Neoadjuvant Chemotherapy with Laser Interstitial Thermal Therapy in Central Nervous System Neuroblastoma: Illustrative Case and Literature Review

Abstract

Primitive neuroectodermal tumors of the central nervous system, or CNS neuroblastoma, are rare neoplasms in children. Recently, methylation profiling enabled the discovery of four distinct entities of these tumors. The current treatment paradigm involves surgical resection followed by chemotherapy and radiation. However, upfront surgical resection carries high surgical morbidity in this patient population due to their young age, tumor vascularity, and often deep location in the brain. We report a case of CNS neuroblastoma that can be successfully treated with neoadjuvant chemotherapy followed by minimally invasive laser interstitial thermal therapy and radiation. The patient has complete treatment with no evidence of recurrence at one year follow-up. This case illustrates a potential paradigm shift in the treatment of these rare tumors can be treated using minimally invasive surgical approach to achieve a favorable outcome.

Keywords: CNS neuroblastoma; LITT; laser interstitial thermal therapy.

Figure 1

(a) Axial, (b) coronal, and (c) sagittal contrast-enhanced MRI at the time of initial diagnosis demonstrated a large multi-lobular, contrast-enhancing, mass-causing mass effect; midline shift; and obstructive hydrocephalus.

Figure 2

Hematoxylin and eosin stain of tumor specimen demonstrated an infiltrative hypercellular embryonal neoplasm without specific architectural patterns.

Figure 3

(a) Axial, (b) coronal, and (c) sagittal contrast-enhanced MRI after 4 cycles of neoadjuvant chemotherapy as per the Children’s Oncology Group Protocol ACNS0334, Induction Regimen A (Vincristine, Cyclophosphamide, Etoposide, Cisplatin), demonstrated significant reduction in the size of the contrast enhancing lesion.

Figure 4

Intraoperative MRI confirming placement for 4 Medtronic Visualase fiber prior to ablation of tumor. Two fibers were inserted into the temporal portion of the tumor laterally. One fiber inserted into the posterior portion of the tumor from an occipital approach. One fiber inserted into the anterior portion of the from a frontal approach.

Figure 5

Serial axial contrast-enhanced MRI after LITT demonstrating area of post-treatment necrosis (arrows), reflecting the ablated area.

Figure 6

(a) Axial, (b) coronal, and (c) sagittal contrast-enhanced MRI after completion of LITT, post LITT craniospinal radiation IMRT, and consolidation chemotherapy 13 months after initial diagnosis. There is no evidence of tumor recurrence.