Von Hippel-Lindau disease in pregnancy: A brief review

Neurocutaneous Disorders in Pregnancy

Importance

Neurocutaneous disorders have significant implications for care of the pregnant patient. As neurocutaneous disorders are uncommon, obstetricians may be unfamiliar with these disorders and with recommendations for appropriate care of this population.

Objective

This review aims to summarize existing literature on the interaction between neurocutaneous disorders and pregnancy and to provide a guide for physicians caring for an affected patient.

Evidence Acquisition

A PubMed, MEDLINE, and Google Scholar search was carried out with a broad range of combinations of the medical subject headings (MeSH) terms "pregnancy," "Sturge -Weber," "Neurofibromatosis Type 1," "neurofibromatosis type 2," "von Hippel Lindau," "Tuberous Sclerosis," "neurocutaneous disorder," "treatment," "congenital malformations," "neurodevelopmental defects," "miscarriage," "breastfeeding," "autoimmune," "pathophysiology," and "management." References of included articles were searched to identify any articles that may have been missed after the above method was used.

Results

Neurocutaneous disorders are associated with increased pregnancy-associated maternal and fetal/neonatal morbidity, largely surrounding hypertensive disorders, epilepsy, and medication exposure. Some features of neurocutaneous disorders may be worsened or accelerated by pregnancy. Neurocutaneous disorders can often be diagnosed prenatally. Therefore, directed assessment should be offered to affected individuals with a personal or family history of a neurocutaneous disorder.

Conclusion and Relevance

Patients affected by neurocutaneous disorders who are pregnant or planning for future pregnancy should be carefully followed by a multidisciplinary team, which could include maternal-fetal medicine, neurology, and anesthesia, as well as other relevant subspecialists. Additional research is required regarding optimal counseling and management of these patients.

Sporadic cauda equina hemangioblastoma: surgical management in a pregnant woman

Hemangioblastoma is a rare benign vascular tumour of the central nervous system that occurs either sporadically or in association with Von Hippel-Lindau syndrome. Hemangioblastoma can be found throughout the central nervous system and usually present with late manifestations due to their slow growth rate. Cauda equina hemangioblastomas are extremely rare, and in the literature, no cases are reported on the surgical management of pregnant patients with this condition. We report the case of a young woman with back pain and sphincter dysfunctions in whom an L1-L2 hemangioblastoma was diagnosed. We describe the perioperative and surgical strategies we adopted to successfully treat the patient and preserve the fetus well-being.

Pregnancy Promotes the Recurrence of Cerebellar Hemangioblastoma?

ABSTRACT

Cerebellar hemangioblastomas with pregnancy is rare, but coexistence of pregnancy and recurrent cerebellar hemangioblastomas is rather rare. And coexistence of other diseases during pregnancy usually leads to misdiagnosis because of pregnancy reaction. A 29-year-old woman, at the 8th week of pregnancy, complained of nausea, vomiting, and episodic posterior occipital pain and was misdiagnosed pregnancy reaction without any special treatment during her several visits to local hospital. The patient was diagnosed cerebellar hemangioblastomas 14 years ago, after surgery, she received regular re-examination without recurrence. At the 15th week of pregnancy, the situation of the patient got worse, and she was admitted to our hospital. Brain magnetic resonance imaging showed a lesion in cerebellum. It was considered to be cerebellar hemangioblastomas and was confirmed finally by postoperative pathological examination. In clinical practice, differential diagnosis is of great importance during pregnancy because many other diseases can mimic pregnancy reaction. In this patient, the intracranial hypertension caused by recurrent cerebellar hemangioblastomas was misdiagnosed as pregnancy reaction and it was suggested that the change of hormones, neuroendocrine, and cardiovascular function promoted the recurrence of cerebellar hemangioblastomas.

Fatal holocord recurrence of a pregnancy-related, low-grade spinal ependymoma: case report and review of an unusual clinical phenomenon

INTRODUCTION

Pregnancy-related spinal tumors (PRSTs) are unusual tumors that present during pregnancy or within a year after delivery. We describe a fatal holocord recurrence of a spinal ependymoma, which, to the best of our knowledge, is one of the most extensive PRSTs reported thus far.

CASE PRESENTATION

A 21-year-old primigravida presented at 6 months of gestation with urinary incontinence for 2 months and spastic paraparesis for 1 month. MRI showed a conus intramedullary lesion from T10 to 12. Near-total resection of the lesion was performed. The histopathological diagnosis was that of a cellular ependymoma (WHO grade II). The patient presented 6 months later with progressive quadriparesis and breathing difficulty. MRI demonstrated holocord recurrence of the tumor with edema extending to the pontomedullary junction. The patient succumbed to respiratory failure before decompression of the tumor could be performed.

DISCUSSION

This case highlights an unusual clinical course of a pregnancy-related, low-grade spinal ependymoma. The possible hormonal and genetic mechanisms underlying the aggressive involvement of the entire spinal cord by the recurrent tumor are discussed in the light of a literature review. Future studies may shed light on the possibility of utilizing these mechanisms as therapeutic targets to alter the clinical course of aggressive spinal ependymomas.

Brain Tumor, Pheochromocytoma, and Pregnancy: A Case Report of a Cesarean Delivery in a Patient With Von Hippel-Lindau Disease

A young woman first diagnosed with von Hippel-Lindau disease (VHL) during pregnancy underwent an uncomplicated cesarean delivery despite having multiple classic VHL tumors, including a large cerebellopontine brain mass and vasoactive pheochromocytoma. Patients with VHL may have multiple tumors of the central nervous system and viscera that greatly impact anesthetic management. This case highlights the anesthetic considerations for a parturient with pheochromocytoma and elevated intracranial pressure, as well as the importance of a multidisciplinary team approach.

Von Hippel-Lindau Disease and the Eye

Retinal hemangioblastoma (also referred to as retinal capillary hemangioma) is a benign lesion originating from the endothelial and glial components of the neurosensory retina and optic nerve head. Historically known as a manifestation of the von Hippel-Lindau (VHL) disease, it can be seen as an isolated finding or in association with some rare ocular conditions. In addition to characteristic ophthalmoscopic features, results of numerous ancillary tests including angiography, ultrasound, optical coherence tomography, and genetic tests may support the diagnosis and differentiate it from similar conditions. Because of serious life-threatening complications of VHL disease, every ocular approach to retinal hemangioblastomas should be in relationship with additional multidisciplinary diagnostic and therapeutic efforts. In addition, any patient with actual or probable diagnosis of VHL disease should be screened for ocular involvement. Unfavorable visual loss can occur early, and ocular complications of VHL range from exudative retinopathy to tractional retinal detachment, neovascular glaucoma, and phthisis bulbi. Accordingly, various treatment methods have been tested with overall acceptable responses, including photocoagulation, cryotherapy, photodynamic therapy, plaque radiotherapy, vitrectomy, and more novel intravitreal injections of anti-vascular endothelial growth factors and propranolol.

Pedigree analysis, diagnosis and treatment in Von Hippel-Lindau syndrome: A report of three cases

The objective of the present study was to systematically investigate the clinical features, diagnosis and therapeutic treatment of Von Hippel-Lindau (VHL) syndrome in order to improve understanding of this disease. A total of 3 cases of VHL syndrome treated at the Affiliated Hospital of Zunyi Medical College (Zunyi, China) between September 2014 and October 2015 were retrospectively analyzed. The associated literature was reviewed, and the diagnostic and therapeutic features were discussed. Case 1 was diagnosed as VHL syndrome accompanied by a renal tumor on the right side, and radical tumor resection in the right kidney was performed. Postoperative pathological examination indicated clear cell carcinoma. Case 2 was diagnosed as VHL syndrome accompanied by bilateral adrenal pheochromocytoma. The left-side adrenal tumor was removed, and postoperative pathological analysis was suggestive of adrenal pheochromocytoma. Case 3 visited the hospital due to the presence of masses on the left and right sides of the kidney, but did not undergo surgery for personal reasons. Follow-ups were scheduled subsequent to surgery at another hospital. The diagnosis in all 3 cases was confirmed by genetic testing, where VHL mutations were detected in all patients. Following surgery, pedigree and genetic analysis was performed in all 3 pedigrees and VHL mutations were identified in 7 family members. The diagnosis of VHL syndrome should be based on the clinical manifestation of the patients and the results of genetic tests. DNA analysis of mutations is the main method for diagnosis. An appropriate surgical plan should be formulated based on the site, size and number of tumors, and the condition of the patient. Since VHL syndrome is an inheritable genetic disorder and relapse following surgery is common, pedigree analysis of the patient and lifelong follow-ups are essential. Additionally, physicians should pay attention to VHL syndrome in order to avoid missing diagnosis or misdiagnosis.

Difficulties in the management of retinal capillary haemangiomas associated with von Hippel Lindau disease

CLINICAL CASE

A 29-year-old female with bilateral retinal capillary haemangiomas (RCH). A genetic analysis was carried out due to the suspicion of von Hippel-Lindau (VHL) disease, with negative results on 2occasions. There was progression of the RCH in the left eye, leading to a macular epiretinal membrane. The patient was treated with laser, intravitreal ranibizumab, and vitrectomy. Finally, a third genetic test detected a de novo mutation in the VHL gene, and led to the genetic diagnosis.

DISCUSSION

VHL syndrome causes a complex ocular disease with a difficult diagnosis that requires early treatment of the RCH in order to modify its visual prognosis.

Therapeutic strategy and outcome of spine tumors in pregnancy: a report of 21 cases and literature review

STUDY DESIGN

A retrospective study was performed.

OBJECTIVE

To illustrate the characteristics of spine tumors during pregnancy and obtain better insight into therapeutic strategies of such tumors by analyzing 21 cases treated in Changzheng Hospital and reviewing previous reports in the literature.

SUMMARY OF BACKGROUND DATA

The concurrence of spine tumors and pregnancy is relatively rare. There are controversies over the treatment options for this disease, which increase the difficulty of the clinical treatment.

METHODS

Between 2002 and 2013, 21 pregnant patients were identified with spine tumors. Clinical data including symptoms, signs, treatment options, and obstetrical and neonatal outcomes were recorded and preserved. Clinical data and treatment efficacy were analyzed via medical record review.

RESULTS

The median age of the 21 patients was 28.87 years (interquartile range, 6.00 yr). Tumor types in this series were giant cell tumor (5 cases), hemangioma (5 cases), schwannoma (4 cases), eosinophilic granuloma (2 cases), neurofibroma (1 case), multiple myeloma (1 case), and with metastatic tumor (3 cases). Two patients underwent spine surgery during pregnancy and 8 patients accepted tumor resection immediately after delivery. Pregnancy termination occurred in 5 patients, whereas the rest of the patients smoothly gave birth to healthy babies including 3 premature infants. Two patients died and 2 patients experienced local recurrence during follow-up.

CONCLUSION

With close observation, it was found that most of pregnant patients with benign spine tumors could postpone surgery after delivery. Surgical treatment should be adopted during pregnancy when patients are with highly malignant tumor or experience a sharp deterioration and the guard of it is safer than radiotherapy and chemotherapy during pregnancy.

LEVEL OF EVIDENCE

4.

Gender specific issues in hereditary ocular disorders

This review is intended to summarize the current knowledge from basic science and clinical medical literature cited within PubMed that pertain to gender-related factors and affect those individuals with hereditary ocular disorders. We consider gender-related biological factors that (a) affect disease onset and progression, (b) gender differences for major X-linked ocular disorders, (c) gender-specific conditions, (d) medications that may influence genetic eye disorders, and finally, (e) gender-related issues that influence the management and quality of life of these patients. Several studies have demonstrated the manner in which sex-related hormones in animal models are capable of influencing cell pathway and survival that are likely to affect hereditary eye disorders. There are very few clinical studies that provide compelling evidence for gender differences in human ocular conditions, other than for a number of X-linked disorders. Disease expression for X-linked disorders may be impacted by genetic mechanisms such as lyonization or uniparental disomy. Clinical evidence regarding the impact of gender-related medical conditions and therapies on eye conditions is extremely limited and primarily based on anecdotal evidence. Gender-specific factors may play a major role in the underlying biological pathways that influence the onset, rate of progression, and clinical findings associated with ocular genetic conditions. Clinicians need to be aware of the variable phenotypes observed in female carriers of X-linked disorders of gender specific issues, many of which are inadequately addressed in the current literature. Clinicians need to be sensitive to gender differences in social, cultural, and religious systems and they should also be aware of how their own gender biases may influence how they counsel patients. Finally, it is clear that the lack of effective clinical studies in this area creates an opportunity for future research that will have real benefits for these patients.

Spinal hemangioblastoma presenting with low back pain in pregnancy

BACKGROUND CONTEXT

Low back pain (LBP) is a very common complaint in pregnancy. For this reason, it is often considered directly attributable to the pregnancy rather than a medical problem requiring diagnostic workup. Pregnancy-related LBP should be differentiated from the rare cases of LBP associated with serious spinal diseases. Hemangioblastoma is a vascular tumor of the central nervous system that very rarely can involve the spinal cord. Pregnancy can increase the growth of hemangioblastomas, leading to the appearance of neurologic symptoms.

PURPOSE

To describe an unusual cause of LBP in pregnancy.

STUDY DESIGN

A case report.

METHODS

A 38-year-old woman, with a history of surgical resection of a cerebellar hemangioblastoma at the age of 15 years, presented at 38 weeks of gestation with worsening LBP and numbness of the lower limbs. Diagnostic workup led to a diagnosis of spinal hemangioblastoma. The tumor was removed after cesarean section in the 39th week of gestation.

RESULTS

The detection of spinal hemangioblastoma resulted in a good outcome for both mother and infant.

CONCLUSIONS

This case emphasizes the main role of clinical evaluation in establishing the diagnostic workup, especially in pregnancy. Although LBP is commonly reported, this patient's medical history and the presence of clinical signs on neurologic examination suggested the need for further investigation.

Effect of pregnancy on hemangioblastoma development and progression in von Hippel-Lindau disease

OBJECT

Prior cases suggest that pregnancy increases the development and progression of CNS hemangioblastomas and/or peritumoral cysts. To determine the effect of pregnancy on CNS hemangioblastomas and peritumoral cysts, the authors prospectively evaluated serial clinical and imaging findings in patients with von Hippel-Lindau (VHL) disease who became pregnant and compared findings during pregnancy to findings in the same patients when they were not pregnant as well as to findings from a cohort of VHL patients who did not become pregnant.

METHODS

Female VHL disease patients enrolled in a prospective natural history study who were of reproductive age (16-35 years at study entrance) were included. Analysis of serial clinical and imaging findings was performed.

RESULTS

Thirty-six consecutive female VHL disease patients harboring 177 hemangioblastomas were included (mean follow-up [± SD] 7.5 ± 2.3 years). Nine patients (25%) became pregnant (pregnancy cohort). The mean rates of development of new hemangioblastomas and peritumoral cysts in these women during pregnancy (0.4 ± 0.4 tumors/year; 0.1 ± 0.2 cysts/year) did not differ significantly (p > 0.05) from the mean rates in the same group during nonpregnant periods (0.3 ± 0.4 tumors/year; 0.1 ± -0.1 cysts/year) or from the rate in the 27 patients who did not become pregnant (the no-pregnancy cohort: 0.3 ± 0.5 tumors/year; 0.1 ± 0.2 cysts/year). Hemangioblastoma growth rates were similar (p > 0.05) during pregnancy (mean 29.8% ± 42.7% increase in volume per year) compared with during nonpregnant periods (41.4% ± 51.4%) in the pregnancy cohort and the no-pregnancy cohort (34.3% ± 55.3%). Peritumoral cyst growth rates during pregnancy (571.0% ± 887.4%) were similar (p > 0.05) to those of the no-pregnancy cohort (483.9% ± 493.9%), but the rates were significantly higher for women in the pregnancy cohort during nonpregnant periods (2373.6% ± 3392.9%; p < 0.05 for comparison with no-pregnancy cohort). There was no significant difference (p > 0.05) in the need for resection or the mean age at resection between the pregnancy (28% of hemangioblastomas in cohort; mean patient age at resection 30.2 ± 2.6 years) and no-pregnancy cohorts (19%; 32.3 ± 5.6 years).

CONCLUSIONS

Pregnancy is not associated with increased hemangioblastoma or peritumoral cyst development or progression in patients with VHL disease.

An analysis of five clear cell papillary cystadenomas of mesosalpinx and broad ligament: four associated with von Hippel-Lindau disease and one aggressive sporadic type

AIMS

Clear cell papillary cystadenoma (CCPC) is associated with von Hippel-Lindau disease (VHLD), but rarely involves mesosalpinx and broad ligament (M/BL). This study provides new data about its behaviour and immunophenotype.

METHODS AND RESULTS

We performed an analysis of four benign cases of CCPC of M/BL with either characteristic clinical features or genetic markers [loss of heterozygosity (LOH)] of VHLD in patients ranging from 24 to 36 years and a sporadic case in a 52-year-old presenting with peritoneal metastases. All CCPCs were papillary but had solid and tubular areas. Haemorrhage, thrombosis and scarring were constant features and related to an unusual pattern of sub-epithelial vascularity. All clear or oxyphilic cells co-expressed cytokeratin 7 (CK7), CAM5.2 and vimentin, with strong apical CD10 and nuclear paired box gene 2 (PAX2) immunoreactivity. Three cases also showed positivity for VHL40, epithelial membrane antigen (EMA), Wilms' tumour suppressor gene (WT-1) and cancer antigen 125 (CA125) but only one expressed renal cell carcinoma (RCC) antigen. Vascular plexus overexpressed nuclear and cytoplasmic WT-1.

CONCLUSION

The VHLD-associated cases appeared to be benign, but the sporadic case exhibited a low malignant potential. CCPCs show histological and immunophenotypical similarities with the recently reported clear cell papillary RCC, although the previously unreported apical CD10 and nuclear PAX2 expression may be related to their mesonephric origin. CCPC has a distinctive sub-epithelial vascular pattern that is consistent with its pathogenesis.

Symptomatic cerebellar hemorrhage from recurrent hemangioblastoma during delivery. Case report

A 30-year-old woman suffered cerebellar hemorrhage during the delivery of her first child. She had undergone surgical removal of a symptomatic cerebellar hemangioblastoma 6 years previously. Neuroradiological examinations indicated recurrent hemangioblastoma, confirmed by histological examination of the surgical specimen. She was discharged with no neurological deficit. Hemangioblastomas are benign tumors that are curable with surgical removal, but can grow during pregnancy. Women of reproductive age who have been treated for hemangioblastoma need careful long-term follow up, even if they show no signs of lesion recurrence.

Neurosurgical considerations in von Hippel-Lindau disease

Von Hippel-Lindau disease is an inherited syndrome predisposing to a variety of benign and malignant neoplasms of the central nervous system and viscera that requires comprehensive screening and follow-up of individuals and their families. As such, it is important for the neurosurgeon to be aware of its clinical features and management issues. In this article we review the clinical aspects, management and surveillance of von Hippel-Lindau disease for neurosurgical practice.

Serous cystic neoplasms of the whole pancreas in a patient with von Hippel-Lindau disease

We describe here a case of von Hippel-Lindau (VHL) disease with a serous cystic neoplasm of the whole pancreas. The patient was a 35-year-old woman suffering from a palpable abdominal tumor. She had a history of hemangioblastomas of the cerebellum. CT revealed large solid tumors in the pancreatic head and body, and multiple cystic lesions in the whole pancreas as well as a right renal tumor. When endoscopic retrograde cholangiopancreatography (ERCP) was performed, bleeding from the duodenal papilla was detected. Since she had some distinguishing clinical features, the diagnosis of VHL disease was made. The preoperative diagnosis of the pancreatic lesion was serous cystic neoplasms with hemosuccus pancreaticus and total pancreatectomy was performed. Histological examination of the specimen revealed serous cystic neoplasms which occupied the entire pancreas. VHL cases operated on for serous cystic neoplasms of the entire pancreas are very rare.