Avoiding misdiagnosing neuroblastoma as Wilms tumor

Radiomics in differential diagnosis of Wilms tumor and neuroblastoma with adrenal location in children

OBJECTIVES

Machine learning methods can be applied successfully to various medical imaging tasks. Our aim with this study was to build a robust classifier using radiomics and clinical data for preoperative diagnosis of Wilms tumor (WT) or neuroblastoma (NB) in pediatric abdominal CT.

MATERIAL AND METHODS

This is a single-center retrospective study approved by the Institutional Ethical Board. CT scans of consecutive patients diagnosed with WT or NB admitted to our hospital from January 2005 to December 2021 were evaluated. Three distinct datasets based on clinical centers and CT machines were curated. Robust, non-redundant, high variance, and relevant radiomics features were selected using data science methods. Clinically relevant variables were integrated into the final model. Dice score for similarity of tumor ROI, Cohen's kappa for interobserver agreement among observers, and AUC for model selection were used.

RESULTS

A total of 147 patients, including 90 WT (mean age 34.78 SD: 22.06 months; 43 male) and 57 NB (mean age 23.77 SD:22.56 months; 31 male), were analyzed. After binarization at 24 months cut-off, there was no statistically significant difference between the two groups for age (p = .07) and gender (p = .54). CT clinic radiomics combined model achieved an F1 score of 0.94, 0.93 accuracy, and an AUC 0.96.

CONCLUSION

In conclusion, the CT-based clinic-radiologic-radiomics combined model could noninvasively predict WT or NB preoperatively. Notably, that model correctly predicted two patients, which none of the radiologists could correctly predict. This model may serve as a noninvasive preoperative predictor of NB/WT differentiation in CT, which should be further validated in large prospective models.

CLINICAL RELEVANCE STATEMENT

CT-based clinic-radiologic-radiomics combined model could noninvasively predict Wilms tumor or neuroblastoma preoperatively.

KEY POINTS

• CT radiomics features can predict Wilms tumor or neuroblastoma from abdominal CT preoperatively. • Integrating clinic variables may further improve the performance of the model. • The performance of the combined model is equal to or greater than human readers, depending on the lesion size.

Prechemotherapy Transperitoneal Robotic-Assisted Partial Nephrectomy (RAPN) for a Wilms Tumor: Surgical and Oncological Outcomes in a Four-Year-Old Patient

BACKGROUND

Wilms tumor (WT) is the most frequent renal tumor in children. The SIOP-UMBRELLA Guidelines allow for nephron-sparing surgery (NSS) in syndromic patients, as well as in cases of small (<300 mL) non-syndromic unilateral WTs, without lymph node involvement, and with a substantial expected remnant renal function, following neoadjuvant chemotherapy. We present a case of prechemotherapy transperitoneal robot-assisted partial nephrectomy (RAPN) for a unilateral, non-syndromic Wilms tumor.

METHODS

A four-year-old child presented with a solid mass measuring 3.6 cm in diameter involving the upper right renal pole, incidentally detected during an abdominal echotomography. CT scan and abdominal MRI revealed no local infiltration or lymph node involvement, suggesting that the exophytic mass could be easily resected via an NSS robotic approach. Preoperative imaging did not strongly suggest WT. A virtual 3D reconstruction of the tumor was performed.

RESULTS

After the oncologic board approval, a robot-assisted partial nephrectomy with an intraperitoneal approach was performed. Histopathological analysis confirmed the diagnosis of WT. The patient subsequently received 10 doses of vincristine as adjuvant chemotherapy. A 28-month follow-up showed no tumor recurrence.

CONCLUSIONS

Intraperitoneal RAPN may be an option for selected WT and warrants consideration as a challenging but advantageous approach.

Photodynamic Therapy in Complex Therapy of Retroperitoneal Tumors in Children

During the period from 2009 to 2021, 93 patients aged 0–11 years (48 boys and 45 girls) with retroperitoneal tumors were treated. There were 66 patients with nephroblastoma and 27 patients with adrenal neuroblastoma among them. As per treatment strategies, the patients were separated into two groups: the control group and the study group. The control group (comparison) received therapy according to the protocols, whereas the study group consisted of patients who received photodynamic therapy (PDT) in addition to the standard treatment. The control group consists of 47 patients with retroperitoneal tumors, including 35 patients with nephroblastoma and 12 patients with adrenal neuroblastoma. The study group included 46 children: 31 patients with nephroblastoma and 15 patients with adrenal neuroblastoma. The 5-year survival rate in the control group was 74.5%, and it was 91.3% in the study group (p = 0.030). Recurrent tumors developed in 14.9% of the patients in the control group, while in the study group, relapse occurred in 8.7% of the patients (p = 0.357). The PDT used in this study for treatment of retroperitoneal tumors improves the results of surgical treatment. It also appreciably increases the survival rate of patients with retroperitoneal tumors. Overall, PDT is a hopeful antitumor approach and can be effectively used in the complex therapy of retroperitoneal tumors in children.

Pediatric Abdominal Masses: Imaging Guidelines and Recommendations

Pediatric abdominal masses are commonly encountered in the pediatric population, with a broad differential diagnosis that encompasses benign and malignant entities. The primary role of abdominal imaging in the setting of a suspected pediatric abdominal mass is to establish its presence, as nonneoplastic entities can mimic an abdominal mass, and to identify characteristic imaging features that narrow the differential diagnosis. In the setting of a neoplasm, various imaging modalities play an important role to characterize the mass, stage extent of disease, and assist in presurgical planning. The purpose of this article is to discuss a practical imaging algorithm for suspected pediatric abdominal masses and to describe typical radiological findings of the commonly encountered abdominal masses in neonates and children with emphasis on imaging guidelines and recommendations.

Primary Renal Neuroblastoma Mimicking Wilms Tumor

Neuroblastoma (NB) is the most common extracranial solid malignancy in children younger than 5 years of age. It is an aggressive malignancy with evidence of secondary metastasis at the time of the initial presentation. NB is rightly known as a great masquerader. Herein, we describe three children who presented with renal masses mimicked as Wilms tumor initially and later diagnosed as NB on biopsy. The response to therapy was not satisfactory in all three children. A higher level of awareness and early recognition is important for diagnosing and managing NB. We should rule out NB when there is a diagnostic dilemma before nephrectomy in these patients. Intrarenal NB should be considered with the combination of renal mass and hypertension with elevated catecholamines. The distinction between these two tumors is important since both malignancies have different therapeutic and prognostic implications.

Diagnostic Errors in Wilms' Tumors: Learning From Our Mistakes

Aim: This study aimed to analyze clinical characteristics and image findings in patients initially diagnosed with renal masses and treated on the Société Internationale d'Oncologie Pédiatrique (SIOP) 2001 protocol for Wilms tumor (WT) that eventually were diagnosed with different pathologies. Methods: We reviewed the preoperative symptoms, laboratory tests, and images of patients who were initially treated for WT and proved to have other diagnoses. Data from these patients were compared to those of the last 10 patients with WT and the last 10 patients with neuroblastoma (NBL) treated at a single institution. Results: From June 2001 to December 2020, we treated 299 patients with NBL and 194 with WT. Five patients treated with preoperative chemotherapy for WT were postoperatively diagnosed with NBL (one patient had bilateral renal masses and one with multifocal xanthogranulomatous pyelonephritis). Three underwent nephrectomy, two biopsies only, and one adrenalectomy due to intraoperative characteristics. Regarding clinical presentation, abdominal mass or swelling was very suggestive of WT (p = 0.011); pain, although very prevalent in the study group (67%), was not statistically significant, as well as intratumoral calcifications on computed tomography (CT) (67%). Urinary catecholamines were elevated in all patients mistreated for WT with the exception of the patient with pyelonephritis in which it was not collected. Conclusion: Some pathologies can be misdiagnosed as WT, especially when they present unspecified symptoms and dubious images. Diagnostic accuracy was 98.1%, which highlights the quality of the multidisciplinary team. Abdominal mass or swelling is highly suggestive of WT, especially in the absence of intratumoral calcifications on CT. If possible, urinary catecholamines should be collected at presentation as they help in the differential diagnosis of NBL.

From Wilms to kidney tumors: which ones require a biopsy?

Ninety percent of childhood renal tumors are Wilms tumors (nephroblastoma). While the Children's Oncology Group (COG) recommends primary surgery, the International Society of Paediatric Oncology (SIOP) recommends neoadjuvant chemotherapy, which can be initiated without histological confirmation if the presentation is typical for Wilms tumor. This review article describes the clinical, biological and radiologic criteria used by the SIOP community to consider diagnostic biopsy, i.e. when the renal origin is doubtful, when a pseudotumor is suspected or when a non-Wilms histology may be anticipated.

Indications and results of diagnostic biopsy in pediatric renal tumors: A retrospective analysis of 317 patients with critical review of SIOP guidelines

OBJECTIVES

According to the Renal Tumor Study Group (RTSG) of the International Society of Paediatric Oncology (SIOP), diagnostic biopsy of renal tumors prior to neoadjuvant chemotherapy is not mandatory unless the presentation is atypical for a Wilms tumor (WT). This study addresses the relevance of this strategy as well as the accuracy and safety of image-guided needle biopsy.

METHODS

Clinical, radiological, and pathological data from 317 children (141 males/176 females, mean age: 4 years, range, 0-17.6) consecutively treated in one SIOP-affiliated institution were retrospectively analyzed.

RESULTS

Presumptive chemotherapy for WT was decided for 182 patients (57% of the cohort), 24 (8%) were operated upfront, and 111 (35%) were biopsied at diagnosis. A non-WT was confirmed after surgery in 5/182 (3%), 11/24 (46%), and 28/111 (25%), respectively. Age at diagnosis was the most commonly (46%) used criterion to go for biopsy but a nine-year threshold should be retrospectively considered more relevant. Tumor volumes of clear cell sarcoma of the kidney and WT were significantly higher than those of other tumors (P = 0.002). The agreement between core-needle biopsy (CNB) and final histology was 99%. No significant morbidity was associated with CNB.

CONCLUSION

The use of SIOP criteria to identify patients eligible for presumptive WT neoadjuvant chemotherapy or upfront surgery avoided biopsy in 65% of children and led to a 97% rate of appropriate preoperative chemotherapy. Image-guided CNB is a safe and accurate diagnostic procedure. The relevance of SIOP biopsy criteria might be improved by using an older age threshold (9 years instead of 6 years) and by adding initial tumor volume.

Recent Trends in the Quantification of Biogenic Amines in Biofluids as Biomarkers of Various Disorders: A Review

Biogenic amines (BAs) are bioactive endogenous compounds which play a significant physiological role in many cell processes like cell proliferation and differentiation, signal transduction and membrane stability. Likewise, they are important in the regulation of body temperature, the increase/decrease of blood pressure or intake of nutrition, as well as in the synthesis of nucleic acids and proteins, hormones and alkaloids. Additionally, it was confirmed that these compounds can be considered as useful biomarkers for the diagnosis, therapy and prognosis of several neuroendocrine and cardiovascular disorders, including neuroendocrine tumours (NET), schizophrenia and Parkinson's Disease. Due to the fact that BAs are chemically unstable, light-sensitive and possess a high tendency for spontaneous oxidation and decomposition at high pH values, their determination is a real challenge. Moreover, their concentrations in biological matrices are extremely low. These issues make the measurement of BA levels in biological matrices problematic and the application of reliable bioanalytical methods for the extraction and determination of these molecules is needed. This article presents an overview of the most recent trends in the quantification of BAs in human samples with a special focus on liquid chromatography (LC), gas chromatography (GC) and capillary electrophoresis (CE) techniques. Thus, new approaches and technical possibilities applied in these methodologies for the assessment of BA profiles in human samples and the priorities for future research are reported and critically discussed. Moreover, the most important applications of LC, GC and CE in pharmacology, psychology, oncology and clinical endocrinology in the area of the analysis of BAs for the diagnosis, follow-up and monitoring of the therapy of various health disorders are presented and critically evaluated.

Synchronous Bilateral Wilms Tumor: Five-Year Single-Center Experience with Assessment of Quality of Life

Context:

Synchronous Bilateral Wilms tumor (sBWT).

Aims:

This study aimed to assess the outcome of patients with sBWT treated on SIOP protocol.

Settings and Design:

Retrospective and prospective randomized study.

Subjects and Methods:

SIOP 93-01 protocol was used to study nine patients of sBWT in a single center and followed up over a period from 2 to 5 years.

Statistical Analysis Used:

Unpaired t-test and Mann–Whitney U-test were used for analysis.

Results:

Of nine patients, six were included in the study as three patients lost to follow-up. Among the six patients, there were four girls and two boys with a median age of 2 years. Mean regression in the size of tumor was 87% in four out of six patients. Tumor with unfavorable histology showed 32% response (ratio of favorable: unfavorable histology 2:1). Event-free survival rate was 81.3% and overall survival was 90% over 2–5 years. Recurrence was seen in two patients of whom one had Denys–Drash syndrome. Mean DTPA glomerular filtration rate was 91.4/ml/min/1.73 m² preoperatively and that of 3 months after completion of treatment was 84/ml/min/1.73 m². Health-related quality of life (HRQOL) using Pediatric Quality of Life Inventory and Lansky Play Performance Scale revealed significant improvement results of all functioning domains such as physical, social, emotional, and school subscales with P < 0.05 and performance scale (P < 0.04).

Conclusions:

We suggest SIOP protocol for sBWT and bilateral nephron-sparing surgery in two stages. However, long-term follow-up is required to assess the ultimate renal function outcome. HRQOL is an essential guide in improving the conditions of pediatric cancer survivors.

Peripheral neuroblastic tumor of the kidney: case report and review of literature

INTRODUCTION

Peripheral neuroblastic tumors (PNTs) account for 8%-10% of all pediatric tumors. Adrenal glands and sympathetic ganglia are the commonest site of tumor growth. In the clinicopathologic spectrum of PNTs, neuroblastoma and ganglioneuroma are the most primitive and the most mature tumor form, while ganglioneuroblastoma represents an intermediate state of maturation. Surgical resection is the therapy of choice in localized disease, but can lead to serious complications when performed in the presence of certain imaging-defined risk factors.

CASE PRESENTATION

We present a rare case of primary intrarenal ganglioneuroblastoma diagnosed in a teenager who underwent conservative surgery and, despite this, developed upper pole renal ischemia without loss of parenchymal function.

CONCLUSION

We underline the complex management of these extremely rare cases of neuroblastic tumors, which require a dedicated multidisciplinary team.

Diffusion-weighted MRI and intravoxel incoherent motion model for diagnosis of pediatric solid abdominal tumors

Background

Pediatric retroperitoneal tumors in the renal bed are often large and heterogeneous, and their diagnosis based on conventional imaging alone is not possible. More advanced imaging methods, such as diffusion‐weighted (DW) MRI and the use of intravoxel incoherent motion (IVIM), have the potential to provide additional biomarkers that could facilitate their noninvasive diagnosis.

Purpose

To assess the use of an IVIM model for diagnosis of childhood malignant abdominal tumors and discrimination of benign from malignant lesions.

Study Type

Retrospective.

Population

Forty‐two pediatric patients with abdominal lesions (n = 32 malignant, n = 10 benign), verified by histopathology.

Field Strength/Sequence

1.5T MRI system and a DW‐MRI sequence with six b‐values (0, 50, 100, 150, 600, 1000 s/mm²).

Assessment

Parameter maps of apparent diffusion coefficient (ADC), and IVIM maps of slow diffusion coefficient (D), fast diffusion coefficient (D*), and perfusion fraction (f) were computed using a segmented fitting model. Histograms were constructed for whole‐tumor regions of each parameter.

Statistical Tests

Comparison of histogram parameters of and their diagnostic performance was determined using Kruskal–Wallis, Mann–Whitney U, and receiver‐operating characteristic (ROC) analysis.

Results

IVIM parameters D* and f were significantly higher in neuroblastoma compared to Wilms' tumors (P < 0.05). The ROC analysis showed that the best diagnostic performance was achieved with D* 90^th percentile (area under the curve [AUC] = 0.935; P = 0.002; cutoff value = 32,376 × 10⁻⁶ mm²/s) and f mean values (AUC = 1.00; P < 0.001; cutoff value = 14.7) in discriminating between neuroblastoma (n = 11) and Wilms' tumors (n = 8). Discrimination between tumor types was not possible with IVIM D or ADC parameters. Malignant tumors revealed significantly lower ADC, D, and higher D* values than in benign lesions (all P < 0.05).

Data Conclusion

IVIM perfusion parameters could distinguish between malignant childhood tumor types, providing potential imaging biomarkers for their diagnosis.

Level of Evidence: 4

Technical Efficacy: Stage 2

J. Magn. Reson. Imaging 2018;47:1475–1486.

Case report: value of gene expression profiling in the diagnosis of atypical neuroblastoma

BACKGROUND

Nephroblastoma and neuroblastoma belong to the most common abdominal malignancies in childhood. Similarities in the initial presentation may provide difficulties in distinguishing between these two entities, especially if unusual variations to prevalent patterns of disease manifestation occur. Because of the risk of tumor rupture, European protocols do not require biopsy for diagnosis, which leads to misdiagnosis in some cases.

CASE PRESENTATION

We report on a 4½-year-old girl with a renal tumor displaying radiological and laboratory characteristics supporting the diagnosis of nephroblastoma. Imaging studies showed tumor extension into the inferior vena cava and bilateral lung metastases while urine catecholamines and MIBG-scintigraphy were negative. Preoperative chemotherapy with vincristine, actinomycine D and adriamycin according to the SIOP2001/GPOH protocol for the treatment of nephroblastoma was initiated and followed by surgical tumor resection. Histopathology revealed an undifferentiated tumor with expression of neuronal markers, suggestive of neuroblastoma. MYCN amplification could not be detected. DNA-microarray analysis was performed using Affymetrix genechip human genome U133 plus 2.0 and artificial neural network analysis. Results were confirmed by multiplex RT-PCR.

RESULTS

Principal component analysis using 84 genes showed that the patient sample was clearly clustering with neuroblastoma tumors. This was confirmed by hierarchical clustering of the multiplex RT-PCR data. The patient underwent treatment for high-risk neuroblastoma comprising chemotherapy including cisplatin, etoposide, vindesine, dacarbacine, ifosfamide, vincristine, adriamycine and autologous stem cell transplantation followed by maintenance therapy with 13-cis retinoic acid (GPOH NB2004 High Risk Trial Protocol) and is in complete long-term remission.

CONCLUSION

The use of gene expression profiling in an individual patient strongly contributed to clarification in a diagnostic dilemma which finally led to a change of diagnosis from nephroblastoma to neuroblastoma. This case underlines the importance of gene-expression profiling in the correct diagnosis of childhood neoplasms with atypical presentation to ensure that adequate treatment regimens can be applied.

Complications in the surgical management of children with malignant solid tumors

With improvement in the outcomes for children with cancer has come an increasing focus on minimizing the morbidity from therapeutic interventions, including surgical procedures, while continuing to have a high likelihood of cure. Thus, an appreciation for the potential complications of surgery, both acute and long term, is critical when considering the risks and benefits of any procedure performed on a child with cancer. Although not meant to be an exhaustive review, here we discuss the most common and significant surgical complications that may occur when performing diagnostic, therapeutic, or supportive procedures in children with the most common malignant solid tumors.

Clear cell sarcoma of the kidney with calcification and a novel chromosomal abnormality: a case report

A 9-year-old male presented with a renal tumor that showed a cystic structure with calcification on computed tomography. A pathological analysis of the resected tumor suggested clear cell sarcoma of the kidney (CCSK). Thus, this patient suffered atypical CCSK with significant calcification and gross necrosis. A novel chromosomal abnormality was also identified in the tumor.

Intrarenal neuroblastoma with pulmonary metastases mimicking a Wilms tumor

Primary intrarenal neuroblastoma is extremely rare and is a mimic of Wilms tumor. We present a case of a renal mass in a 14month old male with lung metastases at the initial presentation. This was thought to represent a Wilms tumor. Histology of a biopsied lung nodule revealed neuroblastoma.

Retroperitoneal neoplasms within the perirenal space in infants and children: differentiation of renal and non-renal origin in enhanced CT images

PURPOSE

To retrospectively demonstrate the specific CT findings of retroperitoneal neoplasms to diagnosis and differential diagnosis renal and non-renal tumors within the perirenal space in infants and children.

MATERIALS AND METHODS

We retrospectively reviewed the clinical data and CT images of 42 consecutive patients with surgically and pathologically proven retroperitoneal neoplasms within the perirenal space. The patients were divided into renal tumors group (n=16) and non-renal tumors group (n=26). The former included nephroblastoma (n=15) and renal lymphoma (n=1), while the latter included neuroblastoma (n=12), retroperitoneal teratoma (n=6), adrenal ganglioneuroma (n=4), retroperitoneal lymphoma (n=2), ectopic pheochromocytoma (n=1) and adrenal cortical carcinoma (n=1). The clinical information of these patients and the major CT imaging findings which were related to lesion localization in the two groups were compared and statistically analyzed using Pearson Chi-Square Test and Risk Estimate.

RESULTS

The mean diameter of tumors was 9.82±6.13 cm (n=42 range: 2.3-3 2cm). The demographic data and chief clinical symptoms between the renal tumor group and the non-renal tumor group showed no statistically significant differences (P>0.05). 30.8% (8/26) of non-renal tumor patients presented elevated urinary vanillylmandelic acid (VMA) level, while no patient showed elevated VMA in renal tumor group (P<0.05). Some CT imaging signs of the renal tumors including "crescent sign" (odds ratio, OR=52), "beak sign" (OR=84), "embedded organ sign" (OR=84), and "prominent feeding artery sign" (OR=36) showed significantly higher incidence when compared to the non-renal tumors (P<0.001). The sign of "renal displacement and renal axis rotation" (OR=0.059) was seen in 23 of 26 (88.5%) non-renal tumors, but in only 5 of 16 (31.3%) renal tumors (P<0.001). The sign of "extra-renal central plane of tumor" (OR=0.038) was displayed in 24 of 26 (92.3%) non-renal tumors, but in only 5 of 16 (31.3%) renal tumors (P<0.001). The CT findings such as "pseudocapsule" (OR=38.5), "necrosis and cystic change" (OR=11.2), "vascularity" (OR=16.867), "distant metastasis" (OR=5.96), and "inferior vena cava tumor thrombus" which were thought to be characteristic of renal tumors were observed with significant higher incidence in renal tumors group than in the non-renal tumors group (P<0.05); while CT signs of "irregular mass" (OR=0.045) and "intratumoral calcifications" (OR=0.065) were observed with lower incidence in renal tumors group than in the non-renal tumors group (P<0.05).

CONCLUSION

The "crescent sign", "beak sign", "embedded kidney sign" and "renal arteries feeding" are the most specific CT signs suggestive of renal tumors and distinguish them from non-renal origin tumors within the perirenal space. Other CT signs, such as "pseudocapsule", "hypervascular tumors" and "Inferior vena cava tumor thrombus", when present, tumors of renal origin are strongly suggested. On the other hand, CT signs of "irregular mass", "intratumoral calcifications", and associated elevated urinary vanillylmandelic acid strongly suggest the non-renal tumors.