primary cerebral rhabdomyosarcoma and problemof … · p. w.leedham millilitres ofopalescentfluid...

Journal of Neurology, Neurosurgery, and Psychiatry, 1972, 35, 551-559

Primary cerebral rhabdomyosarcoma and theproblem of medullomyoblastoma

P. W. LEEDHAM

From the Department of Morbid Anatomy, The London Hospital, London

SUMMARY A case of primary rhabdomyosarcoma in the right cerebral hemisphere of a 45 year oldwoman is reported. This was treated by surgical excision but death occurred 10 months after thefirst symptom. The histogenesis of such a tumour is discussed. The clinical and pathological featuresof 15 previously reported similar tumours of the CNS are compared. Most of these occurred in thecerebellum in children where they have been regarded as medullomyoblastomas (a variant ofmedullo-blastoma), teratomas, or rhabdomyosarcomas. Few have been recorded in adults and only onepreviously in the cerebrum. All of these tumours tend to have a short clinical course, althoughsurvival time seems to be significantly improved by surgical excision followed by radiotherapy. Theremarkable morphological similarities between the tumours are discussed. Argyrophilic fibrils weredemonstrated in the present case and in an unrelated rhabdomyosarcoma of the jaw. This observationmay invalidate the main criterion used for separating medullomyoblastomas and teratomas fromrhabdomyosarcomas in this group of tumours. It is concluded that at present all these tumoursshould be regarded as rhabdomyosarcomas.

Tumours of the central nervous system (CNS)containing striated muscle elements are rare,especially when teratomas are excluded. A caseof primary rhabdomyosarcoma of the cerebrumis reported here. A comparison with othersimilar tumours which have occurred in the CNSleads to a reappraisal of the concept of medullo-myoblastoma.

CASE REPORT

In July 1969, E.P., a 45 year old housewife (LH No.504560) developed transitory involuntary jerkingmovements of the left foot. Three weeks latersimilar attacks occurred on successive days lasting5 to 10 minutes on each occasion. The left shoulderwas also affected and examination after the attacksshowed moderate residual weakness of the left armand leg. She became drowsy and developed a denseleft hemiplegia with some loss ofjoint position senseon the left, bilateral ptosis, and impairment ofconjugate deviation of the eyes to the left. Anelectroencephalogram indicated a space occupyinglesion in the right cerebral hemisphere, and a carotidangiogram showed an avascular lesion in the rightparietal zone with 1-5 cm shift of the midline vesselsto the left and evidence of early tentorial herniation.

At craniotomy a small intracerebral haematoma wasdiscovered in the right posterior frontal region, andthis was evacuated. Biopsy of the wall of the cavityshowed only gliosis. Her level of consciousness, butnot the hemiplegia, improved at first, but over thenext two weeks deteriorated to the previous level.Re-exploration showed a cerebral abscess at the siteof the previous haematoma but this was sterile onculture. After this there was a further temporaryimprovement but a few days later she was againdeeply unconscious and had a left homonymoushemianopia. At the beginning of September thecraniotomy was reopened and the cavity decom-pressed but there were no new findings and her con-dition did not improve. Three weeks later a multi-locular abscess in the right cerebral hemisphere wasexcised in toto. Histological examination showedareas of undifferentiated malignant tumour of un-certain origin in the wall of the abscess. Over thenext five months there was a gradual improvement inher condition and she was able to walk with the aid ofa tripod. The left arm remained weak and the visualfield defect was unchanged. During March 1970 shebecame drowsy and complained of headache. Therewas a precipitous deterioration in her level ofconsciousness, with raised intracranial pressure andbilateral pyramidal signs. One hundred and fifty

i51

Protected by copyright.

on May 22, 2021 by guest.

http://jnnp.bmj.com

/J N

eurol Neurosurg P

sychiatry: first published as 10.1136/jnnp.35.4.551 on 1 August 1972. D

ownloaded from

http://jnnp.bmj.com/

P. W. Leedham

millilitres of opalescent fluid were aspirated from thecraniotomy site but she became deeply unconsciousand remained so until she died towards the end ofApril 1970, 10 months after the onset of her illness.

PATHOLOGY

SURGICAL MATERIAL (SD/6558/69) The materialreceived after total excision of the abscess consisted

bone. The brain (1,107 g) was soft with flattening ofthe cerebral convolutions on the left and bilateraluncal grooving. Mottled haemorrhagic tumour wasvisible through a 5 0 cm diameter defect in the rightparietal cortex and in this region the left hemispherebulged across the midline. The brain was fixed in 400formol-saline for three weeks and then sliced. Theslices showed a large tumour, up to 5 5 cm in

44~~~~~~~~~~~~4

A*mm..

*' 4. \ ^ s * * .

* 'I sz k.........

:; ' ~ '.,. jiX*. sss . ...Af :.

of a ragged roughly spherical mass of soft braintissue 7 0 cm in diameter, weighing 176 g. It con-tained multilocular abscess cavities up to 4 5 cm indiameter. Parts of the wall were thick and fibrousbut other areas adjoined brain tissue withoutfibrous demarcation. Microscopy showed large areasof necrosis and granulation tissue with surroundinggliosis but areas of undifferentiated pleomorphictumour of uncertain origin were also present (Fig. 1).Review of these sections after the necropsy materialwas available revealed some strap-like cells withcross-striations within the areas of granulationtissue.

NECROPSY (No. 85/70) Necropsy was performed40 hours after death. The body weighed 30A4 kg andwas 162 cm long. There was a large surgical scar inthe scalp of the right frontoparietal region deep towhich there was an oval defect in the calvarium,9-5 x 8-5 cm. The right cerebral cortex was adherentto the scalp in this area and was dissected free withdifficulty. A plastic reservoir drained the left lateralventricle through a small trephine in the left parietal

FIG. 1. Surgical materialshowing a pleomorphic cellulartumour with occasionalmitoses. Capillary bloodvessels are seen within thetumour. Haeinatoxylin andeosin, x 350.

maximum diameter, which occupied and distortedthe middle third of the right cerebral hemisphere(Fig. 2). It extended from the level of the opticchiasm to the posterior parietal region where itoccupied the body of the lateral ventricle. Supero-laterally it bulged through the cortical defect whereit was partly covered by fresh blood clot, and partlyby gliotic capsule. The cut surface showed some firmwhite areas and other multilocular cystic areaswhich contained green/grey gelatinous material(Fig. 2). There was considerable disorganization ofthe ventricular system by the tumour on the rightside and some dilatation on the left. Both frontallobes were oedematous. The brain-stem, cerebellum,spinal cord, and cerebral vessels were normal.There was a well-developed bilateral broncho-

pneumonia in the lower lobes of both lungs. Theremaining organs were normal and there was noevidence of tumour elsewhere.

MICROScOPY The gelatinous and cystic areas of thetumour (Fig. 2) were composed of amorphouseosinophilic and necrotic material with some areas

552P

rotected by copyright. on M

ay 22, 2021 by guest.http://jnnp.bm

j.com/

J Neurol N

eurosurg Psychiatry: first published as 10.1136/jnnp.35.4.551 on 1 A

ugust 1972. Dow

nloaded from


Primary cerebral rhabdomyosarcoma and the problem of medullomyoblastoma

FIG. 2. Right cerebral tumour at necropsy. Itdistorts the ventricular system below and is partlycovered by gliotic capsule and blood clot above whereit penetrates the cortical surface. The cut surfaceshows pale solid areas and darker cystic areas.

I. ' ? '~I

.,e.. ..

:-, ..t*t-^ a

4frt

BPC"I

FIG. 3. Necropsy material showingstrap-like spindle cells of varying sizeand a large ovoid-cell with abundantgranular cytoplasm. H and E, x 350.

553

W . rZ. a*.w



http://jnnp.bmj.com

/J N

eurol Neurosurg P


ownloaded from


P. W. Leedham

*.0'

A.....:::.

..V S~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~....

FIG. 4. Cross-striations in a strap-cell at necropsy. Phosphotungstic acid haematoxylin, x 1400.

4*.:: :.

A-

*z ta,#:#FIG. 5. Small cell areas whichresemble those seen in thesurgical material. Transitionalspindle cellforms are present.Hand E, x 350

II

::.. ,AI

.4i.:..# *...,

.ev .....w* .

....IOC'."

'4'I.

1:

rt :t .:.'I..Z ..4:

iWA

i.

'*, C.t& t;

; 4¢f + VI

554P



j.com/

J Neurol N


ugust 1972. Dow

nloaded from


Primary cerebral rhabdomyosarcoma and the problem of medullomyoblastoma

of granulation tissue. A malignant tumour ofvariable histological pattern was present in the firmwhite areas (Fig. 2) and in other areas bordering onadjacent brain tissue. In some places it had widelydispersed stellate cells with few mitoses within aloose connective tissue stroma; the appearancesresembled embryonic mesenchyme. In other areasthere were interlacing bundles of spindle cells, manyof which were strap-like with granular eosinophiliccytoplasm (Fig. 3). Some giant, oval, or round cellswith similar abundant cytoplasm were also present

(Fig. 3). Cross-striations were occasionally seen inthe strap forms on haematoxylin and eosin sectionsand were numerous in sections stained with phospho-tungstic acid haematoxylin (Fig. 4). Areas of un-differentiated cells which resembled those seen in thesurgical material were present particularly at thegrowing edge (Fig. 5). They contained clusters ofsmall cells with a moderate number of mitosesmixed with larger cells which showed occasionalgiant and multinucleate forms. Early transitions tospindle cell forms were clearly seen (Fig. 5) and thin-

FIG. 6. Frozen section of, necropsy material from the

present case. Argyrophilicfibrils radiate from cells of

E all kinds. Weil-Davenport,x 560.

FIG. 7. Frozen section ofnecropsy materialfrom anunrelated rhabdomyosarcomaof the jaw. There are occas-ional short argyrophilicfibrils arising from tumourcells. Weil-Davenport, x 560.

555P



j.com/

J Neurol N


ugust 1972. Dow

nloaded from


P. W. Leedham

walled vascular channels were present in the looseconnective tissue background. Nervous tissue wasnot present within the tumour substance and noother ectodermal or endodermal derivatives wereseen.

Frozen sections of formalin fixed tumour tissue,taken to include all the areas mentioned, werestained by the silver techniques of Weil-Davenport,Bielschowsky, and Scharenberg. Control sectionswere performed on normal brain tissue. By eachmethod numerous argyrophilic fibrils of varyingsize were demonstrated radiating from cells of allkinds (Fig. 6). In view of this apparently non-specific argyrophilia, tissue from an undifferentiatedembryonal rhabdomyosarcoma of the jaw in a 22year old man was stained in a similar fashion. Againa few argyrophilic fibrils were seen despite theanaplastic nature of the tumour (Fig. 7). Electronmicroscopy was attempted on the tumour tissue butthe electronmicrographs were of poor quality due tothe inappropriate fixation in formol-saline. How-ever, fragmented and disorganized myofibrils com-posed of filaments with the appearance of actin andmyosin were seen in the cytoplasm of both the strap-like cells and the small undifferentiated cells.

Sections from the lung confirmed the presence ofmoderate bilateral bronchopneumonia. No signifi-cant abnormality was seen in the other tissues of thebody and there was no evidence of tumour depositselsewhere.

DISCUSSION

The necropsy confirmed the presence of aprimary tumour of the right cerebral hemispherewith no tumour deposits elsewhere. In view ofthe light and electron microscope appearances adiagnosis of rhabdomyosarcoma seemed mostlikely and the absence of derivatives from otherembryonic germ layers helped confirm this. Inthe biopsy material the diagnosis was obscuredby a severe inflammatory reaction and pre-dominance of the undifferentiated component ofthe tumour. The symptoms and signs corre-sponded with the site of the tumour at necropsybut the clinical course was unusual. The initialevent was probably haemorrhage within thetumour from thin-walled vascular channels, andan abscess formed after the blood clot wasevacuated.Rhabdomyosarcomas are rare tumours out-

side of the central nervous system and fall intotwo distinct but related groups (Evans, 1966;Stout and Lattes, 1967). In adults they occur

mainly in the soft tissues of the trunk andextremities; they are often pleomorphic withlittle evidence of cross-striated cells, althoughmore differentiated forms have been recorded(Evans, 1966). In children and adolescents thehead and neck and urogenital tract are the mainsites of origin. In these tumours more differentia-tion may occur and cells with cross-striations aremore frequently seen. The fact that manyrhabdomyosarcomas arise in tissues that do notnormally contain striated muscle has led someauthorities to believe that these tumours derivedirectly from unstable mesenchyme whichundergoes neoplastic change (Evans, 1966;Willis, 1967). A similar origin from mesenchymewould also adequately explain the presence ofsuch a tumour in the central nervous system.The alternative is that the present tumour isrelated to the mixed mesenchymal and neuro-epithelial tumours which have recently beendescribed (Goldman, 1969; Shuangshoti andNetsky, 1971). These tumours differ from thepresent case in that they contain a combinedglioma and sarcoma in which varying degrees ofdifferentiation into fibroblastic, chondroblastic,and rhabdomyoblastic elements have occurred.They are probably related to gliosarcoma(Rubinstein, 1956). An overgrowth of a rhabdo-myoblastic element in such a tumour couldmimic a rhabdomyosarcoma. However, deriva-tion from unstable mesenchyme would seem amore likely explanation.

Only one previous case of a cerebral rhabdo-myosarcoma has been found (Koide, 1957) andthis is poorly documented. There are, however,15 reports of primary tumours of the CNSwhich might also be regarded as rhabdomyo-sarcomas. The clinical and pathological detailsof these are summarized in the Table togetherwith the present case.The first 11 listed are similar to each other

(Table). They are all cerebellar tumours whichhave occurred in children aged 2 to 11 years andall are known to have been in the midline. Thesex ratio is 4F:7M. The clinical histories are ofvariable length (two weeks to nine months). Inmany cases death occurred before or soon aftersurgery but in three cases (3, 4, and 8) surgicalexcision followed by radiotherapy gave a signifi-cant improvement in survival time (12 to 23months). Distant metastases have not occurred

556P



j.com/

J Neurol N


ugust 1972. Dow

nloaded from


557Primary cerebral rhabdomyosarcoma and the problem of medullomyoblastoma

TABLE

DETAILS OF POSSIBLE RHABDOMYOSARCOMAS OF CNS

No. Source Sex Age Diag- Site Microscopic Other Length Treatment Survival(yr) nosis features necropsy of time

findings history (months)(months)

F 5 MM Vermis

M 21 MM Vermis

M 5 MM Vermis

4 Ingraham and M 101 T MidlineBailey (1946) cerebellum(case 4)

5 Bofin and Ebels M 6 MM Vermis and(1963) right cere-

bellum

6 Boellaard (1964) M 8 MM Vermis

7 Gullotta (1967)(case 11)

8 Legier and Wells(1967)

9 Shuangshoti et al.(1968)

10 Unpublished case ofR. S. Beckettqiuoted in 9

11 Misugi and Liss(1970)

12 O'Connell (1946)(case 1)

13 Lopes de Faria(1957)

14 Koide (1957)

15 Galatioto andGaddoni (1971)

(case 1)16 Present case

F 31 MM Vermis

M 3j RS Vermis

F 4 RS Vermis

F 9 RS Midlinecerebellum

Small cell areas; cross-

striated cells nearvessels

Small cell areas; cross-

striated spindle cells

Medulloblast-likecells; smoothmuscle-like cells nearvessels

Small cells with neuro-

fibrils; large cellswith cross-striations

Cellular areas resem-bling medulloblasts;cross-striated spindlecells

Cellular areas resem-

bling neuroblasts;cross-striated spindlecells

Small cell areas; cross-striated spindle cells

Stellate mesenchyme;spindle cells withcross-striations. Noneuroblastic forms

Small cells, pleo-morphic cells,spindle cells withcross-striations. Noneuroblastic forms

Similar to case 9

MI 7j T Midline Small cell areas withcerebellum neuroblastic forms;

cross-striated spindlecells

F 5 T Lumbar cord Spindle cells with cross-striations

F 52 RS Left cerebellar Stellate mesenchyme;hemisphere spindle cells with

cross-striations. Noneuroblastic forms

M 15 RS Right cerebral Pleomorphic cells;hemisphere small cells, cross-

striated spindle cells.No neuroblasticforms

F 26 MY Left cerebellar Small cell areas;hemisphere spindle-cell areas.

No striations seen

F 45 RS Right cerebral Cellular pleomorphichemisphere areas; bundles of

cells with cross-striations; stellatemesenchyme

No tumourelsewhere

Brain onlyexamined

No necropsy

3 None 3

- Decompression 4/28

123 Excision.DXT

No necropsy - Excision. 12DXT

No tumourelsewhere

Lepto-meningesinfiltrated.Brain onlyexamined

No generalnecropsy

Extensivelepto-meningealspread incord

Lepto-meningesof brainbase in-filtrated

8 Partial excision v. short

Short None

9 Exploration

Short Excision.DXT

2/52 None

No necropsy Short Decompression

Spread inspinal cordassociatedwith spinabifida

No tumourelsewhere

No tumourelsewhere

No generalnecropsy

No tumourelsewhere

6 Exploration

5 None

v. short

v. short

23

13/28

3/28

v. short

4 Decompression 2DXT

Short Exploration v. short

6/52 Excision 10

MM = medullomyoblastoma; T= teratoma; RS = rhabdomyosarcoma; MY = myosarcoma. DXT = radiotherapy.

I Marinesco andGoldstein (1933)

2 Russell andRubinstein (1971)(case from 1934)

3 Zuilch (1942)



http://jnnp.bmj.com

/J N

eurol Neurosurg P


ownloaded from


P. W. Leedham

but cases 6, 8, and 9 showed infiltration of theleptomeninges. The microscopic appearances ofindividual tumours are strikingly similar withdescriptions of cellular small cell areas, and lesscellular spindle cell areas mentioned in manyreports. Spindle cells with cross-striations aredescribed in every case except that of Zulch(1941) who did not demonstrate stripes andregarded these as smooth muscle cells (case 3).However, his case resembles the others in allother respects and must be included in thisgroup of tumours. Misugi and Liss (1970)claimed to have demonstrated axon-like struc-tures in the electronmicrographs of their tumour(case 11) but their illustrations are not con-vincing and they also described glial fibres whichmay indicate an admixture of normal neuraltissue within their tumour.

Six of the tumours in this group (cases 1, 2,3, 5, 6, and 7) were called medullomyoblastomasmainly because neurofibrils were demonstratedwithin the small cell areas. Other authors (cases4 and 11) felt that this finding indicated ateratomatous origin. These tumours with appar-ent neuroblastomatous elements have usuallybeen regarded as variants of medulloblastoma,but recently Russell and Rubinstein (1971) havepreferred to call them malignant teratoidtumours. Neural elements were not demon-strated in the remainder (cases 8, 9, and 10).Even so these pure rhabdomyosarcomas havebeen related to medullomyoblastomas by mostauthors, although it has been suggested thatthey represent rhabdomyoblastic differentiationin an embryonal sarcoma (Russell and Rubin-stein, 1971). However, because of the manysimilarities described above it would seem thatthe first 11 cases listed (Table) belong to thesame group of tumours.The tumour described by O'Connell (1946)

occurred in the lumbar cord in a 5 year old girland was associated with spina bifida (case 12).This was probably a rhabdomyosarcoma arisingin a hamartoma associated with the congenitaldefect. The remaining tumours (cases 13, 14, 15,and 16, present case) occurred in the cerebrumor cerebellum of adults and had a rapid clinicalcourse. The microscopic appearances are verysimilar. Galatioto and Gaddoni (1971) failed todemonstrate cross-striations (case 15), but

examination of illustrations and paraffin sectionsof their case shows close similarities in all otherrespects. Clearly it would seem reasonable toclassify these tumours together and examinetheir relationship to the childhood group.Although the adult and childhood tumours

occur in different sites, they do not vary inbehaviour or morphology. In both groups theclinical course is short and stormy and a com-parison of the histological appearances revealsremarkable similarities. Cellular areas composedof small round or oval cells with some pleo-morphism are described in both groups as areless cellular areas of spindle cells. Foci of primi-tive mesenchyme and cells with cross-striationsare also a common feature. It has been possibleto examine sections from the childhood tumourdescribed by Russell and Rubinstein (1971) atthis hospital (case 2) and the cellular areas ofthat tumour are indistinguishable from similarcellular areas in the present case. In additionthere are cells present which are transitionalbetween the spindle and round cell elements asin the present case. On morphological grounds,therefore, there is a strong case for includingboth childhood and adult tumours in the samegroup.The demonstration of neurofibrils by silver

impregnation techniques has been used todistinguish a neuroectodermal element in thosetumours of the childhood groups called medullo-myoblastoma or teratoma. Argyrophilic pro-cesses have been demonstrated in the presentcase and also in material from a primary rhabdo-myosarcoma of the jaw. The reaction in thistype of tumour may therefore be non-specific, afinding which invalidates the main criterion fordistinguishing a neuroblastomatous element.

It is concluded, therefore, that on presentevidence it would be best to regard all thesetumours as rhabdomyosarcomas.

I wish to thank Mr. T. King for allowing me tostudy one of his cases and I am grateful to ProfessorH. Urich for his encouragement, and criticism of themanuscript. Mr. H. Oliver, Miss S. Robinson, andMr. R. Hammond are thanked for technical,secretarial, and photographic assistance. The workwas in part supported by the Cancer ResearchCampaign.

558P



j.com/

J Neurol N


ugust 1972. Dow

nloaded from


Primnary cerebral rhabdomyosarcoma and the problem of medullomyoblastoma

REFERENCES

Boellaard, J. W. (1964). Ein Medulloblastom mit querge-streiften Muskelfasern. Archiv fiur Psychiatrie und Nerven-krankheiten, vereinigt mit Zeitschrift fuir die gesamteNeurologie und Psychiatrie, 206, 228-236.

Bofin, P. J., and Ebels, E. (1963). A case of medullomyo-blastoma. Acta Neuropathologica, 2, 309-311.

Evans, R. W. (1966). Histological Appearances of Tutmours.2nd edition, p. 48-57. Livingstone: Edinburgh.

Goldman, R. L. (1969). Gliomyosarcoma of the cerebrum.American Journal of Clinical Pathology, 52, 741-744.

Galatioto, S., and Gaddoni, G. (1971). Miosarcomi primitividel SNC. Acta Neiurologica (Bari), 26, 297-302.

Gullotta, F. (1967). Das sogenannte Meduilloblastoma.Springer: Berlin.

Ingraham, F. D., and Bailey, 0. T. (1946). Cystic teratomasand teratoid tumors of the central nervous system ininfancy and childhood. Journal of Neurosurgery, 3, 511-532.

Koide, 0. (1957). A case of primary rhabdomyosarcoma ofthe brain [Japanese]. Gann, 48, 645-647.

Legier, J. F., and Wells, H. A., Jr. (1967). Primary cerebellarrhabdomyosarcoma. Case report. Journal of Neurosurgery,26, 436-438.

Lopes de Faria, J. (1957). Rhabdomyosarcoma of cerebellum.Archives ofPathology, 63, 234-238.

Marinesco, G., and Goldstein, M. (1933). Sur une formeanatomique, non encore decrite, de medulloblastome;medullo-myoblastome. Annales d'Anatomie Pathologique,10, 513-525.

Misugi, K., and Liss, L. (1970). Medulloblastoma withcross-striated muscle. A fine structural study. Cancer(Philad.), 25, 1279-1285.

O'Connell, J. E. A. (1946). The subarachnoid disseminationof spinal tumours. Journal of Neurology, Neurosurgery, andPsychiatry, 9, 55-62.

Rubinstein, L. J. (1956). The development of contiguoussarcomatous and gliomatous tissue in intracranial tumours.Joutrnal of Pathology and Bacteriology, 71, 441-459.

Russell, D. S., and Rubinstein, L. J. (1971). Pathology ofTumours of the Nervouts System, 3rd ed., p. 15. Arnold:London.

Shuangshoti, S., and Netsky, M. G. (1971). Neoplasms ofmixed mesenchymal and neuroepithelial origin. Journal ofNeutropathology and Experimental Neurology, 30, 290-309.

Shuangshoti, S., Piyaratn, P., and Viriyapanich, P. L. (1968).Primary rhabdomyosarcoma of cerebellum-necropsyreport. Cancer (Philad.), 22, 367-371.

Stout, A. P., and Lattes, R. (1967). Tumors of the soft tissues.In Atlas of TumorPathology, 2nd Series, Fascicle 1, p. 134-144. Armed Forces Institute of Pathology: Washington,D.C.

Willis, R. A. (1967). Pathology of Tumours. 4th edn., p. 757-771. Butterworths, London.

Zulch, K. J. (1941). Ein Medulloblastom mit glatten Muskel-fasern. Archiv fur Psychiatrie und Nervenkrankheiten,vereinigt mit Zeitschrift fur die gesamte Neurologie undPsychiatrie, 114, 349-352.

559P



j.com/

J Neurol N


ugust 1972. Dow

nloaded from


primary cerebral rhabdomyosarcoma and problemof … · p. w.leedham millilitres ofopalescentfluid...

Documents