Calcification in Liver Metastases from Neuroblastoma

ALTHOUGH roentgenographically visible calcification occurs in about half the primary abdominal neuroblastomas (3, 9), only one case of calcified metastases has been reported, and in this the retroperitoneal lymph nodes were affected (7). The liver is involved either by direct spread or by metastases in one-third the patients when they are first seen (11), but no report of calcified hepatic metastases has appeared. It is the purpose of this paper to describe two cases in children of neuroblastoma with metastases to the liver, which showed calcification on radiographs. Another case in which the radiographic findings simulated calcified neuroblastoma metastases in the liver is also reported, and 2 further cases with this deceptive appearance are illustrated. Case Reports CASE I: J. V., a girl, was first observed at the age of two years and four months. For three months she had not been well. She was lethargic and at times irritable. Examination at the time of presentation revealed a hard swelling about one inch in diameter, apparently arising from the right side of the frontal bone. Radiographs of the skull disclosed findings consistent with neoplastic change, probably neuroblastoma. Two weeks later the patient was admitted to the Royal Children's Hospital, Melbourne. By this time three lumps were palpable on the vertex, and papilledema was noted. X-ray films of the abdomen (Fig. 1) and long bones at that time showed flecked calcification in the region of the right adrenal and scattered throughout the liver. Irregular rarefaction was disseminated through the bony pelvis and both proximal femora and humeri. The patient was anemic, and transfusions were administered. Treatment with vitamin B12, 1,500 micrograms on alternate days, was of no avail, and two weeks after admission the skull metastases were obviously enlarging rapidly and increasing in number. Deep x-ray therapy was instituted, and the patient was discharged, but her condition deteriorated and she died six weeks later. At autopsy the right suprarenal was replaced by an encapsulated mass 7 × 5 × 4 em consistent with neuroblastoma, which contained flecks of calcareous material centrally. Metastases were present in the bones. The liver was large (570 g), and its surface was studded with firm, pale nodules up to 1 em in diameter. These consisted of round cells in a scanty stroma. The round cells varied in size and tended to form rosettes. Deposits of calcium salts were present, both within the nodules and in the adjacent liver. CASE II: C. P. D., a 4-year-old boy, was admitted to the Royal Children's Hospital with a sixweek history of intermittent fever, malaise, anorexia. and painful legs and neck. The liver was enlarged. A lymph node of 2 = 2 em was palpable in the left supraclavicular region. A plain film of the abdomen showed extensive calcification in the liver region, but no separate suprarenal calcification was seen.