Pulmonary blastoma is successfully treated with immunotherapy and targeted therapy

Pulmonary blastomas (PB) are an extremely rare type of lung cancer. Currently, no standard treatment exists for PB. Immunotherapy with checkpoint inhibitors and anti-angiogenesis treatments has been an effective method for lung cancer; however, studies on PB treatment are lacking. Herein, we present a case report of successful conversion therapy with immunotherapy and targeted therapy for PB. After receiving treatment with a PD-1 inhibitor (penpulimab) and a multi-target tyrosine kinase inhibitor (anlotinib) treatment, the patient showed an impressive response and underwent a successful operation. We also summarized and reviewed literature reports on PubMed from January 1, 2000, to December 31, 2022, using the keyword "pulmonary blastoma", discussing the efficacy and specifics of chemotherapy and radiotherapy. Immunotherapy, in combination with targeted therapy, should be considered a potential therapeutic strategy for PB.

Classic biphasic pulmonary blastoma: A case report and review of the literature from 2000 to 2022

Classic biphasic pulmonary blastoma (CBPB), a distinct type of lung cancer, is a dual-phasic tumor characterized by the co-existence of low-grade fetal adenocarcinoma and primitive mesenchymal stroma. Accounting for less than 0.1% of surgically removed lung cancers, CBPB commonly presents in individuals during their fourth to fifth decades of life, with smoking as a significant risk factor. The optimal management strategy entails surgical resection, supplemented by chemotherapy to improve prognosis. The frontline chemotherapeutic agents typically include platinum agents and etoposide, with preoperative neoadjuvant chemotherapy potentially enabling operability for initially inoperable cases. In recent years, targeted therapies, such as antiangiogenic agents, have emerged as promising new treatment strategies for CBPB. For patients exhibiting brain metastases or deemed inoperable, radiation therapy proves to be a crucial therapeutic component. CBPB prognosis is adversely affected by factors such as early metastasis, tumor size exceeding 5 cm, and tumor recurrence. In this regard, serological markers have been identified as valuable prognostic indicators. To exemplify, we recount the case of a 44-year-old female patient with CBPB, wherein serum lactate dehydrogenase levels showed significant diagnostic value. This report further incorporates a comprehensive review of CBPB literature from the past 22 years.

Pleuropulmonary Blastoma in a Child Presenting with Pneumothorax

Pleuropulmonary blastoma is an uncommon primary malignant tumor of the lung. Surgery is the most important part of the treatment. Despite the use of chemotherapy with or without radiotherapy, the prognosis is poor. Here we report on the case of a 2.5 year-old boy presenting with pneumothorax who turned out to have a right hemithoracic mass. The patient underwent surgical resection of the mass. Pathologic diagnosis was type II pleuropulmonary blastoma. Postoperative thoracic CT showed nodular residual densities so the patient was given adjuvant combination chemotherapy with cisplatin and etoposide. He has been disease free for 12 months.

Clinical and pathology analysis of 1 case of adult pleural pulmonary blastoma: A case report

RATIONALE

Pulmonary blastoma is a rare primary lung cancer that can be categorized into adult type and child type. The clinical symptoms and imaging features of pulmonary blastoma are nonspecific, making it difficult to diagnose preoperatively. Postoperative pathology with immunohistochemical staining can help diagnosis.

PATIENT CONCERNS

A 53-year-old male had chest tightness and shortness of breath.

DIAGNOSES

The patient was diagnosed as pleural pulmonary blastoma based on computed tomography (CT) scan, pathology, immunohistochemistry, and molecular pathology. CT examination showed solid mass on the upper lobe of the left lung Intraoperative observation found that tumor tissue was gray with tough texture. The surrounding lung tissue showed AE1/AE3 (+), Vimentin (+), and CD34 (+) staining. No epidermal growth factor receptor gene mutation was detected.

INTERVENTIONS

The left lobe resection plus mediastinal lymph node dissection were performed. After the operation, patient received paclitaxel combined with nedaplatin chemotherapy for 4 times.

OUTCOMES

Four months later, left pleural metastasis, and mediastinal lymph node metastasis was found. The patient died 15 months later.

LESSONS

Pleural pulmonary blastoma is a malignant tumor with rare pathological features that is easy to relapse and metastasis with poor prognosis. Surgical treatment preferably, lobectomy plus mediastinal lymph node dissection, is the first treatment option. The overall prognosis is poor.

Neoadjuvant Chemoradiotherapy Treatment for a Classic Biphasic Pulmonary Blastoma with High PD-L1 Expression

Pulmonary blastomas are rare malignant tumors, comprising only 0.25-0.5% of all malignant lung neoplasms. The prognosis of pulmonary blastoma is very poor, with an overall five-year survival of 16%. No standard treatment has been defined for unresectable disease. We present the case of a 25-year-old woman with unresectable locally advanced classic biphasic pulmonary blastoma (CBPB) successfully treated with neodjuvant chemoradiotherapy based on two chemotherapy induction cycles of cisplatin plus etoposide, followed by concurrent weekly cisplatin to 50.4 Gy radiotherapy treatment. The patient had a significant reduction in tumor size, allowing for complete resection by pneumonectomy. Molecular study for epidermal growth factor receptor (EGFR) mutations, anaplastic lymphoma kinase (ALK), proto-oncogene receptor tyrosine kinase (ROS1) and rearranged during transfection (RET) rearrangements, and programmed death ligand 1 (PD-L1) expression was performed in the pre-treatment tumor sample. Our patient presented a high expression (>90% of tumor cells) of PD-L1. To our knowledge, this is the first report of PD-L1 expression in CBPB. This could lead to new treatment options based on new immunotherapy agents blocking the PD-1/PD-L1 pathway for this rare disease with poor prognosis.

The assessment of primitive or metastatic malignant pulmonary tumors in children

BACKGROUND

The purpose of our study is to assess primitive and secondary malignant pulmonary tumors in children. The presence of lung tumors in newborns and infants is a point of interest to specialists in pediatric surgery, thoracic surgery and genetics due to the high death rate. The 5-years survival rate communicated by EUROCARE-study is less than 10% for primitive tumors and less than 15% in lung metastases.

MATERIALS AND METHOD

We performed a retrospective study which analysed 11 children with pulmonary primary ormetastatic tumors admitted in the Pediatric Surgery Department “Prof. Dr. Al. Pesamosca” of the Emergency Clinical Hospital for Children “Maria Sklodowska Curie”,Bucharest. The analysed and operated patients underwent surgery by Prof. Dr. Al. Pesamosca and the authors during the period of 1985-2011. In our series there where 4 primitive lung tumors and 7 secondary ones: 8 underwent surgery and 2 died before being operated on. The incidence of primitive pulmonary lung malignancies is higher for females, 3 to1, and secondary ones are more frequent in males, 6 to 1.

RESULTS

Patients with primitive pulmonary malignancies were late diagnosed. Their age ranged between 1 to 6 years;3 were operated on, out of which 2 died, and 1 operated still survives. The 7 patients with secondary pulmonary malignancies were late diagnosed, too, probably as a consequence of a late diagnosis of the origin tumor.

CONCLUSIONS

Even if all malignancies require an early diagnosis and treatment, this aim regarding malignant lung tumors is still a desideratum animating all practitioners. Primitive tumors are diagnosed presenting the main clinical manifestation abroncho pulmonary infection. Secondary lung malignancies are usually asymptomatic and are diagnosed when monitoring a patient for a malignancy with another origin. Chemotherapy,radiotherapy and surgery of malignant primitive tumors or metastatic ones in children remain unsatisfactory because of the late diagnosis and the limited methods of treatment. Nowadays genetics identified the responsible oncogenes for pulmonary blastic explosion and better results could be obtained by genetic surgery.

[The application of UHF therapy for the prevention of complications of specific antiblastoma therapy in the patients presenting with III-IV stage lung cancer]

One of the complications of specific antiblastoma therapy in the patients presenting with malignant neoplasms is the suppressed functional activity of blood neutrophil granulocytes. The results of clinical and experimental investigations suggest the enhanced enzymatic activity of neutrophils and lymphocytes under effect of ultrahigh-frequency electromagnetic radiation (UHF EMR). Our study has demonstrated that UHF EMR with a frequency selected on an individual basis in the range from 59 to 63 GHz exerts the protective action on the function and metabolism of blood neutrophils exposed to the damaging action of gamma-radiation in the patients presenting with lung cancer. Moreover, it allows the severity of local and systemic complications of specific antiblastoma chemo- and radiotherapy in these patients to be reduced.

Pleuropulmonary blastoma

Pleuropulmonary blastoma is a rare and aggressive malignant tumour that affects young children. A case of pleuropulmonary blastoma has been presented in a 9-year-old male child who was initially diagnosed and treated as pulmonary tuberculosis. Computed tomography of chest revealed a large heterogeneously enhancing mass with calcification in left hemithorax and left pleural effusion. The mass was seen to invade mediastinum and left hemidiaphragm. Thoracotomy revealed unresectable tumour involving both lobes of left lung with invasion of mediastinum and left hemidiaphragm. Biopsy confirmed type II pleuropulmonary blastoma and the child was treated with chemotherapy and radiotherapy.

Follicular thyroid carcinoma arising after hematopoietic stem cell transplantation in a child with pleuropulmonary blastoma

BACKGROUND

Pleuropulmonary blastoma (PPB) is a rare and aggressive intrathoracic neoplasm that is associated with other dysplastic or neoplastic conditions. The prognosis, especially of type II (cystic and solid) and type III (solid) PPB, is poor. High-dose chemotherapy (HDC) and hematopoietic stem cell transplantation (HSCT) have been attempted to improve survival rates. We report the development of follicular thyroid carcinoma in a girl who was treated at a young age for PPB.

SUMMARY

A 23-month-old girl was evaluated for a clinical diagnosis of pneumonia and was found to have a mass in the left lung that grew rapidly. It was removed and diagnosed as a PPB. At the age of two, she was referred to our hospital for further treatment. She received adjuvant chemotherapy for 6 months but developed a recurred mass in her back at 4.3 years of age. After removal of the mass, she was given a salvage chemotherapy followed by HDC and HSCT but not radiation treatment between 4.4 and 4.9 years of age. At the age of seven, after 2 years without treatment, she presented with multiple thyroid nodules in both lobes that steadily grew over the next 2 years. At the age of nine, she underwent total thyroidectomy, which revealed an invasive follicular carcinoma. She remained without clinical evidence of thyroid cancer for one year since the surgery. Radiation therapy was not administered because of the concerns of causing another malignancy. A literature search combined with the present case indicated that, of the five living patients who had been treated with HDC and HSCT, three developed a follicular thyroid carcinoma.

CONCLUSIONS

The high prevalence (3/5, 60%) of follicular thyroid carcinoma in patients with PPB who were treated with HDC and HSCT is striking. This suggests that, in patients with PPB, either HDC or HSCT contributes to the development of thyroid cancer. Clinicians should be advised of the high risk of thyroid carcinoma occurrence when HDC and HSCT are being contemplated in children with PPB.

Primary pleuropulmonary neoplasms in childhood: fourteen cases from a single center

BACKGROUND

We aimed to review clinical characteristics, treatment results and outcome of pediatric patients with primary pleuropulmonary neoplasms.

METHODS

Medical records of 14 cases diagnosed between 1972-2009 were reviewed retrospectively.

RESULTS

The male/female ratio was 5/9 and the mean age at diagnosis was 9.1 years (2-16). All but one were symptomatic, presenting with fever, coughing, dyspnea, or weight loss. One patient presented with hemoptysis, and another with digital clubbing. One mesothelioma was diagnosed incidentally. Some 8/14 patients were initially diagnosed as having pneumonia (median delay in diagnosis of 2.5 months). Diagnoses included pleuropulmonary blastoma (PPB, n = 5), inflammatory pseudotumor (n = 3), mesothelioma (n = 2), mucoepidermoid carcinoma (MEC, n = 2), and carcinoid tumor (n = 2). Patients with PPB underwent surgery and received chemotherapy with or without radiotherapy. Two carcinoid tumor cases underwent surgery, one further received chemotherapy. Patients with mesothelioma were treated with chemotherapy. Inflammatory pseudotumors were all resected. Two cases with MEC received chemotherapy, one after surgery. 2/5 PPB patients survived without recurrence, 3 died; all carcinoid tumors and inflammatory pseudotumors were alive; 1/2 MEC patients was alive after 252 months, the other one was lost without disease; 1/2 mesothelioma patients was alive without disease, the other was died. For all cases, median follow-up was 30.5 months (0.6-252).

CONCLUSIONS

Primary pleuropulmonary tumors are rare but clinical presentation can be varied and delay in diagnosis is common. Children with persistent coughs, recurrent pneumonia or hemoptysis should be considered as indicators for early diagnosis, very important because the prognosis of these tumors varies with histology and stage.

Pleuropulmonary blastoma. A rare childhood malignancy

Pleuropulmonary blastoma PPB is an extremely rare, intrathoracic neoplasm of early childhood with unfavorable outcome. We present a case of a 4-year-old boy with progressive dyspnea due to tension pneumothorax. After chest tube insertion, the CT scan showed large multilocular cystic lesions containing air and solid areas involving the right lower lobe, and its related pleura. Thoracotomy was carried out, and the cyst was removed with the pleural solid areas. Histopathological examination confirmed the diagnosis of PPB type II. Postoperatively, the patient was scheduled to start chemotherapy in a specialized pediatric oncology center to complete the treatment.

Biphagic pulmonary blastoma with a lesion of yolk sac tumor

Biphagic pulmonary blastoma (BPB) is one of the rare pulmonary malignant neoplasms. Here, we describe a case of BPB with a histological feature of yolk sac tumor, accompanied with an elevated serum alpha-fetoprotein level (531.1 ng/ml). The tumor was detected in the right upper lobe as a 10-cm mass. The patient underwent right upper lobectomy and mediastinal lymph node dissection. Histological examination revealed that the tumor was composed of immature mesenchymal and epithelial elements, and it was accompanied by foci of yolk sac tumor-like features that showed positive staining for alpha-fetoprotein antibody. Adjuvant chemotherapy consisted of cisplatin and etoposide. After surgery, the serum level of alpha-fetoprotein decreased below normal. Local recurrence was disclosed 27 months after surgery, and radiation therapy was performed. The patient is currently alive 70 months after surgery.

Pulmonary Blastoma with Renal Metastasis Responds to Sorafenib

Biphasic pulmonary blastoma is a rare malignancy of the lung composed of proliferating epithelial and mesenchymal cells with a high vessel density at the tumor periphery. We report a rare case of renal metastasis of biphasic pulmonary blastoma that responded to sorafenib, an oral multikinase inhibitor. After 2 months of treatment with sorafenib, the renal tumor size decreased sufficiently to allow a safe laparoscopic radical nephrectomy. We believe that further studies are warranted to confirm the possible effects of sorafenib on pulmonary blastomas.

[Pulmonary blastoma in adults]

Pneumoblastoma (PB) is a rare, malignant, primary, pulmonary tumour, of young adults. Its discovery is fortuitous in asymptomatic patients. It is a well-delimited, homogeneous lesion in the lung periphery. Histologically, its structure looks like a normal fetal lung. The surgical resection is the treatment of choice. The radiotherapy is an empirical palliative treatment to relieve dyspnea when other treatments failed. The prognosis is bad: 16% survive 5 years and 8% beyond 10 years, all treatments included. Metastases could appear in the liver, the brain and the bone.

Combined small cell carcinoma with pulmonary blastoma and adenocarcinoma: Case report and clonality analysis

We describe a rare tumor occurring in the left pulmonary lobe of a 71-year-old Japanese man. The tumor, which was resected by left lower lobectomy, measured 65 x 50 x 50 mm. Histologic examination revealed papillary adenocarcinoma in small cell carcinoma, and chondrosarcoma. Also, the blastemal cells were located between the small cell carcinoma and the chondrosarcoma, and intermingled with both components. In blastemal cells, some glands resembled a well-differentiated fetal adenocarcinoma. The tumor was diagnosed as combined small cell carcinoma with pulmonary blastoma and papillary adenocarcinoma according to the 2004 WHO classification. Immunohistochemically, the small cell carcinoma expressed TTF-1, pancytokeratin, CD56, synaptophysin, and S100 protein, while blastemal cells expressed vimentin, desmin, smooth muscle actin, CD56, and S100 protein. To investigate whether the tumor was clonal or not, p53 gene mutation of each tumor component was analyzed by laser-captured microdissection, polymerase chain reaction-single-strand conformation polymorphism and direct sequencing. Despite the histologic complexity, all components showed the same mutation at exon5 of the p53 gene. These results indicate that the tumor was clonal and arose from a relatively primitive cell, and that p53 mutation occurred before histologic metamorphosis or differentiation.

Pleuropulmonary blastoma: cytogenetic and spectral karyotype analysis

Pleuropulmonary blastoma (PPB) is a rare neoplasm of the pleuropulmonary mesenchyme. The molecular mechanisms underlying the genesis of this tumor are of particular interest as a large number of affected patients as well as their relatives have concurrent disease including additional dysplasia or neoplasia. To date, detailed karyotypes have been published on a limited number of cases. We report clinical, pathologic, and cytogenetic data in 2 cases of PPB including spectral karyotyping in 1 of them. Additionally, we conducted a review of the literature and compiled 15 published karyotypes of this tumor. Gain of chromosome 8 material was a highly prevalent finding in PPB, most times occurring as trisomy, but tetrasomy of the long arm was also frequent. Other occurring abnormalities, in order of observed frequency, included loss of 17p, loss of chromosome 10 or 10q, rearrangement of 11p, loss of chromosome X or Xp, gain of chromosomes/arms 1q, 2, and 7q, and loss of 6q and 18p. Loss of 10q has not been previously emphasized in PPB. The significance of these chromosome findings is discussed in relation to tumorigenesis.

Primary malignant peripheral nerve sheath tumor of the lung in a young child without neurofibromatosis type 1

Malignant peripheral nerve sheath tumors (MPNST) are uncommon in children and almost half of the cases occur in patients with neurofibromatosis 1 (NF1). We report a child with a primary MPNST of the lung without NF1. MPNST of the lung has similar clinical and radiologic characteristics as pleuropulmonary blastoma. We suggest to include MPNST of the lung in the differential diagnosis of intrapulmonary masses in children.

Autologous peripheral blood stem cell transplantation in a patient with relapsed pleuropulmonary blastoma

Pleuropulmonary blastoma (PPB) is a rare and aggressive primary intrathoracic neoplasma of children. The prognosis is extremely poor with frequent metastasis to the brain and bone. We present a 4-year-old girl with a tumor mass in the right hemithorax initially diagnosed as pneumoniae. Tumor resection was performed and the histologic report indicated the diagnosis of PPB. The patient received chemotherapy comprising vincristine, actinomycin D, doxorubicin, cisplatin, and cyclophosphamide. Irradiation was performed with total 45 Gy at the right lower pulmonary lobe. She relapsed 29 months later at the pleura between the right middle and lower pulmonary lobe. Tumor resection and total 45 Gy of irradiation were performed again. High-dose chemotherapy comprising cisplatin, adriamycin, and cyclophosphamide was performed followed by autologous peripheral blood stem cell transplantation (PBSCT). The patient achieved complete hematologic recovery. Thirty-one months after PBSCT, no signs of relapse have been observed. Although it might be that the patient could have been cured with second surgery alone or by the surgery and subsequent chemotherapy, high-dose chemotherapy and PBSCT should be considered for the treatment of relapsed PPB.

Hidden chromosomal abnormalities in pleuropulmonary blastomas identified by multiplex FISH

Background

Pleuropulmonary blastoma (PPB) is a rare childhood dysontogenetic intrathoracic neoplasm associated with an unfavourable clinical behaviour.

Cases presentation

We report pathological and cytogenetic findings in two cases of PPB at initial diagnosis and recurrence. Both tumors were classified as type III pneumoblastoma and histological findings were similar at diagnosis and relapse. In both cases, conventional cytogenetic techniques revealed complex numerical and structural chromosomal abnormalities. Molecular cytogenetic analysis (interphase/metaphase FISH and multicolor FISH) identified accurately chromosomal aberrations. In one case, TP53 gene deletion was detected on metaphase FISH. To date, only few cytogenetic data have been published about PPB.

Conclusion

The PPB genetic profile remains to be established and compared to others embryonal neoplasia. Our cytogenetic data are discussed reviewing cytogenetics PPBs published cases, illustrating the contribution of multicolor FISH in order to identify pathogenetically important recurrent aberrations in PPB.

[A case of pulmonary blastoma--a case report and review of the literature]

Pulmonary blastoma is a rare malignant tumor of the lungs, with a frequency of 0.25-0.5% of all primary malignant lung tumors. We present a case of 42-year old man with biphasic pulmonary blastoma The authors discussed the clinical features, laboratory findings, radiologic and CT features, the operative treatment and the pathologic diagnosis.

An association of pleuropulmonary blastoma and cystic nephroma: possible genetic association

The association of pleuropulmonary blastoma and cystic nephroma is an uncommon entity, with only 4 cases of such an association in the same patient described in English literature. We report a 5th histologically documented case in a 32-month-old boy. The boy underwent a pulmonary biopsy that showed a pleuropulmonary blastoma and a nephrectomy that showed a cystic nephroma. The pleuropulmonary mass showed an important regression with postbiopsy chemotherapy, allowing subsequent tumorectomy. To date very little is known about this rare entity, and a genetic link between these 2 tumors is hypothesized.

Pulmonary blastomas of childhood: histologic, immunohistochemical, ultrastructural aspects and therapeutic considerations

Pulmonary blastomas are rare neoplasms typically occurring in patients of pediatric age, clinically characterized by fever, respiratory distress, and radiologic findings of a pulmonary cystic and/or solid mass with partial or complete obliteration of emithorax. Their behavior is aggressive and outcome is poor due to frequent relapses and metastases. The histological, immunohistochemical, and ultrastructural aspects of a personal series of 6 cases of pulmonary blastoma are described and the differences between childhood and adult types are stressed. Due to the aggressiveness of these rare tumors, therapeutic management is quite difficult. The expression of the transmembrane tyrosin kinase receptor c-kit in all the solid cases of this series leads the authors to hypothesize new possible therapeutic implications for these tumors.

Life-threatening presentation of mediastinal neoplasms: report on 7 consecutive pediatric patients

BACKGROUND

Cases of respiratory failure at presentation in children with anterior mediastinal malignancies can be very challenging for clinicians. Seven consecutive children presenting with superior mediastinal syndrome are reported needing urgent critical care approach.

PATIENTS AND METHODS

Seven children (age range from 0.8 to 14 years; mean, 4.5 years) suffered from critical mediastinal neoplasms. Clinical presentation, laboratory findings, treatment, and outcome are discussed.

SETTING

a tertiary-care 6-bed medical and surgical pediatric intensive care in a university hospital. Interventions included emergency management, resuscitation and intensive care admission, and diagnostic and therapeutic procedures.

RESULTS

All cases showed a respiratory compromise and underwent ventilatory and/or cardiovascular support. Two patients needed renal replacement therapy. Pediatric Intensive Care Unit discharge was achieved in all patients.

CONCLUSIONS

Critical or extreme presentation of mediastinal neoplasms does not preclude a good clinical outcome: an intensive care approach is essential to allow patient recovery and effective antineoplastic therapy administration.

Critical presentation of pleuropulmonary blastoma

We report two cases of critical presentation of a quite rare lung neoplasm of childhood. Presentation findings were at the extremes of the clinical pattern of this polymorphous neoplasm, ranging from an enormous solid mass causing airway compression and dislocation to an apparently benign cystic lesion discovered because of a tension pneumothorax. Both children were discharged from the pediatric intensive care unit and underwent appropriate surgical removal and oncological management. Congenital lung cysts, even asymptomatic, should not be underestimated and need elective surgical excision and histologic examination.

Type II pleuropulmonary blastoma responsive to multimodal therapy

Pleuropulmonary blastoma is a rare and aggressive primary intrathoracic neoplasm of children. T'he prognosis is extremely poor with frequent metastasis to the brain and bone. A 4-year-old boy successfully treated with multimodal therapy despite unfavorable prognostic factors is presented. The authors support the use of aggressive treatment of pleuropulmonary blastoma with surgery, chemotherapy, and radiotherapy.

USCAP Specialty Conference: case 1-type I pleuropulmonary blastoma

Pleuropulmonary blastoma (PPB) was defined in 1988 by Manivel et al. in a series describing 11 intrathoracic pulmonary neoplasms in young children. The PPB is a unique peripheral pulmonary or pleural-based tumor of childhood that is characterized in its earliest form as a bland-appearing multiloculated cyst with small foci of tumor cells and in later forms as mixed and predominantly primitive, overtly malignant neoplasms. Prior to the introduction of the PPB as a distinct entity, this tumor had been reported in the literature as pulmonary blastoma, sarcoma arising in mesenchymal cystic hamartoma, embryonal sarcoma, malignant mesenchymoma, primary pulmonary rhabdomyosarcoma and rhabdomyosarcoma arising in congenital adenomatoid malformation or bronchogenic cyst. Over the past 15 years, PPB has come to be recognized in centers around the world. With the establishment of the Pleuropulmonary Blastoma Registry by Jack Priest, MD, and colleagues, there has been improved understanding of this rare pediatric neoplasm.

Pleuropulmonary blastoma--a rare pathology

Pleuropulmonary blastoma is a rare and highly aggressive pulmonary malignancy in children. The clinical features, radiologic, cytologic, gross and histopathological features of one such case in a 9 year old girl is discussed along with a short review of literature.

Pleuropulmonary blastoma in a child presenting with spontaneous pneumothorax

The authors described a 27-month-old boy with the diagnosis of pleuropulmonary blastoma who presented with spontaneous pneumothorax. The child was admitted to our hospital with the chief complaint of respiratory distress for 8 months. Initial chest X-ray revealed tension pneumothorax on the right side. After chest tube insertion to the right side, a repeated chest X-ray showed minimal pleural effusion and a mass-like lesion at the right lower lung field. Computed tomography (CT) of the chest showed a cavity with intramural mass confined in the right lower lung accompanied with hydropneumothorax. The surgery revealed a cystic and solid mass occupying the right pleural space medially displacing the right lower lung. Total removal of the mass was performed, the histopathologic findings revealed a mixed cystic and solid type of pleuropulmonary blastoma which was composed of primitive blastema with multidirectional differentiation. Combination chemotherapy consisting of vincristine, cyclophosphamide, doxorubicin and dactinomycin was administered two weeks after surgery. The child has been well for almost 6 months since the surgery, without any signs of metastasis or recurrence.

High-dose chemotherapy and autologous peripheral blood stem cell rescue in a patient with pleuropulmonary blastoma

Pleuropulmonary blastoma (PPB) is a rare and aggressive malignant tumor of the lung. Approximately 80 cases of PPB have been published, and in only three cases high-dose chemotherapy with autologous hematopoietic stem cell transplantation (HSCT) was applied. A 5-year-old girl presenting with cough, fever, and shortness of breath was referred to the authors in March 1999. A computed tomography scan of the chest showed a tumor mass in the left hemithorax. The lesion was biopsied and the histopathologic report suggested the diagnosis of PPB. The patient received chemotherapy comprising vincristine, actinomycin D, and cyclophosphamide with only a minor response, and treatment was switched to ifosfamide, carboplatin, and etoposide, which produced a partial response. Tumor resection was performed, but margins were positive for PPB. Due to the high risk of recurrence, the authors elected to administrate high-dose chemotherapy using melphalan, etoposide, and carboplatin, followed by autologous HSCT. The patient achieved complete hematologic recovery, and reimaging after HSCT showed no evidence of disease. She relapsed 4 months later and died about 9 months after the completion of high-dose therapy. The role of high-dose chemotherapy and autologous HSCT is likely to be limited in PPB.

Pulmonary blastoma: case report in an adult

We present a case of biphasic pulmonary blastoma, a rare primary malignant lung neoplasm, in a 48 year old man. Despite its resection followed by postoperative chemotherapy, the neoplasm recurred and the patient survived only 41 months after the diagnosis.

Fine-needle aspiration cytology of pleuropulmonary blastoma: a case report with unusual features

Pleuropulmonary blastoma (PPB) is a rare and aggressive intrathoracic neoplasm of childhood, typically presenting as a pulmonary and/or pleural-based mass with cystic, solid, or combined features. Histologically, the tumor is well characterized with a mixture of primitive mesenchymal and variably differentiated sarcomatous components, and the cytologic features described in the three previous reports are also compatible to the histologic ones. Now, we present another case of PPB showing unusual features. A 3-yr-old boy presented with a pleural- or chest wall-based tumor. The fine-needle aspiration cytologic smears were highly cellular with poorly differentiated cells showing variable size and shape rather than those of typical blastemal cells. The histologic findings were also distinctive, exhibiting diffuse sheets of poorly differentiated cells without typical blastemal cell component. Diagnosis was confirmed by the support of immunohistochemical and ultrastructural features. The patient underwent a typical aggressive clinical course to death within 8 mo after diagnosis.

Gains of chromosome 8 are confined to mesenchymal components in pleuropulmonary blastoma

Pleuropulmonary blastoma, an aggressive tumor that is emerging as a distinct entity of childhood, is characterized by mesenchymal elements (including undifferentiated blastema and often cartilaginous, rhabdomyoblastic, or fibroblastic differentiation) and epithelium-lined spaces. We investigated two patients with pleuropulmonary blastoma, a 3-year-old boy and an 11-year-old girl, both with large cystic masses replacing one lung. In both children, the post-chemotherapy resection specimens showed more maturation of rhabdomyoblasts and more nuclear pleomorphism in all mesenchymal cell lines, compared with biopsies sampled before treatment. Karyotypic analysis demonstrated gains in chromosome 8 in both cases and 17p deletion in one case. Fluorescent in situ hybridization analysis demonstrated that the chromosome 8 gains were present in all mesenchymal elements, including undifferentiated blastematous, rhabdomyoblastic, fibroblastic, and chondroblastic areas. Epithelial cells showed no chromosome 8 gains. The chromosome 8 aberrations were not appreciably different in pre- versus post-chemotherapy tissue. Our findings substantiate previous reports that polysomy of chromosome 8 is a consistent feature of pleuropulmonary blastoma. Further, they indicate that clonal proliferation in pleuropulmonary blastoma is restricted to the malignant mesenchymal elements, supporting the notion that the epithelial components of this tumor are non-neoplastic.

Aggressive multimodal treatment of pleuropulmonary blastoma

Pleuropulmonary blastoma is a rare intrathoracic neoplasm almost solely confined to childhood. Survival is poor. The authors report 2 children with extensive intrathoracic disease who are long term survivors after multimodal therapy. Both children received multiagent neoadjuvant chemotherapy, followed by surgical resection to remove all gross tumor. Postoperative chemotherapy was given to both children; radiotherapy was also given in the second case because of a question of positive tumor margins. Experience supports the use of multimodal therapy, including an aggressive surgical approach in the potentially curative treatment of this tumor.

Pulmonary blastoma

A three-and-half-year-old boy presented with recurrent chest infections, fever and weight loss of three month duration not responding to antibiotics. The chest X-ray and CT scan revealed a large well-circumscribed mass in right upper thorax with collapse of right upper lobe. A preoperative diagnosis could not be made even after fine needle aspiration cytology. Thoracotomy and right upper lobectomy was done and the biopsy report was an inflammatory pseudotumor. The child remained well for three months after which his symptoms and the mass recurred. The histopathology slides were reviewed and revealed a biphasic malignant tumor suggestive of Pulmonary Blastoma (PB). Patient received four cycles of chemotherapy followed by re-exploration. The recurrent tumour could only be excised partly and the child succumbed to persistent shock postoperatively. The final histopathological diagnosis was confirmed as PB. Primary pulmonary neoplasms in children are rare and of these PB which is even rarer, constitutes less than 15%. The report highlights that the lack of familiarity with this entity still causes error in the diagnosis of PB.

Pleuropulmonary blastoma: an aggressive intrathoracic neoplasm of childhood

A case of a 4-year-old girl with pleuropulmonary blastoma is reported. Surgical resection of the tumor was performed and histologic examination revealed pleuropulmonary blastoma with rhabdomyosarcomatous differentiation. Postoperative chemotherapy was administered and 3 weeks after initiation of treatment protocol a second site of lesion in the retroperitoneum was revealed with extension to the mediastinum, which shared similar mesenchymal neoplastic characteristics to the previously diagnosed primary lesion. The girl died 4 1/2 months after initial evidence of disease because of brain metastasis, indicating a very aggressive neoplasm unresponsive to treatment.

Pleuropulmonary blastoma: management and prognosis of 11 cases

BACKGROUND

Pleuropulmonary blastoma (PPB) is a rare and aggressive malignant tumor that affects children and adults. This neoplasm is histologically characterized by primitive blastema and a malignant mesenchymal stroma that often demonstrates multidirectional differentiation. Despite the introduction of multimodal therapy, the prognosis of patients with PPB remains poor.

METHODS

In the current study the authors reported on PPB cases from a national retrospective search performed in 18 Italian Associations for Pediatric Hematology and Oncology centers. Clinical data, surgical notes, pathologic findings, and summaries of chemotherapy and radiotherapy were obtained from reports and correlated with outcome by standard statistical methods.

RESULTS

The series included 11 patients (7 boys and 4 girls) with a median age of 32 months. Respiratory distress was the most common clinical symptom. In three patients the PPB developed from other primary dysplastic diseases: cystic adenomatoid malformation in one case and congenital lung cysts in the other two cases. Five patients experienced disease recurrences (local recurrence in three patients and distant metastasis in two patients, within the central nervous system and an intraocular location, respectively). Patients with a type 2 histologic pattern and/or pleural involvement were found to have a worse outcome compared with patients without such features. Event free survival at 2 years from the time of diagnosis was 45% for all patients. Overall survival at 2 years was 72% for all patients.

CONCLUSIONS

PPB is an aggressive neoplasm of early childhood and to the authors' knowledge no adequate therapy has been defined to date for patients with PPB. After making the diagnosis, the main goal of therapy should be radical surgery, even in patients with microscopic residual disease. Because the response to chemotherapy is poor, the authors' experience suggests that chemotherapy should be given with local radiotherapy in the majority of patients.

Use of multicolor spectral karyotyping in genetic analysis of pleuropulmonary blastoma

Pleuropulmonary blastoma (PPB) is a rare, malignant intrathoracic pediatric tumor. It arises from the lung, pleura, or mediastinum and its pathogenesis and relationship to other pediatric solid tumors is not well understood. In this study, a case of PPB in a 3-year-old girl was studied using a combination of molecular genetic methods and cytogenetics. Molecular analysis of the commonly encountered fusion translocation gene products of pediatric solid tumors failed to detect a rearrangement. Cytogenetic analysis, supplemented by multicolor spectral karyotyping (SKY), identified an unbalanced translocation between chromosomes 1 and X, resulting in additional copies of 1q, an extra copy of Xq, and loss of part of Xp. In addition, trisomy 8 was detected. The identification of new chromosomal alterations and confirmation of previously reported ones in this rare neoplasm helps to improve our understanding of its pathogenesis and association with other pediatric tumors.

The cytomorphology of pleuropulmonary blastoma

Pleuropulmonary blastoma is a rare, primitive primary neoplasm of the thorax in young children. The tumor, which is often but not always associated with cystic lung lesions, may arise in pulmonary parenchyma, the mediastinum, and pleura. Histologically, it is characterized by a biphasic neoplastic population of undifferentiated-appearing small round cells and larger spindle-shaped cells. A proportion of these cancers may also manifest more specific mesenchymal differentiation. In contrast to the pulmonary blastoma of adults, a malignant epithelial component does not occur. We present herein the third known case of a fine needle aspiration biopsy of a pleuropulmonary blastoma in a 5-year-old girl. The smears were moderately cellular and included an admixture of the characteristic small ovoid blastemal elements and scattered spindled mesenchymal tumor cells.

[Pulmonary blastoma and related primary malignant pulmonary neoplasms]

During the last decade more diagnoses of pulmonary blastoma were made worldwide than in previous decades. Whether this increased frequency is caused by better diagnostic procedures (immunochemistry, electron microscopy) or by the growing number of patients having this neoplasm is difficult to distinguish. We present controversies concerning pulmonary blastoma and related biphasic primary pulmonary neoplasms. We agree with Wick et al. that cases in children (called pleuropulmonary blastoma) should be differentiated from cases in adults, which show many similarities to bronchogenic lung cancer. However, our opinion is that the new classification system proposed by Wick et al. does not take into account cases of PB in young adults with intropulmonary growth of the tumor.

Pleuropulmonary blastoma: long-term survival and literature review

BACKGROUND AND PROCEDURE

Pleuropulmonary blastoma (PPB) identifies different types of pulmonary tumors in the pediatric age. It is extremely uncommon and is known to have a very poor prognosis, with only few cases surviving after 10 years follow-up. Our experience with such a patient and long-term follow-up (12 years) is therefore of interest. She was a 2-year-old girl admitted with a history of respiratory distress and underwent a left thoracotomy. The tumor was removed and after 1 month a polychemotherapy course was started using dactinomycin and vincristine for 6 months. The patient remains disease-free 12 years after the operation.

CONCLUSIONS

The biologic behavior of the tumor is considered unpredictable, and for this reason much effort has been expended in trying to identify prognostic factors. The preoperative size of the mass (size <5 cm) in our patient, its complete excision, and the histologic aspects might be helpful in identifying favorable prognostic factors.

[Similarities between pleuropulmonary blastoma and Askin tumor]

Adult pleuropulmonary blastoma is an uncommon mesenchymal tumor of the peripheral lung parenchyma composed of undifferentiated cells. The differential diagnosis with Askin-Rosaï's tumor, an extrapulmonary pleuroparietal neuroectodermal tumor, may be a difficult task. We propose a similar therapeutic approach for these two malignant conditions: surgical excision associated with chemotherapy and autologous bone marrow transplant with adjuvant radiotherapy in case of recurrence. These two entities have many epidemiological, clinical, histological and immunohistochemical similarities.

Pulmonary blastoma in an adult. A case with rapid progression

A case of biphasic type pulmonary blastoma in a 59-year-old man is reported. Although the tumour was radically resected, there was rapid metastasization to the neck, mediastinum, liver and multiple bones. Despite radiotherapy, the patient died about 14 months postoperatively. Close follow-up and aggressive chemotherapy should be considered for such tumours.

Pulmonary blastoma

Pulmonary blastoma is a rare tumor containing both mesenchymal and/or epithelial elements that mimics the embryonal tissues of the developing lungs. We are presenting two cases of pulmonary blastoma for its rarity and reviewed the literature for clinical features, investigative findings, classification, management and prognosis.

Survival with combined modality therapy after intracerebral recurrence of pleuropulmonary blastoma

BACKGROUND

We present and discuss the successful treatment of pleuropulmonary blastoma metastatic to the brain using a multimodality regimen with surgery, high-dose chemotherapy and radiation therapy.

PROCEDURE

A 3-year-old boy referred to our institution with bilateral pulmonary cysts was diagnosed with pleuropulmonary blastoma (PPB). Initial treatment included surgery and multiagent chemotherapy with vincristine, dactinomycin, cyclophosphamide, cisplatin, and doxorubicin. One year after the completion of therapy, his PPB recurred as an intracerebral metastasis, and required further treatment with a multimodality salvage regimen. The child was successfully treated with a subtotal surgical resection, followed by high-dose cyclophosphamide, and radiation therapy. He is now disease-free 24 months later.

RESULTS

Intracerebral metastases of PPB have been a uniformly fatal complication of this tumor. Postsurgical chemotherapy and radiation therapy appear to have contributed to the prolonged survival and potential for cure in our patient.

CONCLUSIONS

The use of this multimodality regimen may be warranted in other patients with recurrent PPB metastatic to the brain.

Pleuropulmonary blastoma: a clinicopathologic study of 50 cases

BACKGROUND

Pleuropulmonary blastoma (PPB) is a unique dysontogenetic neoplasm of childhood that appears as a pulmonary and/or pleural-based mass and is characterized histologically by a primitive, variably mixed blastematous and sarcomatous appearance.

METHODS

Histologic material from all cases was reviewed and the tumors subclassified as type I (purely cystic), type II (cystic and solid), or type III (purely solid). Data regarding presenting symptoms, family history, operative findings, pathologic subtypes, therapeutic interventions, and outcome were correlated with survival by standard statistical methods.

RESULTS

The series was comprised of 24 males and 26 females. Respiratory difficulty with or without fever was the most common clinical symptom reported. Cyst formation in the affected lung was identified radiographically in 19 children (38%) at or before the definitive pathologic diagnosis. The ages at presentation of the 7 type I, 24 type II, and 19 type III PPBs were significantly different: 10, 34, and 44 months, respectively (P < 0.001). Local recurrence developed in 1 of 7 type I PPBs (14%) and in 18 of 43 type II and III PPBs (46%); distant metastasis occurred in 13 patients, chiefly to the brain/spinal cord or bone, and was observed only in those with type II or type III PPB. Patients with pleural or mediastinal involvement fared significantly worse than those without such involvement. Five-year survival was 83% for type I and 42% for types II and III. Survival differences on the basis of pathologic subtype did not reach statistical significance.

CONCLUSIONS

PPB is an aggressive, intrathoracic neoplasm of early childhood with an unfavorable outcome. Although survival differences among patients with different histologic subtypes of disease did not reach statistical significance, the apparently better outcome for patients with purely cystic type I tumors may be borne out in a large series. These observations support the premise that type I and III PPB are bridged morphologically by type II PPB with its combined cystic and solid features. The PPB should be regarded as the pulmonary dysontogenetic analogue to Wilms' tumor in the kidney, neuroblastoma in the adrenal gland, and hepatoblastoma in the liver. Molecular genetic investigations, especially in constitutional PPB, should be revealing. In view of the poor outcomes for patients with types II and III, new and aggressive therapies must be developed.