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Tumors and Tumor-like ConditionsMC neoplasms of childhood = soft-tissue tumors (mesenchymal) - ? adultsBenign tumors more common than cancers2% of all malignant tumors occur in infancy and childhoodTumor-like conditions1. Heterotopia (or Choristoma ) Normal cells or tissues that are present
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1. 7. Pediatric Tumors
2. Tumors and Tumor-like Conditions
MC neoplasms of childhood = soft-tissue tumors (mesenchymal) - ? adults
Benign tumors more common than cancers
2% of all malignant tumors occur in infancy and childhood
Tumor-like conditions
1. Heterotopia (or Choristoma )
Normal cells or tissues that are present in abnormal locations
pancreatic tissue in stomach or small intestinal wall
adrenal cells found in the kidney
2. Hamartoma
excessive, focal overgrowth of cells / tissues native to the organ but not having normal architecture
Examples = Adenomas of the liver, Hemangiomas, lymphangiomas, rhabdomyomas
Benign Tumors
1. Hemangioma = MC tumors of infancy
Cavernous and capillary types
Common on face and scalp
Flat , larger lesions = port-wine stains
Hereditary disorder von Hippel-Lindau disease
3. Benign Tumors contd….
2. Lymphatic tumors
Lymphangiomas (hamartomatous or neoplastic)
increase in size after birth
Encroach on vital structures in mediastinum or nerve trunks of axilla
Lymphangiectasis = not progressive,
3. Fibrous tumors
More common =Fibromatosis, sparsely cellular (multiple fibromas)
Congenital -infantile Fibrosarcomas (t 12:15)
ETV6-NTRK3 fusion transcript = diagnostic marker
ETV6 (transcription factor) and NTRK3 gene is tyrosine kinase
4. Teratomas
Histological maturity correlates with biologic behavior
well-differentiated cystic lesions (mature teratomas),
Age = two peaks ( 2 years of age & late adolescence or early adulthood)
Sacrococcygeal teratomas = MC ( more common in girls (M:F::4:1)
75% are mature and benign teratomas
Other sites of teratomas =testis, ovaries, midline
4. Malignant
Incidence and types (next slide)
Neuroblastic tumors
Wilm’s tumor
Neuroblastic tumors
Tumors of the sympathetic ganglia and adrenal medulla
Derived from neural crest cells
Neuroblastoma
most common extra cranial solid tumor of childhood
median age at diagnosis = 18 months
most frequently diagnosed tumor of infancy
Most of them are sporadic
Most characteristic features
spontaneous or therapy-induced differentiation of primitive neuroblasts into mature elements
spontaneous tumor regression
wide range of clinical behavior and prognosis,
Children younger than 18 months of age have better prognosis
5-year survival is generally 40%
5. Malignant = Incidence and types
6. Malignant = Neuroblastic tumors contd..
Morphology
Site = 40%arise in the adrenal medulla (MC site) followed by paravertebral region of abdomen (25%), posterior mediastinum (15%) and other sites (pelvis, Neck, brain (cerebral neuroblastomas)
Size = minute nodules (in situ lesions) to 1 kg in weight
Larger tumors have necrosis, cystic softening, and hemorrhage
In situ ones are more frequent and spontaneously regress
Histologically
LM= Made of small, primitive cells with dark nuclei, scant cytoplasm, and poorly defined cell borders ; Karyorrhexis and pleomorphism are prominent; rosettes (Homer-Wright pseudorosettes)
IHC =positive immuno –markers ( neuron-specific enolase (NSE), Synaptophysin, Chromogranin A, S100 protein etc.,)
EM =cytoplasmic catecholamine-containing secretory granules with peripheral halo (dense core granules)
Some show signs of maturation ganglioneuroblastoma and ganglioneuroma
Maturation is spontaneous or therapy-induced
Differentiated lesions are accompanied by Schwann cells (this is prerequisite )
Metastases to lymph node or/and liver, lungs, bone marrow, and bones
7. Malignant = Neuroblastic tumors contd..
Morphology
Site = 40%arise in the adrenal medulla (MC site) followed by paravertebral region of abdomen (25%), posterior mediastinum (15%) and other sites (pelvis, Neck, brain (cerebral neuroblastomas)
Size = minute nodules (in situ lesions) to 1 kg in weight
Larger tumors have necrosis, cystic softening, and hemorrhage
In situ ones are more frequent and spontaneously regress
Histologically
LM= Made of small, primitive cells with dark nuclei, scant cytoplasm, and poorly defined cell borders ; Karyorrhexis and pleomorphism are prominent; rosettes (Homer-Wright pseudorosettes)
IHC =positive immuno –markers ( neuron-specific enolase (NSE), Synaptophysin, Chromogranin A, S100 protein etc.,)
EM =cytoplasmic catecholamine-containing secretory granules with peripheral halo (dense core granules)
Some show signs of maturation ganglioneuroblastoma and ganglioneuroma
Maturation is spontaneous or therapy-induced
Differentiated lesions are accompanied by Schwann cells (this is prerequisite )
Metastases to lymph node or/and liver, lungs, bone marrow, and bones
9. Malignant = Neuroblastic tumors contd..
Staging.
Stage 1: Localized with complete gross excision
Stage 2: Localized with incomplete gross resection
Stage 3: Unresectable unilateral, across the midline
Stage 4: distant metastasis
Stage 4S ("S" = special): infants younger than 1 year & dissemination limited to skin, liver, and/or bone marrow
Clinical Course and Prognostic Features
Under age 2 years= present with large abdominal masses, fever, weight loss
Older children = insignificant until metastases; present proptosis (common metastatic site) and ecchymoses
multiple cutaneous metastases ="blueberry muffin baby"
90% of neuroblastomas =produce catecholamines, helps in diagnosis (hypertension is less frequent )? vanillylmandelic acid [VMA] and homovanillic acid [HVA]) in urine or blood
Prognosis
"core" criteria used for risk stratification and therapeutic decision =age, stage, N-MYC status, histology, and DNA ploidy
11. Malignant= Wilm’s tumor
MC primary renal tumor of childhood
Peak age =between 2 and 5 years
Improvements in the cure rates
Pathogenesis and Genetics
Increased association with four syndromes
1. WAGR syndrome =aniridia, genital anomalies, mental retardation; deletions of 11p13 (WT1 gene)
2. Denys-Drash syndrome= higher risk for Wilm's tumor (~90%); gonadal dysgenesis (male pseudohermaphroditism) and early-onset nephropathy; dominant-negative missense mutation in the zinc-finger region of the WT1 gene and increased risk for gonadoblastomas (WT1=critical for normal renal and gonadal development)
3. Beckwith-Wiedemann syndrome (BWS) ="WT2”gene ?genomic imprinting ; overexpression of IGF-2 (embryonal growth factor) is critical ; Organomegaly, macroglossia, emihypertrophy, omphalocele, adrenal cytomegaly;
4. ß-catenin associated Wilms tumors ; belong to WNT (wingless) signaling pathway; 10% of sporadic cases, gain-of-function mutations
Nephrogenic rests =precursor lesions of Wilms tumors
12. Malignant= Wilm’s tumor
Clinical Features =large abdominal mass with hematuria, abdominal pain, intestinal obstruction and HTN
soft-tissue sarcomas, leukemia and lymphomas, and breast cancers
Pulmonary metastases
Prognosis depends on (poor prognostic features)
Anaplasia,
loss of genetic material on chromosomes 11q and 16q,
gain of chromosome 1q
Risk of Second malignancies
soft-tissue sarcomas,
leukemia and lymphomas,
breast cancers
14. WILM’S TUMOR 1stromal -Usually fibrotic or myxoid in nature with Paler type of cells
2blastemal - Bunch of less undifferentiated
Dark cells Less differentiated therefore worse prognosis
3Epithelial -Form of abortive tubules or glomeruli as epithelial rosettes
Better differentiated, therefore better prognosis