NephroblastomatosisSmall islands of primitive metanephricblastema, which are precursor of Wilms tumor, commonly exist in the kidneys of the normal newborn infant. These primitive cells usually spontaneously regress by 4 months of age. A diffuse and proliferative form of persistent renal blastoma is referred to as nephroblastomatosis. The abnormal tissue can form as multiple discrete nodules within the renal parenchyma or may completely replace the renal cortex. -Nephroblastomatosis appears on CT or IV pyelogram as bilateral lobulated and enlarged kidneys with marked compression, stretching, and distortion of the pelvicaliceal structures On US, the kidneys are enlarged, lobular, andechogenic, or enlarged with diffuse hypoechoic thickening of the cortex. In such cases, Wilms tumor should be suspected. Nephrogenic rests are more likely to appear cortical, tend to be homogeneous, and are of low echogenicity on US, low attenuation on CT, and low signal intensity on T1WIs . Small, focal nephrogenic rests smaller than 1 cm are difficult to visualize by US and are better evaluated with contrast-enhanced CT or T1WI
Sagittal image of the right kidney A rounded solid appearing mass is seen in the interpolar region of the right kidney. The mass shows no obvious calcifications.
Sagittal image of the right kidney The right kidney appears enlarged and lobulated. The complex right renal mass is appreciated again in this image. The mass exhibits a few scattered areas that are hypoechoic
Contrast enhanced axial CT scan The right renal mass is again identified in this image. The mass is seen to occupy a large portion of the kidney and invades the right renal hilum; however it does not cross the midline.
Wilm's Tumor. Conventional radiograph of abdomen shows a large right upper mass displacingbowel loops into the pelvis and accross the midline (blue arrows). Coronal and sagittal reformatted CTdemonstrate a large, heterogeneous mass arising from the right kidney (white arrows). A smallsliver of functioning right kidney is seen to enhance (yellow arrow).
Adrenal HemorrhageThe infants may present with an abdominal mass, jaundice, hypotension, or anemia, but small hemorrhages may go unnoticed. Hemorrhage occurs more frequently on the right and is occasionally bilateral. Older children develop adrenal hemorrhage as a result of accidental trauma, child abuse, meningococcemia, or anticoagulant therapyHemorrhage enlarges the gland and causes loss of the V shape. Initially, the hematoma resembles a solid, echogenic mass . As the hemorrhage resolves, it becomes increasingly hypoechoic, starting in the central region and progressing peripherally .
hypo-echoic hematoma in the right adrenalAdrenal hemorrhage longitudinalAdrenal hemorrhage without vascularity longitudinal
The etiology of neuroblastoma is not well understood. The great majority of cases are sporadic and non-familial.detect neuroblastoma is the mIBG scan (meta-iodobenzylguanidine), which is taken up by 90 to 95% of all neuroblastomas, often termed "mIBG-avid
Tc-99m MDP (Bone Scan)MIBG scintiscan
A well-defined, rounded, mildly lobulated, hypoechoic mass that is separate from the liver is noted in the right upper quadrant. The mass has areas of calcification and appears to displace the kidney downwards and medially.
They usually present with an abdominal massHepatoblastomas originate from immature liver precursor cells, usually unifocal and affect the right lobe of the liver more often than the left lobe, can metastasize.Surgical resection is the usual manner in which material for pathologic assessment is obtained. Open biopsy is performed when complete surgical resection is not possible. Needle biopsy is not recommended, because hepatoblastomas usually are highly vascular.
Precontrast CT scan pre shows a large mass encompassing both lobes of the liver, which is of lower density than normal liver. CECT demonstrates mass that appears to be multinodular, with heterogeneous enhancement less than that of the surrounding liver
Metastatic DiseaseNeuroblastoma is the most common childhood tumor to metastasize to the liver, followed by lymphoma, leukemia, and Wilms tumor. Metastatic lesions are usually multiple, and their imaging appearance is generally nonspecific
Echogenic nodular lesion in segment 7 of liver in a known case of RCC, represents metastatic nodule.
Liver metastases, contrast-enhanced CT. Multiple hypoattenuating lesions of varying sizes are seenin both the left and right lobes of the liver, some with indistinct margins
Hemangioendothelioma is a benign endothelial lined vascular mass of the liver seen in infants. It should be suspected in an infant with a large liver mass and congestive heart failure (CHF) or cutaneous hemangiomas.Clinical ManifestationInfantile hemangioendotheliomas are generally noticed within the first few days to months of life. They typically present with a palpable upper abdominal mass with bruit, abdominal distension, hepatomegaly, and high output CHF secondary to arteriovenous shunting. Fifty percent of infants have cutaneous hemangiomas. Hemangioendothelioma can be detected in utero as early as 16 weeks of gestation and is associated with polyhydramnios.
Axial CT scan post-contrast arterial phase at the level of the kidneys showed diffused hepatic masses with intense peripheral enhancement and central non-enhancing areas, B) Venous phase shows diffused enhancement of the lobulated liver segments. Axial unenhanced T1 weighted MRI image shows diffused nodules with low signal intensity, B) Coronal T2 weighted MRI image shows diffuse high signal intensity nodules occupying almost the entire abdomen.
Choledochal cysts are congenital malformations of the intrahepatic or extrahepatic bile ducts. majority of cysts are associated with an anomalous junction of the common bile duct and pancreatic duct Jaundice, pain, and a right upper quadrant mass comprise the classic triad of findings seen with a choledochal cyst. The most common type of choledochal cyst (type 1) is a localized, fusiform or saccular dilation of the common bile duct below the cystic duct.
These patients also have a normal pancreaticobiliary junction.
Ultrasound images reveal a large cystic collection with thickened and shaggy walls, located anterior to left kidney and in close relation to tail and body of the pancreas. These ultrasound findings suggest a diagnosis of pseudocyst of the pancreas
Splenomegaly is a relatively common cause of a left upper quadrant mass in children.
Situsambiguus, also known as heterotaxy is a rare congenital defect in which the major visceral organs are distributed abnormally within the chest and abdomen.The normal position of the organs is known as situssolitus; situsinversusis a condition in which the usual positions of the organs are reversed from left to right as a mirror image of the normal conditionabsent or defective splenic function is associated with a high risk of fulminant bacterial infections, especially with encapsulated bacteria
Left IVC and multiple spleens polysplenia, azygous continuation of the IVC and retroperitoneal hepatic flexure (note no situsinvertus
15-year-old male with Burkitt's lymphoma. CT with contrast. (A) The bulky heterogeneousmassBurkitt lymphoma in a 4 year-old boy infiltrating both kidneys, liver and spleen. a) Axial contrast enhanced CT reveals a homogeneous hypodense nodular lesion in the left kidney (black arrow) and another one that almost replaces the right kidney (yellow arrow). b) Two months later, after chemotherapy, the left kidney lesion was unapparent and the lesion in the right kidney shrunken significantly
The transverse ultrasound image of the pelvis showed a soft tissue mass deep to the urinary bladder This was a prostatic rhabdomyosarcoma.
Axial and coronal CT images below show a complex soft tissue mass, arising from the prostate gland
Ovarian Teratomacomplex cystic and solid pelvic mass containing two teeth and fat
Contrast-enhanced coronal CT images of the abdomen and pelvis, demonstrate a large predominantly cystic left adnexal mass containing multiple septations almost completely occupying the abdomen (black arrow). The twisted vascular pedicle in the left lower quadrant demonstrates a whirlpool sign (white arrows)
Claw signIt refers to the sharp angles on either side of the mass which the surrounding normal parenchyma forms when the mass has arisen from the parenchyma. As such, normal parenchyma extends some way around the mass. Examples where a claw sign is useful include:meningioma vsintraparenchymal brain tumourWilms tumour vsneuroblastomarenal angiomyolipomavs retroperitoneal liposarcoma
Imaging plays an important role in the diagnosis and
Plain radiographs provide clues to the location of the
mass,organomegaly and the presence of calcifications.
Ultrasound is generally the most valuable procedure for
the initial evaluation.
Ultrasound differentiates cystic from solid masses,
indicates the organ of origin, and suggests the diagnosis,
also about the vascular compromise and intraluminal
CT or MR needed when the mass is large, poorly defined,
for staging or when obscured by bowel gas.
Radionuclide for specific applications
• It arises from the primitive metanephric epithelium
• Bilateral synchrous tumours occur in 5-10%.
• Nephroblastomatosis as precursor
• Increased incidence
wiedemann syndorme,Drash syndrome,Horseshoe
• Mostly present as asymptomatic mass
• Abdominal pain
• On ultrasound Wilms tumor characteristically is a
well-defined, predominantly solid mass Appears as
echogenic, heterogeneous with cystic areas. Wilms
tumor has a propensity to extend into the renal vein,
inferior vena cava, and right atrium
• On CT Wilms tumours are heterogeneous soft-
tissue density masses, rarely calcifications and
enhancement is patchy.
• On MRI, tumor tends to have decreased signal on T1
and increased on T2
• The lung is commonest site for metastases.
Determined by imaging and surgical findings.
• Stage 1:Encapsulated tumor completely excised.
• Stage 2:Extends beyond the kidney, completely excised
• Stage 3:Residual tumor confined to abdomen and nodes
• Stage 4:Haemetogenous metastasis
• Stage 5:Bilateral tumours at diagnosis
5 year survival exceeds 90% in those with early stage and
A tumor biopsy is not typically performed due to the
chance of upstaging the cancer and seeding the abdomen
with malignant cells.
• The main types of treatment that can be used for
Wilm's tumor are:
• Radiation therapy
Nephrectomy followed by chemotherapy
• Postoperative radiation therapy for stage II and
• Renal cell carcinoma is very rare in young
children but sometimes occurs in older children
• The imaging characteristics of renal cell
carcinoma are indistinguishable from those of
Commonest cause of adrenal mass
May be unilateral or bilateral
Predisposing factors include large babies, obstetric
trauma, neonatal sepsis, and hypoxia
Ultrasound: demonstrate an avascular heterogeneous
adrenal mass that has becomes cystic and smaller over the
following weeks as clot retractions occur.
Serial ultrasound to document the typical course of cystic
changes and resolution, usually evolves from hyper echoic
to iso-echoic to hypo-echoic.
• Malignant tumor of neural crest cells
• Commonest extracranial solid malignant tumor
• Approximately 70% originate in the abdomen of
which 2/3rd arise in adrenal,20% in the chest
and 10% in the head and neck
• May present as palpable abdominal mass or non
• 50 to 60% of all neuroblastoma cases present
• Ultrasound demonstrates a hyperechoic mass in the
adrenal or central retroperitonuem often with flecks of
calcification. Doppler for flow in encased vessels
• CT confirms the calcification with low attenuation mass.
• The most characteristic imaging feature is the
encasement of adjacent vessels
• 99m Tc MDP scintigraphy is useful for detection of bone
• mIBG scan
Involve the radiological, surgical and bone marrow
• Stage 1:confined to organ of origin
• Stage 2: extending beyond the organ of origin, unilateral
• Stage 3:extending across the midline, bilateral nodal
• Stage 4: distant metastases
• Stage 4s: age<1year,localized primary(stage 1 or 2
metastases to liver, skin and/or bone marrow)
• Treatment options for neuroblastoma largely
depend on the location and size of the tumor and
usually involve multimodal therapy
• 2.Radiation therapy
• Bone marrow transplant
• Accounts for 6% of abdominal masses
• 2/3rd are malignant and 1/3rd are benign.
Most common malignant hepatic tumor
• Majority present under 2 years
• No association with cirrhosis
• Increased risk with beckwith wiedemann syndrome,
affected siblings, familial polyposis coli and trisomy 18.
usually present with an abdominal mass
• On ultrasound single or multiple hyperechoic
masses with distortion of the adjacent vascular
architecture,hepatoblastomas usually are highly
• On CT heterogeneous low attenuation lesion are
seen with areas of necrosis and hemorrhage and
often containing coarse calcification
• Vascular and tumor thrombus strongly suggest
• Lung is the most frequent site of metastases
• Resection and transplantation
• Metastases to the liver are more common than
primary hepatic tumours and most frequently
associated with the neuroblastoma, Wilm's
tumour, lymphoma and leukemia
Ultrasound of liver metastases can have a variety
• hypoechoic: most common ~ 65%
• peripheral halo
• poorly defined (infiltrative)
• common benign hepatic mass in newborn. May
be multifocal or solitary.
• Infantile haemangioendotheliomas have a variable
sonographic appearance and may be either
hypoechoic or hyperechoic or may have mixed
• Colour Doppler sonographic evaluation will show
• On CT enhancement is typical
• On MRI lesions are low signal on T1 and high on T2
with large vascular signal voids
Congenital dilatations of the biliary tree
• Most cause symptoms in childhood and adult life.
There are four types:
• Type 1A: Fusiform dilatation of the CBD below the cystic duct
• Type 1B: Fusiform dilation of the common hepatic duct and
• Type 2: Eccentric diverticulum off the CBD
• Type 3: Choledococele-Dilatation of the distal intramural
portion of the CBD
• Type 4: Caroli’s disease-saccular dilations of the hepatic bile
Complications include cholangitis, biliary calculi,
pancreatitis and biliary cirrhosis.
• On ultrasound or CT the biliary tree dilatation or
cyst can be seen.
• 99mTc-HIDA scinitraphy will show accumulation
of tracer within the cyst.
• Percutanous or endoscopic cholangiography and
MRCP are helpful in preoperative planning.
• Pancreatic pseudocysts occurring as the sequelae
of previous pancreatitis or trauma
• True epithelial line congenital pancreatic cysts are
• Primary pancreatic tumours are rare in childhood
including the pancreticoblastoma,papillary
epithelial neoplasm and endocrine adenomas
• Asplenia and polysplenia occurs as part of heterotaxy
• Asplenia is associated with right
isomerism,malrotation and severe congenital cardiac
defects with majority of infants dying in the first year
• Polysplenia in which multiple well defined masses
are found in the left upper quadrant.
• Wandering spleen is ectopic location outside the
left upper quadrant
Focal splenic lesions
• Splenic cysts may be congenital or acquired
secondary to trauma, infarction or hydatid
• Benign focal splenic masses include
haemangiomas,lymphangiomas, AVM and
• Duplication cysts and mesenteric/omental cysts
• Commonest malignancy is Burkitt’s non
▫ Ill defined mass of adherent bowel loops with
infiltration of the adjacent mesentery and with
• Commonest pediatric soft tissue sarcoma
• Pelvis most frequent site of origin
• In boys mostly arises from the prostate or
• In girls from the urinary bladder, uterus or
• These are aggressive tumors
• Invasion of adjacent viscera and pelvic wall
• Distant spread to lymph nodes, lung and bone
• shows heterogeneous well-defined irregular
mass of low to medium echogenicity
• soft tissue density
• some enhancement with contrast
• adjacent bony destruction seen in over 20% of
• 65% are benign and 35% are malignant
• Ovarian teratomas usually present at puberty
and 90% are benign
• The majority of ovarian malignancies are germ
• Most are large >15cm at presentation
• CA-125 levels - elevated in most ovarian
malignancies (~ 80% in general)
• AFP levels - elevated particularly with immature
ovarian teratomas (~ 50% of cases) and ovarian
yolk sac tumours
• On ultrasound solid and cystic component can
• CT can demonstrate the solid-cystic mass with
fat and calcific components
• It is not possible to determine whether a mass is
benign or malignant unless local invasion or
distant metastasis is present on imaging
• Can occur at any age but is most frequent in the first
two decades of life. The affected ovary may be
normal or containing a cyst or tumour.
• Patients present with acute lower abdominal pain
• Ultrasound demonstrate an enlarged swollen ovary
with peripheral cysts and free fluid in the pouch of
• Doppler signal is usually absent.
Beckwith-Wiedemann syndrome (BWS) is a congenital
• macroglossia - most common clinical finding
• localised gigantism / macrosomia
• cardiac anomalies
• pancreatic islet cell hyperplasia