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.

Congenital Retroperitoneal Teratoma in Neurofibromatosis Type 1

Neurofibromatosis type 1 (NF1) is caused by mutations in the tumor suppressor gene NF1. The increased tumor risk in affected individuals is well established, caused by somatic biallelic inactivation of NF1 due to loss of heterozygosity. Pediatric teratoma has not been reported in individuals with NF1 previously. We report a case of congenital teratoma in an infant with a heterozygous maternally inherited pathogenic NF1 mutation (c.[1756_1759delACTA] and p.[Thr586Valfs*18]). We detected a "second hit" in the form of mosaic whole NF1 deletion in the tumor tissue using multiplex ligation-dependent probe amplification, as a proof to support the hypothesis of NF1 involvement in the pathogenesis of teratoma.

[Opsoclonus-myoclonus syndrome in a 2 year old boy with prenatally diagnosed retroperitoneal tumour]

Opsoclonus-myoclonus syndrome, also named Myoclonic Encephalopathy of Infants, Opsoclonus- Myoclonus Ataxia, Dancing Eyes - Dancing Feet Syndrome, Dancing Eyes Syndrome, Kinsbourne syndrome, is a rare, paraneoplastic or possibly post-viral chronic neurological disorder. The age of presentation ranges from 6 months to 3 years. In 50% of affected children the syndrome is associated with an underlying occult or clinically apparent neuroblastoma. In most patients the tumour is localized, small and well differentiated, with no NMYC gene copy number amplification. The syndrome may also occur after tumour resection or at relapse. The opsoclonus-myoclonus syndrome can occur in children without neuroblastoma, in such idiopathiccases, the onset of neurological symptoms is related to infection. It is assumed, that in idiopathic cases the syndrome could have developed in the course of neuroblastoma which had undergone a complete spontaneous regression. The most characteristic clinical features of opsoclonus-myoclonus syndrome are: opsoclonus, myoclonus, ataxia, irritability, mutism and sleep disturbances. The disease course is usually long-term with episodes of remission and relapses. Approximately 80% of children with opsoclonus-myoclonus syndrome suffer from mild to severe neurological handicaps, mainly cognitive impairment. The authors present a 2-year old boy with opsoclonus-myoclonus syndrome preceded by involution of prenatally documented retroperitoneal area tumour.

Extragonadal teratomas presenting at birth and originating from 3 different sites--a report of 3 cases

Three cases of extragonadal teratomas presented at birth and all the cases arisen from three separate sites are reported in the present study. A huge sacrococcygeal teratoma is being reported and the other two retroperitoneal and nasopharyngeal teratomas, are reported for the rarity of their location in neonatal period. Teratomas of all three babies were mature benign on histopathology and surgical removal sufficed as mode of treatment. No recurrence was noted on follow-up.

Congenital fibrosarcoma with a novel complex 3-way translocation t(12;15;19) and unusual histologic features

Congenital mesenchymal tumors are diagnostically challenging as they are rare and may feature overlapping patterns between several benign, low-grade, and tumors of intermediate malignancy, including myofibromatosis, myofibroma/hemangiopericytoma, congenital fibrosarcoma, and inflammatory myofibroblastic tumor. Their immunophenotype is either silent or minimally expressive, and their ultrastructural features are generically consistent with "fibroblastic/myofibroblastic" differentiation. Cytogenetic analysis allows refined diagnoses, improved classifications, and bettering of our therapeutic armamentarium. However, genotype/phenotype correlations continue rendering novel findings that must be examined for their potential value in diagnosis and treatment. We describe a retroperitoneal congenital fibrosarcoma with an unusually bland histopathology and novel 3-way t(12;15;19) translocation involving chromosome bands 12p13.2, 15q25.3, and 19p13.1, associated with trisomies 8, 11, and 20. Fluorescence in situ hybridization showed one fusion signal in the normal chromosome 12p13.2 and break-apart 3'ETV6 and 5'ETV6 signals in the rearranged 12p13.2 and 15q25.3, respectively. The importance of molecular diagnosis and genotype-phenotype correlations is emphasized.

Congenital Ewing sarcoma in retroperitoneum with multiple metastases

A 7-day-old Japanese female showed the absence of spontaneous movement in her both legs. MRI revealed tumors in the retroperitoneum invading into the spinal canal, the left cerebral hemisphere and the right eyeball. Histological examination of retroperitoneal tumor revealed the sheets of undifferentiated small round cells with hyperchromatic nuclei and scanty cytoplasm. EWS-FLI1 fusion gene was detected by RT-PCR, indicating Ewing sarcoma. She received chemo-radiotherapy and survived for 2 years and 10 months despite the multiple metastases at initial presentation.

Retroperitoneal enteric duplication cyst presenting as a pancreatic cystic lesion. A case report

CONTEXT

Retroperitoneal enteric duplication cysts (EDC) are rare lesions and its presentation during adulthood is a diagnostic challenge for clinicians. The diagnosis of this condition is established following histopathological analysis, which often requires surgical intervention.

CASE REPORT

We report a case of a retroperitoneal enteric duplication cysts, presenting as a cystic lesion of the pancreas in a 19-year-old woman.

CONCLUSIONS

We recommend surgical intervention for retroperitoneal EDCs due to its potential local complications including pressure effects on surrounding structures and neoplastic change.

[Ganglioneuroma in a newborn with early inborn syphilis]

A case is reported of a retroperitoneal sympathic nodes ganglioneuroma in a newborn with classic early inborn syphilis involving practically all systems of the viscera, skin, placenta. Some peculiar morphological features of the tumour are described. Possible teratogenic and oncogenic effects of treponema pallidus on embryonal fetal structures during intrauterine development are suggested.

Blutung in ein kavern�ses retroperitoneales Lymphangiom nach stumpfem Bauchtrauma

The case of a 12-year-old boy with hemorrhage into a previously unknown retroperitoneal lesion following blunt abdominal trauma is reported. Diagnostic work-up of a post-traumatic surgical acute abdomen revealed a giant multicystic tumor in the retroperitoneum, which could be completely removed. Histological examination confirmed the suspected diagnosis of congenital lymphangioma. Attention should be drawn to the possible coincidence of trauma and a preexisting asymptomatic lesion. Knowledge of the characteristic ultrasonographic and computer tomographic features is essential in order to make a correct diagnosis.

Congenital neuroblastoma mimicking early onset sepsis

A newborn girl presented with symptoms of severe early onset sepsis but also with systemic hypertension (SH) at age 3 h. Plasma catecholamine (CAT) levels were extremely elevated, reflecting increased release of CAT from a congenital neuroblastoma (NB). Clinical symptoms at time of admission were: prolonged capillary refill (5 s), tachycardia, tachydyspnoea, metabolic acidosis (pH 7.17, lactate 11.8 mmol/l), fever (38.4 degrees C) and SH: 90/50/65 mmHg (systolic/diastolic/mean). The infant experienced organ failure (lung, heart, liver). A retroperitoneal dumbbell tumour was detected. Plasma CAT levels at age 15 h were: noradrenaline 219 nmol/l; adrenaline 13 nmol/l; and dopamine 65.3 nmol/l. SH responded to intermittent alpha-adrenergic blockage. CAT-related symptoms ceased within 1 week. The intraspinal NB was surgically removed when cord compression became symptomatic. The neurological and developmental state is normal at age 17 months. The abdominal NB regressed spontaneously.

CONCLUSION

A neuroblastoma should be considered in newborn infants presenting with a shock-like condition together with systemic hypertension.

Features and outcome of neuroblastoma detected before birth

BACKGROUND/PURPOSE

The growing use of routine ultrasonography during pregnancy is leading to an increasing number of prenatally diagnosed neuroblastomas. Optimal strategy has not yet been defined for these patients, because knowledge on this particular neuroblastoma (NB) population is still limited. However, definite guidelines are needed to avoid inadequate treatment. The authors analyzed the cases of antenatally detected NB (ADNB) reported in the Italian Neuroblastoma Registry during the past 6 years to elucidate the features of this subset of NB.

METHODS

The Italian Neuroblastoma Registry was reviewed for the period January 1993 to December 1998 to collect clinical, radiographic, surgical, and histopathological data on ADNB cases. NB stage was evaluated according to INSS criteria. All patients had undergone imaging (computed tomography or magnetic resonance imaging) of the primary tumor and bone marrow biopsy before surgical resection.

RESULTS

Seventeen patients were identified. Primary tumour site was adrenal glands in 16 cases and retroperitoneal ganglia in 1. Stage distribution was stage I, 13 cases; stage II-A, 1 case; stage II-B, 1 case; stage IV-S, 2 cases. All cases underwent primary tumour resection. Mean age at surgery was 4 weeks. Resection of primary tumor was radical in 16 cases, partial in 1. All tumors were characterised by favourable histology according to Shimada classification. N-myc gene amplification was studied in 14 patients. N-myc amplification was detected only in a newborn with stage II-A NB, who died of massive bleeding 2 days after tumor resection. DNA index and 1p deletion were studied in 11 and 8 patients, respectively. Both diploidy and deletion of 1p were observed in a newborn who subsequently died of disease progression despite surgery, chemotherapy, and radiation therapy. Fourteen of 17 patients currently are alive and free of disease, and one with IV-S NB and short follow-up is alive with disease.

CONCLUSIONS

Our data give evidence that in most cases infants with ADNB represent a subset of patients with excellent outcome. Aggressive treatment may not always be necessary. Infants with ADNB with unfavorable features should undergo early surgical excision, whereas patients with favourable features could be observed awaiting spontaneous regression of the mass, reserving delayed surgery for tumors that increase in size or do not regress.

Congenital retroperitoneal tumour: rhabdomyoma or rhabdomyosarcoma?

This case report demonstrates the difficulties experienced by pathologists when confronted with a tumour that is not typical of either a benign tumour or its malignant counterpart and adds to the rapidly growing list of conditions diagnosed by means of antenatal ultrasonography.

Case report: congenital retroperitoneal fibrosarcoma

We report a case of congenital retroperitoneal fibrosarcoma presenting in a 17-day-old male in which surgical tumor debulking was followed by chemotherapy. His clinical course was complicated. Intraoperatively, 80% of the tumor was removed and he experienced massive blood loss and significant cardiac arrhythmias. Following surgery he received chemotherapy and suffered life-threatening hepatic, hematological and gastrointestinal toxicity. The treatment resulted in clinical remission after 9 months of follow-up. A review of the current literature revealed the changing opinion of the optimal treatment of fibrosarcomas in children. Chemotherapy is playing an increasingly important role in the treatment of fibrosarcoma, both preoperatively and postoperatively.

Clonal analysis of sacrococcygeal "teratomas"

Congenital masses of the sacrococcygeal region commonly contain multiple tissues and have variously been subclassified as neoplasms or congenital hamartomas based on clinicopathological and embryological observations. We have used a polymerase chain reaction-based assay for nonrandom X chromosome inactivation to infer the clonality of three cogenital sacrococcygeal tumors previously diagnosed as teratomas. One solid immature teratoma was monoclonal, and a predominantly cystic histologically mature mass was polyclonal. A third immature teratoma was noninformative because of baseline asymmetry of polyclonal tissue X inactivation. We confirm that immature teratomas at this site appear to be monoclonal neoplasms and suggest that at least some histologically mature "teratomas" are more appropriately classified as hamartomas.

[A peculiar abnormality of the fallopian tube: induced by embryonic kidney tumor?]

A 17-year-old female with severe pain of the midabdomen was found to have a retroperitoneal cystic tumor, an ectopic ovary and a fallopian tube without fimbriated end. An attempt is made to determine whether these early embryonic malformations could be traced to a common origin. This is possible provided that the tumor is regarded as a mesonephroma. A histological study of the normal development of the Mullerian duct was performed utilizing human embryonic series. Previous development theories and more recent investigations are discussed. Malformations of the tube described in the literature and possible etiologies are summarized.

Nuclear magnetic resonance computerised tomography (NMR-CT) in early diagnosis of dumbbell neuroblastoma

This is a report on a dumbbell neuroblastoma with intraspinal extension first noted by 99mTc-HMDP imaging and CT, and confirmed by NMR-CT before the symptoms of spinal cord compression become clear. Paravertebral neuroblastoma and its intraspinal involvement were successfully excised following laminectomy and abdominal surgery without any residual neurologic complications. We report this case to emphasise that NMR-CT was particularly useful to diagnose the extent of intraspinal portion of the tumour, and should be performed in any patient who presents with neuroblastoma adjacent to the vertebral body.

Paratesticular metastases from congenital retroperitoneal tumor

A retroperitoneal tumor was removed from a fifteen-day-old infant. Light microscopy revealed a teratoma consisting mainly of immature nervous tissue. Three months later the patient had recurrence and numerous peritoneal metastases showing a histologic pattern similar to that of the primary tumor. Twelve months later there was enlargement of the left testis due to metastases from teratoma infiltrating the tunica vaginalis of the left testis, the epididymis, and the spermatic cord. These metastases consisted of mature neurons and glial cells. The early dissemination of the tumor suggests an intracavitary spread pattern. The tumor maturation in paratesticular structures suggests that mesothelial cells are involved in the differentiation of tumoral germ cells.

The association of congenital neuroblastoma and congenital heart disease. Is there a common embryologic basis?

Several authors have reported an association between neuroblastoma and congenital heart disease; others contend that, unlike specific well-known associations between malignancy and congenital defects (Wilm's tumor and aniridia, leukemia and Down's syndrome), no real relationship exists. We present three cases of cyanotic congenital heart disease in which subclinical neuroblastoma was found. We speculate that abnormal neural crest cell migration and development may be a common link between cardiac malformations and congenital neuroblastoma.

Neonatal hypertension and cardiomegaly associated with a congenital neuroblastoma

A neonate who died 12 days after birth from complications related to a congenital neuroblastoma is described. Hypertension and congestive heart failure occurred soon after birth. Hospital course was marked by a consumptive coagulopathy and the development of acute renal and hepatic failure. At autopsy the heart was hypertrophied but normally formed. Although there was elevated urinary excretion of vanilmandelic acid and homovanillic acid, levels of epinephrine, norepinephrine, metanephrine, and normetanephrine were not documented. This case shows that a congenital neuroblastoma may be associated with hypertension and cardiomegaly in the neonatal period.

Congenital fibrosarcoma: a congenital fibrous histiocytoma

Using immunoperoxidase PAP technique in 2 cases of congenital fibrosarcoma, a great number of cells showed positive stain for alpha-1-antitrypsin (A1AT) and alpha-1-antichymotrypsin (A1ACT), both considered to be good histiocytic markers. The ultrastructure in 1 case also provides evidence of histiocytic differentiation. These findings suggest that congenital fibrosarcomas are actually congenital fibrous histiocytomas and may explain the presence of inflammatory infiltrates as in some malignant fibrous histiocytomas.

Neonatal neuroblastoma metastatic to the iris

A newborn infant was found to have Stage IVS retroperitoneal neuroblastoma. Multiple iris nodules were present at birth and regressed in synchrony with the primary tumor mass as chemotherapy was administered. A summary of the ocular manifestations of neuroblastoma is presented. A discussion of the possible significance of the iris lesions in this case is given. As far as we are aware, this is the first case report of neuroblastoma metastatic to the iris.

[Retroperitoneal neuroblastoma diagnosed in utero. Apropos of 1 case]

The authors present a rare case of a retroperitoneal neuroblastoma discovered during a routine pregnancy check in the 29th week of amenorrhea and showing up as a 1.4 cm dia. hyperechoic nodule. A follow-up sonogram, obtained one month later, showed the lesion had increased in size. Following birth, the diagnosis was confirmed during surgery. The overwhelming importance of early diagnosis of this tumor for a favorable prognosis points out the value of systematic examination of the suprarenal regions of the foetus in the course of the last U.S. examination during pregnancy.

Retroperitoneal lipoma in children

A case of retroperitoneal lipoma in a 23-mo old girl is reported together with a brief review of the 11 previously documented cases. It has been encountered through age 8 yr and twice as frequently in girls. The majority had an enlarged abdomen of long duration. The others were asymptomatic and found incidentally or at the time of examination for abdominal pain. Most lipomata were large. The possibility of their being congenital cannot be excluded. None have recurred.

Congenital retroperitoneal hemangioendothelioma with Kasabach-Merritt syndrome

This is the first documented congenital retroperitoneal hemangioendothelioma. The patient presented at birth with a retroperitoneal mass and thrombocytopenia. Postmortem examination revealed the tumor to be a hemangioendothelioma, arising from the posterior abdominal wall. The association of an angiomatous tumor will thrombocytopenia represents the Kasabach-Merritt syndrome.

Congenital neurogenous sarcoma with rhabdomyosarcomatous differentiation

A congenital malignant peripheral nerve sheath tumor contained small rhabdomyosarcomatous portions in both the retroperitoneal pelvic primary and in the subpleural lung metastasis. There was no family history of Von Recklinghausen's disease. Of the 10 patients with this tumor previously reported, the youngest is 14 yr old, and eight had familial neurofibromatosis.