Pediatric Oncologic Pathology
Moderators: Dr. Tony Bourne and Dr. Denis Benjamin
Case 5 -
Dr. C. W. Chow
Royal Children's Hospital
This male baby was born at term by lower segment Caesarian section after breech
labour. He was referred from a peripheral hospital to the Royal Children's Hospital on day 13 following
abdominal distension, vomiting and 10% loss in weight. Suction rectal biopsy was performed.
Acetylcholinesterase showed a prominent submucosal plexus, but the coarse discrete cholinergic nerve
fibres in the muscularis mucosae typical of Hirschsprung's disease were not seen.
Case 5 - Slide 1
This male baby was delivered at term by lower segment Caeserian section following breech labour. He
was admitted from a peripheral hospital on day 13 following vomiting, weight loss of 10% and abdominal
distension. Suction rectal biopsy showed prominent bundles of nerve fibres and clusters of neurons in
the submucosa. These occupy in some sections 1/3 of the submucosal area. Acetylcholinesterase showed no
coarse discrete fibres in the muscularis mucosae. Hirschsprung's disease was excluded but the
significance of the hypertrophied submucosal plexus was unclear. Intestinal ganglioneuromatosis was
considered. However family history showed that the maternal great grandfather had a lock of white hair
and the maternal grandfather had green iris in one eye and brown iris in the other. Mother was normal.
In view of this it was felt that perhaps the changes were related to a form of Waardenberg syndrome.
Although the typical lesion of Waardenberg syndrome is Hirschsprung's disease an occasional report
described decreased or increased neurons . In spite of repeated bowel washouts, there was increasing
abdominal distension. Barium meal showed malrotation. A Ladd's procedure and a colostomy were
performed. At the time of surgery, the appendix and a seromuscular biopsy of the small intestine were
removed, both showing marked hypertrophy of the myenteric plexus, typical of diffuse intestinal
ganglioneuromatosis. Although there was still uncertainty about the cause of the lesion, it was decided
to check the possibility of MEN 2B first, as this was the easiest to arrange. Molecular studies showed a
germline Met918Thr mutation of the RET proto- oncogene. No mutation was
detected in the parents. Follow-up studies at 8 months showed that serum calcitonin level was 270
ng/L(normal <30). Thyroid ultrasound revealed
a 4mm solid nodule in each lobe. The adrenals showed no abnormality. A total thyroidectomy was
performed one month later. Histopathology showed 2 well-circumscribed but non-encapsulated nodules
composed of solid clusters of polyhedral to spindle tumour cells supported by a delicate vascular
stroma. The nuclei were regular, round to oval with fine even chromatin. The cytoplasm was finely granular and eosinophilic. Immunohistochemistry showed that the tumour
cells were positive for calcitonin. The features were those of multifocal medullary thyroid
carcinoma. Post-operative follow-up 15 months later showed that the boy
continues to thrive with the colostomy. Calcitonin levels were not elevated. Metastases were not found.
Suction rectal biopsies are often performed in infants and children with intestinal obstruction for
the diagnosis of Hirschsprung's disease, either by the absence of ganglion cells in the submucosa, or by
the presence of many coarse discrete cholinergic fibres in the muscularis mucosae . After
Hirschsprung's disease has been excluded, there does not appear to be any uniform policy for further
investigations. There are various new studies including immunohistochemical demonstration of
neuropeptides such as substance P, vasoactive intestinal peptide and nitric oxide synthase, physiologic
studies in organ baths, multichannel colonic manometry, and nuclear transit studies . These are still
at the research stage and there do not yet appear to be easily used diagnostic criteria closely
correlated with clinical features. If neurons appear increased in number in the submucosa the term
intestinal neuronal dysplasia (IND) has sometimes been loosely applied without the proposed enzyme
histochemistry or quantitation required for the diagnosis of this entity . In the present patient the
increase in the submucosal plexus was dramatic. This dramatic increase suggested not IND but diffuse
intestinal ganglioneuromatois. In view of this MEN 2B was checked and confirmed by molecular studies.
MEN 2B is an autosomal dominant disease caused by an activating missense mutation in the RET proto-oncogene . More than 95 % of the patients have a germline mutation
with a methionine to threonine change in codon 918 . The remaining patients show mutations elsewhere
in the RET gene e.g. codon 883 . Approximately 50 % of the patients have
been shown to have de novo mutations. The disease is associated with 100%
penetrance. The phenotype comprises mucosal neuromas, intestinal ganglioneuromatosis, Marfanoid facies,
medullary thyroid carcinoma, phaeochromocytoma and parathyroid hyperplasia .
MEN 2B is frequently associated with gastrointestinal symptoms, especially constipation, sometimes
alternating with diarrhoea. Colonic dysmotility has been reported to be present in up to 90% of the
patients, with the symptoms often dating from early infancy
As the disease is associated with a
high rate of de novo mutations and many of the phenotypic features may not
recognizable for several years, it is important to be familiar with the changes in the alimentary tract
if a biopsy is taken early for the investigation of constipation. Once the possibility of this diagnosis
has been raised, confirmation is usually easy as 95% of the patients show the Met918Thr mutation. Early
diagnosis can be critical for patient management as the risk of medullary carcinoma of the thyroid has
been considered to be present in 100% of the patients . This tumour has been reported in patients as
young as 7 months  or 8 months as in this patient.
Metastases can also occur in early childhood .
The typical lesions of MEN 2B in the alimentary tract include mucosal neuromas and diffuse intestinal
ganglioneuromatosis . These are two very distinct lesions although sometimes they seem to be
Mucosal neuromas are composed of numerous tortuous nerves underneath the epithelium
with thickened perineurium and increase in mucoid ground substance. Neurons are seldom seen. Although
the lesions can be noted at birth in some patients, they may not be obvious until the children are
several years old . Ganglioneuromatosis is composed of a marked proliferation of nerve fibres and
neurons involving mainly the myenteric plexus. This lesion has been estimated to be present in 90% of
patients with MEN 2B . The submucosal plexus may be involved, and also
sometimes the mucosa with increase in neurons and nerve fibres in the lamina propria, although the
involvement of these more superficial layers is considered to be less consistent and dramatic. There are
only a few reports of patients in whom hyperplasia of the submucosal plexus is specifically mentioned
In at least two patients the features were initially considered to be indicative of IND
This entity is still highly controversial due to the lack of user friendly diagnostic criteria and
close correlation with clinical features. Whatever one's personal view on IND may be, the suggested
assessment is based on enzyme histochemistry using lactic and succinic dehydrogenases , and the
increase in neurons seem to be subtle as shown by the high rate of discrepancy between closely
collaborating pathologists . If the hypertrophy of the submucosal plexus is dramatic, intestinal
ganglioneuromatosis must be considered, and the possibility of a genetic disease such as MEN 2B checked.
Other genetic conditions which have been reported with diffuse intestinal ganglioneuromatosis include
neurofibromatosis type 1 and Cowden syndrome .
The hypertrophy of the submucosal plexus can be quite dramatic. As seen in this patient up to 1/3 of
the submucosal area is occupied by the nerve fibres and neurons. This change is quite obvious on
standard haematoxylin and eosin stained sections. . In view of the identification of the mutation in
the RET gene and the absence of the Waardenberg syndrome in the mother and
the patient, the family history was considered to be a red herring. Although the changes were obvious in
this patient, it is unclear how regularly this feature is sufficiently developed in early infancy to
allow a confident diagnosis. Only with a large series can the reliability of this diagnostic feature be
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