Pediatric pulmonary tumors: primary and metastatic

Positron emission tomography in the diagnosis and management of primary pediatric lung tumors

Primary pediatric lung tumors are uncommon and have many overlapping clinical and imaging features. In contrast to adult lung tumors, these rare pediatric neoplasms have a relatively broad histologic spectrum. Informed by a single-institution 13-year retrospective record review, we present an overview of the most common primary pediatric lung neoplasms, with a focus on the role of positron emission tomography (PET), specifically 18F-fluorodeoxyglucose (FDG) PET and 68Ga-DOTATATE PET, in the management of primary pediatric lung tumors. In addition to characteristic conventional radiographic and cross-sectional imaging findings, knowledge of patient age, underlying cancer predisposition syndromes, and PET imaging features may help narrow the differential. While metastases from other primary malignancies remain the most commonly encountered pediatric lung malignancy, the examples presented in this pictorial essay highlight many of the important conventional radiologic and PET imaging features of primary pediatric lung malignancies.

Clinical presentation and treatment of four children with pulmonary mucoepidermoid carcinoma

Primary lung cancer in childhood is extremely rare, with an incidence rate of less than 2/100,0000, and pulmonary mucoepidermoid carcinoma (PMEC), is even rarer. Their symptoms are usually not specific, and there are no guidelines for their management, which makes their clinical management a challenge for pediatricians. The purpose of this report is to discuss the clinical presentation, positive signs, examinations, pathological characteristics, surgical modalities, chemotherapy regimens, and prognosis in children. The clinical data of four patients diagnosed with PMEC at the Children's Hospital of Chongqing Medical University from June 2021 to November 2022 were retrospectively analyzed, and their clinical features, treatment, and prognosis were summarized. Among them, two were male and two were female; their ages ranged from 3 years and 10 months to 10 years and 11 months, and all were staged according to tumor node metastasis classification (TNM). Immunohistochemical tests were performed in all children, among which four cases were positive for cytokeratin (CK), two cases were positive for CK7, four cases were positive for p63, about 5-10% of tumor cells were positive for Ki67. Among the four children, three had surgery alone and one had surgery + chemotherapy. All four children are presently living, with no evidence of tumor recurrence or metastasis. PMEC in children is very rare, and its age of onset and symptoms are not specific, and there is no obvious correlation with gender. Its diagnosis mainly relies on pathomorphological diagnosis, and immunohistochemical detection has no specific performance. The prognosis of children with PMEC is related to the clinical stage and whether surgery is performed. Whether further chemotherapy or radiotherapy is needed for patients who cannot undergo surgical resection and for those who have a combination of distant metastases requires further clinical studies.

Pulmonary tumors in childhood

Pulmonary tumors in childhood are rare, but the majority are malignant. The histopathologic spectrum is quite diverse, including inflammatory myofibroblastic tumor, hamartoma, primary pulmonary paraganglioma, carcinoid tumor, mucoepidermoid carcinoma, pleuropulmonary blastoma, adenocarcinoma, squamous cell carcinoma, and sarcomas. Nonspecific clinical and radiological findings result in late and incorrect diagnoses. Although surgical resection is the initial and proper treatment method, additional adjuvant therapy is dependent on both tumor stage and histopathologic type.

Case report: Uniportal video-assisted thoracoscopic sleeve lobectomy in a 6-year-old patient with inflammatory myofibroblastic tumor (IMT)

Inflammatory myofibroblastic tumor (IMT) is a rare neoplasm that can occur in various organs, including the lung. Surgical resection is usually the preferred treatment for localized IMT.A 6-year-old female was admitted to our hospital with complaints of "coughing and vomiting for 6 days". A chest CT scan revealed occlusion of the left main bronchus, segmental atelectasis of the left lower lung, and cystic low-density shadows along the bronchial pathway. Subsequent fiberoptic bronchoscopy confirmed the diagnosis of IMT through pathological biopsy. After excluding surgical contraindications, the patient underwent uniportal video-assisted thoracoscopic sleeve lobectomy for treatment. The patient had an uneventful postoperative course and was discharged four days after surgery. After one month, the patient received a follow-up examination and reported no significant discomfort. A chest CT scan revealed no postoperative complications.Our experience suggests that uniportal video-assisted thoracoscopic surgery may be a safe and effective approach for the treatment of pediatric patients with IMT requiring complex surgical procedures such as sleeve lobectomy and tracheoplasty.

Pulmonary inflammatory myofibroblastic tumor in a male child: A case report

Pulmonary inflammatory myofibroblastic tumor (IMT) is a rare condition in the normal population and specifically in the pediatric population. We reported a 9‐year‐old male child who presented with cough and intermittent fever and weight loss that was most suggestive of the infectious process. We reviewed the consideration of diagnosis and treatment.

Pulmonary IMT is a rare pulmonary mass that might be asymptomatic or manifest by hemoptysis, cough, constitutional symptoms, and pneumonia. It should be in the mind that IMT might mimic neoplasms, by history, radiology, and clinical aspects.

Chirurgische Therapie maligner Lungen- und Brustwandtumoren bei Kindern

Primäre Lungen- und Brustwandtumoren sowie Lungenmetastasen stellen bei Kindern äußerst seltene Erkrankungen dar. Eingebunden in multimodale Therapiekonzepte können thoraxchirurgische Eingriffe bei pädiatrischen onkologischen Erkrankungen dazu beitragen, die Prognose der erkrankten Kinder signifikant zu verbessern. Ziel des Übersichtsartikels ist es, die Indikationsstellung und die aktuellen thoraxchirurgischen Therapieoptionen bei malignen Brustwand- und Lungentumoren darzustellen sowie den aktuellen Stellenwert der pulmonalen Metastasenchirurgie bei Kindern zu beleuchten. Die Arbeit stellt darüber hinaus das Diagnosespektrum und thoraxchirurgische Operationsspektrum im Bereich der onkologischen pädiatrischen Thoraxchirurgie an einem spezialisierten Zentrum in Deutschland dar.

Long-term response to crizotinib in a 17-year-old boy with treatment-naïve ALK-positive non-small-cell lung cancer

BACKGROUND

Lung cancer is the leading cause of cancer-related death. NSCLC accounts for 80-90% of cases. In young patients, adenocarcinoma is the most frequent histotype and 3-7% expresses the rearrangement of ALK oncogene, sensitive to TKIs. Crizotinib is the first ALK inhibitor approved by the FDA.

CASE

We present a case of a 17-year-old male with metastatic treatment-naïve ALK-positive adenocarcinoma. He was treated with crizotinib and obtained a prolonged response with PFS of 33 months.

CONCLUSION

Crizotinib can be extremely effective in adolescents with treatment-naïve ALK-positive NSCLC but fail to prevent a central nervous system relapse. Resistance mechanisms need to be investigated.

Case Report: Primary Bilateral Minimally Invasive Adenocarcinoma of the Lungs in an 11-Year-Old Child: A Rare Case

There are many types of benign and malignant tissue, but primary lung tumor is very rare in children and often remains undiagnosed until after distant metastasis has occurred. Few cases of early lung adenocarcinoma in children have been reported. However, this case concerns an 11-year-old child with primary bilateral minimally invasive adenocarcinoma. As far as we know, this is the youngest reported case of its type.

Pulmonary Hypertension as a Complication of Pediatric Cancer

Pediatric cancer is a life threatening disease known to create multi-organ complications that further compromise medical management affecting patient morbidity and mortality. Pulmonary hypertension (PH) is becoming more recognized as a complication of cancer and its therapies but has not been well characterized in pediatrics. Cancer pathophysiology can be uniquely set up to promote pulmonary vascular injury and remodeling that is similar to PH patients without cancer. This highlights the need to evaluate for PH clinically and with routine testing such as echocardiography during the course of a patient's care even into adulthood. This review article will discuss the direct, indirect and therapy related aspects of cancer which can promote PH in these patients. This understanding is essential to target effective treatment options in a potentially fatal complication. Diagnostic and treatment algorithms are presented in relation to the most recent pediatric PH management guidelines.

Epidemiology and outcomes of primary pediatric lung malignancies: Updates from the SEER database

BACKGROUND

Primary pediatric lung malignancies are rare tumors. We provide an updated analysis of the epidemiology and prognosis of these tumors since the last SEER series published in 2009.

METHODS

The SEER 18 database from 1975 to 2016 was analyzed for patients ages 0-19 years with primary lung and/or bronchus neoplasms.

RESULTS

348 patients met inclusion criteria. The majority were white and ≥12 years of age. The most common histologies were neuroendocrine (41.4%) and blastoma (16.4%). 75.4% of patients had local-regional disease and 81.4% underwent surgery. Significant differences between histologies were seen for age, year at diagnosis, tumor laterality and location, stage, and treatment type. Median survival was 36.6 years (95% CI 33.3-37.4). Blastoma (HR 3.47) and squamous cell (HR 6.26) carried a significantly higher risk of death than neuroendocrine cancer diagnosis.

CONCLUSION

Primary pediatric lung malignancies are rare, long-term survival is favorable but histology-dependent. Surgery continues to be an important treatment modality.

Distinct clinicopathological features of pulmonary primary angiomatoid fibrous histiocytoma: A report of four new cases and review of the literature

BACKGROUND

The aim of this study was to highlight the clinicopathological features of pulmonary primary angiomatoid fibrous histiocytoma (PPAFH) to assist with a differential diagnosis.

METHODS

There were 10 previous reports in the literature and four new PPAFH cases reviewed in this study. Immunohistochemistry (IHC), fluorescence in situ hybridization (FISH) and DNA and RNA-based next-generation sequencing (NGS) was performed in the four new cases reported here.

RESULTS

In the four new PPAFH cases, the ages of occurrence were in patients age from 33 to 55 years and tumor sizes were from 1.5 to 8 cm. Three of four (75.0%) tumors were located in the endobronchus. The most common morphological changes included delineated fibrous capsule (100%, 4/4), lymphoplasmacytic cuff (100%, 4/4), and dense or richly lymphoplasmatic infiltration (100%, 4/4). IHC analysis revealed that the tumor cells of four cases expressed vimentin and TLE1, ALK and CD163 or CD68 was positive in three cases, epithelial membrane antigen (EMA), desmin was positive in two cases, and SMA focal positive expression was observed in two cases. EWSR1 gene rearrangement was positive in all PPAFH cases (100%, 4/4) by FISH detections and four cases were confirmed as EWSR1-CREB1 fusion variant by DNA and RNA based NGS. No regional lymph nodes and distal metastasis, recurrences and death of disease after surgical excision were recorded in all four cases.

CONCLUSIONS

PPAFH is a very unusual pulmonary primary mesenchymal tumor and the clinicopathological features are like other unusual sites counterparts, but with a smaller tumor size, related with large airway, with a tendency to exhibit benign biological behavior, with EWSR1 gene rearrangement and higher frequency of EWSR1-CREB1 gene fusion.

KEY POINTS

Significant findings in the study: In comparison with "classic somatic" and nonpulmonary visceral angiomatoid fibrous histiocytoma, pulmonary primary angiomatoid fibrous histiocytoma display distinct clinicopathological features and prognosis. What this study adds The study provided the pathological differential diagnostic criteria and clinico-pathological features for pulmonary primary angiomatoid fibrous histiocytoma.

Carinal Resection and Reconstruction for an Obstructing Inflammatory Myofibroblastic Tumor in a Child

Inflammatory myofibroblastic tumor (IMT) is a rare soft tissue tumor characterized by proliferation of fibroblastic cells associated with an inflammatory infiltrate. Inflammatory myofibroblastic tumors have a predilection for the pediatric population and are usually found in the lung parenchyma but rarely at the carina. They rarely metastasize but can be locally destructive. Surgical resection is the cornerstone of therapy, which results in excellent survival despite risk of local recurrence. We present the case of a nine-year-old girl with an IMT mass at the carina and obstructing the left main stem bronchus, requiring extensive resection and reconstruction.

Pediatric lung adenocarcinoma presenting with brain metastasis: a case report

BACKGROUND

Diagnosis and treatment of primary lung adenocarcinoma in children remains challenging given its rarity. Here we highlight the clinical history, pathological evaluation, genomic findings, and management of a very young patient with metastatic lung adenocarcinoma.

CASE PRESENTATION

A 10-year-old white girl presented with brain metastases due to primary pulmonary adenocarcinoma. Next generation sequencing analysis with "Comprehensive Cancer Panel" highlighted the presence of multiple non-targetable mutations in the FLT4, UBR5, ATM, TAF1, and GUCY1A2 genes. She was treated aggressively with chemotherapy, surgery, and radiation therapy for local and distant recurrence. Eventually, therapy with nivolumab was started compassionately, and she died 23 months after diagnosis.

CONCLUSIONS

Extremely rare cancers in children such as lung adenocarcinoma need accurate and specific diagnosis in order to develop an optimal plan of treatment. It is also necessary to underline that "children are not little adults," thus implying that an adult-type cancer in the pediatric population might have a different etiopathogenesis. Diagnostic confirmation and primary treatment of such rare conditions should be centralized in reference centers, collaborative networks, or both, with multidisciplinary approaches and very specific expertise.

Pulmonary Inflammatory Myofibroblastic Tumor in Children: A Case Report and Brief Review of Literature

The inflammatory myofibroblastic tumor (IMT) is a rare lesion of unclear etiology and variable clinical course, consisting of a proliferation of fibroblasts and myofibroblasts, mixed with inflammatory cells. Synonyms of IMT are inflammatory pseudotumor and plasma cell granuloma reflecting the alleged inflammatory nature attributed to this lesion, even though this heterogeneity in the disease denomination is probably involved in a dispersion of the literature data. Among primary pulmonary neoplasms, it represents the most frequent endobronchial tumor of childhood and beyond the lung it has been described mainly in the bladder, mediastinum and mesentery. Despite having a tendency for local recurrence, the risk of distant metastasis is low. Clinical presentation depends on localization therefore lung peripheral lesions are often asymptomatic resulting in a delayed diagnosis. Radiological findings can suggest the diagnosis that must be confirmed by histopathology assessment. The tumor has been characterized by the application of immunohistochemical techniques, molecular biology and cytogenetics, which are very precious for the diagnosis. The therapeutic approach consists in the complete surgical excision of the lesion that normally ensures excellent survival. Due to the potential risk of recurrence, close clinical trial is indicated. To date only 24 cases of pulmonary IMT have been described, although the prevalence is probably higher. We present a case report of a 3-year-old girl with pulmonary IMT and a brief review of known literature cases in order to highlight the most common clinical presentations, the most useful diagnostic tools and therapeutic approach.

Primary lung tumors in children: 24 years of experience at a referral center

PURPOSE

Primary lung tumors are rare during childhood and encompass a wide variety of histological types. Each has a different biology and a different therapeutic approach. The aim of this article is to review the experience of a pediatric referral center with this kind of tumors during the last 24 years.

METHODS

A retrospective chart review was performed for patients with diagnosis of primary lung tumor between the years 1990-2014. The variables analyzed were age, sex, course of the disease, symptoms, localization, surgery, histology and outcome.

RESULTS

Between 1990 and 2014, 38 patients with primary lung tumors were treated at our institution. Age at presentation was 6.6 ± 5.2 years (r 0.91-16.58) and the female:male relationship was 1.37. Inflammatory myofibroblastic lung tumor (n = 13), carcinoid tumor (n = 6) and pleuropulmonary blastoma (n = 6) were the most frequent histological types. Persistent radiographic abnormality was the most frequent presenting sign (34 %). Global mortality was 15.8 % varying according to histology.

CONCLUSION

Although the diagnosis of primary lung tumor is rare, the persistence of a radiographic abnormality in spite of adequate treatment for inflammatory processes forces us to evaluate further. The age of the patient is an important factor in the decision of the diagnostic work-up.

Bronchioloalveolar carcinoma in a juvenile rhadomyosarcoma patient

Primary tumors of the lung are uncommon in pediatric patients, particularly bronchioloalveolar carcinoma (BAC). An 11-year-old female suffering from back pain for 1 month was referred to Seoul St. Mary's Hospital for treatment of a pathologic fracture of the lumbar spine. Comprehensive evaluation disclosed numerous pulmonary metastases of rhabdomyosarcoma (stage IV). During chemotherapy, most of the lung lesions regressed, with the exception of two nodules. Wedge resections, intended for diagnosis and cure, yielded a histologic diagnosis of BAC.

Childhood bronchial mucoepidermoid tumors: A case report and literature review

Primary pulmonary neoplasms rarely occur in children, but the majority of those that do are malignant. Mucoepidermoid carcinoma (MEC) represents ~10% of all primary pulmonary malignant tumors. However, MEC is not usually considered in the clinical differential diagnosis in pediatric practice. The present study presents the case of a seven-year-old female with a one-year history of recurrent hemoptysis. Computerized tomography (CT) scans revealed a tumor originating in the right lower lobe bronchus. The patient did not receive any radiation and chemotherapy following a lobectomy on the right lower lung. The tumor was histopathologically determined to be an MEC of the tracheobronchial tree. Subsequent to a six-year follow-up, the MEC was undetectable in this patient, according to the clinical and radiological evidence. The literature with regard to pediatric MEC is also reviewed in this study.

Bronchioloalveolar carcinoma as a second malignancy in a pediatric osteosarcoma survivor: case report

Background

Primary lung cancer is extremely rare in children, while secondary malignancies reportedly develop in 2% to 3% of pediatric osteosarcoma survivors.

Case presentation

A 14-year-old girl was found to have two pulmonary lesions on computed tomography. These tumors had developed 1 year after osteosarcoma surgery. Segmentectomy of right segment 1 and wedge resection of right segment 9 were performed. Both lesions were completely resected and postoperative histopathological examination revealed metastasis of osteosarcoma and bronchioloalveolar carcinoma, respectively.

Conclusion

Bronchioloalveolar carcinoma may present as a solitary pulmonary lesion indistinguishable from a metastatic lesion and should be included in the differential diagnosis of pulmonary lesions in survivors of pediatric cancer. Thus, pulmonary lesions identified in these patients should be biopsied or resected to establish a histological diagnosis.

Locally invasive pulmonary inflammatory myofibroblastic tumors in children

Two uncommon cases of locally invasive pulmonary inflammatory myofibroblastic tumor are reported. Diagnosis was established by a prior thoracotomy and incisional biopsy. Complete excision was curative and both children remain asymptomatic at last follow up.

Lung carcinoma with hypertrophic osteoarthropathy in a teenager

Hypertrophic osteoarthropathy (HOA) characterised by arthralgia, clubbing and periosteal proliferation of long bones, is rarely encountered in children and adolescents. Whereas in adults over 80% of cases are associated with malignancy, in children the majority of cases are due to non-neoplastic causes such as cystic fibrosis, bilary atresia and congenital heart disease. Up to 5% of adults with lung cancer demonstrate signs of HOA. However, lung cancer is extremely uncommon in children and young people. Here we report a case of lung adenocarcinoma in an 18 year old male associated with HOA present both at diagnosis and at subsequent disease progression.

Primary lung tumors in children and adolescents: a 90-year experience

PURPOSE

Primary lung tumors in children are rare. A wide range of histopathologic tumor types occurs. The incidence of these lesions and their outcomes are still largely unknown. This study aims to determine the incidence of different primary lung tumors in children and to contribute data leading to the development of evidence-based treatment models.

METHODS

A single institution retrospective review was performed with institutional review board approval. Patients were included if they had primary, nonhematologic lung tumors. Simple squamous papillomas subjected to endoscopic biopsy and not resected, and vascular lesions associated with multisystem lesions, such as hereditary hemorrhagic telangiectasia, were excluded. Medical records and pathologic material for patients from 1918 to 2008 were reviewed.

RESULTS

Forty patients were identified (23 boys, 17 girls) with a mean age of 9.6 years (range, 3 months to 19 years). Fourteen distinct histopathologic tumor types were identified. The most common tumor types were carcinoid (8), inflammatory myofibroblastic tumor (7), and pleuropulmonary blastoma (6). Rare pediatric lung tumors including small cell carcinoma, adenocarcinoma, and pulmonary capillary hemangiomatosis were also seen. The mortality rate was 17.5% (7) in our series. Chemotherapy was used in 23% (9) and radiation in 20% (8) of the patients. Of the 33 survivors, 28 had follow-up with a median duration of 29.5 months (mean, 63.2 months; range, 1-471 months).

CONCLUSIONS

Primary lung tumors in children are rare and histopathologically diverse. The tumor spectrum involves many types not seen in adults, and unlike adults, patients rarely have a history of exposure to external predisposing factors. Although complete resection remains the standard for treatment of most tumors, addition of adjuvant therapy is dependent on both tumor stage and histopathologic type.

Pulmonary blastoma in a neonate: a lesion distinct from pleuropulmonary blastoma with unique cytogenetic features

Pulmonary blastoma is a rare malignant primary lung neoplasm typically seen in adults that accounts for 0.3-1.3% of lung malignancies. It has been categorized as a subtype of sarcomatoid carcinoma according to the current World Health Organization Classification of Lung Tumours and is distinct from the more common pediatric lung tumor pleuropulmonary blastoma. We report a case of neonatal pulmonary blastoma, illustrating the imaging characteristics of this rare tumor. The subject of pediatric lung masses is confusing because the terms pleuropulmonary blastoma and pulmonary blastoma have been used interchangeably in previously reported cases. We recommend use of the current WHO classification to differentiate these lesions as additional cases are described. Additionally, we discuss distinctive cytogenetic features of this case.

Bronchioloalveolar carcinoma as a second malignancy in osteosarcoma survivors

Second malignancies occur in 2-3% of survivors of pediatric osteosarcoma; treatment-related hematologic and solid malignancies have both been described. We present two cases of patients with pulmonary nodules that developed more than 2 years after treatment of osteosarcoma. Both lesions were completely resected and pathology revealed bronchioloalveolar carcinoma (BAC). Primary BAC is extremely rare in children; however, cases of this malignancy have been described in survivors of pediatric cancer. BAC may present as a solitary pulmonary nodule indistinguishable from a metastatic lesion and should be included in the differential diagnosis of pulmonary nodules in survivors of pediatric cancer.