0:01

This was a patient.

0:02

It was a 54-year-old female with a history

0:05

of an enlarging right neck mass.

0:08

And I want to do the mea culpa.

0:11

This was misread by the Hopkins Neuroradiology team.

0:15

The conclusion of this report was avidly enhancing

0:19

and hypervascular right neck carotid space mass,

0:23

which demonstrates intra enlargement between exams,

0:26

as most suggestive of a paraganglioma.

0:29

Let's look and see where we went wrong.

0:31

So here we have the scans and we see the right

0:37

sided neck mass that was described.

0:40

You can see that indeed it is a hypervascular mass

0:44

with these vessels that are coursing along the surface

0:47

of it, as well as through the lesion itself.

0:50

Now, when we come to the idea of a paraganglioma,

0:54

remember that we have our various types.

0:56

Right, so is this a jugular vein?

1:00

Invading lesion? No.

1:01

So it's unlikely to represent a glomus jugulari.

1:06

Is it a lesion which is displacing the internal

1:09

carotid artery anteriorly? No.

1:13

And therefore is unlikely to represent

1:15

a glomus Vagali tumor.

1:18

Is it a lesion which is displacing the carotid artery

1:22

and the external and internal artery apart

1:26

in the carotid bifurcation? No,

1:28

it's actually lateral to the carotid bifurcation.

1:32

Is it a lesion which is displacing the carotid artery

1:35

anteriormedially and the jugular vein posteriorly,

1:39

laterally, like one would expect of a vagus oneoma?

1:43

No.

1:44

Is it a lesion that is displacing the internal and

1:47

the jugular vein, both of them anteriorly?

1:50

Like one would expect a sympathetic nervous system,

1:53

plexus schwanoma? No. So this hypervascular mass

2:00

does not fit with any of our typical carotid

2:03

space schwannomas or paragangliomas.

2:06

And yet it's hypervascular when you look at the

2:11

remainder of the examination. First off,

2:13

I want you to ignore the enhancing area of the jugular

2:18

vein. While this may look like tumoral enhancement,

2:22

this is thought to be due to the incomplete contrast

2:26

in the veins draining into the jugular vein,

2:29

causing some mixing phenomena.

2:31

So we're going to ignore that for the time being.

2:34

But as we go down further inferiorly,

2:37

we have the carotid artery here and we see

2:41

another enhancing nodule, if you will,

2:45

anterior to the carotid and the jugular vein.

2:49

And we see this eccentric mass arising

2:54

from the top of the thyroid gland.

2:59

Here is another.

3:00

Enhancing mass posterior to the common

3:04

carotid artery in the neck.

3:07

So this patient was sent to surgery for presumed

3:11

paraganglioma by the neuroradiology

3:14

team at Johns Hopkins.

3:16

This was taken out and was found to be thyroid cancer.

3:21

Thyroid cancer is one of the cancers that is known

3:25

to create hypervascular masses and nodal disease.

3:31

So in addition to Castleman's disease

3:34

or angiofolicular hyperplasia,

3:37

thyroid cancer causes hypervascular nodes.

3:42

The primary tumor was this little eccentric enhancing

3:47

nodule coming off of the top of the thyroid gland,

3:51

more superiorly,

3:52

and this was papillary thyroid cancer.