INTESTINAL GANGLIONEUROBLASTOMA IN A 22-WEEK FETUS
Raj P. Kapur, MD, PhD
Department of Pathology, University of Washington, and Children’s Hospital and Medical Center, Seattle, Washington 0
Thomas H. Shepard, MD
Fetal Pediatr Pathol Downloaded from informahealthcare.com by McMaster University on 01/13/15 For personal use only.
0 Department of Pediatrics, University of Washington, and Children’s Hospital and Medical Center, Seattle, Washington
0 The clinical history and autopsy findings of a 22-week fetus with intestinal ganglioneuroblastoma, cardiac anomalies, omphalocele, and ileal atresia are presented. Ganglioneuroblastoma was confined to the large intestine and was not suspected prenatally despite ultrasonographic examination. Although mten‘c ganglia share neural crest lineage with other sites of congenital neuroblastoma, this is the first report o f a primary intestinal ganglioneuroblastoma in a jkttus or child. Various hypotheses are discussed to explain the coexistence of cardiac malformation and congenital neuroblastoma in this fetus and other cases in the literature. It is hypothesized that other malfrmations evident in this fetus were caused by the tumor, possibly as teratogenic effects o f neuroblastoma-derived catecholamines during embryogenesis.
KEY WORDS: colon, cecum, immunohistochemisty, prenatal diagnosis, intestine, neuroblastoma.
INTRODUCTION Neuroblastoma is the most common congenital malignancy ( 1 , 2). Congenital neuroblastoma is frequently an isolated finding but does occur occasionally in association with other congenital anomalies (3-9) or specific familial disorders (10-13). This neoplasm is thought to be derived from neural crest cells, which normally exhibit neurosecretory differentiation in the adrenal medulla, peripheral ganglia, and enteric nervous system. Congenital neuroblastomas have been observed in a number of sites that reflect the diverse regions of the body populated by neural crest cells during embryogenesis. Although there are several reported examples of neuroblastoma detected prenatally by ultrasound examination, most congenital cases are discovered The authors thank Drs. Joe C. Rutledge and Joel Haas (Children’s Hospital and Medical Center, Seattle) for their thoughtful comments regarding this case. In addition, the technical assistance of Ms. Julie Pascoe-Mason was greatly appreciated. Address reprint requests to: Raj P. Kapur, M.D., Ph.D., Department of Pathology, Children’s Hospital and Medical Center, P.O. Box C-5371, Seattle, Washington 98105. Pediatric Pathology, 12:583-592, 1992 Copyright @ 1992 by Hemisphere Publishing Corporation
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postnatally. In addition, fetuses with tumors identified in utero are usually carried to term, so pathologic examination of midgestational neuroblastoma is rarely performed. In this paper, a clinically unsuspected case of colonic ganglioneuroblastoma is reported in a 22-week fetus with multiple congenital anomalies. The intestinal neoplasm was associated with a small omphalocele, ileal atresia, and a congenital heart defect. The possible causal relationships between these anomalies are discussed.
CLINICAL HISTORY The mother of the fetus was a 29-year-old gravida 2, paragravida 0, Caucasian whose previous pregnancy resulted in spontaneous intrauterine fetal demise at an estimated gestational age (EGA) of 5 weeks (post conception). The embryo was not examined. She used no medications, nor was exposed knowingly to teratogens during the pregnancy. The parents were nonconsanguineous and had no family history of congenital disorders. During this pregnancy she received regular prenatal care beginning at 7 weeks EGA. The early part of her pregnancy was unremarkable. A maternal serum afetoprotein level obtained at 16 weeks EGA was 1.26 multiples of the mean and the results of other routine obstetrical laboratory studies were within normal limits. At no time was she hypertensive. At 20 weeks the mothers fundal height measurement was less than expected and an ultrasound examination was performed 2 weeks later. The latter study showed a “small bowel-containing omphalocoele” and a cardiac abnormality ‘‘considered to represent a variant of the hypoplastic left heart syndrome, possibly in association with an atrial septa1 defect.’’ The wall of the echogenic bowel in the omphalocele was described as “mildly thickened.’’ The biparietal diameter and foot length were both appropriate for the EGA. Because of the reported defects, an elective termination of pregnancy was performed by prostaglandin induction at 22 weeks. Following termination, the fetus was refrigerated for 2 days and then sent to the Central Laboratory for Human Embryology at the University of Washington, where it was promptly examined. Cytogenetic studies of placental tissue taken at the time of delivery yielded a normal female karyotype (400 band resolution, 22 cells counted).
AUTOPSY FINDINGS A complete autopsy was performed, including gross and microscopic examination of the brain and placenta. The foot and crown-rump lengths were consistent with the clinically estimated gestational age of 20 weeks (post conception) based on standards established in the laboratory (14). The 538-g fetus
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was phenotypically female and nondysmorphic with the notable exception of a 1.5 x 1.5 x 2.0 cm omphalocele located in the superior aspect of the umbilical cord (Fig. la). The omphalocele consisted of a semitransparent membranous sac through which the cecum was visible. Internal examination revealed several abnormalities. The left atrium and ventricle were moderately hypoplastic and the right ventricle was slightly enlarged. The diameter of the proximal aorta (2.5 mm) was half that of the pulmonary trunk (5 mm), and a 5-mm endocardial cushion defect was present. The latter was a complete atrioventricular communis characterized by a continuous ostium primum atrial septal and subaortic ventricular septal defect that was traversed inferiorly by fused leaflets of the mitral and tricuspid valves (15). The great veins and branches of the aorta were normal and there was no endocardial fibroelastosis. The gastrointestinal tract was malrotated and short. The ileum was atretic 1 cm from the cecum. It terminated abruptly as a “blind pouch” located in the epigastric region adjacent, but not attached, to the distal ileum and cecum. The latter were situated within the omphalocele lumen and the cecum was attached to the internal surface of the omphalocele by a delicate band of connective tissue (Fig. ic). The appendix and a short length of distal ileum retained their normal relationships to the cecum. The large intestine was dramatically thickened and firm. This was most evident in the cecum (external diameter = 1 cm) and became gradually less prominent distally. The terminal third of the colon was grossly normal. Sections of the large intestine demonstrated marked thickening of the wall with obliteration of the cecal lumen and stenosis of the lumen distally (Fig. Id). Microscopic examination of the large intestine revealed infiltration and expansion of the muscularis and submucosa by ganglioneuroblastoma. The neoplasm exhibited two histologic patterns, intersecting fascicles that resembled mature nerve and nests of neuroblasts (Fig. 2a). The latter ranged in maturity from undifferentiated small round cells to large mature nerve cell bodies with eccentric nuclei and prominent nucleoli (Fig. 2b). Interspersed with the mature neural fascicles were many spindle-shaped cells indicative of glial differentiation. In histologic sections taken from the middle colon, where tumor involvement was less, the neoplastic cells were confined to the region of the myenteric plexus, obliterating the normal myenteric ganglia. In the small intestine and more distally in the colon, neoplastic elements were not present and the submucosal and myenteric ganglia appeared normal. The ileum and appendix were not involved and there was no evidence of tumor elsewhere in the fetus or placenta. A panel of immunocytochemical markers was used to more definitively assess cellular differentiation in this tumor. This study was performed by the immunoperoxidase technique with paraffin sections of formalin-fixed tissue.
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FIGURE 1. (a) Close-up photograph of anterior abdominal wall showing omphalocele in base of umbilical cord. T h e pale cecum (arrow) can be seen through the thin membranous omphalocele. (b) A portion of the gastrointestinal tract including a small portion of attached bladder (bl) and anterior abdominal wall. T h e small bowel, which ends blindly as a saccular atretic ileum (i), is shown above the detached colon. T h e cecum (c) is attached to the peritoneal surface of the omphalocele (0). T h e positions of the transverse sections shown in (d) are indicated by arrows. (c) A close-up photograph of the cecum and attached omphalocele sac shows the attenuated distal ileum (large arrow) and a portion of the appendix (small arrow). The proximal large intestine is markedly thickened. (d) Transverse sections of large intestine taken at the corresponding sites indicated in (b) and a longitudinal section of the cecum (right) demonstrate a marked increase in wall thickness with obliteration proximally of the lumen. Bars: (a) 10 mm, (b) 13 mm, (c) 5 mm, (d) 5 mm.
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FIGURE 2. (a, b) Photomicrographs of the neoplasm showing undifferentiated cells (U) admixed with more differentiated areas (D). The more differentiated cell types resemble mature neurons (b, arrows) or neural-glial fascicles (ng). Bars: (a) 84 mm, (b) 42 mm.
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The results of this study are summarized in Table 1. The most differentiated neural elements were strongly immunoreactive with antibodies specific for neuron-specific enolase (NSE) and labeled weakly with antibodies against synaptophysin. Presumptive glial elements associated with differentiated nerve fascicles were strongly labeled by S 100-specific antibodies, whereas NSE and SlOO immunostaining was weaker in the less differentiated areas. No desmin or chromogranin labeling was detected in the neoplastic cells. The only other anomaly evident in this fetus was bicornuate uterus. No metastatic tumor was identified. Although the placental weight (106 g) was less than the fifth percentile (148 g) for fetuses of comparable age or weight (16), no gross or histologic placental pathology was present.
DISCUSSION Neuroblastoma, ganglioneuroblastoma, and their benign counterpart, ganglioneuroma, are all thought to arise from neural crest cells. The latter disperse widely during early embryogenesis and give rise to a diverse spectrum of tissue types including sensory, autonomic, and enteric neurons and adrenal chromaffin cells. The majority of these neural derivatives are paraxial ganglia in the retrothorax, retroperitoneum, and pelvis; and most extraadrenal neuroblastomas occur in corresponding paraxial sites (17). Because the myenteric and submucosal ganglia of the gastrointestinal tract are also crest derived, the enteric system is a logical primary site for this type of neoplasm. Curiously, primary gastrointestinal neuroblastoma is extremely rare. Although neuroblastoma is the most common congenital malignancy, this is the first case of primary intestinal congenital neuroblastoma to be reported in the literature. In fact, we are aware of only three other reported cases of primary intestinal neuroblastoma, all of which occurred in adults. Ritter (18) described two cases. The first, involving a very large mass that incorporated TABLE 1. Summary of Immunocytochemical Results Immunolabeling of neoplastic cells Antigen recognized by antibodf
Well differentiated
Poorly differentiated
Neuron-specific enolase SlOO Synaptophysin Chromogranin Desmin
Strongly positive Strongly positive Weakly positive Negative Negative
Weakly positive Weakly positive Negative Negative Negative
~~
~
~~
~~
~
~~
“All antibodies were obtained as prediluted solutions from Biogenex Laboratories, San Ramon, California. NSE and SlOO were polyclonal rabbit antisera; other antibodies were m u r k monoclonal antibodies.
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portions of mesentery and jejuneum, was presumed to have arisen from the bowel. In the second case, the diagnosis was somewhat uncertain as the tumor had an atypical histologic appearance. Barf et al. (12) published a putative example of primary intestinal neuroblastoma that was discovered incidentally in the small intestine of a 26-year-old woman with Friedreich’s ataxia during cesarean delivery. However, because a similar neoplasm was present in the umbilical cord of the placenta after delivery, the possibility that the intestinal tumor was a metastasis from a primary fetal lesion could not be excluded. Benign intestinal ganglioneuromas have been reported more frequently (19-3 1). Yet, none of 48 cases reported in the literature occurred in patients less than 8 years of age and congenital intestinal ganglioneuromas have not been described. In this case, precise nosology for this tumor is complicated, in part, by its prenatal occurrence and unusual location. Although we believe that (6 ganglioneuroblastoma” describes the combined mature and immature histologic elements evident, the extensive degree of neural and glial differentiation in this tumor and its failure to metastasize suggest that this tumor may be a hamartoma and/or may have matured into a ganglioneuroma had the fetus developed further. Moreover, the longitudinal pattern of spread along the length of the bowel wall is reminiscent of the normal organization of enteric plexuses and in some respects exemplifies an extreme example of “neuronal dysplasia” (32). In this fetus, intestinal ganglioneuroblastoma was associated with omphalocele, ileal atresia, endocardia1 cushion defect, and bicornuate uterus. Ganglioneuromas have been reported as a frequent finding in multiple endocrine neoplasia type 2b (33) and neurofibromatosis (24, 25, 27, 28), and neuroblastoma has been observed sporadically in fetuses and children with multiple malformations (3-9). However, the combined anomalies in this fetus are unlike any of those described previously. Omphalocele, ileal atresia, and/or cardiac malformation may have been secondary effects of the neoplasm, particularly if the tumor originated in the cecum prior to the ninth week of gestation. During this stage of development the midgut exists normally as a segment of bowel that protrudes through the ventral abdominal wall. Studies of murine embryos indicate that neuroblast colonization precedes reduction of the midgut herniation, which is completed during the eighth week of gestation (post conception) in humans (34). It is possible that tumor in the developing cecum prevented complete reduction of the midgut, perhaps because the neoplastic bowel was too large to pass into the abdominal cavity. Incarceration may have led secondarily to ileal ischemia and eventual atresia. There is conflicting evidence concerning an association between congenital neuroblastoma and congenital heart defects (discussed in ref 35). Two epidemiologic studies have shown no significant association between cardiac anomalies
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and clinically apparent neuroblastoma (4, 36). However, autopsy studies that included in situ neuroblastoma in the data base suggest that coincidence of the two conditions occurs more frequently than predicted from the independent frequencies of each (37). At least two hypotheses have been advocated to explain this putative association. De la Monte et al. (6) propose that neuroblastoma could have been induced as a consequence of chronic hypoxia produced by cyanotic congenital heart defects. However, this is an unlikely cause of congenital neoplasia because significant hypoxia is not usually evident until post partum. Bellah et al. (35) hypothesized that coincident neuroblastoma and congenital heart defects reflect an underlying neurocristopathy because cephalic neural crest cells participate in formation of the aorticopulmonary septum (38). This hypothesis has been endorsed by Patrone et al. (9), who reported an infant with extra-adrenal neuroblastoma and DiGeorge anomaly. Alternatively, the cardiac malformation evident in this fetus may have been due to teratogenic effects of catecholamines secreted by the intestinal ganglioneuroblastoma during embryogenesis. The biosynthesis and secretion of catecholamines are common properties of neuroblastomas, although the magnitude of catecholamine production can vary. Secretion of these substances in utero is used to explain fetal neuroblastoma complicated by paroxysmal maternal hypertension (39, 40). Similar to the neural crest cells that give rise to neuroblastomas in the adrenal and sympathetic ganglia, enteric neuroblasts are programmed to synthesize catecholamines. Catecholaminergic differentiation of enteric neuroblasts is an embryonic phenomenon that precedes the development of other neurotransmitter biosynthetic pathways (41 -43). Evidence from murine studies suggests that expression of enzymes necessary for catecholamine production in the developing enteric nervous system normally begins prior to establishment of the midgut herniation, during the period when the aorticopulmonary and membranous ventricular septa are formed (44, 45). Neoplastic transformation of adrenergic enteric neuroblasts may expose the embryonic heart to abnormally high levels of catecholamines. A growing body of literature suggests that adrenergic agents have teratogenic effects. Postgrastrulation murine embryos exposed to adrenergic agonists in vitro develop situs inversus and associated cardiac defects (46, 47). Chick embryos exposed to epinephrine at comparable stages develop cardiovascular anomalies including conotruncal and aortic arch anomalies (48). Because catecholamines in the intestinal venous return would pass through the heart prior to the fetal systemic circulation or placenta, relatively small amounts of catecholamine produced by this tumor may have been present in high concentrations in the heart. In this instance, catecholamines may have promoted cardiac malformation. This hypothesis is admittedly based on data from other species at comparable developmental stages, but it provides an
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alternative explanation for the association of cardiac malformation and congenital neuroblastoma evident in this and other reported cases.
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REFERENCES 1 . Wells HG. Occurrence and significance of congenital malignant neoplasms. Arch Pathol 1940;30:535601. 2. Isaacs H J . Perinatal (congenital and neonatal) neoplasms: A report of 110 cases. Pediatr Pathol 1985;3:165-216. 3. Sy WM, Edmonson JH. The developmental defects associated with neuroblastoma-etiologic implications. Cancer 1968;22 :234-8. 4. Berry CL, Keeling J, Hilton C. Coincidence of congenital malformation and embryonic tumours of childhood. Arch Dis Child 1970;45:229-31. 5. Kouyoumdjian AO, McDonald JJ. Association of congenital adrenal neuroblastoma with multiple anomalies, including an unusual oropharyngeal cavity (imperforate buccopharyngeal membrane). Cancer 1951;4:784-8. 6 . de la Monte SM, Hutchins GM, Moore GW. Peripheral neuroblastic tumors and congenital heart disease. Possible role of hypoxic states in tumor induction. Am J Pediatr Hematol Oncol 1985;7:10916. 7. Reisman M, Goldenberg ED, Gordon J. Congenital heart disease and neuroblastoma. Case report and brief comment. Am J Dis Child 1966;111:308-10. 8. Andersen HJ, Hariri J. Congenital neuroblastoma in a fetus with multiple malformations. Metastasis in the umbilical cord as a cause of intrauterine death. Virchows Arch [A] 1983;400:219-22. 9 . Patrone PM, Chatten J, Weinberg P. Neuroblastoma and DiGeorge anomaly. Pediatr Pathol 1990;10:425-30. 10. Emery LG, Shields M, Shah NR, Garbes A. Neuroblastoma associated with Beckwith-Wiedemann syndrome. Cancer 1983;52: 176-9. 1 1 . Bolande RP, Towler WF. A possible relationship of neuroblastoma to von Recklinghausen’s disease. Cancer 1970;26: 162-75. 12. Barr H , Page R , Taylor W. Primary small bowel ganglioneuroblastoma and Friedreich’s ataxia. J R SOCMed 1985;79:612-3. 13. Sorensen SA, Jensen OA, Klinken L. Familial aggregation of neuroectodermal and gastrointestinal tumors. Cancer 1983;52:1977-80, 14. Tanimura T, Nelson T, Hollingsworth R R , Shepard T H . Weight standards for organs from early human fetuses. Anat Rec 1971;171:227-36. 15. Arey JB. Cardiovascular Pathology in Infants and Children. Philadelphia: W. B. Saunders, 1984;6116. Benirscke K, Kaufmann P. Pathology of the Human Placenta. 2nd ed. New York: Springer-Verlag, 1990;328-50. 17. Coldman AJ, Fryer CJ, Elwood JM, Sonley MJ. Neuroblastoma: Influence of age at diagnosis, stage, tumor site, and sex on prognosis. Cancer 1980;46:1896-901. 18. Ritter SA. Neuroblastoma of the intestine. Am J Pathol 1925;1:519-26. 19. Cohen T, Zweig SJ, Tallis A, Tuazon R, Reich M. Paraganglioma of the duodenum. Report of a case with radiographic findings, angiographic findings and a review of the literature. Am J Gastroenterol 1981 ;75:197-203. 20. Dornetzhuber V. Ganglioneuromatosis of the large intestine. (In German) Zentralbl Allg Pathol 1961 ;102:249-52. 21. Gleason 10, Beauchemin J, Bursk A. Polypoid ganglioneuromatosis of the large bowel. Arch Neurol 1962;6:242-7. 22. Russell DS, Rubinstein LJ. Pathology of Tumours of the Nervous System. 5th ed. Baltimore: Williams & Wilkins, 1989;930-1. 23. Shousha S, Smith PA. Colonic ganglioneuroma: Report of a case in a patient with neurofibromatosis, multiple colonic adenomas, and adenocarcinoma. Virchows Arch [Pathol Anat] 198 1 ;392:105-9.
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24. Raszkowski HJ, Hufner RF. Neurofibromatosis of the colon: A unique manifestation of von Recklinghausen’s disease. Cancer 1971;27:134-42. 25. Brody PA, Hoover HC. Polypoid ganglioneurofibromatosis of the colon. Br J Radiol 1974;47:494-5. 26. Bibro MC, Houlihan RK, Sheahan DG. Colonic ganglioneuroma. Arch Surg 1980;115:75-7. 27. Donnelly WH, Sieber WK, Yunis EJ. Polypoid ganglioneurofibromatosis of the large bowel. Arch Pathol 1969;87:537-41. 28. Schuster M, Causing WC, Zito PF. Ganglioneurofibromatous polyposis of the gastrointestinal tract. Am J Gastroenterol 1971;55:58-65. 29. Marcum MA, Richardson JD, Kuhns JG. Ganglioneuroma of the terminal ileum: An unusual case of occult gastrointestinal bleeding. Am Surg 1990;56:299-301. 30. Dahl EV, Waugh JM, Dahlin DC. Gastrointestinal ganglioneuromas. Brief review with report of a duodenal ganglioneuroma. Am J Pathol 1957;33:953-65. 31. Haff RC, San Diego AG. Ganglioneuroma of the ileocecal valve: Review of the literature. Arch Pathol 1972;93:549-51. 32. Saul RA, Sturner RA, Burger PC. Hyperplasia of the myenteric plexus. Its associations with early infantile megacolon and neurofibromatosis. Am J Dis Child 1982;136:852-4. 33. Carney JA, Hayles AB. Alimentary tract manifestations of multiple endocrine neoplasia, type 2b. Mayo Clin Proc 1977;52:543-8. 34. Cyr DR, Mack LA, Schoenecker SA, et al. Bowel migration in the normal fetus: US detection. Radiology 1986;161:119-2 1. 35. Bellah R , D’Andrea A, Darillis E, Fellows KE. The association of congenital neuroblastoma and congenital heart disease. Is there a common embryological basis? Pediatr Radiol 1989;19:119-21. 36. Miller RW, Fraumeni J F Jr, Hill JA. Neuroblastoma: Epidemiologic approach to its origin. Am J Dis Child 1968;115:253-61. 37. Beckwith JB, Perrin EV. In situ neuroblastomas: A contribution to the natural history of neural crest tumors. Am J Pathol 1963;43:1089-104. 38. Kirby ML, Waldo KL. Role of neural crest in congenital heart disease. Circulation 1990;82:332-40. 39. Voute PA Jr, Wadman SK, van Putten WJ. Congenital neuroblastoma: Symptoms in the mother during pregnancy. Clin Pediatr 1970;9:206-7. 40. Newton ER, Louis F, Dalton ME, Feingold M. Fetal neuroblastoma and catecholamine-induced maternal hypertension. Obstet Gynecol 1985;65(Suppl):49S-52S. 41. Vaos GC, Lister J . Anatomic evidence for coexistence of cholinergic and adrenergic neurons in the developing human intestine: New aspects in the pathogenesis of developmental neuronal abnormalities. J Pediatr Surg 1988;23:231-6. 42. Teitelman G, Joh TH, Reis DJ. Transient expression of a noradrenergic phenotype in cells of the rat embryonic gut. Brain Res 1978;158:229-34. 43. Teitelman G, Gershon MD, Rothman TP, Joh T H , Reis DJ. Proliferation and distribution of cells that transiently express a catecholaminergic phenotype during development in mice and rats. Dev Biol 1981;86:348-55. 44. Baetge G, Gershon MD. Transient catecholaminergic (TC) cells in the vagus nerves and bowel of fetal mice: Relationship to the development of enteric neurons. Dev Biol 1989;132:189-21 1. 45. Baetge G,Schneider KA, Gershon MD. Development and persistence of catecholaminergic neurons in cultured explants of fetal murine vagus nerves and bowel. Development 1990;110:689-701. 46. Fujinaga M, Baden JM. Evidence for an adrenergic mechanism in the control of body asymmetry. Dev Biol 1991;143 :203-5. 47. Fujinaga M, Maze M, Baden JM. Pharmacological evidence that stimulation of receptor-mediated alpha-1 adrenergic pathway is involved in the control of body asymmetry. (Abstract) Teratology 1991 ;43:446-7. 48. Hodach RJ, Gilbert EF, Fallon JF. Aortic arch anomalies associated with the administration of epinephrine in chick embryos. Teratology 1974;9:203-9. Received September 16, 1991 Revision accepted December 16, 1991
Raj P. Kapur, MD, PhD
Department of Pathology, University of Washington, and Children’s Hospital and Medical Center, Seattle, Washington 0
Thomas H. Shepard, MD
Fetal Pediatr Pathol Downloaded from informahealthcare.com by McMaster University on 01/13/15 For personal use only.
0 Department of Pediatrics, University of Washington, and Children’s Hospital and Medical Center, Seattle, Washington
0 The clinical history and autopsy findings of a 22-week fetus with intestinal ganglioneuroblastoma, cardiac anomalies, omphalocele, and ileal atresia are presented. Ganglioneuroblastoma was confined to the large intestine and was not suspected prenatally despite ultrasonographic examination. Although mten‘c ganglia share neural crest lineage with other sites of congenital neuroblastoma, this is the first report o f a primary intestinal ganglioneuroblastoma in a jkttus or child. Various hypotheses are discussed to explain the coexistence of cardiac malformation and congenital neuroblastoma in this fetus and other cases in the literature. It is hypothesized that other malfrmations evident in this fetus were caused by the tumor, possibly as teratogenic effects o f neuroblastoma-derived catecholamines during embryogenesis.
KEY WORDS: colon, cecum, immunohistochemisty, prenatal diagnosis, intestine, neuroblastoma.
INTRODUCTION Neuroblastoma is the most common congenital malignancy ( 1 , 2). Congenital neuroblastoma is frequently an isolated finding but does occur occasionally in association with other congenital anomalies (3-9) or specific familial disorders (10-13). This neoplasm is thought to be derived from neural crest cells, which normally exhibit neurosecretory differentiation in the adrenal medulla, peripheral ganglia, and enteric nervous system. Congenital neuroblastomas have been observed in a number of sites that reflect the diverse regions of the body populated by neural crest cells during embryogenesis. Although there are several reported examples of neuroblastoma detected prenatally by ultrasound examination, most congenital cases are discovered The authors thank Drs. Joe C. Rutledge and Joel Haas (Children’s Hospital and Medical Center, Seattle) for their thoughtful comments regarding this case. In addition, the technical assistance of Ms. Julie Pascoe-Mason was greatly appreciated. Address reprint requests to: Raj P. Kapur, M.D., Ph.D., Department of Pathology, Children’s Hospital and Medical Center, P.O. Box C-5371, Seattle, Washington 98105. Pediatric Pathology, 12:583-592, 1992 Copyright @ 1992 by Hemisphere Publishing Corporation
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postnatally. In addition, fetuses with tumors identified in utero are usually carried to term, so pathologic examination of midgestational neuroblastoma is rarely performed. In this paper, a clinically unsuspected case of colonic ganglioneuroblastoma is reported in a 22-week fetus with multiple congenital anomalies. The intestinal neoplasm was associated with a small omphalocele, ileal atresia, and a congenital heart defect. The possible causal relationships between these anomalies are discussed.
CLINICAL HISTORY The mother of the fetus was a 29-year-old gravida 2, paragravida 0, Caucasian whose previous pregnancy resulted in spontaneous intrauterine fetal demise at an estimated gestational age (EGA) of 5 weeks (post conception). The embryo was not examined. She used no medications, nor was exposed knowingly to teratogens during the pregnancy. The parents were nonconsanguineous and had no family history of congenital disorders. During this pregnancy she received regular prenatal care beginning at 7 weeks EGA. The early part of her pregnancy was unremarkable. A maternal serum afetoprotein level obtained at 16 weeks EGA was 1.26 multiples of the mean and the results of other routine obstetrical laboratory studies were within normal limits. At no time was she hypertensive. At 20 weeks the mothers fundal height measurement was less than expected and an ultrasound examination was performed 2 weeks later. The latter study showed a “small bowel-containing omphalocoele” and a cardiac abnormality ‘‘considered to represent a variant of the hypoplastic left heart syndrome, possibly in association with an atrial septa1 defect.’’ The wall of the echogenic bowel in the omphalocele was described as “mildly thickened.’’ The biparietal diameter and foot length were both appropriate for the EGA. Because of the reported defects, an elective termination of pregnancy was performed by prostaglandin induction at 22 weeks. Following termination, the fetus was refrigerated for 2 days and then sent to the Central Laboratory for Human Embryology at the University of Washington, where it was promptly examined. Cytogenetic studies of placental tissue taken at the time of delivery yielded a normal female karyotype (400 band resolution, 22 cells counted).
AUTOPSY FINDINGS A complete autopsy was performed, including gross and microscopic examination of the brain and placenta. The foot and crown-rump lengths were consistent with the clinically estimated gestational age of 20 weeks (post conception) based on standards established in the laboratory (14). The 538-g fetus
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was phenotypically female and nondysmorphic with the notable exception of a 1.5 x 1.5 x 2.0 cm omphalocele located in the superior aspect of the umbilical cord (Fig. la). The omphalocele consisted of a semitransparent membranous sac through which the cecum was visible. Internal examination revealed several abnormalities. The left atrium and ventricle were moderately hypoplastic and the right ventricle was slightly enlarged. The diameter of the proximal aorta (2.5 mm) was half that of the pulmonary trunk (5 mm), and a 5-mm endocardial cushion defect was present. The latter was a complete atrioventricular communis characterized by a continuous ostium primum atrial septal and subaortic ventricular septal defect that was traversed inferiorly by fused leaflets of the mitral and tricuspid valves (15). The great veins and branches of the aorta were normal and there was no endocardial fibroelastosis. The gastrointestinal tract was malrotated and short. The ileum was atretic 1 cm from the cecum. It terminated abruptly as a “blind pouch” located in the epigastric region adjacent, but not attached, to the distal ileum and cecum. The latter were situated within the omphalocele lumen and the cecum was attached to the internal surface of the omphalocele by a delicate band of connective tissue (Fig. ic). The appendix and a short length of distal ileum retained their normal relationships to the cecum. The large intestine was dramatically thickened and firm. This was most evident in the cecum (external diameter = 1 cm) and became gradually less prominent distally. The terminal third of the colon was grossly normal. Sections of the large intestine demonstrated marked thickening of the wall with obliteration of the cecal lumen and stenosis of the lumen distally (Fig. Id). Microscopic examination of the large intestine revealed infiltration and expansion of the muscularis and submucosa by ganglioneuroblastoma. The neoplasm exhibited two histologic patterns, intersecting fascicles that resembled mature nerve and nests of neuroblasts (Fig. 2a). The latter ranged in maturity from undifferentiated small round cells to large mature nerve cell bodies with eccentric nuclei and prominent nucleoli (Fig. 2b). Interspersed with the mature neural fascicles were many spindle-shaped cells indicative of glial differentiation. In histologic sections taken from the middle colon, where tumor involvement was less, the neoplastic cells were confined to the region of the myenteric plexus, obliterating the normal myenteric ganglia. In the small intestine and more distally in the colon, neoplastic elements were not present and the submucosal and myenteric ganglia appeared normal. The ileum and appendix were not involved and there was no evidence of tumor elsewhere in the fetus or placenta. A panel of immunocytochemical markers was used to more definitively assess cellular differentiation in this tumor. This study was performed by the immunoperoxidase technique with paraffin sections of formalin-fixed tissue.
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FIGURE 1. (a) Close-up photograph of anterior abdominal wall showing omphalocele in base of umbilical cord. T h e pale cecum (arrow) can be seen through the thin membranous omphalocele. (b) A portion of the gastrointestinal tract including a small portion of attached bladder (bl) and anterior abdominal wall. T h e small bowel, which ends blindly as a saccular atretic ileum (i), is shown above the detached colon. T h e cecum (c) is attached to the peritoneal surface of the omphalocele (0). T h e positions of the transverse sections shown in (d) are indicated by arrows. (c) A close-up photograph of the cecum and attached omphalocele sac shows the attenuated distal ileum (large arrow) and a portion of the appendix (small arrow). The proximal large intestine is markedly thickened. (d) Transverse sections of large intestine taken at the corresponding sites indicated in (b) and a longitudinal section of the cecum (right) demonstrate a marked increase in wall thickness with obliteration proximally of the lumen. Bars: (a) 10 mm, (b) 13 mm, (c) 5 mm, (d) 5 mm.
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FIGURE 2. (a, b) Photomicrographs of the neoplasm showing undifferentiated cells (U) admixed with more differentiated areas (D). The more differentiated cell types resemble mature neurons (b, arrows) or neural-glial fascicles (ng). Bars: (a) 84 mm, (b) 42 mm.
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The results of this study are summarized in Table 1. The most differentiated neural elements were strongly immunoreactive with antibodies specific for neuron-specific enolase (NSE) and labeled weakly with antibodies against synaptophysin. Presumptive glial elements associated with differentiated nerve fascicles were strongly labeled by S 100-specific antibodies, whereas NSE and SlOO immunostaining was weaker in the less differentiated areas. No desmin or chromogranin labeling was detected in the neoplastic cells. The only other anomaly evident in this fetus was bicornuate uterus. No metastatic tumor was identified. Although the placental weight (106 g) was less than the fifth percentile (148 g) for fetuses of comparable age or weight (16), no gross or histologic placental pathology was present.
DISCUSSION Neuroblastoma, ganglioneuroblastoma, and their benign counterpart, ganglioneuroma, are all thought to arise from neural crest cells. The latter disperse widely during early embryogenesis and give rise to a diverse spectrum of tissue types including sensory, autonomic, and enteric neurons and adrenal chromaffin cells. The majority of these neural derivatives are paraxial ganglia in the retrothorax, retroperitoneum, and pelvis; and most extraadrenal neuroblastomas occur in corresponding paraxial sites (17). Because the myenteric and submucosal ganglia of the gastrointestinal tract are also crest derived, the enteric system is a logical primary site for this type of neoplasm. Curiously, primary gastrointestinal neuroblastoma is extremely rare. Although neuroblastoma is the most common congenital malignancy, this is the first case of primary intestinal congenital neuroblastoma to be reported in the literature. In fact, we are aware of only three other reported cases of primary intestinal neuroblastoma, all of which occurred in adults. Ritter (18) described two cases. The first, involving a very large mass that incorporated TABLE 1. Summary of Immunocytochemical Results Immunolabeling of neoplastic cells Antigen recognized by antibodf
Well differentiated
Poorly differentiated
Neuron-specific enolase SlOO Synaptophysin Chromogranin Desmin
Strongly positive Strongly positive Weakly positive Negative Negative
Weakly positive Weakly positive Negative Negative Negative
~~
~
~~
~~
~
~~
“All antibodies were obtained as prediluted solutions from Biogenex Laboratories, San Ramon, California. NSE and SlOO were polyclonal rabbit antisera; other antibodies were m u r k monoclonal antibodies.
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portions of mesentery and jejuneum, was presumed to have arisen from the bowel. In the second case, the diagnosis was somewhat uncertain as the tumor had an atypical histologic appearance. Barf et al. (12) published a putative example of primary intestinal neuroblastoma that was discovered incidentally in the small intestine of a 26-year-old woman with Friedreich’s ataxia during cesarean delivery. However, because a similar neoplasm was present in the umbilical cord of the placenta after delivery, the possibility that the intestinal tumor was a metastasis from a primary fetal lesion could not be excluded. Benign intestinal ganglioneuromas have been reported more frequently (19-3 1). Yet, none of 48 cases reported in the literature occurred in patients less than 8 years of age and congenital intestinal ganglioneuromas have not been described. In this case, precise nosology for this tumor is complicated, in part, by its prenatal occurrence and unusual location. Although we believe that (6 ganglioneuroblastoma” describes the combined mature and immature histologic elements evident, the extensive degree of neural and glial differentiation in this tumor and its failure to metastasize suggest that this tumor may be a hamartoma and/or may have matured into a ganglioneuroma had the fetus developed further. Moreover, the longitudinal pattern of spread along the length of the bowel wall is reminiscent of the normal organization of enteric plexuses and in some respects exemplifies an extreme example of “neuronal dysplasia” (32). In this fetus, intestinal ganglioneuroblastoma was associated with omphalocele, ileal atresia, endocardia1 cushion defect, and bicornuate uterus. Ganglioneuromas have been reported as a frequent finding in multiple endocrine neoplasia type 2b (33) and neurofibromatosis (24, 25, 27, 28), and neuroblastoma has been observed sporadically in fetuses and children with multiple malformations (3-9). However, the combined anomalies in this fetus are unlike any of those described previously. Omphalocele, ileal atresia, and/or cardiac malformation may have been secondary effects of the neoplasm, particularly if the tumor originated in the cecum prior to the ninth week of gestation. During this stage of development the midgut exists normally as a segment of bowel that protrudes through the ventral abdominal wall. Studies of murine embryos indicate that neuroblast colonization precedes reduction of the midgut herniation, which is completed during the eighth week of gestation (post conception) in humans (34). It is possible that tumor in the developing cecum prevented complete reduction of the midgut, perhaps because the neoplastic bowel was too large to pass into the abdominal cavity. Incarceration may have led secondarily to ileal ischemia and eventual atresia. There is conflicting evidence concerning an association between congenital neuroblastoma and congenital heart defects (discussed in ref 35). Two epidemiologic studies have shown no significant association between cardiac anomalies
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and clinically apparent neuroblastoma (4, 36). However, autopsy studies that included in situ neuroblastoma in the data base suggest that coincidence of the two conditions occurs more frequently than predicted from the independent frequencies of each (37). At least two hypotheses have been advocated to explain this putative association. De la Monte et al. (6) propose that neuroblastoma could have been induced as a consequence of chronic hypoxia produced by cyanotic congenital heart defects. However, this is an unlikely cause of congenital neoplasia because significant hypoxia is not usually evident until post partum. Bellah et al. (35) hypothesized that coincident neuroblastoma and congenital heart defects reflect an underlying neurocristopathy because cephalic neural crest cells participate in formation of the aorticopulmonary septum (38). This hypothesis has been endorsed by Patrone et al. (9), who reported an infant with extra-adrenal neuroblastoma and DiGeorge anomaly. Alternatively, the cardiac malformation evident in this fetus may have been due to teratogenic effects of catecholamines secreted by the intestinal ganglioneuroblastoma during embryogenesis. The biosynthesis and secretion of catecholamines are common properties of neuroblastomas, although the magnitude of catecholamine production can vary. Secretion of these substances in utero is used to explain fetal neuroblastoma complicated by paroxysmal maternal hypertension (39, 40). Similar to the neural crest cells that give rise to neuroblastomas in the adrenal and sympathetic ganglia, enteric neuroblasts are programmed to synthesize catecholamines. Catecholaminergic differentiation of enteric neuroblasts is an embryonic phenomenon that precedes the development of other neurotransmitter biosynthetic pathways (41 -43). Evidence from murine studies suggests that expression of enzymes necessary for catecholamine production in the developing enteric nervous system normally begins prior to establishment of the midgut herniation, during the period when the aorticopulmonary and membranous ventricular septa are formed (44, 45). Neoplastic transformation of adrenergic enteric neuroblasts may expose the embryonic heart to abnormally high levels of catecholamines. A growing body of literature suggests that adrenergic agents have teratogenic effects. Postgrastrulation murine embryos exposed to adrenergic agonists in vitro develop situs inversus and associated cardiac defects (46, 47). Chick embryos exposed to epinephrine at comparable stages develop cardiovascular anomalies including conotruncal and aortic arch anomalies (48). Because catecholamines in the intestinal venous return would pass through the heart prior to the fetal systemic circulation or placenta, relatively small amounts of catecholamine produced by this tumor may have been present in high concentrations in the heart. In this instance, catecholamines may have promoted cardiac malformation. This hypothesis is admittedly based on data from other species at comparable developmental stages, but it provides an
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alternative explanation for the association of cardiac malformation and congenital neuroblastoma evident in this and other reported cases.
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REFERENCES 1 . Wells HG. Occurrence and significance of congenital malignant neoplasms. Arch Pathol 1940;30:535601. 2. Isaacs H J . Perinatal (congenital and neonatal) neoplasms: A report of 110 cases. Pediatr Pathol 1985;3:165-216. 3. Sy WM, Edmonson JH. The developmental defects associated with neuroblastoma-etiologic implications. Cancer 1968;22 :234-8. 4. Berry CL, Keeling J, Hilton C. Coincidence of congenital malformation and embryonic tumours of childhood. Arch Dis Child 1970;45:229-31. 5. Kouyoumdjian AO, McDonald JJ. Association of congenital adrenal neuroblastoma with multiple anomalies, including an unusual oropharyngeal cavity (imperforate buccopharyngeal membrane). Cancer 1951;4:784-8. 6 . de la Monte SM, Hutchins GM, Moore GW. Peripheral neuroblastic tumors and congenital heart disease. Possible role of hypoxic states in tumor induction. Am J Pediatr Hematol Oncol 1985;7:10916. 7. Reisman M, Goldenberg ED, Gordon J. Congenital heart disease and neuroblastoma. Case report and brief comment. Am J Dis Child 1966;111:308-10. 8. Andersen HJ, Hariri J. Congenital neuroblastoma in a fetus with multiple malformations. Metastasis in the umbilical cord as a cause of intrauterine death. Virchows Arch [A] 1983;400:219-22. 9 . Patrone PM, Chatten J, Weinberg P. Neuroblastoma and DiGeorge anomaly. Pediatr Pathol 1990;10:425-30. 10. Emery LG, Shields M, Shah NR, Garbes A. Neuroblastoma associated with Beckwith-Wiedemann syndrome. Cancer 1983;52: 176-9. 1 1 . Bolande RP, Towler WF. A possible relationship of neuroblastoma to von Recklinghausen’s disease. Cancer 1970;26: 162-75. 12. Barr H , Page R , Taylor W. Primary small bowel ganglioneuroblastoma and Friedreich’s ataxia. J R SOCMed 1985;79:612-3. 13. Sorensen SA, Jensen OA, Klinken L. Familial aggregation of neuroectodermal and gastrointestinal tumors. Cancer 1983;52:1977-80, 14. Tanimura T, Nelson T, Hollingsworth R R , Shepard T H . Weight standards for organs from early human fetuses. Anat Rec 1971;171:227-36. 15. Arey JB. Cardiovascular Pathology in Infants and Children. Philadelphia: W. B. Saunders, 1984;6116. Benirscke K, Kaufmann P. Pathology of the Human Placenta. 2nd ed. New York: Springer-Verlag, 1990;328-50. 17. Coldman AJ, Fryer CJ, Elwood JM, Sonley MJ. Neuroblastoma: Influence of age at diagnosis, stage, tumor site, and sex on prognosis. Cancer 1980;46:1896-901. 18. Ritter SA. Neuroblastoma of the intestine. Am J Pathol 1925;1:519-26. 19. Cohen T, Zweig SJ, Tallis A, Tuazon R, Reich M. Paraganglioma of the duodenum. Report of a case with radiographic findings, angiographic findings and a review of the literature. Am J Gastroenterol 1981 ;75:197-203. 20. Dornetzhuber V. Ganglioneuromatosis of the large intestine. (In German) Zentralbl Allg Pathol 1961 ;102:249-52. 21. Gleason 10, Beauchemin J, Bursk A. Polypoid ganglioneuromatosis of the large bowel. Arch Neurol 1962;6:242-7. 22. Russell DS, Rubinstein LJ. Pathology of Tumours of the Nervous System. 5th ed. Baltimore: Williams & Wilkins, 1989;930-1. 23. Shousha S, Smith PA. Colonic ganglioneuroma: Report of a case in a patient with neurofibromatosis, multiple colonic adenomas, and adenocarcinoma. Virchows Arch [Pathol Anat] 198 1 ;392:105-9.
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R. P. KAPUR AND T. H. SHEPARD
24. Raszkowski HJ, Hufner RF. Neurofibromatosis of the colon: A unique manifestation of von Recklinghausen’s disease. Cancer 1971;27:134-42. 25. Brody PA, Hoover HC. Polypoid ganglioneurofibromatosis of the colon. Br J Radiol 1974;47:494-5. 26. Bibro MC, Houlihan RK, Sheahan DG. Colonic ganglioneuroma. Arch Surg 1980;115:75-7. 27. Donnelly WH, Sieber WK, Yunis EJ. Polypoid ganglioneurofibromatosis of the large bowel. Arch Pathol 1969;87:537-41. 28. Schuster M, Causing WC, Zito PF. Ganglioneurofibromatous polyposis of the gastrointestinal tract. Am J Gastroenterol 1971;55:58-65. 29. Marcum MA, Richardson JD, Kuhns JG. Ganglioneuroma of the terminal ileum: An unusual case of occult gastrointestinal bleeding. Am Surg 1990;56:299-301. 30. Dahl EV, Waugh JM, Dahlin DC. Gastrointestinal ganglioneuromas. Brief review with report of a duodenal ganglioneuroma. Am J Pathol 1957;33:953-65. 31. Haff RC, San Diego AG. Ganglioneuroma of the ileocecal valve: Review of the literature. Arch Pathol 1972;93:549-51. 32. Saul RA, Sturner RA, Burger PC. Hyperplasia of the myenteric plexus. Its associations with early infantile megacolon and neurofibromatosis. Am J Dis Child 1982;136:852-4. 33. Carney JA, Hayles AB. Alimentary tract manifestations of multiple endocrine neoplasia, type 2b. Mayo Clin Proc 1977;52:543-8. 34. Cyr DR, Mack LA, Schoenecker SA, et al. Bowel migration in the normal fetus: US detection. Radiology 1986;161:119-2 1. 35. Bellah R , D’Andrea A, Darillis E, Fellows KE. The association of congenital neuroblastoma and congenital heart disease. Is there a common embryological basis? Pediatr Radiol 1989;19:119-21. 36. Miller RW, Fraumeni J F Jr, Hill JA. Neuroblastoma: Epidemiologic approach to its origin. Am J Dis Child 1968;115:253-61. 37. Beckwith JB, Perrin EV. In situ neuroblastomas: A contribution to the natural history of neural crest tumors. Am J Pathol 1963;43:1089-104. 38. Kirby ML, Waldo KL. Role of neural crest in congenital heart disease. Circulation 1990;82:332-40. 39. Voute PA Jr, Wadman SK, van Putten WJ. Congenital neuroblastoma: Symptoms in the mother during pregnancy. Clin Pediatr 1970;9:206-7. 40. Newton ER, Louis F, Dalton ME, Feingold M. Fetal neuroblastoma and catecholamine-induced maternal hypertension. Obstet Gynecol 1985;65(Suppl):49S-52S. 41. Vaos GC, Lister J . Anatomic evidence for coexistence of cholinergic and adrenergic neurons in the developing human intestine: New aspects in the pathogenesis of developmental neuronal abnormalities. J Pediatr Surg 1988;23:231-6. 42. Teitelman G, Joh TH, Reis DJ. Transient expression of a noradrenergic phenotype in cells of the rat embryonic gut. Brain Res 1978;158:229-34. 43. Teitelman G, Gershon MD, Rothman TP, Joh T H , Reis DJ. Proliferation and distribution of cells that transiently express a catecholaminergic phenotype during development in mice and rats. Dev Biol 1981;86:348-55. 44. Baetge G, Gershon MD. Transient catecholaminergic (TC) cells in the vagus nerves and bowel of fetal mice: Relationship to the development of enteric neurons. Dev Biol 1989;132:189-21 1. 45. Baetge G,Schneider KA, Gershon MD. Development and persistence of catecholaminergic neurons in cultured explants of fetal murine vagus nerves and bowel. Development 1990;110:689-701. 46. Fujinaga M, Baden JM. Evidence for an adrenergic mechanism in the control of body asymmetry. Dev Biol 1991;143 :203-5. 47. Fujinaga M, Maze M, Baden JM. Pharmacological evidence that stimulation of receptor-mediated alpha-1 adrenergic pathway is involved in the control of body asymmetry. (Abstract) Teratology 1991 ;43:446-7. 48. Hodach RJ, Gilbert EF, Fallon JF. Aortic arch anomalies associated with the administration of epinephrine in chick embryos. Teratology 1974;9:203-9. Received September 16, 1991 Revision accepted December 16, 1991
![[Vasoactive intestinal peptide-secreting ganglioneuroblastoma in a 20 month-old child].](/assets/img/hold.png)
