In a child presenting with an abdominal mass discovered by a relative and severe hypertension (150/90 mm Hg), what is the most likely diagnosis?

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Neuroblastoma

In a pediatric patient presenting with an abdominal mass discovered by a relative and severe hypertension (BP 150/90 mmHg), the most likely diagnosis is neuroblastoma (Option B). 1

Clinical Rationale

Hypertension is a classic and well-recognized feature of neuroblastoma that distinguishes it from other pediatric abdominal malignancies. 1 The mechanism occurs through two pathways:

  • Catecholamine excess from tumor secretion of epinephrine and norepinephrine 1
  • Renal artery compression by the tumor mass 1

This combination of abdominal mass with hypertension represents a pathognomonic presentation pattern for neuroblastoma in children. 1

Differential Diagnosis Considerations

Why Not Wilms Tumor (Option A)?

While Wilms tumor is the most common renal malignancy in children and frequently presents with an abdominal mass, hypertension is notably less characteristic compared to neuroblastoma. 1 The typical Wilms tumor presentation involves:

  • Abdominal mass or swelling as the primary finding 2
  • Often asymptomatic or with nonspecific symptoms 2
  • Hypertension can occur but is not a defining feature 1

Why Not Liver Tumor (Option C)?

Hepatoblastoma typically presents with:

  • Abdominal mass in children under 4 years of age 1
  • Elevated alpha-fetoprotein (AFP) levels 3
  • Hypertension is NOT a characteristic feature 1

Immediate Diagnostic Workup

The following tests should be obtained urgently:

  • Urinary catecholamines (VMA and HVA) - elevated in the majority of neuroblastoma patients 1
  • Abdominal ultrasound as initial imaging, 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

Critical Next Steps

Multiple core biopsies or surgical resection are required for definitive diagnosis, with adequate tissue for histologic evaluation and molecular testing (MYCN amplification, ALK mutations). 1 Fine-needle aspiration is specifically not recommended for neuroblastoma diagnosis. 1

MIBG scan should be obtained for neuroblastoma staging and confirmation, with sensitivity of 83.3% and specificity of 98.0%. 1

Common Pitfall to Avoid

Do not delay diagnostic workup by assuming this is Wilms tumor based solely on the abdominal mass. The presence of significant hypertension in a child with an abdominal mass should immediately trigger evaluation for neuroblastoma, as this clinical combination is highly specific for this diagnosis and requires different treatment protocols than Wilms tumor. 1

References

1
Guideline

Neuroblastoma Diagnosis and Management

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

2
Research

Wilms tumor and associated predisposing syndromes and conditions.

JAAPA : official journal of the American Academy of Physician Assistants, 2025

3
Guideline

Pediatric Abdominal Mass Diagnosis and Management

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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