Seminars in Surgical Oncology 2: 125-138 (1986)

Imaging of a Pediatric Abdominal Mass

F. GLEN SEIDEL, MD
From the Departmentbf Radiology and Pediatrics, State University of New York at Buffalo,
School of Medicine, and The Children’s Hospital of Buffalo

The approach to the child with an abdominal mass will be aided by careful
consideration of the radiographic imaging modalities available at an insti-
tution. The relative advantages, disadvantages, costs, and radiation of
each modality are presented. The recommended workup of a pediatric
abdominal mass, as well as the most common masses and their differential
diagnosis, are outlined.

KEY WORDS: radiographic imaging, pediatric abdomen, abdominal mass, x-ray,

pediatric radiology

INTRODUCTION malities. When a chest x-ray is included, the recognition

The child with an abdominal mass presents a unique Of metatastic disease will influence the remaining workup.

problem to the pediatrician, pediatric surgeon, and ra-

diologist. We are faced with a patient whose examination
is frequently limited by an inability to cooperate or com-
municate with the examiner. The radiologist is asked to
help assess the magnitude and origin of the palpable
abnormality. For the referring physician, there is a some-
times bewildering array of imaging modalities available
in a modern radiology department, yet mounting pressure
to control medical costs makes careful selection of im-
aging tests important.
Although a complete discussion of modern abdominal
radiology is beyond the scope of this monograph, a brief
discussion of the physical principles, advantages, and
disadvantages of each modality will help us to better
select and direct a radiographic examination. Finally,
although the typical appearance of the most common
abdominal masses is described elsewhere in this text, a
limited discussion of the radiographic findings and differ-
ential diagnosis will be presented.
IMAGING MODALITIES
Plain Film Examination
This simple examination is sometimes forgotten in the
midst of its more sophisticated colleagues, but is should
remain the initial study of choice in most circumstances. enema are generally not helpful in the initial evaluation
It is inexpensive, relatively low in radiation, and requires
no equipment Or sedation. It
obstruction, fecal masses, calcifications, and bony abnor- Children’s Hospital of Buffalo, 219 Bryant St, Buffalo, NY 14222.
Excretory Urogram (Intravenous Pyelogram)
Since the majority of pediatric abdominal masses arise
from or will affect the kidney, the excretory urogram
(EU) was formerly the mainstay in the evaluation of a
suspected abdominal mass [ 11. With contrast injection,
the function, position, and possible obstruction of the
kidneys, ureters, and bladder can be assessed. Unfortu-
nately, the EU is quite insensitive and is frequently nor-
mal in the face of a large renal mass. Most authors now
feel that in children, as well as adults, an initial evalua-
tion of the kidneys is better accomplished with ultrasound
(US) [2,3]. When evaluating a mass, the injection of
contrast should be reserved for the more useful computed
tomography (CT) examination, which may be required
later [4]. Nevertheless, if hydronephrosis is detected by
US, an EU may provide valuable anatomic information
concerning the site of obstruction. Although fairly low in
cost, the EU has become a relatively rare examination at
most children’s hospitals because of its invasive nature,
insensitivity, and moderate radiation dose.
Barium Examinations
The traditional upper gastrointestinal series and barium
Address reprint requests to F. Glen Seidel, MD, Radiologist, The

0 1986 Alan R. Liss, Inc.

126 Seidel
TABLE 1. Selection of an Imaging Modalitv
Exam type Radiation Sedation
Plain film + 0
EU + 0
UGIIBE ++ 0 +/-
us 0 0
CT ++ +/-
Angio ++++ +++
MRI 0 ++
"Presence of fatigas: + , helpful; -, hindrance; o. o f no consequence.
hApproxiniate relative cost.
of a suspected abdominal mass. They may demonstrate
the presence of a mass and its involvement of the bowel,
and are relatively noninvasive and inexpensive. How-
ever, the radiation dose is fairly high, generally greater
than a CT examination. Furthermore, the presence of
barium within the GI tract will hinder an US and delay
CT until adequate bowel cleansing can be accom-
plished-sometimes for 24-48 hr or more. Therefore,
although these studies may provide valuable information,
they should not be used as screening examinations, par-
ticularily when CT or US may be needed.
Ultrasound
Most pediatric radiologists now consider US to be the
imaging modality of choice in the initial evaluation of an
abdominal mass [ 2 , 3 ] .It is relatively inexpensive (slightly
more than an EU), can usually be performed without
sedation, and involves no radiation. Ultrasound provides
excellent visualization of most intra-abdominal organs,
particularily the liver, gallbladder, kidneys, pancreatic
head, and the pelvis. In can exclude free fluid with
confidence, and under some circumstances it has been
shown to be more sensitive than CT for certain hepatic
parenchymal diseases, including metastases [5]. In par-
ticular, US can differentiate cystic from solid masses
with greater reliability and confidence than CT [6-81.
The ultrahigh frequency sound waves used in US have
little power and no known biologic effect; however, this
lack of power prevents penetration of air or fat. There-
fore, body habitus should be considered when consider-
ing US examination; fortunately, most children have little
body fat. If possible, the patient should be kept with
nothing by mouth (NPO) for a few hours before the exam
to reduce gas within the bowel. This is particularily
important in the left upper quadrant and lower midabdo-
men, the areas most difficult for US. If bowel gas is not
excessive and with minimal patient cooperation, US can
exclude a mass with confidence. However, if the exami-
Relative information Relative
Invasive Fat/gas" yield costb
0 +/- 0.5 1
+ +I- 1-2 2
+/- I 212
0 --/-- 3 3
++ +lo 4 5
+++ +/- - 4 8+
+/- +/o 5 10
nation is suboptimal or confusing, correlation with CT
will provide more complete anatomic detail.
Computed Tomography
Modern CT scanners, with scan times of less than 2
sec and resolution of less than 1 mm, provide excellent
visualization of virtually all intra-abdominal structures.
This can be accomplished despite excessive abdominal
gas; however, because of a lack of intra-abdominal fat in
children, contrast opacification of the bowel and vascular
structures is much more important than in adults. There-
fore, abdominal CT examination in children MUST in-
clude administration of oral, and frequently rectal,
contrast medium as well as bolus intravenous contrast
injection. If patient cooperation (including quiet breath-
ing or breathholding) is not possible, satisfactory seda-
tion will be required.
A moderate radiation dose (about equal to two or three
plain films of the abdomen), higher cost, and the need
for invasive contrast enhancement and sedation are the
disadvantages of CT. Although its cost is about twice that
of US or an EU, it is considerably less than the cost of a
single day in the hospital, and it may complete the diag-
nostic workup with a single test [9,10]. In general, CT
provides the single most sensitive and specific examina-
tion of most body parts currently available.
Magnetic Resonance Imaging
The latest revolution in diagnostic radiology is mag-
netic resonance imaging (MRI), which provides images
approaching, and in many cases exceeding, CT quality
without radiation or contrast injection. MRI provides
multidirectional images including direct coronal, sagittal,
and conventional transaxial slices, all without reposition-
ing the patient. Currently, it is not available at most
centers, and its cost remains very high. Because of the
strong magnetic field required, the logistics of scanning
critically ill patients with IV pumps and respirators have
 Imaging of a Pediatric Abdominal Mass 127

TABLE II. Imaging of an Unknown Mass

Possible mass

Poor exam
1 Good exam
I Strong suspicion
Ultrasound
Normal
Quit

1
I
Mass confirmed
I

CT I
Renal Hepatic Pelvic

1
VCUG
1
Disida scan
1
VCUG
EU ?CT ?CT
Nuclear renograrn ? Transhepatic ? BE/UGI
?CT Cholangiogram

Renal Suprarenal Hepatic

(Wilms’ tumor) (Neuroblastorna)

Chest CT Bone scan DISIDA Scan

Bone scan Skeletal survey ? Angiogram
Skeletal survey

not been completely solved. Because of long scan times,
cardiac, and, possibly, respiratory gating (automatic
scanning at the same point in the cardiac or respiratory
cycle) are frequently necessary in the upper abdomen,
and most children less than 5 years of age must be
sedated. Despite these current disadvantages, technolog-
ical improvements continue at a rapid pace. As the image
quality
- . improves and the costs and scan times decrease,
it is possible that MRI will largely supplant CT imaging
in the next 10 years-particularily in pediatrics, where
the lack of radiation is so attractive.
Angiography
Although angiography provides information about vas-
cular anatomy that cannot be obtained in any other way,
the anatomic detail provided by CT has sharply reduced
the role of angiography in the imaging of abdominal
neoplasms. The exception remains hepatic tumors, where
some surgeons feel that the additional information of the
angiogram is helpful. Although most angiograms can be
accomplished using intravenous sedation, general anes-
thesia is often required. This fact, coupled with the in-
vasive nature of this exam, its expense, and a high
radiation dose have reduced its role sharply at most
pediatric centers.
Nuclear Medicine
Radiopharmaceuticals can provide vital functional in-
formation about many abdominal organs, particularly the
liver and kidneys. The nuclear renogram is the most
sensitive index of renal function and blood flow avail-
able. It is particularly useful to differentiate renal dyspla-
sia (multicystic dysplastic kidney) from severe obstruction
and hydronephrosis in a patient with a nonfunctioning
kidney on IVP [ l l ] . Renal cortical imaging with Tech-
128 Seidel

Fig. 1. Wilms' Tumor: Five-year-old child with large right flank

mass. CT without (A) and with (B) intravenous contrast demon-
strated, a huge complex, slightly calcified mass replacing the right
kidney. Pericaval adenopathy displaces, but does not encase, the
inferior vena cava and renal vessels. L, liver; S , spleen; a, aorta; i,
IVC. Longitudinal ultrasound (C) confirmed the patency of the infe-
rior vena cava (arrows). Chest CT (D) demonstrated extensive meta-
static disease (M) in both lung fields. An abdomen film following the
CT (E) showed downward displacement of a distorted right renal
collecting system.

netium 99m DTPA (T~~~~-DiethyIenetriaminepentaa-

cetic Acid) or Glucoheptonate is the most sensitive screen
for parenchymal loss or abnormality. In the liver, a
Technetium 99m DISIDA (T~~~"'-Diisopropylirnnodi-
acetic acid) scan can demonstrate the patency of the
biliary tract and the functional integrity of the hepato-
cytes [12,13]. Gallium scanning still plays a role in the
assessment of metastatic disease, particularly lymphoma
[14]. In addition, gallium67 chloride or indium"' labeled
white cells are both useful to detecting occult infection
and abcess [151. Bone scanning with technetium99mHDP
( T ~ ~ ~ ~ - H y dMethylene
roxy Diphosphonate) provides de-
tection of skeletal metastatic disease and other abnorrnal-
ities [ 16,171. With most nuclear medicine procedures,
the total body radiation dose is very low, although the
 Imaging of a Pediatric Abdominal Mass 129

Fig. 2. Wilms' tumor: Two-and-a-half-year-old child with palpable

left flank mass. CT without (A) and with (B) intravenous contrast as
well as delayed (C) scans demonstrated a questionably calcified com-
plex mass (M) that arises from or invades the lower pole of the left
kidney (K). Note that no vessel encasement is identified a, aorta; i,
inferior vena cava. Coronal ultrasound (D) confirmed, the complex
solid mass (M-open arrows) arising from the kidney (K-solid arrows).
An abdominal film following the CT scan (E) showed typical distor-
tion of the kidney owing to an exophytic Wilms' tumor (arrows).
Although the CT suggested that the mass arose from the kidney, the
ultrasound provided the most definite evidence of a renal origin.
130 Seidel
Fig. 3. Neuroblastoma: This 3-year-old child presented with an
upper abdominal mass. Initial C T scan without (A) and with (B)
intravenous contrast demonstrated a lightly calcified, generally non-
enhancing mass in the epigastrium associated with a large hepatic
metastasis (M). Note the encasement of the celiac axis (arrow). a,
aorta, i, inferior vena cava. Three months later, follow-up CT with
intravenous contrast (C) and ultrasound (D) demonstrated a poor
response of the tumor mass (arrows) to chemotherapy and radiation.
The patient died shortly thereafter of stage IV neuroblastoma.
dose to the “target organ” may be somewhat higher. The
costs are moderate.
Evaluation of an Unknown Abdominal Mass
The approach to an abdominal mass is, by necessity,
limited to the imaging modalities available at an institu-
tion. Most hospitals have access to CT, US, and routine
radiography. However, the availability of nuclear medi-
cine, angiography, and particularly MRI,is much more
limited. Any examination plan will be limited by these
constraints, and must be tailored to the clinical situation.
The advantages and disadvantages of the various imaging
modalities are summarized in Table I.
Following routine plain films, we would suggest US as
the next examination (Table II). When the presence of an
abnormal mass is confirmed, its location can be deter-
mined. The characteristics of the mass (solid vs cystic,
complex vs uniform) are noted, and the remainder of the
abdomen scanned for the presence of metastatic disease.
If the mass appears to be a hydronephrotic or cystic
kidney, the next study should be a voiding cystourethro-
 Imaging of a Pediatric Abdominal Mass 131

Fig. 4. Neuroblastoma: Four-year-old child with vague left upper

quadrant pain. Transverse prone renal ultrasound (A) demonstrated,
in retrospect, a solid mass (M) anterior to the left kidney (K). This
was not seen on the initial examination performed because of the
suggestion of hydronephrosis on a bone scan. A subsequent intrave-
nous pyelogram demonstrated tiny calcifications (arrow) superior to
the left kidney. CT without contrast ( C ) demonstrated a calcified
(arrow) mass superior to the left kidney. CT with (D) intravenous
contrast confirms the mass encasing the renal artery (arrowhead),
aorta (a). and IVC (i) in a pattern typical for neuroblastoma. Although
the US was performed before the diagnosis was considered clinically,
this case points out the shortcoming of US in the left upper quadrant
for subtle adrenal masses, particularly if gas is present in the bowel
or stomach.
132 Seidel
TABLE 111. Neuroblastoma and Wilms’ Tumor: Computed Tomography and
Ultrasound Characteristics
Wilms’ tumor
Location Intrarenal, expands
and distorts kidney
Shape Round, irregular,
pseudocapsule
Calcification 25-30 % light
Vascular invasion Common, esp. IVC
Midline Crosses, but not
behind aorta
gram (VCUG), followed by an EU or nuclear renogram.
In general, any other mass in the abdomen is then evalu-
ated more completely with CT. If a renal mass suggesting
a Wilms’ tumor is noted, a chest CT is performed at the
same time, since postsurgical atelectasis will delay a
chest CT for several days following surgery.
Common Abdominal Masses
Renal masses are the most common pediatric abdomi-
nal mass, accounting for 55% of masses at any age [18].
In the first month of life, hydronephrosis secondary to
ureteropelvic or ureterovesical junction obstruction or
massive reflux account for 25% of masses, with renal
dysplasias such as multicystic dysplastic kidney or infan-
tile polycystic disease accounting for 15%. Nonrenal
lesions in the newborn include: female pelvic masses
(15%) [hydrometrocolpos, ovarian cyst], gastrointestinal
(15 %) [duplication, meconium ileus], retroperitoneal
(10 %) [adrenal hemorrhage, neuroblastoma], and hepa-
tobiliary ( 5%) [hydrops of gallbladder, hemangioendo-
thelioma, hepatoblastoma] [ 181.
In older infants and children, renal masses continue to
account for 55 % of masses, but 22 % are WiLms’ tumor
and 20 % hydronephrosis. Retroperitoneal masses make
up 23 % , but 2 1 % are due to neuroblastoma. Gastrointes-
tinal masses increase to 18% (10% appendiceal abcess,
6% hepatobiliary). Genital masses decrease to 4% in
these older children [ 181.
Wilms’ Tumor
Wilms’ Tumor (nephroblastoma) is the most common
malignant primary renal tumor in children. The peak age
of diagnosis is 3 to 4 years, but it is seen in infants and
adolescents [ 191.
The tumor is thought to arise in rests of mesodermal
cells within the kidney. As a result, it usually expands
and distorts the ludney, commonly replacing it almost
completely. Exophytic and even extrarenal Wilms’ tu-
mors are less common. The tumor is frequently necrotic
and/or hemorrhagic, and it may extend through the renal
Neuroblastoma
Extrarenal, displaces
+/ - invades kidney
Irregular, “capsule”
unusual
75 % , often dense
Uncommon, encases
Common, behind aorta
capsule or metastasize to the periaortic nodes [20]. Vas-
cular invasion into the renal vein and inferior vena cava
is frequent, and pulmonary metastasis is not unusual
[21,22].
Characteristically, the US examination demonstrates a
complex mass arising from or replacing the kidney (Figs.
1,2) [23]. US is particularly helpful in excluding involve-
ment of the vena cava (Fig. 1), which can be difficult to
see on CT [24]. The CT outlines the sometimes calcified
(lo%),necrotic, or hemorrhagic mass, but is most effec-
tive in defining the extent of disease [25]. CT screens for
metastatic involvement of periaortic nodes, the vena cava,
the liver, and the opposite kidney with a single examina-
tion. Angiography and nuclear medicine are of little help
in the workup.
Neuroblastoma
Fifty percent of all neuroblastomas occur in the first 2
years of life, 28% in the first year. Forty-three percent
occur in the adrenal gland. Of the extra-adrenal tumors,
23.6% are in the abdomen, 15.8% in the chest, and 4.4%
in the pelvis [ 181.
Arising from rests of embryologic neural crest tissue,
the neuroblasts may remain primitive as a neuroblas-
toma, or may mature into a less malignant ganglioneu-
roblastoma or a benign ganglioneuroma. Frequent
invasion of the spinal canal through the neural foramina,
encasement and displacement of blood vessels, and cross-
ing of the midline are noted. Metastases, especially to
the liver, bone marrow, and to the sphenoid bone are
characteristic.
Ultrasound will demonstrate a typically suprarenal
complex solid mass displacing and rarely invading the
kidney (Fig. 3) [26]. Since the kidney is usually normal,
it is easier to miss a subtle adrenal mass on US (Fig. 4).
In fact if neuroblastoma is suspected clinically, CT ex-
amination should be performed even if the US is normal.
Computed tomography easily demonstrates the usually
(75%) calcified mass and its typical encasement of the
aorta, vena cava, and renal vessels 127,281. Tumor ne-
 Imaging of a Pediatric Abdominal Mass 133

.-! ‘ * T I C

Fig. 5. Hepatoblastoma: Five-month-old child with large right upper

quadrant mass. CT scan without (A) and with (B) intravenous contrast
demonstrated a densely calcified, lightly enhancing mass (arrows),
which was thought to most likely originate within the liver. The
differentiai diagnosis included a calcified metastasis from an occult
neuroblastoma, but hepatoblastoma was confirmed at surgery.

crosis is less common, but cystic tumors are described.

Again, the role of angiography is limited, but nuclear
bone scanning is important to exclude skeletal metastases.
The differential diagnosis of neuroblastoma is, most
commonly, Wilms’ tumor [29]. The distinguishing char-
acteristics on CT and US are outlined in Table LII.
Hepatic Masses
Fig. 6. Hepatoblastoma: Four-year-old child with enlarged liver.
Although they are the third most common dXhmina1 Ultrasound (A) demonstrated a complex solid mass (arrows) in the
tumor in children, hepatic tumors are much less common right lobe of the liver. CT without (B) and with (C) intravenous
than neuroblastoma or wilms7 Tumor. Malignant tumors contrast confirmed a noncalcified. lightly enhancing mass (M), which
proved to be a hepatoblastoma.
include hepatoblastoma (Fig. 5,6) in infants and hepato-
carcinomas in older children, who often have underlying
liver disease. They are slightly more common than be-
nign lesions. The benign tumors include hamartoma,
134 Seidel

Fig. 7. Cavernous hemangioma: This newborn presented with

congestive heart failure. A plain film (A) demonstrated a calcified
epigastric mass (arrow) and cardiomegaly. An initial ultrasound (B)
demonstrated a complex, brightly echogenic mass (arrows) with
acoustic shadowing within the left lobe of the liver. g, gallbladder; a,
aorta. CT without (C) and with (D) intravenous contrast demonstrated
a lightly calcified, densely enhancing mass (arrows) within the left
lobe of the liver.
 Imaging of a Pediatric Abdominal Mass 135

Fig. 8. Cystic mesenchymal hemartoma: Three-month-old child with CT without (B) and with (C) intravenous contrast demonstrated irreg-
large left upper quadrant mass. Transverse ultrasound (A) demon- ular enhancement of the mass (M) within the left lobe of the liver.
strated a complex solid mass (M-arrows). K, right kidney; S, spine.

hemangioma, and hemangioendothelioma, which usually the female, hydrometrocolpos due to an intact hymen and
present in infancy with an abdominal mass, heart failure, simple ovarian cyst are most likely. In older females,
and associated cutaneous hemangiomas [30] (Fig. 7,8). considerations include ovarian teratoma, which are
Another uncommon infantile mass in the right upper sometimes malignant. Ultrasound is the most effective
quadrant is the choledochal cyst, essentially aneurysmal imaging modality, generally easily differentiating a sim-
dilatation of the common bile duct [31,32]. (Fig. 9). ple cyst (Fig. 10) from more complex (Fig. 11,12) and
The evaluation of a hepatic mass is similar to that worrisome lesions [36,37].
described above. Again, US provides a sensitive screen-
ing tool, while CT will provide more comprehensive CONCLUSION
anatomy [31,331. Nuclear medicine is especially helpful The approach to a possible abdominal mass and a
in the liver, providing direct visualization of the biliary limited discussion of the most common abnormalities are
tree and hepatic parenchymal function. Angiography is presented. In general, following plain films, US should
occasionally useful in outlining the vascular anatomy for be used to confirm and characterize the suspected mass.
the surgeon [34,35]. If the mass is a cystic renal lesion, correllation with
VCUG, EU, and nuclear renogram are recommended;
Pelvic Masses for solid masses, further imaging with CT is usually
Pelvic lesions in the male are unusual, and they usually needed. Hepatic masses, either cystic or solid, should be
represent a dilated bladder due to urethral obstruction. In evaluated with nuclear medicine scans, generally DIS-
136 Seidel

Fig. 9. Choledochal cyst: Newborn with large right upper quadrant dilated intrahepatic bitiary radicals (arrows) at 40 min (B). At 2 hr
mass. Longitudinal ultrasound (A) demonstrated a simple cyst (C) (C). a large collection of activity was noted medial to the liver.
medial and inferior to the liver (L). DISIDA liver scan demonstrated Intraoperative cholangiogram (D) confirmed a choledochal cyst (C).
 Imaging of a Pediatric Abdominal Mass 137

Fig. 10. Simple ovarian cysts: A newborn female with a pelvic spine. CT scan with intravenous constrast (B) confirmed a nonenhanc-
mass. Transverse ultrasound at the level of the umbilicus (A) demon- ing cystic structure (C) within the lower abdomen. At surgery, a
strated a simple cyst ( C ) extending to the level of the kidneys (K) S, simple ovarian cyst was removed.

Fig. 11. Ovarian teratoma: Sixteen-year-old girl with right lower to the bladder (B). A plain film (B) demonstrated calcified teeth
quadrant mass. Longitudinal ultrasound (A) demonstrated a complex typical for an ovarian teratoma.
cystic mass (C) containing some solid components (arrows) superior

Fig. 12. Ovarian dysgerminoma: Thirteen-year-old girl with protu- (B). CT with contrast (B) confirmed a solid slightly enhancing mass
berant abdomen who was thought to be pregnant. Longitudinal ultra- (M). A malignant ovarian dysgerminoma was found at surgery.
sound (A) demonstrated a solid mass (M), just superior to the bladder
138 Seidel
IDA. MRI presents a new modality with considerable 11. Skel Radiol 5 5 - 7 6 , 1980-a.
promise for the future. 18. Kirks DR, Merten DF, Grossman H, Bowie JD: Diagnostic
ACKNOWLEDGMENTS
The author gratefully acknowledges Carol Jonas and
Charlene Latona for their manuscript preparation and
Brian S. Smistek, Tim R. Palaszewski, and Linda M.
Norsen for photographic assistance.
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