Shunt-related Abdominal Metastases in a Child with Choroid Plexus Carcinoma: Case Report

Leptomeningeal dissemination in pediatric brain tumors

Leptomeningeal disease (LMD) in pediatric brain tumors (PBTs) is a poorly understood and categorized phenomenon. LMD incidence rates, as well as diagnosis, treatment, and screening practices, vary greatly depending on the primary tumor pathology. While LMD is encountered most frequently in medulloblastoma, reports of LMD have been described across a wide variety of PBT pathologies. LMD may be diagnosed simultaneously with the primary tumor, at time of recurrence, or as primary LMD without a primary intraparenchymal lesion. Dissemination and seeding of the cerebrospinal fluid (CSF) involves a modified invasion-metastasis cascade and is often the result of direct deposition of tumor cells into the CSF. Cells develop select environmental advantages to survive the harsh, nutrient poor and turbulent environment of the CSF and leptomeninges. Improved understanding of the molecular mechanisms that underlie LMD, along with improved diagnostic and treatment approaches, will help the prognosis of children affected by primary brain tumors.

Comparison of temporal-to-frontal horn shunt and ventriculo-peritoneal shunt for treatment of trapped temporal horn: a retrospective cohort study

As a localized hydrocephalus, trapped temporal horn (TTH) can be effectively resolved via cerebrospinal fluid shunting. In addition to conventional ventriculo-peritoneal shunt (VPS), temporal-to-frontal horn shunt (TFHS) has been described as a less complex and invasive procedure with promising results; however, there is limited data comparing VPS to TFHS regarding patient outcomes. This study aims to compare TFHS versus VPS for treatment of TTH. We conducted a comparative cohort study with patients undergoing TFHS or VPS for TTH after surgery of trigonal or peritrigonal tumors between 2012 and 2021. The primary outcome was revision rates at 30-day, 6-month, and 1-year. Secondary outcomes included operative duration, postoperative pain, hospital stay, overdrainage, and cost for shunt placement and revision. A total of 24 patients included, with 13 (54.2%) patients receiving TFHS and 11 (45.8%) receiving VPS. Both cohorts shared similar baseline characteristics. There were no significant differences between TFHS and VPS in 30-day (7.7% vs 9.1%, p > 0.99), 6-month (7.7% vs 18.2%, p = 0.576), or 1-year (8.3% vs 18.2%, p = 0.590) revision rates. There were no significant differences in terms of operative duration (93.5 ± 24.1 vs 90.5 ± 29.6 min, p = 0.744), surgical site pain (0 vs 18.2%, p = 0.199), or postoperative length of stay (4.8 ± 2.6 vs 6.9 ± 4.0 days, p = 0.157) between the two groups. For the TFHS cohort, no patient experienced shunt related overdrainage, and there was a trend towards fewer overdrainage (0% vs 27.3%, p = 0.082) compared with VPS. TFHS offered significant reduction in cost for initial shunt (¥20,417 vs ¥33,314, p = 0.030) and total costs for shunt and revision (¥21,602 vs ¥43,196, p = 0.006) compared to VPS. As a technique of valveless shunt and without abdominal incision, TFHS is cosmetic, cost-effective, and completely free of overdrainage with similar revision rates as compared with VPS.

Pilocytic Astrocytoma Arising from the Conus Medullaris in an Adult: A Case Report

Low-grade, sporadic, pilocytic astrocytomas (PAs) are rare spinal cord tumors diagnosed in adult patients. Their localization to the conus medullaris is exceedingly rare, having only been described in a limited number of case reports. Here, we describe a case of a 22-year-old female presenting with back pain, lower extremity weakness, hypoesthesia, and urinary incontinence. Imaging studies demonstrated a cystic lesion of the conus medullaris that was treated with subtotal resection and cyst-subarachnoid shunt placement. Final pathology report confirmed PA from the histology of surgical specimens. We discuss the current literature of conus medullaris lesions and their differential diagnosis.

Anaplastic ependymoma metastases though a ventriculoperitoneal shunt

Ependymomas are rare glial tumors that comprise 10% of intracranial pediatric malignancies. Primary central nervous system malignancies can rarely metastasize extracranially. When metastases occur, it usually does so in the setting of surgical manipulation of the central nervous system and can spread through the blood, lymph, or artificial means, for example, a ventriculoperitoneal shunt. We describe the presentation and progression of an 18-month-old boy diagnosed with an ependymoma. Initially managed with surgery, radiation, and ventriculoperitoneal shunt placement for symptomatic hydrocephalus, the tumor later recurred with drop metastasis to the thoracic spinal cord. The patient subsequently developed extensive metastases within the abdominal cavity, which were seeded through a ventriculoperitoneal shunt. We present a case of a rare complication of intra-abdominal tumor seeding and carcinomatosis from an intracranial ependymoma through a ventriculoperitoneal shunt. This is a rare presentation of a possible complication, which requires awareness of both surgeons and radiologists.

A brainstem mass of Müllerian type Epithelial Origin without any primary cancer source

Brainstem tumors are rare, even rarer is a brainstem tumor containing tissues of an embryologic gynecologic origin. We report a very rare case of presence of a calcified heterogeneously contrast enhancing brainstem mass of Müllerian origin in a patient in a 38 year old female with no female genital tract cancer and past surgical history of ventriculoperitoneal (VP) shunt placement for congenital hydrocephalus. To our knowledge this is the very first and unusual case of a mass of gynecologic origin in the brainstem region especially in the setting of no history of gynecological tumor. The authors also reviewed the literature for all tumors reported for anterograde and retrograde dissemination of tumor cells through VP shunt. This case is a reaffirmation of the importance of brain tumor location and tissue diagnosis for the purpose of adjuvant treatment of neurosurgical lesions in the neurocritical care setting. It also highlights the role of catheters as potential routes of iatrogenic transmission not just in anterograde but also in a retrograde manner to the CNS, which is very unusual. This is the only second case to report retrograde flow of tumor cells from an extraneural source up the VP catheters. The authors suggest that intraperitoneal chemotherapy should be considered in the cases of known extraneural abdominal malignancies of high malignant potential with or without the presence of peritoneal infiltration in order to avoid dissemination through VP shunts.

Widespread Intra-abdominal Carcinomatosis from a Rhabdoid Meningioma after Placement of a Ventriculoperitoneal Shunt: A Case Report and Review of the Literature

Intra-abdominal metastasis (IAM) of central nervous system (CNS) tumors via ventriculoperitoneal shunt (VPS) is rare but has been previously reported (e.g., germinomas and medulloblastomas). However, there has been no previous report in the literature involving meningiomas. A case of primary rhabdoid meningioma with widespread intra-abdominal carcinomatosis after placement of a VPS in a 36-year-old man is described. The patient underwent preoperative angioembolization of the tumor, craniotomy, and surgical excision, followed by postoperative gamma knife radiosurgery. Five months later, he underwent a decompressive craniectomy and surgical excision for tumor recurrence causing raised intracranial pressure and communicating hydrocephalus, necessitating placement of a VPS. One month after placement of the VPS, the patient developed abdominal distension and confusion. He was treated for a VPS infection, and the shunt was explanted. He continued to deteriorate with high output from the peritoneal drain placed at the time of shunt explantation. An exploratory laparotomy revealed multiple diffuse peritoneal and omental nodules which had the same histopathological and immunohistochemical morphology as the primary tumor. We reviewed the current literature on IAM of primary CNS tumors via VPS, which revealed that patients belonging in the pediatric age group, of the male gender, and with a primary intracranial germinoma or medulloblastoma have a higher incidence of IAM. Majority of IAM occurred within 2 years of VPS placement, and patients most commonly present with abdominal distension and ascites. Treatment after diagnosis is varied and the prognosis is poor, with more than half of the patients dying within a year. It is vital for clinicians to maintain a high index of suspicion for similar patients, as early intervention could potentially improve patient outcomes and patient expectations managed more effectively.

Widespread Intra-abdominal Carcinomatosis from a Rhabdoid Meningioma after Placement of a Ventriculoperitoneal Shunt: A Case Report and Review of the Literature

Intra-abdominal metastasis (IAM) of central nervous system (CNS) tumors through ventriculoperitoneal shunt (VPS) is rare but has been previously reported (e.g., germinomas and medulloblastomas). However, there has been no previous reports in literature involving meningiomas. A case of primary rhabdoid meningioma with widespread intra-abdominal carcinomatosis after placement of a VPS in a 36-year-old man is described. The patient underwent preoperative angioembolization of the tumor, craniotomy, and surgical excision, followed by postoperative gamma knife radiosurgery. Five months later, he underwent a decompressive craniectomy and surgical excision for tumor recurrence causing raised intracranial pressure and communicating hydrocephalus, necessitating placement of a VPS. One month after placement of the VPS, the patient developed abdominal distension and confusion. He was treated for a VPS infection and the shunt was explanted. He continued to deteriorate with high output from the peritoneal drain placed at the time of shunt explantation. An exploratory laparotomy revealed multiple diffuse peritoneal and omental nodules which had the same histopathological and immunohistochemical morphology as the primary tumor. We reviewed the current literature on IAM of primary CNS tumors through VPS, which revealed that patients belonging to the pediatric age group of the male gender and with a primary intracranial germinoma or medulloblastoma have a higher incidence of IAM. The majority of IAM occurred within 2 years of VPS placement, and patients most commonly present with abdominal distension and ascites. Treatment after diagnosis is varied, and the prognosis is poor, with more than half of the patients dying within a year. It is vital for clinicians to maintain a high index of suspicion for similar patients as early intervention could potentially improve patient outcomes and patient expectations managed more effectively.

Migration of the distal catheter of the ventriculoperitoneal shunt in hydrocephalus: A Comprehensive Analytical Review from an Anatomical Perspective

There have been many reports on migration of the distal catheter of the ventriculoperitoneal shunt (VPS) since this phenomenon was recognized 50 years ago. However, there have been no attempts to analyze its different patterns or to assess these patterns in terms of potential risk to patients. We comprehensively reviewed all reports of distal VPS catheter migration indexed in PubMed and identified three different anatomical patterns of migration based on catheter extension and organs involved: (1) internal, when the catheter invades any viscus inside the thoracic, abdominal, or pelvic cavity; (2) external, when the catheter penetrates through the body wall either incompletely (subcutaneously) or completely (outside the body); and (3) compound, when the catheter penetrates a hollow viscus and protrudes through a pre-existing anatomical orifice. We also analyzed the association between each migration type and several key factors. External migration occurred mostly in infants. In contrast, internal migration occurred mostly in adults. A body wall weakness was not a risk factor for catheter protrusion. Shunt duration was a critical factor in the migration pattern, as most newly-replaced shunts tended to migrate externally. Clinicians must pay close attention to cases of large bowel perforation, since they were most often associated with intracranial infections. The organ involved in compound migration could determine the route of extrusion, as the bowel was involved in all trans-anal migrations and the stomach in most trans-oral cases. Clin. Anat. 30:821-830, 2017. © 2017Wiley Periodicals, Inc.

Cutaneous presentation of gastrointestinal adenocarcinoma

Seeding of a central nervous system malignancy to the abdominal cavity is an uncommon but well documented complication of a ventriculoperitoneal (VP) shunt. However, the metastasis of a primary gastrointestinal cancer to the skin via a VP shunt is extremely rare. We report the clinical case of an 85-year-old male who presented with a right upper quadrant nodule over his shunt, which on histopathology and tumour marker profile was diagnosed as an adenocarcinoma of likely upper gastrointestinal origin. This case illustrates the importance of proceeding to biopsy to inform prognosis and management, despite the risks of shunt infection.

Imaging evaluation of CSF shunts

OBJECTIVE

The objective of this article is to describe an approach to imaging CSF shunts. Topics reviewed include the components and imaging appearances of the most common types of shunts and the utility of different imaging modalities for the evaluation of shunt failure. Complications discussed include mechanical failure, infection, ventricular loculation, overdrainage, and unique complications related to each shunt type.

CONCLUSION

This article reviews the imaging features of common CSF shunts and related complications with which radiologists should be familiar.

Current management of choroid plexus carcinomas

Choroid plexus carcinoma (CPC) is a World Health Organization (WHO) grade III brain tumor with a poor prognosis that occurs mainly in children. Gross total resection of CPC is highly recommended and is associated with improved overall survival, although it is often associated with increased morbidity. The use of adjuvant therapies has yet to be standardized, although evidence suggests that for patients with incompletely resected CPCs, a combination of chemotherapy and radiation therapy may be beneficial. The use of radiation therapy for younger children (<3 years old) with CPC, however, is not recommended, due to the potential negative neurological sequelae associated with radiation to the developing brain. Given that the majority of CPC patients are young children, questions regarding optimal radiation dose, chemotherapy agents, and how to combine these two adjuvant treatment modalities to achieve the best outcomes remain unanswered. In this paper we summarize the current management of CPC in the literature. Further studies are needed to standardize the treatment paradigm for this malignant brain tumor.

Extraneural metastasis of a nongerminomatous germ cell tumor of the central nervous system in a pediatric patient with a ventriculoperitoneal shunt: a case report and review of the literature

We describe the case of a 7-year-old white boy who presented with a mixed malignant germ cell tumor with predominant embryonal carcinoma component. The patient underwent right ventriculoperitoneal (VP) shunt placement for hydrocephalus at the time of diagnosis. He received multiagent chemotherapy followed by second-look surgery. Despite an initial response to chemotherapy, the patient had metastatic progression of disease within the craniospinal axis. He received craniospinal radiation and high-dose chemotherapy. Although, he had resolution of central nervous system (CNS) disease, follow-up off treatment revealed extra-abdominal metastases. This is a rare case to discuss abdominal metastasis of a CNS germ cell tumor in a patient with a VP shunt. The influence of VP shunt placement on treatment and management decisions of patients with CNS tumors will be discussed.

The impact of radiotherapy fields in the treatment of patients with choroid plexus carcinoma

PURPOSE

To perform a comprehensive literature review and analysis of cases dealing with choroid plexus carcinoma (CPC) to determine the optimal radiotherapy (RT) treatment field.

METHODS AND MATERIALS

A PubMed search of English language articles from 1979 to 2008 was performed, yielding 33 articles with 56 patients who had available data regarding RT treatment field. The median age at diagnosis was 2.7 years (range, 1 month-53 years). Of 54 patients with data regarding type of surgery, 21 (38.9%) had complete resection. Chemotherapy was delivered to 27 (48%) as part of initial therapy. The RT treatment volume was the craniospinal axis in 38 (68%), whole brain in 9 (16%), and tumor/tumor bed in 9 (16%). Median follow-up for surviving patients was 40 months.

RESULTS

The 5-year overall survival and progression-free survival (PFS) rates were 59.5% and 37.2%, respectively. Complete resection (p = 0.035) and use of craniospinal irradiation (CSI; p = 0.025) were found to positively affect PFS. The 5-year PFS for patients who had CSI vs. whole brain and tumor/tumor bed RT were 44.2% and 15.3%. For the 19 patients who relapsed, 9 (47%) had a recurrence in the RT field, 6 (32%) had a recurrence outside the RT field, and 4 (21%) had a recurrence inside and outside the irradiated field.

CONCLUSION

Patients with CPC who received CSI had better PFS compared with those receiving less than CSI. This study supports the use of CSI in the multimodality management of patients with CPC.

Ascites and abdominal pseudocysts following ventriculoperitoneal shunt surgery: variations of the same theme

OBJECT

Ascites and abdominal pseudocysts are two complications that can occur following placement of a ventriculoperitoneal (VP) shunt. Although various factors have been implicated, the exact pathogenesis of the two conditions remains elusive. To the authors' knowledge, there are no studies in which these two obviously related conditions have been compared.

METHODS

The authors retrospectively reviewed the cases of children with abdominal complications caused by a VP shunt. There were 15 patients who developed a pseudocyst and five patients who developed ascites. The cases were analyzed to identify common and distinguishing factors that may help in identifying the mechanism involved. Abdominal symptoms were the mode of presentation for patients with ascites, whereas shunt malfunction was the mode of presentation in 60% of those with pseudocysts. Culture-proven infection, abdominal surgery, and the number of revisions seemed to be more common in cases with pseudocysts than in ascites. The fluid in ascites was found to be a transudate irrespective of the origin of hydrocephalus. Alternative drainage sites were required in the treatment of patients with ascites, and reimplantation in the peritoneum was possible in 66.7% of those with pseudocysts. In the long-term, however, peritoneal reimplantation was possible in three of the five patients with ascites.

CONCLUSIONS

Abdominal pseudocysts and ascites, after VP shunt treatment, are distinct conditions with different modes of presentation and findings during examination of fluid, and therefore they require different management strategies.

Metastatic atypical choroid plexus papilloma: a case report

Choroid plexus papillomas (CPPs) are rare adult tumours and metastatic disease is even less common, more typically associated with choroid plexus carcinoma. We present the case of a 32-year-old patient with multiple metastases arising along the length of the neuraxis 3 years after resection of an atypical fourth ventricular CPP. Metastatic deposits were found from the mid-brain to the lumbar cistern and the patient underwent repeat excision of the fourth ventricular tumour, partial resection of a cervico-thoracic deposit and craniospinal radiotherapy. Possible explanations for the rarity of atypical CPP include unclear diagnostic criteria leading to under-representation in reported cases. We review the current literature on metastatic CPP and discuss the role of surgery and adjuvant therapy in relation to both typical and atypical disease.