P10) Palpable abdominal mass and unexplained weight loss

Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.

Learning Outcomes

  1. Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a pediatric patient with a palpable abdominal mass.
  2. Review the DDx considerations in a pediatric patient with a palpable abdominal mass.
  3. Identify the spectrum of imaging findings in appropriate modalities for evaluating a pediatric patient with a palpable abdominal mass.

History

Physical Exam

Labs

Provisional Diagnosis

Select the Dx you believe is most appropriate
The clinical presentation of weight loss and fatigue, a palpable abdominal mass, periorbital ecchymosis ("raccoon eyes"), and elevated urinary catecholamines is concerning for a neuroblastoma.
Well done. You were correct

Potential Acuity

What is your assessment of the likely acuity for this patient?

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The patient requires routine, but expedited workup.

First Imaging Study

What is the first imaging study you will order?

An abdominal CT scan with and without contrast is appropriate. This imaging modality can help delineate the primary tumor site, possible metastases, and evaluate the tumor's impact on surrounding structures.
View ACR Appropriateness Criteria
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Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

View Report

Watch our video

View the full study if you'd like to take a look yourself.

Second Imaging Study

What is the next imaging study you will order?

An MIBG (metaiodobenzylguanidine) scan is the initial imaging modality of choice as neuroblastomas often exhibit a high affinity for MIBG, making it highly sensitive and specific for detecting primary and metastatic disease. This scan can determine the extent of disease and guide treatment planning.
View ACR Appropriateness Criteria
Well done. You were correct

Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

View Report

Watch our video

View the full study if you'd like to like a look yourself

Third Imaging Study

What is the next imaging study you will order?

No further imaging is required.

What is your Diagnosis now that you have seen the imaging results?

The patient’s presentation and imaging findings are consistent with a metastatic neuroblastoma.

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

The patient requires routine, but expedited workup.

Assessment and Plan

Please provide your assessment and plan for this patient

This is a 3-year-old female presenting with weight loss, fatigue, a palpable abdominal mass, periorbital ecchymosis ("raccoon eyes"), and elevated urinary catecholamines. Imaging studies including CT and MIBG scans confirm a right suprarenal mass, likely a neuroblastoma, with diffuse metastases. The next steps involve engaging Pediatric Oncology and Pediatric Surgery for further diagnostic evaluation and management, potentially encompassing surgical resection, chemotherapy, and radiation therapy.

Lessons Learned:
- Neuroblastomas are neoplasms originating from neural crest cells. Commonly diagnosed around 1-2 years of age, they are a prevalent childhood cancer and can manifest anywhere along the sympathetic chain.
- Elevated urinary catecholamines, specifically Vanillylmandelic Acid (VMA) and Homovanillic Acid (HVA), are frequently associated with neuroblastoma due to the tumor's increased catecholamine metabolism.
- The clinical presentation of neuroblastoma includes constipation, an abdominal mass palpable across the midline, and opsoclonus-myoclonus ataxia syndrome, colloquially known as "dancing hands and feet".
- Diagnostic modalities, like CT and MIBG imaging, can identify tumor localization, and reveal potential metastatic spread to bones and other organs.
- Histological examination typically reveals small, round blue cells with hyperchromatic nuclei and characteristic Homer Wright rosettes.
- Urinalysis often presents elevated metabolites of catecholamines, specifically homovanillic acid (HVA) and vanillylmandelic acid (VMA).
- Treatment strategies are determined by the staging criteria and the presence of MYCN gene amplification, a marker associated with an increased risk of metastasis.

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