Paratesticular neuroblastoma associated with subependymal giant cell astrocytoma

Testis Involvement in Neuroblastoma: Report of 3 Cases in the Turkish Pediatric Oncology Group-Neuroblastoma Study and Review of the Literature

BACKGROUND

Neuroblastoma (NB) is the most common extracranial solid tumor of childhood. Primary and secondary testicular involvement is extremely uncommon in neuroblastoma.

PROCEDURE

All children with neuroblastoma treated with the Turkish Pediatric Oncology Group (TPOG)-Neuroblastoma (NB) Study and who had testis involvement either at diagnosis or at relapse were retrospectively evaluated. A review of all cases with neuroblastoma and testis involvement in the literature was done.

RESULTS

There were 3 children with NB documented to have involvement of the testis, 2 at diagnosis, 1 at recurrence, within the 559 cases (0.5%) treated with the Turkish Pediatric Oncology Group (TPOG)-Neuroblastoma Protocol. All had advanced stage. Two were infants. A total of 57 cases of testicular or paratesticular neuroblastoma have been reported in children, and most cases represent metastases as in the 3 cases in our series.

CONCLUSIONS

Neuroblastoma should be considered in the differential diagnosis of testicular mass and work-up for neuroblastoma should be done before orchiectomy. Scrotal ultrasonography should be used as the first diagnostic tool and abdominal ultrasonography shall be done additionally. Testis examination should be performed at diagnosis and regularly during follow-up for boys diagnosed with neuroblastoma. Testes may be sanctuary sites when neuroblastoma is metastatic, as is the case in leukemia.

Primary paratesticular neuroblastoma: an important differential diagnosis

Primary neuroblastoma as a paratesticular tumor is extremely rare with only 8 described cases worldwide. In this article, we present the case of a 5-month-old boy with this rare tumor location and give an update on the current literature. As in our case, typically these tumors present as Stage 1 disease and simple tumorectomy alone leads to excellent outcome and long-term survival. However, unawareness of this differential diagnosis and misinterpretation of intraoperative frozen sections have shown to result in delay of diagnosis and worse, overtreatment including orchiectomy and unnecessary chemotherapy. Therefore, primary paratesticular neuroblastoma must be considered as a differential diagnosis when evaluating and operating children with paratesticular tumors.

Primary Paratesticular Neuroblastoma: Practical Considerations

Primary neuroblastoma in the paratesticular region is exceedingly rare with only 4 cases reported in the medical literature. The authors report 2 additional cases of primary paratesticular neuroblastoma, both in 6-month old boys who were asymptomatic at presentation. Both cases were stage I diseases, as they typically are in this early pediatric age group. There was no evidence of disease progress or recurrence at 2-year and 10-year follow-up for these 2 patients. The authors also noticed that erroneous assumptions or diagnoses may lead to unnecessary overtreatment, including orchiectomy. In the meantime, frozen section is highly recommended, and a presumptive diagnosis of neuroblastoma from frozen section is usually possible, especially when incorporated with other clinical and lab parameters, and should be attempted. The prognosis typically is favorable. In conclusion, it is becoming clear that primary neuroblastoma is an important differential diagnostic consideration for a paratesticular mass, particularly in the early pediatric age group.

Primary paratesticular neuroblastoma: a case report and review of literature

Only 4 infants with primary paratesticular neuroblastoma have been previously described. To the author's knowledge, this case would be the first report of a child who is older than 1 year whose lesion is in his right hemiscrotum. After simple tumorectomy was performed; he was tumor free at 4 years of follow-up. Patients older than 1 year with localized primary paratesticular neuroblastoma may have good prognosis after simple tumorectomy without further therapy.

Paratesticular neuroblastoma: a case against metastatic disease?

Paratesticular lesions of neuroblastoma are in contrast to testicular infiltration extremely rare. Six cases were reported in literature. It is debated, whether localizations are either metastatic lesions or part of multicentric disease. We present a 9-month-old boy with stage 4 neuroblastoma, in which an unsuspected scrotal localization was already present at birth. This lesion had not grown, in contrast to the other sites. The case illustrates that neuroblastoma is a multicentric tumor, originating in the adrenal area and paratesticular sympathic remnants. The lesions differed in clinical behavior. It further illustrates that multicentric localizations exhibit different clinical behavior.

Neonatal Paratesticular Neuroblastoma Misdiagnosed as In Utero Torsion of Testis

Reports of neuroectodermal primary scrotal tumors are scarce. Primary paratesticular neuroblastomas seem even rarer, and only five infants with this condition have been previously described. To the authors' knowledge, this would be the first report of a neonatal congenital paratesticular neuroblastoma. However, the authors postulate that ischemic compressive features in testis could lead to misdiagnosis as testicular torsion and the condition could usually go undetected. A newborn male baby with a left scrotal tumefaction was referred to the authors in May 2003. Doppler ultrasonography findings were inconclusive, and a diagnosis of intrauterine torsion of the testis was suspected. Surgery showed a paratesticular mass with a small attachment to an intra-abdominal epiploon. Pathologic examination clearly established the diagnosis of neuroblastoma. Cytogenetic findings (no amplification of N-myc oncogene, aneuploidy, and no deletion of chromosome 1p) were favorable. As the tumor was classified as International Neuroblastoma Staging System stage I, no additional chemotherapy was administered. All markers showed a progressive decrease, and herniorrhaphy and orchidopexy of the contralateral side were performed at 4 months of age. The patient was tumor-free at 11 months follow-up.

Testicular and paratesticular involvement by metastatic neuroblastoma

BACKGROUND

Testicular and paratesticular involvement is a less familiar feature in neuroblastoma and its prognostic impact is unclear.

METHODS

The records of 1076 male patients in the German cooperative neuroblastoma treatment trials were searched for patients with testicular or paratesticular involvement.

RESULTS

The authors found 11 children with paratesticular or testicular involvement at the time of manifestation of the disease, 3 children with testicular involvement at the time of relapse, and 1 infant with testicular involvement at the time of progression of neuroblastoma from International Neuroblastoma Staging System (INSS) Stage 4S to Stage 4. In de novo disease, the age of manifestation did not exceed 12 months. Two children had paratesticular involvement per continuitatem by growth of a primary tumor through the inguinal channel. All others had distant primary tumor. Prognosis appeared more favorable for infants (3 of 9 died) than for older children (5 of 6 died), for children with involvement of testes and < 10% involvement of bone marrow (2 of 8 died) than for children with other distant metastasis (6 of 7 died), and for children with intrascrotal involvement at first diagnosis (4 of 11 died) than for children with intrascrotal involvement during relapse of the disease (all 4 children died).

CONCLUSIONS

Paratesticular or testicular metastasis does not per se indicate unfavorable outcome and is compatible with INSS Stage 4S in infants. The age at diagnosis and the time of manifestation during disease contributed to the prognosis in those patients.

Primary neuroblastoma presenting as a paratesticular tumor

A 3-month-old boy was operated on for an inguinal tumor. Histological diagnosis was neuroblastoma. This is the second known case of primary paratesticular neuroblastoma reported in the literature. The treatment of choice for Evan's stage I is surgery.

Paratesticular neuroblastoma with N-myc activation

The authors describe a case of disseminated neuroblastoma discovered as a paratesticular tumor in a 7-month-old boy. The ectopic adrenal tissues adjacent to the paratesticular tumor and multiple lesions in the adrenal gland and skin suggested the possibility of multifocal primary tumors. Although infantile neuroblastoma diagnosed at less than 1 year of age generally responds well to treatment irrespective of distant metastases, metastases developed, and the boy died of disease within 7 months. All multiple lesions had amplification and overexpression of the N-myc protooncogene, which might explain the aggressive phenotype of this rare case.

Brain tumor as a second malignant neoplasm following neuroblastoma stage IV S

A rare brain tumor (spongioblastoma polare) occurring 7 years after treatment of neuroblastoma stage IV S is reported. The literature concerning the occurrence of a second cancer in children exposed to mutagenic therapy for their initial tumor is reviewed, and genetic and environmental factors are discussed. Diminishing aggressiveness of the treatment in childhood cancer with good prognosis should be considered. Continuous follow-up of children cured of cancer is warranted.

Congenital neuroblastoma presenting as a paratesticular tumor

A 1-month-old male newborn was operated upon for a scrotal tumor that was localized outside of the testis. Histological diagnosis was neuroblastoma. Although neuroblastoma often may present as metastatic disease when first seen, this case is unique in that an undetected adrenal neuroblastoma presented as a paratesticular tumor immediately after birth.

Metastatic neuroblastoma and testicular involvement

Neuroblastoma metastatic to the testes is thought to be an extremely rare event and is therefore not routinely considered in the evaluation of neuroblastoma patients. A review of metastatic sites in a series of neuroblastoma patients, however, revealed 11 cases with testicular involvement. Analysis of these cases suggests that the phenomenon may not be uncommon in a subset of neuroblastoma patients, namely, male patients with infra-diaphragmatic primaries and advanced-stage disease. Because the testes constitute a sanctuary site for tumor cells, occult testicular involvement may play a role in the relapse of patients judged to be in complete remission. Accordingly, it is proposed that in the above group of patients special diagnostic attention should be directed at the scrotal contents and, if testicular involvement is detected, orchiectomy or local irradiation should be considered.