Infantile fibrosarcoma of the ileum presenting with congenital bowel obstruction

Mesenchymal tumors of the gastrointestinal tract with NTRK rearrangements: a clinicopathological, immunophenotypic, and molecular study of eight cases, emphasizing their distinction from gastrointestinal stromal tumor (GIST)

Mesenchymal tumors driven by NTRK fusions are clinically and morphologically heterogeneous. With an increasing number of clinicopathological entities being associated with NTRK fusions, the diagnostic and predictive value of the identification of NTRK fusions is uncertain. Recently, mesenchymal tumors in the gastrointestinal tract with NTRK fusions were described as gastrointestinal stromal tumors (GIST), but the nosology of such neoplasms remains controversial. We report eight mesenchymal tumors involving the gastrointestinal tract with NTRK1 or NTRK3 rearrangements. The tumors occurred in six children and two adults, five males and three females (age range 2 months-55 years; median 3.5 years), and involved the small intestine (n = 4), stomach (n = 2), rectum (n = 1), and mesentery (n = 1). Clinical outcomes were variable, ranging from relatively indolent (n = 2) to aggressive diseases (n = 2). Morphologically, the tumors were heterogeneous and could be classified in the following three groups: (1) infantile fibrosarcoma involving the gastrointestinal tract (n = 4), enriched for NTRK3 fusions; (2) low-grade CD34-positive, S100 protein-positive spindle-cell tumors, associated with NTRK1 fusions (n = 2); and (3) unclassified high-grade spindle-cell sarcomas, with NTRK1 fusions (n = 2). By immunohistochemistry, the tumors demonstrated diffuse pan-TRK expression, of variable intensity, and lacked a specific line of differentiation. Four cases expressed CD34, which was coexpressed with S100 protein in three cases. Expression of SOX10, KIT, and DOG1 was consistently absent. Molecular genetic testing identified TPM3-NTRK1 (n = 3), TPR-NTRK1, LMNA-NTRK1, and ETV6-NTRK3 (n = 2), and SPECC1L-NTRK3 in-frame gene fusions. We conclude that the evaluation of mesenchymal spindle-cell neoplasms of the gastrointestinal tract without a definitive line of differentiation should include interrogation of NTRK alterations, particularly in pediatric patients. Mesenchymal tumors of the gastrointestinal tract with NTRK rearrangements are clinically and morphologically heterogeneous, and few, if any, seem related to GIST.

A Case of Congenital Infantile Fibrosarcoma of the Bowel Presenting as a Neonatal Intussusception

Neonatal intussusception of the intestinal tract is rare. However, most neonatal intussusceptions have an organic lead point. For the lead point to be a neoplasm is extremely rare. We report a case that presented with neonatal intussusception with a congenital infantile fibrosarcoma as the lead point. The detection of ETV6-NTRK3 gene fusion was useful, although the definitive diagnosis was achieved by a comprehensive evaluation including this gene analysis, standard histology and immunohistochemistry. Neonatal intussusception should be suspected to be caused by a neoplasm. If pathological diagnosis is difficult, molecular analysis should be utilized to diagnose congenital infantile fibrosarcoma.

Congenital Infantile Fibrosarcoma Causing Intestinal Perforation in a Newborn

Congenital infantile fibrosarcoma (CIF) is a rare malignant mesenchymal tumor and only 14 cases have been reported with gastrointestinal manifestation. We report about a female newborn delivered per emergency cesarean section at 34 weeks of gestation. Postnatally, she rapidly developed an acute abdomen and sonographic evidence of intestinal perforation requiring laparotomy on the first day of life. A perforated 2 × 3 cm sized spherical tumorous structure of the jejunum was identified. Due to unknown histopathology at this point and unclear resectional margins, she received a temporary ileostomy, which was closed two months later. Histopathology revealed a congenital intestinal fibrosarcoma without the characteristic ETV6-NTRK3 fusion transcript. In conclusion, this rare tumor must be considered as differential diagnosis of intestinal perforations in newborns.

Congenital intestinal fibrosarcoma with rapid recurrence requiring adjuvant chemotherapy

A total of 16 cases of congenital fibrosarcoma have been reported from 1975 to March 2015. Five of the 16 had abnormal fusion between erythroblast transformation specific translocation variant 6 and neurotrophin recptor gene neurotrophic tyrosine kinase, receptor, type 3 (ETV6-NTRK3); in another five out of 16 this was absent, and six were not tested. All were managed by surgical resection but none involved metastasis. Herein we report the case of a newborn baby girl with congenital fibrosarcoma negative for ETV6-NTRK3 gene fusion, who presented with ileal perforation and positive resection margin. She had rapid recurrence with lymph node metastasis treated with postoperative chemotherapy. There was no further recurrence at >3 years of follow up.

Intestinal congenital/infantile fibrosarcoma: a new clinico-pathological entity?

Congenital/infantile fibrosarcoma (IFS) is a relatively rare form of fibrosarcoma diagnosed at birth or during early years of life and that differs from its adult counterpart because of a more favorable behavior. IFS is also known as cellular congenital mesoblastic nephroma, when it affects the kidney and is often but not always characterized by the ETV6-NTRK3 fusion transcript. We report herein the first series of an exceptional tumor of the small intestine occurring in newborns. The four patients shared a stereotyped clinico-pathological presentation with early and acute onset, intestinal perforation, and an infiltration by a highly cellular spindle cell tumor within the dilated intestinal wall exhibiting pathologic features typical of IFS. Molecular studies for the ETV6-NTRK3 translocation were negative in the three cases tested. Patients were treated by surgical wide resection alone and are alive and well (follow-up: 36 months-25 years). Thus, this new clinico-pathological entity, even with lack of documented evidence of the ETV6-NTRK3 translocation, should be included in the differential diagnosis of congenital bowel perforation or obstruction and may represent an intestinal counterpart of IFS.

Congenital fibrosarcoma of the bowel: sonographic description of a rare case of neonatal intestinal obstruction

A case of localization in the bowel of congenital fibrosarcoma (a rare soft-tissue tumor usually occurring in the extremities) causing intestinal obstruction in a newborn girl is described. A focal thickening of the ileal wall with features mimicking intussusception was identified at sonography; the final diagnosis was achieved by means of molecular analysis after surgical removal of the mass.

Infantile fibrosarcoma misdiagnosed as vascular tumors

Clinical as well as radiologic diagnosis of infantile fibrosarcoma (IFS) is often a challenging problem due to similarities with tumors of vascular origin. Consequently, in the majority of cases, histological and immunohistochemical studies are considered gold standards for the final diagnosis. The two case reports and the review of literature discussed should increase the important features in the history and the presentation that increase the index of suspicion for IFS, as well as it highlights the important characteristics of imaging and laboratory studies that confirm its diagnosis.

Clinical management of infantile fibrosarcoma: a retrospective single-institution review

BACKGROUND

Infantile fibrosarcoma (IFS) is an uncommon soft-tissue sarcoma. Here we review our experience treating this tumor.

PATIENTS AND METHODS

We retrospectively reviewed records of patients with IFS treated at St. Jude Children's Research Hospital between 1980 and 2009.

RESULTS

We identified 15 patients, 8 girls and 7 boys; 13 white and 2 black. Median age at diagnosis was 3 months. Primary sites included the leg (n = 3), chest wall (n = 2), foot (n = 2), and one each in the tongue, occipital region, axilla, parascapular region, arm, forearm, retroperitoneum, and thigh. All patients underwent resection; 11 upfront surgery, and 4 delayed. Complications included loss of the posterior tibial nerve and artery, axillary vein, biceps, pectoralis major, gallbladder, and transverse/sigmoid sinus. Eight received chemotherapy and three radiotherapy. Seven experienced local recurrence and three lung metastasis. Median follow-up was 65 months. At the time of the review, 12 patients were alive and 3 had died. All deaths were in patients older than 1 year at diagnosis with an axial primary site.

CONCLUSIONS

Non-mutilating surgery should be the primary treatment for IFS. Neoadjuvant chemotherapy is indicated when upfront resection is unfeasible. Patients with positive surgical margins should receive adjuvant chemotherapy. Radiotherapy is indicated for axial primary sites where complete resection is impossible.

Different clinical manifestations between primary gastrointestinal malignancies and benign tumors in children

OBJECTIVE

The purpose of the present study was to review the different clinical manifestations of primary gastrointestinal (GI) malignancies and benign tumors in pediatric patients.

METHODS

The demographic data, duration to diagnosis, clinical features, laboratory data, location and pathology of the tumors, and outcomes of pediatric patients from January 1984 to December 2009 were retrospectively reviewed.

RESULTS

A total of 24 GI malignancies and 62 benign tumors were diagnosed. Patients in the benign group were mostly diagnosed in the first decade of life (73%), whereas majority of patients with malignancies were older than 10 years (79%). The most common tumor location in the benign group was the colorectum, whereas in the malignant group, tumors were distributed equally in the small intestine and colorectum. The median duration from onset to diagnosis in the benign group was longer than that of the malignant group (P>00.05). There was statistically significant increase in the presence of hematochezia in patients with benign tumor compared with those with malignancy (P<00.05). Among the malignancies, 79% presented with abdominal pain, followed by weight loss (25%), anorexia (25%), palpable mass (25%), and fever (21%), with statistically significant differences compared with the benign group (P<00.05). Anemia was found in 47% to 63% of patients in both groups (P>00.05). Two patients with polyposis subsequently developed malignancy.

CONCLUSIONS

Different manifestations of GI malignancies and benign tumors may help pediatricians to detect these early. Patients with polyposis should be aware of the risk of malignant change.