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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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slide2

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
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 diseases ADPKD, ARPKD
toddlers and older children 2 year of life
Toddlers and older children (>2 year of life)
  • Kidneys (45%) Wilms tumour (nephroblastoma) hydronephrosis
  • Retroperitoneal cavity (40%)(adrenal glands, autonomic ganglions, lymph nodes) neuroblastoma teratona lymphoma
  • Gastrointestinal system (15%) - liver, splen, bowels lymphoma duplications hepatoblastoma
retroperitoneal cavity
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
Diagnostic algorithm in children with palpable abdominal tumour

USG and plain abdominal rentgenogram – cystic mass:

diagnostic algorithm in children with palpable abdominal tumour1
Diagnostic algorithm in children with palpable abdominal tumour

USG and plain abdominal rentgenogram – solid mass:

abdominal tumors in children1
Abdominal tumors in children

Hydronephrosis in infant

bilateral,

more pronounced on the right

abdominal tumors in children2
Abdominal tumors in children

Unilateral hydronephrosis

abdominal tumors in children3
Abdominal tumors in children

Newborn – adrenal haematoma

slide11

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 children4
Abdominal tumors in children

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

abdominal tumors in children5
Abdominaltumorsinchildren

Autosomal recessive policystic kidney disease CT

slide15

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?
slide16

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.
slide17

Abdominaltumorsinchildren

Cystic nephroblastoma

WILMS tumour

slide18

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.
slide19

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
slide20

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 children7
Abdominal tumors in children

Adrenal neuroblastoma

slide22

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?
slide23

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
slide24

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.
slide25

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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