This document discusses paediatric abdominal masses. Ultrasound is generally the initial imaging test which can differentiate cystic from solid masses and indicate organ of origin. CT or MRI may be needed for large or complex masses. Specific masses discussed include renal masses like Wilms tumour, adrenal masses like neuroblastoma, hepatic masses like hepatoblastoma, pancreatic masses, splenic masses, gastrointestinal masses, and pelvic masses like rhabdomyosarcoma. Imaging findings, staging, and treatment options are provided for some of the most common paediatric abdominal masses.

1. Paediatric Abdominal Masses
Dr.Aftab Qadir

2. 1.Renal Masses
2.Adrenal
3.Hepatobiliary
4.Pancreatic
5.Spenic
6.Gastrointestinal
7.Pelvic

3. Imaging plays an important role in the diagnosis and
management.
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
thrombosis.
CT or MR needed when the mass is large, poorly defined,
for staging or when obscured by bowel gas.
Radionuclide for specific applications

4. Renal Masses
Congenital Pevicalyceal
dilatation
Infection Neoplasm Vascular
Multicystic
Dysplastic
kidney
Abscess Malignant: Wilm’s
tumour
Renal vein
thrombosis
PUJ obstruction Focal nephritis Benign Haematoma
Cystic renal
disease
Xanthogranulomat
ous pyelonephritis

5. Wilm’s tumour
• It arises from the primitive metanephric epithelium
• Bilateral synchrous tumours occur in 5-10%.
• Nephroblastomatosis as precursor
• Increased incidence
sporadic aniridia,hemihypertrophy,Beckwith-
wiedemann syndorme,Drash syndrome,Horseshoe
kidney,Family history.

6. Presentation
• Mostly present as asymptomatic mass
• Abdominal pain
• Haematuria
• Fever
• Hypertension

7. Imaging
• 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.

12. Tumor staging
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
favorable histology.
A tumor biopsy is not typically performed due to the
chance of upstaging the cancer and seeding the abdomen
with malignant cells.

13. Treatment
• The main types of treatment that can be used for
Wilm's tumor are:
• Surgery
• Chemotherapy
• Radiation therapy
Nephrectomy followed by chemotherapy
• Postoperative radiation therapy for stage II and
IV lesions

14. • Renal cell carcinoma is very rare in young
children but sometimes occurs in older children
and adolescents
• The imaging characteristics of renal cell
carcinoma are indistinguishable from those of
Wilm's tumor.

15. Adrenal Masses
Adrenal Hemorrhage
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.

18. Neuroblastoma
• 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

19. • May present as palpable abdominal mass or non
specific symptoms
• 50 to 60% of all neuroblastoma cases present
with metastases

20. Radiological imaging
• 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
metastasis.
• mIBG scan

25. Staging
Involve the radiological, surgical and bone marrow
aspirate:
• Stage 1:confined to organ of origin
• Stage 2: extending beyond the organ of origin, unilateral
nodal disease
• Stage 3:extending across the midline, bilateral nodal
disease
• Stage 4: distant metastases
• Stage 4s: age<1year,localized primary(stage 1 or 2
metastases to liver, skin and/or bone marrow)

26. • Treatment options for neuroblastoma largely
depend on the location and size of the tumor and
usually involve multimodal therapy
• 1.Surgery
• 2.Radiation therapy
• 3.Chemotherapy
• Immunotherapy
• Bone marrow transplant

27. Hepatobiliary masses
• Accounts for 6% of abdominal masses
• 2/3rd are malignant and 1/3rd are benign.
Hepatoblastoma
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

28. Imaging
• On ultrasound single or multiple hyperechoic
masses with distortion of the adjacent vascular
architecture,hepatoblastomas usually are highly
vascular
• 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
malignancy
• Lung is the most frequent site of metastases

31. Management
• Chemotherapy
• Radiotherapy
• Resection and transplantation

32. Liver metastases
• Metastases to the liver are more common than
primary hepatic tumours and most frequently
associated with the neuroblastoma, Wilm's
tumour, lymphoma and leukemia

33. Ultrasound of liver metastases can have a variety
of appearances
• hypoechoic: most common ~ 65%
• Hyperechoic
• peripheral halo
• Calcified
• Cystic
• poorly defined (infiltrative)

36. Infantile haemangioendothelioma
• common benign hepatic mass in newborn. May
be multifocal or solitary.

37. Imaging
• Infantile haemangioendotheliomas have a variable
sonographic appearance and may be either
hypoechoic or hyperechoic or may have mixed
echogenicity
• Colour Doppler sonographic evaluation will show
increased flow.
• On CT enhancement is typical
• On MRI lesions are low signal on T1 and high on T2
with large vascular signal voids

40. Choledochal Cysts
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
CBD
• 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
ducts

42. 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.

44. Pancreatic masses
• Pancreatic pseudocysts occurring as the sequelae
of previous pancreatitis or trauma
• True epithelial line congenital pancreatic cysts are
less common
• Primary pancreatic tumours are rare in childhood
including the pancreticoblastoma,papillary
epithelial neoplasm and endocrine adenomas

46. Splenic masses
Causes of splenomegaly
Infections Mononucleosis,tuberculosis,septicemia,typhoid,malaria
Portal hypertension
Haemolytic anemia Thalassaemia
Haematological
malignancies
Leukemia,lymphoma
Infiltrative
disorders
Gaucer’s,niemann-pick,Langerhans cell histiocystosis
Collagen vascular
disorders
Rheumatoid arthritis
CCF

48. • Asplenia and polysplenia occurs as part of heterotaxy
syndrome.(Situs ambiguus)
• Asplenia is associated with right
isomerism,malrotation and severe congenital cardiac
defects with majority of infants dying in the first year
of life
• Polysplenia in which multiple well defined masses
are found in the left upper quadrant.
• Wandering spleen is ectopic location outside the
left upper quadrant

51. Wandering spleen

52. Focal splenic lesions
• Splenic cysts may be congenital or acquired
secondary to trauma, infarction or hydatid
disease.
• Benign focal splenic masses include
haemangiomas,lymphangiomas, AVM and
hamartomas

53. Gastrointestinal Masses
• Duplication cysts and mesenteric/omental cysts
• Commonest malignancy is Burkitt’s non
Hodgkin’s lymphoma
▫ Ill defined mass of adherent bowel loops with
infiltration of the adjacent mesentery and with
lymphadenopathy

55. Pelvic masses
• Rhabdomyosarcoma
• Sacrococcygeal teratomas
• Ovarian masses
• Pelvic inflammatory disease

56. Rhabdomyosarcoma
• Commonest pediatric soft tissue sarcoma
• Pelvis most frequent site of origin
• In boys mostly arises from the prostate or
bladder base
• In girls from the urinary bladder, uterus or
vagina

57. • These are aggressive tumors
• Invasion of adjacent viscera and pelvic wall
• Distant spread to lymph nodes, lung and bone

58. Ultrasound
• shows heterogeneous well-defined irregular
mass of low to medium echogenicity
CT
• soft tissue density
• some enhancement with contrast
• adjacent bony destruction seen in over 20% of
cases

61. Ovarian tumors
• 65% are benign and 35% are malignant
• Ovarian teratomas usually present at puberty
and 90% are benign
• The majority of ovarian malignancies are germ
cell tumour
• Most are large >15cm at presentation

62. Serology
• 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

63. Imaging
• On ultrasound solid and cystic component can
be demonstrated
• 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

67. Adnexal torsion
• 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
and vomiting.
• Ultrasound demonstrate an enlarged swollen ovary
with peripheral cysts and free fluid in the pouch of
Douglas
• Doppler signal is usually absent.

69. Beckwith-Wiedemann syndrome (BWS) is a congenital
overgrowth disorder:
• macroglossia - most common clinical finding
• omphalocoele
• localised gigantism / macrosomia
• hemihypertrophy
• cardiac anomalies
• pancreatic islet cell hyperplasia
• organomegalies
• nephromegaly
• hepatosplenomegaly

70. Associations
• Wilms tumour
• Neuroblastoma
• Hepatoblastoma
• Rhabdomyosarcoma

73. •Thank You