Giant Cystic Abdominal Masses in Children and Adolescents: Ultrasonic

Differential Diagnosis

JEFFREY 0. WICKS,’ TERRY M. SILVER,’ AND ROBERT L. BREE”2

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Twelve children and adolescents with a variety of giant 12 patients(cases 1, 2, 8, 9, 11, and 12). Radiologic and/
cystic abdominal masses are described. These masses are or nuclear studies confirmed the presence of a mass in
easily evaluated by ultrasonic scanning. Information regard- those six cases, yet a specific diagnosis was made in
ing location, size, origin, and Internal structure aid in the only case 2. Ultrasound as a single study confirmed the
differential diagnosis. A correct diagnosis was made In a high
presence of a mass and identified it as cystic. On the
percentage of the cases, obviating the need for more invasive
basis of ultrasound evaluation alone, a specific diagnosis
studies. Ultrasound examinations at appropriate Intervals dur-
was reached in five of the six cases (cases 2, 8, 9, 1 1,
ing patient management can document change in position
and/or size. and 12).
Six of the 12 patients did not have definite palpable
masses (cases 3-7 and 10). Five of these six patients had
Ultrasonic scanning for evaluating abdominal masses is
well accepted. Besides confirming the presence of a radiographic studies which suggested the presence of a
suspected mass, ultrasound can differentiate cystic from mass. In only case 4 was a specific diagnosis offered.
solid components and often determine the origin of the Ultrasound confirmed the presence of a cystic mass in
mass [1]. This report evaluates our experience with giant all cases and made a specific diagnosis in all but case 6.
cystic abdominal masses in children and adolescents. Ultrasound was the only diagnostic imaging method
used in case 10. Thus, ultrasound scanning accurately
Subjects and Methods delineated and characterized all the abdominal masses
as cystic, and correctly identified the origin in 10 cases.
Twelve patients from 22 months to 19 years of age,
referred for evaluation of definite or questionable palpa- DifferentialDiagnosis
ble abdominal masses, form the basis of this report. All
Left Upper Quadrant
had masses which fulfilled the accepted sonographic
criteria for cystic structures and occupied at least one Splenic cysts may be congenital or acquired [2]. They
quadrant of the abdomen. appear as smoothly marginated, oval, anechoic, left
Standard contact B-scanning techniques were per- upper quadrant masses with compressed splenic paren-
formed using 2.5-5.0 MHz transducers, depending on chyma laterally and posteriorly (fig. 1). They are separate
patient size and type of commercially available gray scale from the left kidney which may be compressed, thereby
scanning equipment used. All patients were scanned in excluding a distended renal pelvis secondary to uretero-
the supine position with additional prone and/or decu- pelvic junction obstruction (fig. 2). The left upper quad-
bitus scanning as needed. Transverse and longitudinal rant duplication cyst (case 8) was sonographically sepa-
(sagittal) sonograms were obtained at 1-2 cm intervals rate from the spleen.
with additional selected views obtained of regions of Although unusual in this age range, a pancreatic
interest. Images were permanently recorded on either pseudocyst should be included in the differential diag-
Polaroid or x-ray film. Whenever possible, scanning was nosis. We have encountered only one case of posttrau-
performed while the patient had a distended bladder. No matic pseudocyst in a child, but it was small (4 cm) and
sedation was necessary. confined to the tail of the pancreas. Fluid in the gastric
fundus can simulate an abnormal left upper quadrant
Results cystic mass. To confirm a gastric location, careful scan-
The clinical, radiologic, and ultrasound findings are ning with the patient in different positions to document
summarized in table 1 Surgical
. confirmation was avail- changes in size and/or configuration may be required.
able in 11 of the 12 patients. The masses include two Occasionally, scanning after nasogastric suction may be
splenic cysts, two gastrointestinal duplication anoma- necessary.
lies, one mesentenic cyst, one dilated renal pelvis sec-
Right Upper Quadrant
ondary to ureteropelvic junction obstruction, two hy-
dropic gallbladders, and four ovarian tumors. The sizes In the right upper quadrant, gallbladder hydrops
of these masses ranged from 5 to 34 cm in greatest (cases 3 and 10), choledochal cysts, and right uretero-
dimension on the ultrasound study. pelvic junction obstruction may present as cystic masses
A definite abdominal mass was palpated in six of the on the ultrasound study. Hydrops of the gallbladder

Received September 15, 1977; accepted after revision January 9, 1978.

I Department of Radiology, University of Michigan Medical Center, Ann Arbor, Michigan 48109. Address reprint requests to J. D. Wicks.
2 Present address: Toledo Radiology Associates, 3939 Monroe Street, Toledo, Ohio 43606.

Am J Ro.ntq#{149}nol 130:853-857, May 1978 853 0361 -803X/78/0500-0853 $02.00

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 ULTRASOUND OF CYSTIC ABDOMINAL MASSES 855
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B
Fig. 1 -Case 1 , splenic cyst. A, Longitudinal scan showing large anechoic cyst (C) compressing splenic parenchyma (5) near diaphragm. Left
kidney (K) has normal collecting system. Arrow marks umbilicus. B, Transverse scan showing splenic cyst (C) compressing splenic parenchyma
laterally and posteriorly. Cyst is separate from left kidney.

Abdominal

Cystic masses associated with the gastrointestinal

tract can occur anywhere in the abdomen [6]. Duplica-
tion anomalies (enterogenous cysts; cases 4 and 8) may
communicate with the gastrointestinal tract and contain
intraluminal debris differentiating them from mesenteric
P cysts [6, 7] (case 4, fig. 4). Mesentenic cysts may be
unilocular (case 5, fig. 5) or multilocular [8]. These cystic
masses were located superficially just beneath the ante-
nor abdominal wall. While the duplication anomalies
were ovoid, the mesenteric cyst was flatterin anteropos-
tenor diameter and conformed more closely to the ante-
nor abdominal wall instead of distending it. The mesen-
tenic cyst changed configuration with changes in posi-
tion, which may help differentiate it from an ovarian cyst.
FIg 2 -Case 2 left ureteropelvlc junction obstructIon Longitudinal The pliability of mesentenic cysts demonstrated on ultra-
scan showing cystic mass (P) which can be identified as renal pelvis
because of associated calyceal dilatation (C), even though very little sonography explains the frequent clinical dilemma of
renal parenchyma is present. either absent or unreproducible mass on physical exam-
ination.
appears as an elliptical anechoic structure on sagittal Cystic ovarian masses may be impossible to differen-
scans with its origin beneath the anterior surface of the tiate sonographically from mesentenic cysts [9]. The
largest masses we encountered were of ovarian origin.
liver, anterior to the right kidney (fig. 3). Despite gross
They both may be unilocular (case 6, fig. 6), septated, or
enlargement, the gallbladder maintains its characteristic
multilocular (case 12). Although smaller cystic masses
shape on sagittal scans and circular configuration on
transverse scans. In our two cases, there were no asso- may appear to arise from the pelvis, the origin of giant
masses which fill the entire abdomen may be difficult to
ciated dilated intrahepatic biliaryradicals, dilated corn-
assess. Mucinous cystadenomas (case 7, fig. 7) tend to
mon bile duct, or gallstones.
be more septated [10] and contain more solid elements
Although a choledochal cyst may have a similar ap-
than serous cystadenomas. Cystic teratomas may pres-
pearance, biliary obstruction is usually associated in a
high percentage of cases [3]. In addition, an atypically ent a complex sonographic appearance with solid areas,
loculated fluid-filled areas, and calcified elements which
located and appearing gallbladder may also be visualized
may cause acoustic shadowing [1 11.
[4]. Right ureteropelvic junction obstruction can be dif-
ferentiated by the demonstration of dilated calyces in
addition to the huge renal pelvis. Differentiation from a Discussion
developmental renal cyst [5] and an obstructed duplica- Several authors have discussed the usefulness of B-
tion anomaly may be difficult. An adrenal cyst could also scanning in the diagnosis and management of abdomi-
present as a cystic upper quadrant mass, but we have nal masses in children [1 5, 12]. These, reports have
not encountered one in our pediatric population. shown a variety of solid and cystic masses predominately
 856 WICKS ET AL.

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:#{149} G
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G 4ku

Fig. 3. -Case 3, gallbladder hydrops. A , Longitudinal scan showing characteristic gallbladder shape and position of cystic mass (G) beneath anterior
liver (L) surface and anterior to right kidney (K). B, Transverse scan showing typical round configuration of gallbladder (G). Note enhanced posterior
sound transmission.

Any child or adolescent presenting with abdominal

j distension
ultrasound
or palpable
examination.
mass should
Although
have an abdominal
clinical circum-
stances and availability may not always permit this study,
the ease, safety, and relatively high degree of accuracy
r - in diagnosis make ultrasound a useful screening exami-
nation.
Once a cystic mass is identified, ultrasonography can
aid the surgeon by delineating the extent of the mass
and defining its relationship to normal intraabdominal
structures. Associated findings of ascites or hydrone-
phrosis are easily detected. If conservative managem?nt
is required, ultrasound examinations at appropriate in-
tervals can document change in position and/or size
p (case 7).

Fig. 4.-Case 4, duplication anomaly. Transverse scan showing cystic ACKNOWLEDGMENTS

mass in right midabdomen (D) with echogenic debris (arrow).
We thank Chris Malinowski for help in preparing the manu-
script and Tena Hayes for technical assistance.
with bistable reproductions. The noninvasive, nonioniz-
ing nature and the excellent capability of gray scale B-
scanning to characterize cystic masses make this modal- REFERENCES
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 ULTRASOUND OF CYSTIC ABDOMINAL MASSES 857
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. -,,- I ---
Fig. 5.-Case 5, mesenteric cyst. A, Longitudinal scan showing cystic mass (M) located superficially in abdomen. Arrow marks umbilicus. B,
Transverse scan showing mesenteric cyst (M). Differentiation from ovarian serous cytadenoma may be difficult on purely sonographic basis.

a’
C

Fig. 6. -Case 6, serous cystadenoma of ovary. Longitudinal scan

showing unilocular cystic mass (C) extending from pelvis to upper
abdomen. Centimeter marker is at level of umbilicus. Arrows indicate
reverberation artifacts. B = bladder. __ 1 ___

Fig. 7.-Case 7, mucinous cystadenoma of ovary. Transverse scan

showing cystic mass (C) with multiple septae. K = kidney.

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