Malignant peripheral primitive neuroectodermal tumor-peripheral neuroepithelioma of the head and neck: a clinicopathologic study of five cases and review of the literature

Rare presentation in a rare case of pancreatic extraosseous Ewing's sarcoma: A case report

RATIONALE

Extraosseous Ewing's sarcoma is a rare tumor which is aggressive with poor prognosis; it can occur anywhere in the body, but scantily in the pancreas. Pancreatic Ewing's sarcoma is not reported commonly, with inconsistent clinical manifestations. In this regard, early recognition of this disease is very important for the patient's sake.

PATIENT CONCERNS

A 16-year-old boy presented with left lower quadrant abdominal pain for 2 months, and left flank pain with dysuria for 1 month.

DIAGNOSIS

Abdominal and renal ultrasonography found a mass between the spleen and left kidney as well as left renal pelvic dilatation. Abdominal computed tomography found a heterogenous mass derived from the tail of the pancreas. Serial examinations revealed that the mass was a pancreatic Ewing's sarcoma. Furthermore, no metastasis was documented.

INTERVENTIONS

The tumor was totally excised after 6 months of chemotherapy, which included 10 courses of neoadjuvant chemotherapy with vincristine, epirubicin, and cyclophosphamide, alternating with ifosfamide and etoposide. The patient completed consolidation chemotherapy with vincristine, epirubicin, and cyclophosphamide, alternating with ifosfamide and etoposide for 5 courses. Radiotherapy was applied to the tumor-involved region and tumor bed.

OUTCOMES

To date, the malignancy has not recurred since the treatment was completed 4 years ago. There are no complications from the treatment for the patient.

LESSONS

The pancreas is a very rare extraosseous location for Ewing's sarcoma. Pancreatic extraosseous Ewing's sarcoma should be regarded as a differential diagnosis of non-urinary originated left flank pain with dysuria in adolescents.

Head-and-Neck Solid Tumors in Children: A Retrospective Review from a Tertiary Care Institute in North India

Objectives

The aim of this study was to review the clinical profile, management, and outcome of solid tumors in the head-and-neck region in children at our institute.

Methods

We retrospectively reviewed children with head-and-neck solid tumors who were treated jointly under the departments of Pediatric Surgery and Otorhinolaryngology at our institute between 2016 and 2019.

Results

In the study period, 10 children (6 males, 4 females) with a median age of 9.5 years (range 5 days-16 years) were treated by our unit. The patients had four tumors arising from the parotid, 2 from nose/naso-pharynx, 1 each from the tongue, submandibular gland, para-pharyngeal space, and infratemporal fossa. A majority (90%) of the patients underwent complete surgical excision of the tumor, preserving the loco-regional neurovascular structures to minimize postoperative morbidity. Malignant lesions were seen in 4 patients (2 rhabdomyosarcoma, 1 primitive neuro-ectodermal tumor, 1 mucoepidermoid carcinoma) and 6 patients had benign pathology (3 pleomorphic adenoma, 2 mature teratoma, 1 schwanomma). Additional therapy with chemotherapy and local radiotherapy was required in 3 out of 4 patients with malignant pathology. The median follow-up duration is 15 months. At last follow-up, all patients are alive and 9 out of 10 patients (90%) are disease-free.

Conclusion

Our experience highlights rare and difficult tumors in the head-and-neck region in children. These tumors are not commonly managed by the pediatric surgeon in routine practice. The paper outlines the multi-modality management of these tumors, which is essential for an optimal outcome.

Small round blue cell tumors of the sinonasal tract: a differential diagnosis approach

One of the most challenging diagnostic categories within tumors of the sinonasal tract is the small round blue cell tumors. Biopsies are usually small and limited, resulting in considerable diagnostic difficulty for practicing surgical pathologists. These tumors share several overlapping histologic and immunophenotypic findings while also showing considerable variation within and between cases. Specific tumor site of origin, imaging findings, and clinical findings must be combined with the histology and pertinent ancillary studies if the correct diagnosis is to be reached. Discrimination between neoplasms is critical as there are significant differences in therapy and overall outcome. It is important to have a well developed differential diagnosis for this category of tumors, where each of the diagnoses is considered, evaluated, and either confirmed or excluded from further consideration. In an undifferentiated tumor, showing a small round blue cell morphology, using the mnemonic 'MR SLEEP' helps to highlight tumors to consider: melanoma, mesenchymal chondrosarcoma, rhabdomyosarcoma, sinonasal undifferentiated carcinoma, squamous cell carcinoma (including NUT carcinoma), small cell osteosarcoma, lymphoma, esthesioneuroblastoma (olfactory neuroblastoma), Ewing sarcoma/primitive neuroectodermal tumor, pituitary adenoma, and plasmacytoma. A panel of pertinent immunohistochemistry studies, histochemistries and/or molecular tests should aid in reaching a diagnosis, especially when taking the pattern and intensity of reactions into consideration.

Diagnostic imaging of benign and malignant neck masses in children-a pictorial review

Neck masses are frequently encountered in pediatric medicine, and can present a diagnostic dilemma for the clinicians involved. There are several means by which neck masses in children can be subdivided, for example by age at presentation, anatomical location including compartments and fascia of the neck, their classical appearance when imaged, or by etiology. When imaging children the clinicians must be mindful of radiation exposure and as such ultrasound (US) is often attempted first. Cross sectional imaging can be helpful for problem solving with CT being particularly useful for assessing the patient in more acute scenarios, for example when there is airway compromise. Nuclear medicine scintigraphy has a role in specific circumstances and can aid in staging in the presence of malignancy. If required, additional acquisition by means of magnetic resonance imaging (MRI) and computed tomography (CT) can be considered. This pictorial review describe the diagnostic imaging of (I) congenital and Developmental Pathologies, including thyroglossal duct cyst, branchial cleft cyst, cystic hygroma, dermoid cyst, thymic cyst and ectopic thymus; (II) neoplastic lesions, including hemangiomas and vascular malformations, pilomatrixoma, neurofibroma, neuroblastoma, rhabdomyosarcoma, papillary thyroid cancer, lymphoma & leukemia; (III) neck masses of Infective causes, including lymphadenitis, retropharyngeal and peritonsilar abscess, salivary gland inflammation; and (IV) other miscellaneous lesions, including ranula, sternocleidomastoid fibromatosis coli, and goiter. Neck masses are common in the pediatric population with a broad and varied differential; malignant etiologies are less frequently encountered when compared with adults but an awareness of its potential is important when reviewing imaging.

Multimodality Treatment in Ewing's Sarcoma Family Tumors of the Maxilla and Maxillary Sinus: Review of the Literature

The Ewing sarcoma family of tumors (ESFT) encompasses a group of highly aggressive, morphologically similar, malignant neoplasms sharing a common spontaneous genetic translocation that affect mostly children and young adults. These predominantly characteristic, small round-cell tumors include Ewing's sarcoma of the bone and soft tissue, as well as primitive neuroectodermal tumors (PNETs) involving the bone, soft tissue, and thoracopulmonary region (Askin's tumor). Extraosseous ESFTs are extremely rare, especially in the head and neck region, where literature to date consists of sporadic case reports and very small series. We hereby present a review of the literature published on ESFTs reported in the maxilla and maxillary sinus region from 1968 to 2016.

A peripheral primitive neuroectodermal tumor in the larynx: A case report and literature review

Primitive neuroectodermal tumors (PNETs) are malignant tumors comprised of small round cells of neuroectodermal origin. Current evidence indicates that peripheral PNETs (pPNETs), which arise in the non-central nervous system, possess histological similarity to Ewing's sarcoma. Though the occurrence of pPNETs in the head and neck region is rare, these are aggressive malignant tumors, and long-term survival rates following diagnosis remain poor. The current report presents a case of pPNET and evaluates its significance with regard to previous studies. In the present case, a tumor was located in the larynx of the patient, and was diagnosed as pPNET. Immunohistochemical analysis indicated that tumor cells were positive for cluster of differentiation 99. The patient was treated with surgery, multiagent chemotherapy and radiotherapy. Five years subsequent to treatment, the patient had survived and demonstrated no evidence of disease recurrence. In existing literature concerning pPNET located outside the head and neck region, it is recommended that patients are treated with a combination of resection with a wide surgical margin, multiagent chemotherapy and radiotherapy. The present case report concluded that the combination of surgery, systematic chemotherapy and radiotherapy, offers an improved outcome for pPNET localized to the head and neck region, compared with any of these therapies alone.

Nasal Cavity and Paranasal Sinuses

The nasal cavity and paranasal sinuses occupy the top of the upper respiratory tract and form pneumatic spaces connected with the atmosphere. They are located immediately beneath the base of the cranium, where crucial vital structures are harbored. From this region, very much exposed to airborne agents, arise some of the more complex and rare benign and malignant lesions seen in humans, whose difficulties in interpretation make this remarkable territory one of the most challenging in the practice of surgical pathology.

Contents of this chapter cover inflammations and infections, polyps and pseudotumors, fungal and midfacial destructive granulomatous lesions, as well as benign, borderline, and malignant neoplasms. Among the neoplasms, emphasis is made on those entities characteristic or even unique for the sinonasal region, such as Schneiderian papillomas, glomangiopericytoma, intestinal- and non-intestinal-type adenocarcinomas, olfactory neuroblastoma, nasal-type NK-/T-cell lymphoma, and teratocarcinosarcoma. Moreover, recently recognized entities involving this territory, i.e., HPV-related non-keratinizing carcinoma, NUT carcinoma, and SMARCB1-deficient basaloid carcinoma, are also discussed in the light of their specific molecular findings. Furthermore, the text is accompanied by numerous classical and recent references, several tables, and 100 illustrations.

Primitive neuroectodermal tumor of the maxillary sinus in an elderly male: A case report and literature review

Primitive neuroectodermal tumor (PNET), which belongs to the Ewing's sarcoma (ES) family of tumors, is mainly seen in children and young adults. PNETs are extremely rare in the maxilla. Here, we report a case of PNET of the left maxillary sinus in an elderly male. Magnetic resonance imaging (MRI) revealed a slightly enhanced solid mass occupying the left maxillary sinus and infiltrating into the retroantral space. A partial maxillectomy was performed. Despite postoperative chemotherapy, follow-up computed tomography (CT) and MRI revealed a nodal metastasis in the submandibular space. Neck dissection was performed. However, the patient died 10 months after the second surgery because of distant metastasis to the liver. MRI and CT were particularly useful in detecting the extent of the tumor, recurrence, and metastasis. Further, a literature review of the previously reported PNET cases of the maxilla was carried out. In this paper, we also discuss the current approach for the diagnosis and management of these tumors.

Peripheral primitive neuroectodermal tumor of the parotid gland in a child: A case report

Primitive neuroectodermal tumor (PNET) is a term used to describe a group of highly malignant neoplasms of soft-tissue origin, with varying degrees of divergent differentiation. The occurrence of peripheral PNET in the head and neck region has been reported infrequently in the medical literature. This disease generally occurs in adolescents and young adults, and rarely occurs in children <3 years old. The current study presents an extremely rare case of pPNET of the parotid gland in a 2-year-old male, which had been previously misdiagnosed and treated as a mumps. The lesion showed the characteristic histological features of pleomorphic cellular infiltrate with hyperchromatic small cells scattered in the fibrovascular stroma, interposed by fibrous septa and Homer-Wright rosettes. Positive immunohistochemical staining for CD99 and vimentin was detected. The patient was treated with chemotherapy and radiotherapy following surgical removal, and has been under close observation since the treatment (approximately seven months), with no signs of recurrence. The clinical history and radiological and histopathological findings are presented, together with the immunoreactivity of this tumor.

Primary peripheral primitive neuroectodermal tumor of the mandible

Primitive neuroectodermal tumor (PNET) is a broad term that includes a wide array of lesions with varying differentiating potential affecting both the central and peripheral nervous system. Peripheral PNET (pPNET), a variant of PNET, is known to arise in many places throughout the body; involvement of the mandible is however rare. A review of the scientific literature describes only seven reports of pPNET to be arising from the mandible. Given their insidious clinical symptoms, variable locations and rarity, the accurate diagnosis of peripheral PNETs poses a challenge for clinicians. PNETs exhibits characteristic immunophenotypical and genetic features that distinguish them from other small round cell tumors. A multidisciplinary approach is necessary to manage patients affected by PNET. There is however no consensus about the best therapeutic strategy. We recently got to treat a young patient with mandibular PNET; the clinical course as well as the histopathology with immunohistochemistry correlation of this rare entity is discussed.

[Primitive neuroectodermal tumor of the vagus nerve]

Primitive neuroectodermal tumors are a rare type of malignant neuroectodermal tumor that is very aggressive. Cervicofacial location is rare, even exceptional. We report a case of a 4-month-old male infant, referred from the pediatric clinic for severe supralaryngeal dyspnea, a firm mass under the left mandibular angle, mobile and extended to the parotid area, painful, with a curve of the left side wall of the oropharynx. Cervical computed tomodensitometry showed a well-limited mass in the carotid area, enhanced by the contrast product. A vascularized mass, which had developed at the expense of the vagus nerve, was removed surgically. Histology found a primitive neuroectodermal tumor.

Extraskeletal Ewing's sarcoma arising in the larynx

Extraskeletal Ewing's sarcoma (EES), or primitive neuroectodermal tumor, is an uncommon neoplasm with low incidence in the head and neck. Occurrences in the larynx are even more exceptional with only two previous reported cases of EES arising from the larynx. We report the case of a 45-year-old woman with a laryngeal Ewing's sarcoma treated with chemotherapy with radiotherapy to follow. Here we describe the histology, molecular diagnosis and treatment of this unusual tumor.

First description of a primitive neuroectodermal tumor arising in the nose

We report the case of a 12-year-old girl, who consulted us with one-year history of an 8 mm nose lesion that was painless and firm upon palpation. The lesion was resected conservatively. Immunohistochemistry was in favor of a primitive neuroectodermal tumor (PNET)/Ewing's sarcoma lesion, excluding epithelial, lymphoid, and other tumors. After a second resection, our patient was referred to chemotherapy and has already undergone 9 cycles out of 14. The patient is to date with no evidence of persistent or recurrent disease. To our knowledge, this is the first description of a PNET arising in the nose.

A case of malignant small round cell tumor of temporal bone with facial paralysis

Malignant small round cell tumor is very rare, especially in the head and neck area. It is also difficult to make a differential diagnosis due to their undifferentiated or primitive character. Immunohistochemical staining and chromosomal study is useful to categorize these tumors. Since these are rare tumors, treatment protocols are is not well established. While combined treatments (surgery, chemotherapy, radiotherapy) is currently being applied, the tumor still has a poor prognosis. We present a rare case of a rapidly growing temporal bone malignant small round cell tumor which initially showed facial paralysis.

Unusual presentation of peripheral primitive neuroectodermal tumor of the maxilla

The peripheral primitive neuroectodermal tumor (pPNET) is a rare and highly malignant soft tissue neoplasm in children and young adults. Fewer than 10 reported cases of pPNET of maxilla are available in the English literature. A 28-year-old woman was presented with the pPNET of the maxilla and metastasis. Two years after diagnosis, she experienced diplopia, and then magnetic resonance imaging was done, which showed a mass in the optic chiasma and parasellar region. The typical appearance resembled large noncalcified soft tissue masses in the magnetic resonance image and computed tomographic scan of the maxilla. Diagnosis was established by immunohistochemical features. She was treated with surgery, chemotherapy, radiation therapy, and gamma knife. She was under close observation since then (approximately 8 mo), and there has been no recurrence of tumor up to now.

Primary PNET of maxilla: an unusual presentation

Primitive neuroectodermal tumors (PNETs) are a type of small round cell tumors developing from migrating embryonal cells of the neural crest. Peripheral primitive neuroectodermal tumors (pPNETs) are less common with varying incidence of occurrence in head and neck region. Only 8 reported cases of primary PNET of maxilla are available in English literature. We report a case of 8-year-old boy diagnosed as pPNET of maxilla after detailed radiologic, histopathologic, including immuno-histochemical examination and molecular diagnosis using reverse transcription-polymerase chain reaction showing EWS-FLI1 translocation. The boy was treated with multiagent combination chemotherapy to be followed by definitive radiation therapy. A brief literature review of diagnosis and management of the previous 8 reported cases is done. In view of no definitive guideline for management of such cases, treatment on the lines of other pPNET is suggested.

Solitary epidural brain metastasis of a peripheral neuroepithelioma (a primitive neuroectodermal tumor): a case report

A 14 year old male was referred to a CT scan at our hospital for evaluation of headache. The patient was a known case of cervical soft tissue primitive neuroectodermal tumor (PNET) who has undergone surgery and radiotherapy 4 years ago. CT scan showed a large solitary extra axial, epidural lesion in the right parietal region, with mass effect and bony involvement. Subsequently, surgery was performed and the resultant biopsy was neuroepithelioma. After diagnosis the patient has undergone chemotherapy and radiotherapy. He remained symptom free, and also follow up CT scans of the brain, chest, and abdomen were normal after two years post surgery. This is the first reported case of epidural metastasis of a head and neck (peripheral) PNET.

Malignant peripheral primitive neuroectodermal (pPNET) of tongue

Primitive neuroectodermal tumors (PNETs) are relatively rare tumors. Tumors that once would have been diagnosed as Ewing's sarcoma are now often designated as peripheral neuroepithelioma or synonymously PNET. This paper reports a case of PNET located orally on the tongue, which is, to our knowledge, the first case reported in medical literature. The patient was treated with postoperative radiotherapy and chemotherapy. Multiple liver metastases occurred 5 months after the initial diagnosis and following extensive chemotherapy the patient was only able to survive for a further 10 months.

Primitive neuroectodermal tumours (PNETs) located in the spinal canal; the relevance of classification as central or peripheral PNET

Intraspinal location of central PNET (cPNET) is very rare. We present a case, critically review all publications of primary intraspinal cPNET occurrence and discuss tendencies in clinical presentation. In several previous attempts to summarise, authors often confused cPNET with peripheral PNET (pPNET). cPNET and pPNET are different entities with different immunohistochemical profiles and genetic backgrounds. Clinically, they are both aggressive tumours, but exhibit different characteristics in their local manifestation and metastatic spread. Survival rates are quite similar provided that treatment is applied according to the established protocols. Protocols in cPNET treatment differ from those for pPNET as regards the order of the treatment sub-modalities, specific chemotherapeutic regimen and intensity, radiation dose and its extent and consequently, the side effects. Therefore, failure to distinguish cPNET from pPNET leads to clinical guidance and treatment proposals based on false assumptions, which might effect outcomes. Often, distinguishing between cPNET and pPNET is easy, because they occur in different location. In the case of intraspinal tumour location, however, the differentiation is crucial because both primary cPNET and pPNET can occur intraspinally, even though this is rare. Nowadays, demonstrating the expression of MIC2 glycoprotein by immunocytochemical staining (CD99) showing the specific EWS-FLI1 chimeric gene presence in pPNET, offers an easy way of making a differential diagnosis between cPNET and pPNET.

Tumor neuroectodérmico primitivo periférico/ sarcoma de Ewing extraóseo del hueso temporal

The term primitive neuroectodermal tumor (PNET) should be included in the differential diagnosis of small round blue cell tumors, which come from the neural crest and explain their neuroectodermal character. This is one of the most indifferentiated histological types of malignant tumors. In the PNET family, we high light the Ewing's Sarcoma, that is frecuently located in bony sites and has a less frequent localization in soft tissues. We focus on one atypic case of PNET/Extraosseus Ewing's Sarcoma that involves the external auditory canal and infiltrates the temporal bone. Surgery followed by postoperative chemotherapy and radiation offers the best local control of the disease.