Prenatally detected tumor mass in the adrenal gland

The Clinical Value of Prenatal Ultrasonography in the Differential Diagnosis of Fetal Suprarenal Space-Occupying Lesions

Objective

This study aimed to investigate the value of prenatal ultrasonography in the differential diagnosis of fetal space-occupying lesions in the adrenal gland.

Methods

Thirty-six fetuses with adrenal gland space-occupying lesions diagnosed by prenatal ultrasonography between January 2019 and July 2021 were included in this retrospective study. The clinical data, ultrasonographic features, treatments, and prognoses of the fetuses were analyzed. Postnatal diagnoses were made using computed tomography (CT), magnetic resonance imaging, and surgical resection.

Results

Of the 36 fetuses, 10 were diagnosed with adrenal hematomas, eight with adrenal neuroblastomas, seven with adrenal cysts, seven with subphrenic pulmonary sequestration, and four with adrenal teratomas. The accuracy of prenatal diagnosis was highest in those with adrenal cysts and subphrenic pulmonary sequestration, with the accuracy being 85.7% for both conditions. The mean gestational age at first detection of subphrenic pulmonary sequestration was 22.5 ± 3.1 weeks, which was significantly lower than that of other diagnoses (P < 0.05), and the mean diameter of adrenal cysts was 15.1 ± 4.2 mm, which was significantly smaller than that of other lesions (P < 0.05). All newborns with adrenal teratomas and neuroblastomas were treated surgically. Five of the seven patients with subphrenic pulmonary sequestration and three of the seven patients with cysts were also treated surgically. Follow-ups of the remaining cases were carried out by enhanced CT examination, and the prognoses were good.

Conclusion

Prenatal ultrasonography can help differentiate between different types of fetal adrenal space-occupying lesions, and there is a high coincidence rate between the diagnosis of adrenal cysts and subphrenic pulmonary sequestration.

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.

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.

Clinical value of serial ultrasonography in the dynamic observation of foetal cystic adrenal lesions

OBJECTIVES

The objective of the study is to evaluate the diagnostic value of ultrasonography in cystic lesions of the adrenal gland.

METHODS

Twenty-two cases of adrenal cystic lesions found in the foetal period were retrospectively analysed. All foetuses were followed up by ultrasound after birth, and all lesions were confirmed by operation or ultrasound-guided biopsy.

RESULTS

Sixteen foetuses displayed anechoic findings, and 6 had patchy mixed echoic findings. Nevertheless, the characteristics of these lesions changed in the neonatal period: 7 cases presented as anechoic and 15 cases presented as mixed echoic. The final pathology revealed simple cysts in 7 cases, intracystic haemorrhage in 9 cases, and 6 cases of spontaneous haemorrhage of the adrenal glands.

CONCLUSIONS

The ultrasonographic findings of foetal cystic lesions in the adrenal gland and the change they undergo after birth may provide valuable information for clinical diagnosis.

Imaging and differential diagnosis of suprarenal masses in the fetus

Prenatal sonography and magnetic resonance imaging of suprarenal fetal masses is presented, along with clinical information and follow-up. Imaging pearls and differential considerations for each diagnosis will be discussed. Fetal suprarenal mass diagnoses include neuroblastoma, extralobar pulmonary sequestration, congenital adrenal hyperplasia, partial multicystic dysplastic kidney, renal duplication, urinoma, gastric duplication cyst, and splenic cyst. Recognizing the range of malignant and benign suprarenal fetal masses that can present on prenatal imaging can help guide patient counseling and management.

Evaluation of the prenatally diagnosed mass

With the advent of advanced imaging technologies, the field of prenatal diagnosis and counseling has grown rapidly. The use of fetal ultrasound and ultrafast magnetic resonance imaging has allowed for prenatal identification of structural anomalies as well as neoplasm. The differential diagnosis of a fetal mass is dependent upon its location and the tissue characteristics of the mass on imaging. The use of amniocentesis for chromosomal analysis and genetic testing for known tumor-related genetic abnormalities may aid in further refining the diagnosis. Herein we describe a general diagnostic algorithm for fetal masses based upon their location within the body and how the appropriate diagnostic modalities may be applied in the clinical setting.

Clinical features and surgical outcome of a suprarenal mass detected before birth

PURPOSE

With the widespread use of the obstetrical ultrasound, identification of a fetal suprarenal mass has become more common. Most of these masses prove to be congenital neuroblastomas (CNB), but the diagnosis is often confused with other benign lesions and the postnatal management remains to be controversial.

METHODS

The medical records of 18 patients that underwent primary surgical excision for an antenatally detected suprarenal mass, between January 1995 and April 2009, were reviewed. The clinical, radiological, surgical, and pathological data were collected. Staging evaluation was performed after histological confirmation of the CNB.

RESULTS

There were 13 cases of CNB, 1 adrenal cyst, 2 adrenal hemorrhages, and 2 pulmonary sequestrations. The differential diagnosis was impossible before surgery. Most of the CNBs were stage I (N = 11), with 1 stage IV and 1 stage IV-S. Four patients (3 stage I and 1 stage IV-S) had more than one copy of N-myc gene. The stage I patients were cured by surgery alone, and stage IV patients underwent nine cycles of adjuvant chemotherapy and currently have no evidence of disease. The five benign lesions were cured with excision alone. There were no postoperative complications.

CONCLUSION

For early diagnosis and treatment, surgical excision should be considered as the primary therapy for an antenatally detected suprarenal mass. The surgery can be safely performed during the neonatal period and provides a cure in most cases.

Tumours of the fetal body: a review

Tumours of the fetal body are rare, but lesions have been reported in all spaces, especially in the mediastinum, the pericardial space, the adrenals, the kidney, and the liver. Lymphangioma and teratoma are the commonest histological types encountered, followed by cardiac rhabdomyoma. Adrenal neuroblastoma is the commonest malignant tumour. Imaging plays an essential role in the detection and work-up of these tumours. In addition to assisting clinicians it also helps in counselling parents. Most tumours are detected by antenatal US, but fetal MRI is increasingly used as it brings significant additional information in terms of tumour extent, composition and complications.

Prenatally Detected Cystic Adrenal Mass Associated with Beckwith-Wiedemann Syndrome

We report a case of a right-sided cystic adrenal mass, detected after the 21st week of gestation, associated with fetal macrosomia. The diagnosis of Beckwith-Wiedemann syndrome was evoked. Prenatal sonography and magnetic resonance imaging did not allow establishing the origin of the suprarenal mass. The differential diagnosis of cystic neuroblastoma, pseudocystic adrenal haemorrhage, and adrenocortical macrocysts was discussed. A laparotomy was performed 2 weeks after birth due to the increasing size of the tumour and due to its possible malignant origin. Histological findings were haemorrhagic lesions without evidence of malignancy and adrenal cortical cytomegaly. The diagnosis of an adrenocortical macrocyst component of Beckwith-Wiedemann syndrome was established.

The neonate with an abdominal mass

Abdominal masses in neonates reflect a wide spectrum of diseases,from lesions that can cause significant morbidity and mortality,to conditions readily corrected surgically, to entities which maybe safely observed. It is incumbent upon the infant's physician to determine the nature of the mass in a timely, safe, and cost-effective manner.

Prenatal Diagnosis of Neuroblastoma

Reports of the prenatal detection of fetalneuroblastoma have increased over the pastseveral years. Sonography has played a significantrole in the early detection of these masses andhas helped in preparing for the postnatalmanagement of these neonates. In fact, earlysonographic detection of adrenal neuroblastoma, inconjunction with early postnatal surgicalintervention, has helped improve the prognosis ofinfants born with these suprarenal masses.Reported here is a case of fetal adrenalneuroblastoma diagnosed prenatally withconventional gray-scale and color Doppler imaging.

Prenatal and Postnatal Imaging Findings of Congenital Adrenal Neuroblastoma

Neuroblastoma is the most common solid tumorin childhood. There have been several casereports and reviews on the prenatal diagnosis ofcongenital neuroblastoma. The sonographicimaging findings of fetal adrenal neuroblastomaare variable. Most of them are cystic or complex,but uncommonly, solid neuroblastomas arereported. This case study presents prenatal andpostnatal findings of a purely solid echoicadrenal neuroblastoma.

Prenatally Diagnosed Cystic Neuroblastoma: A Report of Two Cases

We report two cases of prenatally diagnosed cystic neuroblastoma (PDCN). In the first case, prenatal ultrasonography (US) at 33 weeks' gestation showed a 30 x 20 mm cyst at the upper pole of the right kidney. The size and content of the mass demonstrated no change during pregnancy. Postnatal US showed no change in the cystic mass 4 weeks after birth compared to the prenatal findings. The infant underwent total resection of the tumour at 28 days of age. In the second case, a left cystic mass measuring 50 x 40 mm was detected in a fetus in the 37th week of pregnancy. Postnatal US showed a cystic mass in the left adrenal gland. The US findings showed no change 18 days after birth and the infant underwent total resection of the tumour at 19 days of age. In both cases, pathological examination revealed a neuroblastoma and all of the biological prognostic factors were favourable. Surgical intervention was necessary for a final histological and biological diagnosis to be made. We recommend that prenatally suspected neuroblastomas should normally undergo surgical intervention, unless tumour size decreases within about 1 month after birth.

Early recognition of infant malignancy: the five most common infant cancers

The incidence of cancer in children is rising in the U.S. Although cancer in the first year of life is relatively rare, understanding the early signs and symptoms of and the historical factors associated with most common infant cancers is essential for providing optimal care to these infants and their families. Neonatal nurses and nurse practitioners play a pivotal role in early recognition and detection of infant malignancy. This article reviews the incidence of and historical factors associated with infant cancers and discusses clinical presentations and available diagnostic images as well as screening tools for the five most common types of infant malignancy.

Outcome of suprarenal localized masses diagnosed during the perinatal period: a retrospective multicenter study

BACKGROUND

The growing use of abdominal ultrasonography during pregnancy and in the postnatal period is leading to the discovery of an increasing number of suprarenal masses. The optimal diagnosis and treatment of these masses has not yet been determined.

METHODS

The authors reviewed the files of patients with suprarenal masses detected prenatally or during the first 3 months of life, between 1986 and 1999, in the pediatric surgery and oncology departments of Paris hospitals.

RESULTS

Thirty masses were detected prenatally and 23 postnatally. In the latter group of patients, the diagnosis was based on ultrasound in 8 cases and on the palpation of a mass in 15 cases, 13 of which were neuroblastoma. At birth, the masses were cystic in 19 cases, solid in 17, and mixed in 13. Sensitivities of methyliodobenzylguanidine and urinary catecholamine assay were 70% and 52% respectively. Surgery was performed in 38 cases with a median age of 42 days. Histologic analysis showed 31 neuroblastomas, 1 adrenal hemorrhage, 2 necrotic masses, 1 bronchogenic cyst, and 3 sequestrations. All the patients were alive and disease free, at a follow-up ranging from 3 months to 13 years.

CONCLUSIONS

In this series, 58% of the suprarenal masses diagnosed perinatally were localized neuroblastoma with a favorable outcome. All other cases either regressed spontaneously or turned out to be benign lesion. Thus, the management of these masses must strike a compromise between aggressive treatment and a wait-and-see attitude. This requires appropriate initial assessment and a close follow-up in a specialized center.

Factors affecting outcomes of prenatally-diagnosed tumours

OBJECTIVE

The outcomes of prenatally-diagnosed tumours affect obstetrical management and parental decisions. The present study reviews the factors affecting outcomes for fetuses with prenatally-diagnosed tumours.

METHODS

Medical records of all fetuses referred to our institutions with antenatally-diagnosed tumours were reviewed for the type and location of the tumours, results of treatment and/or causes of death.

RESULTS

From January 1994 to May 2001, there were 15 fetuses with antenatally- diagnosed tumours: mesoblastic nephroma (MN) (n=2); neuroblastoma (NB) (n=2); cystic hygroma (CH) (n=3); intracranial germ cell tumour (IGCT) (n=2); sacrococcygeal teratoma (SCT) (n=3) and haemangioma (liver, n=2; limb, n=1). One mother had termination of pregnancy for her fetal SCT. Three mothers had Caesarean section for large fetal heads (CH, n=2; IGCT, n=1). Three fetuses died; two with IGCT and one with SCT, who died of heart failure. Two newborns with CH needed emergency intubation and, later, one of them had tracheostomy. One baby had cardiac failure resulting from a lower limb haemangioma and needed drug therapy. All solid tumours (MN, NB, SCT) of the live births had no recurrence after surgery with or without adjuvant chemotherapy.

CONCLUSION

Prenatally-diagnosed tumours without any other associated abnormality cause morbidity and mortality because of their location and vascularity. Solid tumours are relatively benign.

Diagnostic and therapeutic dilemma with large prenatally detected cystic adrenal masses

OBJECTIVES

The prenatal finding of a large cystic adrenal mass raises the dilemma of the differential diagnosis between adrenal hemorrhage and cystic neuroblastoma. The possibility of a neuroblastoma usually leads to surgical excision of such tumors. Nevertheless, an adrenal hemorrhage has to be recognized, so that unnecessary surgery may be avoided.

METHODS

Three cases of large prenatally detected adrenal masses managed nonoperatively are reported. Data studied were: age at the diagnosis, prenatal and postnatal ultrasonographic consistency, and tumor marker levels. Size and sonographic evolution were also studied.

RESULTS

In all 3 cases, a cystic mass, measuring more than 40 mm in size, was detected during the 3rd trimester of pregnancy. The sonographic appearance evolved from a sonolucent tumor to a heterogeneous mass with hyperechoic areas. The tumor marker levels were normal. All infants had a documented decrease in mass size at birth and were managed nonoperatively. All these tumors were considered adrenal hemorrhages.

CONCLUSIONS

Prenatal ultrasonography rarely permits to distinguish an adrenal hemorrhage from a cystic neuroblastoma. The differential diagnosis, even in large masses, is based on close postnatal follow-up with serial sonography. Surgery is not mandatory, unless the size does not decrease. However, without pathologic proof, it is not possible to differentiate an adrenal hemorrhage from a spontaneously resolved neuroblastoma.

Outcome of prenatally diagnosed solid fetal tumors

BACKGROUND/PURPOSE

In the last 10 years, the ability to diagnose fetal tumors in the prenatal period has improved greatly because of technical advances in imaging. Early diagnosis and determination of tumor may affect prognosis.

METHODS

The authors retrospectively reviewed the records of 1316 fetuses who underwent sonographic evaluation for congenital defects at University of California-San Francisco over a 6-year period. Of these, 16 had fetal tumors and were followed up at our institution. There were solid or predominantely solid with small cystic component masses in one of 3 locations: cervical, mediastinal, or abdominal. Excluded from our study were those fetuses with either sacrococcygeal teratoma, congenital cystic adenomatoid malformation of the lung, or ovarian cyst, because these defects have been extensively reviewed elsewhere. In addition, masses that were primarily cystic also were excluded. Data collected included diagnosis, gestational age at diagnosis and at delivery, mode of delivery, fetal and neonatal survival, and disease confirmation.

RESULTS

Of the 16 fetuses, 4 had mediastinal tumors: 2 with pericardial teratomas (both of whom died in utero) and 2 with cardiac rhabdomyomas (1 died; the other presented tuberous sclerosis and is alive at 2 years of age). Four patients had cervical tumors (3 died; 1 survived and is alive and well), and 8 had abdominal tumors (3 with liver tumors, 4 with a left adrenal mass, and 1 with retroperitoneal teratoma). All eight patients with an abdominal tumor are alive and well.

CONCLUSIONS

Fetal tumors are rare, and the prognosis seems to depend on their location and size. Although easier to detect, cervical and mediastinal tumors have a worse prognosis. Abdominal masses are more difficult to detect but have a better prognosis.