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Drs Potisek and Antoon have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

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Nicholas M. Potisek , James W. Antoon; Abdominal Masses. Pediatr Rev February 2017; 38 (2): 101–103. https://doi.org/10.1542/pir.2016-0087

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Finding an abdominal mass on a child can be alarming to both the parents and pediatrician. Abdominal masses are often incidentally discovered by a parent while bathing the child, palpated unexpectedly on routine physical examination, or detected on abdominal imaging. The causes of pediatric abdominal masses are extensive, ranging from benign to neoplastic, and often originating from organs within the intra-abdominal cavity ( Table ).

Causes of Pediatric Abdominal Masses

At presentation, patients may be asymptomatic or report a wide range of associated symptoms , including fever, hematuria, and abdominal pain or distension. New-onset hypertension may be the first sign of an abdominal mass. The child’s age, associated symptoms, location of mass, and laboratory findings provide important clues to the underlying cause and can direct appropriate evaluation and consultation.

Most abdominal masses in infants originate from the kidney and are benign. Often discovered prenatally , hydronephrosis, the most common renal mass in infants , is typically unilateral and results from vesicoureteral reflux and/or obstruction at the ureteropelvic junction. Multicystic dysplastic kidneys are another cause of hydronephrosis described as numerous noncommunicating cysts that vary in size, with little to no normal renal tissue identified. Bilateral renal masses detected on examination or imaging are concerning for autosomal recessive polycystic kidney disease (ARPKD). The presentation of ARPKD varies with the degree of hyperplasia of the collecting tubules and may be detected in utero or later in childhood.

The most common renal neoplasm in infants is congenital mesoblastic nephroma (CMN), which usually presents before 3 months of age as an asymptomatic abdominal mass but may be associated with hematuria, hypertension, hypercalcemia, and even congestive heart failure. Wilms tumor or nephroblastoma, the most common renal malignancy of childhood, primarily occurs between the ages of 2 and 5 years but can develop in infancy. Most cases are sporadic, although hereditary forms do exist. Patients may be asymptomatic or present with abdominal pain and hypertension. Unilateral involvement is most common. Children with WAGR (Wilms tumor, aniridia, genitourinary anomalies, retardation), Denys-Drash, and Beckwith-Wiedemann (BWS) syndromes are at increased risk for the development of Wilms tumor and require frequent screening. Clear cell sarcoma is the second most common childhood renal malignancy. An aggressive tumor typically found in children younger than age 4 years , it can present with hematuria, hypertension, and abdominal pain. During adolescence, renal cell carcinoma is the most common kidney tumor, classically presenting with painless gross hematuria, flank pain, and a palpable mass.

Liver masses account for 5% to 6% of all pediatric intra-abdominal masses and, unlike renal masses, are primarily malignant. Benign vascular tumors usually affect the liver in infants. Hemangiomas are the most common and typically present before age 6 months. Often detected prenatally, congenital hemangiomas are usually solitary lesions that mature by birth and may involute by age 2 years or persist for life. Infantile hemangiomas of the liver are often associated with multiple hemangiomas of the skin. Initially these tumors grow rapidly, then involute, and typically resolve within the first decade of life. Kaposiform hemangioendothelioma is a rare vascular tumor that may present in infancy as a life-threatening consumptive coagulopathy known as Kasabach-Merritt syndrome.

Beyond infancy, hepatoblastoma is the most common primary liver tumor in children , often presenting between ages 1 and 3 years, although it can occur as late as adolescence. The tumor can be associated with genetic syndromes, such as BWS and Aicardi syndrome. Hepatoblastoma should be suspected in the child who has a large, solitary mass of the liver with elevated α-1-fetoprotein (AFP) concentrations. Hepatocellular carcinoma (HCC) can develop in children with liver disease , with cirrhosis serving as a significant risk factor. Children with a liver mass concerning for HCC often have vague symptoms of abdominal pain, weight loss, or decreased appetite and are usually between ages 10 and 14 years.

Neuroblastoma is the most common infantile malignancy and most common extracranial solid tumor in children. Primarily affecting the adrenal glands, neuroblastoma typically present s before age 6 years (median age of 15 months) as a palpable abdominal mass with a wide spectrum of associated symptoms and a propensity to metastasize to bone marrow, cortical bone, the liver, and lymph nodes. Although uncommon, the paraneoplastic opsoclonus-myoclonus syndrome, known also as dancing eyes–dancing feet syndrome, can signal the occurrence of neuroblastoma.

Gastrointestinal (GI) duplication cysts can occur anywhere along the GI tract and are usually spherical cysts not connected with bowel lumen. GI tract duplications may serve as a lead point for a volvulus or intussusception. By far the most common cause of an abdominal mass in a preschool-age child around the time of toilet training is constipation , especially if irregular bowel movements, straining with defecation, or hard stools are reported. Constipation can be confirmed with disappearance of the mass after appropriate use of an osmotic agent.

Only rarely does an abdominal mass in an infant result from a primary tumor or cyst of the pancreas or spleen. Pancreatoblastoma does occur during the first decade of life , again very rarely, manifesting as either an asymptomatic abdominal mass or with vague GI complaints. An upper abdominal mass preceded by pancreatitis or trauma is likely a pancreatic pseudocyst. By enlarging the spleen, both Hodgkin and non-Hodgkin lymphoma can present as a solitary abdominal mass. Other neoplastic tumors of the spleen are rarities. Although uncommon, benign vascular tumors can affect the spleen ; they include hemangiomas, lymphangiomas, and hamartomas.

In older children and adolescents, masses can arise from the genitourinary tract . They can be benign (ovarian cysts, germ cell tumors, teratomas, pregnancy) or malignant ( rhabdomyosarcomas ) .

Once an abdominal mass is identified, management usually consists of abdominal imaging to narrow the differential diagnosis. Abdominal radiographs help with determining location and origin and may detect calcium deposits , but ultrasonography is the preferred initial imaging modality and often the only imaging needed. Ultrasonography can identify the origin and consistency of the mass, along with evaluating the vascular supply with Doppler imaging. If a neoplastic tumor is suspected on ultrasonography or the imaging is unsuccessful, abdominal computed tomography scan or magnetic resonance imaging may be necessary to characterize the mass, assess organ involvement, and stage the disease. Metaiodobenzylguanidine (MIBG) scans are a nuclear medicine study used to stage and evaluate response to therapy in neuroblastomas.

Initial laboratory evaluation typically includes a complete blood cell count, chemistry panel, liver function tests, and urinalysis. Polycythemia, normocytic anemia, pancytopenia, or marked leukocytosis may result from a malignancy. Hypercalcemia occurs with CMN and may also be a paraneoplastic phenomenon. Abnormal liver function test results may indicate a hepatobiliary origin. Urinalysis can indicate the presence of blood , suggesting a renal cause, especially if accompanied by proteinuria. Biomarkers may be helpful in establishing specific diagnoses, such as elevated AFP concentrations associated with both hepatoblastoma and pancreatoblastoma.

Treatment, prognosis, and outcomes of pediatric abdominal masses vary, based on the cause. Most pediatric masses are benign. Referral to a subspecialist or tertiary care center is warranted if the nature of the mass cannot be identified or if the mass requires subspecialty or surgical care.

COMMENT: In their discussion of abdominal masses arising within the GI tract, Drs Potisek and Antoon left out one I find particularly interesting. Bezoars are accumulations of undigested material, most often occurring in the stomach, that can enlarge enough to cause signs and symptoms of obstruction and become palpable as epigastric masses. Two forms of bezoars are especially relevant to pediatricians: lactobezoars in neonates, especially preterm infants, and infants; and trichobezoars in older children and adolescents.

Lactobezoars are gastric concretions of milk (or formula) and mucus that can lead to poor feeding, distention, irritability, vomiting, and poor weight gain, symptoms that are not very different from the more common pyloric stenosis. Gastric trichobezoars, matted collections of hair in the stomach, are often the product of trichotillomania -- compulsive hair-pulling that may be accompanied by anxiety and/or depression. They too can lead to abdominal distention and pain, vomiting, weight loss, and even bleeding and perforation.

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Chapter 388. Abdominal Masses

John C. Densmore; Keith T. Oldham

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The abdominal mass in an infant or child is most commonly an incidental finding first observed by a parent or at the time of a pediatric screening examination. Over 50% of abdominal masses detected by physical examination are actually cases of organomegaly. 1 , 2 The remaining 43% of masses require surgical evaluation and comprise neoplasms, developmental anomalies, and inflammatory or infectious disease. Ninety percent of this group are retroperitoneal masses, approximately half of which derive from the urinary tract. 2 In neonates, multicystic dysplastic kidney and hydronephrosis occur in equal frequency and comprise 75% of abdominal masses. 2 Older children are more likely to have neoplastic processes. 2 Table 388-1 lists the most likely diagnoses that vary by location of the mass and age group.

Data from Papaioannou GaM K. Investigation of an abdominal mass in childhood. Imaging. 2004;16(2):114-123.

Clinical Features

Most masses are asymptomatic, so the history is rarely diagnostic. Signs and symptoms concerning for malignancy include increased abdominal girth, associated abdominal pain, pain with movement or palpation, constipation, or change in pattern of urination. 1 Other helpful elements in the history include signs or symptoms of intestinal obstruction, jaundice, fever, and weight loss. The approximate location of the mass; its mobility, size, and consistency; and any associated developmental anomalies should be noted on physical examination and may be helpful when discussing initial imaging modalities with the radiologist. Ultimately, the age of the patient and physical examination findings narrow the differential diagnosis prior to radiologic imaging.

Diagnostic Evaluation

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INTRODUCTION

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Clinical presentations and imaging findings of neuroblastoma beyond abdominal mass and a review of imaging algorithm

1 Department of Diagnostic Radiology and Organ Imaging

D D Rasalkar

3 Imaging Centre, ZhangJiaGang No.1 People's Hospital, ZhangJiaGang City, Jiangsu Province, P.R. China

F W T Cheng

2 Department of Pediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China

Neuroblastoma is one of the most common malignant neoplasms in childhood. The most common clinical presentation of this tumour is abdominal mass. However, affected children may have various clinical presentations as a result of disseminated metastatic disease or associated paraneoplastic syndromes at the time of diagnosis. In this article we have outlined the imaging findings in seven patients with “extra-abdominal” presentation of neuroblastoma and the pitfalls in making the correct diagnosis. The purpose of this pictorial review is to alert the general radiologist to the possible presentations of this common childhood malignancy to derive early detection and diagnosis.

Neuroblastoma is the most common solid extracranial tumour in infants and children. It represents approximately 7% of all cases of childhood cancer and results in about 15% of cancer deaths in children [ 1 ]. Neuroblastoma arises from primitive neuroblasts of the embryonic neural crest, and therefore can occur anywhere within the sympathetic nervous system [ 2 ]. The most common site of the primary tumour occurs within the abdomen (65%). About half of these tumours arise from the adrenal medulla. Other common sites of neuroblastoma include the neck, chest and pelvis [ 3 ].

The classic clinical presentation of neuroblastoma is well recognised by paediatric radiologists [ 4 ]; however, medical professionals or radiologists working in local hospitals may not be aware of the atypical manifestations of this tumour. As prompt diagnosis and treatment may help to increase survival rates and minimise irreversible damage, especially to the neural system, it is important for both clinicians and radiologists to be aware of some of the less common manifestations of this tumour.

In this article, we illustrate the “extra-abdominal” clinical presentations and imaging findings of seven cases of abdominal neuroblastoma diagnosed in our hospital, a tertiary Children Cancer Centre in Hong Kong, over the past 10 years.

Case reports

Seven patients were included in this pictorial review ( ​ ( ​ ​ ​ ​ ​ Figure Figure 1–7 ). All of them had primary neuroblastoma within the abdomen, but the initial clinical presentation was extra-abdominal. Two of them presented with bone pain with non-specific radiographic and MRI findings at the symptomatic joints. Both patients were initially under orthopaedic care with provisional diagnosis of juvenile idiopathic arthropathy and septic arthritis, respectively. Four patients presented with swelling in the head and neck regions: one patient with scalp nodules, two patients with periorbital swelling and one patient with mandibular swelling. These “lumps and bumps” were subsequently found to be bony metastases from abdominal neuroblastoma. One patient presented with diarrhoea and was initially treated for gastroenteritis. This symptom was retrospectively found to be related to the paraneoplastic syndrome of neuroblastoma. Two of the above children subsequently developed lower limb weakness related to intraspinal extension of the abdominal neuroblastoma. The correct diagnosis was first proposed when cord compression was found on urgent MRI examination.

Right adrenal neuroblastoma in a 6-year-old boy who presented with left shoulder pain, anaemia and raised erythrocyte sedimentation rate (ESR). He was initially misdiagnosed as having juvenile idiopathic arthropathy. (a) Plain radiograph. When compared with the normal right side there is periarticular osteopenia of the left shoulder involving the clavicle (black arrow) and scapula (white arrow). (b) Coronal fat-saturation T 2 weighted image of left shoulder shows multifocal increased marrow signal in the lateral end of the clavicle (black arrow), the scapula (white arrow) and the proximal humerus (arrowhead). A small amount of joint effusion is also evident. (c) Transverse ultrasound image of the abdomen shows a large heterogeneous mass at the right adrenal bed (M). It was confirmed as neuroblastoma after ultrasound-guided biopsy. (d) Contrast-enhanced axial CT image shows a large, poorly enhancing soft-tissue mass with classical vascular encasement of both renal arteries (black arrows) and right renal vein (white arrow).

A 3-year-old boy with Stage IV neuroblastoma who presented with left hip pain, limp and fever. A blood test showed elevated chronic reactive protein (CRP). He was initially misdiagnosed as having septic arthritis. (a) Plain radiography of both hips shows no obvious bony destruction of the left proximal femur when compared with the asymptomatic right side. (b) Coronal MR T 2 weighted image with fat saturation of the left hip reveals marked T2 hyperintense signal of proximal femoral metaphysic and acetablum (white arrows) together with signal change in the surrounding muscle (arrow heads). This was misinterpreted as osteomyelitis at the initial study. (c) MRI of the spine and abdomen shows distal cord and cauda equina compression by a large abdominal soft-tissue mass with intraspinal extension (white arrow). (d) Contrast-enhanced axial CT image shows a large heterogeneously enhancing soft-tissue mass (T) with extensive intratumoural calcifications (white arrow) in the left side abdomen. The left kidney (not shown) is displaced inferiorly and the left renal vein (arrowhead) is encased. Ultrasound biopsy confirmed neuroblastoma.

A 14-month-old girl with Stage IV neuroblastoma who presented with scalp nodules and on/off fever for two weeks. (a,b) Axial CT of brain demonstrates a lentiform soft-tissue mass in right parietal bone (black arrow) associated with bony erosion. (c) Contrast-enhanced axial CT image of abdomen shows a large soft-tissue mass (T) at the left sided retroperitoneal space. The tumour encases the abdominal aorta (white arrow) and invades the left kidney (black arrow). (d) Metaiodobenzylguanidine scintigraphy demonstrates multiple foci of abnormal tracer uptake (arrows) in the abdomen, skull and appendiceal skeleton.

An 8-month-old boy with Stage III neuroblastoma who presented with diarrhoea for 5 days and was treated for gastroenteritis. Subsequently, he was found, by the mother, to have deterioration in standing power. (a) Axial T 2 weighted MRI shows compression of the cord by a left paravertebral tumour (T) with intraspinal extension via the neural foramina (white arrow). (b) Follow-up coronal T 2 weighted MRI reveals residual small left paravertebral tumour after completed treatment (white arrow). There is a short segment of myelomalacia (black arrow) at the distal cord. The patient suffers from a persistent neurological deficit.

Stage IV neuroblastoma in a 7-month-old girl who presented with watery eye discharge and orbital swelling for 10 days. (a,b) CT image of the brain demonstrates bilateral intraorbital soft-tissue masses (white arrows) with bony orbit involvement (black arrows). It extends laterally into the subcutaneous soft tissues. (c) Coronal T 1 weighted MRI shows a heterogeneous mass in which the high signal intensity area corresponds to tumoural haemorrhage (curved arrow).

Stage IV neuroblastoma in a 30-month-old girl who presented with right facial swelling. (a) Axial fat-saturation T 2 weighted image shows a large tumour involving the body, angle and coronoid process of the right side of the mandible (arrow). (b) Axial T 2 weighted MRI shows a large left adrenal tumour (T) encasing the abdominal aorta (white arrow). (c) Sagittal T 1 weighted image and (d) T 2 weighted image reveal direct extension of tumour into the spinal canal via the left T12/L1 intervertebral foramen (black arrow). There are multiple foci of abnormal signal intensity in the vertebral bodies at the level of T10, T12, L1 and L5 (white arrows).

A 17-month-old boy with Stage IV neuroblastoma who presented with fatigue and periorbital swelling. (a) Plain radiography of the skull shows ill-defined lucency (arrow) over left periorbital bone. (b) Transverse ultrasound of abdomen shows an echogenic mass (m) at left adrenal bed with enlarged para-aortic lymph node (arrowhead). (c) Axial post-contrast CT of the abdomen shows a large mass (T) in the retroperitoneum with small amount of tumoural punctuate calcifications (arrows). The major vessels are encased. Diffuse liver metastases (black arrows) are also noted. (d) Metaiodobenzylguanidine scintigraphy shows increase in tracer uptake over left orbital region (black arrow). There is also intense uptake in the primary abdominal tumour (white arrow).

A summary of demographic data, clinical presentation, staging, treatment and outcome of all patients is given in Table 1 .

The presenting signs and symptoms of neuroblastoma are highly variable with a broad spectrum. They are related to the site of the primary tumour, presence of metastases and any associated paraneoplastic syndromes [ 2 ]. A summary of the spectrum of clinical signs is given in Table 2 [ 5 ]. Around 40% of patients present with signs and symptoms owing to localised disease. Paraspinal tumours in the thoracic, abdominal and pelvic regions occur in 5–15% of patients, and these can extend into the neural foramina causing symptoms related to compression of nerve roots and the spinal cord [ 6 – 8 ]. In this case series, Cases 4 and 6 presented with bilateral lower limb weakness owing to intraspinal extension of the neuroblastoma causing spinal cord compression. Two major paraneoplastic syndromes are commonly seen in patients with localised tumours. Secretion of vasoactive intestinal peptide can result in diarrhoea [ 2 ]; this symptom was present in Case 4 of this series. Diarrhoea usually resolves after tumour removal [ 9 ]. Most of the patients with abdominal neuroblastoma in this series had a sizable primary tumour. Medical professionals should be aware of the possible symptoms and signs related to this relatively common paediatric neoplasm. Quick abdominal examination supplemented by ultrasound screening can enable a correct diagnosis and facilitate optimal management of the child.

Extra-abdominal presentations of neuroblastoma

About 50% of patients present with evidence of haematogenous metastases to distant sites such as cortical bone, bone marrow, liver and non-regional lymph nodes.

Skeletal metastases occur in up to 60% of cases with a variable radiological appearance [ 1 ]. Skeletal lesions in long bones may present radiographically as osteolytic focus with or without periosteal reaction, lucent horizontal metaphyseal line or vertical linear radiolucent streaks in the metadiaphysis. Some skeletal lesions may present as a pathological fracture. Vertebral collapse might be seen in spinal metastases while metastases to the cranium often manifest as widening of the cranial suture lines owing to subjacent dural metastases. Early skeletal lesions may be missed when cortical destruction is limited as in Case 1 and 2 of this series. MRI is more sensitive for detection of bony lesion; however, the findings might be misinterpreted as other infective/inflammatory causes that share non-specific MRI features. In Case 1 the patient presented with left shoulder pain and fever. He was initially misdiagnosed with juvenile idiopathic arthropathy as the clinical presentation overlapping with arthritic symptomatology. In Case 2 the patient presented with a limp and left hip pain. His MRI was misinterpreted as septic arthritis owing to the presence of joint effusion, soft-tissue oedema and concurrent fever. Subsequent examination confirmed that their musculoskeletal symptoms were related to bone metastases.

Neuroblastoma also has an unexplained tendency to metastasise to the bony orbit and as a result periorbital ecchymoses (“raccoon eyes”) and proptosis are features of disseminated neuroblastoma [ 2 ]. Cases 5 and 7 in this series presented with periorbital swelling and raccoon eyes. Proptosis was also evident in the latter patient. In Case 3, the patient presented with scalp nodules. The diagnosis of bony metastases in the above cases became obvious when bone destruction and characteristic periosteal reaction were demonstrated on CT images.

Imaging algorithms in neuroblastoma

Successful planning of individual patient therapy requires precise delineation of the local extent of the neuroblastoma and evaluation of distant metastases. CT, MRI and bone scintigraphy are the primary imaging modalities used in staging disease in children with neuroblastoma. The imaging protocol might vary from institution to institution. Brodeur et al [ 10 ] has published the revised criteria for neuroblastoma diagnostic work up based on experience with the International Neuroblastoma Staging System (INSS) and International Neuroblastoma Response Criteria (INRC). The imaging tests recommended for assessment of the extent of the disease are listed in Table 3 . One major modification proposed in Bordeur's paper [ 10 ] is that CT scans or MRI (but not ultrasound) are recommended to evaluate the abdomen. It is recommended that three-dimensional measurements of the primary tumour and large metastases should be obtained by CT or MRI to determine response to treatment, while ultrasound may be a useful modality for interim assessments. Recently, MRI has supplemented CT for the staging of neuroblastoma [ 11 – 13 ]. In small series, MRI has also been shown to be more sensitive in the detection of local disease [ 14 , 15 ]. MRI is better for paraspinal lesions and is essential when assessing intra-g0oraminal extension of the tumour and its potential for cord compression [ 2 ]. MRI is also superior to CT for characterising epidural extension, leptomeningeal disease and for the detection of bone marrow metastases [ 16 ]. However, many district hospitals may not have the facilities for paediatric MRI, particularly in the age group prevalent for neuroblastoma, in whom general anaesthesia is often required. Contrast-enhanced CT is therefore the most commonly used modality for disease staging for neuroblastoma worldwide. CT alone has been reported to be 82% accurate in revealing tumour extent [ 10 ].

3D, three-dimensional; MIBG, 18 I-metaiodobenzylguanidine.

Metaiodobenzylguanidine (MIBG), which is taken up by tumours derived from the neural crest, has excellent sensitivity (>90%) and near-absolute specificity in the context of neuroblastoma owing to its tumour-specific uptake [ 17 ]. A recent study shows that MIBG single photon emission CT (SPECT) bridges the gap between planar MIBG scintigraphy and diagnostic CT [ 18 ]. SPECT is particularly useful in cases where there is difficult differential anatomy to distinguish between bowel loops and eventual involved lymph nodes on CT, and in cases when CT reading is impaired by anatomical distortion after surgery or irradiation. SPECT also enhances the diagnostic certainly for small foci, which are overlooked by CT. 111 In-diethylenetriaminepentaacetic acid (DTPA)-octreotid scan (somatostatin receptor analogue) yields prognostic information for neuroblastoma [ 19 ]. Positive octreotide scintigraphy indicates high level of somatostatic-2 (SST2) receptor gene expression within neuroblastoma and is correlated with a favourable clinical outcome [ 20 ]. However, MIBG scinitgraphy is more sensitive than octreotide scintigraphy for detection of neuroblastoma, therefore both studies have a complementary role in initial diagnostic workup [ 21 ].

In a review by McHugh and Pritchard [ 22 ], the importance of differentiating stage IVS (which has a Stage I/II primary tumour and dissemination limited to the liver, skin and/or bone marrow) and Stage IV (which has metastases to distant lymph nodes, bones, bone marrow, liver and/or other organs) diseases have been emphasised. Several investigators have reported the presence of MIBG scan-negative, bone scan-positive sites of metastatic neuroblastoma [ 17 ]. To omit bone scanning may result in incorrect staging in up to 10% of cases. Supplementary bone scintigraphy reportedly increases the accuracy to 97% [ 10 ]. Bone scintigraphy has been traditionally used to survey for occult bony metastases [ 23 , 24 ]. In the setting of confirmed neuroblastoma and multiple or diffuse abnormalities detected on bone scintigraphy, the positive findings should be regarded as highly suggestive of bone metastases even if plain radiography of the abnormal sites is unrevealing. Ideally, MIBG and bone scintigraphy should be done in all children with neuroblastoma at diagnosis to help decide the correct treatment strategy.

Positron emission tomography-CT (PET-CT) has gained importance in staging child cancer. Fluorodeoxyglucose (FDG) PET-CT has the advantage over the standard imaging modalities of characterising tumours both anatomically and metabolically. In a recent study, 113 paired 18-g0luoro-g0DG PET studies and 123 I-MIBG scintigraphy were compared for their diagnostic accuracy in neuroblastoma [ 25 ]. In general, FDG can better delineate disease extent in the chest, abdomen and pelvis and is superior in depicting Stage I and II neuroblastoma. MIBG is better for detection of bone and marrow metastases and is overall superior in evaluation of Stage IV neuroblastoma, especially during initial chemotherapy. However, in patients with tumours that weakly accumulate 123 I-MIBG, PET studies provide important information during staging and at major decision points during therapy, such as before stem cell transplantation or before surgery.

Relative costs and availability of the above imaging modalities and local expertise as well as the physician's preference will continue to influence the imaging protocol in different institutions. In our institution, all children with neuroblastoma undergo multimodality imaging for initial staging: CT/MR (including thorax, abdomen and pelvis +/− brain and neck regions) for delineating the extent of primary tumour, MIBG and bone scintigraphy with SPECT for correlation with CT/MR, and the PET study is optional as the cost is covered by the patient's family. Octreotide scintigraphy is not currently available in our centre so the prognosis of neuroblastoma is determined by both clinical staging and pathological classification (Shimada system) [ 26 ].

General radiologists and clinicians should be aware of the unusual clinical presentation of neuroblastoma in children. A quick abdominal examination supplemented by ultrasound screening can enable a correct diagnosis while a standardised imaging algorithm can facilitate optimal management of the child.

Abdominal mass

Nov 17, 2014

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Abdominal mass. Michael S. Hong, MD. University of Florida Oral Exam Review. Abdominal Mass DDx. Narrow your differential Age Gender Location Differential guides your H&P. Pediatric Abdominal Mass. Tumors Wilm Tumor – (~3-4 yo ) renal, flank area

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Abdominal mass Michael S. Hong, MD University of Florida Oral Exam Review

Abdominal Mass DDx • Narrow your differential • Age • Gender • Location • Differential guides your H&P

Pediatric Abdominal Mass • Tumors • Wilm Tumor – (~3-4 yo) renal, flank area • Neuroblastoma – Sympathetic Nervous System, usu. Midline • Beckwith-Wiedemann – enlarged kidneys, liver • Teratoma • Rhabdomyosarcoma • GI • Bowel obstruction • Intussusception • Pyloric stenosis • Organomegaly

Abdominal Mass in Elderly • GI • Sigmoid volvulus, Obstruction, Impacted stool, Colon cancer, gastric cancer, biliary cancer, diverticulitis, portal hypertension • GU • Urinary obstruction/retention • Organomegaly • Spleen, liver, kidney • Vascular • Abdominal aortic aneurysm • Other • Hernias, pancreatic pseudocyst, metastatic disease, sarcomas, neuroendocrine tumors, lymphomas, abscess

Abdominal mass in women • Pregnancy • Endometriosis • Ovarian cyst/tumor • Uterine fibroids

Location of Abdominal Mass • Flank – renal, adrenal • RLQ – appendicitis, Crohn’s, carcinoid • RUQ – biliary CA, liver adenoma, cysts/abscess • Epigastric – gastric CA, pancreatic pseudocyst • LUQ – sigmoid volvulus, splenomegaly • LLQ – diverticulosis/litis, colon CA • Pelvic – GU/GYN

History • OPQRST of Pain • Onset • Provoking/palliative factors • Quality of pain • Region/radiation of pain • Severity • Time • GI: nausea, vomiting, last BM, bloody stools, clay colored stools, floating/foul smelling, caliber • Malignancy: fever, chills, night sweats, weight loss • Bleeding/bruising – spleen and coagulation • Recent travel – infectious

History • Mass • Timeframe, rapidity • Mobile/fixed • Local, diffuse • Tender/non-tender • Prior surgery • Risk factors – smoking, alcohol, family history, cirrhosis

Physical exam • Inspection – location, skin changes, size, surgical scars • Ausculation – bowel sounds, bruits • Percussion - ascites • Palpation – peritonitis, elicit pain, pulsatility, mobility, hardness, lymph nodes, rectal exam

Labs/Studies • CBC, BMP, LFT, amylase, lipase, coags • KUB – free air, air-fluid levels, bowel dilatation • Ultrasound – solid or cystic, location • CT/MRI – enhanced anatomy, inflammation, tumor, obstruction, abscess, volvulus

Example 1 • 91 year old demented man from nursing home • Intermittent abd pain, mass • No BM in last several days • Nausea, vomiting • DDx? • Bowel obstruction, stool impaction, ileus, colon CA, rectal CA • Next? • ROS, rectal exam • Labs: CBC, BMP • NPO, NG tube, replace fluids/electrolytes • KUB, CT scan

Example 1 • Dx: Bowel impaction • Tx: NPO, NGT, replace lytes • Colace, senna • Enemas • Manual disimpaction http://www.urmc.rochester.edu/radiology/education/materials/

Example 2 • 76 year old man, mass in LLQ, gradual growth • Last BM 3 days ago, Nausea, Vomiting • Weight loss • Gradually narrowing caliber stools • DDx & Work up similar

Example 2 • Imaging: air fluid levels (obstruction) • “Apple core” lesion in colon • Dx: colon CA • Tx: NPO, NGT, lytes • Staging/monitoring: • CEA • Chest CT • Colonoscopy • Neoadjuvant therapy, Resection • Diverting ostomy http://allbleedingstops.blogspot.com

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• Colin Jones
• April 8, 2024
• Budget Resources , Education , Presentation

Presentation: K-12 Funding Update for the Legislative Gateway Caucus

On March 27, 2024, Deputy Policy Director Colin Jones presented to the Legislative Gateway Caucus on K-12 funding and policy. The presentation included a spotlight on Lawrence, Mass. It also previews upcoming work from MassBudget focused on the adjustments needed to keep the state’s K-12 funding formula (Chapter 70) aligned with inflation. Read the full presentation below.

MassBudget’s Look at the Fiscal Year 2025 House Ways and Means Budget Proposal

How do business taxes in ma compare to other states, presentation: ending the tax penalty against working immigrants.

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