Orbital neuroblastoma metastasis: A case report and literature review

Pediatric head and neck emergencies

PURPOSE

Head and neck emergencies in children are frequent cause of visits to the hospital. Imaging plays a critical role in the management of these patients. This review article aims to familiarize radiologists with the common clinical presentations encountered, imaging characteristics of nontraumatic pediatric head and neck emergencies, and improve their ability to recognize associated complications as well as be aware of common mimics.

METHODS

We researched our database for commonly encountered nontraumatic head and neck emergencies in children. A literature search was done to compare and complete the list of conditions to be discussed in this review.

RESULTS

The review was organized according to anatomical location of the emergent condition. Relevant anatomy has been discussed along with clinical presentation, imaging characteristics and complications. We have presented common mimics with each set of disorders. Key imaging characteristics have been delineated using radiology images.

CONCLUSION

Familiarity with the known complications of head and neck emergencies allows the radiologist to actively search for such findings, encourage early institution of appropriate therapy, and improve outcomes.

Pediatric Orbital and Skull Base Pathology

Pediatric orbital and skull base pathologies encompass a spectrum of inflammatory, sporadic, syndromic, and neoplastic processes that require a broad and complex clinical approach for both medical and surgical treatment. Given their complexity and often multicompartment involvement, a multidisciplinary approach for diagnosis, patient and family counseling, and ultimately treatment provides the best patient satisfaction and clinical outcomes. Advances in minimally invasive surgical approaches, including endoscopic endonasal and transorbital approaches allows for more targeted surgical approaches through smaller corridors beyond more classic transcranial or transracial approaches.

Evaluation of clinical and imaging features for differentiating rhabdomyosarcoma from neuroblastoma in pediatric soft tissue

Background

In this study, we developed a nomogram predictive model based on clinical, CT, and MRI parameters to differentiate soft tissue rhabdomyosarcoma (RMS) from neuroblastoma (NB) in children preoperatively.

Materials and methods

A total of 103 children with RMS (n=37) and NB (n=66) were enrolled in the study from December 2012 to July 2023. The clinical and imaging data (assessed by two experienced radiologists) were analyzed using univariate analysis, and significant factors were further analyzed by multivariable logistic regression using the forward LR method to develop the clinical model, radiological model, and integrated nomogram model, respectively. The diagnostic performances, goodness of fit, and clinical utility of the integrated nomogram model were assessed using the area under the curve (AUC) of the receiver operator characteristics curve (ROC) with a 95% confidence interval (95% CI), calibration curve, and decision curve analysis (DCA) curves, respectively. Diagnostic efficacy between the model and radiologists' interpretations was examined.

Results

The median age at diagnosis in the RMS group was significantly older than the NB group (36.0 months vs. 14.5 months; P=0.003); the fever rates in RMS patients were significantly lower than in patients with NB (0.0% vs.16.7%; P=0.022), and the incidence of palpable mass was higher in patients with RMS compared with the NB patients (89.2% vs. 34.8%; P<0.001). Compare NB on image features: RMS occurred more frequently in the head and neck and displayed homogeneous density on non-enhanced CT than NB (48.6% vs. 9.1%; 35.3% vs. 13.8%, respectively; all P<0.05), and the occurrence of characteristics such as calcification, encasing vessels, and intraspinal tumor extension was significantly less frequent in RMS children compared to children with NB (18.9% vs. 84.8%; 13.5% vs. 34.8%; 2.7% vs. 50.0%, respectively; all P <0.05). Two, three, and four features were identified as independent parameters by multivariate logistic regression analysis to develop the clinical, radiological, and integrated nomogram models, respectively. The AUC value (0.962), calibration curve, and DCA showed that the integrated nomogram model may provide better diagnostic performance, good agreement, and greater clinical net benefits than the clinical model, radiological model, and radiologists' subjective diagnosis.

Conclusion

The clinical and imaging features-based nomogram has potential for helping radiologists distinguish between pediatric soft tissue RMS and NB patients preoperatively, and reduce unnecessary interventions.

A sudden death, an aortic rupture, and an unexpected cause: a report about suspected child abuse

All unexpected deaths of children require an autopsy to determine the cause of death. In cases of aortic rupture, the immediate cause of death is easily identified at autopsy. Although the majority of aortic ruptures are caused by high-energy trauma, other causes should not be missed.We present and discuss the case of a 29-month-old child who died suddenly at home. Her recent medical history and the ecchymotic lesions observed on external examination of the body appeared potentially suspicious of physical abuse. The autopsy concluded that death was due to complete rupture of the abdominal aorta with associated vertebral disjunction. At first glance, the overall forensic picture could suggest a traumatic death. However, careful inspection of the retroperitoneum revealed a discrete atypical mass of infiltrative tissue within the hematoma. Histopathological examinations confirmed tumor proliferation of the soft tissues, triggering vascular and spinal injuries. Other paraneoplastic elements or metastases were ultimately revealed (orbital and subcutaneous). Overall, this was a rare and fatal case of abdominal aortic rupture induced by tumors. Due to the mechanisms and the forces needed to cause vertebral dislocations and aortic rupture, the combination of the two is highly suggestive of child abuse when an accidental traumatic history is absent or inconsistent with the injuries. Nevertheless, this case illustrates the importance of a systematic and rigorous forensic examination, rather than ignoring other possible diagnoses.

Ophthalmologic Manifestations of Neuroblastoma: A Systemic Review

Neuroblastoma (NBL) is the most common extracranial solid tumor found in pediatric patients. It develops from the sympathetic tract tissue. Although the symptoms are associated with tumor localization, sometimes NBL is manifested as ophthalmologic disorders. In this paper, we describe their incidence and the correlation with the prognosis. We searched 2 databases (PubMed and Web of Science) for papers published before April 2022, and concerned pediatric patients with NBL, which caused ophthalmologic changes. We collected 7 papers assessing the occurrence of ophthalmologic findings in the NBL patients, as well as 68 case reports presenting children with orbital changes and NBL, or with other tumors stemming from the sympathetic ganglia. The statistical analysis was performed to synthetize the data. The ophthalmologic signs occurred in 17.89% of the NBL cases; however, they were observed on presentation in 10.68%. The isolated ocular presentation was found in 2.56% of patients, whereas Horner syndrome was most frequent. The ophthalmologic symptoms correlated with patients' age, primary tumor site, and survival rate. NBL may be challenging to diagnose in cases with isolated ophthalmologic manifestations. Numerous possible ocular signs can be observed, which emphasize the need for multidisciplinary care with regard to the NBL patients.

Non-traumatic ecchymoses: A literature review from a medico-legal perspective

Ecchymosis, as a general term, refers to discoloration of the skin due to the presence of extravasated blood into the dermis and/or subcutaneous tissue. However, it can occasionally be observed without any trauma, as a symptom of disease, a clinical condition, or even during the course of treating a disease. It is extremely important that these non-traumatic lesions are known and recognized and can be distinguished from traumatic ecchymoses by both clinicians and forensic scientists. This review of the literature includes detailed descriptions of non-traumatic periorbital ecchymosis, Slapped Cheek Syndrome, Cullen's Sign, Grey Turner's Sign, Stabler's Sign, Ransohoff Sign, Bryant's Sign, postsacral ecchymosis, perianal ecchymosis, Fox's Sign, other lower leg ecchymosis, and ecchymosis on various body regions. In this article, it is emphasized that failure to correctly identify these findings may subject practitioners to malpractice lawsuits, and failure to correctly identify findings by forensic experts may result in unjust legal judgments against people or loss of rights. It is also this review encourages accurate diagnosis of non-traumatic ecchymoses.

Rapidly Progressive Ocular Proptosis as the First Sign of Neuroblastoma in a 16-Month-Old Child: Case Report and Review of Literature

Neuroblastoma (NB) is a malignant neoplasm accounting for 7.5% of malignancy in children. It can originate anywhere along the sympathetic chain with the adrenal medulla being the most common site in 35% of cases. The initial presentation of orbital metastasis is very unusual that accounts for only 8% of all NB cases. We report a rare case of a 16-month-old girl who initially presented with bilateral rapidly progressive ocular proptosis for two weeks. CT scan of the brain and orbits revealed bilateral heterogeneous lateral orbital lesions, and CT scan of the abdomen and pelvis revealed huge heterogeneous right adrenal lesions. Histopathology of the abdominal mass confirmed the diagnosis of stage IV NB with orbital metastasis and the patient was started on an aggressive chemotherapy regimen. Ophthalmologists have a vital role in the diagnosis of NB which should be considered in the differential diagnosis of any rapidly progressive proptosis in young children. Early investigation and systemic workup should be made immediately, as it is a potentially life-threatening malignant tumor that requires aggressive management.

Mandibular metastases in neuroblastoma: Outcomes and dental sequelae

BACKGROUND

Although metastatic involvement of bony sites including cranial bones is common in neuroblastoma (NB), mandibular metastases (MM) are uncommon, and specific outcomes have not been reported upon in the modern therapeutic era.

METHODS

In this retrospective study, medical records on patients with MM from NB were reviewed. Statistical analysis was performed using the Kaplan-Meier method.

RESULTS

Of 29 patients, nine (31%) had MM at diagnosis, whereas in 20 (69%) MM were first detected at NB relapse at a median time of 26 (6-89) months from diagnosis. Median maximal diameter of lesions was 3 (range 0.8-4.9) cm. MM were unilateral in 83% of patients, with ascending ramus (55%) and mandibular body (38%) being the two most common sites. All patients received systemic chemotherapy, and 26 (93%) patients received radiotherapy to MM. At a median follow-up of 37.3 (24.2-219.5) months, eight of nine patients with MM at diagnosis did not experience mandibular progressive disease. Eighteen of 20 patients with MM at relapse received therapeutic radiotherapy; objective responses were noted in 78%. Seventy-two percent (5/18) had not experienced relapse within the radiation field at a median of 12 (2-276) months postradiotherapy. Dental findings at follow-up after completion of NB therapy included hypodontia, hypocalcification of enamel, and trismus. Median 3-year overall survival in patients with relapsed MM was 51 ± 12% months from relapse.

CONCLUSION

MM when detected at diagnosis is associated with a prognosis similar to that for other skeletal metastases of NB. Radiotherapy is effective for control of MM detected both at diagnosis and relapse. Significant dental abnormalities posttherapy warrant regular dental evaluations and appropriate intervention.

Metastatic neuroblastoma mimicking an infantile hemangioma

Neuroblastoma is the most common solid tumor malignancy in the first year of life. We present a rare case of a 5-month-old girl with an infraorbital tumor that simulated an infantile hemangioma clinically but was ultimately diagnosed as metastatic neuroblastoma.