Adrenal masses in children

Expect the unexpected: neuroblastoma in a patient with the VACTERL association

The VACTERL association is characterised by a variable combination of vertebral defects, anorectal malformation, cardiac defects, tracheo-oesophageal fistula, renal anomalies and limb abnormalities. Malignant tumours are not usually detected in these patients.We present the case of an infant diagnosed with the VACTERL association at birth due to an anorectal malformation, cardiac and vertebral anomalies. Further imaging was obtained to investigate potential spinal cord anomalies. This scan detected an incidental left adrenal mass. Diagnostic work-up including biopsy confirmed the adrenal mass as an intermediate risk left adrenal neuroblastoma with encasement of the left renal vessels and superior mesenteric artery.To our knowledge, this is the first case of an infant patient with the VACTERL association and simultaneous diagnosis of a neuroblastoma. This case demonstrates how careful expert review of specialist imaging can incidentally reveal unexpected findings which require a significant alteration of a patient's treatment pathway.

Robot-assisted laparoscopic adrenalectomy: Extended application in children

BACKGROUND

Minimally invasive surgery for paediatric adrenal tumours has evolved, but robot-assisted laparoscopic adrenalectomy (RALA) in children remains poorly studied. The current prospective study aims to demonstrate the safety and efficacy of RALA in treating children with adrenal tumours.

METHODS

A prospective institutional analysis of children presenting with neuroblastic and endocrine tumours treated with RALA was undertaken over a six year-period. For each child, clinical parameters were collected relating to diagnosis, surgery and outcomes.

RESULTS

A total 50 RALA were performed; 23 for unilateral neuroblastic tumours (87 % neuroblastomas) and 27 for endocrine tumours. Eight neuroblastic tumours (35 %) had image-defined risk factors (all due to tumour invading the renal pedicle). Median length of stay was two days. Resection margins were macroscopically clear in all cases. After median follow-up of 2.9 years (1.6-3.9), two children are under treatment for metastatic relapse (high-risk disease) and three died due to refractory disease. Sixteen children had endocrine tumours: pheochromocytoma (n = 13), or bilateral nodular adrenocortical hyperplasia with Cushing's syndrome (n = 14). One child required non-emergent conversion, and one complication occurred (grade IIIb) after median follow-up of 3.3 years (1.0-5.7).

CONCLUSIONS

The current study is the largest reported experience in the literature and confirms the safety and effectiveness of RALA in carefully selected children with adrenal tumours. Through an iterative process and in the setting of a dedicated paediatric robotic surgical team indications have been clarified and extended. The current study confirms RALA has particularly utility in patients with severe disease (IDRF + metastatic neuroblastomas) or genetic predisposition syndromes.

Laparoscopic approach of pediatric adrenal tumors

PURPOSE

To analyze the role of laparoscopic surgery for the management of pediatric adrenal tumors (AT).

METHODS

Retrospective analysis of children diagnosed with AT, operated laparoscopically during 2003-2020. The strategy differed according to tumor extension. AT < 6 cm were resected. Locally advanced tumors (L2) or > 6 cm were biopsied.

RESULTS

N = 28. Complete tumor resection (R0) in 20 (71%), tumor biopsy in 8 (R2). Age (median): 28.8 months (2 months-18 years). 14/28 left-sided, 2 bilateral. Median operating time: 78 min (45-180). Mean tumor size (for resections): 4 cm (2.5-6). Tumor pathology: neuroblastoma (n = 17), Ganglioneuroma (n = 7), Adrenocortical carcinoma (n = 1), Osteosarcoma metastasis (n = 1), Pheochromocytoma (n = 1), Venous malformation (n = 1). Mean hospital stay: 2.5 days (1-3). Mean follow up: 65.5 months (24-192). Overall survival and event-free survival were 86 and 75%, respectively (5 years event-free survival for neuroblastoma: 33% [intermediate risk], 16.6% [high risk]. No surgery-related mortality.

CONCLUSION

Laparoscopic surgery for adrenal tumors is safe. Laparoscopic biopsy is useful for unresectable tumors when a percutaneous approach is not possible. With the proposed selection criteria, the laparoscopic approach should be the first option for resection of small and localized AT in pediatrics.

Genitourinary Tract Tumors in Children: An Update

BACKGROUND

Genitourinary tract tumors in children are less common than in adults. Most of these tumors have different genetic backgrounds, clinical presentation, and oncologic behavior than their adult counterpart. As a result of low prevalence in children, some of the treatment approaches and recommendations are based on treatment experience in adult patients. However, thanks to scientific and technological development, survival rates have risen considerably.

OBJECTIVE

This paper presents a review of the principal features of the tumors involving the genitourinary tract in children and an update in genetic background, diagnosis, and treatment.

METHODS

A narrative review was performed on published literature about genitourinary tract tumors in pediatric patients. Papers presented in English and Spanish literature were reviewed. PubMed, Science Direct, and SciELO databases were used to collect information and present this article.

RESULTS

Kidney tumors are the most common type of genitourinary tumors in children. Among those, Wilms tumor represents the majority of cases and shows the successful work of clinical trial groups studying this tumor type. Other tumors involving the genitourinary tract in children include Rhabdomyosarcoma, Transitional cell carcinoma, Testicular, and Adrenal tumors.

CONCLUSION

Genitourinary tract tumors in children represent significant morbidity and economic burden, so awareness in early diagnosis represents improvement in treatment, clinical, and oncological outcomes.

Imaging findings of primary adrenal tumors in pediatric patients

Apart from neuroblastomas, adrenal tumors are rarely seen in children. The most common adrenal tumors are adrenocortical carcinoma and pheochromocytoma. Adrenocortical carcinoma is usually a large heterogeneous, well-marginated mass with solid/cystic areas and calcifications, with poor prognosis. Most of the pheochromocytomas are benign tumors and usually show intense contrast enhancement, the pattern of which may be diffuse, mottled, or peripheral on computed tomography and magnetic resonance imaging. The purpose of this article is to evaluate primary nonneurogenic adrenal tumors.

Adrenal Ganglioneuroma Presenting as an Incidentaloma in an Adolescent Patient

OBJECTIVE

In an adult endocrine clinic, the majority of patients referred for evaluation of an incidentally discovered adrenal mass are aged more than 30 years, for which many national and international societies have developed management guidelines. However, adrenal incidentalomas in children and young adults are uncommon. We report the case of an 18-year-old woman with an incidentally discovered right-sided adrenal mass.

METHODS

We present the adrenal tests, computed tomography, and magnetic resonance imaging results and treatment of a young woman with an adrenal mass that proved to be a ganglioneuroma.

RESULTS

A computed tomography scan showed a 2.2 × 2.6 cm right-sided adrenal mass with noncontrast Hounsfield units >10 and <50% washout. Magnetic resonance imaging was not typical of a lipid-rich adenoma. Blood and urine tests demonstrated normal secretion of cortisol, aldosterone, adrenal androgens, and catecholamines. Based on the patient's age and imaging studies, she underwent a right adrenalectomy, removing a 2.2 × 2.0 × 2.7-cm ganglioneuroma.

CONCLUSION

The differential diagnosis of an adrenal mass in children and adolescents is quite different compared with adult patients. There are no standardized guidelines for the management of adrenal masses in these younger age groups, although some authors recommend removing all adrenal masses, regardless of size or imaging characteristics, in all children aged more than 3 months. This case emphasizes how the management of adrenal masses in pediatric patients and young adults differs from guidelines published by endocrine and urologic societies.

Imaging features of adrenal gland masses in the pediatric population

The spectrum of adrenal masses in the pediatric population markedly differs from that in the adult population. Imaging plays a crucial role in detecting adrenal masses, differentiating malignant from benign lesions, recognizing extra-adrenal lesions in the suprarenal fossa, and directing further management. Ultrasound is the primary imaging modality of choice for the evaluation of adrenal masses in the neonatal period, whereas MRI or CT is used as a problem-solving tool. In older children, computed tomography or magnetic resonance imaging is often required after initial sonographic evaluation for further characterization of a lesion. Herein, we discuss the salient imaging features along with pathophysiology and clinical features of pediatric adrenal masses.

Adrenal masses in children: Imaging, surgical treatment and outcome

BACKGROUND/OBJECTIVE

This study aims to evaluate the current surgical approach to adrenal masses in the pediatric age group.

METHODS

We retrospectively analyzed cases that underwent surgery for adrenal masses between 2007 and 2017. Patients were assessed regarding age, sex, primary diagnosis, image defined risk factors (IDRF), surgical treatment method, complications, duration of hospital stay, and follow-up.

RESULTS

We examined 50 patients who underwent surgery for adrenal mass (mean age: 4.8 years; range: 5 days-14 years). For IDRF assessment, Ultrasonography was used in 42, Computed Tomography in 36, and Magnetic Resonance Imaging in 36 patients. Lesions were present on the right in 25, left in 21, and bilateral in 4 patients. Histopathological findings were neuroblastoma (n = 29), ganglioneuroma (n = 6), adrenal cortex tumor (n = 5), ganglioneuroblastoma (n = 4), pheochromocytoma (n = 3), cyst (n = 1), and adrenal hematoma (n = 2). Laparotomy was performed on 37 patients, and laparoscopy on 13 patients. None of the cases had any operative complications.

CONCLUSION

The crucial factors determining the surgical approach to adrenal masses in pediatric cases are the histopathology of the mass, volume, and IDRF. Minimally invasive procedures could be reliably performed in appropriate cases.

Imaging of Nonmalignant Adrenal Lesions in Children

The adrenal glands in children can be affected by a variety of benign lesions. The diagnosis of adrenal lesions can be challenging, but assessment of morphologic changes in correlation with the clinical presentation can lead to an accurate diagnosis. These lesions can be classified by their cause: congenital (eg, discoid adrenal gland, horseshoe adrenal gland, and epithelial cysts), vascular and/or traumatic (eg, adrenal hemorrhage), infectious (eg, granulomatous diseases), enzyme deficiency disorders (eg, congenital adrenal hyperplasia [CAH] and Wolman disease), benign neoplasms (eg, pheochromocytomas, ganglioneuromas, adrenal adenomas, and myelolipomas), and adrenal mass mimics (eg, extralobar sequestration and extramedullary hematopoiesis). Multimodality cross-sectional imaging helps to define the origin, extent, and relationship of these lesions to adjacent structures, as well as to guide treatment management. The anatomic and functional imaging modalities used to evaluate pediatric adrenal lesions include ultrasonography, computed tomography (CT), magnetic resonance imaging, and iodine 123 metaiodobenzylguanidine scintigraphy. Identifying the imaging features of nonmalignant adrenal lesions is helpful to distinguish these lesions from malignant adrenal neoplasms. Identifying characteristic imaging findings (eg, enlarged adrenal glands, with cerebriform surface, and stippled echogenicity in CAH; a T2-hyperintense mass with avid contrast enhancement in pheochromocytoma; low CT attenuation [<10 HU] and signal intensity drop on opposed-phase chemical shift images in adenoma; and enhancing suprarenal mass supplied by a systemic feeding artery in extralobar sequestration) can aid in making the correct diagnosis. In addition, clinical features (eg, ambiguous genitalia in CAH and hypertension in pheochromocytoma) can also guide the radiologist toward the correct diagnosis. ^©RSNA, 2017.

A single enhanced phase is sufficient for the initial computed tomography evaluation of retroperitoneal tumors in children

PURPOSE

The goal of this study was to evaluate the incremental value of unenhanced phase in the initial evaluation of retroperitoneal tumors in children by comparison with an enhanced phase alone using computed tomography (CT).

MATERIALS AND METHODS

A total of 53 patients (26 girls, 27 boys) with a total of 53 tumors who had CT examination of the abdomen and pelvis for the initial assessment of retroperitoneal tumor were retrospectively included. All CT examinations were obtained with an unenhanced set of CT images and a set of CT images obtained after intravenous administration of iodinated contrast material. One junior and one senior radiologist independently evaluated the two sets in two separate reading sessions. CT images were analyzed for tumor calcifications, tumor location, vascular encasement, local invasion and tumor content.

RESULTS

Calcifications were present in 24/53 tumors (45%). On the enhanced set, the senior radiologist was able to detect calcifications in 22/24 tumors (92%) and the junior radiologist in 20/24 tumors (83%), yielding sensitivities of 92% and 83%, and specificities of 96.5% and 100%, respectively. Inter-observer agreement was excellent (Kappa=0.89). Tumor location was correctly determined by the senior radiologist in 53/53 tumors (100%) and 37/53 tumors (70%) by the junior radiologist. Using the unenhanced set, the senior radiologist was able to assess vascular encasement in 26/53 tumors (49%) against 21/53 (39%) for the junior radiologist. For tumor content, agreement between the enhanced and combined unenhanced and enhanced CT was 77% for both radiologists.

CONCLUSION

Enhanced CT performs as well as unenhanced CT for evidencing calcifications and is therefore sufficient for the initial assessment of retroperitoneal tumor in children.

Adrenal imaging (Part 2): Medullary and secondary adrenal lesions

Adrenal malignancies can be either primary adrenal tumors or secondary metastases, with metastases representing the most common malignant adrenal lesion. While imaging cannot always clearly differentiate between various adrenal malignancies, presence of certain imaging features, in conjunction with appropriate clinical background and hormonal profile, can suggest the appropriate diagnosis. The second part of the article on adrenal imaging describes adrenal medullary tumors, secondary adrenal lesions, bilateral adrenal lesions, adrenal incidentalomas and provides an algorithmic approach to adrenal lesions based on current imaging recommendations.

Pediatric genitourinary oncology

Tumors of the kidney, bladder, prostate, testis, and adrenal represent a large part of the adult urologic practice, but are relatively infrequent in children. The natural history and management of these tumors in the pediatric age is different from that of the adults. As result of the successful work of several clinical trial groups in recent decades, there has been a significant improvement in their cure rates. The aim of this article is to review their most significant clinical aspects, as well as to present an update in their management.