Primitive neuroectodermal tumor arising from an untreated congenital undescended testicle

A 26-year-old male with a personal history of schizophrenia initially presented with a 13 cm pelvic mass corresponding to a cryptorchidic testis. The patient was treated with primary and second-line chemotherapy for metastatic germ-cell tumor followed by surgical consolidation. Final pathology revealed a primitive neuroectodermal tumor (PNET) mixed with mature teratoma. Despite multidisciplinary management, significant patient non-compliance led to inadequate follow up and treatment delays ultimately resulting in death. To our knowledge, this is the only reported case of teratoma with malignant transformation arising from an untreated congenital undescended testicle.

Ewing's sarcoma/primitive neuroectodermal tumor arising from the adrenal gland: a case report and literature review

We report a rare case of Ewing's sarcoma (ES)/primitive neuroectodermal tumor (PNET) arising from the adrenal gland. A 17-year-old Japanese woman presented with left upper abdominal pain and high fever. Computed tomography and magnetic resonance imaging revealed a 15 × 10 cm tumor replacing the adrenal gland. Preoperative diagnosis was an adrenocortical carcinoma. Resection of the tumor was performed. We obtained the final diagnosis of ES/PNET by immunohistochemical molecular study with positive staining for the MIC2 gene product (CD99) and a Ewing sarcoma breakpoint region 1 (EWSR1) gene rearrangement. Local recurrence was observed one month after the surgery. The patient was then treated with systemic chemotherapy and localized radiotherapy.

Peripheral Primitive Neuroectodermal Tumour (pPNET) in the cervical spine

Primary spinal primitive neuroectodermal tumours are rare. We present a 45-year-old man with a peripheral primitive neuroectodermal tumour arising in the cervical spine. We believe this to be the first report of this type of tumour in the cervical spine.

Familial Currarino syndrome presenting with peripheral primitive neuroectodermal tumour arising with a sacral teratoma

This report illustrates a rare genetic disorder, Currarino syndrome, in association with an unusual malignant transformation to a peripheral primitive neuroectodermal tumour within a sacral teratoma. The triad of features consists of a presacral mass, partial sacral agenesis and anorectal anomalies. The most common presentation is constipation. In this case there was a history of constipation, teratomas and spinal abnormalities in many of the family members over three generations. Detailed family history taken at time of initial presentation may have prevented delay in diagnosis and averted the need for intensive treatment, which may well cause late sequelae.

A Case Report of an Uncommon Cause of Cauda Equina Symptoms

OBJECTIVE

This case report discusses a patient who presented with right-sided buttock pain of apparently uncomplicated mechanical origin that was eventually diagnosed as a primary Ewing sarcoma/primitive neuroectodermal tumor of the sacrum.

CLINICAL FEATURES

A 32-year-old male full-time student presented for care with right-sided buttock pain.

INTERVENTION AND OUTCOME

After examination, the patient was referred to his general practitioner for urgent magnetic resonance imaging, the report revealed no explanation for the presenting symptoms. After further imaging and biopsy, an eventual diagnosis of Ewing sarcoma/primitive neuroectodermal tumor was reached. The patient died 12 months later.

CONCLUSION

This case highlights a nondiscal cause for cauda equina symptoms. It emphasizes potential diagnostic complexities that may present due to preconceptions based upon the probability of symptoms being related to a specific disease process.

Primary intracranial peripheral primitive neuroectodermal tumor/Ewing's sarcoma presenting with acute intracerebral hemorrhage

OBJECTIVE

To report two cases of intracerebral hemorrhage due to primary intracranial peripheral primitive neuroectodermal tumor (pPNET)/Ewing's sarcoma (ES) and review of related literatures.

MATERIAL

Two cases of 17-year-old patients presented with acute increased intracranial pressure one of which also had left hemiparesis.

METHOD

On neuroimaging studies, the first patient had an intraparenchymal hematoma with a size of 4 cm at the right fronto-parietal junction adjacent to tumor infiltrating the superior sagittal sinus. The second patient had a large left temporal tumor with intraventricular hemorrhage. Both patients underwent craniotomy with complete removal of tumor and hematoma.

RESULTS

Pathological examination in both cases revealed numerous small round tumor cells with stippled chromatin pattern and scanty cytoplasm. Tumor cells strongly expressed CD99. Vimentin immunoreactivity was observed. The final diagnosis of pPNET/ES was rendered. There was no evidence of extracranial disease in both cases. Both patients were doing well without evidence of recurrent disease at 12 and 24-month follow-up respectively.

CONCLUSIONS

Peripheral primitive neuroectodermal tumor (pPNET)/Ewing's sarcoma (ES) is a malignant small round cell tumor, commonly arising in soft tissue of the trunk and lower extremity. Those occurring in the intracranium are rare, and most patients present with progressively increased intracranial pressure and/or cranial nerve deficit. The occurrence of intracerebral hemorrhage due to primary intracranial pPNET/ES is exceedingly rare. The role of adjuvant therapy in this condition is yet to be investigated.

[Solid tumours of the vertebral column and spinal cord in children. Reasons and consequences of diagnostic delay]

INTRODUCTION

Primary or secondary tumours of spinal cord and vertebral column have various histological structure, various degree of malignancy and various growth dynamics. Such localisation of neoplastic disease creates problems, connected with the risk of irreversible damage of neurological functions. It is essential to make a proper diagnosis very early.

AIM

An analysis of initial clinical symptoms and reasons for diagnostic delay in children with neoplasms of the vertebral column and spinal cord. This can facilitate and accelerate diagnostic and therapeutic process.

MATERIAL AND METHODS

20 children treated from 1994 to 2004 in Department of Paediatrics, Haematology, Oncology and Endocrinology in the Medical University of Gdańsk, were investigated. Patients were divided into 2 groups. In group I, there were 11 children with neuroblastoma and peripheral primitive neuroectodermal tumour (PNET). The primary focus of the neoplasm was localised beyond the vertebral column with secondary infiltration of the spinal cord. Nine children were included in-group II, with primary focus in the spinal cord: glioma (2), ependymoma (1), meningioma (1) and localised in bones of the vertebra: osteosarcoma (2), chondrosarcoma (1), Ewing sarcoma (1) and those eosinophilic granuloma (1). Patients were admitted to hospital late. In group I, advanced stage of disease (III and IV) was found in 5, and stage IV in 6 children. In the early stage of the disease in-group II, pain and neurological symptoms were predominant. Duration of symptoms was longer than in-group I. It was from 6 weeks to 12 months. In both groups diagnostic delay was noted in 13 out of 20 patients.

RESULTS

In spite of using obligatory treatment protocols diagnostic delay contributed to permanent neurological complications in 65% of patients.

Emergency department presentations of a rare tumor--extraosseous cervical paraspinal Ewing's sarcoma

We report the case of a 9-year-old boy who presented to our community-based Pediatric Emergency Department with complaints of neck pain, stiffness and upper extremity weakness. The symptoms were later identified to be due to cervical extraosseous paraspinal Ewing's sarcoma. The patient had a fatally aggressive clinical course. Cervical extraosseous Ewing's sarcoma is rarely reported in pediatrics. Ewing's sarcoma should be considered in the differential diagnosis of children presenting with complaints of unremitting or recurring non-specific back or neck pain or neurological deficits. Appropriate diagnostic evaluation and treatment should be actively pursued.

Response of hypothalamic NPY mRNAs to a negative energy balance is less sensitive in cachectic mice bearing human tumor cells

We selected three human cancer cell lines [human melanoma (SEKI), human melanoma (G361), and human neuroepithelioma (NAGAI)] that have an ability to develop cancer cachexia syndrome with and without accompanying anorexia and examined the hypothalamic levels of mRNAs for neuropeptide Y (NPY), melanin-concentrating hormone, and orexin. The body weight of sham-operated mice continued to increase, while mice of all tumor-bearing groups lost weight. Competitive reverse transcription-polymerase chain reaction analysis showed that, regardless of feeding status, NPY mRNA levels were elevated in all tumor-bearing mice compared with sham-operated mice, although to a lesser degree than weight-matched pair-weight mice. Melanin-concentrating hormone and orexin mRNA in the hypothalamus followed the same pattern as NPY, although most of the differences did not reach statistical significance. These results support the notion that the response of NPY mRNA to a negative energy balance is less sensitive in these rodent models of cancer cachexia.

[Askin tumor: two cases]

Askin tumor is uncommon, usually observed in young subjects. We report two cases of Askin tumor observed in patients aged 15 and 27 years who were hospitalized for a painful tumefaction of the chest wall with pleural involvement in one patient. We reviewed progress in patient management which has resulted from better understanding of the natural history of Askin tumor and earlier diagnosis due to advances in imaging and immunohistochemistry techniques as well as cytogenetics. A number of points remain controversial.

Exercise-induced spontaneous hemothorax insinuates trauma; yet unmasks a lament disorder

The investigation for a plausible explanation of the development of massive spontaneous hemothorax during exercise in two patients led to the disclosure of two different malignancies. The first patient (pleural fibrosarcoma) passed away shortly after diagnosis. The second patient is alive without signs of disease (peripheral neuro-ectodermal tumor, PNET) since the diagnosis was made 3 years before. Spontaneous hemothorax (SH) arising during exercise does not exclusively designate trauma and full search for anatomical abnormality is warranted.

Peripheral primitive neuroectodermal tumor of the small bowel mesentery: a case showing perforation at onset

A case of peripheral primitive neuroectodermal tumor of the small bowel mesentery with an uncommon clinical onset is reported. A 40-year-old man was admitted to hospital because of acute severe abdominal pain. Chest X-ray revealed a free air sign beneath the diaphragm. At emergency surgery a mass measuring 11.0 x 8.0 cm with perforation was located in the jejunal mesenteric region. Histologically the resected lesion consisted of sheets of undifferentiated small round cells forming abortive Homer Wright rosettes. Some spindle-shaped cells showed perivascular pseudorosettes. Immunohistochemical study revealed that the tumor cells expressed positivity against CD99 (MIC2), neuron-specific enolase, synaptophysin and vimentin. To the authors' knowledge this is the first documentation of peripheral primitive neuroectodermal tumor of the small bowel mesentery with perforation at onset.

Supratentorial primitive neuroectodermal tumor in children: clinical features, treatment outcome and prognostic factors

To investigate clinical features, treatment outcome and prognostic factors of pediatric supratentorial primitive neuroectodermal tumors(ST-PNETs), 28 ST-PNET cases were retrospectively analyzed. The prognostic importance of age, sex, size of tumor, M stage, extent of surgical resection, histological features, immunohistochemical labelling indices (Ki-67, p53), and apoptotic index were assessed. The mean age at diagnosis was 6.8 years, and the male-to-female ratio was 18:10. The presenting symptoms in 22 cases were increased intracranial pressure and focal neurological deficits. Gross total resection was achieved in 17 cases, near-total (>90%) resection in 3, and subtotal in 7; biopsy was performed in 1 case. The mean duration of follow-up was 37 months. For 25 patients who completed planned adjuvant therapy, the 3-year survival rate was 73%. Univariate analysis showed that the presence of tumor necrosis (P=0.002) and extent of resection (P=0.04) correlated with survival. Patients with a high Ki-67 labelling index (>10%) tended to have shorter survival (P=0.095). In multivariate analysis, tumor necrosis showed statistical significance(P=0.03).

[Plastic repair of a defect in the base of the skull with soft tissues from the orbit after the removal of an extensive esthesioneuroepithelioma]

The paper describes a clinical observation of closure of sphenoidal sinus defect and plastic repair of dura mater by using orbital tissues after removal of a tumor from the medial portions of the middle cranial fossa, which spread into the orbit and sphenoidal sinus, in complete irreversible loss of visual function, ophthalmoplegia and ptosis in a patient with skull soft tissue hypotrophy due to multiple operations and radiation therapy and hence unsuitable for displacement and closure. This observation shows it possible to use orbital soft tissue for repair of the base of the skull, in cases when integumentary cranial tissues are impossible to use as a plastic material due to their hypotrophicity. At the same time severe dysfunctions, such as blindness and ophthalmoplegia enable orbital tissues to be employed without significantly deteriorating any functional and cosmetic effect.

Surgical treatment of intractable epilepsy originating from the primary sensory area of the hand--case report

A 14-year-old right-handed girl presented with intractable epilepsy originating from the primary sensory area of the hand, manifesting as sensory partial seizures in the left hand with secondary generalization. Neurological examination showed no abnormal findings. Magnetic resonance imaging, magnetoencephalography, and cortical stimulation using chronic subdural electrodes demonstrated a lesion located in the primary sensory cortex of the hand, in which the ictal onset zone was identified by 24-hour intracranial electroencephalographic recording. Surgical resection of the lesion and multiple subpial transections of the adjacent cortices were performed. The histological diagnosis was dysembryoplastic neuroepithelial tumor (DNT). She was completely free of seizures without permanent sensory deficits postoperatively. DNT located in the primary sensory hand area may be resectable without causing postoperative sensory deficits, if accurate functional mapping and surgical resection are performed.

Psychosis after resection of ganglioglioma or DNET: evidence for an association

PURPOSE

David Taylor and Murray Falconer suggested that some patients may develop a psychotic illness after resection of a ganglioglioma that led to intractable seizures. They implied that the mechanism of this association remained unclear. This concept is currently not universally accepted (M. Trimble, personal communication).

METHODS

We studied six children or young adults from four centers who developed psychosis after resection of a ganglioglioma or dysembryoplastic neuroepithelioma (DNET).

RESULTS

All patients were operated on because of intractable epilepsy. The lesions involved mainly the temporal lobe. Patients had good outcomes for seizure control. In none of the six was potentially psychogenic medication used nor were the psychotic symptoms postictal in nature. The psychosis was schizophreniform with paranoid features and prominent depressive symptoms. Although some behavioral abnormalities were described preoperatively, none had been psychotic before operation. This type of psychotic reaction was not encountered in the four centers in a comparable period after resection of other types of lesions. This complication is rare; it occurred in only one of 39 patients who had such a lesion resected.

CONCLUSIONS

Psychotic illness may rarely occur after resection of a ganglioglioma or DNET for treatment of intractable epilepsy. This does not seem to occur after removal of other types of lesions. Because the patients had good outcomes for seizures, the mechanism may be related to "forced normalization." The original observations of Taylor and Falconer are confirmed by this study; the reasons for the selective occurrence, however, remain speculative.

Infratentorial dysembryoplastic neuroepithelial tumor (DNT) associated with Arnold-Chiari malformation

Dysembryoplastic neuroepithelial tumor (DNT), a benign neoplasm, is now a well recognized clinicopathological entity. We report the second case of DNT in the cerebellum occurring in a 20-year-old male presenting with ataxia. He also had Arnold-Chiari malformation of the adult type. Histologically the tumor was a "simple" DNT having the specific "glioneuronal" element, namely oligodendrocyte-like cells (OLCs), mucoid change and floating neurons (Purkinje cells). A striking feature was the perpendicular arrangement of the neuropil columns extending from the pial surface to white matter similar to those seen in supratentorial examples. On immunstaining some of the OLCs were positive for synaptophysin and negative for glial fibrillary acidic protein (GFAP), glucocerebroside, tau and MAP-2. The neuropil was synaptophysin-positive and focally positive for MAP-2 and GFAP as well. The Purkinje cells were morphologically normal but malaligned and were positive for phosphorylated neurofilament suggesting secondary dysplastic changes. A transition of the lesion into relatively normal cerebellum preserving the folial architecture was observed. The histological and immunochemical features of the DNT in cerebellum suggests its possible origin from the pluripotential external granular layer.

Brain abscesses in children with cancer

BACKGROUND

Brain abscesses in pediatric patients are rare events, and the causative organism and prognosis vary with the population under study. Children with cancer seem to be particularly susceptible to the development of brain abscesses because of the immunological changes induced by cancer and its treatment. We reviewed the records of children who developed a brain abscess during treatment of a malignancy to define the clinical characteristics, prognosis, and management of these patients.

PROCEDURE

We performed a retrospective review of the clinical and laboratory characteristics of all cancer patients younger than age 20 years who were admitted to our institution between 1980 and 1996 for a brain abscess.

RESULTS

Twelve children were identified. Cancer diagnoses were brain tumor in two, systemic PNET in two, and leukemia in eight. Six patients had multiple abscesses. Eleven received prior chemotherapy. Abscesses were surgically excised or aspirated in seven, and empiric antibiotics were given to the other five. At surgery, Listeria monocytogenes, Aspergillus fumigatus (3), Fusarium, and Candida lusitanea were cultured. Aspergillus was identified in other locations in four patients. Abscesses were successfully treated in seven patients, two of whom received antibiotics only; five patients (42%) died from infection.

CONCLUSIONS

Mortality is high in this immunosuppressed population, in part due to the preponderance of fungal infection. The finding of very rare organisms suggests that drainage and culture should be performed whenever possible; empiric antibiotics that include an antifungal agent may, on occasion, be successful.

Dysembryoplastic neuroepithelial tumors: MR and CT evaluation

PURPOSE

To evaluate dysembryoplastic neuroepithelial tumors (DNTs) on MR and CT studies and to compare DNT with other frequently encountered epileptogenic glioneuronal lesions.

METHODS

We analyzed the MR images and CT scans of 16 patients who had complex partial epilepsy and DNT with respect to tumor location, size, CT density, MR signal intensity, mass effect, contrast enhancement, and heterogeneity, and compared these features with CT and MR findings in 51 cases of ganglioglioma and 33 cases of glioneuronal malformation.

RESULTS

DNTs were located in the temporal lobe in 14 patients and in the frontal lobe in 2 patients. The cortex was involved in all cases and the subcortical white matter in 10 cases. Fifty percent of the tumors had poorly defined contours. On MR images, 14 DNTs had multiple cysts and 2 had single cysts. Contrast enhancement was observed in 6 DNTs, and mass effect was present in 9. CT scans disclosed moderately hypodense lesions in 7 patients and markedly hypodense cystic lesions in 6 patients. Two DNTs were calcified. Tumor hemorrhage with perifocal edema was observed in 1 case. Contrary to previous reports, slow but definite tumor growth was present during a 13-year period in 2 of 6 patients in whom serial CT or MR studies were obtained.

CONCLUSION

A multicystic appearance on MR images is a characteristic feature of DNT and corresponds to its myxoid matrix and multinodular architecture. This feature is rare in gangliogliomas and glioneuronal malformations, and, as such, may help differentiate DNTs from these disorders.