RADIOLOGICAL DIFFERENTIATION BETWEEN WILM'S TUMOUR

Transcription

1 Vol. 9, No. 3. September, SINGAPORE MEDICAL JOURNAL 161 RADIOLOGICAL DIFFERENTIATION BETWEEN WILM'S TUMOUR AND NEUROBLASTOMA IN ABDOMINAL MASSES By Yu Sheng Fong, M.B.B.S., D.M.R.D. (Rado Dagnostc Dept., General Hosptal, Sngapore) INCIDENCE OF WILM'S TUMOUR AND NEUROBLASTOMA Wlm's tumour and neuroblastoma each and together represent a sgnfcant proporton of chldhood malgnant lesons. Hope and Koop5 of Amerca assessed the proportons of the varous chldhood malgnant lesons as follows: TABLE I PROPORTIONS OF CHILDHOOD MALIGNANT LESIONS IN AMERICA BY HOPE AND KOOP The total of over 100% s due to some cases presentng themselves wth more than one symptom. Hematura s a bad prognostc sgn4 as t sgnfes nvason of the renal pelvs. The leson most commonly confused wth Wlm's tumour s neuroblastoma1,2. Abehousel put the frequences of lesons msdagnosed as Wlm's tumour as follows: TABLE III LESIONS MISDIAGNOSED WILM'S TUMOUR FROM DATA FROM 93 SURGEONS Leukaema and lymphoma % Neuroblastoma 55 x Tumours of C.N.S. and eye % Congental hydronephross 49 x Wlm's tumour and neuroblastoma 20% Serous cyst of kdney - 20 x Rato = 1 : 2 Polycystc dsease of kdney 18 x The rest 20% Mscellaneous 30 x OUTRAM ROAD GENERAL HOSPITAL Wlm's tumour = 14 cases Neuroblastoma = 13 cases Rato 1 : 1 From the avalable records n the Outram Road General Hosptal between 1959 to 1967 are found these 27 hstologcally proven cases. Unproven cases are rejected. Locally we see a hgher rato of Wlm's tumour to neuroblastoma than n Western centres. PRESENTATION OF WILM'S TUMOUR Wlm's tumour most commonly presents as a slent abdomnal mass for nvestgaton'. Abehousel gave the ncdence of presentng symptoms n 856 cases as follows: TABLE II PRESENTATION OF WILM'S TUMOUR 856 Cases of Abehouse 14 Cases Locally Tumour mass 85% 93% Pa n 30% Hematura 10% 29 % 125% 122% PRESENTATION OF NEUROBLASTOMA The majorty of neuroblastoma present themselves wth the toxc effects of malgant growth. Only a small number present themselves as abdomnal masses alone2. There s no relable fgure to show the exact percentage. However, of the 43 cases of Barrett, 32 had abdomnal masses detectable by radology.2 Of the 129 cases of Bodan 69 % had ther prmary ste n the abdomen.3 The presentatons of the local cases are as follows: TABLE 1V PRESENTATION OF 13 LOCAL CASES OF NEUROBLASTOMA Abdomnal mass - 5 Enlarged lymph nodes - 3 Lump on head - 2 Systemc effects of malgnant leson Blateral proptoss - 1 The dfferental dagnoss of neuroblastoma both clncally and radologcally are numerous

2 162 SINGAPORE MEDICAL JOURNAL TABLE V CLINICAL PARAMETERS Wlm's Tumour 14 Local Cases Age range: 12 to 6 yrs. Age averange: 2.5 yrs. Sex: 8 M 6 F 6 R sded 8 L sdes 856 cases of Abehouse Majorty n frst 4 yrs. of lfe Age average: 3.2 yrs. No sex predomnance Neuroblastoma 13 Local Cases Age range: z to 7 yrs. Age average: 3.5 yrs. Sex: 5 M 7 F 2 R sdes 3 L sdes 43 cases of Barrett Age range at brth to 7 yrs. Age average: 2.6 yrs. No sex predomnance dependng on the presentaton. However when the presentaton s a frm abdomnal mass, the prncpal dfferental dagnoss s Wlm's tumour.6 CLINICAL PARAMETERS OF WILM'S TUMOUR AND NEUROBLASTOMA In the dfferental dagnoss of these two lesons clncal parameters of age, sex and lateralty of tumour mass are not helpful. (Table V) PLAIN FILM DIAGNOSIS In advanced cases of Wlm's tumour and neuroblastoma there could be no dffculty both clncally and radologcally n makng the correct dagnoss. Radologcally n Wlm's tumour there would be the large abdomnal mass wth pulmonary metastass. In neuroblastoma there would be the radologcal trad2 of: a) b) c) TABLE VI RADIOLOGICAL TRIAD OF NEUROBLASTOMA Abdomnal or thoracc prmary Skull changes Perpheral bone lesons Wlm's tumour The dffculty arses when these lesons present as abdomnal masses only. The oversea workers fnd pathologcal calcfcatons of these lesons useful n ther separaton2, 4, 6 but ths has not been our experence: (Table VII) I.V.P. TABLE VII We rely on I.V.P. to dfferentate between these two condtons. I.V.P. TECHNIQUE PATHOLOGICAL CALCIFICATION Wester Seres 1. Adequate amount of contrast medum of up to 1 c.c. per lb. body weght should be gven. 2. In nstances of "non-functonng" kdneys delay flms of up to one or two hours are useful. These flms often show up the renal calyces and prove that the "non-functonng" kdneys are just poorly functonng. (Fgs. 1, 2 and 3). 3. Lateral flms should be taken especally n uncertan cases whether the soft tssue mass s ntrarenal or extrarenal. (Fgs. 4, 5, 6 and 7). The am of the I.V.P. examnaton s to establsh f the leson s ntrarenal and thus a Wlm's Neuroblastoma Typcally dense and n concentrc rngs Typcally stppled, mottled or flaky Local experence Nl n 14 cases Nl n 13 cases

3 SEPTEMBER, ( u Fg. 1. A 30 mnute I.V.P. flm shows a "non-functonng" rght kdney n a case of Wlm's tumour. No later flm was taken. -er ),r... Fg mnute flm of another case of Wlm's tumour shows that the rght kdney s "non-functonng". : wy,, r. Fg mnute flm of the same case n fg. 2 shows that the rght kdney s just poorly functonng. An ntrarenal mass s clearly demonstrated.

4 164 SINGAPORE MEDICAL JOURNAL 1I f,a elrese7 1 0 a Q -r f>. Myell r t 1 Fg. 4. In ths supne I.V.P. flm there s some doubt whether the abdomnal mass s ntra- or extra -renal. m J ' Fg. 5. Lateral vew of the same case n fg. 4 shows that the mass s ntrarenal and thus s a Wlm's tumour. 71) T low f- z 9r. Fg. 6. Ó s 2 Fgs. 6 and 7. These two fgures of a same patent further llustrate the usefulness of lateral flm n decdng f an abdomnal mass s ntra- or extra -renal. r

5 SEPTEMBER, tumour (Fg. 8) or extrarenal and thus a neuro - blastoma (Fg. 9). I.V.P. FINDINGS IN WILM'S TUMOURS In one case both the I.V.P. flms and report are mslad. A summary of the I.V.P. fndngs n the other 13 cases are as follows: NON FUNCTIONING SUMMARY OF IV P FINDINGS INJ,CA SES OF WILM'S TUMOUR AFFECTED KIDNEY SHOWS FUNCTION TUMOUR SITE UNCERTAIN IN I AS FILMS MISLAID ALL 13 CASES SHOW LARGE RENAL OUTLINES S. OF INTRARENAL MASS DEFINITE EVIDENCE. Fg. 8. Ths flm shows a typcal ntrarenal mass of Wlm's tumour wth splayng and stretchng of the calyces..» LINE DRAWINGS OF I V P'S OF WILM'S TUMOURS WITH FUNCTIONING KIDNEYS -U WSH yr t 7 w Fg. 9. Ths flm shows a ty p - cal extrarenal mass of neuroblastoma wth a dsplaced but otherwse normal rght kdney. 7 In all 13 cases revewed the I.V.P. clearly shows that the leson s ntrnsc n the renal substance. It s admtted though Wlm's tumour s by far the commonest unlateral ntrarenal mass, but not all such masses are Wlm's tumours. In the very young hamartoma and renal cyst do occasonally occur.

6 V 166 SINGAPORE MEDICAL JOURNAL I.V.P. FINDINGS IN NEUROBLASTOMAS A summary of the 5 cases of neuroblastomas whch present as abdomnal masses s as follows: SUMMARY I OF P FINDINGS IN 5 CASES OF NEUROBLA STOMA ALL CASES SHOW GOOD RENAL FUNCTION SUPERO - :MEDIAL, MEDIAL - SUPERIOR, In all fve cases the I.V.P. clearly shows that the mass s extrarenal and that the kdney n queston s normal other than beng dsplaced. SUMMARY The presentatons of Wlm's tumours and neuroblastomas are brefly revewed. Almost all cases of Wlm's tumours and some cases of neuroblast.omas present themselves as abdomnal masses for nvestgaton. An adequately done I.V.P. s suffcent n the dagnoss of all cases revewed. ALL CASES SHOW DEFINITE EVIDENCE THAT MASS IS EXTRARENAL LINE DRAWINGS OF IVP S OF NEUROBLASTOMAS ACKNOWLEDGEMENT I would lke to thank my colleagues n the Department of Dagnostc Radology, the Department of Radotherapy and the Paedatrc and Surgcal Unts for ther co-operaton and the use of ther cases. I would also lke to thank Mr. S. C. Chee for the preparaton of the sldes. YCE I 3 í LAD REFERENCES 4g 1. Abehouse, B.S. (1957): "The management of Wlms' I tumour as determned by natonal survey and revew of the lterature", J. Urol., 77, YYM 2. Barrett, A.F. & Toye, O.K.M. (1963): "Sympathcoblastoma", Cln. Rad., 14, Bodan, M. (1959): "Neuroblastoma", Paedat. Cln. 3' N. Amer., 6, P 4. Cresson, S.L. & Pllng, G.P., IV (1959): "Renal.-y tumours", Paedat. Cln. N. Amer., 6, Hope, J.W. & Koop, C.E. (1962): "Abdomnal tum- Fr ours Pho nr nfants, and Chldren", Med. Radogr. 9.9 Photogr., 38, e,' 6. Sherman, R.S. & Learnng, R. (1953): "The Roentgen fndngs n neuroblastoma", Radology, 60, CSM "