Peds Gu

Front 1

Renal Cystic Disease

Back 1

Solitary simple cyst
ARPKD
ADPKD
MCDK
Syndromes
-TS
-VHL
-Meckel Gruber
Cystic neoplasms
-Wilms tumor
-Multilocular cystic nephroma
Calyceal diverticulum

Front 2

Neuroblastoma vs. Wilms Tumor

Back 2

Neuroblastoma:
-Before age 2
-Ca common (85%)
-Surrounds and engulfs vessels
-Inferiorly displaces and rotates kidney
-Lung mets uncommon
-Vascular invasion does not occur
-when crosses the midline, goes posterior to the aorta and raises it

Wilms:
-Peak at 3 years (1-5 years)
-Ca in 15%
-Grows like a ball, displaces vessels
-Arises from kidney, claw sign
-Lung mets more common (20%)
-Invasion of renal vein/IVC
-When crosses the midline, it goes in front of the aorta

Front 3

Disorders associated with Wilms Tumor

Back 3

Nephroblastomatosis
Overgrowth disorders:
-Congenital hemihypertrophy
-Beckwith-Wiedemann
Sporadic aniridia

Front 4

Nephroblastomatosis monitoring: When to be worried about Wilms

Back 4

-When a lesion appearing spherical demonstrates an increase in size compared to previous or
-When a lesion demonstrates more enhancement compared to the more nonenhancing nephrogenic rests

Front 5

Multilocular cystic nephroma

Back 5

-Bimodal age distribution (boys 3 mos-2 yrs and females 5th/6th decades)
-No malignant cells, but difficult to differentiate from a well differentiated Wilms on imaging
-Sx resection performed

Front 6

Mesoblastic Nephroma

Back 6

=fetal renal hamartoma
-The most common renal mass in neonates
-encountered prenatally or during the first few mos of life
-Mean age of dx is 3 mos
-Nontender, palpable abdominal mass
-U/S: intrarenal mass indistinguishable from Wilms
-CT: Solid intrarenal mass with variable enhancement

Front 7

Renal masses

Back 7

-Mesoblastic nephroma
-Wilms
-Nephroblastomatosis
-RCC (most common cause of renal malignancy in older children)
-lymphoma
-Clear cell carcinoma
-Rhabdoid tumor
-AML

Front 8

Adrenal gland masses

Back 8

Neuroblastoma
Neonatal adrenal hemorrhage
Pheochromocytoma
Adrenal carcinoma

Front 9

Neuroblastoma

Back 9

-Tumor of primitive neural crest cells
-Most commonly arises in the adrenal gland, but can occur anywhere along the symphatheric chain
-Metastasizes most frequently to the liver and bone
-Most common extracranial solid malignancy in children, and third most common childhood malignancy (leukemia/primary brain tumors first)
-90% have elevated catecholamines (vanillylmandelic acid) in urine
-Less than 1 yr: spreads to liver and skin (blueberry muffin), good prognosis.
-Over 1 yr: tends to spread to bone, poorer prognosis.
-Evans staging system
-Stage IVs: Age less than 1 year, primary tumor with metastatic disease to skin, liver, or bone marrow (NOT bone cortex): Excellent progress, follow with imaging, no therapy!
-Some say MRI better than CT in order to identify tumor extension into the neural foramina. If positive, neurosurgery will become involved in the surgical resection.
-Lobulated, grows in an invasive pattern, surrounding and engulfing rather than displacing vessels such as the celiac axis, SMA, and aorta.
-Often heterogeneous secondary to hemorrhage, necrosis, and calcifications
-MRI: T2 bright, can be heterogeneous.
-During staging, most also undergo MIBG and bone scan

Front 10

Features associated with better prognosis in patients with neuroblastoma

Back 10

Age less than 1 yr
Histologic grade
Decreased n-myc amplification
Stage IVs
Thoracic primary

Front 11

Neonatal adrenal hemorrhage

Back 11

-Secondary to birth trauma or stress
-Treated differently than neuroblastoma, so diff is important!
-U/S: NB an echogenic mass with diffuse vascularity, AH as an anechoic, avascular mass.
-Serial ultrasounds can be done for problematic cases, because the prognosis for neonates with stage 1 NB is excellent. With time, adrenal hemorrhages decrease in size.
-MRI: hemorrhage low T2, NB high T2

Front 12

Pelvic rhabdomyosarcoma

Back 12

-Rhabdo is most common sarcoma of childhood, typically presents in the first 3 years of life.
-Most common locations include pelvis and GU tract (40%) and head and neck (40%).
-Most common GU locations are the bladder, prostate, spermatic cord, paratesticular tissues, uterus, vagina, and perineum. M=F
-Multilobulated mass in bladder, likened to a bunch of grapes. May result in hydronephrosis.

Front 13

Sacrococcygeal teratoma

Back 13

-Large cystic/solid masses on prenatal imaging or at birth
-Most are benign, but there is an increased risk for malignancy with delayed diagnosis.
-Primarily external (50%), internal within the pelvis (9%), or both (dumbbell shaped, 30%).
-Heterogeneous, with variable cystic, solid, and fatty components

Front 14

Testicular neoplasms

Back 14

-90% are germ cell in origin
-less than 10% are metastatic from leukemia or lymphoma
-If a scrotal mass is extratesticular, the most likely diagnosis is embryonal rhabdomyosarcoma arising from the spermatic cord or epididymis.

Front 15

Testicular microlithiasis

Back 15

-Often no posterior shadowing
-Common
-Controversial if imaging follow up is necessary
-? associated with seminoma

Front 16

Acute scrotum DDx

Back 16

Torsion
Epididymo orchitis
Torsion of the testicular appendage
Testicular hematoma

Front 17

Torsion of the testicular appendage

Back 17

A vestigial remnant of the mesonephric ducts.
A mass of increased echogenicity is seen bwtween the superior pole of the testis and the epididymis.
Enlargement of the appendage greater than 5 mm is the best indicator of torsion.
Periappendiceal hyperemia, normal testicular flow.
Does not require surgical management.......self limited.
May see absence of flow to the testicular appendage.

Front 18

Goals of imaging children with UTI's

Back 18

Boys: after first UTI
Girls: ?after second UTI
U/S and VCUG

Goals:
-identify underlying congenital anomalies
-identify VUR
-identify and document any renal cortical damage
-provide a baseline for renal size

Long term goal: to eliminate the change of renal damage leading to chronic renal disease and hypertension

Front 19

Evaluation of prenatally diagnosed hydronephrosis

Back 19

Must be done within 24 hours of birth, or after 7 days (relative state of dehydration in between)

Front 20

VUR

Back 20

-5 grades
-Grades 1-3: most resolve by ages 5-6, tx is prophylactic abx
-if severe: surgical reimplantation or periureteral injection with deflux (an echogenic mound is seen in bladder wall)

Front 21

MCDK

Back 21

Due to severe obstruction of the renal collecting system during development. Most common appearance is grapelike collections of variably size cysts that do not communicate.
-Hydronephrotic form: central pelvis surrounded by dilated renal cysts.
-Renal scintigraphy can help differentiate severe UPJ obstruction from MCDK...in MCDK, no trace or accumulation is seen within the renal pelvis on 4 hour images.
-Important to exclude congenital anomalies of the contralateral kidney. UPJ obstruction is commonly present. MCDK can be isolated to an upper or lower pole.
-Slowly decrease in size over time
-U/S follow up because there ?may be an increased risk of malignant transformation.
-If hypertension develops, nephrectomy is performed.