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Transcript of 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
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
misleading clinical symptoms
improper diagnostic strategies
maladjusted imaging techniques
unawareness of emergency situations
errors in reasoning
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
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
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?
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
misleading clinical symptoms
improper diagnostic strategies
maladjusted imaging techniques
unawareness of emergency situations
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
misleading clinical symptoms
improper diagnostic strategies
improper imaging techniques
unawareness of emergency situations
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
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
misleading clinical symptoms
improper diagnostic strategies
maladjusted imaging techniques
unawareness of emergency situations
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
misleading clinical symptoms
improper diagnostic strategies
maladjusted imaging techniques
unawareness of emergency situations
errors in reasoning, or…
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)
misleading clinical symptoms
improper diagnostic strategies
maladjusted imaging techniques
unawareness of emergency situations
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
After
chemotherapy
and local
treatment
After 4 months
of maintenance
treatment
Your report?
11-y-old girl
RMS of the parotid gland
After 4 months
of maintenance
treatment
Your report?
Perhaps a phone call
to the physician
before validating the report ?
Chickenpox
1 month ago
misleading clinical symptoms
improper diagnostic strategies
maladjusted imaging techniques
unawareness of emergency situations
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