Cytology of Extraneural Metastases of Nonhematolymphoid Primary Central Nervous System Tumors: Six Cases with Histopathological Correlation and Literature Update

INTRODUCTION

Extraneural/-cranial metastases (ENM) of primary central nervous system (CNS) tumors are rare and may be diagnostically challenging. We describe the cytomorphological and pertinent clinical features of ENM in a case series assessed by fine-needle aspiration (FNA). A search of the laboratory information systems of 2 tertiary care centers in Toronto (2000-2015) was performed. Cases with direct extracranial/-spinal extension of CNS neoplasms were excluded. Microscopic slides of FNA and surgical specimens were reviewed. Demographic and clinicopathological data were retrieved.

CASE PRESENTATION

Six cases were identified with the original diagnoses of glioblastoma, glioblastoma with primitive neuroectodermal tumor-like components, anaplastic ependymoma, myxopapillary ependymoma, atypical meningioma, and hemangiopericytoma. Median patient age at first diagnosis was 44 years (range 22-56). The time interval between initial diagnosis and first metastatic disease manifestation was 3 months to 19 years. All FNA diagnoses were rendered correctly. In 4 cases, immunohistochemistry was used to support the diagnosis. All cases had prior surgical intervention at the primary tumor site. In 4 cases, the ENM location was the ipsilateral parotid or buccal area. Two primary tumors in midline location developed ENM in the scapular area.

DISCUSSION/CONCLUSION

ENM are a rare manifestation of a range of different primary CNS tumors and may involve the ipsilateral head and neck mimicking clinically a salivary gland neoplasm. FNA can rapidly discriminate ENM from other, potentially more indolent conditions. Awareness of the clinical history is paramount to avoid diagnostic confusion.

Extracranial head and neck neurogenic tumors: report of 47 cases

Extracranial head and neck neurogenic tumors are rare and usually revealed by histological examination. The aim of this study was to review the clinical, radiological and therapeutic particularities of these tumors.

METHODS

This retrospective study concerns 47 patients with neurogenic tumors of the head and neck, operated on between 1989 and 2011 (22 years period). All patients had complete physical examination and ultrasonography was performed when a cervical extension was found. CT scan and MRI were performed in 16 cases. Minimum follow up was 4 years.

RESULTS

  A sinusonasal tumor was found in 9 cases and a cervical mass was seen in 28 cases. Parapharyngeal extension was observed in two cases. Two patients had tympano-jugular glomic tumors and 8 of them had a cervical soft tissue tumor. Complete surgical resection was performed in 46 patients. Histological examination revealed a benign tumor in 91% of cases (n=43), 24 of them were schwannomas. Malignant tumors were seen in 4 cases: esthesioneuroblastoma (3 cases) and malignant schwannoma (1 case). These patients received post operative radiotherapy. After surgery, two patients had Claude Bernard Horner syndrome and one had a definitive facial nerve palsy.

CONCLUSION

Extracranial head and neck neurogenic tumors may have several aspects depending on their localisation and their histological type. Surgery, when performed, should be complete with minimum complications.

Truncated vesicular stomatitis virus G protein improves baculovirus transduction efficiency in vitro and in vivo

Pseudotyping of viral vectors has been widely used to enhance viral transduction efficiency. One of the most popular pseudotyping proteins has been the G-protein of the vesicular stomatitis virus, VSV-G. In the present study, we show that the 21-amino-acid ectodomain with transmembrane and cytoplasmic tail domains of VSV-G (VSV-GED) augments baculovirus-mediated gene delivery in vertebrate cells by aiding viral entry. The VSV-GED pseudotyped virus replicated efficiently in insect cells yielding high titers. Five out of six studied cell lines showed improved transduction, as measured by a number of transduced cells or transgene expression level. Nearly 15-fold increase in the transduction efficiency was detected in rat malignant glioma cells as compared to the control virus. In the rat brain, transgene expression could be detected in the walls of lateral ventricles and in subarachnoid membranes. Increased transduction efficiency was also observed in the rabbit muscle. Our results suggest that VSV-GED enhances baculoviral gene transfer by augmenting gp64-mediated endosomal release. Moreover, no cytotoxicity was associated with improved gene transfer efficiency. Thus, VSV-GED pseudotyping provides a simple means to enhance baculovirus-mediated gene transfer in vitro and in vivo.

Cancer gene therapy using a novel secretable trimeric TRAIL

Tumor necrosis factor (TNF)-related apoptosis-inducing ligand (TRAIL), a member of the TNF family, is a type II transmembrane cytokine molecule. Soluble TRAIL has been shown to induce apoptosis in a wide variety of cancer cells in vitro and to suppress tumor growth specifically without damaging normal cells and tissues in vivo. In our previous report, we have demonstrated that an artificial gene encoding the polypeptide composed of the three functional elements (a secretion signal, a trimerization domain and an apoptosis-inducing moiety of TRAIL gene sequence) expresses and secretes highly apoptotic trimeric TRAIL into the culture supernatant. Here, as an approach to TRAIL-based cancer gene therapy, we developed an adenoviral vector delivering the gene that encodes our secretable trimeric TRAIL (stTRAIL). This adenovirus (Ad-stTRAIL) potently induced apoptosis in vitro in cancer cell lines such as HeLa, MDA-MB-231, A549, HCT116 and U-87MG. In an animal xenograft tumor model bearing a human glioma cell line U-87MG, intratumoral delivery of Ad-stTRAIL dramatically suppressed tumor growth without showing detectable adverse side effects. Histological analysis revealed that Ad-stTRAIL suppresses tumor growth by inducing apoptotic cell death. Contrary to the known rapid clearance of systemically delivered TRAIL protein from the blood circulation, stTRAIL expressed by Ad-stTRAIL in tumor tissues persisted for more than 4 days. In a comparison of tumor suppressor activity between Ad-stTRAIL and Ad-flTRAIL (delivering the full-length TRAIL gene) after mixing infected cells with uninfected cells and implanting these mixed cells in nude mice, Ad-stTRAIL showed higher tumor suppressor activity than that of Ad-flTRAIL. Our data reveal that a gene therapy using Ad-stTRAIL has a promising potential to treat human cancers including gliomas.

Neurogenic tumors of the mediastinum

Neurogenic tumors can arise from neural cells in any location; however, they commonly are found in the mediastinum and, more specifically, most often are located in the posterior compartment. Neurogenic tumors can be benign or malignant, with a wide array of both clinical and pathologic features that are commonly classified by the cell type of origin. These tumors are usually detected on routine chest radiograph, and a computed tomographic scan is required to obtain more information about involvement of local structures. A magnetic resonance imaging scan may be necessary if a dumbbell-shaped component is identified or suspected. Treatment options vary depending on the presentation, but most often surgical resection is recommended. Whereas patients with benign neurogenic tumors have an excellent prognosis with complete surgical resection, patients with malignant neurogenic tumors still have poor long-term survival prospects.

Gastrointestinal stromal tumors: current diagnosis, biologic behavior, and management

Gastrointestinal stromal tumors (GIST) are rare tumors of the gastrointestinal (GI) tract that arise from primitive mesenchymal cells. GISTs occur throughout the GI tract but are usually located in the stomach and small intestine. The majority of GISTs are immunohistochemically positive for c-kit protein (CD 117) and CD34. GISTs express a heterogeneous clinical course not easily predicted by standard pathological means. The most important prognostic factors are size > 5 cm, tumor necrosis, infiltration and metastasis to other sites, mitotic count > 1-5 per 10 high-powered fields, and most recently, mutation in the c-kit gene. Surgical resection remains the mainstay of treatment, as chemotherapy and radiation are ineffective. Long-term follow-up is imperative, as recurrence rates are high.

Neurogenic tumors of the head and neck in children

Soft tissue tumors make up 63% of all tumors in children. Tumors of the sympathetic chain make up 7.4% of tumors arising in children (nine new cases a year for every million children in USA) while neurofibrosarcomas make up 3.4% (2.4 new cases per year for every million children). There is a certain difference between the frequency of benign forms (rather elevated) and that of malignant forms (rather low). Diagnosis is possible by echo-scan, computed tomography, magnetic resonance imaging and fine-needle aspiration biopsy. As regards therapy, surgical resection represents the treatment of choice. In our experience, 35 neurogenic tumors in pediatric patients (8-16 years), arising in head and neck spaces, were observed and treated in the period 1976 and 1995. Twenty-six cases were schwannomas, six were neurofibromas and three were olfactory neuroblastomas. All the patients underwent surgery. Sacrifice of the affected nerve was necessary in 12 cases (all neurofibromas and eight neurinomas). In one case of olfactory aesthesioneuroblastoma a combined approach (extra-intracranial approach) was employed. Two patients are alive and disease-free with 5 and 7 years follow-up. As regards dysfunctional pathology following surgical resection, we report definitive facial nerve palsy in two cases, permanent laryngeal palsy in six cases, tongue dysfunction in one case and cheek hypoaesthesia in one case.

[Neurogenic tumors of the head and neck]

The authors present case studies of 65 patients with neurogenic tumors of the head and neck treated in the Department of Otolaryngology of the Medical University of Gdańsk in the years 1948-1993. Age and sex of patients, localization of tumor, symptoms, histopathology and treatment were analysed. This resulted in the noting of difficulties in diagnosis and in showing the importance of immunohistochemical examinations, CT, MRI, USG in the diagnostics of malignant neurogenic neoplasms. Patients with benign tumors, in the majority of cases, were subjected to surgery. Patients with malignant neoplasms were subjected to surgery combined with high voltage radiotherapy. The positive effect of combined chemotherapy in cases of esthesioneuroblastoma is worthy of note. The results of the treatment of benign tumors are positive, whereas in the case of malignant tumors--the results are still not satisfactory.

Neurogenic tumors of the thorax

We have conducted a retrospective review of 134 cases of neurogenic tumors of the thorax, including 66 in infants and children and 68 in adults. Nerve cell tumors were the majority in infants and children (84.8%) and were mostly malignant (67.2%). Nerve sheath tumors were more frequent in adults (73.5%). Nerve cell tumors were the most frequent tumors in males and nerve sheath tumors in females. Nineteen tumors were associated with von Recklinghausen's disease. The tumors were symptomatic in 76.4% of children and 36.7% of adults. Spinal cord compression was observed in 8 infants and children and in 2 adults. Neo-adjuvant treatment was administrated to 3 patients. Resection was complete for 80 benign tumors out of 86 (93%) and for 26 malignant tumors out of 48 (54%). Postoperative chemo- or radiotherapy (or both) was administrated to 17 children and 8 adults. The mean followup periods were 11 years for the infants and children and 8 years, 6 months for the adults. There was one postoperative death. There were no late deaths related to benign tumor. The prognosis of spinal cord compression depended on the malignancy and staging of the tumors. At 5 years postoperatively, 21 children out of 28 with neuroblastomas and 8 out of 9 with ganglioneuroblastomas were alive. The possibility of maturation of neuroblastomas and survival with hepatic metastases was confirmed. The prognosis in cases of chemodectoma depended on the extension. Patients with malignant schwannomas had very poor prognoses, especially when associated with von Recklinghausen's disease.

Current management of mediastinal tumors

The incidence of mediastinal tumors is increasing throughout North America. The benign variants are usually managed by relatively simple surgical procedures. Malignant mediastinal tumors can be among the most challenging of medical and surgical conditions and may require the expertise of medical, radiation, and surgical oncologists. Thymomas, germ-cell tumors, and lymphomas comprise the majority of the malignant mediastinal neoplasms. Some variants are managed entirely medically while others are extirpated initially. Many require multimodality therapies, either according to an accepted protocol or, more challengingly, off protocol.

Gastrointestinal autonomic nerve tumors. A clinicopathological, immunohistochemical, and ultrastructural study of 12 cases

The gastrointestinal autonomic nerve tumor (GAN tumor) is an uncommon stromal tumor of the intestinal tract and retroperitoneum first described by Herrera and associates in 1984. Distinction of GAN tumors from other gastrointestinal stromal tumors is based on electron microscopic findings. Thus far there have been 12 reported cases. We present an additional 12 GAN tumors, identified by us during 4 years. There were seven male and five female patients and they ranged in age from 10 to 85 years (mean: 58 years). Sites of the tumors were stomach (three), jejunum (two), ileum (four), mesentery (one), and retroperitoneum (two). Eight of the tumors measured > 10 cm in greatest dimension. Usually well circumscribed, the neoplasms were tan to light pink, sometimes hemorrhagic, and soft. There was a variety of histologic patterns including fascicles, palisades, and whorls. Mitotic activity varied from 0 to 23 mitosis per 10 high-power fields (HPF). Using a panel of 10 immunohistochemical stains, only vimentin was consistently positive. There was neuron-specific enolase reactivity in six and S-100 protein reactivity in two cases. All muscle markers were negative. Ultrastructural studies showed neuron-like cells with long axonic cytoplasmic processes ending in bulbous synapse-like structures containing dense-core neurosecretory granules and clear vesicles. Basement membrane was absent. These features are reminiscent of ganglia of the intestinal autonomic nervous system. The patients were followed for 5-125 months (mean of 26 months). Tumor recurred or metastasized to the liver in seven patients (58%) and four patients died with tumor. There were correlations between tumor size (> 10 cm), mitotic count (at least five per 10 HPF), and aggressive behavior.

[Neural crest derived retroperitoneal tumors. General review]

Presentation of a series of 14 cases of neural crest derived tumours located in the retroperitoneal space in adult patients (five pheochromocytoma, six paraganglioma, two ganglioneuroma, and one neuroblastoma), and review and update of the diagnostic and therapeutic aspects. All pheochromocytoma cases presented high BP and the classic triad of sudation, tachycardia and headaches, as well as high levels of blood and urine catecholamines and/or their metabolites. CAT, ultrasound scanning and 123MIBG were the main diagnostic techniques used. All four paraganglioma were functioning and generally located surrounding both kidneys (one case was paired). No malignancy was found in any of the 11 tumours while controls remain with normal BP and normal levels of urine catecholamine metabolites. None of the two ganglioneuromas showed specific signs and symptoms but were diagnosed accidentally. The one neuroblastoma was juxtavesical showing a highly unfavourable evolution in spite of radical surgery, radiotherapy and multiple chemotherapy and the patient died within 16 months with local recurrence and haematogenous dissemination to bones and lungs.

Pediatric spinal epidural metastases

A total of 2259 children with solid malignant tumors were treated at St. Jude Children's Research Hospital between the years 1962 and 1987. Of these, 112 (5%) developed spinal epidural metastasis with spinal cord compression during the course of their disease process. Metastatic epidural spinal cord compression was caused most commonly by Ewing's sarcoma and neuroblastoma, followed by osteogenic sarcoma, rhabdomyosarcoma, Hodgkin's disease, soft-tissue sarcoma, germ-cell tumor, Wilm's tumor, and (rarely) hepatoma. There was no significant difference in outcome between patients with small-cell tumors (neuroblastoma, Hodgkin's disease, and germ-cell tumors) who received only chemotherapy and/or radiation therapy and the patients with similar lesions who received a decompressive laminectomy alone or prior to chemotherapy and/or radiation therapy. Patients with spinal cord compression from metastatic sarcoma (Ewing's sarcoma, soft-tissue sarcoma, osteogenic sarcoma, and rhabdomyosarcoma) showed a significant improvement with decompressive laminectomy alone or before medical therapy, compared to those who received radiation therapy and/or chemotherapy without posterior decompression. Pediatric tumors invade the spinal canal via the neural foramen, compressing the spinal cord in a circumferential manner, allowing decompressive laminectomy (posterior approach) to be an effective surgical approach. Sixty-six percent of children who had no evidence of motor or sensory function below the level of the compression became ambulatory after surgical decompression and medical treatment, regardless of tumor type.

Nerve injury complications. Management of neurogenic pain syndromes

Postural brachial plexus compression neuropathy occurs more frequently than usually realized. The cause is multifactorial with certain predisposing anatomic and congenital factors that are not uncommon. An inciting event is required to cause a clinically significant syndrome. The event can be a specific traumatic episode or cumulative trauma leading to an adoption of a guarding posture, which results in a self-perpetuating cycle and brachial plexus nerve compression. The diagnosis and management may be complicated by concurrent vascular compression, concurrent reflex sympathetic dystrophy, and associated inflammatory musculotendinous conditions. Diagnosis relies on the appreciation of a peculiar symptom complex of pain and paresthesias. The important clinical signs are a supraclavicular Tinel's sign and a positive stress abduction test. Treatment includes exercises, patient education, and behavior modification. However, misdiagnosis can lead to inappropriate treatment, such as unnecessary carpal and cubital tunnel releases. Operative treatment is reserved for those severe cases that are resistant to extended and intense physical therapy. The preferred surgical technique involves an anterior, supraclavicular approach allowing for complete visualization and release of intrinsic and extrinsic nerve compression. Awareness is the key to making the diagnosis, and successful treatment requires a multidisciplinary approach. It is generally accepted that injuries to peripheral nerves result in serious losses of function. Paresthesias and motor weakness cause immediate functional limitation, and place the hand at risk for further injury. The system has little regenerative capacity, and the chance for recovery is poor even under the best circumstances. Therefore the treatment of acute nerve injuries can be difficult and frustrating.(ABSTRACT TRUNCATED AT 250 WORDS)

Gas chromatographic determination of urinary vanilglycolic acid, vanilglycol, vanilacetic acid and vanillactic acid-chemical parameters for the diagnosis of neurogenic tumours and the evaluation of their treatment

A gas chromatographic method is described for the determination of urinary vanilglycolic acid, vanilglycol, vanilacetic acid and vanillactic acid as their trimethylsilyl derivatives. These metabolites are chemical parameters for the dignosis of neurogenic tumours. Their determination is especially recommended in order to evaluate the effect of the therapy. Results in normals and controls are given. Data in a number of selected patients with neuroblastoma, ganglioneuroma and phaeochromocytoma are presented and discussed.