Prenatal sonographic diagnosis of a third ventricle choroid plexus papilloma

Bilateral Choroid Plexus Papillomas Diagnosed by Prenatal Ultrasound and MRI

We present a rare prenatal diagnosis of bilateral choroid plexus papillomas by obstetrical ultrasound and fetal MRI at 20 weeks 6 days gestation. The fetus demonstrated bilateral enlarged, echogenic choroid plexus with increased Doppler flow suggestive of vascularized choroid tissue. Same-day fetal MRI demonstrated that the choroid plexus appeared enlarged bilaterally without definite hemorrhage. The combined features on ultrasound and MRI suggested bilateral choroid plexus papillomas with increased cerebrospinal fluid production, leading to ventriculomegaly and enlarged extra-axial spaces. The diagnosis was confirmed by postnatal pathology, which demonstrated WHO grade II atypical choroid plexus papillomas.

Use of High-Dose Chemotherapy in Front-Line Therapy of Infants Aged Less Than 12 Months Treated for Aggressive Brain Tumors

Introduction: Malignant brain tumors in infants less than 12 months of age are extremely rare, and they have poor prognosis. We evaluated genetic characteristics and response rates of infants with congenital brain tumors subjected to high-dose chemotherapy and autologous stem cell transplant after gross total tumor resection. Materials and Methods: In total, 10 infants, aged less than 12 months, were enrolled in this study. The median age was 56 days (range: 1-279 days). Pathological examination demonstrated the following: four anaplastic astrocytomas, two glioblastomas, two central nervous system (CNS) embryonal tumors, not otherwise specified (NOS), and two atypical teratoid/rhabdoid tumors. Results: All patients were exposed to induction chemotherapy regimen, two high-dose chemotherapy courses, and autologous stem cell transplant after maximal surgery. At 1-3-5 years, the global overall survival (OS) was 90, 70, and 70% and the progression-free survival (PFS) was 80-60 and 60%. In all the patients, the copy number variants (CNVs) profile was analyzed using the SNP/CGH array approach. To investigate the clinical relevance of germline SMARCB1 mutation in AT/RT patients, we performed sequence analysis of the coding regions. The two patients with AT/RT were found to have germline SMARCB1 mutations. No BRAF mutations were found, and only NTRK gene fusion was present in one patient. We also have examined the association with OS and PFS and different histological subtypes of infant CNS proving that high-grade astrocytoma has better overall survival than other tumor types (p: 0.007 and p: 0.0590). Conclusion: High-dose chemotherapy regimen represents a valid therapeutic approach for congenital brain tumors with a high rate of response. The molecular analysis has to be analyzed in all infants' brain tumor types. High-grade gliomas are characterized by a better prognosis than other histologies of infant CNS.

Perinatal (fetal and neonatal) choroid plexus tumors: a review

INTRODUCTION

The object of this review is to describe the choroid plexus tumors (CPTs) occurring in the fetus and neonate with regard to clinical presentation, location, pathology, treatment, and outcome.

MATERIALS AND METHODS

Case histories and clinical outcomes were reviewed from 93 cases of fetal and neonatal tumors obtained from the literature and our own institutional experience from 1980 to 2016.

RESULTS

Choroid plexus papilloma (CPP) is the most common tumor followed by choroid plexus carcinoma (CPC) and atypical choroid plexus papilloma (ACPP). Hydrocephalus and macrocephaly are the presenting features for all three tumors. The lateral ventricles are the main site of tumor origin followed by the third and fourth ventricles, respectively. CPTs of the fetus are detected most often near the end of the third trimester of pregnancy by fetal ultrasound. The extent of surgical resection plays an important role in the treatment and outcome. In spite of excellent survival, which is especially true in the case of CPP, surgical resection may carry significant risks in an immature baby. Given the neonatal low blood volume and increased vascularity of the tumors, there is potential risk for hemorrhage. Although advances in neurosurgical techniques have led to a greater degree of complete surgical resections, survival for the perinatal CPC group remains low even with multimodality therapies.

CONCLUSION

Perinatal CPTs have variable overall survivals depending on degree of surgical resection and tumor biology. An increased understanding of the molecular features of these tumors may lead to improved therapies and ultimately survival.

Embolization of a giant hypervascularized choroid plexus papilloma with onyx by direct puncture: a case report

BACKGROUND

Choroid plexus papilloma is a rare intracranial neoplasm derived from choroid plexus epithelium accounting for less than 1 % of all brain tumors. These tumors are highly vascularized, and tumor resection is difficult, especially in small children, due to severe intraoperative bleeding. Preoperative embolization is helpful to reduce intraoperative bleeding, but it may not be possible in small children or if the tumor has no suitable feeding vessels for embolization.

METHODS

We present the case of a 2-year-old girl with a giant choroid plexus papilloma. An attempt of tumor resection was previously performed in another clinic, but the surgery was aborted due to massive intraoperative bleeding and only a biopsy was done. Angiography showed no suitable vessels for embolization. A new attempt of tumor removal was carried out, but again, severe intraoperative bleeding occurred and only a partial resection was possible. Intratumoral embolization with onyx through direct percutaneous puncture was performed.

RESULTS

Radical tumor removal was possible after two additional surgeries. Intraoperative blood loss was 345 ml (first surgery = only partial removal), 250 ml (second procedure = 1/3 of tumor volume resected), and 250 ml (third surgery = total removal). The patient presented no additional deficits.

CONCLUSIONS

Intratumoral percutaneous embolization with onyx was very helpful in reducing intraoperative bleeding in this case. Safe radical tumor resection was possible. This technique may be useful for those surgeons dealing with highly vascularized tumors, especially in small children. No report of intratumoral embolization with onyx in cases of intracerebral tumors could be found in the literature.

Preoperative vincristine for an inoperable choroid plexus papilloma: a case discussion and review of the literature

The authors report the case of a 14-month-old boy with a large right intraventricular choroid plexus papilloma (CPP) for which the first attempt at resection resulted in life-threatening intraoperative hemorrhage. The tumor was unsuitable for embolization, and neoadjuvant ifosfamide, carboplatin, etoposide (ICE) chemotherapy had no effect on tumor size. However, chemotherapy with vincristine, although not impacting on CT perfusion parameters, resulted in a significant decrease in tumor size, enabling complete resection with manageable blood loss. The mechanism underlying the effect of vincristine in this case is uncertain, but it is a treatment strategy that warrants further evaluation for the treatment of CPPs that are not amenable to embolization.

Fetal tumors of the choroid plexus: is differential diagnosis between papilloma and carcinoma possible?

Fetal choroid plexus tumors are uncommon. The prognosis is widely variable and depends on the histological findings: papilloma or carcinoma. We report a case of prenatal diagnosis of choroid plexus mass detected by ultrasound at 33 weeks of gestation. Prenatal (T1, T2, T2* and diffusion weighted sequences) magnetic resonance imaging (MRI) was used to rule out a hematoma. Follow-up examination by ultrasound and MRI revealed a significant increase in the volume of the mass, suggesting a diagnosis of malignant tumor. A healthy neonate was delivered by Cesarean section at 38 weeks of gestation. Full surgical excision of the tumor was performed at 20 days after delivery and histological analysis revealed a papilloma.

Prenatal diagnosis and successful postnatal therapy of an atypical choroid plexus papilloma-Case report and review of literature

This report describes the perinatal management of a prenatally detected choroid plexus papilloma in an otherwise unaltered singleton pregnancy of a healthy woman. After elective Caesarean section, a successful embolization of the feeding vessel followed by a craniotomy and complete removal of the remaining tumor were performed. Histological examination confirmed the diagnosis. One-, 2-, and 3-year follow-up showed a normal development of the girl with a regular neuropediatric status. A review of literature including related papers listed in PubMed between 1985 and 2009 are included.

Choroid plexus hyperplasia: surgical treatment and immunohistochemical results. Case report

Diffuse villous hyperplasia of the choroid plexus is a rare but potential source of nonobstructive hydrocephalus. In addition to discussing the authors' staged surgical approach and medical management decisions in a patient with this rare and challenging condition, immunohistochemical studies of the choroid plexus epithelium are presented to examine the pathophysiological factors involved in abnormal cerebrospinal fluid (CSF) production in this disease. The patient, a 15-month-old girl born at 36 weeks' gestation, underwent a bilateral craniotomy with resection of the choroid plexus to treat her villous hyperplasia. Immunohistochemical studies of the resected choroid plexus were conducted for the purpose of examining the carbonic anhydrase II (CAII) enzyme and the aquaporin 1 (AQP1) membrane protein. Results were compared with immunohistochemical studies conducted in a small series of autopsy specimens of normal human choroid plexuses. There was no change in the immunoreactivity of CAII in the patient with villous hyperplasia compared with normal controls, whereas AQP1 immunoreactivity was significantly weaker in the patient compared with normal controls. Postoperatively, the patient's CSF overproduction resolved and her neurological symptoms improved over time. Shunting techniques and presently available pharmaceutical treatments alone do not provide adequate treatment of high-output CSF conditions. Surgical removal of the affected choroid plexus is a feasible and effective treatment. Results of the immunohistochemical studies reported here support the suggestion that the CAII enzyme is retained in villous hyperplasia of the choroid plexus. However, there appears to be decreased expression and perhaps downregulation of AQP1 in villous hyperplasia compared with normal choroid plexus. Future studies may elucidate the significance of these observations.

II. Perinatal brain tumors: a review of 250 cases

Central nervous system tumors occur considerably less often in the fetus and neonate than in the older child. They are not entirely the same as those present later in life. Their location, biologic behavior, response to therapy, and histologic types are different. Fetal and neonatal brain tumors (n = 250) were collected from the literature and studied for this review. The overall survival rate was 28%. The entire cranial cavity may be filled with tumor, and stillbirth is not uncommon. Macrocephaly was the most frequent presentation regardless of histology. Outcome is related to the size and location of the tumor, the histologic type, surgical resectability, and the condition of the infant at the time of diagnosis. Neonates with choroid plexus papillomas, gangliogliomas, and low-grade astrocytomas have the best prognosis, whereas those with teratomas and primitive neuroectodermal tumors have the worst prognosis.

Tumors of the choroid plexus

Choroid plexus tumors are rare intraventricular papillary neoplasms derived from choroid plexus epithelium, which account for only between 0.4-0.6% of all intracranial and 2-3% of pediatric neoplasms. Plexus papillomas outnumber choroid plexus carcinomas by a ratio of 5:1 and around 80% of choroid plexus carcinomas arise in children. Plexus tumors are most common in the lateral and fourth ventricles; while 80% of lateral ventricle tumors present in children, fourth ventricle tumors are evenly distributed in all age groups. Clinically, choroid plexus tumors tend to cause hydrocephalus and increased intracranial pressure. Histologically, choroid plexus papillomas correspond to WHO grade I, choroid plexus carcinomas to WHO grade III. Immunohistochemically, cytokeratins and vimentin are expressed by virtually all choroid plexus papillomas and most choroid plexus carcinomas while transthyretin and S-100 protein are present in 80-90% of cases, less frequently, though, in choroid plexus carcinomas. Glial fibrillary acidic protein can be found focally in about 25-55% of choroid plexus papillomas and 20% of choroid plexus carcinomas. The mean Ki67/MIB1 labeling index for choroid plexus papillomas is 1.9%, for choroid plexus carcinomas 13. 8%. Choroid plexus papillomas typically show hyperdiploidy with gains particularly on chromosomes 7, 9, 12, 15, 17, and 18 while one choroid plexus carcinoma showed rearrangements of chromosomes 7p11-12, 9q11-12, 15q22, and 19q13.4. Choroid plexus papillomas can usually be cured by surgery alone with a 5-year survival rate of up to 100% with occasional recurrences while choroid plexus carcinomas grow more rapidly and have a less favorable outcome with a 5-year survival rate of 26-40%.

Three-level view of fetal brain imaging in the prenatal diagnosis of congenital anomalies

OBJECTIVE

To determine whether a systematic stream-lined approach could be routinely used in the evaluation of fetal intracranial anatomy.

METHODS

Nine thousand six hundred uncomplicated pregnancies were evaluated using a three-level view of fetal brain imaging. An axial scan, which passed through the level of the lateral ventricles, was first obtained. This was followed by a second view passing through the cavum septum pellucidum anteriorly, the thalami medially, and the 3rd ventricle centrally. Finally, a third view was made passing through the posterior fossa.

RESULTS

Although the fetus had different presentations, we were able to fully image the fetal brain in all three levels in most cases. The intracranial anatomy could be scrutinized in most cases. Ninety-six percent of abnormal cases (126/133) were diagnosed using Levels I, II, or III independently or in combination.

CONCLUSIONS

The three-level view provides a comprehensive and systematic sonographic approach to the evaluation of the fetal intracranial anatomy, and for the diagnosis of anomalous fetal brain development.

Papillomas and carcinomas of the choroid plexus in children

OBJECT

Choroid plexus tumors are rare intraventricular tumors (1% of all intracranial tumors) that occur mainly in children. The pathophysiological characteristics of associated hydrocephalus, surgical management, and oncological issues related to these tumors remain a matter of debate. To understand more about these tumors, the authors have reviewed their experience with the management of 38 children with choroid plexus tumors.

METHODS

There were 25 cases of papilloma and 13 of carcinoma. The mean age of the patients at presentation was 22.5 months, and one-half of the patients were younger than 2 years of age. Hydrocephalus was present in 33 patients and poorly correlated with the size, site, and pathological characteristics of the tumor. In nine children, a ventriculoperitoneal shunt was required after tumor excision, calling into question the notion that cerebrospinal fluid oversecretion is the only cause of hydrocephalus. Complete excision was achieved in 96% of the cases of papilloma and 61.5% of the cases of carcinoma. These surgical procedures were complicated by the risks of intraoperative hemorrhage, which proved to be fatal in two cases, and postoperative brain collapse, which led to subdural fluid collections requiring subdural shunt placement in six patients. Preoperative embolization was partially successful in four cases and significantly assisted surgery. Preoperative controlled drainage of excessively dilated ventricles and intraoperative gluing of the cortical incision have been used to address the problem of postoperative brain collapse. Patients with carcinomas were treated postoperatively by chemotherapy alone (seven cases), radiotherapy (one case), or chemotherapy plus radiotherapy (one case). The overall 5-year survival rate was 100% for patients with papillomas and 40% for those with carcinomas.

CONCLUSIONS

Total surgical excision is curative in cases of papillomas. For carcinomas, the most effective treatment remains total surgical excision; however, adjuvant treatment in the form of chemotherapy in patients younger than age 3 years, supplemented by radiation therapy in older children, can moderately reduce the risk of recurrence.

Papillomas and carcinomas of the choroid plexus in children

Object

Choroid plexus tumors are rare intraventricular tumors (1% of all intracranial tumors) that occur mainly in children. The physiopathological characteristics of associated hydrocephalus, surgical management, and oncological issues related to these tumors remain a matter of debate. To understand more about these tumors, the authors have reviewed their experience with the management of 38 children with choroid plexus tumors.

Methods

There were 25 cases of papilloma and 13 of carcinoma. The mean age of the patients at presentation was 22.5 months and one-half of the patients were younger than 2 years of age. Hydrocephalus was present in 33 patients and poorly correlated with the size, site, and pathological characteristics of the tumor. In nine children, a ventriculoperitoneal shunt was required after tumor excision, calling into question the notion that cerebrospinal fluid oversecretion is the only cause of hydrocephalus.

Complete excision was achieved in 96% of the cases of papilloma and 61.5% of the cases of carcinoma. These surgical procedures were complicated by the risks of perioperative hemorrhage, which proved to be fatal in two cases, and postoperative brain collapse, which led to subdural fluid collections requiring subdural shunt placement in six patients. Preoperative embolization was partially successful in four cases and significantly assisted surgery. Preoperative controlled drainage of excessively dilated ventricles and intraoperative gluing of the cortical incision have been used to address the problem of postoperative brain collapse.

Patients with carcinomas were treated postoperatively by chemotherapy alone (seven cases), radiotherapy (one case), or chemotherapy plus radiotherapy (one case). The overall 5-year survival rate was 100% for patients with papillomas and 40% for those with carcinomas.

Conclusions

Total surgical excision is curative in cases of papillomas. For carcinomas, the most effective treatment remains total surgical excision; however, adjuvant treatment in the form of chemotherapy in patients younger than 3 years, supplemented by radiation therapy in older children, can moderately reduce the risk of recurrence.

Third ventricular choroid plexus papilloma with psychosis. Case report

This 9-year-old boy with a history of behavioral problems and worsening psychosis responded initially to treatment with haloperidol. However, a magnetic resonance image obtained as part of his psychiatric evaluation revealed an anterior third ventricle tumor and mild-to-moderate hydrocephalus. The resected tumor was found on pathological examination to be a choroid plexus papilloma. The patient had an uneventful postoperative course and remained free of psychosis or mood disorder at 1-year follow-up examination.