Neonatal suprarenal mass: differential diagnosis and treatment

Neuroblastoma in a Newborn Female

Neuroblastoma is the most common solid tumor in neonates. Although often aggressive in older children, carrying high mortality rates despite multimodal therapies, neuroblastoma appears to behave differently in the neonatal population. When diagnosis is clear, the disease can often be managed with close observation alone. This is a case of neuroblastoma in a 4-day-old female managed with surgical resection. This case highlights the potential challenges of diagnosis of retroperitoneal masses on prenatal ultrasound and in newborns and the importance of utilizing available resources when making difficult decisions in management.

Application of Machine Learning and Deep EfficientNets in Distinguishing Neonatal Adrenal Hematomas From Neuroblastoma in Enhanced Computed Tomography Images

Background

The aim of the study was to employ a combination of radiomic indicators based on computed tomography (CT) imaging and machine learning (ML), along with deep learning (DL), to differentiate between adrenal hematoma and adrenal neuroblastoma in neonates.

Methods

A total of 76 neonates were included in this retrospective study (40 with neuroblastomas and 36 with adrenal hematomas) who underwent CT and divided into a training group (n = 38) and a testing group (n = 38). The regions of interest (ROIs) were segmented by two radiologists to extract radiomics features using Pyradiomics package. ML classifications were done using support vector machine (SVM), AdaBoost, Extra Trees, gradient boosting, multi-layer perceptron (MLP), and random forest (RF). EfficientNets was employed and classified, based on radiometrics. The area under curve (AUC) of the receiver operating characteristic (ROC) was calculated to assess the performance of each model.

Results

Among all features, the least absolute shrinkage and selection operator (LASSO) logistic regression selected nine features. These radiomics features were used to construct radiomics model. In the training cohort, the AUCs of SVM, MLP and Extra Trees models were 0.967, 0.969 and 1.000, respectively. The corresponding AUCs of the test cohort were 0.985, 0.971 and 0.958, respectively. In the classification task, the AUC of the DL framework was 0.987.

Conclusion

ML decision classifiers and DL framework constructed from CT-based radiomics features offered a non-invasive method to differentiate neonatal adrenal hematoma from neuroblastoma and performed better than the clinical experts.

Prenatal diagnosis of an adrenal mature teratoma mimicking a neuroblastoma

Teratomas are defined by the presence of cell types from different germ layers, they typically involve the gonads or the sacrococcygeal region and are rarely retroperitoneal. Prenatally detected adrenal teratomas are extremely uncommon. Aim of this paper is to share our experience with an adrenal antenatal mass initially diagnosed as a left adrenal neuroblastoma that turned out to be a mature teratoma after microscopical examination. We present the case of a male fetus with antenatal diagnosis of a left adrenal cystic image at the 22nd week of amenorrhea. The fetal magnetic resonance imaging showed a non-calcified cystic mass of the left adrenal gland, compatible with a neuroblastoma. At birth an ultrasound confirmed the presence of an anechogenic lesion of the left adrenal gland. The infant was closely monitored during his first year and in the absence of significant regression of the adrenal mass, it was decided to perform a laparoscopic left adrenalectomy. Unexpectedly, the final pathological diagnosis was mature cystic adrenal teratoma. In conclusion, an adrenal mass diagnosed antenatally is generally a hemorrhage or a neuroblastoma. Adrenal teratomas are very rare and those diagnosed antenatally even more. At present, we have no clinical, biological, or radiological evidence to suspect them before surgical removal. There are only two other cases of unexpected adrenal teratoma in infants described in Literature.

Antenatally Detected Functional Adrenocortical Adenoma: A Case Report and Review of Current Literature

Pediatric adrenocortical tumors (ACTs) are rare entities with an incidence of 0.2% of all pediatric tumors. Only two cases of antenatally detected ACT have been reported in the literature. Our case is the first report of an antenatally detected suprarenal mass which manifested with postnatal virilizing features and was proven to be adrenocortical adenoma on histology.

Prenatal presentation of an adrenocortical tumor

Background

Prenatally identified suprarenal masses are most often found to be adrenal hemorrhage. The most common tumor in this situation is neuroblastoma.

Case Presentation

We report the case of a rare adrenocortical tumor found prenatally on ultrasound. While most patients with adrenocortical tumors present with virilizing symptoms, our patient did not have evidence of virilization and was presumed to have neuroblastoma.

Conclusion

Following a period of observation, our patient underwent surgical resection due to tumor growth revealing the unexpected diagnosis.

Imaging modalities and management of prenatally diagnosed suprarenal masses: an updated literature review and the experience at a high volume Fetal Treatment Center

BACKGROUND/PURPOSE

The differential diagnosis for prenatal suprarenal masses (SRMs) is broad and includes neuroblastoma, adrenal hemorrhage, and subdiaphragmatic extralobar pulmonary sequestration (SEPS). We sought to elucidate the appropriate postnatal management for fetuses found to have an SRM.

METHODS

We conducted a retrospective review of patients prenatally diagnosed with SRM at our institution between 1998 and 2018. Prenatal characteristics, imaging, and neonatal outcomes were collected. We also performed a PubMed literature search and pooled analysis of all patients with a prenatally diagnosed SRM previously described in the literature.

RESULTS

The literature review yielded 32 studies, of which 19 were single case reports. In our case series, 12 patients were included. Seven patients were delivered vaginally, one was terminated. Postnatal diagnoses included: SEPS (n = 5), adrenal hemorrhage (n = 3), polycystic kidney (n = 2), splenic cyst (n = 1), and unknown for one patient. All but two of the final diagnoses had been on the initial diagnostic differential. With the exception of the terminated fetus, all remain alive today. On pooled analysis, patients who underwent operative management were diagnosed later 32 versus 24 weeks and had a significant predominance of left-sided lesions (59.5 versus 39.2%). The published literature demonstrates a trend toward observation versus resection over the past 30 years.

CONCLUSIONS

Patients prenatally diagnosed with an SRM have an excellent prognosis. Our series demonstrates a high incidence of SEPS, which were all resected, and adrenal hemorrhage, which were observed with repeat imaging. These patients can be followed with serial postnatal ultrasounds to determine the diagnosis prior to deciding the appropriate treatment.

Adrenal hemorrhage and hemorrhagic masses; diagnostic workup and imaging findings

Adrenal hemorrhage (AH) is a rare condition. It can be traumatic or non-traumatic. Most common causes are septicemia, coagulopathy or bleeding diathesis, and underlying neoplasms. Other reported less common causes of AH are COVID-19 and neonatal stress. Clinical diagnosis of AH is challenging due to its non-specific presentation and occurrence in the setting of acute medical illness. Therefore, most cases are diagnosed incidentally on imaging. Having high clinical suspicion in the proper clinical setting for AH is crucial to avoid life-threatening adrenal insufficiency that occurs in 16-50% of patients with bilateral AH. We discuss the clinical situations that predispose to AH, review the imaging features on different imaging modalities, highlight a variety of clinical cases, imaging features that should be concerning for an underlying neoplasm, and outline the potential role of interventional radiology in management of AH.

Prenatal Assessment of Atypical Adrenal Glands: A Systematic Approach for Diagnosis

The aim of this study was to identify specific unusual prenatal ultrasound (US) patterns of the adrenal gland and to propose a systematic approach for diagnosis. Six fetuses with unusual aspects of one or both adrenal glands, detected during routine prenatal US screening, were evaluated. Prenatal and postnatal management are described. A checklist of US features was created to perform a detailed analysis of adrenal lesions and guide prenatal management; this includes the time of appearance, location, growth, vascularization, structure, and presence of findings suggestive of malignancy.

Neonatal Neuroblastoma

Neuroblastoma accounts for approximately 8% of all pediatric cancers, with 5% diagnosed during the neonatal period. Despite the disproportionate contribution of neuroblastoma to childhood cancer deaths, neonatal neuroblastoma has a favorable prognosis, often with little or no therapy required. Therefore, minimizing therapy and mitigating complications/toxicities are emphasized, including using a watch-and-wait approach for patients at low risk for disease progression/relapse. However, stage MS neuroblastoma exhibits a unique pattern of disseminated disease, can be challenging to manage, and may require early intervention with systemic chemotherapy. In this review, the epidemiology, treatment options, and anticipated outcomes for neonatal neuroblastoma are discussed.

Prenatal diagnosis of suprarenal mass by magnetic resonance imaging: a case series

Objective: The aim of this study was to evaluate the perinatal outcomes and postnatal follow-up of prenatally diagnosed suprarenal masses (SRMs) evaluated by magnetic resonance imaging (MRI). Methods: Thirteen fetuses with SRMs detected during routine prenatal ultrasound screening were evaluated by MRI between February 2007 and May 2015. The prenatal characteristics of the masses, complications of the pregnancies, and related malformations were collected as the postnatal clinical, radiological, and pathological data. Results: The median gestational age at MRI was 30 weeks (18-41), and birth weight was 3285 (1700-3750) g. The mean follow-up period was 6 years (1.3-10). We observed 69.2% of the masses, which were predominantly cystic (69.2%), located on the left side. Associated malformations were found in 23% of the fetuses, with congenital heart defects being more prevalent. During the pregnancy, 15.4% of the fetuses had involution of the SRM, and one fetus had surgical treatment and different ultrasound and MRI diagnoses. Of the 69.2% of the cases, spontaneous resolution occurred in 30.7% during the first year of life and 38.4% the masses presented without modifications or signs of regression since the neonatal period. Conclusions: Prenatal SRMs were associated with congenital heart defects. Spontaneous regression and absence of modifications in the masses were commonly observed in the long-term follow-up of the SRMs.

Cystic adrenal lesions: focus on pediatric population (a review)

BACKGROUND AND AIM

The cysts may potentially affect any organ; adrenals cysts are rare. This is a review of the literature regarding adrenal cysts, focusing on children and young adults.

GENERAL DATA

Three major types have been described: pure cysts (endothelial, epithelial, and hemorrhagic or pseudocyst), parasitic (as hydatid) cysts and cystic part of a tumour (most frequent are neuroblastoma, ganglioneuroma, pheocromocytoma, and teratoma). The complications are: bleeding, local pressure effects; infection; rupture (including post-traumatic); arterial hypertension due to renal vessels compression. Adrenal hemorrhage represents a particular condition associating precipitating factors such as: coagulation defects as Factor IX or X deficiency, von Willebrand disease, thrombocytopenia; antiphospholipid syndrome; previous therapy with clopidogrel or corticosteroids; the rupture of a prior tumour. At birth, the most suggestive features are abdominal palpable mass, anemia, and persistent jaundice. Adrenal insufficiency may be found especially in premature delivery. The hemorrhage is mostly self-limiting. Antenatal ultrasound diagnosis of a cyst does not always predict the exact pathology result. The most important differential diagnosis of adrenal hemorrhage/hemorrhagic cyst is cystic neuroblastoma which is highly suggestive in the presence of distant metastases and abnormal catecholamine profile. The major clue to differentiate the two conditions is the fact that the tumor is stable or increases over time while the adrenal hemorrhage is expected to remit within one to two weeks.

CONCLUSION

Pediatric adrenal cysts vary from simple cysts with a benign behavior to neoplasia- related lesions displaying severe prognosis as seen in cystic neuroblastoma. A multidisciplinary team is required for their management which is conservative as close follow-up or it makes necessary different surgical procedures in cases with large masses or if a malignancy suspicion is presented. Recently, laparoscopic approach is regarded as a safe procedure by some authors but generally, open surgery is more frequent used compare to adults; in most cases the preservation of normal gland is advisable.

Adrenal abscess in a 3-week-old neonate - a case report

The authors present a case of a 6-year-old boy operated on in the 4th week of life because of adrenal abscess. The diagnosis of an adrenal abscess in the neonatal period is challenging due to its rare occurrence and non-specific signs. Adrenal abscesses can develop via two mechanisms: as a result of a hematogenic infection and a spread of bacteria to "normal" adrenal glands or, which is much more common, a complication of an adrenal hematoma. Early and accurate diagnosis is crucial for appropriate therapeutic management. Imaging, including ultrasound, can be problematic. The final diagnosis is frequently established on the basis of a histological examination of a surgical specimen.

Serum neuron-specific enolase levels in preterm and term newborns and in infants 1-3 months of age

BACKGROUND

Elevated serum levels of neuron-specific enolase (NSE) was initially assumed to be specific to neuronal tumors (particularly neuroblastoma), but is now known to accompany nontumoral conditions and tumors other than neuroblastomas. There is a need to establish normal ranges for NSE, especially in early infancy. The aims of this study were to determine reference values for NSE in newborns and young infants and to assess whether NSE levels in early infancy (i.e., preterm infants and term infants) differ from the adult reference range for this enzyme.

METHODS

We enrolled 140 healthy babies, which included 40 preterm newborns (3-15 days old and born at 28-42 weeks gestation), 40 term newborns (< 1 month old and born at term), and 60 young infants 1-3 months old (n = 20 per subgroup of 1-, 2-, and 3-month-old infants). The determination of NSE levels was performed by the electrochemiluminescence immunoassay (ECLIA) method using the Elecysys 2010 device (Roche Diagnostics, Mannheim, Germany). The mean serum NSE levels for the preterm newborns was 21.83 ± 15.06 ng/mL [95% confidence interval (95%CI), 16.95-26.71 ng/mL]; term newborns, 18.06 ± 12.83 ng/mL (95%CI, 13.94-22.19 ng/mL); and young infants, 9.09 ± 4.38 ng/mL (95%CI, 7.96-10.23 ng/mL). The mean serum NSE level for infants 1-3 months old was within the ECLIA kit's normal range (4.7-18 ng/mL for adults), whereas the corresponding means for the preterm and term newborns were higher (p < 0.001, for both).

CONCLUSION

Our findings suggest that adult reference values should not be applied to the preterm and term age groups.

Adrenal haemorrhage in term neonates: a retrospective study from the period 2001-2013

OBJECTIVE

To assess the incidence, risk factors and clinical presentations of neonatal adrenal haemorrhage (NAH) in uncomplicated, singleton and term deliveries.

METHODS

A retrospective analysis of 26,416 term neonates delivered between 2001 and 2013, and screened with abdominal ultrasonography.

RESULTS

Of the 26,416 neonates, 74 (0.28%) displayed NAH; the male/female ratio was 1.55:1. Vaginal delivery was significantly more frequent than caesarean section among them (71 versus 3; 95.9% versus 4.1%). Unilateral bleeding occurred on the right side in 36 (48.7%), and on the left in 34 (45.9%), without a significant difference; bilateral haematomas were found in four cases (5.4%). The most common risk factors were macrosomia (16, 21.6%) and fetal acidaemia (23, 31%), while four (5.4%) neonates exhibited pathological acidaemia. Clinical presentations included jaundice in 37 (50%), anaemia in six (8.1%) and an adrenal insufficiency in only one (1.3%) case. In three cases, neuroblastoma was diagnosed.

CONCLUSIONS

Vaginal delivery, macrosomia and fetal acidaemia are the most important risk factors for NAH. The adrenal glands on both sides were similarly involved. In the healthy neonates with NAH, the clinical presentations were mild, with spontaneous regression. Differentiation of NAH from tumours is of considerable importance.

Lethal hypoplasia and developmental anomalies of the lungs in a newborn with intrauterine adrenal hemorrhage and cerebral infarcts: a proposed pulmonary disruption sequence

We report a case of a 31-week-gestation male newborn who died soon after birth from intractable respiratory failure and persistent pulmonary hypertension. The pregnancy had been complicated by intermittent bleeding between 13 and 20 weeks' gestation, attributed to peripheral placental separation, as well as bilateral fetal adrenal hemorrhage, first detected at 17 weeks' gestation. Postmortem examination revealed small, calcified adrenal glands as well as several remote cerebral and cerebellar infarcts. The lungs were hypoplastic (lung weight/body weight ratio: 1.64%; 10th percentile for 28-36 weeks' gestation: 2.27%) and distorted by exaggerated lobulation. Microscopically, the lungs exhibited several developmental anomalies, including focal acinar dysgenesis suggestive of arrested development in the pseudoglandular stage of development (8-16 weeks' gestation) (mainly in the upper lobes), and features of bronchial obstruction, including focal lobular hyperplasia and microcystic maldevelopment (mainly in the lower lobes). The adrenal and cerebral findings were consistent with a severe early-gestation hypoxic-ischemic insult, likely related to peripheral placental separation and chronic abruption. The co-occurrence and timing of these well-recognized hypoxic lesions provide further evidence that certain developmental lung anomalies, such as focal acinar dysplasia, focal lobular hyperplasia, and microcystic maldevelopment, may, at least in some cases, have a hypoxic/ischemic etiology.