/CT : FDG avid, SUV-max 8, right neck lesion at the bifurcation of the common carotid artery measuring 2cm. Multiple hyper-metabolic left supraclavicular, mesenteric, para-aortic and iliac nodes with splenic deposits demonstrates different / higher activity compared to the neck mass, up to SUV-max 32 in the mesenteric nodal mass.

CT neck, chest, abdomen and pelvis: There is an enhancing ovoid shaped right neck mass which appears to be splaying the common carotid artery bifurcation.

Ultrasound neck performed to plan biopsy: Duplex ultrasound shows a highly vascularised solid hypoechoic mass in the area of the carotid bifurcation, with splaying of the bifurcation of the internal and external carotid arteries. Biopsy thus not performed.

MRI neck: The right neck mass shows low T1 signal and high T2 signal. Post contrast there is avid enhancement with low internal signal suggestive of flow voids.

Discussion

Background

Carotid body tumours, also known as paragangliomas or chemodectomas, are neuroendocrine neoplasms which arise near the carotid bifurcation within glomus cells derived from the embryonic neural crest [1]. Paragangliomas usually are slow-growing and less than 10% are malignant [2]. The carotid body is the most common site of occurrence [3]. Predominantly cases are found in patients ranging from 50 to 70 years of age with a slightly higher prevalence in women [1]. Approximately 40% are thought to be hereditary [4].

Clinical Perspective

Carotid body tumour classically presents as a non-tender, insidiously enlarging neck mass in an asymptomatic patient [5] and incidentally found on imaging [1]. Untreated, they will ultimately result in a progressive enlarging cervical mass involving and causing dysfunction of cranial nerves [6]. There is an increased prevalence of head and neck paragangliomas with familial genetic syndromes such as von Hippel-Lindau disease (VHL), multiple endocrine neoplasia type 2 (MEN2), and type 1 neurofibromatosis (NF1) [7].

Imaging Perspective

Paragangliomas are hyper-metabolic on FDG PET/CT [8,9] and potentially misinterpreted as false positive metastatic lymphadenopathy [9]. On CT, they are highly vascular [3,10] and typically presents as a well-defined soft-tissue mass within the carotid space of the infrahyoid neck [5]. On ultrasound, there is splaying of the bifurcation of the common carotid artery [3,5]. On MRI they have low signal intensity with standard spin-echo short repetition time (TR)/short echo time (TE) and long TR/short TE sequences and a high signal intensity with long TR/long TE sequences. There is intense enhancement post administration of intravenous contrast [3,5]. If suspected, nuclear medicine tests such as Octreotide and I-123 MIBG SPECT/CT may be performed[14].

Outcome

There is good prognosis with surgical treatment [11]. A multidisciplinary team treatment approach is essential. Accurate imaging assessment for the anatomy and preoperative embolisation of large, vascular tumors can facilitate surgical treatment [1,2,6].

Take Home Message / Teaching Points

1. Carotid body tumours are most commonly located at the bifurcation of the common carotid arteries and are characteristically hypervascular in nature.

2. Paraganglioma is an important differential for neck masses to avoid erroneous interpretation of cervical lymphadenopathy.

3. Meticulous evaluation of a hyper-metabolic lesion on FDG PET/CT is essential, remembering causes of false positive findings including synchronous tumours, benign tumours, inflammation, infection, brown fat and physiological uptake [12,13].

Differential Diagnosis List
Carotid body tumor mimicking cervical lymphadenopathy on 18F-FDG PET/CT
Nodal mass
Vagal schwannoma
Vagal neurofibroma
Final Diagnosis
Carotid body tumor mimicking cervical lymphadenopathy on 18F-FDG PET/CT
Case information
URL: https://www.eurorad.org/case/16970
DOI: 10.35100/eurorad/case.16970
ISSN: 1563-4086
License

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

Figure 1

F FDG PET/CT Axial image

Figure 1 A shows the hyper-metabolic lesion in the right carotid space and Figure 1 B shows the appearance on plain CT compon
Figure 1 A shows the hyper-metabolic lesion in the right carotid space and Figure 1 B shows the appearance on plain CT component.
Figure 1 A shows the hyper-metabolic lesion in the right carotid space and Figure 1 B shows the appearance on plain CT compon
Figure 1 A shows the hyper-metabolic lesion in the right carotid space and Figure 1 B shows the appearance on plain CT component.
Figure 2

F FDG PET/CT Coronal image

Figure 2 A) shows the right neck mass (full arrow) with reduced FDG avidity compared to the abdominal nodal masses (hollow ar
Figure 2 A) shows the right neck mass (full arrow) with reduced FDG avidity compared to the abdominal nodal masses (hollow arrow). Figure 2 B shows the masses on the MIP.
Figure 2 A) shows the right neck mass (full arrow) with reduced FDG avidity compared to the abdominal nodal masses (hollow ar
Figure 2 A) shows the right neck mass (full arrow) with reduced FDG avidity compared to the abdominal nodal masses (hollow arrow). Figure 2 B shows the masses on the MIP.
Figure 3

Axial image of contrast enhanced CT of the neck in arterial phase

The well defined right neck mass appears hypervascular and is displacing the carotid arteries.
The well defined right neck mass appears hypervascular and is displacing the carotid arteries.
Figure 4

Ultrasound study (Figure 4 A) and Doppler (Figure 4 B) shows a well defined hypoechoic vascular mass causing splaying of the
Ultrasound study (Figure 4 A) and Doppler (Figure 4 B) shows a well defined hypoechoic vascular mass causing splaying of the bifurcation and separation of the internal and external carotid arteries.
Ultrasound study (Figure 4 A) and Doppler (Figure 4 B) shows a well defined hypoechoic vascular mass causing splaying of the
Ultrasound study (Figure 4 A) and Doppler (Figure 4 B) shows a well defined hypoechoic vascular mass causing splaying of the bifurcation and separation of the internal and external carotid arteries.
Figure 5

MRI Ax images

The mass is low signal on T1 (Figure 5A) , high signal with flow voids on Ax T2 (Figure 5B) and intense contrast enhancement
The mass is low signal on T1 (Figure 5A) , high signal with flow voids on Ax T2 (Figure 5B) and intense contrast enhancement on Ax T1 with contrast (Figure 5C).
The mass is low signal on T1 (Figure 5A) , high signal with flow voids on Ax T2 (Figure 5B) and intense contrast enhancement
The mass is low signal on T1 (Figure 5A) , high signal with flow voids on Ax T2 (Figure 5B) and intense contrast enhancement on Ax T1 with contrast (Figure 5C).
The mass is low signal on T1 (Figure 5A) , high signal with flow voids on Ax T2 (Figure 5B) and intense contrast enhancement
The mass is low signal on T1 (Figure 5A) , high signal with flow voids on Ax T2 (Figure 5B) and intense contrast enhancement on Ax T1 with contrast (Figure 5C).