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7tumor Abdomen - DR Endangjj
7tumor Abdomen - DR Endangjj
Abdominal Mass
From small lesions to large ones occupying peritoneal cavity, from benign to malignant From unilocular cysts to complex solid ones Malignant ? Compressing vital organ ? There is intestinal hemorrhage ?
The older the child the more likely the mass represents a malignant process
Objective
Points to address in history taking Physical findings associated with abdominal mass Routine laboratory and imaging studies needed Overview of most common pediatric abdominal mass
General Approach
History Onset Location Associated Symptoms Physical Examination Inspection Auscultation Percussion Other Maneuvers Special investigation
General Approach
History
Onset
Location
Associated Symptoms Pain Urinary Symptoms Fever OBGY Symptoms Abd distension Endocrine/ Cardio GI Symptoms Hematologic
General Approach
History
Antenatal : Any abnormalities on antenatal Poly/oligohydramnion Ultrasound findings Duration Age : neonates and infant / older children Rate of growth Significant family history (adenomatous polyposis) Inherited predisposition
Clinical History
Age is important
Neonatal Congenital malformations (GUT / GIT abnormalities)
- malignancies uncommon
Wilms and Neuroblastoma mostly Germ cell tumors Non-Hodgkin lymphoma Non-Hodgkin lymphoma Consider : Inflammation process and pregnancy
Adolescents
Physical Examination
Inspection :
Auscultation : bowel sound, bruit Palpation : tenderness, rigidity, character of mass Percussion : distinguishes causes of distention
Abdominal Examination
Site :
- central / flank
- pelvic filling - unilateral/bilateral - crossing midline
Characteristics : -size
- consistency - tender - smooth /nodular - mobile / fixed
Laboratory Examination
CBC : WBC with left shift (infection) Pancytopenia :
Bone Marrow infiltration by malignancy Marrow suppressed by infection Often seen with liver tumor (thrombopoietin produced by tumor)
Thrombocytosis
Laboratory Examination
Coagulation studies
Presence of DIC Liver dysfunction Hematuria or proteinuria (Renal and bladder function)
Urine VMA, AFP, HCG
Urinalysis
Tumor Markers :
Tumor markers AFP HepB sAg HCG Hepatoblastoma Hepatocellular Ca Germ cell tumors
Special Investigation : bone marrow puncture / biopsy Neuroblastoma Malignant rhabdoid tumor Lymphoma Renal clear cell sarcoma Rhabdomyosarcoma
Chest XR :Metastasis
Staging Malignant effusion Exclude TB
Cheap and readily available Sedation not necessary Good initial imaging helpful with initial diagnosis
Organ of Origin Tissue components : cysts, hemorrhage, calcification Vascular lesions (doppler)
Further Imaging
CT-Scan :
if suspicious of malignancy Determination size and infiltration into vessel or vital organ
PET Scan
Further Imaging
MRI Best imaging of abdominal tumors (abdomen & pelvis) Expensive No radiation : implications for initial and follow up scans. CT Chest Essential to assess chest metastases CT Abdomen Good imaging for blood vessels Radiation : Implication for follow up imaging
Abdominal Mass
History and PE Intra -Abdominal
Malignant
Renal 55% Hydronephrosis 35% Cystic disease 10% Multicystic dysplastic Polycystic dysplastic Solid Tumors 10% Mesonephric nephroma nephroblastomatosis Pelvic / Genital 15% Teratoma Ovarian Cysts Hydrometrocolpos Obstructed bladder Non-Renal Retroperitoneal 10% Adrenal Hemorrhage neuroblastoma
Gastrointestinal 15% Duplication Mesenteric omental cyst Pseudocyst from complicated obstruction Meconium ileus Hepatobiliary 5% Hepatic tumors Hemangioendothelioma Cystic mesenchymal
Choledochal cyst
hamartoma Hepatoblastoma Neuroblastoma
Gastrointestinal 12% Appendiceal Abscess Lymphoma Hepatobiliary 6% Tumors Hepatoblastoma HCC Genital 4% Ovarian Cysts and Teratoma
Hydronephrotic kidney (Peliviureteric junction obstruction), polycystic kidney. Mesenteric mass and cysts. Intestinal Duplication cysts. Hydatid cysts in the older children
2. 3. 4.
Triad of :
1. 2. 3.
Minimal local or general symptoms, usually the mass discovered by the mother.
Organ
Stomach Pancreas Kidney Adrenal Retroperitoneal Ovary Kidney Urachus Omentun,mesentery Bladder, prostate Uterus, vagina Biliary tract Liver Intestine Spleen Appendix Ileum Lymphatic Colon Lymphatic
Diagnosis
Distended stomach from pyloric stenosis, duplication Pseudocyst hydronephrosis, Wilms tumor, dysplastic kidney, ureteral duplication Neuroblastoma, ganglioneuroblastoma, ganlioneuroma Neuroblastoma, ganglioneuroblastoma, ganglioneuroma, teratoma Desmoid, teratoma, ovarian tumors, torsion of ovary Pelvic kidney Urachal cyst Omental, mesenteric, peritoneal cysts Obstructed bladder, rhabdomyosarcoma Hydrometrocolpos, hydrocolpos,rhabdomyosarcoma Cholecystitis, choledochal cyst Hepatomegaly (congestion, hepatitis), hamartoma, hemangioendothelioma, hepatoblastoma, hepatocelullar Ca, abscess,cyst intussusceptions, duplication Splenomegaly (infection, leukemic infiltration, abscess, cyst) Appendiceal abscess Meconium ileus, inflammatory mass Lymphoma, lymphangioma Fecal impaction Lymphoma, lymphangioma Atlas of Pediatric Physical Diagnosis, Fourth edition
Lower abdomen
Tissue Diagnosis
Incisional biopsy Excisional biopsy Special cases Calicified suprarenal mass + bone scan might consider getting dx from bone marrow FNA vs excisional biopsy Bias towards excisional sufficient sample to be representative and to send for special research studies (histology, chromosomes, special studies, research studies)
Calcifications Consider :
ULTRASOUND Confirmed
Solid
Cystic
Adrenal Origin
Renal
Other
Solid CT-scan
Solid CT-scan
Mesoblastik Nephroma Wilms Tumor
Solid CT-scan
Teratoma, Sarcoma Neurobl
Cystic
Lymphangio ma
Reflux
Neurogenic Bladder
Surgery
Surgery
Surgery Surgery
Schwatz Mz, Shaul DB. Ped in Rev 1989;11:172-9
Surgery
CT
Ovarian
mesentric omental
Surgery
Surgery
Conclusion
Abdominal masses in neonates and children reflect a wide spectrum of diseases The patients age is among the most important factors that help narrow the potential etiologies of an abdominal mass Plain abdominal radiographs should be the first imaging studies to evaluate an abdominal mass It is important for physician to determine the nature of the mass in a timely, safe, and cost-effective manner.