Volume 8 Issue 3 - Australasian Society for Ultrasound in Medicine

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Sharon Watson and RJ BenzieFigure 5 Figure 6Figure 7 Figure 8antenatal findings, locating the hyperechoic mass in theright subdiaphragmatic area with possible extension intothe pleural space, with associated compression of the IVCand hepatic vasculature. The liver, right kidney and rightadrenal gland had a normal sonographic appearance (Figure3). A possible feeder vessel was identified on a subsequentscan. The lesion was thought to be an extralobar pulmonarysequestration (Figure 4).Given the location of the lesion andthe ongoing healthy status of the infant, surgical interventionhas not been indicated.Case 2: Left upper quadrant massA 22-year-old woman, gravida 4, para 2 presented for agrowth scan at 38 weeks gestation with a clinical historyof decreased fundal height. Fetal measurements were consistentwith appropriate growth for the stated gestation.However, within the fetal abdomen, a complex, predominantlycystic mass containing mobile septa and solid materialwas identified in the region of the left adrenal gland(Figure 5). A neuroblastoma or adrenal haemorrhage wasconsidered to be the most likely diagnosis.The mass was subsequently reviewed using both 2Dand 3D ultrasound four days later. The possibility of arenal mass was considered at this time. It appeared to haveincreased in both size and degree of complexity. Whilst stillpredominantly cystic in nature, the mass seemed to containmore solid components. The septations also appeared to bethicker and immobile. Colour Doppler evaluation demonstratedflow peripheral to the mass. There was otherwise noevidence of increased vascularity (Figures 6 and 7).Following normal vaginal delivery at 41 weeks gestation,the child remained well. There was no clinical evidence ofadrenal insufficiency or elevated catecholamines. The abdomenwas found to be soft with no palpable mass detected. Theinfant’s blood chemistry was essentially normal.Neonatal ultrasound examination demonstrated a welldefined rounded complex retroperitoneal mass in the leftupper quadrant, medial to and contiguous with, the leftadrenal gland. The mass dimensions were essentiallyunchanged from the examination performed four weekspreviously. The mass was now predominantly solid.No definite calcifications or vascularity could be identified.The liver, kidneys, spleen, biliary system and urinarybladder had a normal sonographic appearance (Figure 8).The differential diagnosis was thought to include adrenalhaemorrhage, lymphangioma and a retroperitoneal teratoma.The child has remained clinically well in the 12 months sincehis birth. The mass has been seen to diminish in size withongoing serial review by both CT and ultrasound.Surgical excision was considered unnecessary since all ofthe features suggest that the mass is an adrenal haemorrhage.DiscussionFetal abdominal tumours account for approximately 5%of abnormalities detected by prenatal ultrasound. The differentialdiagnosis of intraabdominal and/or retroperitoneal20 ASUM Ultrasound Bulletin 2005 August; 8 (3)
Fetal upper abdominal masses; a prenatal diagnostic dilemmaTable 1 Comparison of the sonographic features of upper abdominal massesIntraabdominal Extralobar Adrenal Haemorrhage 2–4 Neuroblastoma 3–5 Teratoma 6 Lymphangioma 7Pulmonary Sequestration(IEPS) 1Pathology Non-functioning lung Pathogenesis in utero is Most common malignant Tumours composed of Benign tumourstissue that does not communicate unknown. tumour in the neonate. tissues derived from of the lymphatic vesselwith bronchial tree. Total or segmental involve- Originating in neural the 3 germinal layers that are mostBetween diaphragm and liver/kidney, ment of the gland. crest cells. of the embryo. commonly diagnosedseparate from adrenal gland. Prenatal diagnosis 32 in the neonatal periodweeks+.or early infancy.Location 8–10% abdomen or Usually intracapsular. 50% associated with 60–65% sacrococcygeal 95% head, neckretroperitoneum. Extension into peritoneal Adrenal gland. region. and axilla.90% left sided cavity or retroperitoneum Retroperitoneal, thoracic 10–20% in the gonads. 63% of abdominalif ruptures. or cervical paravertebral Mediastinum, naso- lymphangiomas.3–4 x more common on regions. pharynx head and neck, occur on the left side.the right side.and the retroperitoneum.Sonographic Circumscribed, homogenous Changes over time. Homogenous hyperechoic, Variable appearance Well delineated,appearance echogenic mass, Initially hyperechoic 50% cystic, or mixed ranging from hypoechoic cystic± cystic components. becoming heterogenous echo pattern. completely anechoic masses of variablebefore finally anechoic. Occasional calcification to completely size. May be uni orMaybe round, triangular Frequently encapsulated hyperechoic. multiloculatedor crescent shaped. displacing kidney. 60% mixed appearance. with fine septations.May contain debris.Vascularity ± feeder vessel Rim shaped peripheral Low impedance Little or no flow on Little or no flow onfrom aorta. vascularity. waveform. colour Doppler.Associated Diaphragmatic hernia, bronchial Displacement of the kidney Hepatomegaly and/or Polyhydramnios fetal Skin oedema,findings agenesis, colonic duplication and caudally. fetal hydrops hydronephrosis hydrops fetalisvertebral anomalies. associated with metastases. and fetal hydrops. and polyhydramnios.Oligo/polyhydramnios.fetal hydrops.masses relies on the accurate evaluation of the size, positionand characteristic sonographic appearances.The most common differential diagnosis of intraabdominalmasses includes congenital neuroblastoma or adrenalhaemorrhage, renal tumours, teratomas and less commonlyintraabdominal extralobar pulmonary sequestration. It isessential that an accurate distinction is made in order thatpatient care be optimised.A comparison of the clinical and sonographic features ofthese conditions can be seen in Table 1.ConclusionIn both of our cases, the diagnosis was made ultimatelyfollowing serial sonographic review correlated with theclinical and biochemical findings. The children are well anddeveloping normally.While ultrasound is the imaging modality of choicewhen evaluating the fetal and neonatal abdomen, it cannotalways provide a definitive diagnosis in the first instance.A number of mostly benign conditions have features whichmay mimic those of masses of a more sinister nature andvice versa. In such cases, the role of the ultrasound examinationis to alert the referring clinician to the presence orabsence of pathology in order that effective clinical managementdecisions can be made.AcknowledgementsWe would like to acknowledge Prof Albert Lam and MrJoseph Lui from the New Children’s Hospital for theirassistance.References1 Pumberger W, Moroder W, Wiesbauer P. Intraabdominal extralobarpulmonary sequestration exhibiting cystic adenomatoid malforma-tion: prenatal diagnosis and characterization of a left suprarenal massin the newborn. Abdom Imaging 2001; 26: 28–31.2 Seigel. Paediatric Sonography 3rd ed. New York: LippincottWilliams and Wilkins; 2002.3 Schwarzler P, Bernard JP, Senat MV, Ville Y. Prenatal Diagnosisof Fetal Adrenal Masses: Differentiation between Hemorrhage andSolid Tumour by Colour Doppler Sonography. Ultrasound ObstetGynaecol 1999; 13: 351–355.4 Kesrouani A, Duchatel F, Seilanian M and Muray JM. PrenatalDiagnosis of Adrenal Neuroblastoma by Ultrasound: A Reportof Two Cases and Review of the Literature. Ultrasound ObstetGynaecol. 1999; 13: 446–449.5 Acharya S, Jayabose S, Kogan SJ, Tugal O, Beneck D, Leslie D,Slim M. Prenatally Diagnosed Neuroblastoma. Cancer 1997; 80 (2):304–309.6 Dahnert W. Dahnert’s Electronic Radiology Review [CD-ROM],Williams and Wilkins, 1998.7 Mentzel HJ, Schramm D, Vogt S, Reuter A, Mentzel T, KaiserWA, (1998) Intraabdominal Lymphangioma in a Newborn. J ClinUltrasound 1998; 26 (6): 320–322.ASUM Ultrasound Bulletin 2005 August; 8 (3)21
Page 1 and 2: ISSN 1441-6891Volume 8 Number 3 Aug
Page 3 and 4: PresidentDr David RogersImmediate P
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