Extracranial Metastases from Central Nervous System Tumors in Children and Adolescents

Abstract

Tumors primary in the brain, spinal cord, and their coverings spread by three means: (a) local invasion, (b) seeding via the cerebrospinal fluid pathways, and (c) remotely by lymphatic and vascular channels. The third—a rare but well recognized complication of these neoplasms—is the subject of this communication. In 1963 Glasauer and Yuan added a case of their own to 88 culled from the literature. These patients were of all ages. Since that time, at least 5 additional cases have been reported (2, 4, 8, 12). Six children with this complication were encountered among 83 patients with central nervous system tumors treated in the Radiotherapy Division of the Children's Hospital Medical Center during the years 1958 to 1963. All the children were under fourteen years of age except for one 18-year-old girl. Also reported are two cases which do not qualify for the study group as defined above. One patient was treated in 1945; the other case is presented through the co-operation of another institution. These 8 cases serve to emphasize certain features of brain tumors as they develop in children, with special reference to extra-cranial metastasis. Case Reports Case I: D. M., a boy, was first seen at the age of six years three months (September 1963) with the chief complaint of anorexia and headaches for three to four weeks and intermittent vomiting for two weeks prior to admission. A ventriculogram showed a right posterior fossa mass. At surgery on Sept. 5 a medulloblastoma that lay partly within the fourth ventricle was removed from the posterior fossa. Postoperative radiation delivered 3,700 R∕t to the entire CNS (central nervous system) axis in forty-two days (h.v.l., 2.5 mm Cu). Recovery was slow and incomplete. In January 1964 the child started to vomit again. Large, firm, and fixed lymph nodes were discovered in both cervical regions, and the craniectomy site was tense and bulging. The child was placed on constant ventricular drainage, but declined rapidly and died in January. Autopsy Findings: Tumor diffusely involved the cerebral and cerebellar subarachnoid space and both cerebral hemispheres, brain stem, cerebellum, and cervical spinal cord. Histology: Poorly differentiated medulloblastoma. The cervical lymph nodes were infiltrated by tumor of the same histologic pattern. Case II: M. A., a girl, was first seen at the age of six years ten months (March 1945), with the chief complaint of intermittent headaches and vomiting for three months and unstable gait for six weeks prior to admission. Bilateral papilledema was found, and skull roentgenograms showed widened sutures. Neurological examination strongly suggested a lesion in the posterior fossa. This was explored, and a large tumor was incompletely removed.