Neonatal adrenal masses: do we have reliable criteria for differential diagnosis and expectant management?

AIM: Differential diagnosis of neonatal adrenal masses (NAM) is often based on empirical criteria. Expectant management relies on spontaneous regression, described either for NB as for adrenal hemorrhage (AH). Histology was available for biopsied cases only. Aim of the study was to correlate clinical, laboratory and imaging data of a series of NAM, to final diagnosis. METHODS: Records of 23 NAM, diagnosed before or after birth, were reviewed, collecting data about: obstetrical history, clinical features, imaging, laboratory data, surgical findings, outcome. RESULTS: M/F ratio was 1.6/1. Size of the lesion ranged from 17 to 50 mm.. Doppler sonography (PD) showed no flow in 14/23. Urinary catecholamines (UCM) were elevated in 5/23. Reduction in a mean time of 3 months occurred in 14/23. MIBG and CT scans resulted positive in 8 and 9 cases among 16 NAM, unvaried or increased at one month. Three cases developed as IV S NB; diagnosis was confirmed by CT guided biopsy; regression occurred within 20 months. Surgery was decided for 6 unchanged/increasing NAM after 3-6 months; they were all NB. Predictive value for NB was high for MIBG and CT scan and was lower for high UCM level and positive PD findings. CONCLUSION: Clear criteria to differentiate AH from NB are still missing. Despite spontaneous regression is thought to indirectly confirm a non neoplastic lesion, benign evolution has also been documented for NB. As histology is available only in operated or biopsied cases, we still lack a reliable set of signs for early differentiation and to reduce repeated, invasive investigations.

Endoscopic subureteral injection for vesicoureteral reflux and the risk of overtreatment.

AIM: Risk of vesicoureteral reflux (VUR) overtreatment was anticipated following introduction of endoscopic treatment (ET). New tool reduces hospitalization and patients discom-fort, with good results and parental preferences may prevail on questions about benefits of treatment. The authors analyzed two series of patients to evaluate impact of ET on management. METHODS: Two hundred sixty-four patients were selected; group A (90 cases) were observed and treated before adoption of ET. Group B included 174 patients who benefited of ET (Deflux). Treatment started from grade III (infections or renal damage). Lower refluxes were treated only in association to an higher grade in the other kidney. 81 ureters were reinplanted in Group A (92% success rate); 67 ureters were reinplanted in group B (98% sr) and 115 had a ET (89% sr). Rate of treatment, time of follow up and age at operation were compared. RESULTS: No differences were found in order to reflux grade distribution, treatment rate and time spent waiting for spontaneous before reinplant or ET. ET was a first choice procedure, for grade III, in group B. Reinplant continued to have a role for grade IV cases, which responded to ET in 85%, and for grade V. Spontaneous resolution was observed respectively in 29% and 30% (grade III) and 13% and 7% (grade IV). CONCLUSIONS: Despite ET is accessible and effective, there are no evidences that extensive indications are of any benefit. Enthusiasm for new tools must be submitted to the need for long term, prospective studies to support our indications.