Clinical, haematological, and radiological features of children presenting with lymphoblastic mediastinal masses

Pulmonary Manifestations of Hematologic and Oncologic Diseases in Children

Pulmonary complications are common in children with hematologic or oncologic diseases, and many experience long-term effects even after the primary disease has been cured. This article reviews pulmonary complications in children with cancer, after hematopoietic stem cell transplant, and caused by sickle cell disease and discusses their management.

Evaluation of Chest Radiographs of Children with Newly Diagnosed Acute Lymphoblastic Leukemia

OBJECTIVE

To evaluate the diagnostic yield of baseline chest radiographs (CXRs) of children with acute lymphoblastic leukemia (ALL).

STUDY DESIGN

We reviewed the CXR findings at diagnosis for 990 patients aged 1-18 years with ALL treated during the Total XV and XVI studies at St. Jude Children's Research Hospital and evaluated the associations of these findings with clinical characteristics and initial management.

RESULTS

Common findings were peribronchial/perihilar thickening (n = 187 [19.0%]), pulmonary opacity/infiltrate (n = 159 [16.1%]), pleural effusion/thickening (n = 109 [11.1%]), mediastinal mass (n = 107 [10.9%]), and cardiomegaly (n = 68 [6.9%]). Portable CXRs provided results comparable with those obtained with 2-view films. Forty of 107 patients with a mediastinal mass (37.4%) had tracheal deviation/compression. Mediastinal mass, pleural effusion/thickening, and tracheal deviation/compression were more often associated with T-cell ALL than with B-cell ALL (P < .001 for all). Pulmonary opacity/infiltrate was associated with younger age (P = .003) and was more common in T-cell ALL than in B-cell ALL (P = .001). Peribronchial/perihilar thickening was associated with younger age (P < .001) and with positive central nervous system disease (P = .012). Patients with cardiomegaly were younger (P = .031), more often black than white (P = .007), and more often categorized as low risk than standard/high risk (P = .017). Patients with a mediastinal mass, pleural effusion/thickening, tracheal deviation/compression, or pulmonary opacity/infiltrate were more likely to receive less invasive sedation and more intensive care unit admissions and respiratory support (P ≤ .001 for all). Cardiomegaly was associated with intensive care unit admission (P = .008). No patients died of cardiorespiratory events during the initial 7 days of management.

CONCLUSIONS

The CXR can detect various intrathoracic lesions and is helpful in planning initial management.

T-cell lymphoblastic lymphoma of the lower jaw in a young child: a case report

Among non-Hodgkin's lymphomas occurring in childhood two major histologic subgroups can be identified: (1) Burkitt's lymphoma and (2) T-cell lymphoblastic lymphoma, an uncommon high-grade malignant non-Hodgkin's lymphoma. Although Burkitt's lymphoma with maxillofacial involvement is a well-documented disease, T-cell lymphoblastic lymphoma in the perioral region is rare. An unusual case of T-cell lymphoblastic lymphoma with initial oral manifestation in an 18-month-old child is presented.

Treatment of advanced stage T cell lymphoblastic lymphoma: results of the United Kingdom Children's Cancer Study Group (UKCCSG) protocol 8503

Ninety-five unselected patients with stage III and IV T cell lymphoblastic lymphoma were treated according to the United Kingdom Children's Cancer Study Group protocol 8503. This was a continuous, intensive leukaemia type regimen including cranial irradiation (18 Gy in 10 fractions) and continuing chemotherapy for 2 years identical to the concurrent Medical Research Council ALL protocol. Four-year event-free survival was 65% (95% CI 50-80%) with no significant difference between stage III and stage IV cases. 4.2% of patients died of infection or non-tumour related events. Following relapse salvage was unlikely without high dose chemotherapy and bone marrow rescue. These results show an improvement over previous U.K. studies but we need to continue to search for subsets of patients with resistant disease for whom even more intensive therapy possibly combined with bone marrow rescue is required.

Non-Hodgkin's lymphomas in children. I. Patterns of disease and classification

Non-Hodgkin's lymphomas (NHL) are part of an overlapping spectrum of lympho-proliferative diseases in childhood. In the first of this 2 part series, the clinicopathological aspects of NHL in childhood are discussed. The rapid progression of disease, the high incidence of micrometastases (over 80%) at diagnosis, and the propensity of hematogenous spread to the bone marrow and the central nervous system (CNS) as well as the clinico-pathologic 'clusters' associated with particular presenting sites distinguish the pediatric forms of disease. Abdominal primary sites most frequently manifest diffuse undifferentiated (Burkitt's or non-Burkitt's) histopathology, B-cell immunophenotype, FAB-L3 cytomorphology and specific karyotypic and/or genotypic alterations of the immuno-globulin genes and the c-myc oncogene. Mediastinal presentation is associated with lymphoblastic histopathology, T-cell immunophenotype and a variety of less consistent karyotypic and genotypic aberrations. Ki-1 lymphoma, a rare subtype of large cell NHL with specific features is often of T cell origin. The requirements for diagnosis, staging and monitoring are presented in the context of the associations between clinico-pathological presentation and subsequent behavior. The most frequent sites of disease progression and relapse are involvement of the bone marrow and the CNS. For Burkitt's lymphoma there is a historic perspective and a description of particular epidemiologic, clinical, virologic, immunophenotypic and genotypic features. Cytogenetic and molecular biologic studies of genomic rearrangements are advancing the understanding of oncogenesis, clonality, lineage, and clinical behavior. The capacity to detect and amplify DNA from submicroscopic disease may contribute to prognostic stratification both at diagnosis and during subsequent monitoring.

Non-Hodgkin's lymphomas in children. II. Treatment

The prognosis of non-Hodgkin's lymphoma (NHL) in childhood has improved steadily in the last 2 decades. This is primarily the result of increasingly effective chemotherapy regimens tailored to defined and relatively homogeneous prognostic categories and tested in prospective clinical trials. Surgical excision remains of prognostic benefit only when near-total resection can be performed without delay of chemotherapy. The role of radiation therapy is now limited to the treatment of overt central nervous system (CNS) lymphoma, disease unresponsive to chemotherapy, and certain emergencies. Effective 'prophylactic' treatment of the CNS has been achieved in most series by intrathecal and systemic chemotherapy alone. The most relevant modality of treatment is chemotherapy and a very large number of protocols have been published. The origins of current multi-agent regimens stem both from early experience with cyclophosphamide in endemic Burkitt's lymphoma and from therapeutic studies of acute lymphoblastic leukaemia. Sub-stratification of non-localized NHL has produced protocols designed for either lymphoblastic (mostly T cell) or non-lymphoblastic (mostly B cell) categories. While the cure rate for lymphoblastic lymphoma now exceed 70%, the non-localized non-lymphoblastic disease remains a major obstacle to cure. These patients frequently present with large abdominal primaries and are prone to regional as well as hematogenous dissemination. In particular, involvement of the CNS is now considered to be the most adverse prognostic variable in this group. Recently, highly intensive regimens are addressing these obstacles. On the other hand, NHL defined as localized has been shown to be curable in up to 95% of children with the use of simple chemotherapy regimens as short as 6 months in duration. Salvage of patients who relapse during or after chemotherapy remains bleak but cures are possible with regimens incorporating bone marrow transplantation from either an autologous or allogeneic source. Experimental methods, including biologic and immune response modifiers may also offer future promise.

Clinical, haematological, and radiological features in T-cell lymphoblastic malignancy in childhood

T-cell lymphoblastic malignancy in childhood includes both T-cell acute lymphoblastic leukemia (T-ALL) and non-Hodgkin's lymphoblastic lymphoma (T-NHL). There is considerable overlap between these disorders, which probably represent two ends of the same disease spectrum. To determine whether there are radiological differences between T-ALL and T-NHL we reviewed the clinical, haematological and radiological features of 58 children seen in one centre over a 9-year period. Splenomegaly and adenopathy were significantly more common in T-ALL than in T-NHL. Patients with T-ALL were usually anaemic and thrombocytopenic, with elevated white blood cell counts; patients with T-NHL had normal blood counts. The radiological abnormalities seen were mediastinal enlargement, pleural effusions, and tracheal compression. All patients with T-NHL had abnormal chest radiographs, whereas 10 of 39 patients with T-ALL had normal chest radiographs. When only abnormal radiographs were compared, however, there were no differences in the degree of mediastinal widening or in the size of pleural effusions. Tracheal compression was more common in T-NHL and was always most marked in the intrathoracic airway and in an antero-posterior direction. We conclude that there is little difference in the radiological abnormalities seen in T-ALL and T-NHL, which further supports the theory that they represent points along a common spectrum of disease. As airway compression is primarily intrathoracic and in an antero-posterior direction, adequate radiological evaluation should include a lateral chest radiograph.

Adjuvant low dose radiation in childhood T cell leukaemia/lymphoma (report from the United Kingdom Childrens' Cancer Study Group--UKCCSG)

From November 1977 to July 1983, 82 children with T leukaemia/lymphoma entered a randomised trial of combination chemotherapy and radiotherapy. Twenty-five were designated T lymphoma and 57 T leukaemia, 28 having greater than 100 x 10(9)1(-1) blasts in peripheral blood at diagnosis. Twenty-seven patients with mediastinal primaries who were treated on the companion non-Hodgkin lymphoma (NHL) trial were comparable in all respects to the T lymphoma patients and the results of treatment were therefore combined and analysed together. Overall 4-year survival (48-53%) and failure-free survival (FFS) (37-40%) were similar in all groups except the 28 with T leukaemia and WCC greater than 100 X 10(9)1(-1) (20% and 13%). There was a significant advantage in FFS for patients randomised to receive low dose mediastinal radiation, and this was most marked in patients with T lymphoma (66% vs 18%, P = 0.006).

Mediastinal mass in acute lymphoblastic leukemia

Patients with acute lymphoblastic leukemia who have a mediastinal mass at the time of diagnosis are said to have a poor prognosis. However, many factors which may not be independent contribute to the success of treatment. We compared the disease characteristics and results of therapy in children having large mediastinal masses and lymphoblastic leukemia without mediastinal mass. Patients with a mediastinal mass had less evidence of marrow failure but were burdened with considerably more leukemic cells as measured by peripheral blood white count and extent of lymphadenopathy. Since the presence of mediastinal mass was strongly associated with these and other poor prognostic characteristics, we used multivariate techniques to determine which characteristics were independently associated with an increased risk for relapse. White count, extent of lymphadenopathy, age, and sex were significant predictors of early relapse, but when controlled for these variables the presence of a mass did not predict prognosis.

Acute lymphoblastic leukemia in children: current status, controversies, and future perspective

Disease-free survival (DFS) in childhood ALL is 60%, and survival in good, average, and poor prognostic groups defined by initial WBC and age is 90, 60, and 45%, respectively. Additional immunological, morphological, biochemical, cytokinetic, and cytogenetic factors have been identified, illustrating the heterogeneity of ALL and its derivation from malignant clones at various stages of differentiation and with varying rates of proliferation. Of biologic importance, these factors may refine further the characteristic features of clinically-determined prognostic groups. Multivariate analysis of large prospective trials with homogeneous therapy will be required to determine the independent prognostic importance of these factors. Current treatment strategies in ALL include (1) tailoring therapy and its intensity to prognostic groups; (2) multiple-drug combinations in induction; (3) early use of intrathecal (IT) methotrexate (MTX); (4) CNS prophylaxis with IT MTX alone in good prognosis patients and combined cranial radiation (CXRT), 1800 rads plus IT MTX, in average and poor prognosis patients. Current studies show a CNS relapse rate of 5% in all prognostic groups. Late neuropsychological defects caused by cranial XRT and IT MTX have prompted programs designed to reduce the potential late toxicity of CNS prophylaxis. More pronounced in younger children, these abnormalities include decreased IQ, visual-motor incoordination, poor performance in mathematics, and memory dysfunction. Until 1980, more intensive induction, consolidation, and maintenance therapy had failed to prolong DFS in children with a poor prognosis. In West Germany (Berlin-Frankfurt-Muenster protocol) a 70 to 75% DFS is seen in all patients regardless of initial WBC, suggesting that effective therapy will override prognostic factors. Ultra-high-dose MTX, without cranial radiation, is also showing promise in poor prognosis patients. Other issues include the optimal duration of therapy, the role of testicular biopsies, and prophylactic testicular radiation. Recent studies suggest that prognostic factors lose their significance after 2 years of continuous complete remission and that 2 years of maintenance therapy is adequate. Bilateral open-wedge testicular biopsies have identified occult testicular disease in 8 to 10% of males. A unified approach to children with leukemia/lymphoma, a group with a particularly poor prognosis, utilizing NHL-type therapy may be more effective than conventional ALL therapy.(ABSTRACT TRUNCATED AT 400 WORDS)