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 (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