The Role of Chemotherapy in Management of Inoperable, Metastatic and/or Recurrent Melanotic Neuroectodermal Tumor of Infancy-Own Experience and Systematic Review

Simple Summary

Melanotic Neuroectodermal Tumor of Infancy (MNTI) is a very rare neoplasm that most commonly develops within maxilla in infants. It usually has a benign clinical course and is treated with only surgery. However, patients with large, inoperable, metastatic or multiply recurring MNTI may require systemic treatment. The role of pre- and post-surgery chemotherapy (CHT) in the management of MNTI is unclear. Here, we have presented the disease courses and outcomes of four infants treated with multidrug CHT due to inoperable/recurrent MNTI. Additionally, a systematic literature review was performed which revealed 38 similar cases in the last 42 years. Most children with primarily inoperable MNTI responded to CHT, which allowed physicians to perform complete, non-mutilating delayed surgery. However, it is still uncertain whether CHT administered after incomplete resection of MNTI prevents recurrence. This study aimed to contribute to the establishment of standards of management in patients with inoperable, metastatic or persistently recurring MNTIs, which are currently lacking.

Abstract

Melanotic Neuroectodermal Tumor of Infancy (MNTI) is a very rare pediatric neoplasm of neural crest origin. In most cases, it develops in infants as a localized tumor of the maxilla, and surgery is usually curative. In less than 10% of patients with inoperable, metastatic or persistently recurring MNTI, chemotherapy (CHT) may be considered; however, its role is still unclear. The aim of our study was to assess the efficacy of CHT in children with large, inoperable, metastatic and/or recurrent MNTI. Four such infants, treated with CHT in Polish and German centers of pediatric oncology, were presented. Additionally, a systematic literature search of the PubMed/MEDLINE, Scopus and Web of Science databases was performed, yielding 38 similar cases within the last 42 years. Neoadjuvant CHT, based mainly on the protocols for neuroblastoma, was often effective, allowing for complete delayed surgery in most cases. However, the role of adjuvant CHT in preventing recurrences after incomplete resection of MNTI remains unclear. Disseminated inoperable MNTI was almost universally associated with poor response to CHT and unfavorable outcome. Further investigations to elaborate standards of management in patients with inoperable, metastatic or persistently recurring MNTIs are necessary to improve outcomes.

Prognostic Factors for Wilms Tumor Recurrence: A Review of the Literature

Simple Summary

A Wilms tumor is a childhood kidney tumor. In high-income countries, 90% of patients with this tumor survive. However, the tumor recurs in 15% of patients. It is important to identify the patients at risk of recurrence in order to adjust treatment in such a way that recurrence may potentially be prevented. However, we are currently unable to determine precisely which patients are at risk of recurrence. Therefore, we present an overview of factors that influence the risk of recurrence, also known as prognostic factors. These factors range from patient-, tumor- and treatment-related characteristics to geographic and socioeconomic factors. In addition to these factors, biological markers, such as genetic alterations, should be studied more intensively as these markers may be able to better identify patients at risk of tumor recurrence.

Abstract

In high-income countries, the overall survival of children with Wilms tumors (WT) is ~90%. However, overall, 15% of patients experience tumor recurrence. The adverse prognostic factors currently used for risk stratification (advanced stage, high risk histology, and combined loss of heterozygosity at 1p and 16q in chemotherapy-naïve WTs) are present in only one third of these cases, and the significance of these factors is prone to change with advancing knowledge and improved treatment regimens. Therefore, we present a comprehensive, updated overview of the published prognostic variables for WT recurrence, ranging from patient-, tumor- and treatment-related characteristics to geographic and socioeconomic factors. Improved first-line treatment regimens based on clinicopathological characteristics and advancing knowledge on copy number variations unveil the importance of further investigating the significance of biological markers for WT recurrence in international collaborations.

Bilateral Nephroblastoma with Dilated Cardiomyopathy as an Indication for Off-Protocol Treatment: A Case Report

Patients with a Wilms tumor are often admitted to the hospital accidentally, with an abdominal mass causing asymmetry of the abdominal wall. Hypertension accompanying a Wilms tumor occurs in about 10–27% of children, but cardiomyopathy associated with a Wilms tumor is very rarely described. This publication presents a case of a 9-month-old girl with a bilateral Wilms tumor accompanied by dilated cardiomyopathy since her initial cancer diagnosis, as well as her off-protocol treatment. The severe condition of the child forced the application of off-protocol treatment, i.e., accelerated resection of a larger tumor, which enabled the improvement of heart performance and made subsequent therapy possible. In the course of the presented treatment, a gradual normalization of cardiac ventricular function and contractility was observed. In conclusion, a massive abdominal tumor associated with abdominal compartment syndrome compromised the functioning of the cardiovascular system in the young child. Therefore, earlier removal of Wilms tumors in patients with heart failure should be considered. This may result in the improvement of cardiovascular function and the possibility of further therapy.

Clinical factors in relapses of Wilms' tumor--results for the Polish Pediatric Solid Tumors Study Group

BACKGROUND

The risk factors responsible for recurrences of Wilms' tumor (nephroblastoma) are still under discussion. The aim of the study was to analyze the relationship between relapses of Wilms' tumor and the patients' clinical history.

MATERIAL AND METHODS

Clinical data from children registered in the Polish Pediatric Solid Tumors Study Group were analyzed. The clinical stages (CS), pathology variants (high risk: HR, intermediate risk: INT, and low risk: LOW) and chemotherapy regimens were correlated with the outcomes.

RESULTS

Recurrences developed in 34 out of 288 (11.8%) patients with Wilms' tumor treated in accordance with International Society for Pediatric Oncology 2001 (SIOP 2001) protocols. Of these 34 patients, 11 initially had CS I, seven were at CS II, four were at CS III, 11 were at CS IV and one had CS V. There were eight patients with second recurrences; of these, seven were in the INT risk group and one in the high histological risk group. There was no correlation between age (p=0.256) or gender (p=0.538) and the risk of tumor recurrence. In the study group, seven out of 10 patients with local recurrences are alive; as are 13 out of 22 patients with distant recurrences (p=0.703). Those who died due to disease progression comprised six out of 26 patients with a first recurrence (four HR, two INT), and seven out of eight with a second recurrence (one HR, six INT).

CONCLUSIONS

The prognosis after relapse in initially metastatic patients did not differ from that in patients who had primarily localized disease. The pathology variants probably had more significance.

Internal hemipelvectomy in the management of pelvic Ewing sarcoma - are outcomes better than with radiation therapy?

BACKGROUND

Pelvic Ewing sarcoma (ES) is commonly associated with a worse prognosis. Large size and location limit local control options to radiation therapy, and local recurrences are common. We evaluated the impact of hemipelvectomy and radiation on outcomes, including function.

MATERIALS AND METHODS

Thirty-nine patients (median age 13.5years) with ES of the pelvis and sacral bones were treated during the period 2000-2012. Fifteen were treated with definitive radiotherapy (RT), 9 patients underwent hemipelvectomy alone, and 15 were treated with combined hemipelvectomy and RT.

RESULTS

Twenty patients (51.2%) are alive with a median follow-up 3.2years from diagnosis. Median time from diagnosis to relapse was 1.3years. Three-year estimates of EFS and OS were 47% and 61%, respectively. Patients treated with surgery or surgery with RT had better outcome than patients treated with RT only (3-year OS 78% or 81% vs. 36%, respectively, p=0.00083). The outcome of patients with pelvic ES treated with hemipelvectomy was not significantly different from the outcome of all patients with Ewing sarcoma treated on the national Polish protocol.

CONCLUSIONS

Internal hemipelvectomy offers good chances of cure for patients with pelvic ES, with a reasonable rate of complications and good function.

Ganglioneuroma in a patient with Turner syndrome

INTRODUCTION

Ganglioneuroma is a benign neuroblastal tumor that derives from immature cells of the sympathetic nerve system. It is a very rare disease and affects newborns and infants more often than adolescents and adults. The benign tumors are relatively difficult to diagnose since they usually are asymptomatic. We present a case of unusual coincidence of an ganglioneuroma and Turner syndrome (TS).

CASE REPORT

An 11.5-year-old TS patient was admitted into the hospital with good general condition. She was 7 months into growth hormone (GH) therapy. The reason for the admission was to carry out control tests. The patient had not complains or abnormalities on physical examination. On the ultrasound examination of the abdomen in the right adrenal area an adrenal tumor was identified. The ultrasound examination of the abdomen performed 13 months earlier did not show any abnormalities. Computed tomography of adrenal glands confirmed right adrenal tumor. The hormonal function of the adrenal gland was normal. The treatment with GH was terminated and the patient was urgently referred to surgical management. The right adrenal gland tumor together with a part of diaphragm was removed. On histopathological examination ganglioneuroma maturum was diagnosed. On the control MIBG examination physiological gaining of tracer in the left adrenal and in the rest tissue in the area of the right adrenal was found. Trepanobiopsy did not confirm neoplastic changes.

CONCLUSIONS

There is a necessity of careful monitoring of TS patients also in face of the possibility of disclosure previously not stated neoplasm after starting GH therapy. It is impossible to rule out that GH therapy promote growth of existing neoplasm.

Surgical treatment of patients with disseminated Ewing sarcoma in our clinical experience

BACKGROUND

Survival in advanced Ewing's sarcoma is unsatisfactory even with combination treatment. This paper tries to evaluate the impact of surgical treatment on treatment results.

MATERIAL AND METHODS

We discuss a series of 24 patients aged 6.1-18.9 years with disseminated Ewing's sarcoma treated in the years 2000-2008. The patients had metastases to the lungs (13 patients), bone (6 patients), or multiple sites (5 patients). The follow-up period ranged from 8 months to 8.5 years. The patients were treated in accordance with the EE99 protocol. 19 out of the 24 patients underwent surgery. Patients with lung metastases underwent resection of both the primary focus (12 children) as well as the lung metastases (6 children) or radiotherapy. Patients with metastases located elsewhere underwent resection of the primary focus and lung metastases, while the remaining metastatic sites were irradiated (7 children). The 6 remaining children received chemotherapy and radiotherapy.

RESULTS

Ten of the 19 patients who were operated on are alive. All those patients that were not operated on have died. The length of survival in the whole group has ranged from 8 months to 8.5 years (mean 2.8 years). Mean overall survival among these patients that were operated on is 3.1 years, and among those who had lung metastases at baseline and underwent metastatectomy, the survival rate is 4.3 years. The average survival rate among the non-operated on patients is 1.6 years.

CONCLUSIONS

Surgery appears to prolong survival among patients with disseminated Ewing's sarcoma.

[Papillary thyroid carcinoma and meningioma in 17-year-old boy- a late effect of acute lymphoblastic leukemia treatment or a new disease? Case report and literature review]

Thyroid carcinoma and meningioma can occur as a primary malignancy (PTM) or secondary after another malignancy (STM). We presented a boy 17 years of age with thyroid carcinoma and meningioma, which were recognized during growth deficiency diagnosis, 11 years after the treatment of ALL and 10 years after the bone marrow transplantation. Children who have been successfully treated for one cancer have a higher than expected incidence rate of additional tumors and therefore they need endocrinological care.

[Thymoma and thymic carcinoma--review of literature and clinical characteristics based on the Polish Paediatric Solid Tumours Study Group experience]

Thymomas and thymic carcinomas are rare neoplasms derived from the epithelial tissue of thymus, very infrequently developing in young adults and children. The estimation of thymomas' invasiveness has been the matter of discussion for many years reflected by numerous clinical and histological classifications. In 1999 the WHO classification was created, joining all the most important issues present in previously used systems. It is believed that histological structure is the most important prognostic factor in thymic carcinomas while in less aggressive types of thymomas the clinical stages influence the outcome. Staging of thymomas is most commonly based on the Masoka classification. Independent evaluation of the stage and histological aggressiveness are necessary to predict the clinical course and outcome in thymomas. Thus the term 'malignant thymoma' has been replaced by 'invasive thymoma' in clinical practice. The treatment strategy depends on the clinical stages of thymoma. Complete resection of the tumour is the treatment of choice with supplementing radiotherapy in more advanced clinical stages. Chemotherapy in invasive thymomas has been reported to play an increasingly important role as induction, supplementing and palliative therapy. It has been proved that combined treatment improves the outcome in invasive thymomas, especially in thymic carcinomas. This paper reviews the literature data concerning the histology, clinical issues and treatment of thymomas and thymic carcinomas. The clinical data on nine children with thymic carcinomas treated between 1992 and 2006 in the Polish oncological and surgical centres were also analysed and presented. Based on multicentre data we were able to conclude the following: 1. Thymic carcinomas in children are very rare and that is why early diagnosis is often difficult. 2. At diagnosis most cases are already inoperable, which results in poorer prognosis. 3. Complex adjuvant chemo- and radiotherapy in childhood thymic carcinomas seem to prolong overall survival. 4. Further detailed analysis in all the cases of thymic carcinomas in children is recommended in order to estimate the optimal strategy of treatment.

[Diagnostic difficulties in pediatric abdominal pain with potential appendicitis]

BACKGROUND

Pediatric abdominal pain is one of the most common symptom of children brought to attention of primary care physicians and pediatric surgeons. In many children clinical symptoms may be uncharacteristic and may lead to diagnostic difficulties.

AIM

Clinical analysis of children with right lower quadrant abdominal pain suspected of appendicitis or children with periappendicular mass.

MATERIALS AND METHODS

The histories of 14 children aged from 18 months to 17 years treated in Pediatric Clinic were analysed. All children were operated because of right lower quadrant abdominal pain or abdominal mass before admission to the Pediatric Clinic or during hospitalization in Pediatric Clinic. Intraoperatively in all children pathologies other than appendicitis were the cause of symptoms.

RESULTS

The most often Crohn's disease were recognized (9 children), in 2 cases with concomitant other pathologies (fecal tumor of appendix in one case and with peritoneal abscess after perforation of intestinal wall). Sporadically the inflammation of the mesenterial lymph nodes caused by Yersinia infection suggested appendicitis. In one boy with ulcerative colitis, during exacerbation of the disease appendicitis complicated by rupture and peritonitis was observed. In 18-month old child with right lower quadrant abdominal mass invagination complicated by perforation of the ileum was recognized. In the case of 14-years old boy 6 months after appendectomy we observed mechanical intestinal obstruction complicated by perforation and peritonitis. Carcinoid of the appendix was the cause of abdominal pain in one child.

CONCLUSIONS

1. Appendicitis is the most frequent surgical etiology of the right lower quadrant pediatric abdominal pain. 2. Despite new diagnostic imagines there are no definite criteria to recognize appendicitis, in most cases physical examination and very carefull evaluation of abdominal pain are the most important. 3. All children with periappendipected of Crohn's disease. 4. All children with equivocal presentations of appendicitis and with normal appendix during operation should undergo further diagnostic evaluation.

[Surgical treatment for malignancies in children--is prolonged bone marrow suppression an absolute contraindication for surgical procedures?]

AIM

To analyze the perioperative period in children who required surgery anticipated in the protocol and suffered from prolonged bone marrow suppression.

MATERIAL AND METHODS

The surgical treatment of 15 children with prolonged bone marrow suppression, resistant to GM-CSF for 5-15 weeks (M=10), was retrospectively analyzed. Criteria to submit a patient to the group were: neutropenia <1000/ml or/and thrombocytopenia <70,000/ml. Four had thrombocytopenia, 8 neutropenia and 3 cytopenia of both cell lines. Neutropenic patients were divided into two groups: severe neutropenia--<500/ml (2), and moderate--500-1000/ml (7). Children with thrombocytopenia were divided into two groups: with thrombocytes <30,000/ml (2) and between 30,000-70,000/ml (5).

RESULTS

Complications (pneumonia and sepsis) were noted in 2 out of 4 children with severe neutropenia, remaining patients had uncomplicated perioperative period. Patients with moderate neutropenia did not show any alarming signs after surgery. As a major haemorrhage we assumed loosing > 30 percent of circulating blood. This was observed only in 1 patient (with thrombocytes <30,000/ml). 13 patients were discharged from our Department between 3-10 days after surgery in good general condition. Two had to be treated for a longer time because of advanced cancers (18 and 21 days).

CONCLUSIONS

Neutropenia does not seem to be an absolute contraindication for surgical procedures needed in complex cure of malignancies. In our opinion thrombocyte level > 30,000/ml appears to be safe enough to conduct surgery.

[Diagnosis and treatment of thyroid cancer in children in the multicenter analysis in Poland for PPGGL]

INTRODUCTION

Differentiated thyroid carcinoma (DTC) in children presents different biological behavior in comparison to adults. Authors presents preliminary results of multicenter analysis concerning incidence, diagnostics and treatment of DTC in children.

MATERIAL AND METHODS

The study is a retrospective analysis of 107 pediatric patients from 14 academic centers based on the data from 2000 to 2005 obtained by questionnaire in hospitals involved in the treatment of DTC in children.

RESULTS

Papillary thyroid cancer was diagnosed in 83 children, follicular thyroid cancer in 10 children and medullary thyroid cancer in 14 children. Incidence of DTC in children was estimated between 18 and 23 cases per year. The biggest group of patients consisted of children between 11 and 15 years of age, with girls to boys ratio 3.3 : 1. Clinically DTC in children presented most often as solitary thyroid nodule. Cervical lymphadenopathy was observed in 42% of patients. Intraoperative verification indicated metastatic nodes in 50% of children. Low stage DTC predominated (T1 in 36% and T2 in 26% of children). One step surgery was performed in 65% of children with DTC, two step surgery in 25% of patients. I131 therapy was undertaken in 80% of children. Lung metastases were indicated in post therapeutic studies in 14% of children with DTC. Prophylactic thyroidectomies were performed in 79% of children in the group of patients with MTC and RET gene mutations.

CONCLUSIONS

The necessity of introduction of unified therapeutic standard in children with DTC in Poland is underlined.

[Ewing's sacroma / PNET--the possibility to assure local control]

Ewing's sarcoma and PNET are more and more frequently submitted to surgical treatment, as this method of local therapy seems to offer a better chance for cure. Which method surgery or radiotherapy (RTx) is more mutilating in childhood, should be carefully considered. The aim of the report is to review the possibility of local resection and reconstruction in various sites of the tumour.

PATIENTS

12 patients with Ewing's sarcoma / PNET were submitted to the site-specific surgical procedures and assessed for local control and function. All were pre-treated with CHT and continued that treatment after surgery. Four patients had fibular Ewing's sarcoma and all underwent subtotal fibulectomy. Long term complete remission (CR) was achieved in all. Two patients had Askin tumours; both developed pleural relapses distant to the primary tumour site. One patient had total scapulectomy (CR for 7 years). One patient had hemipelvectomy supplemented with RTx because of micro residue (CR for 10 years). Two patients were amputated: one for PNET of tibia invading nerves and vessels, another one for Ewing's sarcoma of femur. The first one developed pulmonary metastases and died one year later, the second one has been alive for 13 years but has badly accepted the prosthesis. Two patients with very extensive tumours of pelvis could never be operated on, they never achieved CR despite chemo- and radiotherapy and died.

SUMMARY

Of 10 patients submitted to surgery 7 patients are alive and 4 have an excellent functional result. Of the 2 patients in whom the tumour was inoperable neither is alive. It seems justified to recommend surgical resection of Ewing's sarcoma / PNET; satisfying reconstruction is usually feasible. RTx seems to have value rather as a method supplementing minor failures of surgery than as the only local treatment.

[Intramuscular angiomyolipoma in children--own observations]

Angiomyolipoma (AGML) is a rare benign tumour usually located in the kidneys, but it can occur also in other sites -- e.g. in the skeletal muscles. This location requires differentiation from sarcomas and angiomas. The aim of the study is to assess the diagnostic and therapeutic methods applied in the management of patients with AGML.

PATIENTS

five patients were treated for intramuscular AGML (1998-2001). Tumour localisation was as follows: intermediate head of vastus muscle of the femur, lateral head, medial head, occipital muscles of the head, and the interosteal muscles of the metatarsum. All patients complained of severe, localized pain; the tumour mass was usually small and hardly palpable. The biopsy was preceded by ultrasound examination with Colour-Doppler option and CT examination with "angio" option. After the result of the pathological examination of the biopsy specimen was obtained, surgery was performed. One cm of healthy tissue around the tumour was the required margin of excision. This was obtained in all cases but one. Pain relief was obtained in all patients; in one, local relapse occurred.

CONCLUSION

AGML is a rare neoplasm in extra renal locations. Its appearance seems typical, with severe pain and only small deformation of the muscle. In this sub-group of patients, AMGL is located frequently in the femoral muscles. USG and CT imaging may correctly suggest the character of the tumour; however, the extent of treatment, should be decided after the biopsy histopathological report is known. MRI seems unnecessary when good quality Doppler-sonography and CT are available.

[Malignant vascular tumours in children -- report from the Polish Pediatric Rare Tumors Study]

Malignant vascular tumours represent a rare group of neoplasms, usually treated according to protocols for soft tissue sarcomas.

THE AIM OF THE STUDY

To assess the clinical characteristics, disease course and outcome in Polish children with malignant vascular neoplasms.

MATERIAL AND METHODS

The Polish Paediatric Rare Tumours Study retrospectively analysed multicentre data on 32 children with vascular tumours, registered between 1992 and 2002. On the basis of the histological type of the neoplasm these patients have been divided into three groups: group I -- 10 patients with angiosarcoma (ASA), group II -- 7 children with haemangioendothelioma (HE) and group III- 15 patients with haemangiopericytoma (HP), of both infantile (7 children) and adult-types (8 patients).

RESULTS

Group I: 5 patients presented with local, 3 with systemic and 2 with regional disease. Primary complete resection (PRC) was performed in 7 patients, not resulting in local control in any of them. Radiotherapy (RTX) was administered in 5 patients, chemotherapy (CHT) in all. 7 patients relapsed, 3 never entered clinical remission. 9 of the 10 patients of group I, died of disease progression. Group II: PRC was performed in 5 patients and led to local control in 2. Adjuvant RTX was used in 2 and CHT in 4 patients. 2 children relapsed and died of the disease. Infantile HP: PRC was performed in 3 children, remaining 4 patients received adjuvant CHT All children entered complete remission and are disease-free. Adult-type HP: PRC was performed in 5 patients, resulting in local control in 4. Five children were given adjuvant RTX and six CHT Three patients relapsed and died of disease progression.

CONCLUSIONS

The effectiveness of primary complete resection in all groups was doubtful. The high rate of metastatic relapses suggests that the currently given systemic therapy is not satisfactory. The only tumour with excellent prognosis was infantile type HP (all patients are alive and free of disease). Adequate treatment for children with angiosarcoma remains still unknown -- 9 of 10 patients died of disease progression. Prognosis in patients with haemangioendothelioma is intermediate, however the role of immunotherapy should be further investigated.

[Rare tumours--are they really rare in the Polish children population?]

Clear statement that pediatric neoplasms are really rare is not easy. Thus the incidence of rare tumours in children has not been defined so far. The paper efforts to assess the topic of rare tumours of childhood in the Polish population. Following two categories are proposed: tumours typical for adults, but possible in children (neoplasms of epithelial origin--mainly carcinomas, melanomas, carcinoids) and paediatric tumours consisting less than 10% of cases in corresponding clinical groups according to the ICCC classification. Data on 317 patients aged 0-18 years treated in centres associated in the Polish Paediatric Group for Solid Tumours (PPGST) were analysed. Classical adult malignancies were registered in 130 patients: carcinomas in 90 (mean age 12.6 +/- 4.5 years), melanomas in 25 (mean age 9.4 +/- 4.9) and carcinoids in 9 (mean age 14.5 +/- 1.2 years). Non epithelial neoplasms were registered in 187 patients (mean age 10.4 +/- 5.5). That group included rare tumours of soft tissue, CNS, bones and other organs. Treatments of certain groups were specified by separate therapeutic protocols within PPGST. Rare malignancies of adult-type among children under 18 years of age in Poland comprised 1.5% of all pediatric neoplasms. The incidence of adult-type neoplasms increased with age until 14 years. In patients over 15 years of age the number of registered cases decreased. It may suggest a first peak of incidence in early adolescence or an underestimation of number of patients with carcinoma aged over 15 years. In the analyzed group, the mean age of patients with carcinomas and other epithelial and unspecified tumours significantly exceeded the age of children with rare neoplasms of non-epithelial origin (12.1 +/- 4.7 vs 10.4 +/- 5.5 years; p<0.05). A very young age at diagnosis of malignant melanomas (mean 9.4 years) and numerous cases of carcinomas affecting the digestive tract (n=24; 27% of all carcinomas), especially those located in colorectal region (n=10), seem surprising. The preliminary analysis of the collected data on rare neoplasms in Poland encourage to undertake a prospective study, meant to link the epidemiology and characteristics of rare epithelial tumours in childhood with diagnostic and therapeutic suggestions for these types that are not coordinated within Polish Paediatric Group of Solid Tumours.

[High risk Wilms' tumor in children. Clinico-pathological correlation based on 320 patients registered in the Polish Paediatric Solid Tumor Study Group]

The records of 320 patients treated for Wilms' tumour in the first Wilms' Tumour Study (01-92 schedule) were reviewed and 42 children (13,86%) with unfavourable histology (UH) tumours were identified. There were 18 boys and 24 girls. Diffuse anaplasia was found in 26 patients (61,9%), focal anaplasia in 10 children (23,8%), CCSK and MRT were diagnosed in 3 patients each (7,1%). Clinical stages were: CS I - 5 (11,9%) patients, CS II N(-) - 7 (16,7%), CS II N(+) - 9 (21,4%), CS III - 15 (35,7%), CS IV - 5 (11,9%) and CS V - 1 patient (2,4%). Local and metastatic relapses of the disease occurred in 18 patients (43%). Seven of the 42 patients died, in 2 cases due to complications and in 5 from progression of the disease.

Primary nephrectomy for emergency: a rare event in the International Society of Paediatric Oncology Nephroblastoma Trial and Study no. 9

Experience of the International Society of Paediatric Oncology (SIOP) Trials and Studies indicates that the preoperative chemotherapy in Wilms' tumour improves stage distribution, decreases complication rate and reduces postoperative treatment. However, some situations may lead to prompt primary surgery. The aim of the study is to assess reasons leading to primary emergency nephrectomy. Records of 720 patients with non-metastatic unilateral nephroblastoma who were registered in the SIOP Trial and Study 9 were reviewed. Twenty-four (3%) cases of primary emergency nephrectomy were identified. Reasons leading to emergency nephrectomy were massive bleedings from ruptured tumours in 13 patients, suspicion of an "acute abdomen" in 7, bowel occlusion in 2 and other in 2. Postoperative treatment included radiotherapy in 71% of cases and anthracyclines in 92%. Complications were frequent and happened in 25% of patients, the outcome however, was favourable and 22 of 24 patients are alive (from 9 to 79 months). The 7 patients with a suspicion of an "acute abdomen" probably constitute the group which could have been markedly reduced if adequately diagnosed and observed prior to surgery.

Venoocclusive liver disease (VOD) as a complication of Wilms' tumour management in the series of consecutive 206 patients

In 4 years (1993-1996) 206 pts. with nephroblastoma were treated. All children were treated according to SIOP 93-01 protocol. Overall survival was 92%. In 27 cases hepatotoxic events occurred. In 10 cases, venoocclusive liver disease (VOD) was diagnosed. VOD is a syndrome associated with hepatomegaly, sudden weight gain or ascites and jaundice. It results from damage to the endothelium of hepatic venules and necrosis of central hepatocytes with subsequent proliferation of fibrous tissue and occlusion of the central hepatic veins. Dactinomycin is one of the drugs considered responsible for its development. Mean age of VOD patients was 4 yrs, however 3 of them were below 1 yr. In all cases, VOD occurred during postoperative chemotherapy (mean 16 th week of treatment). All patients received dactinomycin and vincristine. Five children with right kidney tumors underwent post-operative abdominal irradiation. Main VOD symptoms were hepatomegaly and ascites (80%). Hypertransaminasaemia, as well as, on ultrasound, gallbladder wall thickening and/or free abdominal fluid were observed. Median VOD duration was 27 days and its course was usually temporary and self-limiting. However, in 2 cases recurrent VOD episodes were noted. All children received supportive treatment only. In 6 cases, VOD resulted in chemotherapy delay or drug reductions, while in 4 others chemotherapy was completed preliminarily. Nevertheless it did not affect patients' outcome overall survival in VOD group was 90%.

CONCLUSIONS

Total 5% VOD frequency is similar to other reports. Infants and children receiving abdominal irradiation seem to be at special risk of VOD development.

[The surgical treatment of advanced stages of solid tumors in children]

Hope for cure in children with advanced cancer came with introduction of chemo- and radiotherapy, however surgery is still important as a part of the multidirectional treatment. The aim of the review was to assess the impact of surgical treatment in children with advanced cancer. From 1991 to 1997, 30 patients aged from 6 months to 17 years were treated for soft tissue sarcomas (STS: stage III/8 pts, stage IV/2 pts), nephroblastoma (WT: stage IV/5 pts, stage V/3 pts), PNET/Ewing sarcoma (locally advanced/4 pts, metastatic/2 pts) and others (stage III/4 pts, stage IV/2 pts). All patients received pre- and postoperative chemotherapy, all but 6 were irradiated. Twenty one of 30 patients entered remission (CR) after radical surgery for local control: 12 relapsed locally, of whom 7 entered IICR after re-treatment and next surgery and 5 died. 3 of 9 patients who never had any local relapse, died of metastases. Nine of 30 patients never had any radical surgery, 8 died (including 2 toxic deaths) and 1 (stage V Wilms tumour) is in CR after chemotherapy and radiotherapy (12 Gy including both kidney with unresectable tumours). Advanced cancer does not imply the fatal outcome: 14/30 patients are in CR. Possibility of surgical resection of the disease focuses brings some hope for final cure even in initially disseminated disease: 13 such cases of 21 are in ICR or IICR (follow-up: 6 months-7 years) whereas only 1 of 9 those who have never had any radical surgery.

[The role of local surgical and radiological control in the treatment of soft tissue sarcoma sensitive to chemotherapy in children. Report of Polish Pediatric Solid Tumors Treatment Group]

In this paper the role local surgical and radiological control in the treatment of soft tissue sarcomas in children was analyzed. All children were treated according to CWS-91 and SIOP-IV protocols. Eighty three children with RMS A + E, EES/PNET, SS, UDS were included in the analysis. The primary surgery consisted of R0 (5%), R1 (18%) or R2 (16%) resection. In majority of cases (61%) primary surgical intervention was limited to diagnostic biopsy. Conventional or hyperfractionated radiotherapy was performed in 42.8%, 73.8% and 75% of children with disease stage II, III and IV, respectively. Delayed surgery was performed in 20 out of 53 (37.7%) children with stage III of the disease. In 5 patients without primary focus (urinary bladder in 3 and prostate in 2 cases) removed, progression of the disease occurred. In 5 children (stage IV) with progression of the disease no secondary surgery was performed. In 4 of them the primary tumor exceeded 10 cm in diameter. No delayed surgery was performed in 69% of relapsed children with stage III of the disease. Planned radiation therapy was not performed in 15.9% of cases. Primary local surgical control of primary tumor is of great importance for remission duration. In children who underwent delayed surgery the estimated EFS was of 0.7, in comparison with 0.5 EFS of those without secondary surgical treatment.

[Alternative methods of central venous access insertion in pediatric oncology]

Introduction of the central venous access (CVA) in children treated for malignancies is usually planned procedure. Some patients however require the CVA in emergency. Also in emergency, insertion of CVA should be feasible and safe. The standard technique of CVA insertion is through surgically approached internal jugular vein. This technique requires correct blood coagulation and general anaesthesia in younger patients. Alternative ways of the CVA insertion (via cephalic vein, cubital vein or external jugular vein) seem safe also in case of thrombocytopenia (< 40,000/mm3) and coagulopathy. Aim of the report is to compare efficacy (central tip of the catheter in the superior vena cava on X-ray) and safety (complication rate) of both techniques.

PATIENTS

166 children treated for malignancies aged from 0 to 16 years. The standard technique was used in 109 and in 107 was successful. The alternative technique was used in 57 and in 50 was successful. There were no acute complications, the late ones were observed in 7 of 107 in the standard technique group and in 9 of 50 in the alternative technique group. The alternative ways of the CVA introduction are effective and safe, however the longer X-ray monitoring is necessary.

[The influence of orthosilicon acid on traumatic edema of the skin. Introduction]

In the Ward of Children Surgery of the local Hospital 35 children from 0 to 15 years old with burn wounds of skin of different degrees have been treated. In surface, medium-deep and deep wounds regression of oedema, reddening and inflammatory reaction were observed already from 2nd day of treatment. Suppuration of wounds was not observed. It was observed that orthosilicon acid has anti-edematous and cooling (reduces pain) effect, quickens epidermization and shortens the time of appearing of granulation in deep burns. We think that orthosilicon acid is preparation worth further clinical testing of its usage in skin illnesses.

[The role of chemotherapy in treatment of nephroblastoma in children. Report of the Polish Pediatric Group re. treatments of solid tumors]

Retrospective analysis of chemotherapy results of children with nephroblastoma was performed in 220 patients aged from 1 yr to 14 yrs of live in 12 centers. Stage I nephroblastoma was documented in 24.5% but stage II--in 55.3%. Histologically 74.6% cases were diagnosed as medium malignant and 12.7%--high malignant. Therapy results were similar to observed in other centers.