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Solid tumorAwaiting clinical review

Neuroblastoma vs Wilms tumor

The classic abdominal-mass discrimination: a sick child with a firm mass crossing midline (neuroblastoma) versus a well child with a smooth flank mass that stops at midline (Wilms).

Neuroblastoma median age
~18 months
Wilms median age
~3–4 years
Wilms favorable histology survival
>90%
MYCN amplification
High-risk neuroblastoma marker

Tell them apart

  • Neuroblastoma: irregular, firm, crosses the midline, child often ill-appearing with bone pain, periorbital ecchymoses ('raccoon eyes'), and calcifications on imaging.
  • Wilms: smooth, does not cross the midline, child usually well, hematuria and hypertension are common.
  • Neuroblastoma workup: urine homovanillic acid and vanillylmandelic acid, MIBG scan, bone marrow biopsies bilaterally.
  • Wilms associations: WAGR (WT1 deletion), Beckwith-Wiedemann, Denys-Drash, isolated hemihypertrophy — these children get surveillance ultrasounds.

Do not miss

  • Do not biopsy a suspected Wilms tumor without discussing with surgery and oncology first — rupture upstages the tumor and adds radiation.
  • Opsoclonus-myoclonus-ataxia ('dancing eyes, dancing feet') is a paraneoplastic presentation of neuroblastoma; look for the tumor.

Risk and treatment logic

  • Neuroblastoma risk uses age, INRG stage, MYCN amplification, histology, and DNA ploidy. Low-risk disease can be observed — including spontaneous regression in stage MS infants.
  • High-risk neuroblastoma is intensive: induction chemotherapy, surgery, autologous transplant, radiation, then anti-GD2 immunotherapy (dinutuximab) with isotretinoin.
  • Wilms in North America (COG): nephrectomy first, then chemotherapy by stage and histology; Europe (SIOP) gives preoperative chemotherapy. Know that the sequence differs by continent — US exams follow COG.
  • Anaplastic histology is the key adverse Wilms feature; loss of heterozygosity at 1p and 16q intensifies therapy.

Pearls

  • Crosses midline and the child looks sick → neuroblastoma. Stops at midline and the child looks well → Wilms.

  • Dinutuximab causes severe neuropathic pain during infusion — scheduled opioids and antihistamines are part of the order set.

  • A hypertensive child with painless hematuria and a flank mass needs imaging today, not a urology clinic slot in six weeks.

On the ward

  1. 1Measure blood pressure with a correctly sized cuff on every abdominal-mass admission.
  2. 2Write 'do not palpate deeply' in the plan for a friable Wilms mass and tell the team on rounds.
  3. 3For high-risk neuroblastoma, confirm pain plan and premedications are in before dinutuximab starts.

2 vignette questions on this topic.

Quiz me

Sources

  • Children's Oncology Group — Protocol families and risk stratification frameworks used across US pediatric centers.
  • NCCN Guidelines (Pediatric) — US consensus guidance on treatment and supportive care pathways.