Moderator:-Dr. Poonam Nanwani Speaker:- Dr. Narmada Prasad Tiwari
May 31, 2015
Moderator:-Dr. Poonam Nanwani
Speaker:- Dr. Narmada Prasad Tiwari
Histologically, many of the pediatric neoplasms have more primitive origin characterized by sheets of cells ,with small , round nuclei.
Because of their primitive histologic appearance many childhood tumor have been collectively referred to as small round blue cell tumor.
The differential diagnosis of such tumors are:-
NeuroblastomaWilms tumour(Nephroblastoma)RhabdomyosarcomaEwing’s sarcoma/PNETMedulloblastomaRetinoblastomaLymphoma
NEUROBLASTOMA most common extracranial solid tumor of
childhood most frequently diagnosed tumor of
infancy.Median age at diagnosis is 21 months.Most occur sporadically.1 to 2% occur familial- Germ line mutation
in the anaplastic lymphoma kinase (ALK) gene
Clinical course-In childhood 40% of neuroblastoma
arise in adrenal medulla.Other sites-along sympathetic chain post. Mediastinum neck, brain. • under 2 year - large abdominal mass,
fever ,weight loss.About 90% of neuroblastoma regardless
of location produce catecholamines.Neuroblastoma – size- minute nodules
to large masses
Gross-
Neuorblastoma MorphologySmall round blue cell tumor
neuorpil formation (fibers, i.e., axons dendrites, mostly unmyelinated)
rosette formationimmunochemistry – neuron specific enolaseEM – secretory granules (catecholamine)
Usual features of anaplasiahigh mitotic rate is unfavorableevidence of Schwann cell or ganglion
differentiation favorable
Histologically
Undifferentiated type
Differentiating type Poorly differentiated type
Neuroblastoma may metastasize widely through the hematogenous & lymphatic system, particularly to liver, CNS, bone, lymph nodes and bone marrow.
Prognostic factors in neuroblastomaVariable Favourable Unfavourable
(1) Stage 1, 2A,2B,4S 3,4
(2) Age <18 month > 18 month
(3)Histology:-(a)Evidence of schwannnian stroma& gangliocytic differentiation.(b) Mitosis-karyorrhexis index
Present
< 200/5000 cells
Absent
>200/5000 cells
(4) DNA ploidy Hyperdiploidy or near triploidy
Near diploid
(5) N-Myc Not amplified Amplified
(6) Chromosome 17q gain Absent Present
(7) Chromosome 1 p loss Absent Present
(8) Chromosome 11q loss Absent Present
(9) Trk A expression Present Absent
(10)TrkB expression Absent Present
(11) Telomerase expression Low or Absent Highly expressed.
WILMS’ TUMOR(NEPHROBLASTOMA)
Age:- 3 -6 yearsSex:- No sex predelictionClinical features-Large abdominal massHematuriaPain in abdomenHypertension
Molecular Genetic Genetic loci predisposing to wilms’ tumor are WT1 ( located on chromosome 11p 13 ) WT2 ( located on chromosome 11p 15.5 ) - Mutations of B catenin gene-14-20%- Conditions associated with wilms’ tumor
are:-WAGR syndrome:-Wilms’ tumorAniridiaGenital anomaliesRetardation
Beckwith wiedemann Syndrome:-OmphaloceleMacroglossiaHemihypertrophy of organs
Denys Drash Syndrome:-Gonadal dysgenesis( male
psuedohermaphroditism)Early onset nephropathy
Gross:- solid, well circumscribed.On cut-:-solid & pale gray & often exhibit
areas of cystic changes, necrosis & hemorrhage.
Microscopically :- Three major component are identified.
I- Undifferentiated blastemaII – Mesenchymal ( stromal) tissueIII – Epithelial tissue
Blastematous - small round to oval cells, scanty cytoplasm
The mesenchymal element- spindle cell fibroblast like configuration.
Epithelial component- embryonic glomerular and tubular structures.
Additional morphological features-Ciliated,mucinous, squamous or transitional
epithelium, neuroepithelium,mature adipose tissue,Cartilage & bone
Anaplastic wilms tumour
Spread and metastasis-Local spreadLymph nodes-15% casesDistant metastasis- lungs, liver and
peritoneum.
Rhabdomyosarcoma:-Rhabdomyosrcoma is the most common soft
tissue sarcoma of childhood & adolescence, usually appear before age 20 year.
Types:-Embryonal (most common)Alveolar RhabdomyosarcomaPleomorphic (least common)
Morphology:-Pleomorphic Rhabdomyosarcoma:- It is least
common.Site:- Extremities & thigh.Age:- Adult
Grossly :- It is confined within fascial compartment & have the shape of muscle from which it arises.
Microscopically:-Pleomorphic type
Tumor is pleomorphic with giant cells.
Embryonal rhabdomyosarcomaClinical Feature:-Arise from unsegmented
& undifferentiated mesoderm.Site:- Common in head & neck regionOrbitNasopharynxBile ductUrogenital tract
Age :- 3 -12 years, can occur in adults also.Grossly-poorly circumscribed, white,soft.
Embryonal rhabdomyosarcoma composed predominantly of round cells.
There is perivascular pseudorosette around blood vessels.
Microscopically(Embryonal type) Tumor
cells are small & spindle shaped.
Oval eccentric nuclei
acidophilic cytoplasm.
Botryoid typeWhen beneath a mucosal
membrane , such as vagina, urinary bladder or nasal cavity it frequently form large polypoid mass resembling a bunch of grapes- Hence name “Sarcoma Botryoides”
Dense zone of undifferentiated tumor cells immediately beneath the epithelium , aformation of known as Nicholson’s Cambium Layer.
Alveolar rhabdomyosarcomaCommon Site:- ForearmArmPerirectal & perianal regionHead and neck region.Age- 10-25 yrs.
Alveolar type
Microscopically( alveolar type)Tumor cells are
small,round are sepearted in nest by connective tissue septa
Special techniques-
Special Stains:- PTAHMasson’s trichomeSilver impregnation techniqueImmunohistochemically:- Markers areMyogeninDesminSarcomeric actinMyosinMyoglobin
Tropomyosin a actinin,titin, Z proteinVimentinEnzymes( creatine kinase)Neurofilament & S-100 proteinCARP- cardiac ankyrin related protein
EWINGS SARCOMAEwing’s sarcoma limited neural
differentiation. PNET show more neural features.
Age:- 5 to 20 years (commonly) Infancy or adulthood rarelySex:- Male predilection. It generally arise in medullary cavity of shaft
from which it permeate the cortex & invade the soft tissue.
EWINGS SARCOMACommon site- Long bones( femur,tibia,
humerus,fibula).Rare site- Bone of pelvis, rib , vertebra,
mandible, clavicle.Clinical features:PainFeverLeuckocytosis
Genetic Predisposition:-Over 95% show reciprocal translocation of
chromosome 11 : 22 (q24 : q 12).
This leads to fusion of EWS gene with FLI-1.
This tranlocation can be detected by RT-PCR. This can be used for the detection of primary
and metastatic or residual disease in tissue & body fluids including blood.
The EWS rearrangement has also been detected by FISH technique.
Radiograph:-
Ewing’s sarcoma of fibula.
Onion skin appearance
Gross-
Microscopically:-
Histochemically:-
Immunohistochemically:-Positive for Vimentin.Neuron specific enolaseNeurofilamentLeu 7CD -99
Medulloblastoma 5-10 yrs.
Site:- Commonly arise from Cerebellum.
Rapid growth may occlude the flow of CSF leading to hydrocephalous.
The tumor - circumscribed, gray & friable. microscopic - extremely cellular.
small cells with scanty cytoplasm & hyperchromatic nuclei that frequently crescent shaped.
Abundant mitosis.
Variants of medulloblastoma:- - Classical Medulloblastoma - Desmoplastic Medulloblastoma - Neuroblastic medulloblastoma - Anaplastic Medulloblastoma
Medulloblastoma
Desmoplastic medulloblastoma :-Micronodular zone of reduced cellularity( “ pale island”)
“Neuroblastic “ medulloblastoma.
This variant of medulloblastoma is typified by the linear streaming of rounded, ‘neurocytic’ tumor cell nuclei within amassed cytoplasmic processes
Large cell/anaplastic medulloblastoma.
Showing prominent nucleoli & pronunced mitotic & apoptotic activity .
LYMPHOMA(Chronic lymphocytic leukemia/small lymphocytic lymphomaAge:- median age is 60 years.
Sex ratio:- 2:1 male to femaleClinical feature:- Mostly asymptomatic
Morphology:-SLL/CLL:- Low
power view show diffuse effacement of nodal architecture.
-1.with absolute lymphocytosis.2.associated with monoclonal gammopathy3. hypogammaglobulinemia10-15% cases – autoimmune hemolytic
anemia.May transform into diffuse large B cell
lymphoma- richter transformation.IHC- CD20,CD23,CD5, .
RETINOBLASTOMARetinoblastoma is the
most common intraocular neoplasm of children- 16 mths- 2 yrs.
It characteristically present as a LEUKOCORIA / strabisumus .
Bilateral in 30% > 90% familial cases.
Trilateral retinoblastoma
Genetic:- congenital.Sporadiac – 60%Familial – 40% Autosomal dominantGene located on Chromosome –
13q14( retinoblastoma Rb gene)
Knudsons 2 hit hypothesis-Genetic mutation in both allele are
necessary to produce retinoblastoma.Hereditary retinoblastoma – somatic
Mutation in second allele.
Sporadic retinoblastoma – both mutations are somatic.
GROSS:- flat or elevated
Endophytic type:- This is protrude into vitrous.Exophytic type:-They may grow between
retina & pigmented epithelium.
Microscopic:-
Retinoblastoma with typical “ Flexner – wintersteiner rosettes”.
Prognosis-Invasion of optic nerve.Invasion of uveal tract.Invasion of meninges.IHC- NSE,GFAP,S-100 protein retinal
binding protein, retinal S antigen.Long term survivors- osteosarcoma,
rhabdomyosarcoma.
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