Pediatric Hematology Oncology Journal 1 (2016) 96e98
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Pediatric Hematology Oncology Journal
journal homepage: https://www.elsevier.com/journals/pediatric-
hematology-oncology-journal/
Subcutaneous metastasis secondary to surgical tract seeding in a child
with medulloblastoma - A case report
S. Ranjani*, I. Mehdi, C. Sreenath, R. Palassery
Department of Pediatric Hematology, Oncology and BMT, Health Care Global, Bengaluru, Karnataka, India
a r t i c l e i n f o
Article history:
Received 29 January 2017
Received in revised form
31 March 2017
Accepted 13 April 2017
Available online 19 April 2017
1. Introduction
Medulloblastoma is the most common CNS malignancy in
childhood. Drop metastases to the spine are the most common type
of metastasis in medulloblastoma. ENM are rare and seen in about
7e10% of patients with medulloblastoma [1]. The most common
site of ENM in medulloblastoma is the bone and bone marrow.
Subcutaneous metastasis is rarely described in medulloblastoma.
Tumor seeding during surgery for the primary tumor has been
postulated as one of the mechanism of ENM.
2. Material and methods
Here we describe a child with Medulloblastoma who developed
subcutaneous metastasis nine months after the initial surgery for
the primary tumor.
3. Results
A nine year old boy presented with vomiting for 1 month. He
was evaluated with neuroimaging (CT and MRI brain) which
showed a posterior fossa mass with obstructive hydrocephalus,
suggestive of medulloblastoma. He underwent gross total excision
of the mass. Histopathology and immunohistochemistry were
suggestive of Medulloblastoma grade IV (WHO). MRI brain one
* Corresponding author.
E-mail addresses: dr.shashiranjani@gmail.com (S. Ranjani), intezarmehdi@
gmail.com (I. Mehdi).
Peer review under responsibility of Pediatric Hematology Oncology Chapter of
Indian Academy of Pediatrics.
http://dx.doi.org/10.1016/j.phoj.2017.04.001
2468-1245/© 2017 Production and hosting by Elsevier B.V. on behalf of Pediatric Hematology Oncology Chapter of Indian Academy of Pediatrics. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
month after the surgery showed lesion in the post-operative bed
with drop lesion at T1 level. He was treated with cranio-spinal
radiation and concurrent chemotherapy as per PACKER regimen
(CCNU (lomustine), Vincristine and Cisplatin). He developed an
external subcutaneous swelling at the occipital region during 6th
cycle of chemotherapy. MRI brain showed complete resolution of
the brain and spinal cord lesion with an enhancing lesion along the
posterior margin of the surgical site. He underwent near total
excision of the cutaneous swelling. Histopathology was suggestive
of Medulloblastoma grade IV. Two months after the surgery for the
subcutaneous mass he again developed a swelling at the operated
site associated with new onset cervical lymphadenopathy. FDG
PET-CT scan showed a metabolically active mass lesion in the oc-
cipital scalp infiltrating the erector spinae muscles. It also showed
bilateral cervical lymphadenopathy suggestive of lymph node
spread. The option of treatment with high dose chemotherapy and
autologous stem cell rescue vs. metronomic chemotherapy were
discussed. Considering the aggressive and progressive nature of the
disease, he was started on metronomic chemotherapy with oral
Cyclophosphamide and Etoposide. While on metronomic chemo-
therapy, there was minimal reduction in the size of the subcu-
taneous swelling. He developed headache and vomiting along with
serous discharge from the occipital mass, swelling of face and right
lower motor neuron facial palsy. Progressive increase in the size of
the mass along with development of nodular lesions in bilateral
retro auricular and submandibular regions was noted. CT brain
revealed subcutaneous soft tissue nodularity and progression of the
lymph nodes causing compression of bilateral proximal internal
jugular veins. He was treated with antibiotics and steroids. He
succumbed to the disease 4 months after starting metronomic
chemotherapy.
4. Discussion
ENM is a rare phenomenon in cranial tumors. ENM have been
observed post-surgery with probable implantation during surgical
procedures [2]. ENM is also seen with the presence of shunts which
may lead to tumor seeding [3,4]. Other mechanisms involved in
ENM are local lymphatic extension to the extra cranial tissues of the
head and neck [3]. Lymph nodes may be involved secondary to the
subcutaneous tissue involvement or tumor continuity along nerve
 S. Ranjani et al. / Pediatric Hematology Oncology Journal 1 (2016) 96e98
Fig. 1.
roots may lead to invasion of lymphatics and the lymph node [3].
According to Liwnicz and Rubinstein medulloblastomas are the
most common tumors to have ENM [2]. The first case of ENM in
medulloblastoma was described by Nelson [5].
In a report by Slavomir et al., the incidence of ENM ranged be-
tween 5 and 10% [6]. Rochkind et al. reviewed 30 cases of medul-
loblastoma with ENM and reported the incidence of ENM at 7e10%.
ENM to the muscle was reported at 2% [2,3]. Mazloom A et al.
reviewed 119 cases of ENM in medulloblastoma from 1961 to 2007
and reported metastasis to the bone in 84% of patients, bone
marrow in 27%, lymph nodes in 15%, lung in 6% and liver in 6% of
patients. Only 14 cases were reported to have ENM to other sites
which included pancreas, retro peritoneum, pleura, para nasal si-
nuses, skin, oral cavity, and connective tissue [1].
ENM has also been described in gliomas, meningiomas and
medulloblastomas [2]. Woo et al. and Mahoer et al. described
subcutaneous metastases in adults with meningioma after surgery
for the primary tumor [7,8]. Similarly Avecillas et al. reviewed four
patients with scalp metastasis from recurrent meningiomas and
found that in all cases metastasis was located close to the scalp
incision. Scalp metastases were associated with reoperations,
immunosuppression, radiation therapy and torpid course of the
surgical wound [9]. Extra cranial metastasis in glioblastoma mul-
tiforme has been described by Forsynth et al. They reported that the
proximity of the lesions to the previous surgical sites suggest iat-
rogenic seeding and metastasis [10]. Buis et al. reported a case of
subcutaneous tumor seeding after biopsy in gliomatosis cerebri
[11].
Rare isolated case reports of ENM following surgery have been
described in anaplastic ependymoma and anaplastic oligoden-
droglioma by Yamada M et al. and McLemore MS respectively
[12,13]. Post-surgical tumor seeding can lead to intracranial re-
currences also. Schmalisch K et al. have reported three cases of
intracranial ectopic seeding along the surgical tract in craniophar-
yngioma. They concluded that although craniopharyngiomas
exhibit a benign histopathological pattern, seeding along the
97
Fig. 2.
surgical route lead to tumor recurrences [14].
In a study by Pasquier et al., they reported that 96% of patients
with ENM had undergone craniotomy [6]. It is postulated that ENM
can be secondary to disruption of the blood vessels during surgery
or seeding on the incision. To prevent ENM during surgery, the
surrounding tissue must be protected, surgical field must be kept
clean and the dura repaired to ensure a tumor free concept [15].
Dianzhong et al. suggested that if signs of metastasis are observed
radiation should be instituted promptly and close attention should
be paid to the surgical incision to avoid cold spot [15].
The interval between the excision of the primary tumor and
development of metastasis was 9 months in our case which is lesser
than that reported by Rochkind et al. They observed a mean
duration of 20 months between the surgery and development of
metastasis [3].
Chemotherapy and radiotherapy have been proposed as a
treatment option in children with ENM. According to Tanmoy et al.
radiotherapy to the ENM was beneficial in children without CNS
relapse [2]. In our study the child succumbed to the disease 7
months after the development of metastasis. The mean survival
reported by Rochkind et al. is 5 months after the development of
metastasis [3].
5. Conclusions
Extra neural metastasis to the subcutaneous tissue is a rare
phenomenon in Medulloblastoma. Previous shunt procedure and
surgery is associated with increase in ENM. Recent reports suggest
that high dose chemotherapy with stem cell recuse may be tried in
ENM of medulloblastoma. Here we hypothesize that the subcu-
taneous metastasis occurred from the surgical tract seeding with
secondary regional lymph node involvement. This report highlights
98 S. Ranjani et al. / Pediatric Hematology Oncology Journal 1 (2016) 96e98
a previously underappreciated surgical complication and suggests
that meticulous protection of the surgical field and careful handling
of the tumor during the operation is required (See Fig. 1 and Fig. 2).
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