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The Child with an Abdominal Mass Prof. Kais Al-Wattar The Child with an Abdominal Mass After full history and making general, local and rectal examination the steps towards a clinical diagnosis of a mass in the abdomen: 1. Site, characteristics, size, consistency and mobility which will lead to a conclusion as to. 2. The probable organ of origin. 3. Age, knowledge of most likely pathological process arising in the organ affected and these are related to. 4. The length of history and type of symptoms. The commonest malignant abdominal masses are: 1. Neuroblastoma. 2. Wilm’s tumor (Nephroblastoma). 3. Malignant lymphoma (usually Non-Hodgkin lymphoma of the intestine). 4. Lymphosarcoma. 5. Hepatoblastoma. 6. Other Suprarenal tumors (Non Neuroblastoma). 7. Others . The commonest benign masses are those of: 1. Hydronephrotic kidney (Peliviureteric junction obstruction), polycystic kidney. 2. Mesenteric mass and cysts. 3. Intestinal Duplication cysts. 4. Hydatid cysts in the older children A mass in the loin in the toddlers (1-3 years). Triad of : 1. Abdominal Neuroblastoma 2. Wilm’s Tumor. 3. Hydronephrosis. Minimal local or general symptoms, usually the mass discovered by the mother. Investigations of an Abdominal Mass Palpation should be restricted to the minimum. 1. X-Ray: plain X-Ray , calcifications, Renal angiogram, I.V.U. other kidney. 2. U.S. , CT , MRI. 3. Blood & urine. 4. Bone Marrow aspiration or biopsy. 5. Fine Needle Aspiration Cytology (FNAC) when indicated. Neuroblastoma Prof. Kais Al-Wattar Most common and most highly malignant arise from the cells of fetal neural crest, and the adrenal gland is the commonest. The peak age of incidence is usually at 2 years of age. The tumor tends to be ill-defined, firm, nodular, fixed and often extends to the midline, usually associated with fever and loss of weight. Neuroblastoma…cont. Early metastasis to: 1. Bone Marrow. 2. Cortex of long bones. 3. Skull, spine, orbit. 4. Lymph Nodes. 5. Liver. 6. Periorbital metastasis. (the raccoon-like appearance) Neuroblastoma…cont. Outcome: - Spontaneous regression in 3% of cases but in 65-75% of cases the dissemination is already present when the diagnosis is made. Another outcome is maturation to a benign Ganglioneuroma. Spread & Metastasis is common. Neuroblastoma is radiosensitive and responds favorably to cytotoxic agents. Neuroblastoma…cont When the evidence suggests that the mass is a Nuroblastoma the investigations required are: - 1. Bone marrow biopsy. (65-75%) 2. Skeletal Survey. 3. Biopsy of other suspicious sites of metastasis (Lymph Nodes). 4. 24 h collection of urine for VMA , MHMA, Catecholamine metabolites. 5. Chest X-Ray. 6. I.V.U., Ultrasound, MRI. 7. Fine Needle Aspiration cytology ? Biopsy. Neuroblastoma…cont Treatment : Surgical excision rare If it is extending behind the Aorta or Inferior Vena Cava it is non-resectable. The Treatment rests on: 1. Chemotherapy. 2. Radiotherapy. 3. Immunotherapy.
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