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Wk 4, Case 2 - Review

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This is Pediatrics week 4 case 2 and

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the diagnosis were considering is Wilms tumor.

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This is the number one most common tumor in

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pediatric medicine.

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common tumor of the kidney and

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we're going to be using CT to fully evaluate

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this tumor. It may be diagnosed on reading ultrasound.

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In fact, it frequently is but the full extent

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of it can't be diagnosed without doing a CT exam

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and if you have any suspicion of Wilms tumor and

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you're ordering or a physician is ordering a

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CT scan be sure that they obtain chest Imaging as

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well because it is very common for Wilms tumor

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to metastasize to the lungs. So the initial workup of

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Wilms often also finds lung metastases,

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but if you don't look you won't find them.

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So let's go ahead and take a look at this patient. This is a two-year-old

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who had a renal Mass identified on ultrasound.

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We did obtain long Imaging here, although other than

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a little atelectasis and some air trapping in

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the lungs. They were roughly clear, but when we get

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down here to the left of the kidneys you can see

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That there is a hypodense material

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filling the right kidney. It's very circumscribed. It

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appears to be extending slightly out of the medullary space

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into this sort of parapelvic region.

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And when we look at it on the coronal view, we

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get a very similar

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appearance

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however

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We don't see any extension into the

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renal vein, which is something we always want to look for in severe

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cases. It could even extend upward toward

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the liver.

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In the IVC, but in this case, it's not

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doing that. It is a rising from the kidney. There's a

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little bit of a claw sign of renal tissue around it,

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which is confirmatory of diagnosis of

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Wilms tumor and we can see that there's

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normal appearance of the left. Kidney. You always

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got to look because in cases of nephroblastomatosis there

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can be lesions on both sides with tumor transformation

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only on the one side. And again, like

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I mentioned always check carefully the lungs. It's

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a favorite place for metastatic disease in

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this case these tumors respond very

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well to treatment and we would have high hopes for

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a good outcome. That's the end of the case.

Report

EXAM: CT Chest, Abdomen, and Pelvis W/ IV Contrast

INDICATION: Renal mass incidentally noted on right upper quadrant ultrasound.

TECHNIQUE: Axial CT images of the chest, abdomen, and pelvis were obtained after the administration of IV contrast. Coronal and sagittal reformats were obtained for greater anatomic detail.

FINDINGS:

In the chest, and lower neck, the visualized portion of the thyroid gland appear normal. There is no supraclavicular or axillary lymphadenopathy.

The soft tissue density in the anterior mediastinum is consistent with normal thymic tissue. There is no mediastinal or hilar lymphadenopathy. The thoracic esophagus is unremarkable.

The heart is moderately dilated, predominantly at the left ventricle. The thoracic aorta is normal in course and caliber. Pulmonary artery is nondilated.

The central airways are patent. There is mosaic attenuation of the lungs suggestive of air-trapping or prior bronchiolitis. There are bandlike opacities in the lung bases, likely atelectasis. There is no focal consolidation, pleural effusion, or pneumothorax. There are no suspicious pulmonary nodules or masses.

Soft tissues of the chest wall are normal. Bones are normal for developmental age. Negative for lytic or blastic lesions.

In the abdomen and pelvis, the liver enhances homogeneously. Liver size is within normal limits. Punctate calcifications are noted adjacent to the falciform ligament. No intra or extrahepatic biliary dilatation.

A gastrostomy tube is present with balloon inflated inside the gastric lumen. There is fluid within the distended stomach. The proximal small bowel is unremarkable. Dense stool is present throughout the colon. The appendix is not clearly visualized and there are no secondary signs of acute appendicitis.

The pancreas enhances homogeneously. The spleen is within normal limits for size. Calcification of the bilateral adrenal glands is consistent with prior adrenal hemorrhage.

There is a right renal mass measuring 4.5 x 4 x 4.5 cm. The mass is well-circumscribed, without extrarenal extension. There is no extension into the renal vein or IVC. The portal veins are patent.

The left kidney is normal. The bladder is distended and unremarkable in appearance. The abdominal aorta is normal in course and caliber. There are scattered calcifications within the IVC, stable from prior ultrasound. There is no abdominal or pelvic adenopathy. The mesentery appears unremarkable.

The soft tissues of the abdominal wall are within normal limits. There is a partially visualized right inguinal testicle. Fluid within the left inguinal canal may represent hydrocele. Bony structures are normal for developmental age. No lytic or sclerotic lesions.

IMPRESSIONS:

1. Right renal mass measuring 4.5 cm, with imaging features suggestive of Wilms tumor. There is no vascular invasion or extrarenal extension.
2. No evidence of metastatic disease in the chest, abdomen, or pelvis.
3. Cardiomegaly.
4. Hepatic, bilateral adrenal, and small scattered IVC calcifications are unchanged and related to old injury/hemorrhage.

Case Discussion

Faculty

Brandon P Brown, MD, MA, FAAP

Director of Fetal and Perinatal Imaging

Indiana University School of Medicine

Tags

Pediatrics

Nuclear Medicine

Gastrointestinal (GI)

Chest

CT