Approach to Abdominal Masses in children
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Transcript of 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 !