Neuroblastoma differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Zahir Ali Shaikh, MD[2]Haytham Allaham, M.D. [3]

Overview

Intra-abdominal neuroblastoma must be differentiated from other diseases that cause abdominal distension and constipation such as Wilms tumor and ganglioneuroma. Intra-thoracic neuroblastoma must be differentiated from other diseases that cause shortness of breath and chronic cough such as intrathoracic lymphoma and extra lobar pulmonary sequestration.

Differentiationg Neuroblastoma from other Diseases

Abbreviations

ACTH: Adrenocorticotropic hormone, ARR: Aldosterone-renin ratio, CAM: Cellular adhesion molecules, ERCP: Endoscopic retrograde cholangiopancreatography, ESR: Erythrocyte sedimentation rate, CT: Computerized tomography, Fluorescence in situ hybridization, FDG: Fluorodeoxyglucose, FSH: Follicle stimulating hormone, GI: Gastrointestinal, H&E stain: Hematoxylin and eosin stain, LCA: Leukocyte common antigen, LDH: Lactate dehydrogenase, LH: Luteinizing hormone, MEN: Multiple endocrine neoplasia, MRCP: Magnetic resonance cholangiopancreatography, MRI: Magnetic resonance imaging, N/A: Not applicable/Not available, N/L: Normal, PAS stain: Periodic acid–Schiff stain, PET: Position emission tomography, PGP: Protein gene product 9.5, TB: Tuberculosis, U/S: Ultrasound, ZF: Zona fasciculata, ZG: Zona granulosa, ZR: Zona reticularis.

Adrenal Cortex	Product	Clinical manifestations		Diagnosis							Other features
		Symptoms	Signs	Blood & Urine	Histopathological	Others	Ultrasound	CT scan	FDG PET/CT	MRI
Adrenal Adenoma	Aldosterone	Headache Vision problems Muscle cramps Muscle weakness & cramps Numbness Temporary paralysis Polyuria and polydipsia	Hypertension Refractory hypertension	Hypokalemia Alkalosis ↑ Plasma aldosterone ↓ Plasma Renin ↑ ARR	Single or multiple nodules Encapsulated Abundant clear cytoplasm Uniforming nuclei Histopathology may resemble: ZF (large, lipid-laden clear cells) ZG (small, compact cells with moderate amount of lipid) ZR (lipid-sparse cytoplasm)	Fludrocortisone suppression testing (Gold standard) Oral Sodium loading Saline infusion testing Captopril test Adrenal venous sampling Posture test Genetic testing Immunohistochemical staining	Adrenal mass or nodule	Adrenal mass or nodule Unilateral or bilateral adrenal atrophy Hypodense mass	Iso and low FDG uptake compared with liver	Hyperintense on in-phase and hypointense on oppose-phase	Glucocorticoid-Remediable Aldosteronism responds to glucocorticoids Higher cardiovascular and cerebrovascular morbidity
	Cortisol	Weight gain Growth retardation Headache Amenorrhea Virilization (rare) Acne Violaceous striae Acanthosis nigricans Sleep disruption Mental changes Muscular weakneness	Hypertension Hirsutism Hypogonadism Growth retardation Facial plethora Acne Striae Bruising Acanthosis nigricans Mental changes Muscular weakneness	↑ Plasma cortisol ↑ 24 Hour urinary cortisol ↓ or inappropriately normal plasma ACTH ↑ Blood glucose	Yellow fat Brown discoloration Large cells with increased lipid contetnt (zona fasciculata) May contain pigment (lipofuscin) Adjacent atrophied cells Hemorrhage and calcification (Pre-malignant lesions)	Diurnal plasma cortisol variation Low dose and high dose dexamethasone suppression test Dexamethasone-CRH test Adrenal venous sampling Genetic testing Immunohistochemical staining Dual-energy X-ray absorptiometry	Adrenal mass or nodule ↑ Fat	Adrenal mass or nodule Unilateral or bilateral adrenal atrophy ↑ Fat Hypodense mass	Iso and low FDG uptake compared with liver	Hyperintense on in-phase and hypointense on oppose-phase	Associated with Carney complex Associated with MEN-1 Plasma levels of cortisol and ACTH may show false positive and false negative results due to normal diurnal hormonal variation
	Androgens	Hirsutism Virilization Amenorrhea Precocious puberty Testicular atrophy & diminished libido (male)	Clitorimegaly Male pattern baldness Resistant hypertension Gynecomastia	↑ Serum testosterone ↑ Serum androstenedione ↑ Serum dehydroepiandrosterone sulfate (DHEA-S) ↑ Urine 17-ketosteroids ↑ Plasma and urine estrogens	Pale tan to brown Pseudocapsule or the fibrous capsule Nesting, alveolar, cords, trabeculae Eosinophilic cytoplasm May see clear, vacuolated cytoplasm	FSH, LH, prolactin levels Cortisol levels FDG PET/CT Pelvic Ultrasound Adrenal Venous sampling	Well-defined Solid mass	Homogeneous enhancement (CT contrast)	N/A	Hyperintense on in-phase and hypointense on oppose-phase	Extremely rare Most androgen secreting adenomas are mixed tumors
	Non-functional	Asymptomatic Abdominal pain Abdominal distenstion Nausea/vomiting Sub-clinical Cushing syndrome Sub-clinical hyperaldosteronism	Asymptomatic Abdominal asymmetry Abdominal mass Sub-clinical Cushing syndrome Sub-clinical hyperaldosteronism	N/L ↓ Adrenal hormones ↑ Serum cortisol (sub-clinical) ↑ Serum aldosterone(sub-clinical) ↑ Serum androgens (sub-clinical)	Well-defined margins Large monomorphic cells Abundant/foamy cytoplasm Typically resemble normal adrenal histology May see hemorrhage & necrosis	Adrenal hormones levels Blood glucose level Plasma catecholamines and urinary metanephrines ARR Immunohistochemical staining	Solid, well defined mass	High lipid content and adjacent compression	N/A	Hyperintense on in-phase and hypointense on oppose-phase	2-fold increased risk for Diabetes mellitus in some studies Work up must exclude Cushing syndrome, pheochromocytoma and adrenal carcinoma
Adrenal Carcinoma	Cortisol Aldosterone Androgens Non-functional Erythropoietin	Symptoms of adrenal hormones excess as mentioned in adrenal adenoma Constitutional symptoms such as cachexia, night sweats, fever Localized symptoms such as abdominal pain, mass, fullness, early satiety	Hypertension Signs of adrenal hormones excess as mentioned in adrenal adenoma Constitutional Localized signs such as abdominal mass,abdominal distension	N/L ↑ Serum cortisol ↑ Serum aldosterone ↑ Serum androgens Hypokalemia Alkalosis ↑ ARR ↑ Blood glucose	Brown to orange to yellow Necrosis & mitosis Hypercellular & solid and/or diffuse growth pattern Low to high lipid content Nuclear pleomorphism Lymphovascular invasion	Serum ACTH Low dose and high dose dexamethasone suppression test Urinary adrenal metabolites Proton MR spectroscopy [11C]MTO PET Immunohistochemical staining	N/A	Heterogeneous enhancement	Heterogeneous mass with intense FDG uptake greater than liver	Heterogenous hyper-intensity (T2-weighted) and hypo-intensity on (T1-weighted)	May cause hypoglycemia (Anderson's syndrome} May be associated with: Hyperreninemic Hyperaldosteronism Erythropoietin-associated polycythemia Leukocytosis
Adrenal Hyperplasia	Cortisol (most common) Aldosterone Androgens Non-functional	Depending on the product secreted, may present as: Cushing syndrome Hyperaldosteronism Virilization Hirsutism Menstrual irregularities Testicular atrophy Diminished libido Localized symptoms such as abdominal pain, mass, fullness, early satiety	Depending on the product secreted, may present as: Cushing syndrome Hyperaldosteronism Virilization Hirsutism Menstrual irregularities Testicular atrophy Gynecomastia Localized symptoms such as abdominal pain, mass, fullness, early satiety	↑ Serum cortisol ↑ Serum aldosterone ↑ Serum androgens Hypokalemia Alkalosis ↑ ARR ↑ Blood glucose ↑ Serum testosterone ↑ Serum androstenedione ↑ Serum dehydroepiandrosterone sulfate (DHEA-S) ↑ Plasma and urine estrogens	Diffuse or nodular enlargement Increased thickness of zona reticularis and zona fasciculata Large polygonal cells with/without lipid depletion May contain pigment (lipofuscin) endocrine atypia Small nodules	Adrenal venous sampling Pelvic & pituitary imaging Genetic testing Fludrocortisone suppression testing Saline infusion testing Diurnal plasma cortisol variation Low dose and high dose dexamethasone suppression test FSH, LH, prolactin levels Cortisol levels	Adrenal mass Unilateral or bilateral adrenal enlargement or thickening	Unilateral or bilateral adrenal enlargement or thickening Density is same as that of normal adrenal gland	N/A	Unilateral or bilateral adrenal enlargement or thickening Signaling is same as that of normal adrenal gland	Congenital adrenal hyperplasia presents in children/young adults Associated with Carney complex Plasma levels of cortisol and ACTH may show false positive and false negative results due to normal diurnal hormonal variation
Medulla	Product	Clinical manifestations		Diagnosis							Other features
		Symptoms	Signs	Blood & Urine	Histopathological	Others	Ultrasound	CT scan	FDG PET/CT	MRI
Pheochromocytoma	Catecholamines	Headaches Palpitations Excessive sweating Anxiety Pallor Pain in chest/abdomen Weakness, fatigue Nausea/vomiting Dizziness Paresthesias Constipation (rarely diarrhea) Visual disturbance	Hypertension Postural hypotension Tachycardia or reflex bradycardia Tremulousness Pallor Flushing (rare) Weight loss Fasting hyperglycaemia Decreased GI motility Pallor ↑ Respiratory rate Psychosis	↑ Plasma and urine catecholamines (Gold standard) ↑ Plasma and urine metanephrines (Gold standard) ↑ Chromogranin A ↑ Plasma methoxytyramine	Loosely cohesive clusters Scattered tumor cells with prominent anisokaryosis, abundant eosinophilic granular cytoplasm and indistinct cell borders Occasional bi-nucleate cells	Genetic testing Provacative glucagon test Clonidine suppression test Metaiodobenzyl-guanidine scintigraphy PET scan Octereoscan	Cystic or solid with necrotic areas or hemorrhages	Heterogeneous appearance, often with some cystic areas. Calcification or hemorrhage may also be present	N/A	T2-bright lesions, with/without cystic or necrotic components	May mimic panic attack May be associated with Von Hippel-Lindau disease, MEN type 2 and neurofibromatosis type 1. Arise from the chromaffin cells Stains positive for Chromogranin A (CGA) Protein gene product (PGP) 9.5 Synaptophysin (SYN) CD56 (N-CAM) Glial fibrillary acidic protein (GFAP)
Neuroblastoma	Catecholamines	Constitutional Failure to thrive Abdominal pain Diarrhea Constipation Dyspnea Prolonged cough Strabismus Proptosis	Abdominal mass Pallor Tachycardia Hypertension Failure to thrive Strabismus Proptosis	N/L Slight elevation in catecholamines ↑ Urinary metanephrines Anemia ↑ Ferritin ↑ LDH Thrombocytosis	Pathological examinations are gold standard. Cells may show: Undifferentiation Poor differentiation Differentiating neuroblasts Necrosis Salt and pepper chromatin Spindle-like fibers	Immunohistochemical staining PET scan Octereoscan 131I-metaiodobenzylguanidine (MIBG) scintigraphy FISH Genetic testing	Large mass May cross midline	Large mass extending across the midline Heterogeneous enhancement Calcification & hemorrhage	N/A	Calcification & hemorrhage Non-homogeneous and hyperintense Hypointense (T1-weighted)	Stains positive for: Chromogranin A (CGA) Protein gene product (PGP) 9.5 Neuron-specific enolase Synaptophysin (SYN) CD56 & CD57 Glial fibrillary acidic protein (GFAP)
Ganglioneuroma	Catecholamines VIP Cortisol Androgens	Asymptomatic Abdominal pain Diarrhea	N/L Abdominal mass Hypertension	N/L ↑ Plasma and urinary catecholamine ↑ VIP ↑ Cortisol and testosterone	Pathological examinations are gold standard. Mature type: mature Schwann cells, ganglion cells and peri-neural cells Maturing type: Schwann cells, ganglion cells and peri-neural cells with varying maturation	Pathological examinations are gold standard. Ultrasound Immunohistochemical staining 18F-2-fluoro-deoxy-D-glucose-positron emission tomography (PET)	N/A	Well-defined, Homogeneous Punctate or discrete calcification	N/A	Hypointense (T1-weighted) Varied signal (T2-weighted)	Stains positive for: S100 Synaptophysin Neurofilament (NF) protein Chromogranin A Glial fibrillary acidic protein PGP 9.5 Type IV collagen VIP
Stroma	Product	Clinical manifestations		Diagnosis							Other features
		Symptoms	Signs	Blood & Urine	Histopathological	Others	Ultrasound	CT scan	FDG PET/CT	MRI
Lipoma/Myolipoma	N/A	Asymptomatic Abdominal pain Back pain Fever	N/L Abdominal mass Fever	N/L	Pathological examinations are gold standard. Yellow adipose tissue Hemorrhagic foci Islands of hematopoietic cells (myolipoma) and mature fat cells (Lipoma)	RFTs LFTs Urine analysis Ultrasound	Heterogeneous mass	Retro-peritoneal mass Well-defined heterogenous enhancement	N/A	High signal	Myolipoma: mature adipose tissue and haematopoietic elements Lipoma: mature fat cells
Others	Product	Clinical manifestations		Diagnosis							Other features
		Symptoms	Signs	Blood & Urine	Histopathological	Others	Ultrasound	CT scan	FDG PET/CT	MRI
Tuberculosis	N/A	Weakness Malaise Nausea Fatigue Anorexia Abdominal pain Orthostatic hypotension Constipation Salt craving Adrenal crisis Symptoms of pulmonary TB	Weight loss Hyperpigmentation of the skin Fever Hypotension Adrenal crisis Signs of pulmonary tuberculosis	Anemia Leukocytosis Hyponatremia Hyperkalemia Hypoglycemia Low early morning serum cortisol levels Low basal urinary cortisol ↑ ACTH ↓ Aldosterone ↑ Plasma renin	Enlarged, necrotic adrenal glands Central caseous necrosis Rim of granulomatous inflammatory cells (Langerhans giant cells and lymphocytes) Identifiable acid-fast stain-positive bacteria with Ziehl-Neelsen or fluorescent stains	Laparoscopic adrenalectomy Chest X-ray Chest CT scan Tuberculin test ACTH stimulation test Insulin induced hypoglycemia Metyrapone stimulation tests	Variable	Calcification Hypodense areas Rim enhancement	High FDG uptake by adrenal glands	Calcification Variable signals	Majority of the cases are secondary to: Pulmonary TB Genitourinary TB HIV infection May present with shock with severe hypotension and hypoglycemia due to glucocorticoid insufficiency
Histoplasmosis	N/A	No adrenal symptoms Adrenal insufficiency: Weakness & malaise Nausea, fatigue and anorexia Abdominal pain Orthostatic hypotension Constipation Salt craving Symptoms of pulmonary/skin/bone histoplasmosis	Weight loss Hyperpigmentation of the skin Fever Hypotension Adrenal crisis Signs of pulmonary/skin/bone histoplasmosis	Anemia Leukocytosis Hyponatremia Hyperkalemia Hypoglycemia Low early morning serum cortisol levels Low basal urinary cortisol ↑ ACTH ↓ Aldosterone ↑ Plasma renin	Necrotizing granulomatous inflammation similar to tuberculosis Capsulated yeast forms of Histoplasma (Giemsa stain) Histoplasma identification (H&E stain) Focal ovoid bodies with a clear halo (PAS stain)	Ultrasound-guided fine needle aspiration cytology (USG-FNAC) is gold standard. Laparoscopic adrenalectomy Endoscopic ultrasound Abdominal ultrasound Chest X-ray ACTH stimulation test Metyrapone stimulation tests	Enlarged adrenal glands Calcification	Enlarged adrenal glands Calcification Heterogeneous enhancement	Abnormal FDG uptake by adrenal glands	Enlarged adrenal glands Calcification Isointense adrenal mass (MRI)	Patient may exhibit no clinical manifestations of adrenal involvement Majority of the cases are secondary to: Pulmonary histoplasmosis HIV infection May present with shock with severe hypotension and hypoglycemia due to glucocorticoid insufficiency
Cysts	N/A	Abdominal pain Abdominal mass Abdominal fullness Hematuria Infection Symptoms of malignancy (Cystic part of other tumors)	Abdominal mass & assymetry Fever Hypertension (Renal compression) Hypotension (Hemorrhage into cyst) Signs of malignancy (Cystic part of other tumors)	N/L Anemia Leukocytosis	Vascular or endothelial cyst: lined by flattened endothelial cells Epithelial: lined by epithelium Pseudocyst: lined by fibrous tissue Hydatid cyst: 3 layers (germinal layer, laminated membrane and dense fibrovascular tissue)	Complete endocrine panel [18F]FDG PET/CT (if malignancy is suspected) Biopsy (if malignancy is suspected) ACTH stimulation test	Gold standard Circumscribed anechoic or hypoechoic mass	Homogeneous mass No enhancement Calcification Low density	N/A	High signal	3 major subtypes Pure cysts (vascular or endothelial cyst, pseudocyst and 'true' epithelial cysts) Parasitic cysts Cystic part of an otherwise solid tumor
Hematoma	N/A	Flank/back pain Weakness Hypovolemic shock Adrenal crisis (massive hemorrhage) Adrenal insufficiency Symptoms of underlying cause	Hypotension Abdominal/flank mass Hypovolemic shock Adrenal crisis (massive hemorrhage) Adrenal insufficiency Signs of underlying cause	Anemia ↓ Serum and urinary adrenal hormones and metabolites Findings related to underlying cause	Pseudocyst: lined by fibrous tissue Findings related to underlying cause	Adrenal ultrasound ACTH stimulation test Tests related to underlying cause	Variable	High density (acute hemorrhage)	N/A	Isointense and low signal (Early hemorrhage) Hypointense (Late hemorrhage)	Majority of the cases in neonantal peiod Majority of the cases caused by trauma
Hemangioma	Cortisol (rare) Aldosterone (rare) Androgens (rare)	Abdominal mass & discomfort Nausea & vomiting Back pain Hypovolemic shock (hemorrhage) Symptoms of hormonal excess (very rare)	Abdominal mass Hypovolemic shock (hemorrhage) Symptoms of hormonal excess (very rare)	N/L Anemia (hemorrhage) ↑ Serum and urinary adrenal hormones and metabolites (very rare)	Histopathology is gold standard Most often cavernous Peripheral dilated vascular spaces Monostromatic endothelium Absence of atypia Central necrosis Calcification Hemorrhage	Complete endocrine panel Ultrasound FDG-PET scan Endoscopic ultrasound Post-resection biopsy (if malignancy is suspected)	Calcification Phleboliths	Calcification Phleboliths Irregular peripheral enhancement	N/A	Hyperintensity (T2) hypointensity (T1) Peripheral spotty and centripetal enhancement	Majority of the cases diagnosed incidentally Majority of the lesions are non-functional with female pre-dominance
Lymphoma	N/A	Fatigue Loss of appetite Weight loss Pigmentation of skin Flank/abdominal pain Fever Nausea & vomiting	Hypotension Altered mental status Abdominal/flank mass Fever Weight loss	↑ ESR ↑ LDH ↑ Serum ACTH ↓ Hyponatremia Low early morning serum cortisol levels Low basal urinary cortisol ↓ Aldosterone	Histopathology is gold standard Diffuse growth pattern with large cells ( 5× normal lymphocytes) resembling immunoblasts Extensive necrosis May resemble anaplastic large cell lymphoma or metastatic carcinoma Abundant T-cells	Complete endocrine panel Ultrasound ACTH stimulation test CT-guided needle biopsy 18F-fluorodeoxyglucose (FDG) positron emission tomography PET/CT	Heterogeneous mass Hemorrhages	Heterogeneous mass Hemorrhages Necrosis	N/A	Enlarged retroperitoneal lymph nodes Low intensity (T1) High intensity (T2)	May stain positive for: CD3, CD19, CD20, CD22 BCL6 / CD10 CD43, CD45 Surface Ig CD68 CD79a LCA Pax 5
Cystic Lymphangioma	N/A	Asymptomatic Flank/back/abdominal pain Abdominal/flank mass GI obstruction	N/L Palpable mass Hypertension Fever	N/L	Histopathology is gold standard Cystic channels and spaces Flat endothelial cells Mature lymphoid aggregates	Complete endocrine panel Ultrasound FDG-PET scan Aspiration & biopsy	Well-demarcated Calcification	Well-demarcated Low-density Calcification	N/A	T1 hypointense & T2 hyperintense	Associated with Gorlin-Goltz syndrome Stains positive for CD31, CD34, and D2-40 and negative for cytokeratin
Teratoma	N/A	Asymptomatic Abdominal/back discomfort & pain Abdominal distension Lumbago Nausea & vomiting Local obstructive symptoms	N/L Abdominal distension Abdominal mass Weight loss Urinary retention Lower extremity edema Peritoneal effusion or peritonitis (rupture)	N/L	Fibrous tissue, adipose tissue and muscle fibers Stratified squamous epithelium, hair shafts, fat cells, GI and respiratory epithelium Necrosis Calcification	Complete endocrine panel 18F-fluorodeoxyglucose (FDG) positron emission tomography PET/CT Post-resection biopsy (if malignancy is suspected)	Heterogeneous Mixed echo (U/S)	Heterogeneous Mixed density elements Egg-shell calcification Mild enhancement	N/A	Mild enhancement Mixed signals (MRI)	Derived from germ layers Majority are benign, but about one forth of adrenal teratoma are malignant lesions
Metastases	Related to the primary tumor	Asymptomatic Adrenal insufficiency Abdominal mass & discomfort Symptoms due to primary tumor that may include: Lung cancer Breast cancer Gastric cancer Liver cancer Pancreatic cancer Renal cell carcinoma Melanoma Lymphoma	Asymptomatic Adrenal insufficiency Abdominal mass Signs due to primary tumor that may include Lung cancer Breast cancer Gastric cancer Liver cancer Pancreatic cancer Renal cell carcinoma Melanoma Lymphoma	Varies depending on the primary tumor N/L If adrenal insufficiency: Hyponatremia Hyperkalemia Hypoglycemia Low early morning serum cortisol levels Low basal urinary cortisol ↑ ACTH ↓ Aldosterone ↑ Plasma renin	Single or multiple firm masses Hemorrhage Necrosis Morphology similar to the primary tumor Compression and atrophy of adjacent adrenal tissue	Blood and urine lab testing Complete endocrine panel Imaging of chest, abdomen, and pelvis Immunohistochemistry Endoscopy MRCP & ERCP 18F-fluorodeoxyglucose (FDG) positron emission tomography PET/CT	Calcification Hemorrhage	Calcification Hemorrhage Irregular peripheral enhancement	N/A	Low signal on T1-weighed MRI and high signal on T2-weighed MRI OR Isointense on T1- and T2-weighed MRI	Metastases more common than primary adrenal tumors Adrenal hemorrhage is the most serious complication and may present as adrenal crisis and/or shock