Neurofibromatosis: a common neurocutaneous disorder

A case of appendiceal ganglioneuroma in neurofibromatosis type 1

BACKGROUND

Neurofibromatosis type 1 is an autosomal dominant inherited disease associated with multiple skin neurofibromas or other neurogenic tumors, such as nodular plexiform neurinoma or cerebrospinal tumor. Gastrointestinal stromal tumors are often complicated in patients with neurofibromatosis type 1, although involvement of the appendix is rare, and there have been few reports of appendiceal ganglioneuroma.

CASE PRESENTATION

The patient was a 29-year-old man diagnosed with neurofibromatosis type 1 based on physical findings and his family history. During the follow-up of neurofibromatosis, computed tomography was performed to detect neurological tumors, such as neurofibromas in the brain, spinal cord, and gastrointestinal tract. Computed tomography showed a markedly thickened appendix wall, and an appendiceal tumor was suspected. Laparoscopic appendectomy was performed, and a 50 × 35 mm appendiceal submucosal tumor was resected with a negative resection margin. At histopathological examination, the tumor was diagnosed as ganglioneuroma; it showed short spindle-shaped cells and ganglion cells diffusely infiltrated into the proper muscle layer and fibrous tissue that grew around nerve cells. The patient was discharged on the 5th postoperative day without postoperative complications and was doing well at 13 months following the operation.

CONCLUSIONS

Gastrointestinal stromal tumor and neurofibroma are the most common gastrointestinal tumors associated with neurofibromatosis type 1, but ganglioneuroma of the appendix is rare. Appendiceal neurogenic tumors should be considered in patients with neurofibromatosis type 1, and surgical resection is necessary because of the risk of malignancy.

Association between pheochromocytoma and neurofibromatosis type I: a rare entity in the African population

The association of pheochromocytoma in patients with neurofibromatosis type I has rarely been reported in low-income countries, especially on the African continent. A 43-year-old woman with neurofibromatosis type I was diagnosed with a right adrenal pheochromocytoma in Pretoria, South Africa. To our knowledge, this report is the first case to be published of a patient with neurofibromatosis type I diagnosed with a pheochromocytoma in Pretoria, and one of three cases on the African continent. The rarity may be due to the two associated conditions being under-reported, undiagnosed, misdiagnosed or possibly the association is rare on the African continent. The clinician dealing with these two conditions should be aware of the association.

Simultaneous diagnosis of glioblastoma, cervical schwannoma, adrenal masses and growth hormone-secreting adenoma in a previously healthy patient

A constellation of newly diagnosed benign tumours and glioblastoma is an uncommon occurrence in a single individual. We present a case of a patient with a history of skin lipomas who presented with seizures and was found to have a left frontotemporal multifocal enhancing mass on MRI. Work-up for metastatic disease revealed a benign lung carcinoid tumour, a cervical schwannoma, adrenal masses, a growth hormone-secreting pituitary adenoma, and lastly a glioblastoma following brain biopsy.

Appendiceal ganglioneuroma in neurofibromatosis type 2

Here we report the case of a 30-year-old woman with a history of neurofibromatosis type 2 (NF2) who presented with an incidentally discovered pelvic mass on an ultrasound. The identity of the mass remained indeterminate following a CT and MRI, although appendiceal pathology was suspected. An elective laparoscopy and appendectomy were performed without complication and pathology on the specimen demonstrated an appendiceal ganglioneuroma. To our knowledge, there has been no prior documented case of an appendiceal ganglioneuroma in a patient with NF2. Furthermore, the current case is the first to report the MR characteristics of appendiceal ganglioneuromas.

Multicenter Study of Wound Healing in Neurofibromatosis and Neurofibroma

Based on clinical experience, the senior author has become convinced that wounds produced to correct the deformities of patients with neurofibromatosis (NF-1) have produced remarkably good scars, the interesting feature being that progression to keloid or hypertrophic scar is rare. The other point noted was that this situation did not change, no matter the patient's race or skin color. There have been few reports describing or discussing this hypothesis. The purpose of this study was to investigate whether wounds produced in the patients with NF-1 produce keloid or hypertrophic scars. The patients with solitary neurofibroma were also included in this study; these were compared with the NF-1 group. This was conducted as a multicenter study. Patients with neurofibromatosis/solitary neurofibroma, who were operated on from 1990 to 2000, were evaluated by reviewing their medical charts and photographs retrospectively. The patients were treated in centers from five different countries. The analysis was undertaken based on the following points: 1) age and sex at surgery; 2) race of the patients; 3) past and family histories of hypertrophic scar and keloid; 4) surgical site(s); 5) diagnosis, NF1 or solitary neurofibroma; 6) surgical complications; 7) number of reoperations to manage the complications; 8) adjuvant therapy for the tumor; 9) depth of the tumors; and 10) incidence of malignant degeneration. A total of 101 cases with neurofibromatosis or solitary neurofibroma was analyzed. The age at surgery ranged from 1 year 6 months to 74 years; sex ratio was 47 males and 54 females. The racial distribution of the patients was 13 white, 13 black, 3 Hispanic, and 58 Asian. There was no past or family history of hypertrophic scar or keloid. The surgical sites were head and neck in 70 cases, trunk in 20 cases, upper extremities in 22 cases, and lower extremities in 20 cases. The clinical diagnosis was NF-1 in 57 cases, solitary neurofibroma in 35 cases, plexiform neurofibroma in four cases, and no distinct clinical diagnosis in five cases. There were no other types of neurofibromatosis. Hematoma and white wide scar were the main postoperative complications found in six cases of NF-1. Infection was also noted in four cases. However, no patient developed hypertrophic scar or keloid in the neurofibromatosis group, whereas two cases showed hypertrophic scar in the solitary neurofibroma group. The outcome showed that the patients with NF-1 and plexiform neurofibroma, no matter the racial group, produce good scars without keloid or hypertrophic changes, whereas solitary neurofibroma has a potential to cause hypertrophic scar.

Massive plexiform neurofibromas in childhood: natural history and management issues

OBJECT

The authors review their experience with massive plexiform neurofibromas (PNs) in patients with pediatric neurofibromatosis Type 1 (NF1) to better characterize the natural history and management of these complex lesions.

METHODS

The authors performed a retrospective review of data obtained in seven patients with NF1 in whom massive PNs were diagnosed at The Hospital for Sick Children in Toronto, Ontario, Canada. These patients attended routine follow-up examinations conducted by a number of specialists, and serial neuroimaging studies were obtained to monitor disease progression. The most common presenting feature of PN was that of a painful, expanding lesion. Furthermore, two patients harbored multiple, distinct PNs affecting different body sites. With respect to management, two patients were simply observed, undergoing serial neuroimaging studies; two patients underwent biopsy sampling of their plexiform lesions; two patients underwent attempted medical treatment (farnesyl transferase inhibitor, R11577, and cyclophosphamide chemotherapy); and three patients required surgical debulking of their PNs because the massive growth of these tumors caused functional compromise. Ultimately, one patient died of respiratory complications due to progressive growth of the massive PN lesion.

CONCLUSIONS

In this review of their experience, the authors found certain features that underscore the presentation and natural history of PNs. The management of these complex lesions, however, remains unclear. Slow-growing PNs may be observed conservatively, but the authors' experience suggests that resection should be considered in selected cases involving significant deterioration or functional compromise. Nevertheless, patients with massive PNs will benefit from close surveillance by a team of specialists to monitor for ongoing disease progression.

Neuroimaging of the child with developmental delay

Developmental delay (DD) affects approximately 1% to 3% of all children in the United States. This diagnosis significantly impedes quality of life and full participation in the life of the family, school, and community. In this setting, the clinician's ability to detect, diagnose, and possibly treat the cause for DD in a timely manner depends on a multimodality approach to neuroimaging and a robust understanding of the various imaging algorithms aimed at determining the etiology of disease, structural and/or anatomic defects, functional activity, metabolic profiles, and genetic characteristics. Taken separately and in combination, these features are effectively depicted and analyzed using an array of brain imaging modalities: ultrasound, computed tomography, nuclear medicine, magnetic resonance (MR) spectroscopy, and a growing mix of sophisticated MR imaging (MRI) techniques, including diffusion-weighted imaging, diffusion tensor imaging, perfusion MRI, and functional MRI. Thus, equipped with these advanced imaging capabilities, pediatric neurologists and neuroradiologists are now positioned to diagnose with greater accuracy and speed; this, in turn, results in more effective treatment plans and improved patient outcomes as measured by progress in reaching developmental milestones and in ameliorating secondary conditions such as seizures, poor motor control, incontinence, and impulsivity. The purpose of this article is to present the numerous causes of pediatric DD, describe their respective neuroimaging findings, discuss various neuroimaging approaches for elucidating etiology, and offer specific guidelines for optimizing imaging results in the setting of multimodality imaging capabilities.

Lack of evidence for an association between neurofibromatosis and pulmonary fibrosis

STUDY OBJECTIVES

To reassess the association between neurofibromatosis and pulmonary fibrosis.

DESIGN

Retrospective single-center study with analysis of patients' chest radiographs, CT scans, and medical records.

SETTING

Tertiary care, referral medical center.

PATIENTS

One hundred fifty-six adult patients with neurofibromatosis seen over a 6-year period between 1997 and 2002.

RESULTS

A review of chest radiographs revealed abnormal findings in 70 patients (44.9%). The most common radiographic abnormalities were extrapulmonary nodules or masses seen in 22 patients (14.1%), followed by skeletal abnormalities in 16 patients (10.3%). Bilateral interstitial infiltrates were noted in only three patients (1.9%), all of whom had potential causes other than neurofibromatosis for their lung infiltrates, including smoking-related interstitial lung disease, rheumatoid lung disease, recurrent pneumonias, and a history of ARDS. CT scans were available in two of these patients and revealed nonspecific patterns of abnormalities with no honeycombing. Six patients had bullae or cystic airspaces demonstrated on chest radiography or CT scan; all of these findings occurred in the context of smoking-related emphysema. Combined together, bilateral interstitial lung infiltrates or cystic airspaces were demonstrated in five patients (3.2%) by chest radiography, and in eight patients (5.1%) by chest radiography or CT scanning; one patient had both findings on the CT scan.

CONCLUSIONS

We found little evidence to support an association between neurofibromatosis and pulmonary fibrosis or any other form of parenchymal lung disease. Interstitial lung disease and bullae described in association with neurofibromatosis in previous reports may have, in part, represented smoking-induced manifestations.

Neurofibromatosis Type 1

Neurofibromatosis type 1 (NF1) is an autosomal dominant congenital dysplasia of the neural crest cells that affects the development of tissue and structures arising from the 3 germinal layers. Affected patients may present with spinal deformities or with bone or soft tissue abnormalities. Imaging plays an important role in the evaluation of these patients. In this article, a working diagnosis approach is proposed and the spectrum of spinal imaging findings in the NF1 patient is reviewed.

Feline periocular peripheral nerve sheath tumor: a case series

The objective of this retrospective study was to describe signalment, clinical presentation, surgical treatment, outcome, histopathologic, and immunohistochemical characteristics of periocular peripheral nerve sheath tumor in a series of cats. Six cats with a histologic diagnosis of peripheral nerve sheath tumor of the eyelid and/or conjunctiva were identified from 3997 feline ocular histopathologic submissions to the Comparative Ocular Pathology Laboratory of Wisconsin between 1976 and 2002. Medical records were reviewed and data were collected for signalment, eye affected, location, duration, and history of tumor recurrence. Ancillary diagnostic tests, surgical approach, and histopathology were also described. Special stains and immunohistochemistry panels were performed on the tissue. Follow-up information was obtained through telecommunications with the owner and local veterinarian. The mean age of the cats was 8 years (range: 5-15 years). There was an equal distribution of males and females. Breeds represented were two Domestic Long-haired (DLH) cats, three Domestic Short-haired (DSH) cats, and one Manx. The right eye was affected in four cats and the left eye in two cats. The superior eyelid was affected in four cats, the superior conjunctiva in two cats, and the inferior eyelid in one cat. All of the cats that underwent surgical excision, cryoablation, or laser ablation had an average of three recurrences of the tumor. Four of six cats undergoing wide excision with enucleation, exenteration or rhomboid flap had no recurrence of the tumor. Histomorphologically, all of the tumors were of spindle cell type with five of six tumors showing histologic features of Antoni type B tissue. All six tumors stained positive for vimentin. Five of six tumors stained positive for S-100 and laminin. All six tumors were negative for smooth muscle actin. Definitive histologic diagnoses of spindle cell tumors can be difficult. The presence of Antoni A and B histologic patterns as well as immunohistochemical reactivity for vimentin, S-100, and laminin suggest a diagnosis of peripheral nerve sheath tumor. Our findings suggest that local aggressive recurrence is common and that wide surgical excision combined with enucleation or exenteration may be indicated.

Pheochromocytoma and functional paraganglioma syndrome: no longer the 10% tumor

Pheochromocytomas and abdominal paragangliomas are catecholamine-producing tumors of the sympathetic nervous system, while head and neck paragangliomas are non-secreting tumors of parasympathetic origin. Recent developments in clinical and molecular research on these tumor forms have significantly clarified their genetic backgrounds and challenged the view of "pheochromocytoma as the 10% rule tumor." Firstly, a larger proportion of these tumors are today discovered in normotensive patients during imaging carried out for other reasons than suspicion of pheochromocytoma. Secondly, although the differential diagnosis between malignant and benign tumors remains a challenge, the risk of malignancy well exceeds the classical 10% in patients with extra-adrenal disease, and/or carriers of germ-line SDHB mutations. Finally, up to a third of patients carry a germ-line mutation in a gene predisposing to pheochromocytoma and/or paraganglioma. Identification of a constitutional mutation in RET, VHL, SDHD, or SDHB has implications for clinical screening and follow-up for both the patient and for relatives at risk who can be identified by screening for the same mutation. Genetic testing in apparently sporadic cases is therefore regarded as beneficial, especially in patients diagnosed before 50 years of age, and in patients with bilateral, multifocal, malignant and/or extra-adrenal disease.

Neuroimaging findings in neurofibromatosis type 1 and 2

Neuroimaging, particularly MR imaging, plays an important role in the diagnosis and management of the patient with neurofibromatosis type 1 and 2. These phakomatoses are complex disorders affecting multiple cell types and multiple systems of the body with a wide range of expression. This article summarizes the neuroradiologic central nervous system findings in these neurocutaneous disorders.

Massive hemoptysis caused by endobronchial schwannoma in a patient with neurofibromatosis 2

Neurogenic tumor of the lung is very uncommon. To the best of our knowledge, endobronchial schwannoma complicated by massive hemoptysis in a patient with neurofibromatosis 2 has not been reported previously. We report a case of endobronchial schwannoma complicated by massive hemoptysis in an 18-year-old man with neurofibromatosis 2. The diagnosis of neurofibromatosis 2 was established by demonstration of bilateral vestibular schwannomas on magnetic resonance imaging of the brain and pathologic examination of the resected brain tumors. Massive hemoptysis developed after surgical removal of the brain tumors in this patient. Bronchoscopy was done immediately after the first episode of hemoptysis and a tumor protruding from the orifice of the right lower lobe bronchus was found. Despite 2 additional bronchoscopies to stop bleeding and ameliorate airway obstruction in the consecutive 2 days, hemoptysis recurred rapidly and caused profound oxygen desaturation. The patient was subjected to right lower lobectomy and endobronchial schwannoma was evidenced pathologically.

Oral manifestations of systemic disease

Most systemic diseases can affect the oral cavity. Some oral changes are nonspecific, whereas others directly lead to the diagnosis of a particular disorder. A systems approach is used here to catalog these oral changes. In some instances it is difficult to separate the oral manifestations of pharmacotherapy for a particular disease from that entity. The oral manifestations of pharmacotherapy are presented for selected disease processes. This article introduces the most common oral manifestations of systemic disease.

Neurocutaneous disorders

"Neurocutaneous disorders" is a catch-all phrase that includes all disorders involving both the nervous systems and the skin. These may range from disorders in which cutaneous findings are essential to diagnosis to those with less significant involvement of the skin. Because of the variety of disorders that involve the skin and the nervous system, this article reviews a few of the more essential diagnoses, and those with recent advancements in diagnosis and management. Many of these diseases are single gene disorders, for which the genes have been discovered in the past few years. The article is divided into sections, highlighting disorders transmitted by different inheritance pattern.

Development and implementation of a carboplatin desensitization protocol for children with neurofibromatosis, type 1 and hypersensitivity reactions in an outpatient oncology clinic

Neurofibromatosis, type 1 (NF 1), is a relatively common disorder. Children with NF 1 are at much greater risk for the development of optic pathway tumors, which are sometimes treated with chemotherapy. As a result, many oncology centers and clinics are now seeing and treating NF patients. One of the most frequently used drugs is carboplatin. However, as many as 30% of NF patients may develop a reaction to carboplatin, which can include anaphylaxis. This often results in the cessation of the medication and treatment protocol. At the Children's Hospital of Philadelphia a desensitization protocol has been instituted with children who have had such reactions and whose tumors have demonstrated a positive response to the treatment. The desensitization process is quite complex and requires an interdisciplinary approach. However, it is the nursing personnel that are key to the successful coordination and delivery of such a protocol in an oncology outpatient clinic on a regular basis.

Pedal plexiform neurofibroma: review of the literature and case report

Plexiform neurofibroma typically occurs in the setting of neurofibromatosis type 1, and is included in the diagnostic criteria for neurofibromatosis. Plexiform neurofibromas generally affect larger peripheral nerves and are uncommon in the foot and ankle. While there are several reports of large neurofibromas involving the foot, they have been described on the plantar aspect. We report the first known case of plexiform neurofibroma involving the deep peroneal nerve of the foot. A review of the literature is also presented.

Prevalence of hypopigmented maculae and café-au-lait spots in idiopathic epileptic and healthy children

The cutaneous lesions and findings related to the central nervous system are frequently seen concomitantly in many patients. Neurocutaneous syndromes are the most typical examples supporting this observation. The prevalences of hypopigmented maculae and café-au-lait spots were investigated in 210 idiopathic epileptic children between the ages of 2 and 17 years and 2754 healthy children between the ages of 5 and 15 years. In the group of epileptic children, hypopigmented maculae and café-au-lait spots were observed in 30 (14.3%) and 63 (30%) children, respectively. In the group of healthy children, the prevalence of hypopigmented maculae was 1.6% (44 children) and of café-au-lait spots was 2.83% (78 children). The difference between the two groups was very significant statistically (P < .0001).

Multiple endocrine neoplasias

The multiple endocrine neoplasia syndromes form a distinct group of genetic tumor syndromes. They include multiple endocrine neoplasia types 1 and 2, von Hippel Lindau syndrome, neurofibromatosis, and Carney complex. Research over the past decade has identified a molecular basis for each of these syndromes. This knowledge has revolutionized not only the clinical management but also has illuminated the field of human cancer research by the identification of new and important genes critical for regulation of cell growth, differentiation, and death. This review focuses on the structure, physiologic function, and molecular abnormalities of the genes involved in these syndromes.

Malignant transformation of neurofibromas in neurofibromatosis 1 is associated with CDKN2A/p16 inactivation

Patients with neurofibromatosis 1 (NF1) are predisposed to develop multiple neurofibromas (NFs) and are at risk for transformation of NFs to malignant peripheral nerve sheath tumors (MPNSTs). Little is known, however, about the biological events involved in the malignant transformation of NFs. We examined the CDKN2A/p16 gene and p16 protein in NFs and MPNSTs from patients with NF1. On immunohistochemical analysis, all NFs expressed p16 protein. The MPNSTs, however, were essentially immunonegative for p16, with striking transitions in cases that contained both benign and malignant elements. None of the benign tumors had CDKN2A/p16 deletions, whereas three of six MPNSTs appeared to have homozygous CDKN2A/p16 deletions. Methylation analysis and mutation analysis of CDKN2A/p16 in MPNSTs did not reveal any abnormalities. These results show that malignant transformation of NF is associated with loss of p16 expression, which is often secondary to homozygous deletion of the CDKN2A/p16 gene. The findings suggest that CDKN2A/p16 inactivation occurs during the malignant transformation of NFs in NF1 patients and raises the possibility that p16 immunohistochemistry may provide ancillary information in the distinction of NF from MPNST.