Prenatal presentation of cervical congenital neuroblastoma

EXIT-to-airway: Fundamentals, prenatal work-up, and technical aspects

Ex-utero intrapartum treatment (EXIT) is a delivery strategy developed to manage a variety of prenatally diagnosed conditions in the transition to newborn life. This procedure allows control and provides time for intervention in otherwise life-threatening malformations, such as congenital upper airway obstructions. EXIT-to-airway has changed the outcome of fetuses with these anomalies. The main purpose of this intervention is to improve the safety of establishing a reliable airway at birth. Maximal but controlled uterine relaxation to maintain feto-maternal perfusion and thus gas exchange, while keeping the fetal and maternal well-being are the paradigms of any type of EXIT. The most important aspect of fetal airway management is to consolidate a highly trained, well-coordinated, multidisciplinary team that is prepared for every contingency. A comprehensive prenatal assessment, including ultrasound, fetal echocardiogram, fetal MRI, and genetic testing is imperative for patient selection. Extensive preoperative planning, ad-hoc team meetings, and surgical simulations for challenging cases are critical strategies to achieve the best outcomes. This article outlines the prenatal work-up, decision making, technical aspects, and principles for a successful EXIT-to-airway procedure.

Malignant primitive epithelioid sarcoma with features of rhabdoid tumor presenting in utero with diffusely metastatic disease

Diagnosis of a tumor in utero is a rare occurrence and poses diagnostic and therapeutic challenges. In cases of tumor-associated hydrops, there is significant risk of fetal demise, and prenatal intervention may be considered to avoid this outcome when possible. When fetal intervention is unlikely to improve survival, information can be useful for counseling families. We present a rare case of fetal diagnosis of a primary renal malignancy with widespread metastases and hydrops, with unique immunohistochemical findings consistent with malignant primitive epithelioid sarcoma with features of rhabdoid tumor.

Congenital Oral Masses: An Anatomic Approach to Diagnosis

Although congenital oral masses are rare, they are readily detectable during fetal US screening. Most congenital oral masses are benign, but some may cause mechanical airway obstruction, resulting in poor outcomes at delivery. The radiologist's ability to describe these abnormalities and their physiologic sequelae accurately can have a substantial effect on perinatal treatment. Furthermore, despite being rare, congenital oral lesions encountered at screening and at follow up fetal MRI provide the opportunity to make a specific diagnosis by following a simple anatomic approach. This article describes an anatomic algorithm as the framework for accurate diagnosis of congenital oral lesions. The imaging appearance of the most common congenital oral cavity neoplasms is outlined, including vascular anomalies, epulides, choristomas, congenital lingual thyroid anomalies, lingual hamartomas, and epignathi, and other conditions that mimic these at US. Also reviewed are perinatal management of masses that affect the fetal airway and the imaging features key to optimizing delivery outcomes. Online supplemental material is available for this article. ^©RSNA, 2019.

Prenatally diagnosed fetal tumors of the head and neck: a systematic review with antenatal and postnatal outcomes over the past 20 years

AIM

The aim of this study was to review prenatally diagnosed tumors of the head and neck in the fetus and to report antenatal and postnatal outcomes.

METHODS

PubMed/Medline, EMBASE/SCOPUS, Cochrane database and Google Scholar were reviewed over the last 20 years. No language or article type restriction was used.

RESULTS

A total of 1940 record were retrieved. Of the 713 records screened, 566 full-text articles were assessed for eligibility. After 445 articles were excluded for specified reasons, 111 studies met the research criteria and were included for qualitative analysis. Overall, 306 cases of fetal tumors of the head and neck were reviewed. Maternal age was an independent factor. The mean maternal age was 28.2 years and gestational age at prenatal diagnosis was 27.1 weeks. Conventional 2D ultrasound was the standard diagnostic procedure in 27.9% of cases and was implemented in 27.3% of cases by 3D ultrasound and fetal magnetic resonance imaging (MRI). Diagnostic evaluation of intracranial spreading and high-airway obstructions was greatly enhanced by fetal MRI. The more common type of fetal tumor was hemangioma/lymphangioms (42.1%), followed by teratomas (29.7%), tumors of the gingiva (10.1%) and lymphatic venous malformations (9.1%), respectively. Fetal karyotyping was performed only in 9.8% of cases; within fetuses undergoing karyotype, chromosomal abnormalities accounted for 20% of cases. The most common pregnancy complication was polyhydramnios (26.3%). Ex utero intrapartum treatment (EXIT) procedure was performed in 30.1% of cases while surgical excision was used in 22.9% during postnatal life. The survival rate was 35.35%.

CONCLUSION

Fetal tumors of the head and neck are rare congenital malformations. Two-dimensional ultrasound is diagnostic in almost all cases; however, MRI may be an important diagnostic adjunct in targeted cases and help patient selection for immediate intubation at the time of delivery. EXIT procedure and surgical removal of the tumor was associated with good prognosis.

Current Role of Fetal Magnetic Resonance Imaging in Body Anomalies

Fetal MR body applications have become more common in recent years as both in utero therapies, including fetoscopic surgery, and improvements in perinatal care have increased the demand for precise antenatal anatomic detail. This article discusses the variety of fast imaging sequences available to the fetal imager and describes their applications to both common and unusual congenital pathologies, including of the neck, chest, abdomen/pelvis and musculoskeletal systems.

Thoracic ganglioneuromas resulting in nonimmune hydrops fetalis

Introduction Most often, ganglioneuromas affect older pediatric and adult patients. They are typically slow growing tumors that remain clinically silent until they become large enough to cause symptoms by compression of adjacent structures. Case We report a case of a 22-year-old Hispanic gravida 2 para 1 female patient who was found to have massive hydrops fetalis at 20 completed gestational weeks. Fetal echocardiography revealed a narrowed distal ductal arch and proximal descending aorta. Cesarean delivery was undertaken at 29 completed gestational weeks for refractory labor and nonreassuring fetal status. The neonate expired at 47 minutes of life despite aggressive resuscitation. At autopsy, multiple thoracic masses were found adjacent to a compressed proximal descending aorta. Histological and immunohistochemical analysis confirmed the diagnosis of a ganglioneuroma, a rare type of neural crest tumor. Discussion A variety of intrathoracic masses have previously been reported to cause hydrops fetalis including teratomas, fibrosarcomas, and lymphangiomas. To our knowledge, this case is the first description of hydrops fetalis caused by ganglioneuromas. We propose that multiple thoracic ganglioneuromas led to biventricular distal outflow tract obstruction and hydrops fetalis.

Perinatal management of infant tumors and the promise of fetal surgery

PURPOSE OF REVIEW

This review outlines the current approaches to prenatal imaging, differential diagnosis, antenatal natural history, and the available treatment options for the most commonly prenatally diagnosed malignant tumors.

RECENT FINDINGS

In-utero diagnosis of fetal tumors, although still a rare event, has become more common as prenatal imaging modalities have improved. In general, this prenatal diagnosis allows more informed prenatal counseling and better perinatal planning for potentially high-risk deliveries. There are rare indications for prenatal fetal intervention.

SUMMARY

Diagnosis of a fetal tumor should prompt referral to a specialized center. Further understanding of these rare patients will require multicenter collaboration.

Tracheoesophageal displacement index and predictors of airway obstruction for fetuses with neck masses

PURPOSE

There are no established selection guidelines to determine which fetuses with giant neck masses may benefit from delivery using an ex utero intrapartum treatment procedure. The purposes of this study were to describe the tracheoesophageal displacement index (TEDI), a novel measurement of fetal airway displacement, and to correlate this measurement and other prenatal findings to the extent of airway obstruction at birth.

METHODS

The medical records of all fetuses with giant neck masses evaluated between 2001 and 2011 were reviewed. At birth, each infant's airway was categorized as uncomplicated or complicated. Prenatal variables were correlated with airway difficulty.

RESULTS

There were 24 fetuses with large neck masses (11 lymphatic malformations, 10 teratomas, 3 others). One fetus died in utero, and 3 underwent pregnancy termination. Variables associated with a complicated airway at birth included polyhydramnios, teratoma diagnosis, and tracheoesophageal displacement index. Tracheoesophageal displacement index greater than 12 correlated strongly with a complicated airway (area under the curve = 0.80). All fetuses classified with an uncomplicated airway (n = 7) had a diagnosis other than teratoma and normal amniotic fluid volume.

CONCLUSION

In fetuses with giant neck masses, the presence of polyhydramnios, teratoma diagnosis, or tracheoesophageal displacement index greater than 12 are predictive of a complicated airway at birth. Our data suggest that fetuses without any of these findings may be delivered safely without an ex utero intrapartum treatment approach.

Fetal cervical neuroblastoma: prenatal diagnosis

Neuroblastoma is the most frequent extracranial solid tumor in childhood, but it is seldom diagnosed prenatally. It usually presented with adrenal masses. Presentation of other localization is extremely rare. We report a case of cervical neuroblastoma identified at 20 weeks of gestational age. This is the third case diagnosed antenatally on neck region in the literature. Additionally, it is the first case that extended to the brain. We also discussed the literature for cervical neuroblastoma detected prenatally.

Ex-utero intrapartum treatment procedure for giant neck masses--fetal and maternal outcomes

BACKGROUND/PURPOSE

For fetuses with giant neck masses and tracheal obstruction, an ex-utero intrapartum treatment (EXIT) procedure allows for safe nonemergent airway management while on placental support. Our objective was to examine fetal and maternal outcomes after EXIT procedure specifically for giant neck masses.

METHODS

The medical records of all patients referred to a comprehensive fetal center for a giant neck mass between 2001 and 2010 were reviewed retrospectively.

RESULTS

Among 24 patients referred, an EXIT procedure was performed in 12 with evidence of tracheal compression. An EXIT procedure was not performed because of minimal tracheal involvement (n = 8), elective abortion (n = 2), fetal demise (n = 1), or obstetric complication (n = 1). In all fetuses, the airway was successfully secured; tracheal intubation was achieved with rigid bronchoscopy (n = 10), direct laryngoscopy (n = 1), and tracheostomy (n = 1). Eleven patients survived to discharge, whereas 1 patient with significant pulmonary hypoplasia died 8 days after emergency EXIT procedure. Of 11 surviving infants, 10 are neurodevelopmentally intact. All mothers who desired future pregnancies have subsequently had uncomplicated deliveries (n = 6).

CONCLUSIONS

Ex-utero intrapartum treatment procedure for giant neck mass can be performed safely for both mother and child. Most fetuses can be orotracheally intubated with minimal long-term morbidity. The potential for future pregnancies is preserved.

Prenatal diagnosis of a cervical teratoma with a cytogenetic study

We describe a cervical teratoma revealed in the prenatal period that was studied cytogenetically. We were recently confronted with the case of a fetal solid neck mass suggestive of a teratoma. After termination of pregnancy the tumor was studied cytogenetically. This is the first case in the recent literature where a clone of cells with an additional chromosome marker has been detected. Cytogenetic study of the fetal blood in addition to cytogenetic study of the tumor after the termination of pregnancy showed the karyotypes 46,XY and 46,XY/47,XY + m, respectively. Fetal cervical teratoma is a rare condition. Genetic investigation in the case should be considered in order to reveal chromosome rearrangements.

Nomograms of the fetal neck circumference and area throughout gestation

OBJECTIVE

The purpose of this study was to create reference range nomograms of the axial fetal neck circumference (FNC) and fetal neck area (FNA) throughout gestation.

METHODS

This prospective cross-sectional study involved pregnant patients between 14 and 40 weeks' gestation. Inclusion criteria consisted of well-established dates (confirmed by early sonography) and nonanomalous singleton fetuses with intact fetal membranes. Sonographic measurements included biparietal diameter, head circumference, abdominal circumference, femur length, humerus length, transcerebellar diameter, and sonographically estimated fetal weight. Axial FNC and FNA values were calculated as means of 3 separate measurements. The 5th, 50th, and 95th percentiles were estimated at each week of gestational age (GA) by least squares regression for the mean and SD of the FNC and FNA as functions of GA. R(2) and associated P values for the relationships between the FNC, FNA, and other sonographic biometric measurements were calculated.

RESULTS

The study included 720 consecutive patients. The mean maternal age +/- SD was 27.3 +/- 6.6 years; median gravidity, 3 (range, 1-13); and median parity, 1 (range, 0-10). The following equations were devised: mean FNC (centimeters) = -11.85 + 1.687 x GA (weeks) -0.043 x GA(2) + 0.0004951 x GA(3); SD(FNC) = 3.15 - 0.3823 x GA + 0.01733 x GA(2) - 0.0002179 x GA(3); mean FNA (square centimeters) = 37.29 - 7.0 x GA + 0.4717 x GA(2) - 0.01245 x GA(3) + 0.0001222 x GA(4); and SD(FNA) = 7.08 - 0.9413 x GA + 0.04135 x GA(2) - 0.0004829 x GA(3). Both the FNC and FNA correlated significantly and strongly with biparietal diameter, head circumference, abdominal circumference, humerus length, femur length, transcerebellar diameter, and sonographically estimated fetal weight.

CONCLUSIONS

Current nomograms of the axial FNC and FNA throughout gestation have been provided.

Retropharyngeal neuroblastoma in a neonate: case report and literature review

Primary cervical neuroblastoma (NB) in neonates is extremely rare. We treated a 1-day-old male neonate who presented with stridor and feeding difficulty and was subsequently diagnosed with NB of the retropharynx. The tumor was excised in toto transorally, and no metastatic lesions were confirmed. Histopathology and molecular genetic analysis showed poorly differentiated NB with no N-myc amplification, stage I NB. He has had no signs of recurrence or adverse sequelae during 18 months of follow-up. We report our experience and review the literature.

Perinatal neuroblastoma

One-fifth of all neuroblastomas are diagnosed either antenatally or in the first 3 months of life. Over the past two decades, routine prenatal ultrasound has significantly increased the rate of diagnosis of fetal neuroblastoma. More than 90% of these tumors arise in the adrenal gland, suggesting a link between perinatal tumors and the nodular collections of neuroblasts that are part of normal adrenal development. In fact, there is compelling evidence that the cystic variant of perinatal neuroblastoma is caused by a perturbation of the involution program of these neuroblastic nodules. The vast majority of these cases are localized tumors with favorable biological features, which correlates with a 4-year survival of greater than 95%. The high rate of spontaneous regression of these tumors, coupled with the significant risks of resectional surgery in small neonates, has prompted the development of a prospective clinical trail of expectant observation as primary therapy for infants with small, localized tumors. The ultimate goal of such studies is to define an ultra-low-risk group of neuroblastoma patients who do not require invasive procedures or chemotherapy to achieve an excellent outcome.

Giant hemangioma of the fetal neck, mimicking a teratoma

We present a case involving a giant hemangioma of the fetal neck, prenatal diagnosis of which was a teratoma. A 32-year-old pregnant woman was referred to our hospital at 31 weeks' gestation owing to a giant solid mass of the fetal neck and excessive amniotic fluid. The mass seemed to be occupying the neck almost entirely, extending to the nasopharyngeal cavity, the mandible, the surface of the left orbit and the left shoulder. Based on sonographic and magnetic resonance imaging (MRI) findings, diagnosis of a giant teratoma was made. Cesarean section was performed at 35.5 weeks' gestation, and a female infant weighing 2826 g was delivered. Purpurae were observed on the neck of the infant, and the tumor turned out to be a hemangioma. Postnatal MRI findings, in which the tumor's signal intensity differed from that of the prenatal findings, were quite compatible with the diagnosis of a typical hemangioma. Laser and corticosteroid treatment successfully decreased the volume of the mass. Although it may not always be possible to make a prenatal differential diagnosis between a hemangioma and a teratoma in the neck of the fetus, serial ultrasound and MRI examination are mandatory to evaluate the prognosis and to plan suitable treatment. Moreover, possible postnatal changes to the tumor characteristics have to be taken into consideration when evaluating the findings of prenatal diagnostic imaging.

[Prenatal ultrasound diagnosis of neuroblastoma]

With the progress of foetal ultrasonography, diagnosis of foetal tumors can be made before birth. We report five cases of prenatally detected neuroblastoma of the adrenal glands. Diagnosis was made during the third trimester in all cases. At birth no clinical sign related to the tumor was present, and urinary catecholamines were within normal ranges. On ultrasound scans the tumor was cystic in 1 case, solid in 2 cases and of mixed echogenicity in 2 cases. All children were operated on without pre or postoperative chemotherapy. In each setting the tumor was a stage I neuroblastoma according to the Evans classification. All children are alive and disease-free with a follow-up of 32 months at 14 years.

From the Archives of the AFIP

Fetal tumors are a diverse group of neoplasms, which are unique in their histologic characteristics, anatomic distribution, and pathophysiology. The biologic behavior of tumors in the fetus may differ dramatically compared with that of the same tumor detected later in life. Teratomas are the dominant histologic type and constitute the majority of both extracranial and intracranial neoplasms. Although often histologically mature, they may prove lethal because of their location and metabolic demands on the fetus. Large solid tumors may lead to cardiovascular compromise and hydrops fetalis. Extracranial teratomas are most commonly located in the sacrococcygeal area, followed by the head and neck, chest, and retroperitoneum. Fetuses with intracranial tumors have a poor prognosis regardless of histologic type. There are, however, two notable exceptions: lipomas and choroid plexus papillomas, both of which have a more favorable outcome. Neuroblastoma is the most common fetal malignancy. It may be either solid or cystic and is more often located on the right side. It typically has favorable biologic markers and stage at presentation. The prognosis for prenatally diagnosed cases is excellent. Other fetal neoplasms include soft-tissue tumors (both benign and malignant), leukemia, mesenchymal hamartoma of the kidney, and liver tumors (hemangioendothelioma, mesenchymal hamartoma, and hepatoblastoma).

Congenital cervical teratoma, associated with agenesis ofcorpus callosum and a subarachnoid cyst

Cervical teratoma is a neoplasm composed of embryonic tissues with representation of all three germ layers. We report an extremely rare case of fetal cervical teratoma presenting at 24 weeks of gestation. A submaxillary mass and agenesis of corpus callosum were identified on ultrasonography, associated with agenesis of corpus callosum and a subarachnoid cyst.

Congenital cervical neuroblastoma

Primary congenital cervical neuroblastomas are very rare. A history of upper aerodigestive compromise with Horner syndrome can be of value for the early diagnosis of this lesion. Congenital neuroblastomas usually have a favorable outcome. Like all the other clinically relevant groups of neuroblastomas, management should take into consideration the biological findings of each tumor, which predicts outcome than other clinical findings.