Pediatric Abdominal Masses Andrew Phelps MD Assistant Professor of Pediatric Radiology UCSF Benioff Children's Hospital No Disclosures Take Home Message All you need to remember are the 5 common masses that shouldn’t go to pathology: 1. Infection 2. Adrenal hemorrhage 3. Renal angiomyolipoma 4. Ovarian torsion 5. Liver hemangioma Keys to (Differential) Diagnosis 1. Location? 2. Age? 3. Cystic? OUTLINE 1. Kidney 2. Adrenal 3. Pelvis 4. Liver OUTLINE 1. Kidney 2. Adrenal 3. Pelvis 4. Liver Renal Tumor Mimic – Any Age Infection (Pyelonephritis) Don’t send to pathology! Renal Tumor Mimic – Any Age Abscess Don’t send to pathology! Peds Renal Tumors Infant: 1) mesoblastic nephroma 2) nephroblastomatosis 3) rhabdoid tumor Child: 1) Wilm's tumor 2) lymphoma 3) angiomyolipoma 4) clear cell sarcoma 5) multilocular cystic nephroma Teen: 1) renal cell carcinoma 2) renal medullary carcinoma Peds Renal Tumors Infant: 1) mesoblastic nephroma 2) nephroblastomatosis 3) rhabdoid tumor Child: 1) Wilm's tumor 2) lymphoma 3) angiomyolipoma 4) clear cell sarcoma 5) multilocular cystic nephroma Teen: 1) renal cell carcinoma 2) renal medullary carcinoma Renal Tumors - Infant 1) mesoblastic nephroma 2) nephroblastomatosis 3) rhabdoid tumor Renal Tumors - Infant 1) mesoblastic nephroma 2) nephroblastomatosis 3) rhabdoid tumor - Most common - Can’t distinguish from congenital Wilms. Renal Tumors - Infant 1) mesoblastic nephroma 2) nephroblastomatosis 3) rhabdoid tumor Look for Multiple biggest or diffuse and masses. ugliest. Renal Tumors - Infant 1) mesoblastic nephroma 2) nephroblastomatosis 3) rhabdoid tumor - Ugly - Subcapsular fluid - Metastases Renal Tumors - Infant 1) mesoblastic nephroma 2) nephroblastomatosis 3) rhabdoid tumor Common Multi Ugly Peds Renal Tumors Infant: 1) mesoblastic nephroma 2) nephroblastomatosis 3) rhabdoid tumor Child: 1) Wilm's tumor 2) lymphoma 3) angiomyolipoma 4) clear cell sarcoma 5) multilocular cystic nephroma Teen: 1) renal cell carcinoma 2) renal medullary carcinoma Renal Tumors - Child 1) Wilms 2) Lymphoma 3) Angiomyolipoma 4) Clear cell sarcoma 5) Multilocular cystic nephroma Renal Tumors - Child - Most Common - Nonspecific - Local invasion 1) Wilms - Metastases 2) Lymphoma 3) Angiomyolipoma 4) Clear cell sarcoma 5) Multilocular cystic nephroma Renal Tumors - Child - Nonspecific - Single Mass - Multiple Masses - Diffuse Infiltr. 1) Wilms 2) Lymphoma 3) Angiomyolipoma 4) Clear cell sarcoma 5) Multilocular cystic nephroma Renal Tumors - Child - Macroscopic Fat - Tuberous Sclerosis 1) Wilms Don’t send to pathology! 2) Lymphoma 3) Angiomyolipoma 4) Clear cell sarcoma 5) Multilocular cystic nephroma Renal Tumors - Child Looks just like Wilms! 1) Wilms 2) Lymphoma 3) Angiomyolipoma 4) Clear cell sarcoma 5) Multilocular cystic nephroma Renal Tumors - Child Cystic! 1) Wilms 2) Lymphoma 3) Angiomyolipoma 4) Clear cell sarcoma 5) Multilocular cystic nephroma Renal Tumors - Child Common Fat Wilms? Multi 1) Wilms 2) Lymphoma 3) Angiomyolipoma Cystic 4) Clear cell sarcoma 5) Multilocular cystic nephroma Peds Renal Tumors Infant: 1) mesoblastic nephroma 2) nephroblastomatosis 3) rhabdoid tumor Child: 1) Wilm's tumor 2) lymphoma 3) angiomyolipoma 4) clear cell sarcoma 5) multilocular cystic nephroma Teen: 1) renal cell carcinoma 2) renal medullary carcinoma Renal Tumors - Teenager 1) Renal cell carcinoma 2) Renal medullary carcinoma Renal Tumors - Teenager 1) Renal cell carcinoma 2) Renal medullary carcinoma - Nonspecific - Invasion - Mets Renal Tumors - Teenager 1) Renal cell carcinoma 2) Renal medullary carcinoma - Nonspecific - Sickle cell association Renal Tumors - Teenager 1) Renal cell carcinoma 2) Renal medullary carcinoma Sickle cell Common Peds Renal Tumors Infant: 1) mesoblastic nephroma 2) nephroblastomatosis 3) rhabdoid tumor Child: 1) Wilm's tumor 2) lymphoma 3) angiomyolipoma 4) clear cell sarcoma 5) multilocular cystic nephroma Teen: 1) renal cell carcinoma 2) renal medullary carcinoma OUTLINE 1. Kidney 2. Adrenal 3. Pelvis 4. Liver Peds Adrenal Tumors Infant: Hemorrhage Child: Neural crest tumor Teen: Cortical carcinoma Peds Adrenal Tumors - Infant Infant: Hemorrhage Child: Neural crest tumor Teen: Cortical carcinoma - Cystic - Avascular - Will resolve Adrenal Hemorrhage Ultrasound 3 days 1 month 4 months Don’t send to pathology! Peds Adrenal Tumors - Child Infant: Hemorrhage Child: Neural crest tumor Teen: Cortical carcinoma Neuroblastoma: - Calcification - Encase vessels - Bone mets - MIBG positive Peds Adrenal Tumors - Teen Infant: Hemorrhage Child: Neural crest tumor Teen: Cortical carcinoma - Large adrenal mass - Calcification - Precocious puberty OUTLINE 1. Kidney 2. Adrenal 3. Pelvis 4. Liver Peds Pelvis Masses Any age: infection ovarian torsion rhabdomyosarcoma Peds Pelvis Masses Any age: infection ovarian torsion Don’t sendrhabdomyosarcoma to pathology! After antibiotics: Peds Pelvis Masses Any age: infection ovarian torsion rhabdomyosarcoma Don’t send to pathology! Adnexal mass? 143 mL Peds Pelvis Masses Any age: infection ovarian torsion rhabdomyosarcoma Outlet2013-10-21 - MR-11 - 1 Obstruction OUTLINE 1. Kidney 2. Adrenal 3. Pelvis 4. Liver Peds Liver Tumors Infant 1) hemangioma Child: 1) metastasis 2) hepatoblastoma 3) mesenchymal hamartoma 4) embryonal sarcoma Teen: 1) same ddx as adults Peds Liver Tumors Infant 1) hemangioma Child: 1) metastasis 2) hepatoblastoma 3) mesenchymal hamartoma 4) embryonal sarcoma Teen: 1) same ddx as adults Hemangioma by Ultrasound Lobular Hypervascular Mass Hemangioma by CT Centripetal Enhancement Don’t send to pathology! Peds Liver Tumors Infant 1) hemangioma Child: 1) metastasis 2) hepatoblastoma 3) mesenchymal hamartoma 4) embryonal sarcoma Teen: 1) same ddx as adults Peds Liver Tumors - Child 1) metastasis 2) hepatoblastoma 3) mesenchymal hamartoma 4) undifferentiated sarcoma Peds Liver Tumors - Child 1) metastasis 2) hepatoblastoma 3) mesenchymal hamartoma 4) undifferentiated sarcoma - Multiple lesions - Known primary Peds Liver Tumors - Child 1) metastasis 2) hepatoblastoma 3) mesenchymal hamartoma 4) undifferentiated sarcoma Solid AFP +++ Peds Liver Tumors - Child 1) metastasis 2) hepatoblastoma 3) mesenchymal hamartoma 4) undifferentiated sarcoma Cystic AFP - Peds Liver Tumors - Child 1) metastasis 2) hepatoblastoma 3) mesenchymal hamartoma 4) undifferentiated sarcoma Solid > Cystic AFP – Mets Peds Liver Tumors - Child 1) metastasis 2) hepatoblastoma 3) mesenchymal hamartoma 4) undifferentiated sarcoma Multi AFP Cystic Mets Peds Liver Tumors Infant 1) hemangioma Child: 1) metastasis 2) hepatoblastoma 3) mesenchymal hamartoma 4) embryonal sarcoma Teen: 1) same ddx as adults OUTLINE 1. Kidney 2. Adrenal 3. Pelvis 4. Liver REVIEW of CYSTIC TUMORS Mesenchymal Multilocular Hamartoma Cystic Nephroma NOT FOR PATHOLOGIST: Keys to (Differential) Diagnosis 1. Location? 2. Age? 3. Cystic? QUESTIONS QUESTION 1 Which of the following tumors is cystic? a) Hemangioma b) Hepatoblastoma c) Mesenchymal hamartoma d) Embryonal sarcoma QUESTION 1 Which of the following tumors is cystic? a) Hemangioma b) Hepatoblastoma c) Mesenchymal hamartoma d) Embryonal sarcoma Ref: Pugmire BS, Towbin AJ. Magnetic resonance imaging of primary pediatric livertumors. Pediatr Radiol. 2016 May;46(6):764-77 QUESTION 2 Which of following conditions can mimic a tumor? a) Adrenal hemorrhage b) Cystitis c) Ovarian torsion d) All of the above. QUESTION 2 Which of following conditions can mimic a tumor? a) Adrenal hemorrhage b) Cystitis c) Ovarian torsion d) All of the above. Ref: Donnelly LF, Jones BJ, O’Hara SM, Anton CG. Diagnostic Imaging: Pediatrics. Elseveier Health Sciences. 2005 .