Clinical Aspects

When evaluating a child's abdominal mass, the patient's age, sex, history and clinical findings are the most important parameters to be included in the process of establishing a diagnosis. This renders pediatric radiology a distinct clinical specialty. Two different processes may look morphologically similar, yet have completely different pathogenesis and significance. With the necessary clinical information and professional experience, one should be able to make a reasonable or even distinct diagnosis in a given case (Fig. 2, 3). On the other hand, the abdominal mass may be an incidental observation by the child or the parent and there may be no additional symptoms. A child with nephroblastoma, unless traumatized, commonly presents with a large abdominal mass, without pain and apparently in good health. Parents may report that the mass appeared quite suddenly. Such a remark is not unusual, since nephroblas-toma is known for its rapid growth. Neuroblastoma, on the other hand, may lead to symptoms such as pallor, fatigue and failure to thrive. Morphologically, each of these two retroperitoneal tumors has specific characteristics that render the diagnosis in the majority of instances. However, each may present a differential diagnostic challenge (Fig. 4, 5).

An inflammatory mass is commonly caused by an infectious process, such as appendicitis or infection of the urogenital tract. Therefore, the signs and symptoms, including laboratory data, are those of an infectious disease and are often associated with abdominal pain. Local or diffuse pain, although quite nonspecific,

Fig.3. Hematocolpos in a 15-year-old adolescent with acute urinary retention. Midsagittal ultrasonography through anterior lower abdomen shows two partially superimposed cystic structures similar to Fig. 2 (a before and b after spontaneous micturition). With a less filled bladder, numerous tiny echoes due to menstruation and uterine cervix are noticeable

Fig.3. Hematocolpos in a 15-year-old adolescent with acute urinary retention. Midsagittal ultrasonography through anterior lower abdomen shows two partially superimposed cystic structures similar to Fig. 2 (a before and b after spontaneous micturition). With a less filled bladder, numerous tiny echoes due to menstruation and uterine cervix are noticeable

Fig.2. Cystic teratoma in a 3-week-old girl with urinary retention. a Plain film of abdomen shows huge midline mass reaching from pelvic floor to displaced stomach. Midsagittal ultrasonographic scans through anterior lower abdomen show two partially superimposed cystic structures (b before, c after catheterization of bladder). Catherization helps in distinguishing antero-superior bladder with changing volume from infero-posterior cystic teratoma. Tiny linear structure in cranial aspect of teratoma is a hint for diagnosis

Fig.2. Cystic teratoma in a 3-week-old girl with urinary retention. a Plain film of abdomen shows huge midline mass reaching from pelvic floor to displaced stomach. Midsagittal ultrasonographic scans through anterior lower abdomen show two partially superimposed cystic structures (b before, c after catheterization of bladder). Catherization helps in distinguishing antero-superior bladder with changing volume from infero-posterior cystic teratoma. Tiny linear structure in cranial aspect of teratoma is a hint for diagnosis

Fig. 4. Nephroblastoma in a 2-year-old boy with painless left abdominal mass. Left coronal ultrasonographic scan shows apparently solid tumor mass in left flank suspected to be a Wilms' tumor (a). Intravenously enhanced CT scans through mid part of well defined tumor (b, c) shows its dor-sally exophytic growth; irregular contrast enhancement suggests partial tumor necrosis

Fig. 5. Neuroblastoma in a 6-week-old boy causing ipsilat-eral urinary obstruction. Transverse ultrason-ography with the child prone (a) and coronal (b) demonstrate solid echogenic mass next to right kidney; obstructive hydrone-phrosis from proximal extrinsic ureteral compression due to tumor. Renal artery is engulfed by mass (a); arterial Doppler signal not illustrated. Intravenously contrast-enhanced CT shows correlating features on three consecutive scans (c, d, e), including displacement and compression of inferior vena cava is the most frequent symptom in abdominal disease, whether or not there is an appreciable anatomical correlate. Pain may also be a sequela of a noninflammatory mass that has been traumatized. Beside pain, functional abnormality of an organ system, fever, loss of weight and/or appetite, systemic disease, and even severe illness are all nonspecific in conjunction with an abdominal mass and do not, per se, indicate malignancy. Some may, however, be characteristic of a specific disease process such as lymphoma, leukemia or metastatic disease.

Urinary retention may be a serious symptom. Therefore, a pre- or rather, retrorectal mass causing the symptom must be excluded or differentiated (Fig. 1, 2). On the other hand, clinical uncertainty means that 'urinary retention' is a notoriously claimed symptom leading to imaging procedures recommended because of inadequate evaluation of the patient's history (e.g., no fluid intake for many hours with a subsequent lack of urine production and, thus, an empty bladder).

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