Placental infiltration in congenital neuroblastoma: a case study with ultrastructure

Trisomy 21-associated transient abnormal myelopoiesis involving the maternal space of the placenta: a case report and literature review

We report a case of a male newborn with trisomy 21 and transient abnormal myelopoiesis at birth whose placenta showed extravasated fetal blasts in the perivillous (maternal) space. Concern for possible maternal spread of fetal malignancy prompted a Kleihauer-Betke test and flow cytometric analysis of the maternal peripheral blood on postpartum day 2. Notably, no evidence of the persistence of fetal cells in the maternal blood was identified, a finding that likely reflected successful maternal immunologic clearance of the fetal blasts and erythrocytes, and/or blast cellular fragility and limited viability. Ours is the first report, to our knowledge, documenting maternal peripheral-blood follow-up evaluation of this disorder in the English literature. We discuss our case in the context of a comprehensive review of fetoneonatal solid tumor and leukemic proliferative disorders with placental involvement and evidence of maternal metastasis.

Perinatal pathology: practice suggestions for limited-resource settings

The practice of perinatal pathology in much of the world suffers, as do all subspecialties of anatomic pathology, from inadequate resources (equipment, consumables, and both professional and technical personnel), from lack of education (not only of the pathologist but also of the clinicians responsible for sending the specimens, and the technicians processing the specimens), and from lack of appropriate government sector support. Perinatal pathology has significant public health-related utility and should be championing its service by providing maternal and fetal/infant mortality and morbidity data to governmental health ministries. It is with this pathologic data that informed decisions can be made on health-related courses of action and allocation of resources. These perinatal pathology data are needed to develop appropriate public health initiatives, specifically toward achieving the Millennium Developmental Goals as the best way to effectively decrease infant and maternal deaths and to determine causes of perinatal mortality and morbidity. The following overview will focus on the utility of perinatal pathology specifically as related to its public health function and will suggest methods to improve its service in resource-poor settings. This article is offered not as a critique of the current practice that most pathologists find themselves working in globally, but to provide suggestions for improving perinatal pathology services, which could be implemented with the limited available resources and manpower most pathology departments currently have. In addition, we offer suggestions for graded improvements ("ramping up") over time.

Fetal and placental malignancies: prenatal diagnosis and management

Fetal and placental malignancies are rare complications during pregnancy, but when they occur they may present significant challenges for the perinatology team. Owing to their rarity, there is limited information on many of these entities, with much data derived from individual case reports or small case series. Prenatal diagnosis of these entities is rare and inconsistent, usually in the form of isolated case reports. In the majority of fetal tumors, prenatal features are those of a mass lesion, with or without other non-specific features of fetal compromise such as polyhydramnios, fetal hydrops or intrauterine death, the final diagnosis in most cases being based on postnatal pathological examination.Expectant management is almost always indicated antenatally, with serial ultrasound examinations performed to detect rapid enlargement, metastasis or secondary fetal complications, such as non-immune hydrops, which may require intervention. Delivery should be planned in a specialist center in conjunction with pediatric surgeons and oncologists to allow appropriate neonatal management. Placental malignancy is most commonly in the form of gestatational trophoblastic disease, which requires assessment and management in specialist centers.

Placental pathology, a survival guide

Placental pathology continues to be an underutilized, undertaught, and inadequately handled surgical subspecialty. The requests for placental pathology are soaring, due partly to demands from obstetricians and to the litigious environment in which they practice, and to improved obstetrical care leading to pregnancies in medically challenging situations. Evaluation of the placenta requires a good understanding of the questions and issues concerning both the fetus/infant and the mother. Information from placental pathology can be critical in early neonatal care and in reproductive planning for the family, and it can provide risk assessment for neurologic outcome of the infant. A comfortable interaction among the obstetric staff, mothers, and pathologists often obviates need for legal intervention in unexpected pregnancy outcomes. Some critical pathologic features that involve maternal and fetal management are illustrated herein. A template for gross examination and a few critical histopathologic diagnostic features with clincopathologic correlation are included.

Clinical significance of placental examination in perinatal medicine

Complete pathologic evaluation of the placenta provides valuable information for perinatal care for the obstetrician, neonatologist, pediatrician, and family. The histopathology of the placenta can answer specific questions about in utero insults, give insight into management of subsequent pregnancies, and provide an assessment of the newborn risk. Placental pathology has been a key litigious informant in inferring timing of insults. Despite these well known advantages of placental pathologic examination, it remains an under-utilized part of perinatal medicine. This stems from a historically under-taught part of surgical and autopsy pathology resulting in inadequate reporting. This review will focus on the utility of the placental examination for fetal and maternal well-being. This review will be restricted to singleton births.

Neuroblastoma, ganglioneuroblastoma, and ganglioneuroma: radiologic-pathologic correlation

Neuroblastoma, ganglioneuroblastoma, and ganglioneuroma are tumors of the sympathetic nervous system that arise from primitive sympathogonia and are referred to collectively as neuroblastic tumors. They arise wherever sympathetic tissue exists and may be seen in the neck, posterior mediastinum, adrenal gland, retroperitoneum, and pelvis. The three tumors differ in their degree of cellular and extracellular maturation; immature tumors tend to be aggressive and occur in younger patients (median age, just under 2 years), whereas mature tumors occur in older children (median age, approximately 7 years) and tend to behave in a benign fashion. The most benign tumor is the ganglioneuroma, which is composed of gangliocytes and mature stroma. Ganglioneuroblastoma is composed of both mature gangliocytes and immature neuroblasts and has intermediate malignant potential. Neuroblastoma is the most immature, undifferentiated, and malignant tumor of the three. Neuroblastoma, however, may have a relatively benign course, even when metastatic. Thus, these neuroblastic tumors vary widely in their biologic behavior. Features such as DNA content, tumor proto-oncogenes, and catecholamine synthesis influence prognosis, and their presence or absence aids in categorizing patients as high, intermediate, or low risk. Treatment consists of surgery and, usually, chemotherapy. Despite recent advances in treatment, including bone marrow transplantation, neuroblastoma remains a relatively lethal tumor, accounting for 10% of pediatric cancers but 15% of cancer deaths in children.

Intra-uterine death resulting from placental metastases in adenocarcinoma of unknown primary

A thirty-five year old woman presented with bilateral neck, chest wall and back masses. She was 16 weeks pregnant. Lymph node excision revealed metastatic poorly differentiated adenocarcinoma of unknown primary. Abdominal ultrasound showed a mildly enlarged spleen and a 2-3 cm porta hepatis node. All other investigations were negative. The lymph node and cutaneous metastases progressed rapidly so it was decided to initiate systemic chemotherapy with a view to delivery at 28 weeks gestation by Caesarean section. Shortly after the second 3-weekly cycle of cisplatinum chemotherapy the patient suffered severe lower back and hip pain with MRI scan showing multiple bony metastases in the pelvic girdle. Ultrasound revealed the fetus to have been dead for at least 10 days. The products of conception were delivered following medical induction of labour. Two days later the patient suffered a cardiac arrest from which she could not be resuscitated. Placental histology revealed extensive metastases. With the exception of melanoma this has rarely been reported in solid adult malignancy. As a cause of fetal death, placental metastases are extremely rare.

Investigation of stillbirth

The pathologic investigation of stillbirth is often frustrating, and may be viewed as unrewarding, because the reason for death of the infant frequently is not identifiable. This outline attempts to identify an approach to the examination of the stillborn and accompanying placenta, with appropriate use of ancillary studies that may uncover the cause of death and/or identify factors that could prejudice future pregnancies.

Neuroblastoma in the neonate

Neuroblastoma is the most common malignant neoplasm occurring in the neonate and arguably the most variable in its presentation. This review examines differences in the tumor's clinical course in the context of known biologic determinants of behavior. Tumors that would go undetected except for prenatal ultrasonography or postnatal neuroblastoma screening characteristically undergo spontaneous regression or maturation and require little or no treatment. Most low stage tumors with favorable biological features are effectively treated with surgery alone. The more bulky locoregional (stage 3) tumors require chemotherapy in addition to surgery. The most challenging tumors are those that are disseminated at birth (stages 4 and 4S). Management plans for these tumors are based on the biological characteristics of the tumor and (in the case of stage 4S tumors) on the presence and extent of functional embarrassment of vital organs.

Benign hepatocellular tumor of the placenta

Neoplasms of the placenta, other than trophoblastic tumors and chorangiomas, are exceedingly rare and predominantly include teratomas and metastatic maternal tumors. There has been a single case report of a hepatocellular adenoma-like neoplasm of the placenta that was characterized as most likely representing a specialized monodermal teratoma. We report a second apparent case of a hepatocellular adenoma-like lesion occurring in a preterm placenta with compelling morphologic, immunohistochemical, and ultrastructural validation of tissue hepatic in origin. It remains inconclusive that this lesion represents a neoplasm rather than a rare ectopic or heterotopic occurrence.

Fetal neuroblastoma: prenatal diagnosis and natural history

Obstetrical sonography has helped diagnose and define the features of some congenital malformations and tumors. We present five fetal neuroblastomas detected by routine prenatal sonography. All were adrenal tumors diagnosed between 26 and 39 weeks gestation. All 5 tumors were completely resected postnatally and the patients have remained disease free from 2 months to 10 years after resection without adjuvant therapy. A literature review collated 16 other cases of fetal neuroblastoma detected by sonography between 29 and 38 weeks gestation. These cases included 1 cervical, 1 thoracic, and 14 adrenal tumors. Thirteen neonates had Evans stage I or II tumors, and three had more advanced disease. Eleven mothers did not have hypertension or preeclampsia during the pregnancy, and the neonates all had stage I or II disease. Four mothers had hypertension or preeclampsia. Three of these neonates had stage IV or IVS disease with liver metastases, and all three had fetal hydrops. Review of the congenital neuroblastoma literature documented 71 cases diagnosed soon after birth, and several of these cases had unusual features that could have been detected by prenatal ultrasound. Four of the tumors were so large that dystocia resulted and fetal dismemberment was required for delivery. Eight of the tumors metastasized to the placenta, and 1 metastasized to the umbilical cord with subsequent fetal death. We conclude that fetal neuroblastoma can be diagnosed by prenatal sonography. Accurate staging is difficult by sonography, but in mothers with no preeclampsia symptoms the chance of widely disseminated disease is small.(ABSTRACT TRUNCATED AT 250 WORDS)

Congenital leukemia with placental involvement. Report of a case with ultrastructural study

The study of a stillborn infant and the placenta, showing extensive infiltration of fetal organs and chorionic villi by leukemic cells, is reported. The nature of the malignant cells was not apparent by light microscopic examination. Ultrastructural examination showed that these were immature myeloblasts, stressing the usefulness of electron microscopic study in establishing the diagnosis. The current case study seems to be the first in the literature in which both placenta and fetus were studied in extenso.

Differential diagnosis of hydrops fetalis

Apart from isoimmunization, a number of conditions may present as hydrops fetalis and now account for a large proportion of hydropic infants. A large differential diagnosis must be considered when investigating the hydropic fetus and placenta while in utero, in the neonatal period, and at autopsy. An investigative protocol is proposed.