7tumor abdomen_dr endang

8/22/2019 7Tumor Abdomen_dr Endang

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Abdominal Solid Tumor:Clinical Diagnosis and

ManagementEndangWindiastutiHematology-Oncology DivisionDepartment of Child Health

FMUI dr Cipto M Hospital, J akarta


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Abdominal Mass

Serious finding

Very broad spectrum of pathologies

From small lesions to large ones occupying peritoneal cavity,

from benign to malignant From unilocular cysts to complex solid ones

Need to find out if :

Malignant ? Compressing vital organ ?

There is intestinal hemorrhage ? The older the child the more likely the mass represents

a malignant process


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Objective

Points to address in history taking

Physical findings associated with abdominal

mass Routine laboratory and imaging studies

needed

Overview of most common pediatricabdominal mass


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General Approach

History

Onset

Location

Associated Symptoms

Physical Examination

Inspection

Auscultation Percussion

Other Maneuvers

Special investigation


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History Onset acute

chronicprogression

Location Upper Abdomen

Lower Abdomen

Associated Symptoms

Pain Urinary Symptoms

Fever OBGY Symptoms Abd distension Endocrine/ Cardio

GI Symptoms Hematologic

General Approach


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History Antenatal : Any abnormalities on antenatal

Poly/oligohydramnionUltrasound findings

Duration Age : neonates and infant / older children

Rate of growth Significant family history (adenomatous

polyposis) Inherited predisposition

General Approach


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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 mostlyGerm cell tumorsNon-Hodgkin lymphoma

Adolescents Non-Hodgkin lymphomaConsider :Inflammation process and pregnancy


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Physical Examination

Inspection : Shape of abdomen Scar Superficial lesions Bulges

Auscultation : bowel sound, bruit

Palpation : tenderness, rigidity, character of mass Percussion : distinguishes causes of distention (gas, fluid, solid)


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Abdominal Examination

Site : - central / flank- pelvic filling- unilateral/bilateral

- crossing midline Characteristics : -size

- consistency- tender

- smooth /nodular- mobile / fixed

Associated findings : ascitespleural effusion


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Initial Blood Work

Renal function/ Possible renal Electrolyte involvement / impairment

Uric acid/ Increased cell turn over LDH (+ALT) suggesting malignancy

FBC / Diff Bone marrow involvement

LFT Liver involvement


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Laboratory Examination

CBC : WBC with left shift (infection)

Pancytopenia :

Bone Marrow infiltration by malignancy

Marrow suppressed by infection

Thrombocytosis

Often seen with liver tumor(thrombopoietin produced by tumor)


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Coagulation studies

Presence of DIC

Liver dysfunction Urinalysis

Hematuria or proteinuria

(Renal and bladder function) Tumor Markers :

Urine VMA, AFP, HCG

Laboratory Examination


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Tumor Specific Investigation

Tumor markers AFP HepatoblastomaHepB sAg Hepatocellular Ca HCG Germ cell tumors

Urine HVAs Neuroblastoma Ferritin Neuroblastoma

Urine NMA (24 hrs) Pheochromocytoma

ESR Lymphoma

Special Investigation : bone marrow puncture / biopsy Neuroblastoma Malignant rhabdoid tumor

Lymphoma Renal clear cell sarcoma

Rhabdomyosarcoma


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Initial Imaging for Diagnosis

X-Ray Abd XR :Controversial as to necessityDescribe location & density?Obstruction

?Calcification

Chest XR :MetastasisStaging

Malignant effusionExclude TB


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Ultrasound

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)

Initial Imaging for Diagnosis


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Further Imaging

CT-Scan : if suspicious of malignancy

Determination size and infiltration into vessel or vital organ

MIBG Scan Neuroblastoma

Bone Scan Neuroblastoma

Clear cell sarcoma

PET Scan Lymphoma


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Further Imaging

MRI

Best imaging ofabdominal tumors(abdomen & pelvis)

Expensive

No radiation :

implications forinitial and follow upscans.

CT Chest

Essential to assesschest metastases

CT Abdomen

Good imaging forblood vessels

Radiation : Implicationfor follow up imaging


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Abdominal Mass

History and PE

Abdominal WallIntra -Abdominal

Infectious Non-Infectious

Malignant Non-Malignant

Intraperi toneal Retroperitoneal


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Neonatal Abdominal Masses

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

Meconiumileus Hepatobiliary 5%

Hepatic tumors Hemangioendothelioma Cystic mesenchymal

hamartoma

Hepatoblastoma Neuroblastoma

Choledochal cyst

Kirk et al., 1981 Radiol. Clin. North Am., 19:527-545


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Distribution of abdominal mass in neonates by organ systemKirks et al. Radiol Clin North Am 1981;19:527-545


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Abdominal Masses in Older Children

Renal 55%

Wilms (& other) 25%

Hydronephrosis 20%

Cystic disease 5%

Non Renal Retroperitoneal 23%

Neuroblastoma 21%

Teratoma 1%

Other 1%

Gastrointestinal 12%

Appendiceal Abscess

Lymphoma

Hepatobiliary 6%

Tumors

Hepatoblastoma

HCC

Genital 4%

Ovarian Cysts andTeratoma

Kirk et al., 1981 Radiol. Clin. North Am., 19:527-545


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The Commonest Malignant

Abdominal Masses in Children:1. Neuroblastoma.

2. Wilms tumor (Nephroblastoma).

3. Malignant lymphoma (usually Non-Hodgkinlymphoma of the intestine).

4. Hepatoblastoma.

5. Lymphosarcoma.6. Other Suprarenal tumors (Non Neuroblastoma).

7. Others .


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The commonest benign masses

1. Hydronephrotic kidney (Peliviuretericjunction obstruction), polycystic kidney.

2. Mesenteric mass and cysts.

3. Intestinal Duplication cysts.

4. Hydatid cysts in the older children


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A mass in the toddlers (1-3 years).

Triad of :1. Abdominal Neuroblastoma

2. Wilms Tumor.

3. Hydronephrosis.

Minimal local or general symptoms, usually themass discovered by the mother.


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Region Organ Diagnosis

Epigastrium Stomach Distended stomach from pyloric stenosis, duplication

Pancreas Pseudocyst

Flank Kidney hydronephrosis, Wilms tumor, dysplastic kidney, ureteral duplication

Adrenal Neuroblastoma, ganglioneuroblastoma, ganlioneuroma

Retroperitoneal Neuroblastoma, ganglioneuroblastoma, ganglioneuroma, teratoma

Lower abdomen Ovary Desmoid, teratoma, ovarian tumors, torsion of ovary

Kidney Pelvic kidney

Urachus Urachal cyst

Omentun,mesentery Omental, mesenteric, peritoneal cysts

Pelvic Bladder, prostate Obstructed bladder, rhabdomyosarcoma

Uterus, vagina Hydrometrocolpos, hydrocolpos,rhabdomyosarcoma

Right upper quadrant Biliary tract Cholecystitis, choledochal cyst

Liver Hepatomegaly (congestion, hepatitis), hamartoma, hemangio-endothelioma, hepatoblastoma, hepatocelullar Ca, abscess,cyst

Intestine intussusceptions, duplicationLeft upper quadrant Spleen Splenomegaly (infection, leukemic infiltration, abscess, cyst)

Right lower quadrant Appendix Appendiceal abscess

Ileum Meconium ileus, inflammatory mass

Lymphatic Lymphoma, lymphangioma

Left lower quadrant Colon Fecal impaction

Lymphatic Lymphoma, lymphangioma

Atlas of Pediatric Physical Diagnosis, Fourth edition

Possible Diagnoses of Abdominal Masses in Infancy and Childhood


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Work up two components

Staging X-ray of primary site

CT chest, abdomen, &pelvis

CXR (baseline) Bone scan

Specialty tests

Gallium, MIBG, PET

Bone marrow

ESR

Evaluate for complications ofthe tumor

CBC with diff. count

Others

LDH, uric acid tumor lysis, rapidcell growth

Creatinine renal function

Transaminases hepaticinvolvement

Specialty tests

Tumor markers

HCG, AFP

HVA / VMA


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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 sampleto be representative and to send for specialresearch studies (histology, chromosomes,special studies, research studies)


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Algorithm for Evaluation of a Neonatal Mass

Abdominal Mass

Abdominal Radiograph

Bowel gas displacement

Surgery

Bowel obstruction

Consider :Contrast studies

Calcifications

Consider :NeuroblastomaTeratomaHepatoblastomaMeconiumperitonitis

ULTRASOUND

Flank Mass

Confirmed

Intraperitoneal Mass Pelvic Mass

Adrenal Origin Renal Other

Solid Cystic

Solid Cystic Complex CysticSolid

Schwatz Mz, Shaul DB. Ped in Rev 1989;11:172-9


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Flank Mass

Adrenal Origin Renal Other

Solid Solid SolidCystic Cystic Cystic

CT-scan CT-scan CT-scan

Neuroblastom

Adrenalhemorrhage?

Surgery

Observation

Mesoblastik

Nephroma

Wilms Tumor

NormalUreter

DilatedUreter

Surgery

IVP,Renal

Scan

Multicystic

kidney

Obstruction

Surgery

No reflux

RefluxObstructionNeurogenicBladder

Surgery

Surgery

Neurogenic

Bladder

Teratoma,

Sarcoma

Neurobl

Lymphangioma

Surgery



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Intraperitoneal Mass

Solid Cystic Complex

CT

Organomegaly

Tumor :

Hepatoblastoma

Hemangioma

Surgery

Angiogram ?

Ovarianmesentric

omental

Intestinal

duplication

Spleen

Surgery

Ovarian

teratomaMeconium cyst

Surgery



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Conclusion

Abdominal masses in neonates and children reflect awide spectrum of diseases

The patients age is among the most important factors

that help narrow the potential etiologies of an abdominalmass

Plain abdominal radiographs should be the first imagingstudies to evaluate an abdominal mass

It is important for physician to determine the nature ofthe mass in a timely, safe, and cost-effective manner.


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