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This is Pediatrics week 3 case number one

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and the topic we're considering is neuroblastoma.

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Of all tumors in the very

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young in infants. This is the number one most common. So

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if you're dealing with a patient with a suspected tumor,

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this is certainly one to think about

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in the early days

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Most of the time this is diagnosed or

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initially via ultrasound and on

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ultrasound you'll see a lot of heterogeneity in the

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region of the adrenal glands. Typically, the adrenal is the source organ,

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but it can be elsewhere in the nerve plexus.

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And there may or may not be calcifications involved

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as well, which can be a helpful diagnostic clue.

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Finally any kind of cystic lesion of

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the adrenal glands, although not the most common.

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Presentation of neuroblastoma should cause you

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to consider cystic neuroblastoma. So what

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we have here is a follow-up Imaging study. This

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is a spect CT with mibg and

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the idea of course is to pick a radio Tracer that

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the tumor is AVID.

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To uptake and what we've done is we've fused

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the CT images with the nuclear

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study. So we have spec CT images.

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This is a non-contrast exam. So it makes it a little

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bit more difficult to evaluate the soft

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tissues by themselves, but that's okay because we have

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our radio tracer.

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Images as well to look for avidity for the

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mibg.

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So we're looking at the level of the chest and

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here I'm down at the lower chest

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and right on the pericardial margin you

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can make out two different structures nodular appearing

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structures. Those are definitely not cardiac structures

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when we switched along Windows. We're going

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to recognize these aren't part of the lung either. These are

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little plural based nodules right at that angle where the

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pleura and the pericardium meet. So we

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have some pulmonary lesions. They're solid appearing and

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given the

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Case is about neuroblastoma. You can start to

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suspect that their metastatic lesions. We're going to switch back

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to abdomen windows and keep scrolling into the abdomen. This

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is again a little difficult without IV contrast.

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But when we look at our Fusion images, we're going to get a lot of

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help.

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And the first thing you should notice here is abnormal density at

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the midline. There's no structure there that

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should be as dense as bone. So we have some calcifications and

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we've also got a lack of fat intervening

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in this region. We should see little areas of

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fat separating the organs in this case the kidney

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from surrounding structures and here we've got some fat

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planes separating stomach from other structures, but

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over here at the right mid abdomen and right abdomen

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there is isn't really a lot of separation and

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it makes you think that there's some type of infiltrative mass

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here and given the fact that we

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saw these densities here. It's a partially calcified infiltrative

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mass now in the very young

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neuroblastoma is a common

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tumor. So that's something you should think about but other

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tumors that can arise that also might be in

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the same location depending on what age group you're

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dealing with if it's not the very earliest days of life, you might

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also consider Wilms and

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One of the differences between Wilms and neuroblastoma is

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the way that they grow neuroblastoma tends to

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insinuate itself. It also develops calcifications Wilms

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tumor is much more of a push

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everything out of the way type of tumor space occupying

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Mass Effect oriented tumor. This one

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is infiltrative. We see more calcifications here

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in the right kind of Perry renal space.

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And as we scroll all the way down through we can see even more. This

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is a pair of spinal Mass probably originated

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at the level of the adrenal gland just

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for comparison sake I'll scroll over on this

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coronal image and I just want to

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give you a sense of just how much space is being occupied by

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this expansive infiltrative Mass with Foci

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of calcification here and here it's a facing

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the upper pull of the kidney, but it

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is not invading the kidney if we thought this Mass

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was truly a rising from the kidney. We would be thinking of Wilms

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tumor, but we really aren't thinking of Williams tumor especially

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in a newborn

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So we're going to go ahead and look at how this tumor behaves

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how it takes up the radio Tracer. We're

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going to put at it and we're going to give mibg. So I'm going

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to scroll over and look at these fused images. I'm going to

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look at this coronal and right away. We can see quite a bit of activity. Look

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at all of this mibg avidity in the

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right abdomen and midline taking up by

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this tumor. However, it's not just in the

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region of the tumor. We also see a little

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bit of a video at those pulmonary plural based nodules, and

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we also see some down here in inguinal iliac chain

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probable lymph node involvement.

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There's also some extension inferiorly and

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over across the midline. So this tumor is crossing the

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midline. That's an important point and we see

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some paratracheal and subcarinal involvement as

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well. So there's nodal involvement. There's metastatic lesions.

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There's a large mass in the abdomen.

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Approximately centered at the adrenal gland. So this

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is metastatic neuroblastoma. It's going to need both medical

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treatment possibly surgical treatment,

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which is used for larger tumors, but sometimes it's not

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necessary. That's the end of the case.