Gastric Ganglioneuroblastoma in an Elderly man: A Case Report and Literature Review

Background. Ganglioneuroblastoma is a borderline tumor of sympathetic origin that is considered a childhood disease, with the majority of patients occurring in children less than five years old and few patients occurring in adults. There are no treatment guidelines for adult ganglioneuroblastoma. Here, we report a rare patient of adult gastric ganglioneuroblastoma that was completely resected by a laparoscopic approach. Case presentation. A 73-year-old man presented with dull pain in the upper abdomen along with abdominal distension for one month. Gastroscopy examination revealed chronic gastritis and submucosal tumors of the gastric antrum. Endoscopic ultrasonography showed a hypoechoic mass in the gastric antrum arising from the muscularis propria. An abdominal computed tomography scan revealed an irregular soft tissue mass in the gastric antrum with heterogeneous enhancement in the arterial phase. The mass was completely resected by laparoscopic surgery. Postoperative histopathology revealed that the mass contained differentiated neuroblasts, mature ganglion cells and ganglioneuroma components. The pathological diagnosis was ganglioneuroblastoma intermixed, and the patient was determined to be in stage I. The patient received no adjuvant chemotherapy or radiotherapy. At his two-year follow-up, the patient was doing well and showed no signs of recurrence. Conclusion. Despite the rarity of gastric ganglioneuroblastoma as a primary site of origin, it should be considered in the differential diagnosis of gastric masses in adults. Radical surgery is sufficient for the treatment of ganglioneuroblastoma intermixed, and long-term follow-up should be performed.

Outcomes and Histological Variations of Neuroblastoma and Ganglioneuroblastoma with Paraneoplastic Syndromes

BACKGROUND

Neuroblastomas are the most common extracranial solid malignancy in children with variable manifestations and complications depending on the presence of paraneoplastic syndromes.

MATERIALS AND METHODS

We performed a single institution retrospective cohort study of all patients less than 18 years old diagnosed with neuroblastoma or ganglioneuroblastoma between January 2002 and July 2022. Patients were identified through the pathology and cancer registry and cross-referenced with pediatric records. Patient demographics, clinical presentation, treatment, and outcomes were collected. A univariate descriptive analysis of the collected data was conducted.

RESULTS

In our study period, 130 children were diagnosed with neuroblastoma, and 15 were diagnosed with ganglioneuroblastoma. There were 12 children with a paraneoplastic syndrome identified, 8 with NBL and 4 with ganglioneuroblastoma (GNBL). The average age at diagnosis was 22 months. All but 1 underwent resection prior to treatment of paraneoplastic syndrome, and 4 children required neoadjuvant therapy. Neurological complications were the most common with 10 children (83%). The average time from symptom onset to diagnosis was 0.7 months. Eight children had complete resolution of their symptoms after treatment and resection, 2 children recently started treatment within a year, 1 had partial resolution, and 1 died during treatment. The presence of tumor-infiltrating lymphocytes occurred in 4 children with neurologic paraneoplastic syndromes. Six children had neuropil rich tumors.

CONCLUSION

The histological profile of paraneoplastic syndromes of neuroblastoma and ganglioneuroblastoma and their treatment across a single institution can be highly variable. The presence of tumor-infiltrating lymphocytes and neuropil may have an impact on paraneoplastic pathology.

Characteristics of benign neuroblastic tumors: Is surgery always necessary?

PURPOSE

Ganglioneuroma (GN) and ganglioneuroblastoma-intermixed (GNB-I) represent benign variants of neuroblastic tumors in children; however, differentiating from more aggressive histological variants of GNB including the nodular subtype (GNB-N) prior to resection can be challenging, even with biopsy. Currently, no standard treatment guidelines exist. The purpose of this study was to identify pre-operative characteristics of benign neuroblastic tumors and evaluate outcomes for patients who underwent surgical resection or observation.

METHODS

Retrospective chart review of children treated at a single institution between 2009 and 2019 for non-metastatic tumor with a tissue diagnosis of GN, GNB-N or GNB-I. Demographics, imaging, labs, operative details and outcomes were recorded and analyzed.

RESULTS

Of 53 patients, 45% were male. The most common tumor location was abdomen (49%), followed by thorax (34%). Forty-five percent had at least one image defined risk factor. Biopsy was performed in 32% (17/53) and upfront surgery in 68% (36/53). Three patients (3/53, 5.6%) with biopsy demonstrating GN tumors were observed due to high surgical risk. Pathology of resected specimens demonstrated GN in 52% (26/50) and GNB-I or GNB-N in 48% (24/50). The majority of GNB tumors (75% (18/24) were GNB-I and 25% (6/24) were GNB-N. Therefore, 88% of the resected tumors were benign spectrum neuroblastic tumors (GN & GNB-I). Seven (7/50, 14%) patients experienced perioperative complication (temporary paralysis, Horner's syndrome, chylothorax, vocal cord paralysis). Recurrence was noted in 1 patient with GN (1/50, 2%) and 3 with GNB-N (3/50, 6%). There were no tumor-related deaths. Patients with GN were older than those with GNB (8.8 years (IQR 6-11.25) vs 5.6 years for GN (IQR 3-7); p = 0.01). GNB tumors were also more likely to have calcifications on imaging (63% vs. 38%, p = .01) and more commonly had MIBG avidity (88% vs 66%, p = .04). There were no significant differences in tumor size or symptoms at presentation.

CONCLUSIONS

In children with neuroblastic tumors, older age, CT without tumor calcifications, lack of MIBG avidity, and/or normal urine catecholamines may indicate benign GN. Close observation could be considered for asymptomatic patients meeting these criteria with biopsy-proven GN, with resection reserved for progressive growth or symptom development. However, larger, multicenter studies are needed for further validation.

LEVEL OF EVIDENCE

IV.

Composite Neuroblastoma Metastatic to a Lymph Node: The Novel Histopathologic Diagnosis of a Unique Multiclonal Neoplasm

OBJECTIVE

Composite neuroblastoma is a tumor composed of multiple tumoral clones within the neuroblastoma family. To date, establishing this unique histopathologic diagnosis has required the evaluation of the primary tumor mass. We report a case of composite neuroblastoma diagnosed by evaluation of a metastatic lymph node.

METHODS

One abdominal lymph node involved by tumor was evaluated in a 6-year-old boy. The primary abdominal mass was not examined. Following histopathologic examination, clonality studies using comparative genomic hybridization (CGH) and fluorescence in situ hybridization (FISH) were also performed.

RESULTS

Two distinct tumor components were identified by histopathologic evaluation and classified as differentiating neuroblastoma (component A) and poorly differentiated neuroblastoma (component B). Based on the patient's age, each clone was further classified as Unfavorable Histology. The presence of these two different tumoral clones was confirmed by CGH and FISH.

CONCLUSION

This case affirms the histopathologic approach to evaluating composite tumors, as established by the International Neuroblastoma Pathology Classification (INPC) model for ganglioneuroblastoma, nodular tumors. Also, when both components are metastatic, this case demonstrates that composite tumors can be diagnosed by the evaluation of metastatic lesions alone. Finally, it supports the addition of composite neuroblastoma to a future version of the INPC.

Primary orbital ganglioneuroblastoma in a child: A case report

RATIONALE

Ganglioneuroblastoma (GNB) is a transitional tumor of sympathetic origin that has never been described as primarily involving the orbit. Herein we report an extremely rare case of GNB with primary orbital involvement and its treatment strategies.

PATIENT CONCERNS

A 9-year-old girl presented with progressive and recurring right orbital mass for 2 years.

DIAGNOSIS

Computed tomography (CT) showed a well-defined, well-circumscribed, and homogeneous extraconal soft tissue mass occupying most of the right superior orbital area. Magnetic resonance imaging (MRI) revealed that there was a neoplasm of the right superior orbit molding around the globe with long T1 and T2 signals, and contrast-enhanced MR image showed a heterogeneous enhancement of the mass. Histopathologic examinations were performed after surgery and the characteristics were consistent with a diagnosis of GNB.

INTERVENTIONS

Surgery was performed and the mass was completely resected.

OUTCOMES

Postoperatively, the patient was on a regular follow-up for 19 months and so far, has had no orbital mass recurrence.

LESSONS

Herein we present a rare case of GNB primarily involving the orbit, and the findings showed that GNB could originate from the orbit. The patient underwent surgical tumor resection. The histopathological and immunohistochemical features were consistent with the diagnosis of GNB. For this case, there was no recurrence for 19 months after complete surgical excision of the tumor; however, a regular long-term follow-up is required.

Adrenal masses in children: Imaging, surgical treatment and outcome

BACKGROUND/OBJECTIVE

This study aims to evaluate the current surgical approach to adrenal masses in the pediatric age group.

METHODS

We retrospectively analyzed cases that underwent surgery for adrenal masses between 2007 and 2017. Patients were assessed regarding age, sex, primary diagnosis, image defined risk factors (IDRF), surgical treatment method, complications, duration of hospital stay, and follow-up.

RESULTS

We examined 50 patients who underwent surgery for adrenal mass (mean age: 4.8 years; range: 5 days-14 years). For IDRF assessment, Ultrasonography was used in 42, Computed Tomography in 36, and Magnetic Resonance Imaging in 36 patients. Lesions were present on the right in 25, left in 21, and bilateral in 4 patients. Histopathological findings were neuroblastoma (n = 29), ganglioneuroma (n = 6), adrenal cortex tumor (n = 5), ganglioneuroblastoma (n = 4), pheochromocytoma (n = 3), cyst (n = 1), and adrenal hematoma (n = 2). Laparotomy was performed on 37 patients, and laparoscopy on 13 patients. None of the cases had any operative complications.

CONCLUSION

The crucial factors determining the surgical approach to adrenal masses in pediatric cases are the histopathology of the mass, volume, and IDRF. Minimally invasive procedures could be reliably performed in appropriate cases.

Resection of Abdominal, Pelvic and Retroperitoneal Tumors

BACKGROUND

Mesenchymal malignancies are relatively rare tumors with distinct behaviors that are usually surgically removal. However, it is sometimes impossible to perform such surgery according to standardized procedures. In particular, surgical removal of intraperitoneal and retroperitoneal tumors differs among individuals.

CASE REPORTS

We present two cases with intra-abdominal and retroperitoneal sarcomas who were treated at our comprehensive oncology center. The first patient was a 36-year-old male who was initially diagnosed with a tumor in the subrenal space that measured 95 × 90 × 140mm, contacted the inferior vena cava and right kidney, and had the same blood supply as the upper pole of the right kidney. Primary histological analysis indicated that the tumor was a schwannoma. After further examinations, the tumor was removed and the right kidney was preserved. A ganglioneuroblastoma was diagnosed based on definitive histological analysis. Adjuvant radiotherapy was administered to the tumor bed. The patient is disease-free at 1 year after resection. The second patient was a 52-year-old male who was diagnosed with a liposarcoma in the retroperitoneal space that measured 50 × 36 × 15cm and weighed 14kg upon resection. Resection involved left-side nephrectomy and adrenalectomy. Adjuvant chemotherapy with IFO/ADM was administered. A recurrence in the tumor bed was resected 31 months after the primary resection. Three new foci appeared in the retroperitoneal space after another 18 months and were removed. Another recurrence in the left funiculus was removed after a further 6 months. The patient has been disease-free for 3 months.

CONCLUSIONS

Treatment of soft tissue sarcoma is complex and should be performed at a comprehensive oncology center if possible. Preoperative biopsy is essential. Key words: sarcoma - surgical procedures Supported by MZ ČR-RVO (MOÚ,00209805). The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers. Submitted: 6. 3. 2018 Accepted: 20. 3. 2018.

Primary cervical ganglioneuroblastoma: A case report

RATIONALE

Ganglioneuroblastoma is usually located in the adrenal gland, retroperitoneal ganglia, or posterior mediastinum, but rarely occurs in the parapharyngeal space.

PATIENT CONCERNS

A 4-year-old girl presented with complaint of progressive inspiratory dyspnea and dysphagia, accompanying left-side Horner's syndrome.

DIAGNOSE

Computed tomography (CT) scan revealed a giant mass with irregular low density in left oropharyngeal and posterior pharyngeal wall. The left carotid artery sheath was pushed to the right. After enhancement, the central part of the mass was strengthened, and the surrounding bones structures appeard normal. Magnetic resonance imaging (MRI) showed a solid mass in the left parapharyngeal space displacing the left carotid sheath posteriorly and laterally. A ganglioneuroblastoma was diagnosed.

INTERVATIONS

The girl was treated by surgery.

OUTCOMES

The postoperative course was uneventful. There was no recurrence was observed during the 1-year follow-up.

LESSONS

The primary cervical ganglioneuroblastoma is rare, we recommended the ganglioneuroblastoma should be considered in the differential diagnosis of a child presenting with a parapharyngeal space mass.

Expression of Extracellular Signal-regulated Kinase 5 and Ankyrin Repeat Domain 1 in Composite Pheochromocytoma and Ganglioneuroblastoma Detected Incidentally in the Adult Adrenal Gland

Composite pheochromocytoma (cPC) is extremely rare, arising in the adrenal medulla as a mixture of PC and other tumors of neural origin. We herein report on a case of adrenal incidentaloma post-operatively diagnosed as cPC with ganglioneuroblastoma (GNBL). The PC component had 7 points on the PASS, a Ki-67 index of 5.1%, a focal absence of sustentacular cells, and no genetic aberrations in succinate dehydrogenase subunit B. The GNBL component exhibited no N-myc amplification. Tumor cells of both components were stained positively for extracellular signal-regulated kinase 5 and ankyrin repeat domain 1. The aberrant activation of growth signaling may play a role in the marginal malignancy of cPC.

[Thoracoscopic operations for neurogenic tumors in children]

AIM

To present an overall experience of endoscopic operations in children with neurogenic tumors in two medical institutions.

MATERIAL AND METHODS

Thoracoscopic excision of tumors was performed in 19 children aged 1 month-7.5 years (mean 1.5 years) in two clinics for the period 2010-2014. In 9 children (47.3%) age did not exceed 1 year. In our study ganglioneuroma was diagnosed in 9 cases, ganglioneuroblastoma--in 2 patients, neuroblastoma stage I--in 8 cases. All patients were under observation and treated according to NB2004 protocol. Tumor's diameter ranged from 1 to 6 cm (mean 4.9±1.9 cm). Mean duration of surgery was 62±22 minutes. There were no any intraoperative complications. Early postoperative period in all patients after endoscopic surgery was more favorable than in those after open operations. Any local recurrences were not observed for the follow-up period.

RESULTS

Thoracoscopic operations can become more preferable method in treatment of children with neurogenic tumors if great vessels are not involved into neoplastic process and limited volume of tumor is absent.

Approach to one lung ventilation during the surgical resection of an intrathoracic ganglioneuroblastoma in a three-year-old child: a case report and review of the literature

One lung ventilation (OLV) in children is a challenge and requires creative solutions. A case of OLV with bronchial placement of a fiberscope inspection-guided vascular embolectomy catheter in a three-year-old girl, scheduled for the resection of an intrathoracic tumor through thoracotomy is described. The availability of a broad range of vascular catheters as well as of fiberscope inspection material was decisive in managing the airway intra-operatively. Over the last 20 years, the need for OLV in children has increased, and various methods for performing it have been reported. Knowing all existing strategies in that domain is important to provide optimal perioperative care. In this paper, several methods of OLV in children will be discussed, such as selective endobronchial intubation, types of bronchial blockers, Univent tube, pediatric double lumen tubes, as well as the Marraro double lumen tube.

Video-assisted thoracic surgery resection for pediatric mediastinal neurogenic tumors

BACKGROUND/PURPOSE

Video-assisted thoracoscopic surgery (VATS) resection of mediastinal neurogenic tumors is still controversial in children. The aim of this study was to review the cases of VATS resection of such tumors in children from 3 institutions located in different countries.

METHODS

This retrospective study included 17 children treated between July 1995 and February 2011. Medical charts were reviewed for collection of data on age, sex, histologic type of tumor, clinical manifestations, age and weight at surgery, tumor size, duration of thoracic drainage, surgical complications, tumor recurrence, and mortality.

RESULTS

Thirteen (76.5%) males and 4 (23.5%) females were studied. Median age was 16 months (range, 10.6-60 months), and median weight was 11.9 kg (range, 9.3-27.4 kg). Ten children had neuroblastoma (58.8%), 4 had ganglioneuroma (23.5%), and 3 had ganglioneuroblastoma (17.7%). The median duration of the operation was 90 minutes (range, 45-180 minutes), with complete thoracoscopic resection in all cases. Two children (11.8%) developed Horner syndrome postoperatively. No deaths were reported, and no recurrence was noted during a median follow-up period of 16 months (range, 8.9-28.6 months).

CONCLUSIONS

Video-assisted thoracoscopic surgery resection of mediastinal neurogenic tumors in children produced good results, with no recurrence and minimal postoperative complications. The major advantages of this approach are the avoidance of thoracotomy complications and the enhanced surgical accuracy provided by improved visualization.

Cerebral ganglioneuroblastoma of adult onset: two patients and a review of the literature

Ganglioneuroblastoma is a rare tumor variant of neuroblastoma. Only five cases have been observed in the adult brain, and we report here on two more adult patients with cerebral ganglioneuroblastoma. Additionally, a review was carried out on all 50 published adult cases with ganglioneuroblastoma, located in the adrenal gland (9), mediastinum (8), retroperitoneal area (7), the brain parenchyma (7), or the spinal cord (3). Median age at onset was 39 years, and 52% of patients were female. For extracranial locations, treatment usually consisted of surgery followed by radiotherapy and adjuvant chemotherapy. Of the cases with cerebral involvement only one patient did not receive any treatment. The other six patients underwent surgical resection and radiation therapy, in four cases followed by chemotherapy with temozolomide. The median survival of cerebral ganglioneuroblastomas was 14 months and did not differ from the whole group of ganglioneuroblastomas (12 months). For cerebral ganglioneuroblastoma, the preferred regimen would seem to be neurosurgical removal, followed by chemoradiotherapy including temozolomide.

[Correlation between typing of peripheral neuroblastic tumors and prognosis: a clinicopathologic study of 135 cases]

OBJECTIVE

To study the clinicopathologic characteristics of peripheral neuroblastic tumors and to investigate the prognostic significance of International Neuroblastoma Pathology Classification (INPC).

METHODS

One hundred and thirty-five cases of peripheral neuroblastic tumors encountered in Shanghai Children's Medical Center were enrolled into the study. All the cases were classified according to INPC and International Neuroblastoma Staging System (INSS). The follow-up data were analyzed.

RESULTS

The consensus diagnoses of the 135 cases were as follows: 80 cases (59.2%) of neuroblastoma, 24 cases (17.8%) of ganglioneuroblastoma, intermixed, 17 cases (12.6%) of ganglioneuroma and 14 cases (10.4%) of ganglioneuroblastoma, nodular. The cases were subdivided into 2 subgroups: favorable histology (number = 90, 66.7%) and unfavorable histology (number = 45, 33.3%). According to INSS, the number of cases in stages I, II, III and IV was 22 (16.3%), 24 (17.8%), 34 (25.2%) and 55 (40.7%), respectively. The survival of peripheral neuroblastic tumors correlated with histologic diagnosis, INPC and INSS (P < 0.05).

CONCLUSION

Diagnostic categorization of peripheral neuroblastic tumors according to INPC is of prognostic value.

[Neurogenic tumors of the mediastinum in adults]

In adults, mediastinal neurogenic tumours constitute the third group of mediastinal tumours, after thymomas and lymphomas. If the group of neurogenic tumour is frequent, each type of tumour is relatively unusual in everyday's clinic. Among them, nerve sheath tumours are the more frequent, followed by tumour of the autonomic system. Askin tumour remains uncommon. Treatment of this tumour requires complete preoperative work-up, including standard radiography, CT-scan, MRI, and sometimes nuclear imaging. In most cases, the treatment is based on surgical resection, and may be associated with radiotherapy or chemotherapy in case of malignant tumour or incomplete resection. Better understanding of these tumours, including their molecular abnormalities, may lead to new changes in their classifications, and to their management.

Rituximab for treatment of opsoclonus-myoclonus syndrome in neuroblastoma

Opsoclonus-myoclonus syndrome (OMS) is a rare paraneoplastic syndrome that occurs in 2%-3% of patients with neuroblastoma. The cause of this syndrome is believed to be immune mediated, but the exact mechanism still remains unclear. There is an urgent need to improve our current strategies for treating patients with OMS, as many patients have significant long-term neurologic deficits and behavior disorders with current treatment approaches. Therapies that have shown to improve symptoms in these patients have ranged from ACTH and corticosteroids, to intravenous gammaglobulin and plasmapheresis. We report our experience with Rituximab in a patient with neuroblastoma and OMS.

Overlapping free bone graft with galea-pericranium in reconstruction of the anterior skull base to prevent CSF leak and sequestrum formation

Background. Reconstruction of the skull base after resection of a tumour is important to prevent postoperative complications such as infectionsand cerebrospinal fluid (CSF) leakage. Several reconstructive methods of the anterior skull base have been reported but, their long-term results are not clear. Methods. We describe a technique used after removal of an olfactory neuroblastoma with infiltration of the skull base. The reconstructed dura was covered with a galeal patch, a replicated galeal-pericranial flap, a graft from the inner table of skull, and a vascularised galeal-pericranial flap placed on the skull base defect. All layers were fixed with fibrin glue. Conclusion. Three dimensional computed tomography (3D-CT) at bone window settings demonstrated the bone graft covered the bone defect and was not absorbed and after 11 years there have been no signs of tumour regrowth or complications.

Ganglioneuroblastoma of the cerebellum: neuroimaging and pathological features of a case

OBJECTIVE: To report a case of ganglioneuroblastoma of cerebellum, with emphasis to the neuroimaging and pathological findings. CASE REPORT: A one year and eight-month-old girl presented with a two-month history of hypoactivity and tremor in the legs. The MRI showed an enhancing cerebellar mass hypointense on T1 and hyperintense on T2-weighted images. The patient underwent a craniotomy with resection of the lesion. The histological and immunohistochemical studies defined the diagnosis of ganglioneuroblastoma. CONCLUSION: The MRI findings of our case showed no features which could help in the differentiation between ganglioneuroblastoma and the other common types of posterior fossa neoplasms in the pediatric population.

Surgical treatment of malignant mediastinal neurogenic tumors in children

INTRODUCTION

The aim of this study was to identify the role of surgical resection in the treatment of malignant mediastinal neurogenic tumors in children.

MATERIALS AND METHODS

Thirty-eight consecutive children, who underwent surgical resection of a malignant mediastinal neurogenic tumor between 1986 and 2004, were included in this study. The tumor cell types were neuroblastoma in 23 patients (60.5%), ganglioneuroblastoma in 14 (36.8%), and malignant neuroepithelioma in 1 (2.6%). Surgery was performed for curative resection in localized tumors and salvage resection of residual mediastinal masses after chemotherapy in stage IV tumors. Of the 16 patients (42.1%) who underwent salvage resection, 14 had neuroblastoma and 2 ganglioneuroblastoma.

RESULTS

Mean patient age was 3.4+/-3.0 years (1 month-13 years) and 26 patients (68.4%) were symptomatic at presentation. Adjacent structure invasion was found in eight patients (21.1%), invasion of chest wall in four, heart and vena cava in two, lung in one, and chest wall and lung in one. Complete gross resection was possible in 30 patients (78.9%) and there was no surgical mortality. Surgical morbidity occurred in 10 patients (26.3%) and Horner's syndrome was the most frequent complication (n=7). The 5-year survival was 95.2% for a localized tumor and 52.5% for a stage IV tumor (p=0.004). The significant risk factors of long-term survival were adjacent structure invasion (p=0.002) and a stage IV tumor (p=0.002) by multivariate Cox regression analysis.

CONCLUSIONS

Surgical resection of localized malignant mediastinal neurogenic tumor in children showed good long-term survival, and salvage operations after chemotherapy showed acceptable long-term survival.

[Efficacy of chemotherapy regimen using ifosphamide and carboplatin on recurrent or refractory neuroblastoma]

BACKGROUND & OBJECTIVE

About 30% of neuroblastoma patients have poor response to first-line chemotherapy or progress during chemotherapy. Although advanced neuroblastoma patients could achieve complete remission after combined treatment, most of them relapsed finally. This study was to evaluate the efficacy of ifosphamide and carboplatin as a salvage chemotherapy regimen on recurrent or refractory neuroblastoma.

METHODS

Nine refractory neuroblastoma patients and 23 recurrent neuroblastoma patients were treated with ifosphamide (1.5 g/m(2) daily for 5 days) and carboplatin (400 mg/m(2) on day 1). Mesna was applied at a dosage of 20% of ifosfamide 3 times at 4-hour intervals after termination of the ifosfamide infusion. Chemotherapy was administered every 2-3 weeks.

RESULTS

None of the 32 patients achieved complete remission; 19 (59.4%) achieved partial remission. The median remission time was 4.2 months (1-28 months). After chemotherapy, 8 patients received operation to resect tumors. Main adverse events included grade III-IV neutropenia (44.7%), grade III-IV thrombocytopenia (53.1%), neutropenia accompanied with infection (18.8%), grade I liver dysfunction (12.5%), and hemorrhagic cystitis (9.4%). All adverse events were reversible.

CONCLUSIONS

Recurrent and refractory neuroblastoma responds well to chemotherapy regimen of ifosphamide plus carboplatin. The toxicities are tolerable. But the long-term prognosis is poor. More effective strategies are needed to improve its long-term survival.

Mood and behavioral dysfunction with opsoclonus-myoclonus ataxia

Opsoclonus-myoclonus ataxia syndrome is a paraneoplastic syndrome of cerebellar damage associated with neuroblastoma. The authors assessed psychiatric symptoms of opsoclonus-myoclonus ataxia syndrome in 17 children, who were 16 months to 12(1/2) years of age. Psychiatric symptoms examined included disruptive behavior, affective dysregulation, irritability, impulsivity, cognitive impairment, and poor attention.

Growth hormone deficiency after localized ganglioneuroblastoma: A case report

Growth hormone deficiency (GHD) related to standard dose chemotherapy has rarely been described. We report on a case of localized ganglioneuroblastoma treated by carboplatin/etoposide for 2 courses and surgery, which developed a serious GHD after 56 months. At present, the child is growing on by GH replacement therapy. We discuss about the hypothesis that GHD may be related to chemotherapy and we report a review of previous published cases.

Syndrome de Lambert-Eaton et neuroblastome chez l'enfant : à propos de 2 observations

Lambert-Eaton myasthenic syndrome is a paraneoplasic syndrome which can reveal a primitive tumor. Frequently, the first diagnosis is myasthenia gravis. This disease is extremely rare in children. Only 10 cases have been reported in the last 35 years. We report 2 new observations occurring in very young patients, aged 2 and 3 years, with a ganglioneurobastoma as primitive tumor.

Extradural spinal cord and intraabdominal ganglioneuroblastoma

We report a rare case of a giant extradural and intraabdominal ganglioneuroblastoma in a young Malay girl who presented to a paediatrician initially at 5 days of life with a palpable abdominal mass. Unfortunately, the parents refused any form of surgical intervention until the child was 3 years old. She subsequently underwent vascular embolisation followed by the removal of this large tumour both via the abdomen and through a laminectomy approach and subsequently refused chemotherapy. The c-myc amplication in this patient was absent and there were no chromosomal aberrations, During the 2 year folow-up the patient remained well, and ambulatory with no tumour recurrence.

Thoracoscopic Removal of Neurogenic Mediastinal Tumors in Children

PURPOSE

The aim of this study was to evaluate the feasibility and advantages of thoracoscopic removal of neurogenic mediastinal tumors (NMTs) in children.

METHODS

From January 1998 to December 2001, 6 patients, ages 1.1 to 6.8 years (mean, 3.5 years), underwent thoracoscopic removal of NMT. A retrospective study was done to assess the type of anesthesia, conversions to standard thoracotomy, operative time, complications, and the current status of each patient.

RESULTS

General anesthesia using a Fogarty catheter as an ipsilateral bronchial blocker was utilized. Four 5-mm ports were placed in all patients. All NMTs were successfully removed without a need to convert to standard thoracotomy. The tumor was captured in an extraction bag, fragmented, and then removed through the trocar site, which had been enlarged up to 2.0-2.5 cm in each case. Pathologic diagnosis was neuroblastoma in 1 patient, ganglioneuroblastoma in 2, and ganglioneuroma in 3 patients. The mean operative time was 230 minutes. There was no need for transfusion and no serious complication related to this approach. All patients are alive at the time of writing, without any evidence of tumor recurrence.

CONCLUSION

All tumors were successfully removed. Thoracoscopic surgery is a feasible, safe, and effective technique in the treatment for children with NMT.

[The VIP-secreting tumor as a differential diagnosis of protracted diarrhea in pediatrics]

BACKGROUND

Vasoactive intestinal peptide (VIP) can be produced by mature neurogenic tumors. Pathologically elevated VIP plasma levels cause secretory diarrhea with excessive loss of water and electrolytes. Despite the clinical severity diagnosis of a VIP-secreting tumor is often delayed and subsequently its extirpation as the mainstay of therapy.

PATIENTS

We report on two patients with ganglioneuroblastoma and secretory diarrhea. We contrast the case of a 13-month-old boy with advanced symptoms of secretory diarrhea, high VIP plasma levels, and late diagnosis to the case of a 14-month-old boy with mild secretory diarrhea and normal VIP plasma levels but positive proof of VIP in tumor tissue. Reviewing the literature we found 57 cases of pediatric VIP-secreting tumors.

RESULTS

The clinical situation is characterized by the typical symptoms of secretory diarrhea with hypokalemia and metabolic acidosis. Histopathology predominantly reveals ganglioneuroblastoma or ganglioneuroma. The symptoms mostly stop after complete resection of the tumor whereas lack of resection is associated with elevated mortality rates.

CONCLUSIONS

In case of prolonged therapy-resistant secretory diarrhea the existence of a VIP-secreting tumor should be considered. Diagnostic work-up should include the assessment of VIP plasma levels, catecholamines in urine, and appropriate imaging techniques in order to rule out or confirm the possibility of a VIP producing tumor.

Hyperexcitable blink reflex preceding the diagnosis of neuroblastoma

The diagnosis of neuroblastoma is sometimes preceded by development of a paraneoplastic syndrome, most commonly opsoclonus-myoclonus-ataxia (OMA). The authors describe a patient who developed a hyperexcitable blink reflex, without symptoms of OMA, prior to his oncologic diagnosis. The authors believe this may represent a distinct paraneoplastic process caused by increased dopaminergic stimulation of the blink reflex and suggest that children manifesting an unexplained hyperexcitable blink reflex should be screened for occult neuroblastoma.

Thoracic neuroblastoma: outcome of incomplete resection

The prognosis for thoracic neuroblastoma has been documented as good, but the reasons have not been elucidated. We reviewed our experience of patients with thoracic neuroblastoma who were treated over the past decade. Among 102 patients treated for neuroblastoma at our hospital between December 1987 and June 1997, 20 patients had thoracic neuroblastoma (stage 1: nine, stage 2: five, stage 3: three, stage 4: three). Tumor characteristics and survival rate were compared between thoracic and nonthoracic neuroblastoma. The surgical margin was positive in 13 of the 20 patients with thoracic neuroblastoma. However, local recurrence was observed in only one patient who later underwent complete resection. All patients survived 4-14 years of follow-up. Among those over 1 year old, thoracic neuroblastoma was detected at an earlier stage than in their nonthoracic counterparts (stages 1 and 2 vs. 3 and 4: 6/3 vs. 1/17, p=0.003), and the 5-year survival rate was better than in their nonthoracic counterparts (100% vs. 44.5%, p=0.015). The incidence of ganglioneuroblastoma was significantly higher in the thoracic group at the age of >1 year ( p=0.003). In six of nine patients from the thoracic group who were >1 year old, small areas of ganglioneuroma were identified in the tumor tissue. There was a stronger tendency for the maturation of neuroblastoma into ganglioneuroma in the thoracic group. Complete resection is not required for thoracic neuroblastoma regardless of the patient's age.

Ataxia and secretory diarrhea: two unusual paraneoplastic syndromes occurring concurrently in the same patient with ganglioneuroblastoma

The presence of rare paraneoplastic syndromes, the opsoclonus-myoclonus-ataxia syndrome (OMA), presumably caused by antineuronal antibody production, and diarrhea, caused by vasoactive intestinal peptide (VIP) secreted by neuroblastoma, may strongly signal the presence of neuroblastoma. The authors describe a child who presented with both syndromes concurrently; this has never been described previously in the same patient. However, diagnosis of neuroblastoma was delayed by a workup focused on the prolonged diarrhea rather than the ataxia. The diarrhea resolved after tumor resection, whereas OMA required further therapy. Increased awareness of VIP-secretory diarrhea, especially in an ataxic child, might contribute to an earlier diagnosis of neuroblastoma.

Adult-type ganglioneuroblastoma in the adrenal gland treated by a laparoscopic resection: report of a case

A case of ganglioneuroblastoma in the adrenal gland of a 50-year-old man is reported. The patient was incidentally found to have a nonfunctioning tumor in the right adrenal gland. The tumor, measuring 4.5 cm, was successfully removed using laparoscopy. Histologically, the tumor was diagnosed to be a ganglioneuroblastoma. Immunohistochemically, a few MIB-1-positive cells and no S-100 protein-positive cells were observed. There has been no evidence of recurrence for 2.5 years to date after the operation. Adrenal ganglioneuroblastoma is extremely rare in adults, and only seven such cases have been previously reported in the literature.

Intestinal pseudoobstruction as a paraneoplastic syndrome in ganglioneuroblastoma

Intestinal pseudoobstruction may be part of a paraneoplastic syndrome. We report a teenage girl with ganglioneuroblastoma who presented with severe constipation. The intestinal pseudoobstruction was presumed to be due to inflammation of the myenteric plexus with destruction of the ganglion cells caused by antineuronal nuclear antibodies (ANNA or Anti-Hu).

Primary pediatric neuroblastic tumors of the neck

Neuroblastic tumors are the third most common cause of solid tumors in early childhood. Cervical tumors account for only 5% of cases. In this report, we describe a series of four pediatric neuroblastic tumors of the neck. The histological diagnosis was ganglioneuroblastoma in three cases and neuroblastoma in one case. Presenting signs were solitary cervical mass in two cases and respiratory distress in association with Claude-Bernard Horner's syndrome in two cases. Mean age at presentation was 15 months. Cervical computed tomography scan and/or magnetic resonance imaging depicted calcifications within the tumor in 50% of cases and allowed accurate assessment of extension. Increased urine catecholamine levels were observed only in the patient with neuroblastoma. Scintigraphy with [131]iodine-methyliodobenzylguanidine demonstrated selective uptake by the tumor in two cases. Amplification of N-myc oncogene, a documented unfavorable prognostic sign, was not found in any case. Surgical treatment was performed in all patients. Neoadjuvant chemotherapy was performed in one case. All patients underwent regular surveillance. No evidence of recurrence has been observed with a mean follow-up period of 7 years.

Observation of untreated patients with neuroblastoma detected by mass screening: a "wait and see" pilot study

BACKGROUND

Recent studies have indicated that mass screening for neuroblastoma detects tumors that otherwise would have regressed spontaneously without recognition. Therefore, we started an observation program for these patients to determine how frequently spontaneous regression occurs.

PROCEDURE

Eighteen patients were detected by mass screening between June 1994 and December 1996. Eight of these cases matched the following criteria and entered the observation program: Stage I or II, less than 5 cm in diameter; no involvement of large vessels or organs; not difficult to resect; informed consent. If there were an increase in tumor size, an elevation of tumor markers, or evidence of metastasis, the tumor would be immediately resected.

RESULTS

Five of the eight cases showed spontaneous regression. Although the remaining three tumors were resected 6-10 months after diagnosis, all patients survived without evidence of recurrence.

CONCLUSIONS

At least 60% of neuroblastoma cases who entered our observation program regressed spontaneously.

Clinicopathologic study of mass-screened neuroblastoma with special emphasis on untreated observed cases: a possible histologic clue to tumor regression

Spontaneous regression and maturation of neuroblastoma (NB) are well documented and occur frequently in infants, including those detected by mass screening. To seek histologic clues for regression/maturation in mass-screened NB, clinicopathologic features of 12 tumors that were resected after 2 to 18 months of untreated observation were reviewed. Unobserved screened and age-matched unscreened patients were also studied. To evaluate the possible important role of apoptosis, apoptotic cells were detected by in situ deoxyribonucleic acid (DNA) nick end labeling and immunohistochemical stain for activated caspase-3. Nests with a varying degree of reduced cellularity ("less cellular" and "hypocellular" nests) were common in patients younger than 18 months of age, and were rare in older patients. Two characteristic cells, which have not been focused previously, were frequent, especially in the hypocellular nests. One showed amorphic eosinophilic cytoplasm with pyknotic nuclei and the other contained plump cytoplasm with well-maintained nuclei. These cells were also observed in 89% of the unobserved screened NBs and 79% of the age-matched unscreened patients with good outcome, whereas they could not be confirmed in any of the age-matched unscreened NBs with poor outcome. The amorphic and plump cells were negative for activated caspase-3 and in situ DNA nick end labeling. From these results, the authors hypothesize that these cells most likely represent a degenerative process, in either a state before the activation of caspase-3 or a caspase-independent form of cell death. The presence of less cellular and hypocellular nests with amorphic/plump cells may serve as one of the important clues in predicting tumor prognosis.

Ganglioneuroblastoma of the cauda equina

A 39-year-old lady presented with low back pain and neurogenic claudication. Magnetic resonance imagining revealed an intradural neoplasm in the cauda equina region. The patient underwent lumbar laminectomy and total excision of the neoplasm. Biopsy showed it to be a ganglioneuroblastoma, which is rare in the spinal canal and so far does not appear to have been reported in the region of the cauda equina. Its management is discussed.

Shoulder pain in a child: a case presentation of ganglioneuroblastoma

A four and one-half year-old child presented with a several month history of shoulder pain. Her workup revealed a large, homogeneous tumor in the apex of the chest. Surgical resection was performed demonstrating ganglioneuroblastoma. This case illustrates an unusual cause of joint discomfort in children.

Extended left hepatectomy (left hepatic trisegmentectomy) in childhood

BACKGROUND/PURPOSE

Extended left hepatectomy, also referred to as left hepatic trisegmentectomy, in which segments II, III, IV, V, and VIII are excised, is rarely performed in children. Experience with 7 such resections is reported to describe the anatomy, technique, indications, and outcomes of the operation.

METHODS

The medical records of all pediatric patients treated at our institution over the last 15 years who underwent extended left hepatectomy were reviewed. Demographic information as well as operative, pathological, and follow-up data were analyzed.

RESULTS

Seven patients underwent extended left hepatectomy over this period. There were 5 boys and 2 girls ranging in age between 4 months and 9 years with a median age of 3.1 years. Follow-up ranged from 8 months to 5 years with a median of 3.5 years. Diagnoses included hepatoblastoma (HB, n = 3), focal nodular hyperplasia (FNH, n = 1), leiomyosarcoma (LMS, n = 1), hepatocellularcarcinoma (HCC, n = 1), and metastatic neuroblastoma (NB, n = 1). All surgical margins were grossly negative. Median operative blood loss was 13 mL/kg (range, 5 to 32 mL/kg), and mean hospital stay was 9 days (range, 7 to 12 days). No major intra- or postoperative complications were encountered, and there was no perioperative mortality. The 3 HB patients, 1 FNH patient, 1 LMS patient, and 1 NB patient are without evidence of disease, whereas the 1 child with HCC died of recurrent and distant disease. The 6 surviving children have normal hepatic function.

CONCLUSION

Although technically challenging and rarely performed, extended resection of the left hepatic lobe is feasible in children and can yield curative results with minimal morbidity.

Results of surgery for a compound adrenal tumor consisting of pheochromocytoma and ganglioneuroblastoma in an adult: 5-year follow-up

A rare, compound adrenal tumor consisting of ganglioneuroblastoma and pheochromocytoma was completely resected in an adult woman. Most of the tumor was occupied by the ganglioneuroblastoma component. This ganglioneuroblastoma was an intermixed tumor, which is known to have a favorable prognosis in children. Based on the lack of spread, the resectability of the tumor, and the histology of the ganglioneuroblastoma, no adjuvant therapy was employed. There was no evidence of recurrence at the 5-year follow-up. This suggests that adjuvant therapy may not be necessary in these compound tumors.

Pineal ganglioneuroblastoma in an adult

A 57-year-old male with pineal ganglioneuroblastoma was reported. The tumor was composed of a predominant ganglioneuromatous component and a small neuroblastic component. Primary ganglioneuroblastoma of the pineal region is extremely rare. To our knowledge, only three cases have been documented. This case may have a good prognosis because there is a predominant ganglioneuromatous component defined by both neurofilament triplet proteins and synaptophysin. The clinical significance of the neuronal differentiation in the present case and pathological considerations are discussed.

[Ganglioneuroblastoma in the adult]

BACKGROUND

Ganglioneuroblastoma is commonly observed in children but rarely in adults. Therapy and prognosis are not well defined in adults.

CASE REPORT

We report the case of a female adult who developed a ganglioneuroblastoma of the left adrenal gland with liver metastasis. Surgical treatment combined with radio and chemotherapy led to complete remission.

DISCUSSION

The outcome in our patient and data reported in the literature suggest that a multidisciplinary approach is necessary and that initial surgical resection should be performed whenever possible. Adjuvant radiotherapy or chemotherapy have been shown to be somewhat effective in children but their true impact in adults remains to be ascertained. Follow-up after resection should include physical examination, assay of adrenal derivatives in plasma and urine and imaging.

Adult ganglioneuroblastoma of the anterior mediastinum

A case of ganglioneuroblastoma occurring in the anterior mediastinum of a 79 year-old man is reported. The tumor was mainly composed of neuroblasts with occasional ganglion cells. Foci of melanin-laden cells were also identified. Immunohistochemistry revealed that the tumor cells showed both schwannian and melanocytic differentiation with immunoreactivity to anti-S100 protein and anti-HMB45 antibodies. In addition, the tumor contained several microcysts lined by squamous epithelial and one lymphoid tissue abundant in T lymphocytes, which appeared to be derived from thymic tissue. This case is unique in that neuroblastoma group tumors including ganglioneuroblastoma is uncommon in the elderly and in the thymic region, and rarely shows melanocytic differentiation. To the best of our knowledge, this case is a tumor of neuroblastoma group occurring in the eldest patient.