Diagnostic and Therapeutic Dilemma with Large Prenatally Detected Cystic Adrenal Masses

Abstract

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.

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“…Neuroblastoma and enteric duplication are the most frequent differential diagnoses [11]. Other differential diagnoses of EPS include congenital cystic adenomatoid malformation (CCAM), duplication cysts, angiomas, and teratomas.…”

Complex communicating bronchopulmonary foregut malformation with pancreatic heterotopy depicted with fetal magnetic resonance imaging: a case report

“…In cases of isolated suprarenal lesions, management guidelines have been recently proposed [5]. Cyst appearance is a singular situation in which neurogenic tumor, adrenal hemorrhage, teratoma, and enteric duplication can be assumed [6]. If no feeding vessel is detected, imaging data can rarely contribute to an accurate diagnosis.…”

Neuroblastoma in childhood: review and radiological findings

“…A right-sided location, diagnosis in the third trimester, and cystic or mixed echogenicity, help differentiate it from an intra-abdominal sequestration [6, 17–19]. Without pathologic proof, it is not possible to differentiate an adrenal haemorrhage from a spontaneously resolving NBL and non-invasive monitoring of these small supra-renal lesions with repeat ultrasound examinations and urine catecholamine levels measurements are advocated [20]. Foetal NBL is rarely associated with foetal hydrops and maternal pre-eclampsia from placental vascular metastases that secrete catecholamines, hepatic and less commonly marrow metastases.…”