Abdominal tumors in children
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Abdominal tumors in children. Abdominal tumor ≠ abdominal neoplasm. In neonatal and infantile period the majority of palpable masses in abdomen are anomalous or enlarged o rgans .

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Abdominal tumors in children

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Abdominal tumors in children


Abdominal tumor ≠ abdominal neoplasm

In neonatal and infantile period the majority of palpable masses in abdomen are anomalous or enlarged organs .

Congenital abnormalities of kidneys are the cause of 55% of all unilateral and 90% of bilateral abdominal masses in newborns and infants


Newborns and infants (< 2 year of life)

  • Unilateral abdominal tumours:

  • Kidneys – 55%hydronephrosismulticystic dysplastic kidneymesoblastic nephroma

  • Retroperitoneal cavity (besides kidneys) – 15%adrenal haematomaneuroblastomateratoma

  • Gastrointestinal system – 15%duplications

  • Genital system – 10%ovary cyst

  • Hydromethrocolpos

  • Liver – 5%hepatoblastoma

  • Bilateral abdominal masses:

  • Kidneys (90%) polycystic kidneys diseasesADPKD, ARPKD


Toddlers and older children (>2 year of life)

  • Kidneys (45%)Wilms tumour (nephroblastoma)hydronephrosis

  • Retroperitoneal cavity (40%)(adrenal glands, autonomic ganglions, lymph nodes)neuroblastomateratonalymphoma

  • Gastrointestinal system (15%) - liver, splen, bowels lymphomaduplicationshepatoblastoma


Retroperitoneal cavity

BENIGN TUMOURS:

Adrenal - haematoma

Kidney enlargement – hydronephrosis, abscess, renal veins thrombosis

MALIGNANCIES:

Renal – Wilms tumour

Lymph nodes – lymphoma

adrenals and autonomic ganglions – neuroblastoma


Diagnostic algorithm in children with palpable abdominal tumour

USG and plain abdominal rentgenogram – cystic mass:


Diagnostic algorithm in children with palpable abdominal tumour

USG and plain abdominal rentgenogram – solid mass:


Abdominal tumors in children

Hydronephrosis in infant

bilateral,

more pronounced on the right


Abdominal tumors in children

Unilateral hydronephrosis


Abdominal tumors in children

Newborn – adrenal haematoma


Abdominaltumorsinchildren

  • ADRENAL HEMATOMA

  • detection by ultrasound (hypoechoic mass above the upper pole of the kidney, mixed echogenicity

  • with hyperechoic areas are possible)

  • follow up examination to demonstrate volume regression

  • calcifications in follow-up studies

  • difficult to distinguish from neuroblastoma (laboratory findings- catecholamine metabolites in

  • urine can help)

  • MRI or CT is not necessary in early detection after birth.Only in suspicious neuroblastoma for

  • any other reason, isfurther imaging necessary. If volume regression is absent,MRI becomes

  • necessary. Hyperintense T1w signal is indicative of hemorrhage.


Abdominal tumors in children

Autosomal recessive policystic kidney disease urography:bilateral massive enlargement of kidneys


Abdominaltumorsinchildren

Autosomal recessive policystic kidney disease CT


Abdominal tumors in children

WILMS tumour


Case 1: This well 5-year-old child presented with a left-sidedabdominal mass. Ultrasound revealed a large rounded softtissue mass arising from the kidney. A CT examination was performed .

  • What are the imaging features shown?

  • What are thedifferentiating features that

  • allow a provisional diagnosisto be made?

  • What other investigation should beperformed?


  • post contrast CT shows a well definedsoft tissue mass in the left upper quadrant

  • there isnormal enhancing renal tissue inferior to the mass

  • there is some displacement of the surroundingstructures but no encasement

  • there is no visiblecalcification

  • the diagnosis of a Wilm’s tumour is made upon the ageof the child, the fact that the

  • child is relatively well, thetumour is displacing surround structures rather than

  • encasing them and there is an absence of calcificationseen on the CT examination.

  • the staging Wilm’s tumour is open to debate. In somecentres the presence of chest

  • metastases is determinedby a chest X-ray while other centres may perform chest

  • CT. With all abdominal imaging is important to stage thetumour and in particular to

  • look for the presence oftumour spread of the renal vein and into the inferior vena

  • cava.


Abdominaltumorsinchildren

Cystic nephroblastoma

WILMS tumour


Abdominaltumorsinchildren

  • NEPHROBLASTOMA (WILMS’ TUMOUR)

  • is the most commonrenal tumour in childhood

  • occur mainly in children of less than 5 years (peak incidence between 2 and 5 years of age)

  • asymptomatic,occasionally fever, pain and hypertension may be present

  • preferredlocations for metastases are the locoregional lymphnodes and the lung (‘cannonball’

  • metastases). Livermetastases are possible. Other distant metastases, e.g. in the skeletal system,

  • are rare.

  • in the first 6 months of life, mesoblastic nephromaoccurs more often than Wilms’ tumour.


Abdominaltumorsinchildren

  • NEPHROBLASTOMA (WILMS’ TUMOUR)

  • US is the fundamental imaging method

  • MRI preferred for local tumour extension and abdominal metastases

  • homogeneous or inhomogeneous renal mass (bilateral involvement in 10% of cases)

  • displacement of neighbouring anatomical structures

  • echogenic tumour thrombus in renal vein or inferior vena cava(as the tumor often grows directly

  • into the renal veins or IVC)

  • lymph node enlargement

  • tumour bleeding with central fluid/sedimentation levels

  • cystic tumours with tumour parenchyma are found inthe case of cystic nephroblastoma


Abdominaltumorsinchildren

  • NEPHROBLASTOMA (WILMS’ TUMOUR)

  • MR

  • hypointense pseudocapsule in T2w sequences

  • in T2 hyper- and T1 hypointensive renal mass with displacement of other organs

  • - hyperintense tumour thrombus in hypointense vessel signal in T2w sequences

  • contrast enhancement of residual renal parenchyma, contrast enhancement of vital tumour areas,

  • hypointense tumour necrosis

  • hyperintensive bleeding in the tumour in T1w sequences

  • CT

  • hyperdense areas in case of bleeding in native scans

  • calcifications in about 14% of nephroblastomas

  • - inhomogeneous enhancement after contrast administration


Abdominal tumors in children

Adrenal neuroblastoma


Case 2: A 2-year-old child presented with a large intra-abdominal mass. There was associated vomiting and weight loss. A CTand nuclear medicinestudywere performed.

  • What are the CT findings?

  • What is the nuclear medicine study and what does it show?

  • What is the overall diagnosis?


  • the CT examination shows a large abdominal mass that iscalcified and encases the

  • great vessels. These are theimaging features of a neuroblastoma

  • the nuclear medicine study is a meta-iodo-benzyl-guanidine (MIBG) study.

  • An MIBG is used to detect skeletal metastases inchildren with neuroblastoma(MIBG

  • as an analogon of catecholamine precursors istaken up in neuroblastoma and other

  • neuro-endocrine tissue.

  • Normally the skeleton should have no areas of increased activity. In this case

  • there is marked uptake seen at the ends of the long bonesindicting skeletal

  • metastases. There is also activity in thecentre of the abdomen within the primary

  • tumour.

  • normal activity on an MIBG scan is seen within thesalivary glands, spleen, liver and

  • myocardium.This study involved the useof radioactive iodine, as such the thyroid

  • should beprotected by the use of blocking agents. In children this isusually

  • performed bygiving potassium perchlorate 3 days prior to the study


Abdominaltumorsinchildren

  • NEUROBLASTOMA

  • is most frequently diagnosed in infants belowthe age of 5 years

  • originate in neuralcrest cells of the sympathetic nervous system. Nearly 70%of neuroblastomas

  • arise in the abdomen. A typical location(about 50%) is the adrenal gland.

  • the tumour extendsto surrounding tissue by local invasion and to regional lymph nodes.

  • metastatic spread in bone marrow, skeletonand liver is frequent. More than 50% of patients have

  • metastatic disease.

  • tumours localized to one side ofthe abdomen often cross the midline.

  • frequently secrete neurogenically derived substances, e.g.catecholamine metabolites or neuron

  • specific enolase.


Abdominaltumorsinchildren

  • NEUROBLASTOMA

  • Primary diagnosis is performed with ultrasound. Imagingstudies include local staging with MRI or CT of the tumourregion and chest radiograph. Bone scan and meta-iodobenzylguanidine

  • (MIBG) scintigram define sites of metastases and demonstrate tumour response to chemotherapy.

  • Possible findings:

  • - encasement of retroperitoneal vessels

  • - ventral displacement of aorta and vena cava

  • - stippled tumour calcifications

  • - single tumour of the adrenal gland

  • extended tumour mass in the retroperitoneum

  • - infiltration of adjacent organs

  • - infiltration into neuroforamen


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