tips and tricks in pediatric tumors - esrnm.comesrnm.com/pdf/tips-and-tricks-sylvia.pdfintra-sinusal...

Tips and tricks

in pediatric tumors

S Neuenschwander

ESRNM 2013

Cairo, 13-15 Apr 2013

../../Documents/

Cancer is a rare occurrence in children BUT :

• a delay in diagnosis of cancer can be highly detrimental : increased risk of metastatic disease with a heavier therapeutic regimen

• an excess in diagnostic procedures in a pseudotumoral disease leads to unnecessary stress and needless complementary investigations

misleading clinical symptoms

improper diagnostic strategies

maladjusted imaging techniques

unawareness of emergency situations

errors in reasoning

Benign or malignant?

Small nodule of the forearm

14 year-old-girl

Synovial sarcoma

2-month-old girl

Systematic clinical exam

Painless swelling of the neck

Angioma

Hemangioma?

Here is a typical infantile hemangioma :

The most frequent soft tissue tumor in children

♀ >♂

Absent at birth

Occurs in the first months of life,

grows between 6 and 10 months of age

then decreases spontaneously T2

Hypersignal and flow void

T2

Numerous vessels, high velocity arterial

flow with low resistance

But our girl?

Biopsy : PNET

Soft tissue mass

There is no specificity of malignancy

Suspect if heterogeneous > 5 cm

No surgery before at least a color doppler ultrasound

US allows the diagnosis of hemangioma, lipoma, cysts

MR helps in identifying vascular tumor or malformation, fibrous lesions, neurofibromas

Polyps :

Must the physician be the only one to care about them?

7-years old

« polyp »

of the right nasal fossa

9305880

0106210

10-years old

« polyp »

of the left EAC

Nasopharyngeal RMS Ear RMS invading the petrous bone

The hidden bit of the iceberg

below the see

Intra-sinusal mass

• Malignant :

RMS

– lymphoma

• Benign :

– Polyposis (cystic fibrosis)

– Mucocele

Kilian polyp

– Osteoma

– Fibrous dysplasia

0106291

Coll. Dr Garel

3-y-old boy with right exophtalmia

referred for presumptive orbital RMS

9804160

The physician comes to you for audience

What questions should we radiologists be asking?

What do you recommand?

Metastatic abdominal neuroblastoma

Abdominal ultrasound

mIBG scintigraphy

Neuroblastoma

2/3 of abdominal neuroblastomas are

discovered by metastases (bone / bone marrow)

Frequent site of bony metastasis : skull

In the skull, metastases are frequently

found near the sutures

What is the most dangerous location ?





errors in reasoning

15-y-old-boy Right iliac fossa pain

T° > 38°

↑ CRP

Coelioscopy : normal appendix

caecum pushed forward .. By a mass?

Ewing tumor of the right iliac wing

An US before surgery might have helped

4-year-old boy Abdominal pain

Vomiting

T° 37°

Burkitt lymphoma

Percutaneous biopsy

chemotherapy

Intussusception

search for

leading point :

Meckel or

lymphoma

Osteomyelitis ?

Limp of the right leg

T° 38°

Asthenia

Metaphyseal

abnormalities

Metastatic NB



improper imaging techniques


errors in reasoning

15-year-old boy

Left sciatalgia

Examinations performed :

1 Spine X ray : normal

2 Lumbar spine CT : normal

3 Lumbar spine MR : normal

4 Left Knee MR : normal

5 Abdomen and pelvis CT : normal…..excepted the last slice!

The last straw syndrome

Osteosarcoma of the left femur

Sciatalgia : always the same old story …

Ewing tumor of the left iliac wing

More than 6 months for making the diagnosis of…

Sciatalgia

In childhood, discal disease is even rarer

than tumors

The sciatic nerve is very long !

Pelvic bone tumours are difficult to diagnose

17-y-old

probable tibial osteosarcoma

with obvious knee involvement

DP

T1 FS + C

T1

MRI # 2 (still before treatment)

Skip metastasis :

Detection critical for the local treatment

Are these the proper

kind of images ?

5-year-old girl

Limb alveolar RMS

Are these

the proper kind of images ?

Non palpable lymph node involvement :

Critical for staging

Imaging a (potential) oncologic patient

Don’t let yourself be obsessed by the tumor

Always keep in mind that an assessment of the

extent of the disease will be necessary

Try to do the maximum in a single exam





errors in reasoning

0005934

15-y-old boy

cough, dyspnea & orthopnea

Superior vena cava sd

Quelle modalité?

General anaesthesia contraindicated

Intensive

care unit

Minimally

invasive

biopsy

Chimiothérapie première

Thoracic NB

with intraspinal

extension

and medullary

compression

Requires an urgent treatment





errors in reasoning, or…

13-y-old boy

Paraplegia

Epidural mass

Biopsy : RMS

Where was the primary ?

Probably metastatic

Primary site

Humeral metastasis

Whole body MRI

Revealing bone metastasis

In young child (12 mths – 4 y) :

think of neuroblastoma

and make Chest XRay, abdominal US,

mIBG scintigraphy

In older child :

think of RMS

and make a whole- body exam (including hands

and feet)





errors in reasoning, or…not paying attention to

the medical file

Surveillance screening of an Ewing tumor in CR

What do you do ?

Regenerative nodular hyperplasia

Appearance of a solitary

hepatic nodule

Never forget treatment-related

abnormalities

RNH : Non specific tissue adaptation to heterogenous blood flow in the liver

May be observed several years after treatment

Frequently lobulated shape, hypervascular on the arterial phase,

iso or hypodense later

Search for a history of liver VOD during treatment, or hepatotoxic

chemotherapy

No biopsy needed. Close radiological follow-up

11-y-old girl

RMS of the parotid gland

Initial lung CT :

3 small nodules

?

Left biopsy :

metastasis

11-y-old girl


After

chemotherapy

and local

treatment

After 4 months

of maintenance

treatment

Your report?

11-y-old girl


After 4 months

of maintenance

treatment

Your report?

Perhaps a phone call

to the physician

before validating the report ?

Chickenpox

1 month ago





errors in reasoning, or…when you are very tired

The last straw ....that broke the camel’s back

14-y-old boy

Ewing tumor of the pelvis

Follow-up of lung micronodules

The last straw ....that broke the camel’s back

9-year-old boy with right foot alveolar RMS

N1

Moral of the story :

Never go on working

when you are too tired !!!!!