Primary peripheral neuroectodermal tumor (PNET) of the adrenal gland: a rare entity

PURPOSE

Ewing Sarcoma/Primitive Neuroectodermal Tumor (ES/PNET) is a malignant small round cell tumor belonging to the Ewing Sarcoma Family of Tumors. It occurs more commonly in children and young adults. Its localization in the adrenal gland is extremely rare. We reviewed 35 cases of ES/PNET of the adrenal gland reported in the literature and presented our case.

METHODS

Data were collected by searching for ES/PNET and adrenal gland key words on Google Scholar and PubMed in March 2018, including a case diagnosed in our department. We analyzed all reviewed cases for diagnosis, surgical and systemic therapy and outcome.

RESULTS

To date 24 articles presenting cases of ES/PNET of the adrenal gland are reported in the literature. We included in our review 35 cases previously described and one new case. Histologically all cases consisted of sheets of small round cells. Immunohistochemistry was also performed in all cases. Most cases stained positive for CD99 and negative for lymphocytic markers. Markers of epithelial differentiation displayed variable results. In all cases tested, characteristic translocations were displayed supporting the diagnosis. All patients but four were treated surgically and the majority received adjuvant therapy. Only very few cases received neoadjuvant chemotherapy.

CONCLUSIONS

Primary ES/PNET of the adrenal gland is a rare tumor, showing specific morphological, immunohistochemical and cytogenetic characteristics. Treatment consists of surgery, chemotherapy and radiotherapy. Further investigations paired with long term follow-up are necessary to define prognosis for this rare entity.

Epidemiology of primary intracranial tumours in NW Italy, a population based study: stable incidence in the last two decades

Data about the epidemiology of primary intracranial tumours (PIT) are still heterogeneous depending on different methodological approach in collecting data. In Valle d' Aosta, north west side of Italy, we have carried out a prospective consecutive population based study to calculate the incidence of PIT in the last decade (1992-1999) and to compare these rates with the previous period (1986-1991), data reported in a previous paper. The mean annual PIT incidence rate (ri) per 100,000 inhabitants was 25.48. The mean annual incidence rates in the two period of comparison were adjusted to the 1991 Italian population by the direct method. The standardised ratio was 26.43 in the previous period and 23.24 in the second decade. There is no statistically significant difference. The mean annual PIT incidence rates by tumour types were meningiomas 13.27/100,000 (men 9.77; women 16.7), neuroepithelial group 9.3 (men 10.62; women 8.1), adenomas 1.26, neurinomas 0.7. Mean annual incidence rates by tumour class were also stable. The stable incidence rate in the two periods and the similar incidence in England (21.04/100,000 person year), strengthen the evidence for a stable incidence rate of PIT in the last decade. These three papers used similar methodology. The homogeneous methodology allows comparison and further evaluation.

[Dysembryoplastic neuroepithelial tumor. An epidemiological study from a single institution]

The true incidence of dysembryoplastic neuroepithelial tumor (DNT) is unknown. Variable estimations have been advanced according to the type of recruitment of patients. In series of patients with tumors who were operated on for pharmacoresistant epilepsy, the rates varied widely, from 5% to 87%. Among 600 pediatric tumors in a series, 9 DNT (1.5%) were found. Since DNT was identified only in 1988, we reviewed our cases (1975-1991) of gangliogliomas (n = 25), oligoastrocytomas (n = 9), temporal oligodendrogliomas (n = 11), temporal astrocytomas grade II (OMS 1993) (n = 44) irrespective to age, as well as all astrocytomas grade II (n = 61) and oligodendrogliomas (n = 10) in patients up to 20 years of age. Seven DNT were encountered. Four cases had been formerly diagnosed as gangliogliomas and 3 as astrocytomas grade II. From 1992 on, 4 more DNT were diagnosed, making up a total of 11 cases. Eight patients were under age 17 (6 y to 17 y, mean 10.3 y) and 3 were 27, 42 and 51 year-old. Eight tumors were temporal, 1 frontal and 2 occipital. All patients have had pharmacoresistant epilepsy. Among all neuroepithelial tumors diagnosed in our Division in the last 22 years, DNT comprises 1.2% in patients under age 20 (n = 660), 0.24% in patients over 20 years (n = 1254), and 0.63% all ages considered (n = 1914).

Esthesioneuroblastoma: a general review of the cases published since the discovery of the tumour in 1924

Esthesioneuroblastoma (ENB) arises from the neuroepithelium in the olfactory rim of the nasal cavity. It accounts for about 3% of all intranasal tumours. Reviews since the first description by Berger and Luc in 1924 never reported more than a hundred cases, stressing the rarity of the tumour. However, a thorough literature review revealed a total of 945 reported cases. In our search we found a total of 1,457 cases chronicled in the literature of which perhaps 487 were cited in more than one paper, bringing the total of reported cases to 945. Author cases accounted for 198 and therefore collaborative efforts accounted for 747 cases. Sex distribution was 53.36% male and 46.64% female. Kadish classification was applied to 553 cases revealing 103 (18.29%) class A cases, 182 (32.33%) class B and 278 (49.38%) class C cases. This distribution was generally stable through the decades. Treatment could be classified in 898 cases. It consisted of surgery alone in 25.17% (226 cases), radiotherapy alone in 18.37% (165 cases), combined surgery and radiotherapy in 43.21% (388 cases) and chemotherapy in 13.2% (119 cases), followed in 11 cases (1.22%) by bone marrow transplant. In the reported cases an overall follow up could be evaluated in 477 cases, while in only 234 cases a five-year follow up was done. The outcome was 68.38% alive and disease free, 12.82% alive with disease and 18.80% dead. From these 20.51% had surgery only, 11.11% radiotherapy and 68.38% combined surgery and radiotherapy. The best survival rates were obtained by combined therapy (72.5% vs. 62.5% surgery alone and 53.85% radiotherapy alone). Death rates were highest after radiotherapy alone (30.77% versus 18.75% in combined therapy and 12.50% after surgery alone). In conclusion, ENB is a rare but not exceptional tumour. It is best treated with combined surgery and radiotherapy. Unfortunately early diagnosis is still uncommon and no significant changes to the proportions of Kadish classes at first diagnosis have been noted in recent decades. A greater awareness of the tumour and earlier diagnosis seems the major focus for future research.

Ewing's sarcoma and peripheral primitive neuroectodermal tumor

Disease-free survival for patients with small sarcomas of bone has been impressively improved with the use of intensive combination chemotherapy and safe local control with surgery or radiation. The ability of monoclonal antibodies to recognize different antigens has allowed new insights into the histogenesis and has distinguished a neural variant now referred to as malignant peripheral neuroectodermal tumor. Both entities share the translocation t(11;22) (q24;q12) as a constant phenomenon. The breakpoint region has now been cloned, allowing for molecular identification and detection of tumor cells and opening a new era of diagnostic and staging possibilities. Patients with disseminated disease, either at diagnosis or in relapse, have benefitted from megatherapy regimens followed by bone marrow or peripheral stem cell rescue. However, this approach is still under investigation and remains to be standardized.

Ethmoidal cancers: a retrospective study of 22 cases

From April 1978 to June 1990, 22 patients with ethmoidal cancer were treated at Fondation Bergonié by a combination of surgery and radiation therapy. The mean age was 59.6 years (range 34-79 years) and the sex ratio is 2.7 (16 males/6 females). Histologic types were: adenocarcinoma, 13 cases; squamous carcinoma, 4 cases; undifferentiated carcinoma, 3 cases and esthesioneuroblastoma, 2 cases. Exposure to wood dust was encountered in 11 patients, especially in cases of adenocarcinoma: 10/13 (77%). Staging according to the classification of the University of Florida was: Stage I, 10 patients; Stage II, 5 patients and Stage III, 7 patients. Resection was considered as complete in 16 cases and only one orbital exenteration was performed. The postoperative radiation therapy delivered a mean given dose of 55.7 Gy (range 50-70 Gy) expressed to the hot spot using a technique adapted to tumor location and extension. Complete remission was achieved in 20 cases. Median follow-up is 28 months. The 5-year overall and disease-free survival are 44% and 38%, respectively. Analysis of recurrences according to staging gives: 5/10 Stage I, 2/5 Stage II and 5/7 Stage III. Recurrence is pejorative since death occurs in all cases within an average of 6 months following salvage treatment, except for three patients still alive within less than 6 months and in second remission. Prognosis of ethmoidal cancer depends on staging and local control.

Esthesioneuroblastoma: the UCLA experience 1970-1990

A retrospective review was conducted of all esthesioneuroblastoma cases treated at UCLA Medical Center from 1970 through 1990. Patients were staged according to the staging systems of Kadish, et al., Biller, et al., and a new staging system proposed by the authors. Of 26 patients treated, 74% were alive at 5 years and 60% were alive at 10 years. Combined treatment with surgery and radiation is advocated since a recurrence-free status was achieved in 92% of the patients, compared with 14% for surgery alone and 40% for radiation alone. A craniofacial resection was performed in 7 patients, all of whom have remained disease free. Negative prognostic factors included: age over 50 years at presentation, female sex, tumor recurrence, and metastasis. The proposed new staging system predicted disease-free status better than the other staging systems.

[Neuroepithelial tumors in the pediatric population]

We have studied the neuroepithelial tumors in childhood, about their epidemiological, clinical and histological aspects, the macroscopic tumoral structure and the findings obtained by magnetic resonance imaging. We stress the differential diagnosis features among the various tumoral types, based on bibliography and our own clinical experience.

Olfactory neuroblastoma--management of a rare tumour at the Queensland Radium Institute and literature review

Olfactory neuroblastoma (esthesioneuroblastoma) is an extremely rare tumour arising from the olfactory epithelium of the nasal cavity close to the cribriform plate. Most institutions will have little experience in recognising the clinical and histological features, or management of this tumour and reliance is placed on researching the literature when the individual patient presents. This study reviews seven patients with olfactory neuroblastoma treated at the Queensland Radium Institute from 1971 to January 1990. The overall local control rate in this series is 57% (four of seven patients) and 43% of patients (three of seven) remain alive. Conservative surgery and post-operative radiotherapy is recommended for early disease and more radical surgery with post-operative radiotherapy for advanced disease.

Olfactory esthesioneuroma: a report of 40 cases

Olfactory esthesioneuroma is a rare malignant tumor arising in the olfactory epithelium. Forty cases observed at the Institut Gustave-Roussy from 1956 to 1987 are reported. This tumor usually grows slowly and is usually local, but it is important to be aware of the possibility of lymph node involvement (17%) and, particularly, of rapid development of distant metastases (25%), usually within 6 months. CT scan, and more recently, NMR have proved to be of value in choosing the surgical approach. In view of the usual point of departure, a combined neurosurgical and transfacial approach seems to be a satisfactory approach for obtaining oncological control of the lesion. The role of chemotherapy is discussed. The main prognostic factors seem to be the size of the lesion, the intracranial extension, and the lymph node involvement.

Malignant teratoid medulloepithelioma in an adult

A 50-year-old man presented with a reddish, well-vascularized mass in the region of a nasal iridodialysis of his left eye, pushing the whole iris in this sector forwards; the mass had a pinkish, partly cystic appearance in the pupil. The tumour was transparent on diaphanoscopy. A-scan sonography revealed a solid tumour of the ciliary body with partial retinal detachment suggesting a malignant melanoma. Fluorescein biomicroscopy did not confirm this suspicion. The enucleated eye demonstrated a malignant teratoid medulloepithelioma of the whole nasal and lower ciliary body, infiltrating the deep iris stroma, the anterior choroid, the neighbouring vitreous body and spreading along the inner retinal surface back to the equator of the eye. The occurrence of medulloepithelioma in adult and senior persons is rather exceptional and this is the reason for this publication.

Olfactory esthesioneuroblastoma

Esthesioneuroblastomas are malignant tumours, usually of slow, invasive growth and low metastatic rate. Skeletal destruction must be assumed to be common, but is often demonstrable only by tomographic sections. Clinically these tumours do not differ from others of the same site, so that the diagnosis has to be based upon the histological appearances. In the light microscope the presence of neurofibrils is considered a specific differential diagnostic factor against other small-cell malignant tumours in this region. There seems to be no basis for a morphological classification into previously described sub-groups, neither according to histogenetic, light, nor ultra-microscopic findings. The general degree of differentiation and the number of mitoses appear to be the main factors of prognostic significance. Combined irradiation and surgical excision is considered the best treatment.