Evaluating the risk of tuberous sclerosis in cases with prenatal diagnosis of cardiac rhabdomyoma

Healthcare provider recognition of pregnancy related risks and management considerations in patients with tuberous sclerosis complex

BACKGROUND

Patients with tuberous sclerosis complex (TSC) face an increased risk of maternal health complications and worsening disease manifestations during pregnancy. There are no established consensus guidelines that address the management of pregnancy in patients with TSC and healthcare providers rely on their individual experiences and preferences to derive treatment decisions. We sought to obtain provider opinion of pregnancy related maternal complications in patients with TSC, and the common evaluation and management strategies used to address these issues.

METHODS

We conducted a cross-sectional survey of healthcare providers with diverse areas of expertise related to the multisystem nature of involvement in TSC. Descriptive analyses were used to analyze our three primary variables: (1) provider recognition of maternal risks/complications; (2) provider recommendations before and during pregnancy; and (3) provider/clinic protocols.

RESULTS

We received responses from 87 providers from 11 countries, with 40.7% (n = 35) seeing > 30 TSC patients yearly. The majority of providers (n = 70, 88.6%) deemed that a patient with TSC needed expert care beyond the standard of care for a typical pregnancy, with over 25% of providers reporting that they have seen lymphangioleiomyomatosis (LAM) exacerbation, seizures, and preterm labor in pregnant patients with TSC. Providers who managed patients treated with mTOR inhibitors (mTORi) also agreed that mTORi use should be stopped prior to pregnancy (n = 45, 68.2%) but there was uncertainty about when to stop the mTORi (one month 28.9%, two months 11.1%, three months 42.2%, and 6-12 months 2.2%). Additionally, there were mixed opinions on restarting mTORi in response to disease progression during pregnancy. When asked about provider or clinic specific protocols, 71.6% (n = 53) of providers stated that they do not have a clear protocol for management decisions for patients with TSC before or during pregnancy.

CONCLUSION

Healthcare providers recognize that patients with TSC are at an increased risk for maternal health complications during pregnancy. However, there are wide inter-individual variances in practice, especially pertaining to decisions regarding mTORi use. There is a critical need to better understand the implications of pregnancy for patients with TSC, and to draft consensus recommendations to guide management decisions.

Fetal neurosonography as accurate tool for diagnosis of brain involvement in tuberous sclerosis

OBJECTIVE

To demonstrate the potential utility of dedicated neurosonography for the diagnosis of fetal brain involvement in tuberous sclerosis complex.

METHODS

This was a multicenter retrospective study of fetuses at high risk for tuberous sclerosis complex. Dedicated neurosonographic, fetal magnetic resonance imaging (MRI) and postnatal reports were reviewed. Data collected included reason for referral, gestational age at which cardiac rhabdomyoma was first suspected and final number of cardiac rhabdomyomas detected on dedicated imaging. We searched for tuberous sclerosis complex-related brain involvement, defined as the presence of one or more of the following findings: white-matter lesions; subependymal nodules; cortical/subcortical tubers; and subependymal giant-cell astrocytoma.

RESULTS

We included 20 patients at high risk of tuberous sclerosis complex, of whom 19 were referred for the presence of cardiac rhabdomyomas and one for a deletion in chromosome 16 involving the tuberous sclerosis complex gene locus. Cardiac rhabdomyomas were diagnosed at a mean gestational age of 27 + 2 weeks (range, 16 + 0 to 36 + 3 weeks) and the mean number of cardiac rhabdomyomas per patient was 4 (range, 1-10). Brain involvement was present in 15 fetuses, in 13 of which the disease was confirmed in one or more of the following ways: chromosomal microarray analysis (n = 1), exome sequencing (n = 7), autopsy (n = 4), clinical tuberous sclerosis complex in the newborn (n = 4) and a sibling diagnosed with clinical tuberous sclerosis complex (n = 1). In two cases, the disease could not be confirmed: one was lost to follow-up and autopsy, following termination of pregnancy, was not performed in the other. Among the five cases without brain findings, tuberous sclerosis complex was confirmed in three by exome sequencing (n = 2) and/or autopsy findings (n = 2). The two remaining cases had normal exome sequencing; one case had five cardiac rhabdomyomas, which was a highly suggestive finding, while in the final case, the autopsy was considered normal, representing the only false-positive case in our cohort.

CONCLUSIONS

Contrary to current literature, dedicated neurosonography appears to be effective in the diagnosis of brain involvement in fetuses at risk of tuberous sclerosis complex and should be used as the first-line approach. Although the number of cases in which MRI was performed was small, it seems that, in the presence of ultrasound findings, the added value of MRI is low. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Rhabdomyoma of the Larynx: A Case Report and Literature Review of a Rare Tumor in an Uncommon Location

OBJECTIVES

Laryngeal rhabdomyomas are extremely rare, benign striated muscle tumors that have been documented only ∼50 times in the literature. They can be subdivided into two types: fetal and adult types, with the adult type being more common. Common presenting symptoms include hoarseness or progressive dysphagia. Diagnosis is made via immunohistochemical and microscopic analysis. Management is typically surgical, most commonly endoscopic, or open resection.

METHODS

A comprehensive literature review was conducted with PubMed's MEDLINE index using the following search string: "rhabdomyoma" AND ("larynx" OR "laryngeal" OR "head" OR "neck"). After exclusion criteria were applied, a total of 58 cases were included. The purpose of our literature review was to elucidate information about age/gender, location, size, chief complaint and duration, treatment, and recurrence from each of the 58 cases to identify trends that could guide future diagnosis and management.

RESULTS

The average age at diagnosis of laryngeal rhabdomyoma was 52.6 years with a 2.22:1 male predominance. Hoarseness and/or dysphonia was the most common chief complaint (42/58 cases, 72%), followed by dysphagia (12/58 cases, 21%). Common treatment options included endoscopic excision (18/48 cases, 37.5%) or open surgical resection (10/48 cases, 21%). Tumor recurrence was reported in 5/40 cases (14%), most likely due to incomplete removal of the tumor.

CONCLUSIONS

Although laryngeal rhabdomyomas are rare, they should be considered in the differential diagnosis for patients with a submucosal laryngeal mass. Curative treatment is surgical via endoscopic resection. It is the preferred technique because of decreased morbidity compared to open resection. However, endoscopic resection was shown to have both higher rates of recurrence and shorter time to recurrence compared to open resection, necessitating frequent postoperative surveillance.

The Genetics and Diagnosis of Pediatric Neurocutaneous Disorders: Neurofibromatosis and Tuberous Sclerosis Complex

Neurofibromatosis (NF) and tuberous sclerosis complex (TSC) are the two most common neurocutaneous disorders, both transmitted as autosomal dominant or, in the case of NF, also as a mosaic condition. The causative genetic mutations in these neurocutaneous disorders can lead to benign skin changes or uninhibited growth and proliferation in multiple organ systems due to the loss of tumor suppression in mitogen-activated protein kinase and mammalian target of rapamycin signaling pathways. Common clinical features in NF include pigmented lesions, known as café au lait patches, neurofibromas, intertriginous freckles (Crowe's sign), and benign fibrous growths, such as hamartomas in multiple organ systems. Common clinical features in TSC include hypopigmented macules, known as ash leaf spots, in addition to neurologic sequelae, such as autism, seizures, and developmental delays. Advances in genetic sequencing technologies have allowed an exponential expansion in the understanding of NF and TSC. Consensus criteria have been established for both diagnoses that can be confirmed in most cases through gene testing. Once diagnosed, the clinical and diagnostic value of disease-specific surveillance include early identification of benign and malignant tumors. Genetic counseling is important for informed reproductive decision-making for patients and at-risk family members. The improvement in understanding of pathways of pathogenic disease development and oncogenesis in both conditions have produced a new series of therapeutic options that can be used to control seizures and tumor growth. Tremendous advances in life expectancy and quality of life are now a reality due to early introduction of seizure control and novel medications. While we lack cures, early institution of interventions, such as seizure control in tuberous sclerosis, appears to be disease-modifying and holds immense promise to offer patients better lives.

A systematic review on the burden of illness in individuals with tuberous sclerosis complex (TSC)

Objective

This review will summarize current knowledge on the burden of illness (BOI) in tuberous sclerosis complex (TSC), a multisystem genetic disorder manifesting with hamartomas throughout the body, including mainly the kidneys, brain, skin, eyes, heart, and lungs.

Methods

We performed a systematic analysis of the available literature on BOI in TSC according to the PRISMA guidelines. All studies irrespective of participant age that reported on individual and societal measures of disease burden (e.g. health care resource use, costs, quality of life) were included.

Results

We identified 33 studies reporting BOI in TSC patients. Most studies (21) reported health care resource use, while 14 studies reported quality of life and 10 studies mentioned costs associated with TSC. Only eight research papers reported caregiver BOI. Substantial BOI occurs from most manifestations of the disorder, particularly from pharmacoresistant epilepsy, neuropsychiatric, renal and skin manifestations. While less frequent, pulmonary complications also lead to a high individual BOI. The range for the mean annual direct costs varied widely between 424 and 98,008 International Dollar purchasing power parities (PPP-$). Brain surgery, end-stage renal disease with dialysis, and pulmonary complications all incur particularly high costs. There is a dearth of information regarding indirect costs in TSC. Mortality overall is increased compared to general population; and most TSC related deaths occur as a result of complications from seizures as well as renal complications. Long term studies report mortality between 4.8 and 8.3% for a follow-up of 8 to 17.4 years.

Conclusions

TSC patients and their caregivers have a high burden of illness, and TSC patients incur high costs in health care systems. At the same time, the provision of inadequate treatment that does not adhere to published guidelines is common and centralized TSC care is received by no more than half of individuals who need it, especially adults. Further studies focusing on the cost effectiveness and BOI outcomes of coordinated TSC care as well as of new treatment options such as mTOR inhibitors are necessary.

Fetal heart rhabdomyomatosis: a single-center experience

Objectives: The primary aim of the study was to evaluate the prevalence of fetal heart tumors in a single tertiary referral center over a period of 15 years. The secondary aim was to confirm the presence of tuberous sclerosis complex (TSC) through the evaluation of germline mutation in TSC1/TSC2 and assess the outcomes in affected fetuses and newborns.Methods: A retrospective study was conducted between 2003 and 2017. Fetal echocardiography was performed in the second trimester of pregnancy in the study population. The identification of heart tumors and further follow-up were performed by a pediatric cardiologist. Molecular genetic analysis was conducted on fetuses and children in cases where TSC was suspected.Results: In total, 39,018 fetuses were examined between 2003 and 2017. Heart tumors were detected in nine fetuses and were diagnosed as rhabdomyoma in all cases. We identified mutations in one of the TSC1 or TSC2 genes in all cases with multiple rhabdomyomas (8/9). In all born children (5/9), the genetically confirmed diagnosis of TSC was established, and clinically pathological deposits in the brain were found.Conclusion: Fetal heart tumors are usually represented by rhabdomyomas having a good cardiac prognosis. However, rhabdomyoma is usually the first symptom of TSC with a subsequent brain disorder and impaired neurological development.

Prenatal and Postnatal Diagnosis of Rhabdomyomas and Tuberous Sclerosis Complex by Ultrafast and Standard MRI

OBJECTIVE

To examine the features of cardiac rhabdomyomas and tuberous sclerosis in fetuses and infants using magnetic resonance imaging (MRI) and to determine whether MRI is an effective tool to facilitate early detection of tuberous sclerosis complex (TSC).

METHODS

Fifteen patients with TSC were evaluated by ultrafast or standard MRI between June 2005 and September 2016. Fifteen patients were divided into two groups. Group A included five cases in utero and followed in infancy with gestational ages from 26 + 1 to 38 + 2 wk. Group B included ten cases aged from 36 d to 18-mo-old.

RESULTS

There were 11 and 10 cardiac lesions of prenatal and postnatal period respectively in five subjects of Group A and 27 cardiac lesions in ten subjects of Group B. There were more than 31 prenatal brain lesions and 30 postnatal brain lesions in Group A and 169 lesions in Group B. Standard postnatal brain MRI confirmed the prenatal study of Group A. At 1 y follow up of Group A, there was partial regression of 2 cardiac lesions, complete regression of 1 cardiac lesion, no obvious regression of 8 cardiac lesions.

CONCLUSIONS

When one or multiple cardiac tumors are detected by ultrasound in fetal period or some specific clinical manifestations are presented in infancy, fetal ultrafast MRI or standard MRI is suggested to make early diagnosis of TSC.

Fetal Primary Cardiac Tumors During Perinatal Period

Fetal primary cardiac tumors are rare, but they may cause complications, which are sometimes life threatening, including arrhythmias, hydrops fetalis, ventricular outflow/inflow obstruction, cardiac failure, and even sudden death. Among fetal primary cardiac tumors, rhabdomyomas are most common, followed by teratomas, fibromas, hemangiomas, and myxomas. Everolimus, a mammalian target of rapamycin inhibitor, has been reported to be an effective drug to cause tumor remission in three neonates with multiple cardiac rhabdomyomas. Neonatal cardiac surgery for the resection of primary cardiac tumors found by fetal echocardiography has been reported sporadically. However, open fetal surgery for pericardial teratoma resection, which was performed successfully via a fetal median sternotomy in one case report, could be a promising intervention to rescue these patients with large pericardial effusions. These recent achievements undoubtedly encourage further development in early management of fetal cardiac tumors. Owing to the rarity of fetal primary cardiac tumors, relevant information in terms of prenatal diagnosis, treatment, and prognosis remains to be clarified.

Brain MRI in Fetuses with Cardiac Tumours

Tuberous sclerosis complex (TSC) is an autosomal dominant multisystem disorder which affects the skin, brain, heart and other organs. It is caused by mutations of two genes: TSC1 (on chromosome 9q34) or TSC2 (on 16p13.3). 70% of cases are sporadic with new mutations. This study aimed to highlight the utility of prenatal MRI as an adjunct imaging modality in the diagnosis and prognosis of tuberous sclerosis complex. Prenatal ultrasound and magnetic resonance imaging were performed in seven fetuses at a gestational age of 30, 32, 34 and 35 weeks using a 1.5 T MRI scanner. SSFSE,T2- and FGRE/T1-weighted images were obtained in axial, coronal and sagittal planes. Postnatal MRI was performed in two cases. Intracardiac tumors (rhabdomyomas) were revealed on ultrasound in all fetuses. On sonographic examination the brain tissue appeared normal in all cases. Brain MRI revealed focal low-signal-intensity lesions, localized along the walls of the lateral ventricles of five fetuses. Another hypointense lesion was seen at the grey/white matter junction in one case. Brain MRI of two fetuses was normal. The diagnosis of TSC was established in five cases. Postnatal MRI in two cases confirmed prenatal findings. MRI allows more complete evaluation of the fetus and helps to determine the diagnosis and prognosis in cases of TSC. The use of prenatal MR imaging in addition to prenatal sonography has the potential to improve genetic counseling and prenatal diagnosis of patients with tuberous sclerosis.

Regression of massive cardiac rhabdomyoma on everolimus therapy

Cardiac rhabdomyoma is the primary feature of the genetic disease, tuberous sclerosis complex, the most common cardiac tumor diagnosed in neonates and infants. Spontaneous regression is observed in most cases, but these tumors may cause hemodynamic instability, arrhythmias or other complications. We describe the case of a critically ill neonate, resuscitated after cardiac arrest secondary to massive locally invasive cardiac rhabdomyoma, who was successfully treated with everolimus (mammalian target of rapamycin [mTOR] inhibitor). Rapid tumor regression was observed on echocardiography, but it was unlikely that it was confounded by the natural disease course of regression. The presented case suggests that mTOR inhibitors may play a significant role in the treatment of large cardiac rhabdomyomas in critically ill neonates.

Prenatal diagnosis and outcomes of fetal cardiac rhabdomyomas: evaluation of seven cases

In this case series, we aimed to determine the outcome of prenatally diagnosed fetal cardiac rhabdomyoma. This case series is a retrospective evaluation of seven cases of fetal cardiac rhabdomyoma determined during pregnancy. Only one of these cases has been associated with tuberous sclerosis (TS). Two of the cases had just a single tumor, whereas the others were found to have multiple tumors. Termination was performed to one fetus due to hydrops fetalis. The presence of risk factors of TS in a family and multifocal or large tumors, appears to be the most important factors affecting neonatal outcomes.

Right atrial cardiac rhabdomyoma with premature foramen ovale restriction: A case report

Fetal cardiac rhabdomyoma is the most common cardiac tumor in fetuses. However, this benign tumor can cause hemodynamic repercussions and intrauterine fetal mortality. The present study reports a case of rare fetal cardiac rhabdomyoma located in the right atrium, accompanied by premature restriction of the foramen ovale and moderate pericardial effusion, as determined by tomographic ultrasound imaging (TUI). Fetal mortality subsequently occurred late in the second trimester of pregnancy and the diagnosis was confirmed by pathology. The present study discusses the occurrence and diagnosis of this rare abnormality. TUI mode with spatio-temporal image correlation offline imaging provides the physician with clear views of abnormal intracardiac structures in the beating heart. With improvements in sonographic technology, the diagnosis of fetal cardiac rhabdomyoma may be easier and more accurate in the clinical arena.

Fetal demise secondary to massive rhabdomyoma in the early second trimester of pregnancy

Rhabdomyoma is the most common cardiac tumor in fetuses, often associated with tuberous sclerosis complex and usually diagnosed in the third trimester of pregnancy, with a benign course in the majority of cases. The hemodynamic impact of cardiac tumor depends on the location and size of the mass and the presence of dysrhythmia (4). Fetal cardiac rhabdomyoma accounts for less than 10% of fetal demise cases (1). This report presents a case of massive cardiac rhabdomyoma filling the entire right heart with pericardial extension, leading to hydrops and subsequent fetal death in the early second trimester of pregnancy.

Characterization and Management of Cardiac Tumors

Cardiac tumors are infrequent clinical entities with an autopsy frequency ranging from 0.001% to 0.030%. The occurrence of metastatic cardiac tumors has been reported a 100-fold more commonly than primary lesions. Three quarters of primary cardiac tumors are benign; approximately half of these are cardiac myxomas, and the rest are lipomas, papillary fibroelastomas, and rhabdomyomas. Among malignant primary cardiac tumors, the most reported are those histopathologically considered as undifferentiated, followed by angiosarcomas and leiomyosarcomas. Traditionally, cardiac tumors have been identified as curious autopsy findings resulting in a literature paucity of large clinical series, therefore, providing knowledge mostly based on case report collection. However, recent technological advances in noninvasive imaging modalities such as echocardiography and cardiac magnetic resonance imaging (MRI) have resulted in a rapid acquisition of real-time heart images with high spatial and temporal resolution and an excellent tissue characterization of the tumor. This consequent earlier, more frequent, and more complete assessment of cardiac tumors before significant symptoms develop has challenged cardiologists, cardiac anesthesiologists, and surgeons to create a tailored referral pattern and approach.

Prenatal diagnosis of cardiac rhabdomyomas: incidence of associated cerebral lesions of tuberous sclerosis complex

OBJECTIVES

To determine the prevalence of specific cerebral lesions of tuberous sclerosis complex (TSC) and neurological outcome in cases diagnosed prenatally with cardiac rhabdomyomas.

METHODS

We reviewed all fetuses diagnosed prenatally with cardiac rhabdomyomas which had undergone detailed ultrasound evaluation and cerebral magnetic resonance imaging (MRI) and which were recorded in the database of a single institution covering the period January 1992 to December 2005.

RESULTS

Fifty-one fetuses were included in the study. MRI was performed at a mean +/- SD gestational age of 30 +/- 3 gestational weeks and showed specific lesions of TSC in 49% of cases. Termination of pregnancy was chosen by the parents in 26 cases. Neurological development was studied in 20 cases, follow-up lasting 4.8 +/- 2.9 years. Neurodevelopmental events occurred during the follow-up period in 45% of cases. Neurological complications occurred in 67% of patients who had cerebral lesions at MRI and in 33% of patients with normal MRI results. There was no significant difference between the two groups of patients (P = 0.2).

CONCLUSION

In fetuses with cardiac rhabdomyomas detailed ultrasound examination and third-trimester cerebral MRI are able to diagnose most TSC cerebral lesions, but fail to determine neurological outcome.

Outcome of antenatally diagnosed cardiac rhabdomyoma: case series and a meta-analysis

OBJECTIVES

Rhabdomyoma, the most common primary fetal cardiac tumor, is often associated with tuberous sclerosis (TS). We aimed to evaluate outcome in cases diagnosed with fetal cardiac rhabdomyoma.

METHODS

This study presents 11 cases with fetal cardiac rhabdomyoma. In addition, all relevant published cases of antenatally diagnosed cardiac rhabdomyoma since 1982 were identified from MEDLINE. We evaluated the following risk factors associated with clinical impact and perinatal outcome: family history of TS, gestational age at diagnosis, tumor size, site and number of tumors, tumor progression, and associated intracardiac and extracardiac anomalies.

RESULTS

In this meta-analysis, 138 cases, including nine newly added by us, were categorized into Group A (107 live babies) and Group B (16 neonatal deaths and 15 intrauterine fetal deaths). Univariate analysis showed that large cardiac tumors (P < 0.0001), fetal dysrhythmia (P < 0.0001) and hydrops (P < 0.0001) were strong predictors of neonatal outcome. Tumor size >or= 20 mm (relative risk (RR), 20.6; 95% CI, 2.2-195.9; P = 0.009) and fetal dysrhythmia (RR, 13.6; 95% CI, 2.9-62.3; P = 0.001) were significantly associated with neonatal morbidity. TS, present in 85/133 (63.9%) cases, was significantly associated with multiple cardiac tumors (P < 0.0001) and family history of TS (P = 0.02).

CONCLUSIONS

Large tumor size and hydrops are significantly associated with poor neonatal outcome, whereas family history of TS and multiple fetal cardiac tumors are associated with TS. Any sonographic detection of a fetal cardiac tumor should warrant further investigation for the possible presence of associated disorders.

Clinical presentation and diagnosis of tuberous sclerosis complex in infancy

The age-dependent nature of the characteristic features of tuberous sclerosis complex has historically presented challenges for the diagnosis in infancy. Although the increasing availability of neuroimaging and genetic testing has facilitated the diagnosis in neonates and infants, there are few reports describing how tuberous sclerosis complex presents in this age group. We performed a retrospective review of children diagnosed with tuberous sclerosis complex during the first year of life, compiling their clinical features at presentation and diagnosis, seizure history, and imaging findings. We identified 41 infants diagnosed with tuberous sclerosis complex before age 1 year. Their age at initial presentation ranged from antenatal to 9 months of age. Twenty-three patients (56%) initially presented with a cardiac rhabdomyoma, of which 15 were identified antenatally. Fourteen patients (34%) initially presented with seizures, and 6 (15%) initially presented with hypomelanotic macules. Five infants (12%) had a family history of tuberous sclerosis complex. A definitive diagnosis of tuberous sclerosis complex was accomplished antenatally in 4 patients, whereas the rest were diagnosed at a median age of 2 months. All 41 patients underwent neuroimaging during infancy; 36 (88%) had radiographic evidence of cortical tubers, and 38 (93%) had subependymal nodules. Neuroimaging resulted in a definitive diagnosis of tuberous sclerosis complex in 95% of patients. The diagnosis of tuberous sclerosis complex in infancy is aided by a high index of suspicion and timely access to neuroimaging. Early diagnosis of tuberous sclerosis complex may be essential to the success of future therapies by providing a window of opportunity for their use.

Indikationen zur fetalen Magnetresonanztomographie

Indications to perform fetal magnetic resonance imaging (MRI) are composed of common ones related to methodological problems of ultrasound (US) assessment (such as for instance hydramnios) and special ones. The latter are related to MR capability of high-resolution soft tissue contrast and an extended field of view that allows visualization of the whole fetus, even in later stages of pregnancy. The most important indications include confirmation of US findings, work-up of malformations with respect to individual prognosis and genetic background, differentiation between acquired conditions and malformations, visualization of pathologies that have to be treated surgically immediately after birth, and morphological changes of the placenta.

Fetal magnetic resonance imaging and human genetics

The use of fetal magnetic resonance imaging (MRI), in addition to prenatal genetic testing and sonography, has the potential to improve prenatal diagnosis of genetic disorders. MRI plays an important role in the evaluation of fetal abnormalities and malformations. Fetal MRI often enables a differential diagnosis, a determination of the extent of the disorder, the prognosis, and an improvement in therapeutic management. For counseling of parents, as well as to basically understand how genetic aberrations affect fetal development, it is of great importance to correlate different genotypes with fetal MRI data.

Prenatal diagnosis and management for a large fetal cardiac tumor complicated with hydrops fetalis

Fetal cardiac tumor is a rare disease, and its prognosis varies in relation to the complications such as arrhythmia and out-flow obstruction. Hydrops fetalis is one of severe complications that result in an unfavorable outcome. A case is presented herein of a large fetal cardiac tumor diagnosed at 28 weeks gestation. At 30 weeks gestation, the fetus complicated with hydrops fetalis because of impaired cardiac function. Increased peak systolic velocity in the ascending aorta and marked reversed flow in the ductus venosus were observed. Oral digoxin therapy was administered to the mother as a cardiotonic agent and the hydropic condition was immediately diminished. After normal delivery, the cardiac tumor gradually decreased in size and the infant developed normally, but required an antiarrhythmic drug. The case indicates that the in utero digoxin therapy could be a choice for hydrops fetalis caused by cardiac tumor.

Assessment of cortical maturation with prenatal MRI: part II: abnormalities of cortical maturation

The fetal cortical maturation is a long process with predefined steps. Abnormalities can occur at different stages of cortical maturation, resulting in various malformations. They can result from disturbance in cell proliferation, cell differentiation, cell migration and in organization of the cortex. Analysis of the different abnormalities of cortical maturation is given with illustrations of the principal malformations encountered in utero and accessible to MRI.

Precise prenatal diagnosis of tuberous sclerosis by sequencing the TSC2 gene

BACKGROUND

The presumptive prenatal diagnosis of tuberous sclerosis (TSC) previously depended upon fetal imaging. Cloning of the two TSC genes (TSC1 and TSC2) now enables precise molecular diagnosis by gene sequencing. We used this approach for the prenatal diagnosis of a fetus showing multiple intracardiac tumors.

METHODS

DNA extracted from cultivated amniotic fluid cells underwent sequencing of all coding regions and exon-intron boundaries of the TSC1 and TSC2 genes.

RESULTS

A mutation (R611Q) was found in exon 16 of the TSC2 gene. Thus far, neither clinically unaffected parents has provided blood samples for mutation analysis.

CONCLUSION

For the first time, mutation analysis of a TSC gene enabled a precise prenatal diagnosis.

Prenatal echocardiographic differential diagnosis of fetal cardiac tumors

OBJECTIVES

To present data on echocardiographic findings of fetal cardiac tumors and discuss their differential diagnoses.

METHODS

We retrospectively reviewed 14 cases of fetal echogenic cardiac mass diagnosed between 1990 and 2003; 12 were confirmed to be cardiac tumors and two were false-positive diagnoses. The echocardiographic characteristics examined included number, size, location and associated complications.

RESULTS

Eight fetuses had a single tumor and four fetuses had multiple tumors. The left ventricle was most often affected. Parents of eight fetuses opted for termination of pregnancy, one fetus died in utero and three affected fetuses survived. Histopathological examination revealed cardiac rhabdomyoma in six fetuses, fibroma in two, teratoma in two, lipoma in one and hemangioma in one. The pitfalls associated with prenatal echocardiographic diagnosis of cardiac tumors include: they may be too small to be visualized, intracardiac echogenic foci may mimic tumors, and echogenicity resulting from extracardiac structures or neoplasms near the heart may falsely appear as tumors.

CONCLUSION

Fetal cardiac tumors can be detected by echocardiography. However, differential diagnosis is important as this will affect prognosis and subsequent management.

Association between cardiac tumors and tuberous sclerosis in the fetus and neonate

A retrospective review was performed in 94 patients with > or =1 cardiac tumors seen on prenatal or neonatal echocardiography at 5 major referral centers. Tuberous sclerosis was present in 68 patients diagnosed with a cardiac tumor in utero or during the neonatal period, including 61 of 64 with multiple tumors.