Neuroblastoma
The most likely diagnosis is neuroblastoma (Option B), as the combination of abdominal mass with hypertension in a pediatric patient is a classic presentation of this malignancy. 1
Why Neuroblastoma is the Primary Diagnosis
Abdominal mass with hypertension is specifically recognized as a classic presentation of neuroblastoma, with hypertension occurring through two distinct mechanisms: catecholamine excess from the tumor itself or mechanical compression of the renal artery by the mass. 1 This dual mechanism makes hypertension a well-recognized and characteristic clinical feature that distinguishes neuroblastoma from other pediatric abdominal malignancies. 1
The American College of Cardiology and other medical societies specifically recommend evaluating for neuroblastoma when a child presents with this combination of findings. 1
Why Not Wilms Tumor (Option A)
While Wilms tumor can present with both abdominal mass and hypertension, hypertension is less characteristic of Wilms tumor compared to neuroblastoma. 1
Key distinguishing features:
- Wilms tumor hypertension occurs through renin-mediated mechanisms from renal parenchymal disease, since it originates from the kidney itself 2
- The mass would be clearly renal in origin on ultrasound 2, 3
- Hypertension in Wilms tumor, while possible, is not as consistently present as the classic neuroblastoma presentation 4, 5
Why Not Liver Tumor (Option C)
Hepatoblastoma (the most common pediatric liver tumor) typically presents with abdominal mass but hypertension is not a characteristic feature. 1, 2
Distinguishing features of hepatoblastoma:
- Elevated AFP levels are characteristic 2, 3
- Hepatic mass location on ultrasound 2, 3
- Occurs predominantly in children under 4 years of age, with peak incidence in infancy 1
- Hypertension is notably absent from the typical presentation 1, 2
Critical Next Steps in Workup
Urinary catecholamines (VMA and HVA) are essential for diagnosis, as they are elevated in the majority of neuroblastoma patients. 1 This should be obtained immediately.
Additional immediate workup:
- Abdominal ultrasound initially, followed by CT or MRI to characterize the mass and assess for renal artery compression 1
- Complete blood count with differential and comprehensive metabolic panel 1
- Assess for additional supportive features: fever, weight loss, irritability, bone pain, periorbital ecchymosis, or opsoclonus-myoclonus-ataxia syndrome 1
Management Considerations
Given the severe hypertension (BP 150/90), immediate antihypertensive therapy should be initiated with calcium channel blockers or ACE inhibitors as first-line agents. 2
Be vigilant about labile hypertension during chemotherapy, as tumor lysis can cause catecholamine release and worsen blood pressure control. 6 Multiple antihypertensive agents may be required, including α- and β-adrenergic receptor blockers if catecholamine excess is confirmed. 7, 6