Utility of bronchoalveolar lavage in the diagnosis of pulmonary infection in children with haematological malignancies

BACKGROUND

Fibre-optic bronchoscopy with bronchoalveolar lavage (BAL) is a safe procedure and is associated with low morbidity and mortality in immunocompromised children. Although many studies have highlighted the advantages of positive BAL results in the diagnosis of pulmonary infections, there have been few reports examining the impact of a negative BAL result on clinical management in immunocompromised children on empiric broad-spectrum antimicrobial therapy.

AIM

The aim of this study was to evaluate BAL in the diagnosis of pulmonary infections in children with haematological malignancies who develop pneumonia unresponsive to empiric antimicrobial therapy, and also to determine whether a negative BAL result contributed to the clinical management of these patients.

MATERIALS AND METHODS

A retrospective review of 44 BAL procedures performed in 33 children with haematological malignancy diagnosed and treated at Our Lady's Children Hospital, Crumlin, Dublin 12, Ireland, over a 10-year period was carried out.

RESULTS

We identified a pathogen causing pneumonia in 24 of 44 BAL procedures (54.5 %). The BAL procedure resulted in modification of antimicrobial treatment after 20 of 24 procedures with positive results (83.3 %) in 16 of 20 patients (80 %). Management was changed after 8 of 20 procedures with negative results (40 %) in 8 of 18 patients (44.4 %). The procedure was well tolerated in all patients.

CONCLUSIONS

Our study supports the use of bronchoscopy with BAL as a diagnostic intervention in this patient population. We consider BAL a safe procedure from which both positive and negative results contribute to the patient's clinical management.

Stratification of Wilms tumor by genetic and epigenetic analysis

Somatic defects at five loci, WT1, CTNNB1, WTX, TP53 and the imprinted 11p15 region, are implicated in Wilms tumor, the commonest childhood kidney cancer. In this study we analysed all five loci in 120 Wilms tumors. We identified epigenetic 11p15 abnormalities in 69% of tumors, 37% were H19 epimutations and 32% were paternal uniparental disomy (pUPD). We identified mutations of WTX in 32%, CTNNB1 in 15%, WT1 in 12% and TP53 in 5% of tumors. We identified several significant associations: between 11p15 and WTX (P=0.007), between WT1 and CTNNB1 (P less than 0.001), between WT1 and pUPD 11p15 (P=0.01), and a strong negative association between WT1 and H19 epimutation (P less than 0.001). We next used these data to stratify Wilms tumor into three molecular Groups, based on the status at 11p15 and WT1. Group 1 tumors (63%) were defined as 11p15-mutant and WT1-normal; a third also had WTX mutations. Group 2 tumors (13%) were WT1-mutant. They either had 11p15 pUPD or were 11p15-normal. Almost all had CTNNB1 mutations but none had H19 epimutation. Group 3 tumors (25%) were defined as 11p15-normal and WT1-normal and were typically normal at all five loci (P less than 0.001). We also identified a novel clinical association between H19 epimutation and bilateral disease (P less than 0.001). These data provide new insights into the pattern, order, interactions and clinical associations of molecular events in Wilms tumor.

Review of family-based psychosocial interventions for childhood cancer

OBJECTIVE

To report the findings of a systematic review of family-based psychosocial interventions with pediatric oncology populations.

METHODS

A number of intervention studies documenting psychosocial interventions for childhood cancer populations, that incorporated multiple family members, were examined.

RESULTS

Twenty-one studies were identified that met the criteria for inclusion and provided the data necessary for synthesizing the results. Findings illustrate that multiple family members are integrated into interventions for childhood cancer in a number of ways. Considerable variation was observed regarding the family member combinations targeted and the intervention modalities employed. A minority of interventions met the criteria for empirically validated treatments; however, evidence of beneficial outcomes was observed across the majority of interventions reviewed.

CONCLUSIONS

Findings suggest the feasibility, acceptability, and potential effectiveness of family-based psychosocial interventions in pediatric oncology. Recommendations for conducting future intervention studies are provided including the integration of qualitative methods in evaluations of family-based interventions.

Minimal residual disease detection in childhood acute lymphoblastic leukaemia patients at multiple time-points reveals high levels of concordance between molecular and immunophenotypic approaches

In this single centre study of childhood acute lymphoblastic leukaemia (ALL) patients treated on the Medical Research Council UKALL 97/99 protocols, it was determined that minimal residual disease (MRD) detected by real time quantitative polymerase chain reaction (RQ-PCR) and 3-colour flow cytometry (FC) displayed high levels of qualitative concordance when evaluated at multiple time-points during treatment (93.38%), and a combined use of both approaches allowed a multi time-point evaluation of MRD kinetics for 90% (53/59) of the initial cohort. At diagnosis, MRD markers with sensitivity of at least 0.01% were identified by RQ-PCR detection of fusion gene transcripts, IGH/TRG rearrangements, and FC. Using a combined RQ-PCR and FC approach, the evaluation of 367 follow-up BM samples revealed that the detection of MRD >1% at Day 15 (P = 0.04), >0.01% at the end of induction (P = 0.02), >0.01% at the end of consolidation (P = 0.01), >0.01% prior to the first delayed intensification (P = 0.01), and >0.1% prior to the second delayed intensification and continued maintenance (P = 0.001) were all associated with relapse and, based on early time-points (end of induction and consolidation) a significant log-rank trend (P = 0.0091) was noted between survival curves for patients stratified into high, intermediate and low-risk MRD groups.

Cytomegalovirus infection in paediatric haemopoietic stem cell transplantation

A retrospective audit of CMV infection was undertaken to determine prevalence and outcome in the national paediatric Haemopoietic Stem Cell Transplant (HSCT) unit, with particular reference to surveillance and treatment. All patients undergoing HSCT (125 allogeneic, 50 autologous) from January 1994 to December 2004 were included. Nine underwent a second transplant for graft failure or disease recurrence. Of 134 allogeneic transplants performed, 62 were unrelated. Shell vial cultures of throat swabs and urine, and blood samples for pp65 antigenemia +/- PCR were tested weekly for a mean of 147 days post transplant. CMV negative blood products and filters were used in all. 11 rec+/donor-, 12rec-/donor+ and 10rec+/donor+ transplants were performed. All received prophylactic acyclovir, IVIG was prescribed for all but CMV -/- transplants. Initial detection of CMV was urine in 5 cases, four of whom developed antigenemia. Of ten patients who developed antigenemia, nine were treated with ganciclovir +/- foscarnet and two of these patients developed CMV pneumonitis and died. The current policy of strict surveillance, matching donor and recipient CMV status, use of CMV negative blood products and filters and pre-emptive therapy appears to be effective in controlling CMV disease/infection in the peritransplant period.

Penile malignant peripheral nerve sheath tumour (schwannoma) in a three-year-old child without evidence of neurofibromatosis

Malignant schwannoma (malignant peripheral nerve sheath tumour, MPNST) is a rare high-grade tumour arising from peripheral nerves. We report the case of a 3-year-old male who presented with a non-tender lesion on the dorsum of his penis. The lesion was excised and a formal circumcision performed. Histology of the lesion revealed a spindle cell tumour. Immunohistochemistry showed the tumour cells to be strongly positive for S100 and Vimentin. A diagnosis of intermediate grade malignant peripheral nerve sheath tumour was made. Malignant schwannoma is rare in children and is previously unreported in the penis in the paediatric age group without evidence of neurofibromatosis.

Safety of summer camp for children with chronic and/or life threatening illness

The purpose of this work was to retrospectively evaluate the medical needs of children with chronic and/or life-threatening illness attending summer camp at Barretstown Gang Camp (Ireland). Data on medical facility visits collected over 28 sessions (2120 children) between 1998 and 2001 were reviewed. Children originated from 20 different European countries. The most common diagnoses were leukaemia, lymphoma, sarcoma and brain tumour. Forty-eight percent of the children required medical care during their stay and 3386 total visits were recorded. The most common cause of medical facility visit was pain, followed by injury (trauma, bruises, burn) and flu/cold symptoms. Only 8 brief hospital transfers were necessary for the 2120 children. This large-scale study confirms the safety of a well-organized medically supervised summer therapeutic recreational program for children with chronic conditions, including children undergoing chemotherapy treatment and factor replacement.

High-Resolution Analysis of Chromosomal Breakpoints and Genomic Instability Identifies PTPRD as a Candidate Tumor Suppressor Gene in Neuroblastoma

Although neuroblastoma is characterized by numerous recurrent, large-scale chromosomal imbalances, the genes targeted by such imbalances have remained elusive. We have applied whole-genome oligonucleotide array comparative genomic hybridization (median probe spacing 6 kb) to 56 neuroblastoma tumors and cell lines to identify genes involved with disease pathogenesis. This set of tumors was selected for having either 11q loss or MYCN amplification, abnormalities that define the two most common genetic subtypes of metastatic neuroblastoma. Our analyses have permitted us to map large-scale chromosomal imbalances and high-level amplifications at exon-level resolution and to identify novel microdeletions and duplications. Chromosomal breakpoints (n = 467) generating imbalances >2 Mb were mapped to intervals ranging between 6 and 50 kb in size, providing substantial information on each abnormality. For example, breakpoints leading to large-scale hemizygous loss of chromosome 11q were highly clustered and preferentially associated with segmental duplications. High-level amplifications of MYCN were extremely complex, often resulting in a series of discontinuous regions of amplification. Imbalances (n = 540) <2 Mb long were also detected. Although the majority (78%) of these imbalances mapped to segmentally duplicated regions and primarily reflect constitutional copy number polymorphisms, many subtle imbalances were detected that are likely somatically acquired alterations and include genes involved with tumorigenesis, apoptosis, or neural cell differentiation. The most frequent microdeletion involved the PTPRD locus, indicating a possible tumor suppressor function for this gene.

Evolution of unbalanced gain of distal chromosome 2p in neuroblastoma

Neuroblastoma, one of the most common tumors of childhood, presents at diagnosis with a vast number of recurrent chromosomal imbalances that include hyperdiploidy for whole chromosomes, partial loss of 1p, 3p, 4p, 11q, 14q, partial gain of 1q, 7q, 17q and amplification of MYCN. These abnormalities are nonrandomly distributed in neuroblastoma as loss of 3p and 11q rarely occur in MYCN amplified neuroblastomas. Here, we report on a patient who had a non-MYCN amplified 3p-/11q- neuroblastoma at diagnosis who subsequently developed a high level of MYCN amplification in bone marrow metastases 41 months after induction of complete remission. The tumor at diagnosis had low level unbalanced gain of distal 2p. In order to assess the frequency of low level gain of distal 2p in neuroblastoma, we examined the comparative genomic hybridization results from 60 neuroblastomas. Among non-MYCN amplified neuroblastomas, 8/45 (18%) had low level gain of distal 2p. Low level gain for a segment of 2p (i.e. a region larger than the 2p23-->p24 undergoing amplification) was also detected in five of the 15 tumors that had high level MYCN amplification. The possibility that low level gain of distal 2p is a risk factor for high level MYCN amplification is discussed.

Molecular cytogenetic analysis of recurrent unbalanced t(11;17) in neuroblastoma

Loss of 11q material occurs in approximately 30% of advanced stage neuroblastoma and defines a distinct genetic subtype of this disease. These tumors almost always possess unbalanced gain of the 17q, along with many additional recurrent chromosomal imbalances. Loss of 11q and gain of 17q is often the consequence of an unbalanced translocation between the long arms of both chromosomes, but because of the involvement of other chromosomal mechanisms, the actual frequency of t(11;17) is unknown. In addition, chromosomal breakpoint positions for the t(11;17) are variable in different tumors, with breakpoints on neither the 11q nor 17q being well defined. We have used interphase fluorescence in situ hybridization analysis to detect a der(11)t(11;17) in a series of neuroblastomas with 11q loss/17q gain using a statistical approach which could be applicable to the detection of translocations in other solid tumors. The frequency of der(11)t(11;17) was approximately 90% in our neuroblastoma series. A balanced t(11;17) was also detected in a MYCN amplified tumor, which is a distinctly different genetic subtype from the 11q- tumors. Breakpoint positions on 11q were determined to be variable, whereas all breakpoints on 17q appeared to cluster proximal to position 43.1 Mb on the DNA sequence map. The majority of tumors had large numbers of nuclei with 2 or more copies of der(11)t(11;17), which led to unbalanced gain of 11p, and further increases in 17q imbalance. The prevalence of t(11;17) in neuroblastoma warrants additional studies to further define the range in variation in breakpoint positions on both chromosomes and to elucidate the molecular mechanisms that lead to this important and interesting recurrent genetic abnormality.

Oligonucleotide microarray analysis of gene expression in neuroblastoma displaying loss of chromosome 11q

A number of distinct subtypes of neuroblastoma exist with different genetic abnormalities that are predicative of outcome. Whole chromosome gains are usually associated with low stage disease and favourable outcome, whereas loss of 1p, 3p and 11q, unbalanced gain of 17q and MYCN amplification (MNA) are indicative of high stage disease and unfavourable prognosis. Although MNA and loss of 11q appear to represent two distinct genetic subtypes of advanced stage neuroblastoma, a detailed understanding of how these subtypes differ in terms of global gene expression is still lacking. We have used metaphase comparative genomic hybridization (CGH) analysis in combination with oligonucleotide technology to identify patterns of gene expression that correlate with specific genomic imbalances found in primary neuroblastic tumours and cell lines. The tumours analysed in this manner included a ganglioneuroma, along with various ganglioneuroblastoma and neuroblastoma of different stages and histopathological classifications. Oligonucleotide microarray-based gene expression profile analysis was performed with Affymetrix HU133A arrays representing approximately 14 500 unique genes. The oligonucleotide microarray results were subsequently validated by quantitative real-time PCR, immunohistochemical staining, and by comparison of specific gene expression patterns with published results. Hierarchical clustering of gene expression data distinguished tumours on the basis of stage, differentiation and genetic abnormalities. A number of genes were identified whose patterns of expression were highly correlated with 11q loss; supporting the concept that loss of 11q represents a distinct genetic subtype of neuroblastoma. The implications of these results in the process of neuroblastoma development and progression are discussed.

Are gains of chromosomal regions 7q and 11p important abnormalities in neuroblastoma?

Neuroblastoma exhibiting deletion of a segment of the long arm of chromosome 11 represents a genetic subtype of tumor that is distinct from those exhibiting MYCN amplification or 1p deletion. The 11q- genetic subtype is further characterized by gain of 17q and loss of distal 3p material. Gain of 11p material has also been reported in neuroblastoma with 11q loss, but at a considerably lower frequency than gain of 17q or loss of the distal 3p region. Our results, however, indicate that gain of 11p may occur more frequently in 11q- neuroblastoma than what was previously realized. Comparative genomic hybridization analyses of neuroblastoma tissue from eleven patients indicated that six of 11 tumors (55%) with loss of 11q also possessed gain of 11p. The shortest region of 11p gain was 11p11.2-->p14. G-banding and fluorescence in situ hybridization analysis performed on tumor cells from primary and metastatic sites from one patient allowed us to infer that gain of 11p arose secondarily to the abnormality that led to the loss of 11q material. Gain of an entire chromosome 7 was detected in 17 of 43 (40%) tumors, whereas gain of 7q was detected in 5 of 43 (12%) tumors. Unlike gain of 11p, gain of an entire chromosome 7 appears to be prevalent in all tumor stages and is not limited to the 11q- tumor subtype. Gain of 7q, however, is more prevalent in higher stage tumors. G-band cytogenetic analysis indicated that an unbalanced t(3;7) was responsible for the gain of 7q and loss of 3p material in one case. We discuss the possibility that gain of 7/7q, and 11p material may contribute to either tumorigenesis or progression.

Potentiation of vincristine toxicity by itraconazole in children with lymphoid malignancies

Eight consecutive paediatric patients with acute lymphoblastic leukaemia (ALL) (n = 7) and T-cell non-Hodgkin's lymphoma (NHL) (n = 1) presenting within a 5-wk interval were started on a standard induction protocol which included weekly treatment with vincristine for 4 wk. Itraconazole was commenced as antifungal prophylaxis, 1-21 d after the first injection of vincristine. Within 2 to 4 wk, enhanced vincristine neurotoxicity was noted in all patients, abdominal cramps and constipation occurred most frequently, and one patient developed a bowel perforation associated with paralytic ileus. Hyponatraemia associated with SIADH was observed in three patients and four patients developed seizures. An additional patient with B cell NHL developed seizures 5 d after an injection of vincristine. Recovery was complete in all patients and ranged from 2 d to 15 wk.

CONCLUSION

The extent and consistency of adverse effects documented in this study support the recommendation that concurrent administration of vincristine and itraconazole should be avoided.

A comparison of oral ondansetron syrup or intravenous ondansetron loading dose regimens given in combination with dexamethasone for the prevention of nausea and emesis in pediatric and adolescent patients receiving moderately/highly emetogenic chemotherapy

This double-blind, parallel-group, multicenter study compared the efficacy and safety of intravenous (i.v.) ondansetron with oral syrup ondansetron plus oral dexamethasone in the prevention of nausea and emesis in pediatric patients receiving moderately/highly emetogenic chemotherapy. On each day of chemotherapy, patients were administered ondansetron 5 mg/m2 i.v. and placebo syrup orally (n = 215) or ondansetron 8 mg syrup orally and placebo i.v. (n = 223) plus dexamethasone 2-4 mg p.o. Ondansetron 4 mg syrup p.o. was administered twice daily for 2 days following the cessation of chemotherapy. Complete or major control of emesis was obtained in 89% patients in the i.v. group and 88% patients in the oral syrup group during the worst day of chemotherapy treatment (90% CI: -6, 4) and in 85% and 82% patients, respectively, during the worst day of the study period (90% CI: -8, 3). Intravenous or oral syrup ondansetron plus dexamethasone was well tolerated and effective in preventing chemotherapy-induced emesis in pediatric patients.

[Oral granisetron solution as prophylaxis for chemotherapy-induced emesis in children: double-blind study of 2 doses]

This multicentric double-blind, dose-ranging study was to compare efficacy and safety of two oral doses of granisetron solution in the prevention of chemotherapy-induced emesis in children with malignant diseases : 294 children, aged 1 to 16, treated with a moderately or highly emetogenic chemotherapy were randomly assigned to receive oral granisetron either 20 microg/kg (n = 143) or 40 microg/kg (n = 151) before and 6 to 12 hours after the start of chemotherapy. Fifty-one percent of patients treated with 20 microg/kg bd of oral granisetron solution achieved a complete response (no vomiting, no worse than mild nausea, no rescue therapy and no withdrawal during the specified period) and 59% achieved a major response (no more than one episode of vomiting, no worse than mild nausea, no rescue therapy and no withdrawal during the specified period). There was no difference between the two oral doses of granisetron. Treatment was rated as good or very good by investigators in 70% of cases. In conclusion, oral granisetron suspension either at 20 microg/kg bd or at 40 microg/kg bd showed good efficacy and safety in the prevention of chemotherapy-induced emesis in children with malignant diseases. Oral granisetron solution can be used as prophylaxis of emesis in children receiving moderately or highly emetogenic chemotherapy.

Comparative genomic hybridization in pediatric acute lymphoblastic leukemia

Comparative genomic hybridization (CGH) was used to clarify the chromosomal status of 15 patients diagnosed with childhood acute lymphoblastic leukemia (ALL). Bone marrow samples from 10 of the 15 patients were selected because no metaphases were obtained for cytogenetic analysis. Three patients with normal trypsin and giemsa banding (GTG) karyotypes were also studied by CGH to determine whether significant abnormalities might have been missed by banding analysis, and samples from an additional 2 patients with hyperdiploidy were also included. Seven of the 10 patients with failed GTG banding analysis were found to be chromosomally abnormal by CGH; 2 out of 3 patients with normal GTG band karyotypes were abnormal, indicating that the metaphases available for karyotyping were not malignant cells, and that CGH analysis of hyperdiploid samples provided more accurate resolution than karyotyping alone. The prognostic value of chromosomal aberrations detected by CGII and the efficiency of the technique suggest a central role for CGH in routine clinical cytogenetics.

Conservative surgical management of bilateral Wilms tumor: results of the United Kingdom Children's Cancer Study Group

PURPOSE

Bilateral Wilms tumor presents the clinician with a treatment dilemma. Since 1980 most centers of the United Kingdom Children's Cancer Study Group have used a conservative surgical approach with initial biopsy followed by chemotherapy and delayed surgical resection. We assess the outcome of this treatment approach in terms of survival, and preservation of renal mass and function.

MATERIALS AND METHODS

We retrospectively analyzed the records of 71 children with bilateral Wilms tumor diagnosed between 1980 to 1995 at 17 United Kingdom Children's Cancer Study Group centers. In 57 patients conservative surgical treatment with initial biopsy was followed by chemotherapy and delayed tumor resection, while 13 underwent initial surgical resection followed by chemotherapy. One patient was excluded from study because the lesion in 1 kidney proved to be a benign cyst. Mean followup was 6 years (range 1 to 15). The percentage of renal tissue involved with tumor and preserved was estimated, and renal function at the last followup was recorded.

RESULTS

Overall survival was 69% with similar survival in the conservatively treated and initial surgical resection groups. At the last followup renal function was normal in 80% of the patients in each group. Mean preserved renal mass was 45 and 35% in the conservatively treated and initial resection groups, respectively, with a trend toward better preservation in those treated conservatively. Bilateral Wilms tumor with an unfavorable histology was associated with a poor prognosis.

CONCLUSIONS

Conservative surgical treatment of favorable histology bilateral Wilms tumor may improve the preservation of renal mass and function without impairing patient survival.

Histological parameters as predictors of prognosis in childhood brain tumors

Using histological parameters with high recognition reliability, we retrospectively analyzed all newly diagnosed patients under the age of 16 years (n = 100) with brain and spinal cord tumors presenting to the National Neuroscience Centres of the Richmond and Beaumont Hospitals, Dublin, Ireland, between 1985 and 1990, allowing analysis of 5-year survival in all cases. Tumor histology was reviewed by two neuropathologists blinded to previous histological diagnosis and to the site of lesion. We found that certain histological features such as very low cell density and microcyst formation had a positive effect on prognosis. Mitoses and pleomorphism had a negative effect on prognosis, whereas necrosis and meningeal involvement had no effect on prognosis. It is suggested that identification of reliably recognized histological features rather than assignation of tumors to particular diagnostic categories may be a more reliable predictor of tumor behavior in the pediatric age-group.

Central venous catheter infections treated with teicoplanin

A novel way of using teicoplanin in situ to treat central venous catheters is described. Profound immunosuppression and the fact that the lines remain indwelling for long periods are two of the main reasons for these infections. In children it is also difficult to prevent these lines being played with, which increases the likelihood of infection. The different types of infection that can occur in a central venous catheter are described and the clinical definition of a catheter infection is provided. In an initial study, infective episodes in a small group of 11 children were treated successfully with in situ amikacin. Most pathogens were Gram-negative cocci. None of the catheters had to be removed, and catheter life was prolonged by a mean of 118 d. Due to the high incidence of Staphylococcus epidermidis in the initial study, in situ teicoplanin was assessed in a subsequent study. Over the course of 1 yr, 20 line infections occurred in 12 children. Empirical amikacin therapy was instituted and switched to teicoplanin once the pathogen was confirmed as Gram-positive. An antibiotic-heparin mixture was introduced into the line and left in place for 24 h, after which time it was replaced with fresh mixture until cultures were sterile. All pathogens were sensitive to teicoplanin, all infections were treated successfully and no catheters had to be removed. Overall, catheter life was prolonged by a mean of 136 d. It was concluded that in situ teicoplanin was effective and well tolerated for line infections (no side-effects were reported during the study). A minimum of 6 d therapy was recommended. The patients with less severe infections would have been suitable for treatment at home by their parents, district nurse or general practitioner (GP).

Control of a nosocomial outbreak of vancomycin resistant Enterococcus faecium in a paediatric oncology unit: risk factors for colonisation

In order to determine the extent of vancomycin resistant enterococcus (VRE) colonisation within a paediatric oncology unit, the risk factors for the acquisition of the organism, the molecular epidemiology of the isolates and the impact of infection control measures, extensive patient and environmental surveillance was undertaken with identification, antibiotic susceptibility testing and pulsed-field gel electrophoresis (PFGE) of all VRE isolates. A matched case control study was carried out. Fourteen patients (19% of screened patients) with VRE colonisation were identified (12 with Enterococcus faecium). All isolates manifested the Van A phenotype. Extensive environmental contamination with VRE was present. PFGE of E. faecium isolates from 10 patients and from five of six environmental cultures revealed patterns suggesting genetic relatedness. Following comparison of the 14 cases with 41 controls matched for age (+/- 4 years) and cohabitation on the oncology unit, risk factors for colonisation with VRE included duration of neutropenia, (OR, 3.72; 95% CI, 1.0-13.1), and antibiotic therapy, (OR, 4.07; 95% CI, 1.08-15.3), the number of antibiotic agents received, (OR, 8.4; 95% CI, 1.34-34.3) and the duration of therapy with amikacin, (OR, 10.7; 95% CI, 1.4-81.5), ceftazidime, (OR, 11.5; 95% CI, 2.2 59.9) or teicoplanin, (OR, 12.3; 95% CI, 2.25-67.4). Implementation of stringent infection control measures reduced environmental contamination from 25% of samples in week 1 to none in week 11. Two additional colonised patients were identified during the subsequent 6 months.

CONCLUSION

Risk factors for VRE colonization in paediatric oncology patients included duration of neutropenia, duration of any antibiotic therapy, exposure to ceftazidime, amikacin or teicoplanin and the number of antibiotics used. The study suggests that environmental contamination played an important role in patient-to-patient transmission of VRE and interventions including implementation of infection control measures were associated with a decreased incidence of gastro-intestinal colonisation.

SIOP Working Committee on psychosocial issues in pediatric oncology: guidelines for communication of the diagnosis

This is the fourth official document of the SIOP Working Committee on psychosocial issues in pediatric oncology constituted in 1991. This document develops another topic discussed and approved by the SIOP Committee: "communication of the diagnosis" is addressed to the pediatric oncology community as guidelines that could be followed. The highly stressful nature of the diagnostic period must be acknowledged, and communication involving the staff and all family members should cover both medical and psychosocial issues. A well-planned and extensive initial session should be followed by continuing discussions. The goal is a knowledgeable family that can talk openly with its members and with the staff.

Benign giant cell tumour of bone in a child with pulmonary metastases at presentation

The clinical course of a 14-year-old boy who presented with a giant cell tumour of bone with pulmonary metastases is reported. There was a partial response to chemotherapy which included vincristine, adriamycin, ifosfamide, carboplatinum and etoposide. Two enlarging metastatic lung lesions were later resected because of chest pain, with symptomatic improvement. The patient is currently well almost 7 years from diagnosis despite the presence of radiological disease.

Ifosfamide nephrotoxicity in paediatric cancer patients

Ifosfamide is an alkylating agent which has been incorporated into frontline therapy for a number of malignant paediatric tumours. Recent data appears to suggest that tubular dysfunction may result from incorporation of this drug into chemotherapy schedules and that toxicity may be dose related. A detailed investigation of renal function was performed in a group of patients, ranging in age from 8 months to 15.9 years (median 8.6 years) with rhabdomyosarcoma (n = 11) and Ewing's sarcoma (n = 9) who were currently receiving (n = 4) or had completed ifosfamide (n = 16) therapy a mean of 16 months at the time of study. All but one patient demonstrated some degree of renal dysfunction and toxicity did not necessarily appear to be dose related. Implications for incorporation of this agent into future schedules for childhood sarcomas, which can expect to cure more than 60% of such children, must be addressed. The importance of ongoing monitoring is emphasised.

Is there a danger in delaying radiotherapy in childhood medulloblastoma?

Approximately 45-50% of children with medulloblastoma are cured by conventional surgery and radiotherapy, but survivors may face severe late neuropsychological toxicity. Studies showing good partial responses to platinum-based chemotherapy in relapsed patients and the theoretical possibility of a therapeutic window immediately after surgery have prompted neoadjuvant treatment studies which are ongoing. However, the absolute benefit of chemotherapy for the treatment of medulloblastoma in childhood is, as yet, not proven. There is a danger that chemotherapy may simply delay radiotherapy, and in so doing reduce the radiological impact of this known effective treatment. We report four children with medulloblastoma presenting consecutively to this unit over a 6-month period, whose management was problematic because of either failure to respond to neoadjuvant chemotherapy or their very young age. These cases are discussed in the light of the current literature and future treatment strategies that must seek to improve the therapeutic ratio of multimodality therapy.

Aural symptoms as primary presentation of Langerhan's cell histiocytosis

Langerhan's cell histiocytosis is an uncommon granulomatous disease, characterized by the idiopathic proliferation of Langerhan's cells or their marrow precursors. It encompasses the diseases previously associated with histiocytosis X-eosinophilic granuloma, Hand-Schuller-Christian syndrome and Letterer-Siwe syndrome. A series of 54 patients were diagnosed with this condition in Dublin over a 33-year-period (1959-1992). Twenty-seven patients had aural symptoms, of whom 15 had no other lesions at the time of presentation. Otorrhoea was the most frequent otological symptom, followed by lesions in the temporal bone. LCH may mimic common aural conditions such as otitis externa, otitis media or acute mastoiditis and a high index of suspicion is required to recognize it on clinical presentation. The clinical presentation of multi-focal disease may be so dramatic that the otologic findings may be initially overlooked. The mortality rate was 14.8%. Therapeutic regimes included no treatment, curettage, chemotherapy, radiotherapy or multi-modality treatment.

Extrarenal Wilms' tumor

Extrarenal nephroblastoma (Wilms' tumor) is very rare with to date just 34 cases described. Two such cases out of a total of 61 patients with WT presenting to a single institution over a 10-year period are presented. Both children, a boy aged three years and a girl aged four years, both presented with an abdominal mass which had crossed the midline. Ultrasonography and contrast studies in the two patients revealed retroperitoneal tumors distinct from kidneys, but unilateral hydronephrosis was noted in both patients. Primary surgical excision was performed and both patients grouped as stage III favorable histology. Postoperative treatment included chemotherapy and radiotherapy as per UKCCSG protocols. The patients are clinically well with no evidence of disease 7 years and 20 months respectively from diagnosis. An individualized approach to treatment of extrarenal WT is advocated.

Neuroblastoma--a surgical perspective

The role of an aggressive surgical policy in the management of neuroblastoma (NBL) was examined in a retrospective study from a total of 57 patients presenting to a single institution between 1979 and 1989. Surgery consisted of either primary excision of tumour or elective resection following intensive chemotherapy. Two year disease-free survival (DFS) for the entire group was 100% for Stage I patients (n = 2), 86% for Stage II (n = 7), 55% for Stage III (n = 11), 12% for stage IV (n = 33) and 50% for stage IVs (n = 4). In all long-term survivors, surgical excision of primary tumour had been achieved. Elective surgery of primary tumour was not performed in six patients with Stage IV disease; median survival for these patients was eight months compared with 19 months for those other patients with Stage IV disease who did have surgery +/- high dose melphalan and autologous bone marrow rescue. Postoperative complications were documented in 13 of 48 operated patients (27%), emphasising the technical challenges encountered in resection of NBL. Age at presentation and site of primary tumour were major factors affecting prognosis: patients who presented < 1 years of age (n = 15) achieved 80% DFS, > 1 year and < 2 years (n = 12), 33%, and > 2 years (n = 30) 13%; 10 of 11 patients (91%) with primary supradiaphragmatic disease are alive and well compared with 10 out of 46 (22%) with infradiaphragmatic disease (P = 0.01). Based on the experience from this centre, it would appear that surgery can be curative for patients with Stage I, II and III disease but can only, at best, prolong DFS for Stage IV patients. Alternative therapeutic strategies are indicated for this latter group of patients.

Renal size and function after cure of Wilms' tumour

Now that most patients with Wilms' tumour are cured, it is practicable to study the long-term morbidity of their treatment and use this information to reduce treatment sequelae in the future. In this study we evaluate the size and function of the remaining kidney in 53 survivors of Wilms' tumour with a mean off treatment follow-up of 13 years. There was evidence of renal dysfunction in 17 (32%), including ten (19%) with a low GFR (< 80 ml/min/1.73 m2SA), six (11%) with hypertension and five (9%) with increased urinary albumin excretion. Measurements of renal size showed 'good' renal compensatory hypertrophy in only 55% of patients. 'Good' refers to renal size of more than 2 s.d. above the mean renal length for children with two kidneys. There were no correlations between GFR, renal size, blood pressure, microalbuminuria or type of treatment. However, children less than 24 months at diagnosis and children receiving chemotherapy with radiation doses to remaining kidney of more than 1200 cGy had a worse renal prognosis. Patients whose Wilms' tumour is diagnosed in infancy should have careful long-term follow-up of renal function and size. Older patients may safely be followed up less often, unless their remaining kidney was received > 1200 cGy.

A new approach to the management of Broviac catheter infection

Infection continues to be a major complication of the use of indwelling venous catheters. In an attempt to avoid removal of the catheter and to minimize the systemic side-effects of antibiotics, the potential value of in-situ treatment of confirmed Broviac catheter infection was assessed in carefully selected patients attending an oncology unit. Fourteen episodes from 11 children were included in the study. A variety of organisms were encountered. Infective episodes were divided into two categories: (a) those occurring in patients with negative peripheral blood cultures and neutrophil count greater than 1.5 x 10(9) l-1 which were treated only by local instillation of heparinized antibiotic 8-hourly for 7-14 days (N = 8); (b) those occurring simultaneously with positive peripheral blood culture (or peripheral blood culture not performed) regardless of neutrophil count, or infection restricted to Broviac catheter but with a neutrophil count of less than 1.5 x 10(9) l-1; these were treated, with one exception, as above with the addition of systemic antibiotics (N = 6). Treatment was successful in 100% of infective episodes with negative cultures achieved between 5 and 12 days. Catheters remained in use a mean of 118 days following treatment of infection. This approach has obvious advantages but requires careful patient selection and monitoring. It prolongs the catheter life, obviates the need for systemic antibiotics for a local infection, and with appropriate instruction to parents and family practitioner, treatment may be administered on an outpatient basis.

DNA quantitation of Wilms' tumour (nephroblastoma) using flow cytometry and image analysis

AIMS

To compare flow cytometry (FCM) with image analysis (IA) in the DNA quantitation of Wilms' tumour (WT) and to correlate data so obtained with recognised clinical and pathological prognostic parameters.

METHODS

Thirty six patients with histologically proved WT diagnosed between 1980-89 were investigated. Fifteen patients had stage I disease, 10 stage II, six stage III, two stage IV and three stage V. Suspension of nuclei obtained by pepsin digestion of paraffin wax embedded tumour tissue was analysed using a FAC-Scan flow cytometer, and a CAS-100 image analyser.

RESULTS

Tumours were concordant in most instances, however, IA identified aneuploidy in two tumour samples which were diploid by FCM. Aneuploidy was detected in 5/33 tumours with favourable histology and 3/3 with unfavourable histology. Three of 28 patients with Stage I, II and V disease and 5/8 patients with stage III and IV had aneuploid tumours. All patients with unfavourable histology died of disease. In the group with favourable histology, 4/5 patients with aneuploid tumours developed recurrent disease compared with 1/27 diploid tumours (p less than 0.0001).

CONCLUSIONS

Ploidy may be a useful additional prognostic indicator in Wilms' tumour with favourable histology. Larger scale studies are needed to confirm the relation of ploidy to survival in early stage WT.

Childhood leukaemia in Ireland

In response to professional and public concern about health consequences, in particular cancer risk, from previous and current levels of ionising radiation in the Irish Sea, a study of incidence and mortality from acute lymphoid leukaemia (ALL) and other lymphoid malignancies in children was undertaken. Overall rates were similar to those found in other western populations and distribution of high rates was quite random over the country as a whole. There was a small but significant excess in incidence of ALL for the years 1974-76 in a narrow three mile wide strip along the east coast. It is not possible in the context of this study to postulate aetiological factors which might explain this finding.

Osteogenic sarcoma and Rothmund Thomson syndrome

Rothmund Thomson syndrome (RTS) is a rare autosomal recessive disorder characterised by poikiloderma, dermal atrophy, dystrophic nails, short stature and hypogonadism. An increased incidence of malignancy has been reported in patients with this syndrome secondary, it is postulated, to DNA repair defects. We report the occurrence of an osteogenic sarcoma in an 11-year-old Irish girl with RTS. Although fibroblast cultures demonstrated enhanced radiosensitivity, there was no undue toxicity associated with treatment, which included methotrexate, cisplatinum and Adriamycin. Following conservative surgery, she is currently off treatment and disease-free 2 years from diagnosis.

Primary hepatic tumours in children: a 26-year review

Twenty-one children were admitted to a single paediatric institution between 1964-1990 with histologically proven primary liver tumours. The diagnosis was hepatoblastoma (HBL) in 15 patients, hepatocellular carcinoma (HCA) in 2, rhabdomyosarcoma (RMS) in 2, non-Hodgkin's lymphoma (NHL) in 1, and haemangioendothelioma (HE) in 1. The common presenting clinical features were anaemia, abdominal mass, and abdominal pain. Serum alpha-foetoprotein was useful in establishing a diagnosis in HBL and in monitoring disease activity. Computed tomographic (CT) scan, ultrasound, and angiography were useful preoperative investigations for assessing site and resectability of tumour. There were no survivors in patients with malignant hepatic tumours (n = 10) who had surgery alone prior to 1981. Of 7 patients with HBL diagnosed after 1981 who had adequate surgical resection and chemotherapy, 5(72%) are currently alive and disease free between 15 months and 8 years from diagnosis. We conclude that adequate surgical resection and adjuvant chemotherapy can improve disease free survival for children with HBL. Optimal treatment has yet to be devised for other malignant hepatic tumours.

The changing role of surgery in the management of rhabdomyosarcoma

A retrospective analysis was performed of 56 patients presenting to Our Lady's Hospital for Sick Children, Crumlin, Dublin, Ireland, over a 25 year period with a diagnosis of rhabdomyosarcoma, in an effort to assess the changing role of surgery in the management of this disease. There were 38 males and 18 females; the age range at presentation was from birth to 13 years with a median of three years. Head and neck tumors occurred most frequently (23) followed by pelvic (14), paratesticular (6), extremities (6), gastrointestinal (4) and thoracic (3). Prior to 1971 there were no survivors while a doubling of survival has been observed within the past decade (31% to 63%). The minimum period of follow-up was four years. Surgical intervention ranged from total primary excision (20) to biopsy only (21) with total or subtotal resection performed electively in 15. Surgical evaluations, including examinations under anesthesia, staging laparotomy and second look laparotomy were also invaluable in assessing disease status. The incorporation of multiagent chemotherapy together with more selective use of radiotherapy has enabled a more conservative role to be adopted by the surgical oncologist thereby minimizing longterm sequelae.

Langerhans cell histiocytosis--a 31 year review

Forty-one patients with Langerhans Cell Histiocytosis (LCH) were treated over a thirty-one year period in our institution. These children were classified according to the number of systems involved: twenty-two had unisystem disease while nineteen had multisystem disease. A histological diagnosis was reached in 82% of cases, the remainder being diagnosed on both radiological and clinical grounds. 68% of those with multisystem disease had a rash at diagnosis whilst 64% had a persistent ear discharge. The diagnosis was established accidentally in 25% of those with unisystem disease. The mortality rate was 21% and was confined to those who were under two years of age at diagnosis, all of whom had multisystem disease. Morbidity was 20% and was restricted to patients with multisystem disease. Only one patient died within the last 10 years; there were no therapy related deaths. Treatment related morbidity was seen in only three children. In keeping with other series, our review has identified the following adverse prognostic factors a) age under 2 years at presentation, b) multisystem disease and c) major organ dysfunction. In view of the natural history of the disease, it is suggested that chemotherapy only be used in those patients who have major organ dysfunction or progressive disease and that radiotherapy is rarely indicated.

Short duration, high dose, alternating chemotherapy in metastatic neuroblastoma. (ENSG 3C induction regimen). The European Neuroblastoma Study Group

Fifty-one children, aged from 15 months to 13 years 5 months with metastatic neuroblastoma presenting sequentially at the participating institutions received four 3 to 4 weekly courses of high dose multiagent chemotherapy. High dose cisplatin (200 mg m-2) combined with etoposide (500 mg m-2), HIPE, was alternated with ifosfamide (9 g m-2), vincristine (1.5 mg m-2), and adriamycin (60 mg m-1), IVAd. Disease status was re-evaluated 3 to 4 weeks after the fourth course and the response classified according to the International Neuroblastoma Response Criteria (INRC). The overall response rate in evaluable patients was 55% and response rates by site were: bone marrow 67% (complete response 47%); bone scan 68%; primary tumour 61%, and urinary catecholamine metabolites (VMA/HVA) 95%. Serial 51Cr EDTA renal clearance studies showed a glomerular filtration rate (GFR) decline in 40% of patients but in only seven cases to below 50% of the pretreatment value. There was no instance of renal failure during induction, though two patients developed severe renal failure following 'megatherapy' given to consolidate remission. Serial audiometry showed a significant decline in hearing at frequencies above 2,000 Hz in 37% of children but at or below 2,000 Hz in only 17%. Neutropenia and thrombocytopenia were severe and intravenous antibiotics were required after 30% of courses. Each of two treatment-related deaths occurred during pancytopenia following courses of IVAd. Complete, or greater than 90%, removal of primary site tumour was possible in 70% of cases following this induction regimen and 75% of patients proceeded to elective megatherapy within a median time of 24 weeks after diagnosis. This short intensive induction programme is highly effective at achieving cytoreduction, enabling early surgery and early megatherapy procedures. It is, however, too early to draw firm conclusions about the impact of this approach to treatment on the cure rate.

Recent experience with intensive combination chemotherapy for treatment of childhood acute lymphoblastic leukaemia

Forty-eight children with acute lymphoblastic leukaemia (ALL) who presented to the Oncology Department of Our Lady's Hospital for Sick Children, Crumlin, Dublin over a 52 month period were treated using a schedule modified from the BFM-81 protocol. All patients achieved remission within four weeks. With a minimum follow up period of 18 months, actuarial disease free survival was 68% and overall survival 75%. Mean hospital stay throughout the treatment period was 31 days. While these results represent an improvement in overall survival compared with historical controls, careful selection of risk categories will be the major aim of future studies so that more appropriate treatment can be instituted for high risk patients while minimising therapy for low risk disease.

Monoclonal antibodies as targeting agents for cytotoxic compounds in vivo: a current assessment

Monoclonal antibodies have proved useful in the in vitro diagnosis of tumour type. Radiolabelled antibodies have also been investigated as targeting agents for the in vivo diagnosis of tumour metastasis. These studies have revealed the potential of using 'targeting agents' to identify tumours, but in addition have exposed some of the problems associated with the technique. This review describes our experiences using radiolabelled antibodies for the identification and treatment of tumours arising from the neuro-ectoderm. Based on a small number of 4 patients studies, we conclude that there are limitations on the use of radiolabelled antibodies for targeting isotopes to primary tumour masses. In addition, we outline a possible important role for antibodies in targeting therapeutic agents to minimal residual disease and diffuse tumours presenting as micro-metastasis.

Orbital fibrous histiocytoma in an infant

A rare case of fibrous histiocytoma in an infant is described. The tumour appeared to arise in the medial orbit, invading the ethmoid and maxillary sinuses. Surgical and medical management, and the subsequent clinical course in a 11 year follow-up period are described. Histogenesis of this primary mesenchymal tumour is discussed.

Very-high-dose cisplatin and etoposide in children with untreated advanced neuroblastoma

Between January and December 1985, 17 children with advanced neuroblastoma who were greater than 1 year old (16 stage IV, one stage III) were administered cisplatin (CPDD, 200 mg/m2) and etoposide (VP-16, 500 mg/m2) as a pilot study of toxicity and response rates for the European Neuroblastoma Study Group (ENSG). The study was designed to assess toxicity of two courses of treatment, and evaluate response rates after this short therapy. The creatinine clearance declined in seven of 15 patients. No patient experienced clinically significant hearing loss, but formal audiometric assessment of nine children revealed characteristic high tone loss in seven patients. Peripheral neuropathy was not seen. Asymptomatic hypomagnesemia (less than 0.7 microEq/L) was frequent, despite routine supplementation. Asymptomatic electrolyte imbalances occurred frequently, but were generally transient. Myelosuppression was severe, but brief. Seven patients required platelet transfusions and seven were readmitted between courses due to febrile episodes while neutropenic. There were no treatment-related deaths. According to strictly defined criteria, 12 of 17 patients showed a partial response (PR), and extensive marrow evaluation showed complete clearing of disease in six of 15 patients. This high-dose regimen, if carefully supervised, is associated with acceptable toxicity, comparable to that seen when the dose of CPDD is spread over several months. The rapidity and degree of response was encouraging and merits further evaluation.

131-I coupled to monoclonal antibodies as therapeutic agents for neuroectodermally derived tumors: fact or fiction?

It has been suggested that monoclonal antibodies may be useful in targeting cytotoxic compounds to tumor cells. We have explored their use in targeting 131-I to highly radiosensitive primitive neural tumors such as neuroblastoma and pineoblastomas. Two routes of administration have been employed, intravenous and intrathecal. Our current experience in using radiolabelled antibodies is described, indicating toxicities seen and any therapeutic benefit observed. The results of the study suggest that if targeted radiation has a role in the treatment of these malignancies, it will be restricted to the eradication of small tumor masses from the body.

Renal papillary adenocarcinoma following treatment for Wilms' tumor

A 7-year-old girl treated for Wilms' tumor in 1975 developed a renal papillary adenocarcinoma (RPA) in her remaining kidney five years later. This second tumor was detected by abdominal ultrasound during routine assessment of the growth and function of her remaining kidney. An abdominal computerized axial tomogram confirmed the presence of an intrarenal mass, but a renal anteriogram was entirely normal. The second tumor was enucleated by blunt dissection. No further treatment was given. The child remains well and disease-free 22 months following surgery.

Nucleoside incorporation into DNA and RNA in acute leukaemia: differences between the various leukaemia sub-types

The incorporation of the labelled deoxyribonucleosides 3H-deoxythymidine (3H-TdR), H3-deoxycytidine (3H-CdR), 3H-deoxyadenosine (3H-AdR), 3H-deoxyguanosine (3G-GdR), 3H-deoxyuridine (3H-UdR) and of labelled uridine (3H-UR) into DNA and RNA was studied in bone marrow (BM) and peripheral blood (PB) cells from 10 normal donors and 11 patients with acute myeloblastic leukaemia, 13 with acute non-T non-B common ALL (c-ALL) and seven with thymic acute lymphoblastic leukaemia. 3H-TdR incorporation was highest into the DNA of normal BM cells, 3H-CdR into DNA in Thy-All and 3H-UdR into DNA of c-ALL cells. Purine deoxynucleoside (3H-AdR and 3H-GdR) incorporation was highest in AML cells and they were incorporated mainly into RNA indicating that before utilization they are partially degraded from the deoxyribose to the corresponding ribose form. In all but three leukaemia samples, the 3H-UdR/3H-TdR incorporation ratio was above the range found in normal bone marrow, suggesting the leukaemic cells are more dependent than a normal mixed marrow cell population on the de novo pathway of thymidylate synthesis. The incorporation of nucleosides by peripheral blood cells was usually much lower than by the corresponding bone marrow cells, irrespective of blast percentage.

The aplastic presentation of childhood leukaemia: a feature of common-ALL

Transient pancytopenia preceded the onset of acute leukaemia in eight of 360 (2%) of children with acute lymphoblastic leukaemia (ALL) but did not occur in 70 cases of acute non-lymphoblastic leukaemia. The patients developed overt leukaemia within 5-38 weeks of first presentation with features of marrow failure. Immunological classification of blast cells was performed in six of the eight patients and all had phenotype of common-ALL (c-ALL). We conclude that the sydnrome of pre-leukaemia aplasia in childhood is a feature of c-ALL.