Neuroblastoma is the Most Likely Diagnosis
A pediatric patient presenting with an abdominal mass and hypertension should be evaluated for neuroblastoma, as this combination is a classic presentation of this malignancy. 1
Why Neuroblastoma is the Answer
The combination of abdominal mass with hypertension is highly characteristic of neuroblastoma through two distinct mechanisms 1:
- Catecholamine excess from tumor secretion (occurs in majority of cases)
- Renal artery compression by the tumor mass itself
Hypertension occurs in approximately 25% of neuroblastoma cases and can be severe and labile, particularly in catecholamine-secreting tumors 2, 3. The American College of Cardiology and other medical societies specifically recommend evaluating for neuroblastoma when a child presents with this clinical picture 1.
Why Not Wilms Tumor
While Wilms tumor is in the differential diagnosis of any pediatric abdominal mass, hypertension is significantly less characteristic compared to neuroblastoma 1. Although hypertension can occur with Wilms tumor (affecting approximately 20% of cases), it is not the defining associated feature 3. The National Comprehensive Cancer Network acknowledges Wilms tumor should be considered but notes hypertension is less typical 1.
Why Not Hepatoblastoma
Hepatoblastoma typically presents with abdominal mass but hypertension is not a characteristic feature 1, 4. Instead, hepatoblastoma is characterized by:
- Elevated alpha-fetoprotein (AFP) levels 4
- Hepatic mass on ultrasound 4
- Peak incidence in children under 4 years, particularly infancy 1
Immediate Diagnostic Workup Required
Once neuroblastoma is suspected, proceed with 1:
- Urinary catecholamines (VMA and HVA) - elevated in the majority of neuroblastoma patients
- Abdominal ultrasound initially, followed by CT or MRI to characterize the mass and assess for renal artery compression
- Complete blood count with differential and comprehensive metabolic panel
Definitive Diagnosis
Multiple core biopsies or surgical resection are required for definitive diagnosis, with adequate tissue for histologic and molecular evaluation including MYCN amplification and ALK mutations 1. Fine-needle aspiration is not recommended 1.
Clinical Pitfall to Avoid
Be vigilant during chemotherapy administration, as tumor lysis can cause catecholamine release leading to severe labile hypertension that may be multi-drug resistant 2, 5. This requires careful multidisciplinary management with multiple antihypertensive agents including ACE inhibitors, alpha- and beta-adrenergic receptor blockers, and potentially tyrosine hydroxylase inhibitors 5.