Arch Dis Child: first published as 10.1136/adc.41.216.193 on 1 April 1966. Downloaded from Arch. Dis. Childh., 1966, 41, 193. Differential Diagnosis of Neuroblastoma and Burkitt's Tumour HILARY GRANT and R. J. V. PULVERTAFT From the Departments of Paediatrics and of Pathology, University College Hospital, Ibadan, Western Nigeria Case Report In Nigeria, as in most of tropical Africa, it is often S.A., a l-2-year-old Yoruba girl, was brought to impossible to determine the nature of a tumour University College Hospital Ibadan on April 15, 1965. involving the facial bones of a child, by clinical or Her mother had noticed a swelling of the left side of the radiological examination. The histology of a face, which had been gradually enlarging for 3 months. growing neuroblastoma has often been Feeding had become difficult, and there had been some rapidly loss of weight. confused with other types of undifferentiated round She was a pale thin child weighing 16 lb. (7 25 kg.) cell malignant tumour, including retinoblastoma with a very large hard swelling ofthe left maxilla (Fig. la). and Burkitt's tumour (African childhood lympho- The teeth had been loosened and displaced by tumour ma). This case of neuroblastoma is described as an tissue, and the alveolar margin, which had an ulcerated instance in which tissue culture provided an accurate bleeding surface, was protruding through the mouth. A diagnosis quickly, with minimal disturbance to the firm mass with an indefinite border was felt in the left copyright. patient. hypochondrium. Received August 5, 1965. http://adc.bmj.com/ on September 25, 2021 by guest. Protected (a) (b) FIG. 1.-(a) Tumour of maxilla, neuro- (b) Tumour of maxilla, Burkitt's tumour, blastoma, secondary deposit. primary growth. 193 Arch Dis Child: first published as 10.1136/adc.41.216.193 on 1 April 1966. Downloaded from 194 Grant and Pulvertaft The tumour of the maxilla was indistinguishable on though the history of early cases clearly discloses clinical examination from a typical Burkitt's tumour their true nature. (Fig. lb) which is by far the most common type of In Nigeria malignant tumours affecting the bones malignant tumour seen in children in Ibadan, accounting of the face include two, the neuroblastoma and for 70% of all malignant disease in children under the age of 14 years (Edington and Maclean, 1964). The age retinoblastoma, which are well recognized in Europe, of the patient caused doubt about this diagnosis, as no and one, the Burkitt tumour, which is common in proved case of Burkitt's tumour has yet been seen in children in Nigeria and certainly most unusual in Ibadan in a child under 3 years, though three 2-year-old Europe. All three tumours are composed of darkly- children were included by Burkitt (1958) in his original staining cells with spherical nuclei, about 15 ,u to series from Kampala. 20 p in diameter, and experience shows that sections of these tumours embedded in paraffin Investigations. Haemoglobin genotype AA. Blood and stained with haematoxylin and eosin are group B rhesus positive; haemoglobin 8-2 g./100 ml. frequently confused with each other. While both (570%);PCV 25%;MCHC 33%o. WBC 8,600 per c.mm.; the retinoblastoma and the neuroblastoma may show neutrophils 72%, eosinophils 15%, lymphocytes 13%. Bone-marrow was megaloblastic with giant metamyelo- rosettes, these are never found in Burkitt's tumour, cytes; no tumour cells seen. and the rosette, when present, is a diagnostic feature Radiographs of the facial bones showed considerable of conclusive import. It is emphasized, however, destruction of the left maxillary region with dental that even in retinoblastomas and neuroblastomas, displacement and a large soft tissue tumour. This rosettes are only rarely found, and then only in slow- appearance was unhelpful in the differential diagnosis. ly growing tumours. A Burkitt's tumour involving the jaw may show typical Tissue culture as a diagnostic measure was first radiological signs, including early loss of the lamina dura carried out by Murray and Stout (1947) on 8 cases (Cockshott, 1964), but, as other neoplastic and inflam- matory conditions can sometimes produce the same including 2 adults in whom differential diagnosis appearance, a diagnosis cannot be made on this evidence was disputable. They were made in lying drops, alone. An intravenous pyelogram showed the left and, since phase contrast was not then in routine use, kidney displaced downwards by a large suprarenal mass. the excellent illustrations are mainly of material copyright. This strongly suggested the diagnosis of neuroblastoma stained by Bodian's method. Within 24 hours but did not exclude a Burkitt's tumour. The absence of neurites were produced, and the value of tissue tumour deposits visible on chest radiograph, and the culture in distinguishing this tumour from lympho- presence of an osteolytic lesion in the left femoral neck sarcoma and Ewing's tumour is stressed. By a would be consistent with the diagnosis of either neuro- coincidence, a paper by Lichtensten and Jaffe on blastoma or Burkitt's tumour. The diagnosis of neuroblastoma was established with Ewing's sarcoma appears in the same volume, and certainly supports the view that histology alone is certainty by tissue culture, as described below, within http://adc.bmj.com/ 24 hours of the patient being seen. A very small not decisive in the classification of tumours consist- quantity of tumour tissue is required for this technique, ing of spherical cells with a diameter of from 12 ,. and this was easily obtained from the maxillary tumour to 20 ,u. In this connexion it is noteworthy that with an ordinary syringe and needle, without any special no case of Ewing's sarcoma has been diagnosed in preparation of the patient. Nigeria (G. M. Edington, 1965, personal communi- Although the prognosis is known to be very poor when cation). Long-term culture, from 7 days to over a neuroblastoma is diagnosed after the age of 1 year, and has been recorded by Goldstein, Burdman, when bone metastases are present (Gross, Farber, and year, Martin, 1959), it was decided to attempt treatment with and Journey (1964) with evidence in many cases of on September 25, 2021 by guest. Protected cytotoxic drugs in addition to large doses ofvitamin B12. maturation and transformation into ganglion cells. Cyclophosphamide produced a rapid effect on the The method used by them was explantation in fluid tumour cells as shown by the second tissue culture 40 media or in thick plasma clot under perforated hours after treatment was started, but the clinical response 'cellophane'; the fluid phase was 40% calf or human was disappointing. There was no decrease in the size of serum in 199 or modified Eagle's medium. The the tumour and the child's condition was deteriorating. illustrations are very convincing, but the 'cellophane' Intravenous vincristine, started on May 12, 1965, seemed layer somewhat interferes with critical optics. to produce a more favourable response. The child is and in Ibadan one ofus (R.J.V.P.) still alive, with the abdominal and maxillary tumours Both in London decreasing in size, two months later. has made a routine practice of examining material, suspected as being of neuroblastomatous origin, by some form of short-term tissue culture. Since, in Tissue Culture most cases material comes from bone-marrow, it has According to Willis (1953), early in this century usually been examined on agar in roller slides neuroblastomas were regarded as lymphosarcomas, (Pulvertaft, 1965). Under these conditions neuro- Arch Dis Child: first published as 10.1136/adc.41.216.193 on 1 April 1966. Downloaded from Differential Diagnosis of Neuroblastoma and Burkitt's Tumour 195 blastoma cells are very characteristic, but difficult to both filamentous mitochondria and granules moved photograph as they show very little phase contrast. up the filament, but it was never possible to be They appear as chains or sheets of bright cells and certain that true continuity had been established. mitose freely. Fibril formation is not convincing However, the appearances are contrasted with what on agar; many cells, such as fibroblasts, may show is observed when two processes from adjacent single non-branching fibrils over 100 ,u long. fibroblasts make contact. In this case it seems clear Therefore, while on agar a diagnosis of a secondary that each cell remains as a functional and structural malignant deposit can be made, it is less easy to be unit and organoids from one never enter the other. certain of its category. Only when a syncitium is formed, e.g. by giant cell Cellophane is not necessary for culture on glass, formation in the presence of measles virus, has true nor is a fibrin clot, as the cells adhere almost cytoplasmic fusion been observed by one of us immediately and very firmly. Fibril formation, (R.J.V.P.). however, while freely developing on collagen, may When a cell entered mitosis, one daughter cell not occur on glass (Pulvertaft, 1965). remained in fibrillar contact with others and the In this case, remarkably free fibril development second extruded a fibril which soon made contact. was found on glass. The cytoplasm contained very characteristic organoids (Fig. 3a). These were concentrated on Techniques. The material was received in a one side only of the nucleus, and the group nearest 10 ml. syringe on two occasions. About 2 ml. of the nucleus was poorly contrasted and appeared heavilyblood-stained semi-solid substance was avail- brown by phase. The peripheral groups were able; under the microscope it was seen to consist highly contrasted and appeared black. almost entirely of coherent cells of uniform appear- The cultures were readily fixed and stained by ance and Burkitt's tumour was immediately Wigglesworth's osmic acid ethyl gallate technique, excluded.