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has associated symptoms or hepatic enlargement. Metastatic disease usually is
characterized by diffuse nontender enlargement of the liver or multiple small
nodules rather than a single dominant mass. Neuroblastoma and advanced
hematologic malignancies such as ALL, AML, lymphoblastic lymphoma, and
Burkitt’s commonly metastasize to the liver. Although tumors may block biliary
drainage, hepatic synthetic function is rarely affected by malignancy in the liver.
Clinical Assessment
Emergent management is rarely required except in the extremely rare setting of liver
failure (see Chapter 91 Gastrointestinal Emergencies ), tumor rupture that may
require rapid repletion of intravascular volume and blood loss, or severe
coagulopathy (see Chapter 93 Hematologic Emergencies ). History may elicit risk
factors or systemic symptoms such as malaise and anorexia that are more common
with HCC than HB. Pain does not help with the differential diagnosis but does
require management. Jaundice is most common with HCC but can occur with all
liver tumors.
Management
Initial workup should include measurement of AST, ALT, total and direct bilirubin,
CBC, PT, PTT, and fibrinogen. Alpha fetoprotein (AFP) can be elevated in both HB
and HCC. It is important to note that high AFP values are normal in the first months
of life, especially in premature infants. Initial diagnostic imaging should include an
ultrasound, which can help identify if a palpable mass is likely to be hepatic in
origin and if the liver contains one or multiple masses. If a CT scan is done in the
ED, it is important to give intravenous contrast to look for intravascular extension of
tumor from the hepatic veins, into the inferior vena cava, and possibly into the right
atrium. Renal function should be checked before giving intravenous contrast. Since
HB can metastasize to the lungs, consider performing a chest CT scan at the same
time in patients younger than 10 years who have a primary liver tumor.
Children who are clinically stable and have a new liver tumor may be discharged
from the ED to the care of a pediatric surgeon experienced with liver tumors or a
pediatric oncologist. If the patient is unstable, they should be admitted to a center
with experience in treating childhood malignancies.

Tumors of the Pancreas
Pancreatic tumors in children are very rare. They may develop in the setting of a
predisposition, such as multiple endocrine neoplasias type 1 (MEN-1) syndrome,
which is associated with insulinomas of the pancreas. Insulinomas will present with
signs and symptoms of hypoglycemia and a history of “irrational behavior.” Other
tumors of the pancreas cause either an abdominal mass or vague, nonspecific