Case 140 - Discussion

Uploaded: 2007-10-31, Updated: 2007-10-31

  • Tumor NSE positive for but S100 negative.;

  • Diagnosis: Neuroblastoma, poorly differentiated

Neuroblastoma

The Key Features

  • Young kid, mass of abdomen (especially adrenal);

  • Opsoclonus/myoclonus, alopecia, heterochromia iridis, watery diarrhea;

  • Lobular growth with incomplete fibrovascular septa; small, round dark cells; Homer-Wright rosettes;

  • Deletion of 1p36.1-2; N-myc amplification.

Clinical Futures

 
  • Belong to the family of neuroblastic tumors that include ganglioneuromas, ganglioneuroblastomas and neuroblastomas. Neuroblastic tumors are of the sympathetic nervous system that originate from neural crest sympathogonia.

  • Neuroblastoma is the most common extracranial pediatric solid neoplasm and the third most common pediatric malignancy after leukemia and CNS tumors. The incidence in USA is about 8.7 per million.

  • Most cases (88%) less than 5-year-old, median age 21 months.

  • Neuroblastomas can arise from anywhere along the sympathetic chain. They most commonly occur in the adrenal medulla (35-38%). Usually only one adrenal gland is involved, and bilateral involvement is rare, followed by extraadrenal in the abdomen (30%), and thorax (14-20%).

  • They have been associated with a number of disorders, such as Hirschsprung disease, fetal alcohol syndrome, DiGeorge syndrome, Von Recklinghausen disease, and Beckwith-Wiedemann syndrome.

  • Approximately 45-54% of patients with neuroblastoma have a palpable abdominal mass. These patients may have abdominal pain. Nearly 10% of patients develop hypertension as a result of renal vein compression. Hypertension in patients with neuroblastoma may also be related to renal arterial compression and excess catecholamine production. Extradural extension of neuroblastomas can present with focal or diffuse paralysis and bowel or bladder dysfunction. Pelvic neuroblastomas can also cause bowel or bladder dysfunction.

  • Unusual manifestations or associations with childhood neuroblastoma: (1), "blueberry muffin" baby with cutaneous metastasis; (2), opsoclonus/myoclonus, 2-7%; (3), alopecia; (4), heterochromia iridis; (5), Horner's syndrome; (6), Watery diarrhea due to secretion of VIP, 6%; (7), Asymmetric crying syndrome; (8), Cushing's syndrome.

Gross Findings

 
  • Gross specimens of neuroblastomas can appear well circumscribed or infiltrative. They do not have capsules. They range from minute nodules or in situ lesions to large masses weighing more than 1 kg.

  • Calcification may be apparent on gross inspection as punctuate, opaque foci, or a gritty sensation.

Microscopic Findings

 
  • Architectural patterns: lobular growth with delicate and often incomplete fibrovascular septa (not as well developed as in pheochromocytoma); May have more diffuse or solid areas; 

  • Cytological morphology: tumor cells are small, round or ovoid with little cytoplasm; nuclei are dark with small indistinct nucleoli, and the chromatin is dispersed with a "salt and pepper" pattern. Homer-Wright rosettes, circular, ovoid or angular zones of pale-stained fibrillary material that is surrounded by tumor cells. They are typical of neuroblastomas but are not present in all cases.

  • Alterations in stroma: hemorrhage, necrosis, calcification or cystic changes can be present.

Differential Diagnosis

 
  • Ewing's sarcoma: t(11;22)(q24;q12)

  • Desmoplastic small round cells tumor: t(11;22)(p13;q12 or q11.2)

  • Malignant rhabdoid tumor

Immunohistochemical Findings

 
  • Positive for NSE, chromogranin A, synaptophysin, microtubule-associated proteins (MAP-1 or MAP-2), S100+ in stellate to dendritic cells adjacent to the vessels;

Electron Microscope

 
  • Small, dense core neurosecretory granules can be identified, but usually sparse; neurofilaments (8-12nm) and neurotubules (24-26 nm in diameter) can be seen.

Cytogenetic Studies

 
  • Deletion of 1p36.1-2

  • N-myc amplification

Prognosis

 

Reference

 
  • Rha SE, Byun JY, Jung SE, et al: Neurogenic tumors in the abdomen: tumor types and imaging characteristics. Radiographics 2003 Jan-Feb; 23(1): 29-43

  • AFIP, Tumor of the adrenal gland and extra-adrenal paraganglia, 3rd series

  • http://www.webpathology.com/ (For gross and slides of ganglioneuroma)

  • http://www.emedicine.com/radio/topic293.htm

  • http://www.emedicine.com/RADIO/topic472.htm