Choroid plexus papillomas in infancy and childhood

Management of Choroid Plexus Tumors and the Benefit of Preoperative Embolization in Pediatric Patients: Report of 46 Cases from a Single Institution

OBJECTIVE

Optimal choroid plexus tumor (CPT) treatment involves gross total resection; however, intraoperative hemorrhage risk remains significant given tumor vascularity. This study describes pediatric CPT management and identifies patients most likely to benefit from preoperative embolization.

METHODS

CPTs resected from 1997 to 2021 were included. The characteristics of embolized patients were compared to nonembolized patients; nonembolized patients were further stratified based on open vascular control-pedicle feeder ligation versus no pedicle ligation prior to tumor debulking. Statistical analyses identified factors associated with estimated blood loss (EBL), transfusion, length of stay, and complications.

RESULTS

Among the 46 CPT cases identified, 98% achieved gross total resection, and 15% received embolization. Embolized patients were younger, smaller, and had larger tumors compared to nonembolized patients (median: 0.8 vs. 2.1 years; 9.3 vs. 14.4 kg; 91.08 vs. 5.5 cm3). Transfused patients were similarly younger and smaller (P < 0.05) than nontransfused patients. Among nonembolized patients, open vascular control was achieved in smaller tumors (<13 cm3) with significantly lower EBL (P = 0.002). Higher EBL was observed in patients with larger tumors, hydrocephalus, transependymal edema, vomiting, lethargy, and developmental regression (all P < 0.05). Patients with lethargy had longer hospital stays and a higher likelihood of postoperative complications (P < 0.05). There were no significant differences in complication rates between the embolization and nonembolization groups.

CONCLUSIONS

Despite higher surgical risk profiles, embolized patients had similar complication rates and postoperative hydrocephalus management as nonembolized patients. Embolization was particularly beneficial in patients at high risk for surgical morbidity, such as those <2 years, weighing <10 kg, and with a tumor volume >15 cm3.

Preoperative Devascularization of Choroid Plexus Tumors: Specific Issues about Anatomy and Embolization Technique

(1) Background: Surgical treatment of choroid plexus tumors is challenging, burdened by a notable risk of bleeding. Neoadjuvant chemotherapy and preoperative embolization have been attempted, with encouraging results; however, the consensus on these procedures is lacking. (2) Methods: We present a case of a 10-month-old girl who underwent preoperative embolization of a hemorrhagic choroid plexus carcinoma of the lateral ventricle via the anterior choroidal artery, followed by total resection. (3) Results: The endovascular procedure was successfully completed, despite the rectification of the anterior choroidal artery associated with the absence of flow proximal to the plexal point. Minimal bleeding was observed during resection and the patient remained neurologically intact. (4) Conclusions: The time from entrance to exit in the anterior choroidal artery should be monitored and regarded as a potential 'occlusion time' in this specific group of patients. Nevertheless, our case supports the feasibility and effectiveness of preoperative embolization of a choroid plexus carcinoma of the lateral ventricle via the anterior choroidal artery, without complications. Furthermore, we suggest the use of a fast-embolic agent, such as N-butyl cyanoacrylate glue, as the preferred agent for this specific pathology and patient population.

Superior parietal lobule approach for choroid plexus papillomas without preoperative embolization in very young children

OBJECT Choroid plexus papillomas (CPPs) are rare neoplasms, often found in the atrium of the lateral ventricle of infants, and cause overproduction hydrocephalus. The extensive vascularity and medially located blood supply of these tumors, coupled with the young age of the patients, can make prevention of blood loss challenging. Preoperative embolization has been advocated to reduce blood loss and prevent the need for transfusion, but this mandates radiation exposure and the additional risks of vessel injury and stroke. For these reasons, the authors present their experience using the superior parietal lobule approach to CPPs of the atrium without adjunct therapy. METHODS A retrospective review was conducted of all children who presented to Columbia University/Morgan Stanley Children's Hospital of New York with a CPP in the atrium of the lateral ventricle and who underwent surgery using a superior parietal lobule approach without preoperative embolization. RESULTS Nine children were included, with a median age of 7 months. There were no perioperative complications or new neurological deficits. All patients had intraoperative blood loss of less than 100 ml, with a mean minimum hematocrit of 26.9% (range 19.6%-36.2%). No patients required a blood transfusion. The median follow-up was 39 months, during which time no patient demonstrated residual or recurrent tumor on MRI, nor did any have an increase in ventricular size or require CSF diversion. CONCLUSIONS The superior parietal lobule approach is safe and effective for very young children with CPPs in the atrium of the lateral ventricle. The results suggest that preoperative embolization is not essential to avoid transfusion or achieve overall good outcomes in these patients. This management strategy avoids radiation exposure and the additional risks associated with embolization.

Pre-operative embolisation of choroid plexus tumours in children. Part II. Observations on the effects on CSF production

OBJECTIVE

Choroid plexus tumours are one of the few causes of hydrocephalus secondary to increased CSF production. Operative treatment aided by pre-op embolisation is being used in our institution as a primary option of treatment. Our aim was firstly to quantify the effects of embolisation on CSF production and secondly to assess whether the use of pre-operative embolisation would lead to reduction of CSF production thus reducing the need for CSF diversion procedures in the perioperative and long term.

METHODS

From 1996 till 2009, 30 patients (mean age, 2.25 years) underwent surgical treatment for 24 choroid plexus papillomas and 6 choroid plexus carcinomas. Thirteen underwent pre-operative super-selective embolisation of the feeding vessels with Histoacryl glue. The need for CSF diversion-external ventricular drain (EVD)/shunt-was recorded together with the daily CSF production between the two groups (embolised: EMB+ vs. not embolised: EMB-) RESULTS: The embolisation was successful in 13 of 15 (86.6 %) patients. The average post-op daily CSF production between the EMB+ and EMB- groups was (67 vs. 135 ml/day; p = 0.005). EVD days in situ post-operatively was 7.9 vs. 12.1 (p = 0.033). However, the need for permanent CSF diversion was similar in both groups (five vs. six).

CONCLUSION

We have established the safety of pre-operative embolisation as an adjunct to operative treatment of choroid plexus tumours. As we expected, this technique, by removing the tumour's blood supply, reduces the rate of CSF production. This has had a positive impact on the post-operative management of these patients. We cannot say the same for the need of permanent CSF diversion in our study.

Preoperative embolisation of choroid plexus tumours in children: part I-does the reduction of perioperative blood loss affect the safety of subsequent surgery?

OBJECTIVE

Operative management of choroid plexus tumours is hindered by excessive bleeding and significant CSF production. Our aim was to assess whether the use of preoperative embolisation would increase the safety of surgery by reducing the perioperative blood loss and achieve higher rates of resection of the tumour.

METHODS

Between 1996 and 2009, 30 patients (mean age 2.25 years) with choroid plexus tumours (24 papillomas, 6 carcinomas) were treated. Fifteen of them underwent preoperative super-selective embolisation of the feeding vessels with histoacryl glue. The perioperative blood loss as a percentage of estimated blood volume loss (EBV) was recorded together with mortality and morbidity of the two groups (embolised, EMB+ vs. not, EMB-).

RESULTS

The embolisation was successful in 13/15 (86.6 %) patients. This manoeuvre rendered the tumour relatively avascular making the operative field "less hazardous" as reported by the surgeon. In addition, higher gross total resection rate was achieved (100 vs. 41 %; p = 0.001) at the first operative attempt in the EMB+ group. The percentage EBV loss was 96 % in EMB- group vs. 224 % in EMB+ group (p = 0.038).

CONCLUSION

Our observations with regards to preoperative embolisation of choroid plexus tumours show an acceptable safety profile for the endovascular technique. At the same time, it renders the operative treatment of the tumours safer by reducing perioperative blood loss resulting in a high gross total resection rate. In summary, we suggest that preoperative embolisation is a useful adjunct that should be considered prior to surgical resection in managing these patients.

Choroid plexus papilloma of the cerebellopontine angle

We report a case of a transdural choroid plexus papilloma of the cerebellopontine angle in a 23-year-old woman. Choroid plexus papillomas are rare intracranial tumors, usually occurring intraventricularly. Those found in the cerebellopontine angle are uncommon and almost always subdural. The investigation, treatment, and follow-up are discussed.

Atypical choroid plexus papilloma in an adult

We present an extremely rare case of the atypical choroid plexus papilloma in an adult which developed at the trigone of right lateral ventricle. A 62-year-old woman presented with the history of intermittent and gradually progressive headache and left side hemiparesis for 6 months. The brain magnetic resonance image showed highly enhanced and well demarcated mass at the trigone of lateral ventricle attached to the choroid plexus. Gross total resection was performed by transcortical approach via the middle temporal gyrus. The tumor was diagnosed as an atypical choroid plexus papilloma. She had no neurologic deficit after the surgery. We report a case of atypical choroid plexus papilloma in adult and introduce newly classified pathologic characteristics of this tumor.

Preoperative embolization in the treatment of choroid plexus papilloma in an infant. Case report

The authors report a case of preoperative embolization and resection of a choroid plexus papilloma of the lateral ventricle in a 4-month-old boy. These vascular tumors of the central nervous system present a significant intraoperative bleeding risk. Attempts at preoperative embolization to reduce the bleeding risk have rarely succeeded because of the small and tortuous vessels feeding these tumors in infants. The case presented here supports the feasibility of preoperative embolization as a therapeutic adjunct in infants.

Variations of disseminated choroid plexus papilloma: 2 case reports and a review of the literature

BACKGROUND

Choroid plexus papillomas are typically considered benign lesions, but histology is not always predictive of their behavior. These tumors can metastasize anywhere along the neuraxis and may be intraventricular, subarachnoid, or intraparenchymal. We present 2 cases that illustrate the wide diversity with which choroid plexus papillomas can disseminate.

CASE DESCRIPTIONS

The patient described in case 1 had a primary fourth ventricular choroid plexus papilloma that produced diffuse cystic subarachnoid and leptomeningeal lesions. Patient 2 also had a primary fourth ventricular tumor but with subsequent suprasellar and spinal drop metastases. Patient 1 was treated with temozolomide, resulting in regression of symptoms including headache and dizziness. Patient 2 has been treated with several modalities, including radiation therapy and chemotherapy, with slowing of symptom progression.

CONCLUSIONS

Variations of choroid plexus papilloma dissemination include intraventricular, subarachnoid, and leptomeningeal nodules or cystic lesions, and intraparenchymal locations. There is no consensus on the most effective treatment for choroid plexus papilloma metastases; surgical resection, chemotherapy, and radiation therapy may all yield benefits. The prognosis for patients with disseminated choroid plexus papilloma can range from prolonged stable disease and symptoms to death within months.

Differentiation of choroid plexus tumors by advanced magnetic resonance spectroscopy

Object

The management of pediatric intraventricular tumors is highly dependent on identification of the tumor type. Choroid plexus papillomas, a common intraventricular tumor in children, can be difficult to distinguish radiographically from choroid plexus carcinomas and other common pediatric central nervous system (CNS) tumors. In this study to overcome the limitations of current noninvasive imaging modalities, the authors use novel magnetic resonance (MR) spectroscopy techniques in vivo to elucidate the identifying biochemical features of choroid plexus tumors that may facilitate diagnosis and treatment.

Methods

Based on an Internal Review Board–approved protocol, six children with newly diagnosed, untreated intraventricular brain tumors were identified. On retrospective review, this series included three choroid plexus papillomas and three choroid plexus carcinomas. Single-voxel proton MR spectroscopy with a short echo time was performed, and absolute metabolite concentrations (in mmol/kg) were determined using fully automated quantitation. These results were compared with MR spectroscopy profiles obtained in 54 other untreated CNS neoplasms in children.

The myo-inositol (mI) level was significantly higher in choroid plexus papillomas (> 10 mmol/kg), uniquely distinguishing these tumors from choroid plexus carcinomas and all other tumors. Choroid plexus carcinomas, on the other hand, had significantly elevated levels of choline when compared with choroid plexus papillomas.

Conclusions

In this study the authors find that mI is a biochemical constituent that uniquely identifies choroid plexus papillomas and can be used as a noninvasive means of diagnosis and for follow-up evaluations in patients with this disease.

Choroid plexus tumors in children: significance of stromal invasion

OBJECTIVE

A group of choroid plexus tumors fit the cellular criteria for choroid plexus papilloma (CPP) except for invasion into the adjacent parenchyma, with associated loss of the normal villus architecture at the site of invasion. These tumors retain a benign cellular appearance. In the existing literature, it is unclear whether these tumors are classified as choroid plexus carcinomas or as CPPs. In our experience, although evidence of invasion is present, these tumors tend to exhibit benign behavior. We suggest that stromal invasion of this type remains consistent with a benign clinical course, although surgical results may demonstrate higher morbidity rates, given the invasive nature of the tumors. The failure to classify these tumors as CPPs may explain some of the variability in outcomes reported for various studies.

METHODS

To study this question, clinical and histological data for children diagnosed with CPPs (either with or without stromal invasion) between 1985 and 1995 were examined. Only cases with pre- and postoperative magnetic resonance imaging data were included in the series.

RESULTS

A total of 12 patients with CPPs were identified, with 4 tumors being notable for stromal invasion. After gross total tumor removal, none of the eight children with CPPs received adjuvant therapy at our institution; all are alive without evidence of tumor recurrence after surgical excision (mean, 108 mo). Of the four patients with stromal invasion, three underwent gross total resection. The one patient who underwent subtotal resection received chemotherapy at another facility. All four of these patients are alive, after a mean of 100 months of follow-up monitoring.

CONCLUSION

It is recommended that CPPs with a benign cellular appearance but with evidence of local parenchymal invasion and loss of the normal villus architecture at the site of invasion be classified as CPPs. Patients with these tumors respond to surgical therapy alone, without the need for adjuvant treatment.

Lateral ventricle choroid plexus papilloma in childhood: management and complications

BACKGROUND

A review of the choroid plexus papilloma of the lateral ventricle in the pediatric age group is presented. The characteristic clinical features, imaging studies, preoperative, and operative approaches, as well as complications, will be included.

METHODS

Among a group of 24 patients with ventricular choroid plexus papilloma treated by the authors over a 12-year period, seven patients were selected for this study. The selection included patients under the age of 8 years at the time of their presentation with choroid plexus papilloma of the lateral ventricle. Adult patients and children with choroid plexus papilloma at other sites or choroid plexus carcinoma were excluded. At least a 30-month follow-up period was available for all patients except one. Preoperative and postoperative imaging studies confirming total tumor resection were available for all patients.

RESULTS

Developmental delays and regression were the most consistent clinical features. Magnetic resonance imaging (MRI) proved to be the diagnostic test of choice. The addition of magnetic resonance angiogram (MRA) obviates the need for angiography. Our attempts at tumor embolization failed.

CONCLUSION

An intersulcal splitting approach to the lateral ventricular trigone, combined with a perioperative external ventricular drainage, may be of value in the avoidance of symptomatic subdural effusions.

Choroid plexus papilloma of the temporal horn associated with transtentorial herniation

In the pediatric age group choroid plexus papillomas are most commonly located in the trigones and bodies of the lateral ventricles. This paper reports a 1-year-old patient with choroid plexus papilloma of the temporal horn of the lateral ventricle associated with transtentorial herniation.

Diffuse craniospinal seeding from a benign fourth ventricle choroid plexus papilloma. Case report

Choroid plexus papillomas can metastasize to the subarachnoid space, but extensive metastasis has only been reported when the tumors are malignant. The authors report a case of diffuse, extensive metastasis to the craniospinal leptomeninges from a benign fourth ventricular choroid plexus papilloma in an adult. This 19-year-old woman presented with a 2-year history of headache, blurred vision, diplopia, and ataxia. Magnetic resonance imaging of the brain and spinal cord revealed obstructive hydrocephalus caused by a 4-cm, partially calcified, inhomogeneously enhancing tumor of the fourth ventricle that was displacing the pons, medulla oblongata, and cerebellum. Innumerable cystic lesions of varying size were also seen in the cranial and spinal leptomeninges. Histological examination of the resected fourth ventricular tumor and of a few of the leptomeningeal lesions revealed a benign choroid plexus papilloma and leptomeningeal choroid plexus cysts. This singular case of diffuse and extensive metastasis to the craniospinal leptomeninges from a histologically benign fourth ventricular papilloma adds to the available information about the biological potential of these tumors and expands the differential diagnosis of posterior fossa lesions with subarachnoid metastasis.

Multiple choroid plexus papillomas of the lateral ventricle distinct from villous hypertrophy. Case report

Except for villous hypertrophy of the choroid plexus that may not be true tumors, multiple choroid plexus papillomas are extremely rare. The authors report a case involving multiple choroid plexus papillomas that were distinct from villous hypertrophy. These lesions were localized, one in the atrium of the right lateral ventricle and the other in the inferior horn of the left lateral ventricle. A review of the literature revealed that this case represented the first reported case of true multiple choroid plexus papillomas documented by findings on magnetic resonance imaging.

Imaging of atypical choroid plexus papillomas

The authors report a rare case of benign choroid plexus papilloma arising in the cerebellopontine angle (CPA) in a 34-year-old man. Atypical features are described. This is the fourth case of MR evaluation of such tumor in available literature and the second case in the United States. Differential diagnosis is discussed. Choroid plexus papilloma should be considered among calcified, vascular, enhancing masses of CPA even in adulthood. The authors also report an unusual case of choroid plexus carcinoma.

Prenatal sonographic diagnosis of a third ventricle choroid plexus papilloma

We report a case of fetal hydrocephalus secondary to a third ventricle choroid plexus papilloma detected by ultrasound at 33 weeks' gestation. The prenatal sonographic and colour flow Doppler findings of this rare fetal intracranial tumour are discussed.

Choroid plexus tumors in childhood. Histopathologic study and clinico-pathological correlation

Choroid plexus tumors are rare and account for only 2.3% (8/352) of primary childhood intracranial neoplasms in our series. Most of our patients were under 2 years of age. The tumors had a predilection for the lateral ventricle. Calcification was found in half of these tumors, and ossification was seen in 1 case. Histological features of malignancy including invasion, loss of differentiation, and severe nuclear pleomorphism pointed to a poor prognosis. Such features were found in 2 cases. Neither a large number of mitoses nor necrosis was a constant feature in cases of malignancy. Transthyretin, a marker for choroid plexus tumors, was positive in all cases. However, negative S-100 or positive carcinoembryonic antigen was not necessarily associated with a more aggressive histological pattern. All the papillomas could be totally resected without recurrence, and all the patients with carcinoma died within a few months.