Rhabdomyosarcoma or Fibrosarcoma? A Case of Large Ulcerated and Necrotic Lesion on the Forearm of a Newborn

Congenital infantile fibrosarcoma (CIFS) is a rare malignant soft tissue tumor. The incidence of fibrosarcoma is estimated to be 0.3 per 100 000 population per year, and it accounts for less than 1% of all soft tissue sarcomas. We present a case of a 7-day-old newborn with a large ulcerated and necrotic lesion on the left forearm, which was initially misdiagnosed as rhabdomyosarcoma. Magnetic resonance imaging (MRI) revealed a soft tissue mass with cystic components affecting the forearm and distal humerus muscles. Fine-needle biopsy was performed and initially diagnosed as rhabdomyosarcoma but later confirmed as low-grade fibrosarcoma with positive immunostaining for vimentin. The patient underwent a transhumeral amputation with follow-up chemotherapy at a specialized oncology center. This case underscores the importance of interdisciplinary collaboration and specialized care in managing complex medical conditions in infants. Early detection and appropriate management of these tumors are essential for improving outcomes and reducing morbidity and mortality. Despite the rarity of this case, it serves as a reminder of the importance of considering neoplastic lesions in the differential diagnosis of soft tissue masses in newborns.

Congenital-Infantile Fibrosarcoma: Study of Two Cases and Review of the Literature

Background

Congenital-infantile fibrosarcoma is a rare tumor of the pediatric age. It involves subjects under 5 years of age, and more than 200 cases have been reported in the literature.

Methods

The authors present the clinicopathologic findings of 2 cases and review the literature.

Results

Of our 2 patients, the first was a 2-years and 6-months-old female and the second a newborn male. The female presented a tumor in the retroperitoneum without recurrences or metastasis after 17 months, and the male on left foor with a recurrence after 3 months. Histologically, the tumors were mainly composed of spindle-shaped cells. Immunohistochemically, in both cases, neoplastic cells were positive for vimentin; focal positivity for muscular specific actin was present in the tumor of the female. Ultrastructurally, tumors were composed of mesenchymal cells with fibroblastic and myofibroblastic features. Flow cytometric analysis of the retroperitoneal tumor showed an aneuploid population of neoplastic cells.

Conclusions

Congenital-infantile fibrosarcoma should be considered a borderline tumor; its biologic behavior is better than that of adult fibrosarcoma. Histologic diagnosis is not easy; the microscopic picture may be confused with fibromatosis or with malignant mesenchymal neoplasms. Only a follow-up of many years can confirm the benignancy or malignancy of any individual tumor, even though clinico-pathologic features may be distinctive enough to permit its recognition.

Hemothorax in Congenital Neuroblastoma

The authors report a case of massive left hemothorax in a 15-day-old baby girl, caused by the rupture of a thoracic neuroblastoma.

A case of congenital infantile fibrosarcoma in a newborn

Infantile fibrosarcoma is a malignant tumor, which is most common in infants, preferentially localized in the lower limbs. An important prognostic factor of the disease is early diagnostics, both clinical and instrumental. The operative treatment of infantile fibrosarcoma is a leading treatment method. The article describes a clinical case of infantile fibrosarcoma in a newborn with fetal development of the disease.

Congenital mesoblastic nephroma: a study of 19 cases using immunohistochemistry and ETV6-NTRK3 fusion gene rearrangement

Mesoblastic nephroma (MN) is the most common renal tumour in the first 3 months of life and accounts for 3-5% of all paediatric renal neoplasms. To further understand the morphological variants of MN, we identified 19 cases of MN (five classic, eight cellular and six mixed) and examined each case for markers known to be important in urogenital embryological development (PAX8, WT1 and RCC), stem cell associated markers (Oct 4, CD34 and c-kit), muscle/myofibroblastic markers (muscle specific actin, calponin and h-caldesmon), aberrant transcription factors, cell cycle regulation and other oncogenic proteins (p16, cyclin D1 and beta-catenin). Fluorescence in situ hybridisation (FISH) testing for ETV6-NTRK3 gene fusion/rearrangement revealed further differentiation between the subtypes with ETV6-NTRK3 gene fusion detected in 0/5 of the classic MN, 8/8 of the cellular MN and 5/6 of the mixed MN cohorts, respectively. Our results conclude that cyclin D1 and beta-catenin may be useful markers for differentiating between cellular MN and classic MN when the histology is not conclusive. The absence of expression of stem cell markers and markers involved in urogenital development suggests that MN is not a nephroma and most likely represents a soft tissue tumour, with congenital infantile fibrosarcoma representing cellular MN with a predilection to arise in the kidney. In addition, the immunophenotype and genetic fingerprint of mixed MN most likely represents a heterogenous group of tumours that are mostly cellular type, with areas that are phenotypically less cellular.

Congenital fibrosarcoma in complete remission with Somatostatin, Bromocriptine, Retinoids, Vitamin D3, Vitamin E, Vitamin C, Melatonin, Calcium, Chondroitin sulfate associated with low doses of Cyclophosphamide in a 14-year Follow up

At birth, a male child presented a 6 cm tumour in the right leg. The tumour was partially removed after just 12 days. Histology showed a congenital fibrosarcoma associated with reactive lymphadenitis. A first cycle of adjuvant chemotherapy did not prevent the rapid progression of the disease. Subsequent evaluation for surgical removal raised serious concerns due to the need for a major operation involving total amputation of the right leg and hemipelvectomy. Since surgery could not exclude the possibility of disease recurrence and since the traditional cycles of chemotherapy did not offer any possibility of a cure, the parents opted for the Di Bella Method. The combined use of Somatostatin, Melatonin, Retinoids solubilized in Vit. E, Vit. C, Vit. D3, Calcium, and Chondroitin sulfate associated with low doses of Cyclophosphamide resulted in a complete objective response, still present 14 years later, with no toxicity and without the need for hospitalization, allowing a normal quality of life and perfectly normal adolescent psycho-physical development.

Congenital infantile fibrosarcoma of the colon: a case series and literature review

Congenital infantile fibrosarcoma is rare and only three cases affecting the colon have previously been reported. We describe two further cases that presented in the neonatal period and were both successfully treated with surgical excision and have no evidence of recurrence or metastasis at 31 and 27 months follow-up, respectively.

Congenital-infantile fibrosarcoma of the foot--avoidance of amputation

Congenital-infantile fibrosarcoma is a rare entity with a five year survival rate of over 90%. Surgery is still the most common treatment modality with amputation often necessary. There have been reports supporting the use of neoadjuvant chemotherapy to debulk the tumour in an effort to facilitate limb sparing surgery. We report a case of a newborn who presented with a life threatening haemorrhage from a fibrosarcoma of the foot, successfully treated with Vincristine, Actinomycin and Cyclophosphamide (VAC) chemotherapy alone.

Urologic and anorectal complications of sacrococcygeal teratomas: prenatal and postnatal predictors

PURPOSE

Anorectal and urologic sequelae are observed in long-term survivors of sacrococcygeal teratoma (SCT). In this study we evaluate the incidence and predictors of anorectal and urologic complications in SCT.

METHODS

A retrospective review was performed for all SCT patients who underwent resection at a single institution between 2000 and 2012. Enrollment criteria included a minimum of 12months follow-up. Categorical variables were analyzed by Fisher's exact test and continuous variables by Mann Whitney test (p<0.05).

RESULTS

Forty-five patients were studied. Anorectal complications occurred in 29%, including severe chronic constipation (n=13) and fecal incontinence (n=4). Urologic complications occurred in 33%, including neurogenic bladder (n=12), vesicoureteral reflux (n=5), and urinary incontinence (n=7). Prenatal imaging by fetal MRI demonstrated mass effect with obstruction of the bowel (n=4) or bladder and collecting system (n=7) in a subset of patients with postnatal complications (anorectal 4/4, PPV 100%; urologic 6/7, PPV 86%). Postnatal complications were associated with obstructive findings on prenatal imaging, prenatal therapeutic interventions, Altman classification, perineal reconstruction, and tumor recurrence. No anorectal or urologic complications occurred in patients with Altman type I tumors.

CONCLUSIONS

Urologic and anorectal complications are common in patients with SCT. Higher Altman classification and prenatal imaging suggestive of intestinal or urologic obstruction should prompt focused prenatal counseling and postnatal screening for anorectal and urologic dysfunction.

Recurrent NCOA2 gene rearrangements in congenital/infantile spindle cell rhabdomyosarcoma

Spindle cell rhabdomyosarcoma (RMS) is a rare form of RMS with different clinical characteristics between children and adult patients. Its genetic hallmark remains unknown and it remains debatable if there is pathogenetic relationship between the spindle cell and the so-called sclerosing RMS. We studied two pediatric and one adult spindle cell RMS by next generation RNA sequencing and FusionSeq data analysis to detect novel fusions. An SRF-NCOA2 fusion was detected in a spindle cell RMS from the posterior neck in a 7-month-old child. The fusion matched the tumor karyotype and was confirmed by FISH and RT-PCR, which showed fusion of SRF exon 6 to NCOA2 exon 12. Additional 14 spindle cell (from 8 children and 6 adults) and 4 sclerosing (from 2 children and 2 adults) RMS were tested by FISH for the presence of abnormalities in NCOA2, SRF, as well as for PAX3 and NCOA1. NCOA2 rearrangements were found in two additional spindle cell RMS from a 3-month-old and a 4-week-old child. In the latter tumor, TEAD1 was identified by rapid amplification of cDNA ends (RACE) to be the NCOA2 gene fusion partner. None of the adult tumors were positive for NCOA2 rearrangement. Despite similar histomorphology in adults and young children, these results suggest that spindle cell RMS is a heterogeneous disease genetically as well as clinically. Our findings also support a relationship between NCOA2-rearranged spindle cell RMS occurring in young childhood and the so-called congenital RMS, which often displays rearrangements at 8q13 locus (NCOA2).

A case of congenital infantile fibrosarcoma of sigmoid colon manifesting as pneumoperitoneum in a newborn

Congenital infantile fibrosarcoma (CIF) is a rare soft-tissue tumor in the pediatric age group and seldom involves the gastrointestinal tract. A 2-day-old boy was transferred to our hospital with a pneumpoperitoneum. After emergency operation, we could find a solid mass wrapping around a sigmoid colon and performed a segmental resection of sigmoid colon including a mass. Histopathologic examination showed an infantile fibrosarcoma origining from the muscular layer of colon. The baby was discharged on the 17th hospital day and followed for 1 yr without recurrence.

[Sacrococcygeal teratoma: review of the literature]

Sacrococcygeal teratoma (SCT) is rare germ cell tumor composed of multiple types of cells derived from the three primitive germ cell layers. SCT is the most common tumor of germ cells. In recent years the routinely use of prenatal obstetric ultrasonography has led to increase in the prenatal diagnosis of type of malformation. Management should be multidisciplinary and integrated by pediatric neurosurgeons, pediatric surgeons, pediatricians and oncologists. The advent of fetal surgery to identify fetuses at risk has improve survival. We present a review of the literature aimed to enable better understanding of this pathology.

Rapidly involuting congenital hemangioma: a case of complete prenatal involution

We report a case of rapidly involuting congenital hemangioma of the flank, which was diagnosed in the 2(nd) trimester of gestation and showed complete involution before term. In our case sonography revealed a highly vascular soft tissue mass with smooth contours, which was isointense with the placenta on T2-weighted MR images. The fetus was born with scar tissue at the site of the lesion. To our knowledge this is the 1(st) reported case of rapidly involuting congenital hemangioma showing complete involution before term.

[Benign sacrococcygeal teratoma in a child: a case report with a review of the literature]

Sacrococcygeal teratomas are rare congenital tumors, generally discovered at birth. These tumors are seldom observed in children. Radical resection must be performed to avoid potentially malignant recurrence even if the primary lesion is benign. We report a case in an 8-year-old girl who did not have a past medical history. Since the age of 2 years, she presented a progressive sacral tumefaction with no neurological deficit. The MRI showed a large sacrococcygeal cyst in hypointense-signal T1-weighted imaging with no contrast enhancement, and a hyperintense signal in T2-weighted imaging. At surgery, the tumor was totally removed. The intraoperative aspect was that of a viscous cyst. The histological study showed a sacrococcygeal teratoma.

[Soft tissue tumors in neonates]

Soft tissue tumors account for approximately 25% of neonatal tumors and are most often benign (more than 2/3 of cases). Vascular tumors are the most frequent benign tumors and infantile hemangioma accounts for 32% of these tumors, affecting 1 out of 200 children at birth. Kaposiform hemangioendothelioma (KH) is a rare vascular tumor with locally aggressive behavior. More than 50% of KH are associated with the Kasabach-Merritt phenomenon, a condition characterized by thrombocytopenia and consumptive coagulopathy. Malignant soft tissue tumors are, after neuroblastoma, the second cause of cancer in neonates. Infantile fibrosarcoma (IF) is a rare tumor that most often affects the extremities of children aged 4 years or younger. A recurrent t(12;15) (p13;q25) rearrangement fusing the ETV6 gene with the NTRK3 neurotrophin-3 receptor gene has been identified in IF. Complete conservative surgical resection is usually curative. Chemotherapy is indicated when initial surgical removal cannot be accomplished without unacceptable morbidity. Prognosis of IF is excellent, with reported overall survival rates ranging from 80 to 100%. Neonatal rhabdomyosarcoma (RMS) is a rare tumor (0.5-1% of RMS). The primary tumor predominantly involves the limbs and the genitourinary tract. Treatment is based on age-adapted chemotherapy and surgery. Prognosis of RMS in children less than 1 year old appears to be comparable with that of older children.

Long-term functional sequelae of sacrococcygeal teratoma: a national study in The Netherlands

BACKGROUND

Long-term functional sequelae after resection of sacrococcygeal teratoma (SCT) are relatively common. This study determines the incidence of these sequelae associated clinical variables and its impact on quality of life (QoL).

PATIENTS AND METHODS

Patients with SCT treated from 1980 to 2003 at the pediatric surgical centers in The Netherlands aged more than 3 years received age-specific questionnaires, which assessed parameters reflecting bowel function (involuntary bowel movements, soiling, constipation), urinary incontinence, subjective aspect of the scar, and QoL. These parameters were correlated with clinical variables, which were extracted from the medical records. Risk factors were identified using univariate analysis.

RESULTS

Of the 99 posted questionnaires, 79 (80%) were completed. The median age of the patients was 9.7 years (range, 3.2-22.6 years). There were 46% who reported impaired bowel function and/or urinary incontinence (9% involuntary bowel movements, 13% soiling, 17% constipation), and 31% urinary incontinence. In 40%, the scar was cosmetically unacceptable. Age at completion of the questionnaire, Altman classification, sex, and histopathology were not risk factors for any long-term sequelae. Size of the tumor (>500 cm3) was a significant risk factor for cosmetically unacceptable scar (odds ration [OR], 4.73; confidence limit [CL], 1.21-18.47; P = .026). Long-term sequelae were correlated with diminished QoL.

CONCLUSION

A large proportion of the patients with SCT have problems with defecation, urinary incontinence, or a cosmetically unacceptable scar that affects QoL. Patients who are at higher risk for the development of long-term sequelae cannot be clearly assessed using clinical variables.

Spinal hamartoma associated with spinal dysraphism

OBJECTS

The aims of the study were (1) to review the pathological findings of spinal lipomatous masses associated with congenital spinal dysraphism and (2) to discuss the pathological diagnosis.

METHODS

The pathological records of 47 patients at our institution were reviewed, and three illustrative cases were presented.

CONCLUSION

Spinal tumorous lesions associated with spinal dysraphism have been traditionally described as lipoma since they are composed mostly of fatty tissue. However, they are different from lipomas arising in other part of the body in that they often contain various tissues of ecto- and mesodermal origin. In our study, we detected such heterotopic components in 24 out of 47 cases. Although they are also similar to teratoma, it is generally accepted that they are malformative lesions which lack neoplastic potential. We therefore should diagnose them as hamartoma rather than lipoma or teratoma.

Congenital fibrous hamartoma of the knee

A full-term male infant presented at birth with a hard swelling of the left knee. The lemon-sized lesion was fixed to the underlying knee muscles, while the overlying skin was stretched and shiny; there was no bruit. Radiography, sonography and MRI suggested a soft-tissue tumour. After surgical excision, histology showed the presence of fibrous and mesenchymal tissue, with mature adipose tissue. Fibrous hamartoma of infancy was diagnosed. Among soft-tissue tumours, fibrous hamartoma of infancy is a rare and benign lesion, occurring in the first 2 years of life. The tumour mainly affects the trunk, axilla, and upper extremities. This infant had unique involvement of the knee. The treatment of choice is local excision.

Imaging of the pediatric hand: Soft tissue abnormalities

This review attempts to demonstrate the spectrum of soft tissue masses encountered in the child's hand. The diagnosis may be suggested by the combination of physical exam and radiographs. Frequently the etiology of a soft tissue mass cannot be established by conventional radiographs and further imaging is necessary. MRI by virtue of its ability to provide detailed soft tissue characterization is the preferred method of imaging the problematic soft tissue mass.

Aspect inhabituel d’un lipoblastome axillaire chez un nourrisson

Lipoblastoma is an uncommon benign soft tissue tumor of infancy and early childhood with a predilection for the extremities. CT and MRI can confirm the presence of fat components in the tumor. In addition, MRI better shows the anatomical extent. By showing lipoblastoma proliferation, histology confirms the diagnosis. Gross total excision is the treatment of choice. The authors report a case of unusual lipoblastoma of the axillary region, composed of fatty components with multiple cystic areas presenting at birth, with recurrence 9 months after excision.

A case of congenital soft tissue chondroma

Soft tissue chondromas are rare benign tumors unrelated to bone that arise primarily in the distal extremities, especially in the fingers of middle-aged adults. We report an extremely rare case of congenital soft tissue chondroma, arising in the left great toe of a new-born infant. The present case is, to our knowledge, the first to be described in the dermatologic literature and the second reported case of congenital soft tissue chondroma.

Vascular malformation of hand: cavernous lymphangioma

A case of congenital cavernous lymphangioma of the hand presenting in a newborn is presented. The mass on the dorsum of the hand was removed with the overlying skin and underlying paratenon at three years of age. Re-surfacing was performed with a free flap transfer. There were no post-operative complications during one year of follow-up.

Fibrous Hamartoma of Infancy: A Case Report With Associated Cytogenetic Findings

A 2-month-old male infant presented with a subcutaneous mass on the left middle finger; the mass had been present since birth. This was treated with local excision, and there has been no recurrence. Histology revealed the typical features of a fibrous hamartoma. Cytogenetic studies revealed a reciprocal translocation, t(2;3)(q31;q21), as the sole abnormality. To our knowledge, this is the first report of the cytogenetic findings in fibrous hamartoma, and it suggests that this lesion represents a benign neoplasm.

A case of neonatal neuroblastoma mimicking Altman type III sacrococcygeal teratoma

The authors report a case of neonatal neuroblastoma mimicking Altman type III sacrococcygeal teratoma. A newborn male infant delivered after a normal pregnancy was found to have an extremely large sacrococcygeal mass. Imaging studies strongly suggested Altman type III sacrococcygeal teratoma. On the 10th day after the birth, the tumor was incompletely removed at surgery. Histopathologic examination of the tumor showed neuroblastoma. The tumor disappeared completely after chemotherapy. One year after diagnosis, no local recurrence or metastasis had been detected. To the authors' knowledge, this is the first case of neonatal neuroblastoma mimicking Altman type III sacrococcygeal teratoma.

Congenital nodular multiple glomangioma: a case report

A 13 year old girl presented with recurrent painful "varicosities" on her right calf. These lesions were subsequently clinically diagnosed as "cavernous haemangiomas" after normal duplex scanning and were excised. Histological examination revealed multiple glomangiomas (glomus tumours). A literature review revealed only two reported cases of nodular multiple glomangioma, so that this is the third case to be reported in the literature.

Pathophysiology of capillary haemangioma growth after birth

Capillary haemangiomas (CHs) are the most common soft tissue tumours of infancy. It is generally believed that the primary defect in CHs is intrinsic to endothelial cells, but their pathogenesis is yet poorly understood. The relatively low oxygen environment, in which the human foeto-placental unit develops, during the first trimester, is necessary to induce vasculo-angiogenesis via embryonic endothelial cells proliferation, since these cells are sensitive to hypoxia and acidosis. In newborn infants with haemangioma, persistent embryonic primitive endothelial cells trapped in the intimae underneath the developing vessels, and representing "leader" endothelial cells, can stabilise the labile vascular endothelial growth factor mRNA (VEGF mRNA), produce other angiogenic factors, degrade the underlying basement membrane and invade into the stroma of the neighbouring tissue. With bearing down, the transition from intra- to extra-uterine life is accompanied by more or less pronounced hypoxia. Consequently, in babies with haemangioma, hypoxia can act as a switch to activate these "leader" endothelial cells and thereby initiate a cascade of reactions leading to CH proliferation. As they are regulated by embryonic cells, the haemangioma growth mechanisms pursue the pathway of embryonic angiogenesis and it will stop at the end of the embryonic endothelial cell cycle. Addressing this mechanism in vivo has partly been done (the angiogenic peptide bFGF varies with haemangioma growth). Thus, early treatment seems necessary in infants with haemangioma, before the endothelial cells achieve their proliferative stage. The use of an antibody to interfere with VEGF receptors provides a particular attractive strategy.

Monosomy 9q and trisomy 16q in a case of congenital solitary infantile myofibromatosis

Although infantile myofibromatosis (IM) is the most common fibrous proliferation of infancy, many aspects of this benign lesion have not been explored. IM histogenesis is still poorly understood, despite immunohistochemical staining and ultrastructural features that suggest a myofibroblastic origin. IM diagnosis is often made difficult by the predominance of small primitive spindle cells over myofibroblasts and the presence of intravascular growth. Genetic information is scarce, with only one karyotyped case. Here we describe a case of solitary IM discovered at birth in an otherwise healthy girl. The tumor was well circumscribed, arranged in nodules and made up of ovoid cells without atypia, in a myxoid background. Immunohistochemical evaluation indicated a myofibroblastic differentiation. The cytogenetic and fluorescence in situ hybridization analyses revealed an abnormal chromosome 9, derived from an unbalanced whole-arm translocation between chromosomes 9 and 16. On both chromosomes, the breakpoints were located in the pericentric heterochromatic region. This clonal abnormality has not been reported in other tumors and is different from the chromosome 6q deletion reported in the single previous reported IM karyotype.

[Congenital solid tumors. A thirteen-year review]

Tumors diagnosed during the first month of life are infrequent: 0.5 to 2% of all childhood neoplasms. This is an interesting group of tumors because their type, relative incidence, natural history and response to treatment differ from those seen in older children.

AIM

To contribute the experience of our institution in congenital tumors the last 13 years.

MATERIAL AND METHODS

The records of all neonates (< 31 days old) diagnosed with solid tumors since January 1990 to December 2002 have been retrospectively reviewed.

RESULTS

Twenty-seven neonates have been diagnosed with tumors in the last 13 years. Thirteen patients (48%) were prenatally diagnosed. Nine babies were diagnosed at the initial neonatal exam (40% of those diagnosedd after birth). Neuroblastoma was the commonest tumor (10 cases, 37%), of which 4 were stage I, 4 stage IV-S and 2 stage III. There were 8 teratomas (3 sacrocoxigeal, 1 retroperitoneal, 1 in the CNS, 1 orbitary and two oronasal), two hepatic tumors (1 hepatoblastoma, 1 hemangioendothelioma, two CNS tumors, two giant nevus (one on a hamartoma), and one each Wilms tumor, infantile fibrosarcoma and myofibroblastic tumor. Treatment was surgical resection alone in 17 cases (68%) and surgery + chemotherapy in 8 (32%) (5 neuroblastomas, one CNS tumor, one Wilms tumor and one presacral teratoma who developed a yolk sac tumor); 3 patients died (11%): one at surgery, one of tumoural airway obstruction at birth and one with craniopharyngioma. Among the 14 tumors that were initially not malignant, two can be locally agressive, one was an immature teratoma, the giant nevus with hamartoma developed in situ melanoma, the other nevus had meningeal melanosis with hydrocephalus, and one mature presacral teratoma developed a yolk sac tumor.

CONCLUSIONS

Diagnosis of congenital tumors is performed earlier in recent years due to the wide use of prenatal ultrasound. Their natural history is more benign than in other age groups, except for CNS tumors and very large or obstructing tumors. The histological patern is not determinant of the outcome. Complete surgical excision is the treatment of choice, most cases not need adjuvant chemotherapy. We ought to pass this message on to our colleagues in prenatal diagnosis, so parents get reliable information.

Deforming lipoblastomatosis of the lower extremity

OBJECTIVE

Lipoblastomatosis is a rare disorder in infants and children and nonexistent in adults. We discuss a case of a newborn child with lipoblastomatosis extensively involving the pelvis and lower extremities. The clinical and radiological characteristics of the disorder are discussed.

CLINICAL FEATURES

A 2-month-old male had an enlarging deformity of the pelvis and lower extremities with progression of the condition from birth. There was no family history related to the disease. No other clinical abnormalities were present.

INTERVENTION AND OUTCOME

Lipoblastomatosis is initially treated with surgical excision of the lipomatous neoplastic tissue. The postsurgical outcome is satisfactory; however, the likelihood of recurrence has been reported.

CONCLUSION

We present the features of lipoblastomatosis, an uncommon disorder affecting infants and children. The clinical and radiologic manifestations of the disease are assessed with emphasis on magnetic resonance imaging.

Congenital fibrosarcoma with metastasis in a fetus

It is well known that congenital or infantile fibrosarcoma has a much less aggressive behavior than fibrosarcoma in adults, and it rarely metastasizes. We report a case of congenital fibrosarcoma in a 26-wk-old fetus, the diagnosis of which was made by an in utero needle core biopsy. Metastatic tumors were identified at autopsy when the pregnancy was terminated 3 wk later. English literature of metastatic congenital fibrosarcoma was also reviewed.

Ineffectiveness of dietary folic acid supplementation on the incidence of lipomyelomeningocele: pathogenetic implications

OBJECT

Periconceptual folic acid supplementation is effective in myelomeningocele prevention. The relationship between folic acid and lipomyelomeningocele (LMM) and the overall incidence of this occult form of spina bifida has never been studied. The objectives of this study were to determine the impact of dietary folic acid supplementation on the incidence of LMM and to measure its overall incidence.

METHODS

In a retrospective population-based study the authors calculated the incidence of LMM in Nova Scotia between 1985 and 2001. Because of changes in public policy during this period, there are three intervals defined in relation to the treatment of the food supply with folic acid: 1) prior to folic acid fortification (1985-1994); 2) postsupplementation but prefortification (1995-1998); and 3) postfortification. The overall incidence of LMM in Nova Scotia between 1985 and 2001 was 16 per 100,000 live births or one case per 6121 live births. Its incidence between 1985 and 1994 was 15 per 100,000 live births, and between 1995 and 1998 it was 12 per 100.000 live births (relative risk [RR] 0.82, 95% confidence interval [CI] 0.31-2.22; p = 0.7). Between 1999 and 2001, the incidence of LMM was 29 per 100,000 live births, which was not significantly different from that between 1995 and 1998 (RR 2.41. 95% CI 0.79-7.36; p = 0.11) or between 1985 and 1994 (RR 1.98, 95% CI 0.86-4.56; p = 0.1).

CONCLUSIONS

The overall incidence of LMM between 1985 and 2001 in Nova Scotia was 16 per 100,000 live births and has not been reduced by dietary folic acid supplementation. This finding provides epidemiological evidence that the embryogenesis of LMM is fundamentally different from that of myelomeningocele.

Congenital and childhood plexiform (multinodular) cellular schwannoma: a troublesome mimic of malignant peripheral nerve sheath tumor

We present six cases of a plexiform nerve sheath tumor of childhood that previously had been designated a form of malignant peripheral nerve sheath tumor (MPNST), and we provide evidence that such tumors are in fact benign plexiform cellular schwannomas. At presentation, the four girls and two boys ranged in age from 2 to 15 months with tumors of the leg (four), deep groin and upper thigh (one), and pelvis (one). Of the six lesions, five were congenital and none was associated with type 1 neurofibromatosis. Tumor sizes ranged from 2.0 to 9 cm, with three larger than 5 cm. Three tumors were well circumscribed, two were purely infiltrative, and one had a mixed circumscribed and infiltrative growth pattern. Peripheral nerve involvement was evident in two cases. Grossly, the tumors were multinodular or plexiform in configuration and, on sectioning, lobulated and homogeneously tan without necrosis. Characteristic histologic features included hypercellularity, composition of cells spindle in shape with elongate hyperchromatic nuclei, and indistinct cellular outlines. Their nuclei varied minimally in size and shape but were at least three times the size of typical neurofibroma nuclei. Mitoses were seen in every tumor and in the areas of greatest proliferative activity ranged from 4 to 31/10 high power fields. MIB-1 staining of at least 30% of the cells was noted in three cases. In five cases in which p53 immunoreactions were performed, no nuclear staining was evident. That the tumors are schwannomas was evident from their uniform strong staining for S-100 protein and an ultrastructure in all five cases showing only differentiated neoplastic Schwann cells. Architecturally, the tumors differed from conventional schwannoma and nonplexiform cellular schwannomas by their lack of both well-formed capsules and degenerative changes. Follow-up was available in all cases and ranged from 2 to 13.6 years. All tumors recurred locally and were treated by local resections. With the exception of one child lost to follow-up at 25 months, all the children are alive and free of disease. Our data combined with cases previously reported by Meis-Kindblom and Enzinger show a childhood peripheral nerve tumor unassociated with type 1 neurofibromatosis, occurring most commonly in infants, often presenting as a congenital tumor and, though prone to local recurrence, having no metastatic potential. The behavior is that of a benign tumor, although its often rapid growth, hypercellularity and increased mitotic activity, sometimes locally aggressive behavior, and difficulties encountered in obtaining tumor-free margins are unsettling to pathologist and clinician alike. These features may lead to a misdiagnosis of malignancy, which could result in harmful overtreatment.

Successful treatment of life-threatening generalized infantile myofibromatosis using low-dose chemotherapy

Infantile myofibromatosis is the most common fibrous tumor of infancy. The generalized form of the disease is associated with a high rate of early mortality, especially if visceral structures are involved. Various therapeutic strategies have been used in these patients, including high-dose chemotherapy, with the risk of therapy-related toxicity. The authors present two cases of generalized infantile myofibromatosis, with life-threatening visceral and nonvisceral involvement, in which the patients were cured with a combination of low-dose chemotherapy and intensive care. The authors propose a prospective international trial using a safe low-dose chemotherapy protocol to test the efficacy of this treatment strategy.

Lipoblastoma-lipoblastomatosis associated with unilateral limb hypertrophy: a case report in a newborn

Lipoblastoma is a benign mesenchymal tumor of embryonic adipose tissue, uncommon in infancy. Multicentricity, absence of a capsule and histopathology best defines a lipoblastoma. Synonyms for this lesion are embryonic lipoma, fetal lipoma, lipoblastic tumor, and congenital lipomatoid tumor. Lipoblastoma is more common in males (approximately 80%), is usually located in the subcutaneous soft tissue (benign lipoblastoma) or in the deep interstitium (benign lipoblastomatosis), or sometimes in all corporeal segments. Primary treatment is complete excision. Relapse is between 14-25%, many of which are more "mature," and difficult to differentiate from lipoma. The differential diagnosis includes liposarcoma, which is rare under ten years. Radical excision in children is recommended with relapses, especially with lipoblastomatosis. Chromosomal markers help discriminate between liposarcoma and lipoblastoma.

Non-resectable congenital tumors with the ETV6-NTRK3 gene fusion are highly responsive to chemotherapy

BACKGROUND

Recently, the ETV6-NTRK3 gene fusion has been identified in both infantile fibrosarcoma and cellular mesoblastic nephroma. For both these tumors standard curative treatment has been primarily surgical with wide local excision. This has frequently involved radical and even mutilating surgery.

PROCEDURE

This report discusses three infants with congenital tumors, two congenital fibrosarcomas, and one atypical congenital mesoblastic nephroma, not easily amenable to surgical intervention.

RESULTS

All three were treated with pre-operative chemotherapy with excellent responses negating the need for amputation in two patients. In each patient, the ETV6-NTRK3 gene fusion was identified by reverse transcriptase-polymerase chain reaction (RT-PCR) in the tumor specimens.

CONCLUSIONS

Our findings suggest that the ETV6-NTRK3 gene fusion may underlie the distinctive biological properties of these tumors and may also indicate tumor chemosensitivity. In this group of patients pre-operative chemotherapy may abrogate the need for morbid surgical procedures.

A case of congenital mucinous nevus: a connective tissue nevus of the proteoglycan type

Mucinous nevus is a very rare entity and can be classified as both a cutaneous mucinosis (CM) and a connective tissue nevus (CTN). We describe the clinicopathologic features of an unusual case of mucinous nevus in a 14-year-old Korean boy who presented with zosteriform plaques of congenital onset.

[Plexiform fibrohistiocytic tumour - case report of a rare low-malignant tumour with frequent localisation at the upper limb]

A male child aged nine months was admitted due to a slow growing, painless resistance at the palmar aspect of the proximal phalanx of the index finger. The intraoperative aspect of the tumour showed a yellow to white soft tissue mass with signs of infiltration. After special histopathological stainings, the diagnosis of a plexiform fibrohistiocytic tumour was confirmed. In literature almost 100 cases were reported since first description by Enzinger and Zhang in 1988. In this paper, 41 of 65 described cases showed tumour localization in the upper limb. This is the second case ever published in Germany and the first with localisation to the hand. There is very little clinical experience with this tumour entity. Local recurrence, lymphatic and pulmonal metastases with lethal outcome in rare cases are described. In the presented case, after secondary radical excision of the tumour, the patient has been free of local recurrence and actually in complete remission for 14 months.

In utero ultrasound detection of a large fetal sarcoma of the back

A congenital fibrosarcoma, a very rare soft-tissue tumor of infancy, was suspected on prenatal ultrasound at 23 weeks' gestation. On sonography, a large soft tissue growth on the left side of the fetal back, measuring 53 x 65 x 22 mm, was observed. The diagnosis was further validated by magnetic resonance imaging. Delivery by Cesarian section occurred at 31 weeks of gestation, due to fetal distress. The baby underwent an unusual embolization of the tumor-feeding arteries and an operation at the age of 1 month to remove the tumor. The pathological and cytogenetic examinations were consistent with the diagnosis of a fibrosarcoma.

Neonatal alveolar rhabdomyosarcoma with skin and brain metastases

BACKGROUND

Approximately 5-10% of patients with rhabdomyosarcomas (RMS) are diagnosed during the first year of life, and their clinical characteristics have been well documented. However, because RMS rarely occurs during the neonatal period, little is known about neonatal RMS.

METHODS

Four patients with neonatal RMS were treated at St. Jude Children's Research Hospital between 1962 and 1999. The authors report the results of a review of these patients and of cases described in the literature. Clinical, radiologic, and pathologic features of these patients and their outcomes were evaluated.

RESULTS

One patient with embryonal RMS was treated successfully with a combination of systemic chemotherapy and local control measures. The other three patients had alveolar RMS. Two of them had multiple skin and subcutaneous metastatic nodules at the time of diagnosis and developed brain metastases early in their course. In one of these patients, the PAX3-FKHR fusion transcript was detected. Three other similar cases of neonatal alveolar RMS with metastases to the skin and brain have been reported in the literature.

CONCLUSIONS

A distinct syndrome of neonatal RMS is described. This syndrome is characterized by alveolar histology, multiple skin and subcutaneous metastases, and fatal outcome as the result of early brain metastasis.