approach to abdominal masses in children

Malignant Abdominal masses in Children

Approach to evaluation and diagnosis

Mia Lesaca-Medina, MD

Abdominal mass

• Serious finding !• Need to find out if:

– Malignant ?– Compressing vital

organs ?– there is internal

hemorrhage ?• Establish diagnosis, dissipate

worries, start treatment when necessary

Objectives

• Points to address in history taking• Physical Findings associated with

abdominal masses

• Routine lab and imaging studies needed

• Overview of most common pediatric abd malignancies

Clinical History

AGE is important

Neonatal Congenital malformations (GUT/GIT abnormalities)- Malignancies uncommon

Older infants and children(peak age 1 – 5 years old)

Wilms and neuroblastoma mostlyHepatoblastoma

Germ cell tumors

Non Hodgkin’s Lymphoma

Adolescents Non-Hodgkin’s Lymphoma*Consider:

inflammatory process & pregnancy

Other special points to address

• How long mass has been present

• Rapidity of growth

• Possible genetic or inherited predisposition– Familial adenomatous polyposis or Gardner’s

syndrome Hepatoblastoma

History taking

• Increased abd girth

• Tenderness(NOT all malignant masses are NON tender)

• Constipation or decreased urination

History

• Pallor or weakness (hemorrhage into mass

or infiltration of BM)

• Bleeding, bruising, bone pain

History taking

• High incidence of renal causes Hydronephrosis, polycystic kidney Renal vein thrombosis, Wilms’ tumor

– focus on urinary tract

• Constitutional symptoms – fever, pain, night sweats and weight loss

Detection during routine check up

• Many are asymptomatic and found accidentally– Case series by Golden (2002) –

• 16/121 abdominal malignancies were based on a finding from a well child examination

– Very good prognosis :94% SURVIVAL !

Take home point:SPEND A FEW EXTRA

SECONDS DURING ANY PX ENCOUNTER TO PALPATE THE ABDOMEN !

Physical Examination

Abdominal examination• Not easy• Have child relax before palpating

– Divert child’s attention– Bottle or pacifier

• Remember !

- some structures are normally

palpable in children : Liver edge, spleen,

kidneys, aorta, sigmoid colon,

feces, spine

Abdominal examination

• Location of mass, size, crosses midline, consistency

• Bruit

• Ascites

Abdominal Examination

• Estimate dimensions relative to a landmark (rib cage, umbilicus, anterior iliac crest)

• Venous distention on abd surface

IMAGING

• Plain Abdominal Radiograph– To rule out

gastrointestinal obstruction

IMAGING

• ULTRASOUND– Organ of origin

• Kidney, adrenal, liver, adnexa ?

– Tissue components• Cysts, hemorrhages,

calcifications

– Vascular lesions (doppler)

• Hemangiomas

IMAGING

• CT SCAN– If suspicious for

malignancy– Determine size

and infiltration into vessels or vital organs

Consult surgeon

Laboratory studies

• CBC– Inc WBC w/ left shift:

• Tumor obstruction infection

– Pancytopenia• BM infiltration by malignancy • Marrow stressed by infection

– Thrombocytosis• Often seen with liver tumors (thrombopoeitin produced by tumor)

Laboratory Studies

• Coagulation studies– presence of DIC– Liver dysfunction– Clear for surgery

• Urinalysis– Hematuria or proteinuria (renal or bladder

tumors)

• Tumor markers– Urine VMA, AFP, B-HCG

Most frequently encountered malignant abdominal masses

Neuroblastoma

Wilms’ tumor

Hepatoblastoma

Lymphoma

Neuroblastoma

• Occurs anywhere along sympathetic chain or adrenal medulla– But abdominal in 65% of

cases

• Most common extracranial tumor in infants

• 36% < 1 year old• 75% < 4 years old

• Metastatic at dx: 75%

S/Sx highly associated with Neuroblastoma

– Systemic signs/sxs: Anorexia, wt loss, pallor, abd pain, irritability, weakness

– Exophthalmos– Periorbital hemorrhage

(raccoon eyes) obstruction of the palpebral vessels (branches of the ophthalmic and facial vessels) by tumor tissue in and around the orbits

– Horner’s syndromeMeiosis, ptosis, enophthalmos,

anhydrosis (2 cervical sympathetic involvement)

– Massive hepatomegaly

S/Sx highly associated with neuroblastoma

– Constipation, abdominal pan

– Localized back pain, weakness

– Scoliosis, bladder dysfunction

– Palpable nontender subQ nodules (neonatal)

– Elevated urine VMA

Wilms’ Tumor

• Arises from embryonic renal precursor cells

• Most common pediatric malignancy of the kidney

• Peak age at diagnosis : 2-3 years (80% diagnosed

before 5 years of age)

• Rare in infants Max Wilms

1867-1933

German Surgeon

Wilms’ Tumor

• Asymptomatic mass in flank• 25% with associated systemic S/Sx

– Malaise– Pain– Hematuria (usually microscopic)– Hypertension (inc renin)

– Hemorrhage into tumor (10% of cases)

HEPATOBLASTOMA

• Most common liver tumor of childhood

(liver tumors = only 1-2% of childhood cancers)

• Mean age at dx – 1 year (80% diagnosed before 3 yrs old)

• Advanced disease at presentation – 40%

Hepatoblastoma

• Seen in association with– Beckwith-

Wiedemann syndrome

– Isolated hemihypertrophy

– FAPolyposis– prematurity

Hepatoblastoma

• Asymptomatic abdominal mass

• Anorexia, pain, weight loss (15%)

• Jaundice - rare

• Thrombocytosis (as high as 1,500,000)

• AFP – elevated in almost all

Lymphoma

• Diffuse aggressive malignancy in children

• Can present at 1-5 years old, but more common in older children and adolescents

• 60% NHL; 40% Hodgkin’s• 1/3 of NHL present with

abdominal disease

Lymphoma s/sx

• Abdominal pain• Vomiting• Diarrhea• Abdominal

distention• Intussusception• Peritonitis• Ascites

Intussusception in child > 1 year old – strong warning to look for lymphoma

Summary

• history taking– Age is important – Rapidity of enlargement– Systemic symptoms– Genetic syndromes /familial tendencies

Physical Findings associated with abdominal masses

• Many asymptomatic and diagnosed accidentally

take a few seconds to palpate abdomen in all patients

• Location , size, consistency of mass

• Bruit , ascites, distended superficial abdominal veins

Routine lab and imaging studies needed

• CBC

• Coagulation studies

• Urinalysis

• Tumor markers (AFP, HCG, VMA)

• Plain abdominal x-ray / UTZ / CT scan

Overview of most common pediatric abd malignancies

Neuroblastoma -Most common malignancy in infancy- anywhere along sympathetic chain/adrenal gland; 60% abd- raccoon eyes, subQ nodules, massive hepatomegaly, bladder dysfunction-Elevated urine VMA

Wilms’ -Most common renal malignancy-Peak age: 2-3 years-Asymptomatic flank mass- Malaise, pain, hematuria, hypertension, hemorrhage into mass

Hepatoblastoma - Most common liver tumor in children- Peak age: 1-2 years- Asymptomatic abd mass-Thrombocytosis, elevated AFP-Beckwith-Wiedemann syndrome, isolated hemihypertrophy, prematurity, FAP

Lymphoma - A diffuse, aggressive malignancy- present in older children and adolescents- NHL 60% of lymphomas - 1/3 abdominal- Abdominal pain, vomiting, diarrhea, abd distention- Intussusception in > 1 year old think lymphoma lead point

Thank you

for your attention !