Choroid plexus tumors: A clinico-pathological and neuro-radiological study of 23 cases

Orthopedic manifestations of Li-Fraumeni syndrome: Prevention and treatment of a polymorphic spectrum of malignancies

Li-Fraumeni syndrome (LFS) is a rare hereditary cancer predisposition syndrome characterized by a heightened risk of developing various malignancies at an early age. Emerging evidence suggests a correlation between LFS and orthopedic manifestations, underscoring the importance of orthopedic screening in individuals with this syndrome. Pediatric cancer is rare. It is estimated that more than 10%-15% of tumors are secondary to a pathogenic variant in a cancer predisposition gene. More than 100 cancer predisposition genes and their association with syndromes or isolated tumors have been identified. LFS is one of those who have been most widely described. Patients with this syndrome present a high risk of developing one or more tumors. Its knowledge enables the establishment of a follow-up protocol for the patient and affected family members, facilitating early detection of new tumors and reducing tumor and treatment-related morbidity and mortality. The primary objective of this invited editorial article is to provide a thorough review of the existing knowledge of LFS and its polymorphic spectrum of related malignancies, with a focus on aspects directly linked to orthopedic manifestations. Another objective is to offer an update on the most modern prevention, treatment and follow up guidelines that could be useful for the physicians dealing with this cohort of patients.

Choroid plexus tumors: A spectrum from benign to malignant

Choroid plexus tumors (CPT) are believed to originate from outgrowths of the choroid plexus. Despite their broad spectrum of symptoms, invasive nature, and prognosis, most CPTs typically exhibit similar presentations due to their relationship with the cerebral ventricles, as well as the mechanical obstruction and mass effect associated with their growth. In addition, these tumors mainly affect the pediatric population, further complicating the differentiation between benign and malignant subtypes. The World Health Organization classifies CPTs into three grades, namely, grades I, II, or III, based on their mitotic activity, which determine the benign or malignant nature of the tumors. CPTs classified by the World Health Organization (WHO) include choroid plexus papillomas (CPP), atypical CPPs (aCPP), and malignant choroid plexus carcinomas (CPC). Choroid plexus adenomas represent an additional category of benign CPTs not officially classified by the WHO. Despite the variations in histology, immunohistochemistry, imaging, treatment, and prognosis, CPTs cannot be reliably distinguished based solely on clinical presentation. Therefore, in this review, we aim to provide a comprehensive overview of each tumor subtype, along with the current management approach and emerging treatments.

Diagnosis of symmetric bilateral lateral ventricular subependymomas: A case report

Subependymomas are rare benign tumors that are hypovascular and noninvasive. Subependymomas tend to present as solitary lesions in the fourth ventricle or the frontal horn of the lateral ventricle. When multiple lesions are present, determining the correct diagnosis between subependymoma and other intraventricular neoplasms can be challenging. The characterization of imaging features and enhancement patterns can help narrow down the list of potential differential diagnoses. In this article, we describe a case of bilateral subependymomas in the lateral ventricles in a 40-year-old Asian man, including the clinical features, imaging results from conventional magnetic resonance imaging, magnetic resonance spectroscopy, and magnetic resonance perfusion, histological outcomes, and the disease management approach.

Choroid Plexus Carcinoma with Hyaline Globules: An Uncommon Histological Finding

Background: Choroid plexus carcinoma (CPC) is a predominately pediatric CNS tumor with a variety of histologic features, with hyaline globules only reported once previously. Case report: A two-year-old male child presented with headaches, vomiting, and lower limb weakness. Radiological examination revealed a right temporoparietal intra-axial tumor. On histology, it showed features of CPC containing multiple eosinophilic intracytoplasmic and extracellular hyaline globular structures, which were PAS-positive, diastase resistant, and immunoreactive for alpha-fetoprotein (AFP). Conclusion: CPC can occasionally show AFP immune-positive hyaline globules.

Case Report: Ventriculoperitoneal Shunting and Radiation Therapy Treatment in a Cat With a Suspected Choroid Plexus Tumor and Hypertensive Hydrocephalus

A 14-year-old male neutered domestic short-hair cat was presented for a history of behavioral changes and episodes of urinary retention. Neurological examination was consistent with a multifocal intracranial neuroanatomical localization, with suspected right sided lateralisation and suspected raised intracranial pressure (ICP). Brain magnetic resonance imaging (MRI) revealed an intraventricular multilobulated well-defined T2W-hyperintense and T1W-isointense, markedly contrast enhancing mass lesion within the dorsal aspect of the III ventricle extending into the left lateral ventricle, causing hypertensive obstructive hydrocephalus. A ventriculoperitoneal shunt (VPS) was placed within the left lateral ventricle, followed by a radiation therapy (RT) course of 45 Gy total dose in 18 daily fractions. Six-months post-RT, computed tomography revealed mild reduction in mass size and resolution of the hydrocephalus. The patient was neurologically normal with no medical treatment. Raised ICP causes severe clinical signs, can lead to brain ischaemia and herniation, and significantly increases anesthetic risk during RT. Placement of a VPS in cats with hypertensive obstructive hydrocephalus may allow improvement of neurological signs due to raised ICP, and therefore making the patient a more stable candidate for anesthesia and radiation therapy.

Li-Fraumeni Syndrome and Whole-Body MRI Screening: Screening Guidelines, Imaging Features, and Impact on Patient Management

OBJECTIVE

Li-Fraumeni syndrome (LFS) is a rare autosomal-dominant inherited syndrome containing a germline mutation in the TP53 gene, which predisposes to oncogenesis. Leukemia and tumors of the brain, soft tissues, breasts, adrenal glands, and bone are the most common cancers associated with this syndrome. Patients with LFS are very susceptible to radiation, therefore the use of whole-body MRI is recommended for regular cancer screening. It is important to recognize the common tumors associated with LFS on MRI, and it is also important to be aware of the high rate of false-positive lesions.

CONCLUSION

Whole-body MRI is useful for the detection of cancer in patients who come for regular screening; however, it is associated with pitfalls about which the radiologist must remain aware.

Aberrantly expressed microRNAs and their implications in childhood central nervous system tumors

Even though the treatment of childhood cancer has evolved significantly in recent decades, aggressive central nervous system (CNS) tumors are still a leading cause of morbidity and mortality in this population. Consequently, the identification of molecular targets that can be incorporated into diagnostic practice, effectively predict prognosis, follow treatment response, and materialize into potential targeted therapeutic approaches are still warranted. Since the first evidence of the participation of miRNAs in cancer development and progression 20 years ago, notable progress has been made in the basic understanding of the contribution of their dysregulation as epigenetic driver of tumorigenesis. Nevertheless, among the plethora of articles in the literature, microRNA profiling of pediatric tumors are scarce. This article gives an overview of the recent advances in the diagnostic/prognostic potential of miRNAs in a selection of pediatric CNS tumors: medulloblastoma, ependymoma, pilocytic astrocytoma, glioblastoma, diffuse intrinsic pontine glioma, atypical teratoid/rhabdoid tumors, and choroid plexus tumors.

Next generation DNA sequencing of atypical choroid plexus papilloma of brain: Identification of novel mutations in a female patient by Ion Proton

Choroid plexus papilloma (CPP) is a rare benign tumor of the central nervous system that is usually confined to the cerebral ventricles. According to the World Health Organization, CPP corresponds to a grade I atypical CPP (a-CPP); however, it can become more aggressive and reach grade II, which can rarely undergo malignant transformation into a choroid plexus carcinoma (grade III). To the best of our knowledge, identification of these tumors mutations by next generation DNA sequencing (NGS) has not been yet reported. In the present study, NGS analysis of an a-CPP case was performed. Data were analyzed using Advaita Bioinformatics i-VariantGuide and Ion Reporter 5.6 programs. The results from NGS identified 12 novel missense mutations in the following genes: NOTCH1, ATM, STK36, MAGI1, DST, RECQL4, NUMA1, THBS1, MYH11, MALT1, SMARCA4 and CDH20. The PolyPhen score of six variants viz., DST, RECQL4, NUMA1, THBS1, MYHI1 and SMARCA4 were high, which suggested these variants represents pathogenic variants. Two novel insertions that caused frameshift were also found. Furthermore, two novel nonsense mutations and 14 novel intronic variants were identified in this tumor. The novel missense mutation detected in ATM gene was situated in c.5808A>T; p. (Leu1936Phe) in exon 39, and a known ATM mutation was in c.5948A>G; p. (Asn1983Ser). These novel mutations had not been reported in previous database. Subsequently, the quality statistics of these variants, including allele coverage, allele ratio, P-value, Phred quality score, sequencing coverage, PolyPhen score and alleles frequency was performed. For all variants, P-value was highly significant and the Phred quality score was high. In addition, the results from sequencing coverage demonstrated that 97.02% reads were on target and that 97.88% amplicons had at least 500 reads. These findings may serve at determining new strategies to distinguish the types of choroid plexus tumor, and at developing novel targeted therapies. Development of NGS technologies in the Kingdom of Saudi Arabia may be used in molecular pathology laboratories.

Third Ventricular Tumors: A Comprehensive Literature Review

Third ventricle tumors are uncommon and account for 0.6 - 0.9% of all the brain tumors. Tumors of the third ventricle are classified into primary tumors, such as colloid cysts, choroid plexus papillomas, and ependymomas, or secondary tumors, such as craniopharyngiomas, optic nerve gliomas, pineal tumors, and meningiomas. Third ventricular tumors are uncommon, and their treatment involves significant morbidity and mortality. The colloid cyst has a better surgical outcome and many approaches are available to achieve a complete cure. Choroid plexus papilloma is also a common tumor documented with its treatment majorly based on surgical resection. In addition to multiple treatment options for craniopharyngiomas, surgery is the most preferred treatment option. Ependymomas also have few treatment options, with surgical resection adopted as the first line of treatment.

Rapid malignant progression of an intraparenchymal choroid plexus papillomas

Background:

Choroid plexus tumors (CPTs) are rare neoplasms accounting for only 0.3–0.6% of all brain tumors in adults and 2–5% in children. The World Health Organization (WHO) classification describes three histological grades: grade I is choroid plexus papilloma (CPP), grade II is atypical papilloma, and grade III is the malignant form of carcinoma. In adults, CPTs rarely have a supratentorial localization.

Case Description:

Here we report a very rare case of an intraparenchymal parietal CPP with a rapid histological transition from grade I to grade III WHO in a 67-year-old man, in <7 months.

Conclusion:

Because of the rarity of these oncotypes, descriptions of each new case are useful, mostly to consider this diagnostic entity in extraventricular brain tumors of adults, despite an unusual location.

Successful treatment of primary intracranial sarcoma with the ICE chemotherapy regimen and focal radiation in children

OBJECT Primary CNS sarcomas are very rare pediatric tumors with no defined standard of care. METHODS This study was a retrospective review of children diagnosed with a primary CNS sarcoma and treated at 2 Canadian tertiary care centers between 1995 and 2012. This report focuses on patients with cerebral hemispheric tumor location due to their specific clinical presentation. RESULTS Fourteen patients with nonmetastatic primary CNS sarcoma were identified; in 9 patients, tumors were located in the cerebral hemisphere and 7 of these patients presented with intratumoral hemorrhage. One infant who died of progressive disease postoperatively before receiving any adjuvant therapy was not included in this study. The final cohort therefore included 8 patients (4 males). Median patient age at diagnosis was 11.8 years (range 5.8-17 years). All tumors were located in the right hemisphere. Duration of symptoms prior to diagnosis was very short with a median of 2 days (range 3-7 days), except for 1 patient. Three (37.5%) patients had an underlying diagnosis of neurofibromatosis Type 1 (NF1). Gross-total resection was achieved in 5 patients. The dose of focal radiation therapy (RT) ranged between 54 Gy and 60 Gy. Concomitant etoposide was administered during RT. ICE (ifosfamide, carboplatin, etoposide) chemotherapy was administered prior to and after RT for a total of 6-8 cycles. Seven of the 8 patients were alive at a median time of 4.9 years (range 1.9-17.9 years) after treatment. CONCLUSIONS In this retrospective series, patients with primary CNS sarcomas located in the cerebral hemisphere most commonly presented with symptomatic acute intratumoral hemorrhage. Patients with NF1 were overrepresented. The combination of adjuvant ICE chemotherapy and focal RT provided encouraging outcomes.

Choroid plexus of the fourth ventricle: Review and anatomic study highlighting anatomical variations

Relatively few studies have been performed that analyze the morphology of the choroid plexus of the fourth ventricle. Due to the importance of this tissue as a landmark on imaging and during surgical intervention of the fourth ventricle, the authors performed a cadaveric study to better characterize this important structure. The choroid plexus of the fourth ventricle of 60 formalin fixed adult human brains was examined and measured. The horizontal distance from the midline to the lateral most point of the protruding tip of the horizontal limbs was measured. In the majority of the 60 brain specimens, right and left horizontal limbs of the choroid plexus were seen extending from the midline and protruding out of their respective lateral apertures of the fourth ventricle and into the subarachnoid space. However, on 3.3% of sides, there was absence of an extension into the foramen of Luschka and in one specimen, this lack of extension into the foramen of Luschka was bilateral. On two sides, there was discontinuity between the midline choroid plexus and the tuft of choroid just outside the foramen of Luschka. For specimens in which the choroid plexus did protrude through the foramen of Luschka (96.7%), these tufts were located anterior to the flocculus and inferolateral to the facial/vestibulocochlear nerve complex and posterosuperior to the glossopharyngeal/vagal/accessory complex. A thorough understanding of the normal and variant anatomy of the fourth ventricular choroid plexus is necessary for those who operate in, or interpret imaging of, this region.

Extraventricular Intraparenchymal Choroid Plexus Tumors in Cerebral Hemisphere: A Series of 6 Cases

OBJECTIVE

Extraventricular intraparenchymal choroid plexus tumors (CPTs) in the cerebral hemisphere are extremely rare. The aim of this study was to investigate the clinical characteristics, radiologic findings, and surgical outcomes of this atypical type of CPT.

METHODS

The study comprised 6 patients with pathologically proven extraventricular intraparenchymal CPTs who were surgically treated at Qilu Hospital of Shandong University. The PubMed database was searched for similar cases published before January 2015, and these cases were reviewed.

RESULTS

Patients were 5 (83.3%) men and 1 (16.7%) woman with an average age of 46.5 years. Symptoms and signs of CPT were usually associated with increased intracranial pressure and invasion of functional areas by tumor. Magnetic resonance imaging commonly demonstrated a contrast-enhancing intraparenchymal mass with cysts; hydrocephalus was not observed in any cases. Subtotal resection and gross total resection were achieved in 1 (16.7%) and 5 (83.3%) cases, respectively. There were 3 cases (50.0%) of choroid plexus papilloma, 2 cases (33.3%) of atypical choroid plexus papilloma, and 1 case (16.7%) not otherwise specified. There was a low incidence of postoperative complications, and surgical outcomes of CPTs were satisfactory.

CONCLUSIONS

In contrast to typical lesions, extraventricular intraparenchymal CPTs in the cerebral hemisphere are rarely associated with hydrocephalus. Magnetic resonance imaging features are key in preoperative diagnosis; nevertheless, it is difficult to distinguish this atypical type of CPT from other lesions. Surgical removal of the tumor is safe and efficacious.

Imaging of brain tumors

Neuroimaging plays a crucial role in diagnosis of brain tumors and in the decision-making process for therapy. Functional imaging techniques can reflect cellular density (diffusion imaging), capillary density (perfusion techniques), and tissue biochemistry (magnetic resonance [MR] spectroscopy). In addition, cortical activation imaging (functional MR imaging) can identify various loci of eloquent cerebral cortical function. Combining these new tools can increase diagnostic specificity and confidence. Familiarity with conventional and advanced imaging findings facilitates accurate diagnosis, differentiation from other processes, and optimal patient treatment. This article is a practical synopsis of pathologic, clinical, and imaging spectra of most common brain tumors.

Clinical outcome of adult choroid plexus tumors: retrospective analysis of a single institute

BACKGROUND

Choroid plexus tumors are rare brain tumors with clinical features that vary according to the histological grade. We reviewed the treatment outcomes of 15 adult patients with choroid plexus tumors, focusing on surgical outcomes and current therapeutic strategies.

METHOD

Patient demographic and clinical characteristics, operative findings, adjuvant therapies, disease progression and survival rates were reviewed.

RESULTS

The median age at diagnosis was 33.7 ± 10 years (19-59 years) for patients with choroid plexus tumors. Postoperative chemotherapy was given to 26.7 % of patients, and 13.3 % of patients received radiotherapy. The Ki-67 labeling index and mitotic index increased at higher histological grades. All of the choroid plexus papilloma and atypical choroid plexus papilloma patients have survived. The overall survival rate of patients with choroid plexus carcinoma was 50 % in the first year, but none of the patients survived to the second year. Five patients underwent permanent cerebrospinal fluid diversion surgery because of hydrocephalus or subdural effusion.

CONCLUSIONS

Choroid plexus papilloma and atypical choroid plexus papilloma patients can be treated with complete surgical resection. Choroid plexus carcinoma has a poor prognosis, and aggressive multi-modal treatments are generally needed for treatment. Chemotherapy and radiotherapy are important adjuvant therapies for choroid plexus carcinoma. If hydrocephalus and/or subdural effusion occur, permanent cerebrospinal fluid (CSF) diversion should be added to the therapeutic strategy.