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Kastenberg ZJ, Short SS, Riehle KJ, Utria A, Lautz TB, Ott KC, Murphy AJ, Mansfield S, Lal DR, Hallis B, Murphy JT, Roach JP, Polites SF, Beckhorn C, Tracy ET, Fialkowski EA, Seemann NM, Bütter AM, Rich BS, Glick RD, Bondoc AJ, Ofori-Atta BS, Presson AP, Chen SY, Zamora AK, Kim ES, Vasudevan S, Rinehardt HN, Malek MM, Lapidus-Krol E, Putra J, Superina RA, Langham MR, Meyers RL, Tiao G, Dasgupta R, Baertschiger R. Management of undifferentiated embryonal sarcoma of the liver: A Pediatric Surgical Oncology Research Collaborative study. Pediatr Blood Cancer 2024; 71:e30975. [PMID: 38556718 PMCID: PMC11039358 DOI: 10.1002/pbc.30975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 02/14/2024] [Accepted: 03/11/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Undifferentiated embryonal sarcoma of the liver (UESL) is a rare tumor for which there are few evidence-based guidelines. The aim of this study was to define current management strategies and outcomes for these patients using a multi-institutional dataset curated by the Pediatric Surgical Oncology Research Collaborative. METHODS Data were collected retrospectively for patients with UESL treated across 17 children's hospitals in North America from 1989 to 2019. Factors analyzed included patient and tumor characteristics, PRETEXT group, operative details, and neoadjuvant/adjuvant regimens. Event-free and overall survival (EFS, OS) were the primary and secondary outcomes, respectively. RESULTS Seventy-eight patients were identified with a median age of 9.9 years [interquartile range [IQR): 7-12]. Twenty-seven patients underwent resection at diagnosis, and 47 patients underwent delayed resection, including eight liver transplants. Neoadjuvant chemotherapy led to a median change in maximum tumor diameter of 1.6 cm [IQR: 0.0-4.4] and greater than 90% tumor necrosis in 79% of the patients undergoing delayed resection. R0 resections were accomplished in 63 patients (81%). Univariate analysis found that metastatic disease impacted OS, and completeness of resection impacted both EFS and OS, while multivariate analysis revealed that R0 resection was associated with decreased expected hazards of experiencing an event [hazard ratio (HR): 0.14, 95% confidence interval (CI): 0.04-0.6]. At a median follow-up of 4 years [IQR: 2-8], the EFS was 70.0% [95% CI: 60%-82%] and OS was 83% [95% CI: 75%-93%]. CONCLUSION Complete resection is associated with improved survival for patients with UESL. Neoadjuvant chemotherapy causes minimal radiographic response, but significant tumor necrosis.
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Affiliation(s)
- Zachary J. Kastenberg
- Primary Children’s Hospital, University of Utah School of Medicine, Salt Lake City, UT
| | - Scott S. Short
- Primary Children’s Hospital, University of Utah School of Medicine, Salt Lake City, UT
| | - Kimberly J. Riehle
- Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, WA
| | - Alan Utria
- Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, WA
| | - Timothy B. Lautz
- Lurie Children’s Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Katherine C. Ott
- Lurie Children’s Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | | | - Dave R. Lal
- Children’s Wisconsin, Medical College of Wisconsin, Milwaukee, WI
| | - Brian Hallis
- Children’s Wisconsin, Medical College of Wisconsin, Milwaukee, WI
| | - Joseph T. Murphy
- Children’s Health Specialty Center, University of Texas – Southwestern Medical Center, Dallas, TX
| | - Jonathan P. Roach
- Children’s Hospital Colorado, University of Colorado School of Medicine, Denver, CO
| | | | - Catherine Beckhorn
- Duke Children’s Health Center, Duke University School of Medicine, Durham, NC
| | - Elisabeth T. Tracy
- Duke Children’s Health Center, Duke University School of Medicine, Durham, NC
| | | | - Natashia M. Seemann
- Children’s Hospital London Health Sciences Centre, Western University, London, ON
| | - Andreana M. Bütter
- Children’s Hospital London Health Sciences Centre, Western University, London, ON
| | - Barrie S. Rich
- Cohen Children’s Medical Center, Donald and Barbara Zucker School of Medicine, New Hyde Park, NY
| | - Richard D. Glick
- Cohen Children’s Medical Center, Donald and Barbara Zucker School of Medicine, New Hyde Park, NY
| | - Alex J. Bondoc
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Blessing S. Ofori-Atta
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Angela P. Presson
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Stephanie Y. Chen
- Children’s Hospital Los Angeles, Keck School of Medicine, Los Angeles, CA
| | - Abigail K. Zamora
- Children’s Hospital Los Angeles, Keck School of Medicine, Los Angeles, CA
| | - Eugene S. Kim
- Children’s Hospital Los Angeles, Keck School of Medicine, Los Angeles, CA
| | | | - Hannah N. Rinehardt
- UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Marcus M. Malek
- UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Eveline Lapidus-Krol
- The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, ON
| | - Juan Putra
- Department of Pathology, Boston Children’s Hospital, Boston, MA
| | - Riccardo A. Superina
- Lurie Children’s Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Rebecka L. Meyers
- Primary Children’s Hospital, University of Utah School of Medicine, Salt Lake City, UT
| | - Greg Tiao
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Roshni Dasgupta
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Reto Baertschiger
- The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, ON
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Langham MR. Commentary on "Social Determinants of Health: What Every Pediatric Surgeon Should Know". J Pediatr Surg 2024:S0022-3468(24)00154-4. [PMID: 38565476 DOI: 10.1016/j.jpedsurg.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 03/04/2024] [Indexed: 04/04/2024]
Affiliation(s)
- Max R Langham
- University of Tennessee Health Science Center, Memphis, TN, USA.
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Fleming AM, Hendrick LE, Yakoub D, Abdelhafeez H, Deneve JL, Langham MR, Glazer ES, Davidoff AM, Merchant NB, Dickson PV, Murphy AJ. ASO Visual Abstract: Malignant Solid Pseudopapillary Neoplasm of the Pancreas-An Orthogonal Analysis. Ann Surg Oncol 2024; 31:1946. [PMID: 37962743 DOI: 10.1245/s10434-023-14542-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Affiliation(s)
- Andrew M Fleming
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Leah E Hendrick
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Danny Yakoub
- Department of Surgery, Augusta University Medical Center, Augusta, GA, USA
| | - Hafeez Abdelhafeez
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jeremiah L Deneve
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Max R Langham
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Evan S Glazer
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Andrew M Davidoff
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Nipun B Merchant
- Department of Surgery, University of Miami Health System, Miami, FL, USA
| | - Paxton V Dickson
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Andrew J Murphy
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA.
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN, USA.
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Fleming AM, Mansfield SA, Jancelewicz T, Gosain A, Eubanks JW, Davidoff AM, Langham MR, Murphy AJ. Hepatic Metastasectomy in Pediatric Patients: An Observational Study. J Pediatr Surg 2024; 59:247-253. [PMID: 37980196 DOI: 10.1016/j.jpedsurg.2023.10.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 10/11/2023] [Indexed: 11/20/2023]
Abstract
BACKGROUND The role of hepatectomy for metastatic disease in children is controversial. Rationales include potential cure, obtaining a diagnosis, and guiding chemotherapy decisions. This study examines the safety and utility of hepatic metastasectomy for children at a single institution. METHODS After IRB approval (#22-1258), medical records were reviewed from 1995 to 2022 for children undergoing hepatic metastasectomy. En-bloc hepatectomies during primary tumor resection were excluded. RESULTS Hepatic metastasectomy was performed in 16 patients for a variety of histologies. Median patient age was 12.2 years [IQR 6.9-22.6], and 13/16 patients were female (81 %). Number of hepatic metastases ranged from 1 to 23 and involved between 1 and 8 Couinaud segments. Anatomic resections included 4 hemihepatectomies and 1 sectionectomy. All other resections were nonanatomic. 3/6 resections for germ cell tumor (GCT) revealed only mature teratoma, driving adjuvant therapy decisions. When indicated, median time to adjuvant chemotherapy was 19 days [IQR 11-22]. No patients had Clavien-Dindo Class III or higher perioperative morbidity. Three patients (1 GCT, 1 adrenocortical carcinoma (ACC), and 1 gastric neuroendocrine tumor (GNET) experienced hepatic relapse. The patients with relapsed GCT and GNET are alive with disease at 17 and 135 months, respectively. The patient with ACC died of disease progression and liver failure. One patient with Wilms tumor experienced extrahepatic, retroperitoneal recurrence and died. With a median follow-up of 38 months, 10-year disease-specific and disease-free survival were 77 % and 61 %, respectively. CONCLUSIONS Hepatic metastasectomy can be accomplished safely in children, may guide adjuvant therapy decisions, and is associated with long-term survival in selected patients. LEVEL OF EVIDENCE Level IV. TYPE OF STUDY Treatment Study, Case series with no comparison group.
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Affiliation(s)
- Andrew M Fleming
- St. Jude Children's Research Hospital, Department of Surgery, Memphis, TN, USA; The University of Tennessee Health Science Center, Department of Surgery, Memphis, TN, USA
| | - Sara A Mansfield
- St. Jude Children's Research Hospital, Department of Surgery, Memphis, TN, USA; The University of Tennessee Health Science Center, Department of Surgery, Memphis, TN, USA
| | - Tim Jancelewicz
- St. Jude Children's Research Hospital, Department of Surgery, Memphis, TN, USA; The University of Tennessee Health Science Center, Department of Surgery, Memphis, TN, USA
| | - Ankush Gosain
- St. Jude Children's Research Hospital, Department of Surgery, Memphis, TN, USA; The University of Tennessee Health Science Center, Department of Surgery, Memphis, TN, USA
| | - James W Eubanks
- St. Jude Children's Research Hospital, Department of Surgery, Memphis, TN, USA; The University of Tennessee Health Science Center, Department of Surgery, Memphis, TN, USA
| | - Andrew M Davidoff
- St. Jude Children's Research Hospital, Department of Surgery, Memphis, TN, USA; The University of Tennessee Health Science Center, Department of Surgery, Memphis, TN, USA
| | - Max R Langham
- St. Jude Children's Research Hospital, Department of Surgery, Memphis, TN, USA; The University of Tennessee Health Science Center, Department of Surgery, Memphis, TN, USA
| | - Andrew J Murphy
- St. Jude Children's Research Hospital, Department of Surgery, Memphis, TN, USA; The University of Tennessee Health Science Center, Department of Surgery, Memphis, TN, USA.
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Fleming AM, Hendrick LE, Yakoub D, Abdelhafeez H, Deneve JL, Langham MR, Glazer ES, Davidoff AM, Merchant NB, Dickson PV, Murphy AJ. Malignant Solid Pseudopapillary Neoplasm of the Pancreas: An Orthogonal Analysis. Ann Surg Oncol 2024; 31:475-487. [PMID: 37768414 DOI: 10.1245/s10434-023-14343-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND Pancreatic solid pseudopapillary neoplasms (SPN) are generally indolent; however, some patients present with "malignant" SPN. An orthogonal analysis of multiple datasets was performed to investigate the utility of complete surgical resection (CSR) for malignant SPN. METHODS A systematic review was performed for cases of malignant SPN, defined as T4, N1, and/or M1. Malignant SPN was analyzed within the National Cancer Database (NCDB) and compared with T1-3N0M0 SPN. Predictors of malignant SPN were assessed, and treatments were analyzed by using survival analysis. RESULTS The systematic review yielded 164 cases of malignant SPN. Of 31 children, only one died due to malignant SPN. Among adults, CSR was associated with improved disease-specific survival (DSS) (P = 0.0002). Chemotherapy did not improve malignant SPN DSS, whether resected (P = 0.8485) or not (P = 0.2219). Of 692 adults with SPN within the NCDB, 93 (13.4%) had malignant SPN. Pancreatic head location (odds ratio [OR] 2.174; 95% confidence interval [CI] 1.136-4.166; P = 0.0186) and tumor size (OR 1.154; 95% CI 1.079-1.235; P < 0.0001) associated with the malignant phenotype. Malignant SPN predicted decreased overall survival (OS) compared with T1-3N0M0 disease (P < 0.0001). Resected malignant SPN demonstrated improved OS (P < 0.0001), including resected stage IV malignant SPN (P = 0.0003). Chemotherapy did not improve OS for malignant SPN, whether resected (P = 0.8633) or not (P = 0.5734). Within a multivariable model, resection was associated with decreased hazard of death (hazard ratio 0.090; 95% CI 0.030-0.261; P < 0.0001). CONCLUSIONS Approximately 13% of patients with SPN present with a malignant phenotype. Pediatric cases may be less aggressive. Resection may improve survival for malignant SPN, which does not appear chemosensitive.
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Affiliation(s)
- Andrew M Fleming
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA.
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN, USA.
| | - Leah E Hendrick
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Danny Yakoub
- Department of Surgery, Augusta University Medical Center, Augusta, GA, USA
| | - Hafeez Abdelhafeez
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jeremiah L Deneve
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Max R Langham
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Evan S Glazer
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Andrew M Davidoff
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Nipun B Merchant
- Department of Surgery, University of Miami Health System, Miami, FL, USA
| | - Paxton V Dickson
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Andrew J Murphy
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN, USA
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6
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Kastenberg ZJ, Baertschiger RM, Cuenca AG, Galvan NTN, Lemoine CP, Roach JP, Walther AE, Dunn SP, Goss JA, Healey PJ, Karpelowsky J, Kim ES, Langham MR, Meyers RL, Superina RA, Tiao GM, Weldon CB, Bondoc AJ, Riehle KJ, Vasudevan SA. Critical elements of pediatric liver cancer surgery. Semin Pediatr Surg 2023; 32:151340. [PMID: 38008042 DOI: 10.1016/j.sempedsurg.2023.151340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2023]
Abstract
The appropriate management of pediatric liver malignancies, primarily hepatoblastoma and hepatocellular carcinoma, requires an in depth understanding of contemporary preoperative risk stratification, experience with advanced hepatobiliary surgery, and a good relationship with one's local or regional liver transplant center. While chemotherapy regimens have become more effective, operative indications more well-defined, and overall survival improved, the complexity of liver surgery in small children provides ample opportunity for protocol violation, inadequate resection, and iatrogenic morbidity. These guidelines represent the distillation of contemporary literature and expert opinion as a means to provide a framework for preoperative planning and intraoperative decision-making for the pediatric surgeon.
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Affiliation(s)
- Zachary J Kastenberg
- University of Utah School of Medicine/Primary Children's Hospital, Salt Lake City, UT 84113, USA
| | | | | | | | - Caroline P Lemoine
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA
| | | | - Ashley E Walther
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Stephen P Dunn
- Nemours Children Hospital Delaware, Wilmington, DE 19803, USA
| | - John A Goss
- Texas Children's Hospital / Baylor College of Medicine, Houston, TX 77030, USA
| | | | | | - Eugene S Kim
- Cedars-Sinai Guerin Children's, Los Angeles, CA 90048, USA
| | - Max R Langham
- St Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Rebecka L Meyers
- University of Utah School of Medicine/Primary Children's Hospital, Salt Lake City, UT 84113, USA
| | - Riccardo A Superina
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA
| | - Greg M Tiao
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | | | - Alex J Bondoc
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | | | - Sanjeev A Vasudevan
- Texas Children's Hospital / Baylor College of Medicine, Houston, TX 77030, USA.
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Thompson PA, Malogolowkin MH, Furman WL, Piao J, Krailo MD, Chung N, Brock L, Towbin AJ, McCarville EB, Finegold MJ, Ranganathan S, Dunn SP, Langham MR, McGahren ED, Tiao GM, Weldon CB, O'Neill AF, Rodriguez-Galindo C, Meyers RL, Katzenstein HM. Vincristine/irinotecan/temsirolimus upfront window treatment of high-risk hepatoblastoma: A report from the Children's Oncology Group AHEP0731 Study Committee. Pediatr Blood Cancer 2023; 70:e30365. [PMID: 37073741 DOI: 10.1002/pbc.30365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 03/08/2023] [Accepted: 03/27/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND Survival for children with metastatic hepatoblastoma (HB) remains suboptimal. We report the response rate and outcome of two courses of vincristine/irinotecan/temsirolimus (VIT) in children with high-risk (HR)/metastatic HB. PROCEDURES Patients with newly diagnosed HB received HR window chemotherapy if they had metastatic disease or a serum alpha-fetoprotein (AFP) level less than 100 ng/mL. Patients received vincristine (days 1 and 8), irinotecan (days 1-5), and temsirolimus (days 1 and 8). Cycles were repeated every 21 days. Responders had either a 30% decrease using RECIST (Response Evaluation Criteria in Solid Tumors) criteria OR a 90% (>1 log10 decline) AFP decline after two cycles. Responders received two additional cycles of VIT intermixed with six cycles of cisplatin/doxorubicin/5-fluorouracil/vincristine (C5VD). Nonresponders received six cycles of C5VD alone. RESULTS Thirty-six eligible patients enrolled on study. The median age at enrollment was 27 months (range: 7-170). Seventeen of 36 patients were responders (RECIST and AFP = 3, RECIST only = 4, AFP only = 10). The median AFP at diagnosis was 222,648 ng/mL and the median AFP following two VIT cycles was 19,262 ng/mL. Three-year event-free survival was 47% (95% confidence interval [CI]: 30%-62%), while overall survival was 67% (95% CI: 49%-80%). CONCLUSION VIT did not achieve the study efficacy endpoint. Temsirolimus does not improve the response rate seen in patients treated with vincristine and irinotecan (VI) alone as part of the initial treatment regimen explored in this study. Additionally, AFP response may be a more sensitive predictor of disease response than RECIST in HB.
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Affiliation(s)
- Patrick A Thompson
- North Carolina Children's Hospital and the University of North Carolina, Chapel Hill, North Carolina, USA
| | - Marcio H Malogolowkin
- University of California at Davis Comprehensive Cancer Center, Sacramento, California, USA
| | - Wayne L Furman
- University of Tennessee Health Science Center and St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jin Piao
- University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Mark D Krailo
- University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Nadia Chung
- Children's Oncology Group, Monrovia, California, USA
| | - Lindsay Brock
- Children's Oncology Group, Monrovia, California, USA
| | | | - Elizabeth B McCarville
- University of Tennessee Health Science Center and St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | | | | | | | - Max R Langham
- University of Tennessee Health Science Center and St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Eugene D McGahren
- University of Virginia Children's Hospital, Charlottesville, Virginia, USA
| | - Gregory M Tiao
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Christopher B Weldon
- Dana-Farber Cancer Institute/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA
| | - Allison F O'Neill
- Dana-Farber Cancer Institute/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA
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Vasudevan SA, Meyers RL, Finegold MJ, López-Terrada D, Ranganathan S, Dunn SP, Langham MR, McGahren ED, Tiao GM, Weldon CB, Malogolowkin MH, Krailo MD, Piao J, Randazzo J, Towbin AJ, BethMcCarville M, O'Neill AF, Furman WL, Rodriguez-Galindo C, Katzenstein HM. Outcomes of children with well-differentiated fetal hepatoblastoma treated with surgery only: Report from Children's Oncology Group Trial, AHEP0731. J Pediatr Surg 2022; 57:251-256. [PMID: 35810020 PMCID: PMC9474653 DOI: 10.1016/j.jpedsurg.2022.05.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/13/2022] [Accepted: 05/24/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hepatoblastoma (HB) requires surgical resection for cure, but only 20-30% of patients have resectable disease at diagnosis. Patients who undergo partial hepatectomy at diagnosis have historically received 4-6 cycles of adjuvant chemotherapy; however, those with 100% well-differentiated fetal histology (WDF) have been observed to have excellent outcomes when treated with surgery alone. PATIENTS AND METHODS Patients on the Children's Oncology Group non randomized, multicenter phase III study, AHEP0731, were stratified based on Evan's stage, tumor histology, and serum alpha-fetoprotein level at diagnosis. Patients were eligible for the very low risk stratum of surgery and observation if they had a complete resection at diagnosis and rapid central histologic review demonstrated HB with 100% WDF histology. RESULTS A total of 8 eligible patients were enrolled on study between September 14, 2009 and May 28, 2014. Outcome current to 06/30/2020 was used in this analysis. The median age at enrollment was 22.5 months (range: 8-84 months) and the median AFP at enrollment was 714 ng/ml (range: 18-77,747 ng/mL). With a median follow-up of 6.6 years (range: 3.6-9.8 years), the 5-year event-free (EFS) and overall survival (OS) were both 100%. CONCLUSION This report supports that HB with 100% WDF histology completely resected at diagnosis is curable with surgery only. The development of evidence-based surgical guidelines utilizing criteria based on PRETEXT group, vascular involvement (annotation factors), tumor-specific histology and corresponding biology will be crucial for optimizing which patients are candidates for resection at diagnosis followed by observation. LEVEL OF EVIDENCE Prognosis study, Level I evidence.
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Affiliation(s)
- Sanjeev A Vasudevan
- Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin, Houston, TX 77030, United States
| | - Rebecka L Meyers
- Primary Children's Hospital, University of Utah, 100N. Mario Capecchi Dr., Salt Lake City, UT 84113, United States
| | - Milton J Finegold
- Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin, Houston, TX 77030, United States
| | - Dolores López-Terrada
- Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin, Houston, TX 77030, United States
| | - Sarangarajan Ranganathan
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229, United States
| | - Stephen P Dunn
- AI Dupont Hospital for Children, 1600 Rockland Rd., Wilmington, DE 19803, United States
| | - Max R Langham
- St Jude Children's Research Hospital and University of Tennessee Health Science Center, 262 Danny Thomas Place, Memphis, TN 38015, United States
| | - Eugene D McGahren
- University of Virginia Hospital, 1215 Lee St., Charlottesville, VA 22903, United States
| | - Greg M Tiao
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229, United States
| | - Christopher B Weldon
- Dana-Farber Cancer Institute and Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, United States
| | - Marcio H Malogolowkin
- University of California Davis Comprehensive Cancer Center, 2279 45th St., Sacramento, CA 95817, United States
| | - Mark D Krailo
- University of Southern California Keck School of Medicine, 1975 Zonal Ave., Los Angeles, CA 90033, United States
| | - Jin Piao
- University of Southern California Keck School of Medicine, 1975 Zonal Ave., Los Angeles, CA 90033, United States
| | - Jessica Randazzo
- Children's Oncology Group, 800 Royal Oaks Dr., Suite 210, Monrovia, CA 91016, United States
| | - Alexander J Towbin
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229, United States
| | - M BethMcCarville
- St Jude Children's Research Hospital and University of Tennessee Health Science Center, 262 Danny Thomas Place, Memphis, TN 38015, United States
| | - Allison F O'Neill
- Dana-Farber Cancer Institute and Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, United States
| | - Wayne L Furman
- St Jude Children's Research Hospital and University of Tennessee Health Science Center, 262 Danny Thomas Place, Memphis, TN 38015, United States
| | - Carlos Rodriguez-Galindo
- St Jude Children's Research Hospital and University of Tennessee Health Science Center, 262 Danny Thomas Place, Memphis, TN 38015, United States
| | - Howard M Katzenstein
- Nemours Children's Hospital, 1600 Rockland Road, Wilmington DE 19803, United States.
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9
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Short SS, Kastenberg ZJ, Wei G, Bondoc A, Dasgupta R, Tiao GM, Watters E, Heaton TE, Lotakis D, La Quaglia MP, Murphy AJ, Davidoff AM, Mansfield SA, Langham MR, Lautz TB, Superina RA, Ott KC, Malek MM, Morgan KM, Kim ES, Zamora A, Lascano D, Roach J, Murphy JT, Rothstein DH, Vasudevan SA, Whitlock R, Lal DR, Hallis B, Bütter A, Baertschiger RM, Lapidus-Krol E, Putra J, Tracy ER, Aldrink JH, Apfeld J, Le HD, Park KY, Rich BS, Glick RD, Fialkowski EA, Utria AF, Meyers RL, Riehle KJ. Histologic type predicts disparate outcomes in pediatric hepatocellular neoplasms: A Pediatric Surgical Oncology Research Collaborative study. Cancer 2022; 128:2786-2795. [PMID: 35561331 DOI: 10.1002/cncr.34256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 02/06/2022] [Accepted: 03/10/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is a rare cancer in children, with various histologic subtypes and a paucity of data to guide clinical management and predict prognosis. METHODS A multi-institutional review of children with hepatocellular neoplasms was performed, including demographic, staging, treatment, and outcomes data. Patients were categorized as having conventional HCC (cHCC) with or without underlying liver disease, fibrolamellar carcinoma (FLC), and hepatoblastoma with HCC features (HB-HCC). Univariate and multivariate analyses identified predictors of mortality and relapse. RESULTS In total, 262 children were identified; and an institutional histologic review revealed 110 cHCCs (42%; 69 normal background liver, 34 inflammatory/cirrhotic, 7 unknown), 119 FLCs (45%), and 33 HB-HCCs (12%). The authors observed notable differences in presentation and behavior among tumor subtypes, including increased lymph node involvement in FLC and higher stage in cHCC. Factors associated with mortality included cHCC (hazard ratio [HR], 1.63; P = .038), elevated α-fetoprotein (HR, 3.1; P = .014), multifocality (HR, 2.4; P < .001), and PRETEXT (pretreatment extent of disease) stage IV (HR, 5.76; P < .001). Multivariate analysis identified increased mortality in cHCC versus FLC (HR, 2.2; P = .004) and in unresectable tumors (HR, 3.4; P < .001). Disease-free status at any point predicted survival. CONCLUSIONS This multi-institutional, detailed data set allowed a comprehensive analysis of outcomes for children with these rare hepatocellular neoplasms. The current data demonstrated that pediatric HCC subtypes are not equivalent entities because FLC and cHCC have distinct anatomic patterns and outcomes in concert with their known molecular differences. This data set will be further used to elucidate the impact of histology on specific treatment responses, with the goal of designing risk-stratified algorithms for children with HCC. LAY SUMMARY This is the largest reported granular data set on children with hepatocellular carcinoma. The study evaluates different subtypes of hepatocellular carcinoma and identifies key differences between subtypes. This information is pivotal in improving understanding of these rare cancers and may be used to improve clinical management and subsequent outcome in children with these rare malignancies.
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Affiliation(s)
- Scott S Short
- Division of Pediatric Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Zachary J Kastenberg
- Division of Pediatric Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Guo Wei
- Division of Pediatric Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Alex Bondoc
- Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Roshni Dasgupta
- Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Greg M Tiao
- Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Erin Watters
- Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Todd E Heaton
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Dimitra Lotakis
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael P La Quaglia
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew J Murphy
- Department of Surgery, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Andrew M Davidoff
- Department of Surgery, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Sara A Mansfield
- Department of Surgery, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Max R Langham
- Department of Surgery, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Timothy B Lautz
- Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | - Riccardo A Superina
- Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | - Katherine C Ott
- Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | - Marcus M Malek
- Division of Pediatric Surgery, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Katrina M Morgan
- Division of Pediatric Surgery, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Eugene S Kim
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Abigail Zamora
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Danny Lascano
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Jonathan Roach
- Department of Pediatric Surgery, Children's Hospital of Colorado, Denver, Colorado
| | - Joseph T Murphy
- Division of Pediatric Surgery, Children's Medical Center, University of Texas Southwestern, Dallas, Texas
| | - David H Rothstein
- Division of Pediatric General and Thoracic Surgery, Department of Surgery, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Sanjeev A Vasudevan
- Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Richard Whitlock
- Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Dave R Lal
- Division of Pediatric Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Brian Hallis
- Division of Pediatric Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Andreana Bütter
- Division of Pediatric Surgery, Children's Hospital, London Health Sciences Center, London, Ontario, Canada
| | - Reto M Baertschiger
- Department of General and Pediatric Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Eveline Lapidus-Krol
- Department of General and Pediatric Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Juan Putra
- Division of Pediatric Pathology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Elisabeth R Tracy
- Division of Pediatric Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jennifer H Aldrink
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Jordan Apfeld
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Hau D Le
- Division of Pediatric Surgery, American Family Children's Hospital, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Keon Y Park
- Division of Pediatric Surgery, American Family Children's Hospital, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Barrie S Rich
- Division of Pediatric Surgery, Cohen Children's Medical Center, Zucker School of Medicine at Northwell/Hofstra, New Hyde Park, New York
| | - Richard D Glick
- Division of Pediatric Surgery, Cohen Children's Medical Center, Zucker School of Medicine at Northwell/Hofstra, New Hyde Park, New York
| | - Elizabeth A Fialkowski
- Division of Pediatric Surgery, Oregon Health and Science University Doernbecher Children's Hospital, Portland, Oregon
| | - Alan F Utria
- Division of Pediatric Surgery, Oregon Health and Science University Doernbecher Children's Hospital, Portland, Oregon
| | - Rebecka L Meyers
- Division of Pediatric Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Kimberly J Riehle
- Division of Pediatric General and Thoracic Surgery, Department of Surgery, Seattle Children's Hospital, University of Washington, Seattle, Washington
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10
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Fleming AM, Duffy C, Gartrell J, McCarville MB, Langham MR, Ruiz RE, Santiago T, Murphy AJ. Giant focal nodular hyperplasia with a background of hepatic steatosis in a 14-year-old boy. J Surg Case Rep 2022; 2022:rjac238. [PMID: 35665385 PMCID: PMC9155174 DOI: 10.1093/jscr/rjac238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 05/03/2022] [Indexed: 11/13/2022] Open
Abstract
Giant focal nodular hyperplasia (GFNH) is rarely seen in children, presenting complex diagnostic and management considerations. Pathognomonic radiographic findings can be absent in this population, and the nuances of pathologic examination are critical. We present a child with a GFNH involving the right side of the liver arising in the background of hepatic steatosis. The details of the diagnosis and therapeutic decisions involved in his treatment are discussed.
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Affiliation(s)
- Andrew M Fleming
- Department of Surgery, St Jude Children’s Research Hospital, Memphis, TN, USA
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Caitlyn Duffy
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, TN, USA
| | - Jessica Gartrell
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, TN, USA
| | - M Beth McCarville
- Department of Diagnostic Imaging, St Jude Children’s Research Hospital, Memphis, TN, USA
| | - Max R Langham
- Department of Surgery, St Jude Children’s Research Hospital, Memphis, TN, USA
- Division of Pediatric Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Robert E Ruiz
- Department of Pathology, St Jude Children’s Research Hospital, Memphis, TN, USA
| | - Teresa Santiago
- Department of Pathology, St Jude Children’s Research Hospital, Memphis, TN, USA
| | - Andrew J Murphy
- Department of Surgery, St Jude Children’s Research Hospital, Memphis, TN, USA
- Division of Pediatric Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
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11
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Katzenstein HM, Malogolowkin MH, Krailo MD, Piao J, Towbin AJ, McCarville MB, Tiao GM, Dunn SP, Langham MR, McGahren ED, Finegold MJ, Ranganathan S, Weldon CB, Thompson PA, Trobaugh-Lotrario AD, O’Neill AF, Furman WL, Chung N, Randazzo J, Rodriguez-Galindo C, Meyers RL. Doxorubicin in combination with cisplatin, 5-flourouracil, and vincristine is feasible and effective in unresectable hepatoblastoma: A Children's Oncology Group study. Cancer 2022; 128:1057-1065. [PMID: 34762296 PMCID: PMC9066555 DOI: 10.1002/cncr.34014] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 10/01/2021] [Accepted: 10/07/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND The Children's Oncology Group (COG) adopted cisplatin, 5-flourouracil, and vincristine (C5V) as standard therapy after the INT-0098 legacy study showed statistically equivalent survival but less toxicity in comparison with cisplatin and doxorubicin. Subsequent experience demonstrated doxorubicin to be effective in patients with recurrent disease after C5V, and this suggested that it could be incorporated to intensify therapy for patients with advanced disease. METHODS In this nonrandomized, phase 3 COG trial, the primary aim was to explore the feasibility and toxicity of a novel therapeutic cisplatin, 5-flourouracil, vincristine, and doxorubicin (C5VD) regimen with the addition of doxorubicin to C5V for patients considered to be at intermediate risk. Patients were eligible if they had unresectable, nonmetastatic disease. Patients with a complete resection at diagnosis and local pathologic evidence of small cell undifferentiated histology were also eligible for an assessment of feasibility. RESULTS One hundred two evaluable patients enrolled between September 14, 2009, and March 12, 2012. Delivery of C5VD was feasible and tolerable: the mean percentages of the target doses delivered were 96% (95% CI, 94%-97%) for cisplatin, 96% (95% CI, 94%-97%) for 5-fluorouracil, 95% (95% CI, 93%-97%) for doxorubicin, and 90% (95% CI, 87%-93%) for vincristine. Toxicity was within expectations, with death as a first event in 1 patient. The most common adverse events were febrile neutropenia (n = 55 [54%]), infection (n = 48 [47%]), mucositis (n = 31 [30%]), hypokalemia (n = 39 [38%]), and elevated aspartate aminotransferase (n = 28 [27%]). The 5-year event-free and overall survival rates for the 93 patients who did not have complete resection at diagnosis were 88% (95% CI, 79%-93%) and 95% (95% CI, 87%-98%), respectively. CONCLUSIONS The addition of doxorubicin to the previous standard regimen of C5V is feasible, tolerable, and efficacious, and this suggests that C5VD is a good regimen for future clinical trials.
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Affiliation(s)
- Howard M Katzenstein
- Nemours Children’s Specialty Care and Wolfson Children’s Hospital, Jacksonville, FL
| | | | - Mark D Krailo
- University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Jin Piao
- University of Southern California Keck School of Medicine, Los Angeles, CA
| | | | - M Beth McCarville
- University of Tennessee Health Science Center and St Jude Children’s Research Hospital, Memphis, TN
| | - Gregory M Tiao
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | | | - Max R Langham
- University of Tennessee Health Science Center and St Jude Children’s Research Hospital, Memphis, TN
| | | | | | | | | | | | | | - Allison F O’Neill
- Dana-Farber Cancer Institute, and Boston Children’s Hospital, Boston, MA
| | - Wayne L Furman
- University of Tennessee Health Science Center and St Jude Children’s Research Hospital, Memphis, TN
| | | | | | - Carlos Rodriguez-Galindo
- University of Tennessee Health Science Center and St Jude Children’s Research Hospital, Memphis, TN
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12
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Trobaugh-Lotrario A, Katzenstein HM, Ranganathan S, Lopez-Terrada D, Krailo MD, Piao J, Chung N, Randazzo J, Malogolowkin MH, Furman WL, McCarville EB, Towbin AJ, Tiao GM, Dunn SP, Langham MR, McGahren ED, Feusner J, Rodriguez-Galindo C, Meyers RL, O'Neill AF, Finegold MJ. Small Cell Undifferentiated Histology Does Not Adversely Affect Outcome in Hepatoblastoma: A Report From the Children's Oncology Group (COG) AHEP0731 Study Committee. J Clin Oncol 2022; 40:459-467. [PMID: 34874751 PMCID: PMC8824398 DOI: 10.1200/jco.21.00803] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 10/09/2021] [Accepted: 11/01/2021] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Small cell undifferentiated (SCU) histology in hepatoblastoma (HB) tumors has historically been associated with a poor prognosis. Tumors from patients enrolled on Children's Oncology Group (COG) study AHEP0731 underwent institutional and central pathologic review for identification of SCU histology. PATIENTS AND METHODS Patients with SCU histology identified at the local treating institution who had otherwise low-risk tumors were upstaged to the intermediate-risk treatment stratum, whereas those only identified by retrospective central review were treated per the local institution as low-risk. Patients with otherwise intermediate- or high-risk tumors remained in that treatment stratum, respectively. Central review was to be performed for all tissue samples obtained at any time point. Treatment was per local review, whereas analysis of outcome was based on central review. RESULTS Thirty-five patients had some elements (1%-25%) of SCU identified on central review of diagnostic specimens. All but two patient tissue sample retained nuclear INI1 expression. The presence of SCU histology did not correlate with age, alpha-fetoprotein level at diagnosis, or sex. The presence of SCU did not affect event-free survival (EFS). EFS at 5 years for patients with low-risk, intermediate-risk, and high-risk with SCU HB was 86% (95% CI, 33 to 98), 81% (95% CI, 57 to 92), and 29% (95% CI, 4 to 61), respectively, compared with EFS at 5 years for patients without SCU enrolled with low-risk, intermediate-risk, and high-risk of 87% (95% CI, 72 to 95), 88% (95% CI, 79 to 94), and 55% (95% CI, 32 to 74; P = .17), respectively. CONCLUSION The presence of SCU histology in HB does not appear to adversely affect outcome. Future studies should be able to treat patients with SCU HB according to risk stratification without regard to the presence of SCU histology.
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Affiliation(s)
| | | | | | | | - Mark D. Krailo
- University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Jin Piao
- Children's Oncology Group, Monrovia, CA
| | | | | | | | - Wayne L. Furman
- University of Tennessee Health Science Center and St Jude Children's Research Hospital, Memphis, TN
| | - Elizabeth B. McCarville
- University of Tennessee Health Science Center and St Jude Children's Research Hospital, Memphis, TN
| | | | - Greg M. Tiao
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Stephen P. Dunn
- AI duPont Hospital for Children and Thomas Jefferson University, Philadelphia, PA
| | - Max R. Langham
- University of Tennessee Health Science Center and St Jude Children's Research Hospital, Memphis, TN
| | - Eugene D. McGahren
- University of Virginia Children's Hospital and University of Virginia, Charlottesville, VA
| | | | - Carlos Rodriguez-Galindo
- University of Tennessee Health Science Center and St Jude Children's Research Hospital, Memphis, TN
| | | | - Allison F. O'Neill
- Dana-Farber Cancer Institute, and Boston Children's Hospital, Boston, MA
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13
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Jancelewicz T, Langham MR, Brindle ME, Stiles ZE, Lally PA, Dong L, Wan JY, Guner YS, Harting MT. Survival Benefit Associated With the Use of Extracorporeal Life Support for Neonates With Congenital Diaphragmatic Hernia. Ann Surg 2022; 275:e256-e263. [PMID: 33060376 DOI: 10.1097/sla.0000000000003928] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To measure the survival among comparable neonates with CDH supported with and without ECLS. SUMMARY OF BACKGROUND DATA Despite widespread use in the management of newborns with CDH, ECLS has not been consistently associated with improved survival. METHODS A retrospective cohort study was performed using ECLS-eligible CDH Study Group registry patients born between 2007 and 2019. The primary outcome was in-hospital mortality. Neonates who did and did not receive ECLS were matched based on variables affecting risk for the primary outcome. Iterative propensity score-matched, survival (Cox regression and Kaplan-Meier), and center effects analyses were performed to examine the association of ECLS use and mortality. RESULTS Of 5855 ECLS-eligible CDH patients, 1701 (29.1%) received ECLS. "High-risk" patients were best defined as those with a lowest achievable first-day arterial partial pressure of CO2 of ≥60 mm Hg. After propensity score matching, mortality was higher with ECLS (47.8% vs 21.8%, odds ratio 3.3, 95% confidence interval 2.7-4.0, hazard ratio 2.3, P < 0.0001). For the subgroup of high-risk patients, there was lower mortality observed with ECLS (64.2% vs 84.4%, odds ratio 0.33, 95% confidence interval 0.17-0.65, hazard ratio 0.33, P = 0.001). This survival advantage was persistent using multiple matching approaches. However, this ECLS survival advantage was found to occur primarily at high CDH volume centers that offer frequent ECLS for the high-risk subgroup. CONCLUSIONS Use of ECLS is associated with excess mortality for low- and intermediate-risk neonates with CDH. It is associated with a significant survival advantage among high-risk infants, and this advantage is strongly influenced by center CDH volume and ECLS experience.
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Affiliation(s)
- Tim Jancelewicz
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Max R Langham
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Mary E Brindle
- Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
| | - Zachary E Stiles
- University of Tennessee Health Science Center, Memphis, Tennessee
| | - Pamela A Lally
- McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, Texas
| | - Lei Dong
- University of Tennessee Health Science Center, Memphis, Tennessee
| | - Jim Y Wan
- University of Tennessee Health Science Center, Memphis, Tennessee
| | - Yigit S Guner
- Children's Hospital of Orange County, University of California Irvine, Orange, California
| | - Matthew T Harting
- McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, Texas
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14
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Langham MR. Commentary on supporting recovery after adverse events: An essential component of surgeon well-being. J Pediatr Surg 2021; 56:839-840. [PMID: 33461745 DOI: 10.1016/j.jpedsurg.2021.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 01/05/2021] [Indexed: 11/16/2022]
Abstract
This is a commentary on the manuscript titled "Supporting Recovery after Adverse Events: An Essential Component of Surgeon Well-Being" by Berman L, Rialon K, Mueller C, et al.
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Affiliation(s)
- Max R Langham
- Professor of Surgery and Pediatrics, University of Tennessee Health Science Center, 49 North Dunlap Street, Memphis, TN, 38105.
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15
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Morrison ZD, Reyes-Ferral C, Mansfield SA, Alemayehu H, Bowen-Jallow K, Tran S, Santos MC, Bischoff A, Perez N, Lopez ME, Langham MR, Newman EA. Diversity, Equity, and Inclusion: A strategic priority for the American Pediatric Surgical Association. J Pediatr Surg 2021; 56:641-647. [PMID: 33309300 DOI: 10.1016/j.jpedsurg.2020.11.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/06/2020] [Accepted: 11/14/2020] [Indexed: 01/10/2023]
Affiliation(s)
| | | | | | - Hanna Alemayehu
- Children's and Women's Hospital, University of South Alabama Health System, Mobile, AL, USA
| | | | - Sifrance Tran
- University of Texas Medical Branch, Galveston, TX, USA
| | | | | | - Numa Perez
- Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Erika A Newman
- CS Mott Children's Hospital, The University of Michigan, Ann Arbor, MI, USA.
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16
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Sutthatarn P, Morin CE, Gartrell J, Furman WL, Langham MR, Santiago T, Murphy AJ. Bilateral Diffuse Nodular Pulmonary Ossification Mimicking Metastatic Disease in a Patient with Fibrolamellar Hepatocellular Carcinoma. Children (Basel) 2021; 8:children8030226. [PMID: 33809687 PMCID: PMC8002229 DOI: 10.3390/children8030226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 03/04/2021] [Accepted: 03/12/2021] [Indexed: 11/16/2022]
Abstract
Pulmonary ossification (PO) is a rare finding, characterized by mature bone formation in the lung parenchyma. We report a 20-year-old female patient diagnosed with fibrolamellar hepatocellular carcinoma (FL-HCC) and bilateral diffuse nodular PO. The patient presented with a unifocal left liver mass and multiple bilateral pulmonary lesions, which were treated as metastatic disease. The patient received neoadjuvant chemotherapy, followed by left hepatectomy, and bilateral staged thoracotomies for clearance of the pulmonary disease. The histology of the pulmonary nodules demonstrated nodular type PO. We present the history, the course of treatment, imaging, and histologic findings of this rare disease process that could mimic metastatic pulmonary disease.
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Affiliation(s)
- Pattamon Sutthatarn
- Department of Surgery, St. Jude Children’s Research Hospital, Memphis, TN 38105, USA; (P.S.); (M.R.L.)
- Department of Surgery, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok 10330, Thailand
| | - Cara E. Morin
- Department of Diagnostic Imaging, St. Jude Children’s Research Hospital, Memphis, TN 38105, USA;
| | - Jessica Gartrell
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN 38105, USA; (J.G.); (W.L.F.)
| | - Wayne L. Furman
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN 38105, USA; (J.G.); (W.L.F.)
| | - Max R. Langham
- Department of Surgery, St. Jude Children’s Research Hospital, Memphis, TN 38105, USA; (P.S.); (M.R.L.)
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Teresa Santiago
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, TN 38105, USA;
| | - Andrew J. Murphy
- Department of Surgery, St. Jude Children’s Research Hospital, Memphis, TN 38105, USA; (P.S.); (M.R.L.)
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN 38163, USA
- Correspondence:
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17
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Langham MR. Commentary regarding prognostic profiling of children with serious postoperative complications: A novel probability model for failure to rescue. J Pediatr Surg 2021; 56:213-214. [PMID: 33558031 DOI: 10.1016/j.jpedsurg.2020.09.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 09/27/2020] [Indexed: 10/23/2022]
Abstract
This is a commentary on the manuscript by Mpody C, Arends J, Aldrink J, et al., titled "Prognostic Profiling of Children with Serious Post-Operative Complications: A Novel Probability Model for Failure to Rescue".
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Affiliation(s)
- Max R Langham
- University of Tennessee Health Science Center, 49 North Dunlap Street, Memphis, TN 38105.
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18
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Vasudevan SA, Ha TAN, Zhu H, Heaton TE, LaQuaglia MP, Murphy JT, Barry WE, Goodhue C, Kim ES, Aldrink JH, Polites SF, Leraas HJ, Rice HE, Tracy ET, Lautz TB, Superina RA, Davidoff AM, Langham MR, Murphy AJ, Bütter A, Davidson J, Glick RD, Grijalva J, Gow KW, Ehrlich PF, Newman EA, Lal DR, Malek MM, Le-Nguyen A, Piché N, Rothstein DH, Short SS, Meyers R, Dasgupta R. Pancreaticoduodenectomy for the treatment of pancreatic neoplasms in children: A Pediatric Surgical Oncology Research Collaborative study. Pediatr Blood Cancer 2020; 67:e28425. [PMID: 32658372 PMCID: PMC7674210 DOI: 10.1002/pbc.28425] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 04/23/2020] [Accepted: 05/04/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND To better characterize short-term and long-term outcomes in children with pancreatic tumors treated with pancreaticoduodenectomy (PD). METHODS Patients 21 years of age or younger who underwent PD at Pediatric Surgical Oncology Collaborative (PSORC) hospitals between 1990 and 2017 were identified. Demographic, clinical information, and outcomes (operative complications, long-term pancreatic function, recurrence, and survival) were collected. RESULTS Sixty-five patients from 18 institutions with a median age of 13 years (4 months-22 years) and a median (IQR) follow-up of 2.8 (4.3) years were analyzed. Solid pseudopapillary tumor of the pancreas (SPN) was the most common histology. Postoperative complications included pancreatic leak in 14% (n = 9), delayed gastric emptying in 9% (n = 6), marginal ulcer in one patient, and perioperative (30-day) death due to hepatic failure in one patient. Pancreatic insufficiency was observed in 32% (n = 21) of patients, with 23%, 3%, and 6% with exocrine, or endocrine insufficiencies, or both, respectively. Children with SPN and benign neoplasms all survived. Overall, there were 14 (22%) recurrences and 11 deaths (17%). Univariate analysis revealed non-SPN malignant tumor diagnosis, preoperative vascular involvement, intraoperative transfusion requirement, pathologic vascular invasion, positive margins, and need for neoadjuvant chemotherapy as risk factors for recurrence and poor survival. Multivariate analysis only revealed pathologic vascular invasion as a risk factor for recurrence and poor survival. CONCLUSION This is the largest series of pediatric PD patients. PD is curative for SPN and benign neoplasms. Pancreatic insufficiency is the most common postoperative complication. Outcome is primarily associated with histology.
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Affiliation(s)
- Sanjeev A. Vasudevan
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children’s Surgical Oncology Program, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX, US
| | - Tu-Anh N. Ha
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children’s Surgical Oncology Program, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX, US
| | - Huirong Zhu
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children’s Surgical Oncology Program, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX, US
| | - Todd E. Heaton
- Division of Pediatric Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, NY, US
| | - Michael P. LaQuaglia
- Division of Pediatric Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, NY, US
| | - Joseph T. Murphy
- Division of Pediatric Surgery, UT Southwestern Medical School, Children’s Medical Center, Dallas, TX, US
| | - Wesley E. Barry
- Division of Pediatric Surgery, Department of Surgery, Children’s Hospital Los Angeles, USC Keck School of Medicine, Los Angeles, CA, US
| | - Catherine Goodhue
- Division of Pediatric Surgery, Department of Surgery, Children’s Hospital Los Angeles, USC Keck School of Medicine, Los Angeles, CA, US
| | - Eugene S. Kim
- Division of Pediatric Surgery, Department of Surgery, Children’s Hospital Los Angeles, USC Keck School of Medicine, Los Angeles, CA, US
| | - Jennifer H. Aldrink
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH, US
| | - Stephanie F. Polites
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, OH, US
| | - Harold J Leraas
- Division of Pediatric Surgery, Duke University Medical Center, Durham, NC, US
| | - Henry E Rice
- Division of Pediatric Surgery, Duke University Medical Center, Durham, NC, US
| | - Elisabeth T Tracy
- Division of Pediatric Surgery, Duke University Medical Center, Durham, NC, US
| | - Timothy B Lautz
- Division of Pediatric Surgery, Division of Transplant Surgery, Ann & Robert H Lurie Children’s Hospital of Chicago, Northwestern University, Chicago, IL, US
| | - Riccardo A Superina
- Division of Pediatric Surgery, Division of Transplant Surgery, Ann & Robert H Lurie Children’s Hospital of Chicago, Northwestern University, Chicago, IL, US
| | - Andrew M. Davidoff
- Department of Surgery, St. Jude Children’s Research Hospital, University of Tennessee Health Science Center, Memphis, TN, US
| | - Max R. Langham
- Department of Surgery, St. Jude Children’s Research Hospital, University of Tennessee Health Science Center, Memphis, TN, US
| | - Andrew J. Murphy
- Department of Surgery, St. Jude Children’s Research Hospital, University of Tennessee Health Science Center, Memphis, TN, US
| | - Andreana Bütter
- Division of Pediatric Surgery, Children’s Hospital, London Health Sciences Centre, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Jacob Davidson
- Division of Pediatric Surgery, Children’s Hospital, London Health Sciences Centre, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Richard D. Glick
- Division of Pediatric Surgery, Cohen Children’s Medical Center, Zucker School of Medicine at Hofstra/Northwell, Queens, NY, US
| | - James Grijalva
- Division of Pediatric Surgery, Seattle Children’s Hospital, Seattle, WA, US
| | - Kenneth W. Gow
- Division of Pediatric Surgery, Seattle Children’s Hospital, Seattle, WA, US
| | - Peter F. Ehrlich
- Department of Surgery, C.S. Mott Children’s Hospital, The University of Michigan, Ann Arbor, MI, US
| | - Erika A. Newman
- Department of Surgery, C.S. Mott Children’s Hospital, The University of Michigan, Ann Arbor, MI, US
| | - Dave R. Lal
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, US
| | - Marcus M. Malek
- Division of Pediatric General and Thoracic Surgery, Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pittsburgh, PA, US
| | - Annie Le-Nguyen
- Division of Pediatric Surgery, CHU Sainte-Justine, University of Montreal, Montreal, Qc, Canada
| | - Nelson Piché
- Division of Pediatric Surgery, CHU Sainte-Justine, University of Montreal, Montreal, Qc, Canada
| | - David H. Rothstein
- Department of Pediatric Surgery, John R. Oishei Children’s Hospital, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, US
| | - Scott S. Short
- Division of Pediatric Surgery, Primary Children’s Hospital, University of Utah School of Medicine, Salt Lake City, UT, US
| | - Rebecka Meyers
- Division of Pediatric Surgery, Primary Children’s Hospital, University of Utah School of Medicine, Salt Lake City, UT, US
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, OH, US
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Weldon CB, Madenci AL, Tiao GM, Dunn SP, Langham MR, McGahren ED, Ranganathan S, López-Terrada DH, Finegold MJ, Malogolowkin MH, Piao J, Huang L, Krailo MD, Meyers RL, Katzenstein HM. Evaluation of the diagnostic biopsy approach for children with hepatoblastoma: A report from the children's oncology group AHEP 0731 liver tumor committee. J Pediatr Surg 2020; 55:655-659. [PMID: 31126688 PMCID: PMC6842675 DOI: 10.1016/j.jpedsurg.2019.05.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 04/17/2019] [Accepted: 05/06/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND The histopathological assessment of pediatric liver tumors at presentation is critical to establish a diagnosis, guide treatment, and collect appropriate research samples. The purpose of this study was to evaluate complications associated with different approaches to liver biopsy for newly diagnosed hepatoblastoma. METHODS Children with hepatoblastoma were enrolled on Children's Oncology Group study AHEP0731 (September 2009-March 2012). This analysis evaluated the study cohort of initially unresectable patients who therefore underwent a biopsy procedure at diagnosis. The primary endpoint was clinically significant postbiopsy hemorrhage, defined as requiring red blood cell transfusion. RESULTS We identified 121 children who underwent open (n = 76, 63%), laparoscopic (n = 17, 14%), or percutaneous (n = 28, 23%) liver biopsies. All biopsy procedures yielded adequate tissue for diagnosis. Postbiopsy hemorrhage requiring transfusion occurred after 26% (n = 31) of biopsies. Need for blood product transfusion most frequently occurred following open (n = 27/76, 36%) and laparoscopic (n = 4/17, 24%) biopsies, compared with percutaneous (n = 0/28, 0%) biopsies (p < 0.01). CONCLUSIONS Pretreatment biopsy of pediatric liver tumors via a percutaneous approach yielded the lowest frequency of clinically significant hemorrhage requiring transfusion, without evidence of sacrificing diagnostic accuracy. LEVEL OF EVIDENCE Level I.
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Affiliation(s)
- Christopher B Weldon
- Departments of Surgery & Pediatric Oncology, Boston Children's Hospital/Dana Farber Cancer Institute, Boston, MA.
| | - Arin L Madenci
- Departments of Surgery & Pediatric Oncology, Boston Children's Hospital/Dana Farber Cancer Institute, Boston, MA.
| | - Gregory M Tiao
- Department of Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Stephen P Dunn
- Department of Surgery, Nemours Children's Health System, Wilmington, DE
| | - Max R Langham
- Division of Pediatric Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Eugene D McGahren
- Department of Pediatric Surgery, University of Virginia Health System, Charlottesville, VA
| | | | - Dolores H López-Terrada
- Department of Pathology and Immunology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Milton J Finegold
- Department of Pathology and Immunology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Marcio H Malogolowkin
- Division of Hematology/Oncology, Department of Pediatrics, University of California Davis Comprehensive Cancer Center, Sacramento, CA
| | - Jin Piao
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA; Children's Oncology Group, Monrovia, CA
| | - Li Huang
- Children's Oncology Group, Monrovia, CA
| | - Mark D Krailo
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA; Children's Oncology Group, Monrovia, CA
| | - Rebecka L Meyers
- Division of Pediatric Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, UT
| | - Howard M Katzenstein
- Division of Hematology/Oncology, Department of Pediatrics, Nemours Children's Specialty Care/Wolfson Children's Hospital, Jacksonville, FL
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20
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Newman EA, Abdessalam S, Aldrink JH, Austin M, Heaton TE, Bruny J, Ehrlich P, Dasgupta R, Baertschiger RM, Lautz TB, Rhee DS, Langham MR, Malek MM, Meyers RL, Nathan JD, Weil BR, Polites S, Madonna MB. Update on neuroblastoma. J Pediatr Surg 2019; 54:383-389. [PMID: 30305231 DOI: 10.1016/j.jpedsurg.2018.09.004] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 09/09/2018] [Accepted: 09/14/2018] [Indexed: 12/15/2022]
Abstract
Neuroblastoma is an embryonic cancer arising from neural crest stem cells. This cancer is the most common malignancy in infants and the most common extracranial solid tumor in children. The clinical course may be highly variable with the possibility of spontaneous regression in the youngest patients and increased risk of aggressive disease in older children. Clinical heterogeneity is a consequence of the diverse biologic characteristics that determine patient risk and survival. This review will focus on current progress in neuroblastoma staging, risk stratification, and treatment strategies based on advancing knowledge in tumor biology and genetic characterization. TYPE OF STUDY: Review article. LEVEL OF EVIDENCE: Level II.
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Affiliation(s)
- Erika A Newman
- C.S Mott Children's Hospital, The University of Michigan Medicine, Ann Arbor, MI.
| | | | | | - Mary Austin
- Memorial Hermann Texas Medical Center, Houston, TX
| | - Todd E Heaton
- Memorial Sloan Kettering Cancer Center, NY, New York
| | | | - Peter Ehrlich
- C.S Mott Children's Hospital, The University of Michigan Medicine, Ann Arbor, MI
| | | | | | - Timothy B Lautz
- Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL
| | | | - Max R Langham
- University of Tennessee Health Science Center and St. Jude Children's Research Hospital, Memphis, TN
| | - Marcus M Malek
- Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - Rebecka L Meyers
- Primary Children's Hospital, University of Utah, Salt Lake City, UT
| | | | - Brent R Weil
- Boston Children's Hospital and Dana-Farber Cancer Institute, Boston, MA
| | | | - Mary Beth Madonna
- Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL
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21
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Jancelewicz T, Brindle ME, Harting MT, Tolley EA, Langham MR, Lally PA, Gosain A, Storgion SA, Kays DW. Extracorporeal Membrane Oxygenation (ECMO) Risk Stratification in Newborns with Congenital Diaphragmatic Hernia (CDH). J Pediatr Surg 2018; 53:1890-1895. [PMID: 29754878 DOI: 10.1016/j.jpedsurg.2018.04.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 03/05/2018] [Accepted: 04/08/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND A means for early postnatal stratification of ECMO risk in CDH newborns could be used to comparatively assess the utilization and outcomes of ECMO use between centers. While multiple CDH mortality risk calculators are available, no validated tool exists specifically for prediction of ECMO use. The purpose of this study was to derive and validate an ECMO risk stratification model. METHODS The study population was obtained from CDH Study Group registry for the period between 2007 and 2016. Only centers offering ECMO were included. The cohort was restricted to ECMO candidates and then divided into derivation and validation sets. Using all relevant perinatal predictors in the registry, univariate analysis was performed for the composite outcome of ECMO use or death without ECMO use. The model was derived using the derivation cohort with multivariable logistic regression and automatic stepwise forward selection (P < 0.05 for qualifying variables), and a c-statistic was obtained. The model was then tested on the validation cohort. Sample reuse validation and bootstrap validation were performed. The validated model was then tested for accuracy on CDH subgroups. RESULTS There were 1992 patients in the derivation cohort. Four significant variables were identified in the final ECMO risk model: 1-min and 5-min Apgar scores and highest and lowest post-ductal partial pressure of CO2 during the first 24 h of life. The model c-statistic was 0.824 which was confirmed with cross-validation and bootstrap optimism correction. The validation cohort c-statistic was 0.823 (N = 993). The model had good discrimination for left and right CDH, inborn and outborn patients, patients born before and after 2011, and high and low volume centers. The model performed significantly better for postnatally diagnosed patients. CONCLUSIONS This study represents proof-of-concept that a risk model can accurately estimate the probability of ECMO use in CDH newborns. This stratification could assist centers as a metric for assessment of ECMO usage and outcomes. Refinement and prospective validation of this model should be carried out prior to clinical application. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Tim Jancelewicz
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Mary E Brindle
- Alberta Children's Hospital and Cumming Medical School, University of Calgary, Calgary, AB, Canada
| | - Matthew T Harting
- University of Texas McGovern Medical School and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Elizabeth A Tolley
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Max R Langham
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Pamela A Lally
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Ankush Gosain
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Stephanie A Storgion
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - David W Kays
- Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
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22
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Jen HC, Raval MV, Langham MR, Calkins CM, Dasgupta R, Shah SR, Stafford SD, Bernstein IH, Chen LE. Attitudes and Beliefs of Pediatric Surgical Specialists on Costs of Care and High Deductible Health Plans. Am Surg 2018; 84:1410-1414. [PMID: 30268167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Health care consumers are burdened with rising out-of-pocket medical expenses. Surgical specialists' experience and attitude towards patients' out-of-pocket costs and the influence of these factors on healthcare utilization are unknown. Our aim was to define the pediatric surgeons' experience with the financial concerns of their patients. Members from the American Academy of Pediatrics Sections on Plastic Surgery, Surgery and Urology were surveyed. Analysis of variance was used to investigate practice differences. Two hundred and eighteen out of 973 surgeons representing 38 states completed the survey. Nearly half of the surveyed surgeons did not know if cost was a determinant for their patients' choice in surgical facility, or if parents compared costs prior to the visit. Eighty four per cent of the surgeons would consider patient costs if medically appropriate, to entertain less costly alternatives, and adjust surgical scheduling to decrease economic burden. Most pediatric surgical specialists are unaware if out-of-pocket costs influenced patients' preoperative decisions. Nonetheless, they are sympathetic to the issue. As the financial burden of health care shifts to consumers, our survey indicates that surgeons are open to candid discussion surrounding finances and may alter recommendations accordingly if appropriate.
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23
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Jen HC, Raval MV, Langham MR, Calkins CM, Dasgupta R, Shah SR, Stafford SD, Bernstein IH, Chen LE. Attitudes and Beliefs of Pediatric Surgical Specialists on Costs of Care and High Deductible Health Plans. Am Surg 2018. [DOI: 10.1177/000313481808400941] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Health care consumers are burdened with rising out-of-pocket medical expenses. Surgical specialists’ experience and attitude towards patients’ out-of-pocket costs and the influence of these factors on healthcare utilization are unknown. Our aim was to define the pediatric surgeons’ experience with the financial concerns of their patients. Members from the American Academy of Pediatrics Sections on Plastic Surgery, Surgery and Urology were surveyed. Analysis of variance was used to investigate practice differences. Two hundred and eighteen out of 973 surgeons representing 38 states completed the survey. Nearly half of the surveyed surgeons did not know if cost was a determinant for their patients’ choice in surgical facility, or if parents compared costs prior to the visit. Eighty four per cent of the surgeons would consider patient costs if medically appropriate, to entertain less costly alternatives, and adjust surgical scheduling to decrease economic burden. Most pediatric surgical specialists are unaware if out-of-pocket costs influenced patients’ preoperative decisions. Nonetheless, they are sympathetic to the issue. As the financial burden of health care shifts to consumers, our survey indicates that surgeons are open to candid discussion surrounding finances and may alter recommendations accordingly if appropriate.
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Affiliation(s)
| | - Howard C. Jen
- From the Mattel Children's Hospital at UCLA, Los Angeles, California
| | | | - Max R. Langham
- University of Tennessee Health Science Center, Memphis, Tennessee
| | | | - Roshni Dasgupta
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Shawn D. Stafford
- From the Mattel Children's Hospital at UCLA, Los Angeles, California
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24
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Nguyen R, McCarville MB, Sykes A, Mao S, Wu J, Langham MR, Furman WL. Rapid decrease of serum alpha-fetoprotein and tumor volume predicts outcome in children with hepatoblastoma treated with neoadjuvant chemotherapy. Int J Clin Oncol 2018; 23:900-907. [DOI: 10.1007/s10147-018-1285-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 04/24/2018] [Indexed: 12/30/2022]
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25
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Abstract
The operating room (OR) is a special place wherein groups of highly skilled individuals must work in a coordinated and harmonious fashion to deliver optimal patient care. Team dynamics and human factors principles were initially studied by the aviation industry to better understand and prevent airline accidents. As a result, crew resource management (CRM) training was designed for all flight personnel to create a highly reliable industry with a commitment to a culture of safety. CRM has since been adapted to health care, resulting in care improvement and harm reduction across a wide variety of medical specialties. When implemented in the OR, CRM has been shown not only to improve communication and morale for OR staff, but also reduce morbidity and mortality for patients. As increasing focus is placed on quality, safety, and high-reliability, surgeons will be expected to participate and lead efforts to facilitate a team approach in this new era of patient care.
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Affiliation(s)
- Derek Wakeman
- Department of Surgery, University of Rochester School of Medicine, 601 Elmwood Ave, Box SURG, Rochester, NY 14642, USA.
| | - Max R Langham
- Department of General Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
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26
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Akbilgic O, Langham MR, Walter AI, Jones TL, Huang EY, Davis RL. A novel risk classification system for 30-day mortality in children undergoing surgery. PLoS One 2018; 13:e0191176. [PMID: 29351327 PMCID: PMC5774754 DOI: 10.1371/journal.pone.0191176] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 12/03/2017] [Indexed: 12/21/2022] Open
Abstract
A simple, objective and accurate way of grouping children undergoing surgery into clinically relevant risk groups is needed. The purpose of this study, is to develop and validate a preoperative risk classification system for postsurgical 30-day mortality for children undergoing a wide variety of operations. The National Surgical Quality Improvement Project-Pediatric participant use file data for calendar years 2012–2014 was analyzed to determine preoperative variables most associated with death within 30 days of operation (D30). Risk groups were created using classification tree analysis based on these preoperative variables. The resulting risk groups were validated using 2015 data, and applied to neonates and higher risk CPT codes to determine validity in high-risk subpopulations. A five-level risk classification was found to be most accurate. The preoperative need for ventilation, oxygen support, inotropic support, sepsis, the need for emergent surgery and a do not resuscitate order defined non-overlapping groups with observed rates of D30 that vary from 0.075% (Very Low Risk) to 38.6% (Very High Risk). When CPT codes where death was never observed are eliminated or when the system is applied to neonates, the groupings remained predictive of death in an ordinal manner.
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Affiliation(s)
- Oguz Akbilgic
- University of Tennessee Health Science Center-Oak Ridge National Laboratory Center for Biomedical Informatics, Memphis, Tennessee, United States of America
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, United States of America
| | - Max R. Langham
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, United States of America
- * E-mail:
| | - Arianne I. Walter
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, United States of America
| | - Tamekia L. Jones
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, United States of America
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee, United States of America
- Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, Tennessee, United States of America
| | - Eunice Y. Huang
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, United States of America
| | - Robert L. Davis
- University of Tennessee Health Science Center-Oak Ridge National Laboratory Center for Biomedical Informatics, Memphis, Tennessee, United States of America
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27
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Mahajan R, Shin EK, Shaban-Nejad A, Langham MR, Martin MY, Davis RL, Akbilgic O. Disparities in Population-Level Socio-Economic Factors Are Associated with Disparities in Preoperative Clinical Risk Factors in Children. Stud Health Technol Inform 2018; 255:80-84. [PMID: 30306911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
African American children are more than twice as likely as white American children to die after surgery, and have increased risk for longer hospital stays, post-surgical complications, and higher hospital costs. Prior research into disparities in pediatric surgery outcomes has not considered interactions between patient-level Clinical Risk Factors (CRFs) and population-level Social, Economic, and Environmental Factors (SEEFs) primarily due to the lack of integrated data sets. In this study, we analyze correlations between SEEFs and CRFs and correlations between CRFs and surgery outcomes. We used a dataset from a cohort of 460 surgical cases who underwent surgery at a children's hospital in Memphis, Tennessee in the United States. The analysis was conducted on 23 CRFs, 9 surgery outcomes, and 10 SEEFs and demographic variables. Our results show that population-level SEEFs are significantly associated with both patient-level CRFs and surgery outcomes. These findings may be important in the improved understanding of health disparities in pediatric surgery outcomes.
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Affiliation(s)
| | | | | | - Max R Langham
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
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28
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O'Neill AF, Towbin AJ, Krailo MD, Xia C, Gao Y, McCarville MB, Meyers RL, McGahren ED, Tiao GM, Dunn SP, Langham MR, Weldon CB, Finegold MJ, Ranganathan S, Furman WL, Malogolowkin M, Rodriguez-Galindo C, Katzenstein HM. Characterization of Pulmonary Metastases in Children With Hepatoblastoma Treated on Children's Oncology Group Protocol AHEP0731 (The Treatment of Children With All Stages of Hepatoblastoma): A Report From the Children's Oncology Group. J Clin Oncol 2017; 35:3465-3473. [PMID: 28892430 DOI: 10.1200/jco.2017.73.5654] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Purpose To determine whether the pattern of lung nodules in children with metastatic hepatoblastoma (HB) correlates with outcome. Methods Thirty-two patients with metastatic HB were enrolled on Children's Oncology Group Protocol AHEP0731 and treated with vincristine and irinotecan (VI). Responders to VI received two additional cycles of VI intermixed with six cycles of cisplatin/fluorouracil/vincristine/doxorubicin (C5VD), and nonresponders received six cycles of C5VD alone. Patients were imaged after every two cycles and at the conclusion of therapy. All computed tomography scans and pathology reports were centrally reviewed, and information was collected regarding lung nodule number, size, laterality, timing of resolution, and pulmonary surgery. Results Among the 29 evaluable patients, only 31% met Response Evaluation Criteria in Solid Tumors (RECIST) for measurable metastatic disease. The presence of measurable disease by RECIST, the sum of nodule diameters greater than or equal to the cumulative cohort median size, bilateral disease, and ≥ 10 nodules were each associated with an increased risk for an event-free survival event ( P = .48, P = .08, P = .065, P = .03, respectively), with nodule number meeting statistical significance. Ten patients underwent pulmonary resection/metastasectomy at various time points, the benefit of which could not be determined because of small patient numbers. Conclusion Children with metastatic HB have a poor prognosis. Overall tumor burden may be an important prognostic factor for these patients. Lesions that fail to meet RECIST size criteria (ie, those < 10 mm) at diagnosis may contain viable tumor, whereas residual lesions at the end of therapy may constitute eradicated tumor/scar tissue. Patients may benefit from risk stratification on the basis of the burden of lung metastatic disease at diagnosis.
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Affiliation(s)
- Allison F O'Neill
- Allison F. O'Neill and Christopher B. Weldon, Dana-Farber Cancer Institute, Boston Children's Hospital, and Harvard Medical School, Boston, MA; Alexander J. Towbin and Greg M. Tiao, Cincinnati Children's Hospital, Cincinnati, OH; Mark D. Krailo, University of Southern California Keck School of Medicine, Los Angeles; Caihong Xia and Yun Gao, Children's Oncology Group, Monrovia; Marcio Malogolowkin, University of California Davis Comprehensive Cancer Center, Sacramento, CA; M. Beth McCarville, Wayne L. Furman, and Carlos Rodriguez-Galindo, St Jude Children's Research Hospital; Max R. Langham Jr, Le Bonheur Children's Hospital and University of Tennessee, Memphis; Howard M. Katzenstein, Vanderbilt University School of Medicine, Monroe Carell Jr Children's Hospital, Nashville, TN; Rebecka L. Meyers, Primary Children's Hospital and University of Utah, Salt Lake City, UT; Eugene D. McGahren, University of Virginia Children's Hospital and University of Virginia, Charlottesville, VA; Stephen P. Dunn, duPont Hospital for Children and Thomas Jefferson University, Philadelphia; Sarangarajan Ranganathan, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; and Milton J. Finegold, Baylor College of Medicine, Houston, TX
| | - Alexander J Towbin
- Allison F. O'Neill and Christopher B. Weldon, Dana-Farber Cancer Institute, Boston Children's Hospital, and Harvard Medical School, Boston, MA; Alexander J. Towbin and Greg M. Tiao, Cincinnati Children's Hospital, Cincinnati, OH; Mark D. Krailo, University of Southern California Keck School of Medicine, Los Angeles; Caihong Xia and Yun Gao, Children's Oncology Group, Monrovia; Marcio Malogolowkin, University of California Davis Comprehensive Cancer Center, Sacramento, CA; M. Beth McCarville, Wayne L. Furman, and Carlos Rodriguez-Galindo, St Jude Children's Research Hospital; Max R. Langham Jr, Le Bonheur Children's Hospital and University of Tennessee, Memphis; Howard M. Katzenstein, Vanderbilt University School of Medicine, Monroe Carell Jr Children's Hospital, Nashville, TN; Rebecka L. Meyers, Primary Children's Hospital and University of Utah, Salt Lake City, UT; Eugene D. McGahren, University of Virginia Children's Hospital and University of Virginia, Charlottesville, VA; Stephen P. Dunn, duPont Hospital for Children and Thomas Jefferson University, Philadelphia; Sarangarajan Ranganathan, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; and Milton J. Finegold, Baylor College of Medicine, Houston, TX
| | - Mark D Krailo
- Allison F. O'Neill and Christopher B. Weldon, Dana-Farber Cancer Institute, Boston Children's Hospital, and Harvard Medical School, Boston, MA; Alexander J. Towbin and Greg M. Tiao, Cincinnati Children's Hospital, Cincinnati, OH; Mark D. Krailo, University of Southern California Keck School of Medicine, Los Angeles; Caihong Xia and Yun Gao, Children's Oncology Group, Monrovia; Marcio Malogolowkin, University of California Davis Comprehensive Cancer Center, Sacramento, CA; M. Beth McCarville, Wayne L. Furman, and Carlos Rodriguez-Galindo, St Jude Children's Research Hospital; Max R. Langham Jr, Le Bonheur Children's Hospital and University of Tennessee, Memphis; Howard M. Katzenstein, Vanderbilt University School of Medicine, Monroe Carell Jr Children's Hospital, Nashville, TN; Rebecka L. Meyers, Primary Children's Hospital and University of Utah, Salt Lake City, UT; Eugene D. McGahren, University of Virginia Children's Hospital and University of Virginia, Charlottesville, VA; Stephen P. Dunn, duPont Hospital for Children and Thomas Jefferson University, Philadelphia; Sarangarajan Ranganathan, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; and Milton J. Finegold, Baylor College of Medicine, Houston, TX
| | - Caihong Xia
- Allison F. O'Neill and Christopher B. Weldon, Dana-Farber Cancer Institute, Boston Children's Hospital, and Harvard Medical School, Boston, MA; Alexander J. Towbin and Greg M. Tiao, Cincinnati Children's Hospital, Cincinnati, OH; Mark D. Krailo, University of Southern California Keck School of Medicine, Los Angeles; Caihong Xia and Yun Gao, Children's Oncology Group, Monrovia; Marcio Malogolowkin, University of California Davis Comprehensive Cancer Center, Sacramento, CA; M. Beth McCarville, Wayne L. Furman, and Carlos Rodriguez-Galindo, St Jude Children's Research Hospital; Max R. Langham Jr, Le Bonheur Children's Hospital and University of Tennessee, Memphis; Howard M. Katzenstein, Vanderbilt University School of Medicine, Monroe Carell Jr Children's Hospital, Nashville, TN; Rebecka L. Meyers, Primary Children's Hospital and University of Utah, Salt Lake City, UT; Eugene D. McGahren, University of Virginia Children's Hospital and University of Virginia, Charlottesville, VA; Stephen P. Dunn, duPont Hospital for Children and Thomas Jefferson University, Philadelphia; Sarangarajan Ranganathan, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; and Milton J. Finegold, Baylor College of Medicine, Houston, TX
| | - Yun Gao
- Allison F. O'Neill and Christopher B. Weldon, Dana-Farber Cancer Institute, Boston Children's Hospital, and Harvard Medical School, Boston, MA; Alexander J. Towbin and Greg M. Tiao, Cincinnati Children's Hospital, Cincinnati, OH; Mark D. Krailo, University of Southern California Keck School of Medicine, Los Angeles; Caihong Xia and Yun Gao, Children's Oncology Group, Monrovia; Marcio Malogolowkin, University of California Davis Comprehensive Cancer Center, Sacramento, CA; M. Beth McCarville, Wayne L. Furman, and Carlos Rodriguez-Galindo, St Jude Children's Research Hospital; Max R. Langham Jr, Le Bonheur Children's Hospital and University of Tennessee, Memphis; Howard M. Katzenstein, Vanderbilt University School of Medicine, Monroe Carell Jr Children's Hospital, Nashville, TN; Rebecka L. Meyers, Primary Children's Hospital and University of Utah, Salt Lake City, UT; Eugene D. McGahren, University of Virginia Children's Hospital and University of Virginia, Charlottesville, VA; Stephen P. Dunn, duPont Hospital for Children and Thomas Jefferson University, Philadelphia; Sarangarajan Ranganathan, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; and Milton J. Finegold, Baylor College of Medicine, Houston, TX
| | - M Beth McCarville
- Allison F. O'Neill and Christopher B. Weldon, Dana-Farber Cancer Institute, Boston Children's Hospital, and Harvard Medical School, Boston, MA; Alexander J. Towbin and Greg M. Tiao, Cincinnati Children's Hospital, Cincinnati, OH; Mark D. Krailo, University of Southern California Keck School of Medicine, Los Angeles; Caihong Xia and Yun Gao, Children's Oncology Group, Monrovia; Marcio Malogolowkin, University of California Davis Comprehensive Cancer Center, Sacramento, CA; M. Beth McCarville, Wayne L. Furman, and Carlos Rodriguez-Galindo, St Jude Children's Research Hospital; Max R. Langham Jr, Le Bonheur Children's Hospital and University of Tennessee, Memphis; Howard M. Katzenstein, Vanderbilt University School of Medicine, Monroe Carell Jr Children's Hospital, Nashville, TN; Rebecka L. Meyers, Primary Children's Hospital and University of Utah, Salt Lake City, UT; Eugene D. McGahren, University of Virginia Children's Hospital and University of Virginia, Charlottesville, VA; Stephen P. Dunn, duPont Hospital for Children and Thomas Jefferson University, Philadelphia; Sarangarajan Ranganathan, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; and Milton J. Finegold, Baylor College of Medicine, Houston, TX
| | - Rebecka L Meyers
- Allison F. O'Neill and Christopher B. Weldon, Dana-Farber Cancer Institute, Boston Children's Hospital, and Harvard Medical School, Boston, MA; Alexander J. Towbin and Greg M. Tiao, Cincinnati Children's Hospital, Cincinnati, OH; Mark D. Krailo, University of Southern California Keck School of Medicine, Los Angeles; Caihong Xia and Yun Gao, Children's Oncology Group, Monrovia; Marcio Malogolowkin, University of California Davis Comprehensive Cancer Center, Sacramento, CA; M. Beth McCarville, Wayne L. Furman, and Carlos Rodriguez-Galindo, St Jude Children's Research Hospital; Max R. Langham Jr, Le Bonheur Children's Hospital and University of Tennessee, Memphis; Howard M. Katzenstein, Vanderbilt University School of Medicine, Monroe Carell Jr Children's Hospital, Nashville, TN; Rebecka L. Meyers, Primary Children's Hospital and University of Utah, Salt Lake City, UT; Eugene D. McGahren, University of Virginia Children's Hospital and University of Virginia, Charlottesville, VA; Stephen P. Dunn, duPont Hospital for Children and Thomas Jefferson University, Philadelphia; Sarangarajan Ranganathan, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; and Milton J. Finegold, Baylor College of Medicine, Houston, TX
| | - Eugene D McGahren
- Allison F. O'Neill and Christopher B. Weldon, Dana-Farber Cancer Institute, Boston Children's Hospital, and Harvard Medical School, Boston, MA; Alexander J. Towbin and Greg M. Tiao, Cincinnati Children's Hospital, Cincinnati, OH; Mark D. Krailo, University of Southern California Keck School of Medicine, Los Angeles; Caihong Xia and Yun Gao, Children's Oncology Group, Monrovia; Marcio Malogolowkin, University of California Davis Comprehensive Cancer Center, Sacramento, CA; M. Beth McCarville, Wayne L. Furman, and Carlos Rodriguez-Galindo, St Jude Children's Research Hospital; Max R. Langham Jr, Le Bonheur Children's Hospital and University of Tennessee, Memphis; Howard M. Katzenstein, Vanderbilt University School of Medicine, Monroe Carell Jr Children's Hospital, Nashville, TN; Rebecka L. Meyers, Primary Children's Hospital and University of Utah, Salt Lake City, UT; Eugene D. McGahren, University of Virginia Children's Hospital and University of Virginia, Charlottesville, VA; Stephen P. Dunn, duPont Hospital for Children and Thomas Jefferson University, Philadelphia; Sarangarajan Ranganathan, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; and Milton J. Finegold, Baylor College of Medicine, Houston, TX
| | - Greg M Tiao
- Allison F. O'Neill and Christopher B. Weldon, Dana-Farber Cancer Institute, Boston Children's Hospital, and Harvard Medical School, Boston, MA; Alexander J. Towbin and Greg M. Tiao, Cincinnati Children's Hospital, Cincinnati, OH; Mark D. Krailo, University of Southern California Keck School of Medicine, Los Angeles; Caihong Xia and Yun Gao, Children's Oncology Group, Monrovia; Marcio Malogolowkin, University of California Davis Comprehensive Cancer Center, Sacramento, CA; M. Beth McCarville, Wayne L. Furman, and Carlos Rodriguez-Galindo, St Jude Children's Research Hospital; Max R. Langham Jr, Le Bonheur Children's Hospital and University of Tennessee, Memphis; Howard M. Katzenstein, Vanderbilt University School of Medicine, Monroe Carell Jr Children's Hospital, Nashville, TN; Rebecka L. Meyers, Primary Children's Hospital and University of Utah, Salt Lake City, UT; Eugene D. McGahren, University of Virginia Children's Hospital and University of Virginia, Charlottesville, VA; Stephen P. Dunn, duPont Hospital for Children and Thomas Jefferson University, Philadelphia; Sarangarajan Ranganathan, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; and Milton J. Finegold, Baylor College of Medicine, Houston, TX
| | - Stephen P Dunn
- Allison F. O'Neill and Christopher B. Weldon, Dana-Farber Cancer Institute, Boston Children's Hospital, and Harvard Medical School, Boston, MA; Alexander J. Towbin and Greg M. Tiao, Cincinnati Children's Hospital, Cincinnati, OH; Mark D. Krailo, University of Southern California Keck School of Medicine, Los Angeles; Caihong Xia and Yun Gao, Children's Oncology Group, Monrovia; Marcio Malogolowkin, University of California Davis Comprehensive Cancer Center, Sacramento, CA; M. Beth McCarville, Wayne L. Furman, and Carlos Rodriguez-Galindo, St Jude Children's Research Hospital; Max R. Langham Jr, Le Bonheur Children's Hospital and University of Tennessee, Memphis; Howard M. Katzenstein, Vanderbilt University School of Medicine, Monroe Carell Jr Children's Hospital, Nashville, TN; Rebecka L. Meyers, Primary Children's Hospital and University of Utah, Salt Lake City, UT; Eugene D. McGahren, University of Virginia Children's Hospital and University of Virginia, Charlottesville, VA; Stephen P. Dunn, duPont Hospital for Children and Thomas Jefferson University, Philadelphia; Sarangarajan Ranganathan, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; and Milton J. Finegold, Baylor College of Medicine, Houston, TX
| | - Max R Langham
- Allison F. O'Neill and Christopher B. Weldon, Dana-Farber Cancer Institute, Boston Children's Hospital, and Harvard Medical School, Boston, MA; Alexander J. Towbin and Greg M. Tiao, Cincinnati Children's Hospital, Cincinnati, OH; Mark D. Krailo, University of Southern California Keck School of Medicine, Los Angeles; Caihong Xia and Yun Gao, Children's Oncology Group, Monrovia; Marcio Malogolowkin, University of California Davis Comprehensive Cancer Center, Sacramento, CA; M. Beth McCarville, Wayne L. Furman, and Carlos Rodriguez-Galindo, St Jude Children's Research Hospital; Max R. Langham Jr, Le Bonheur Children's Hospital and University of Tennessee, Memphis; Howard M. Katzenstein, Vanderbilt University School of Medicine, Monroe Carell Jr Children's Hospital, Nashville, TN; Rebecka L. Meyers, Primary Children's Hospital and University of Utah, Salt Lake City, UT; Eugene D. McGahren, University of Virginia Children's Hospital and University of Virginia, Charlottesville, VA; Stephen P. Dunn, duPont Hospital for Children and Thomas Jefferson University, Philadelphia; Sarangarajan Ranganathan, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; and Milton J. Finegold, Baylor College of Medicine, Houston, TX
| | - Christopher B Weldon
- Allison F. O'Neill and Christopher B. Weldon, Dana-Farber Cancer Institute, Boston Children's Hospital, and Harvard Medical School, Boston, MA; Alexander J. Towbin and Greg M. Tiao, Cincinnati Children's Hospital, Cincinnati, OH; Mark D. Krailo, University of Southern California Keck School of Medicine, Los Angeles; Caihong Xia and Yun Gao, Children's Oncology Group, Monrovia; Marcio Malogolowkin, University of California Davis Comprehensive Cancer Center, Sacramento, CA; M. Beth McCarville, Wayne L. Furman, and Carlos Rodriguez-Galindo, St Jude Children's Research Hospital; Max R. Langham Jr, Le Bonheur Children's Hospital and University of Tennessee, Memphis; Howard M. Katzenstein, Vanderbilt University School of Medicine, Monroe Carell Jr Children's Hospital, Nashville, TN; Rebecka L. Meyers, Primary Children's Hospital and University of Utah, Salt Lake City, UT; Eugene D. McGahren, University of Virginia Children's Hospital and University of Virginia, Charlottesville, VA; Stephen P. Dunn, duPont Hospital for Children and Thomas Jefferson University, Philadelphia; Sarangarajan Ranganathan, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; and Milton J. Finegold, Baylor College of Medicine, Houston, TX
| | - Milton J Finegold
- Allison F. O'Neill and Christopher B. Weldon, Dana-Farber Cancer Institute, Boston Children's Hospital, and Harvard Medical School, Boston, MA; Alexander J. Towbin and Greg M. Tiao, Cincinnati Children's Hospital, Cincinnati, OH; Mark D. Krailo, University of Southern California Keck School of Medicine, Los Angeles; Caihong Xia and Yun Gao, Children's Oncology Group, Monrovia; Marcio Malogolowkin, University of California Davis Comprehensive Cancer Center, Sacramento, CA; M. Beth McCarville, Wayne L. Furman, and Carlos Rodriguez-Galindo, St Jude Children's Research Hospital; Max R. Langham Jr, Le Bonheur Children's Hospital and University of Tennessee, Memphis; Howard M. Katzenstein, Vanderbilt University School of Medicine, Monroe Carell Jr Children's Hospital, Nashville, TN; Rebecka L. Meyers, Primary Children's Hospital and University of Utah, Salt Lake City, UT; Eugene D. McGahren, University of Virginia Children's Hospital and University of Virginia, Charlottesville, VA; Stephen P. Dunn, duPont Hospital for Children and Thomas Jefferson University, Philadelphia; Sarangarajan Ranganathan, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; and Milton J. Finegold, Baylor College of Medicine, Houston, TX
| | - Sarangarajan Ranganathan
- Allison F. O'Neill and Christopher B. Weldon, Dana-Farber Cancer Institute, Boston Children's Hospital, and Harvard Medical School, Boston, MA; Alexander J. Towbin and Greg M. Tiao, Cincinnati Children's Hospital, Cincinnati, OH; Mark D. Krailo, University of Southern California Keck School of Medicine, Los Angeles; Caihong Xia and Yun Gao, Children's Oncology Group, Monrovia; Marcio Malogolowkin, University of California Davis Comprehensive Cancer Center, Sacramento, CA; M. Beth McCarville, Wayne L. Furman, and Carlos Rodriguez-Galindo, St Jude Children's Research Hospital; Max R. Langham Jr, Le Bonheur Children's Hospital and University of Tennessee, Memphis; Howard M. Katzenstein, Vanderbilt University School of Medicine, Monroe Carell Jr Children's Hospital, Nashville, TN; Rebecka L. Meyers, Primary Children's Hospital and University of Utah, Salt Lake City, UT; Eugene D. McGahren, University of Virginia Children's Hospital and University of Virginia, Charlottesville, VA; Stephen P. Dunn, duPont Hospital for Children and Thomas Jefferson University, Philadelphia; Sarangarajan Ranganathan, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; and Milton J. Finegold, Baylor College of Medicine, Houston, TX
| | - Wayne L Furman
- Allison F. O'Neill and Christopher B. Weldon, Dana-Farber Cancer Institute, Boston Children's Hospital, and Harvard Medical School, Boston, MA; Alexander J. Towbin and Greg M. Tiao, Cincinnati Children's Hospital, Cincinnati, OH; Mark D. Krailo, University of Southern California Keck School of Medicine, Los Angeles; Caihong Xia and Yun Gao, Children's Oncology Group, Monrovia; Marcio Malogolowkin, University of California Davis Comprehensive Cancer Center, Sacramento, CA; M. Beth McCarville, Wayne L. Furman, and Carlos Rodriguez-Galindo, St Jude Children's Research Hospital; Max R. Langham Jr, Le Bonheur Children's Hospital and University of Tennessee, Memphis; Howard M. Katzenstein, Vanderbilt University School of Medicine, Monroe Carell Jr Children's Hospital, Nashville, TN; Rebecka L. Meyers, Primary Children's Hospital and University of Utah, Salt Lake City, UT; Eugene D. McGahren, University of Virginia Children's Hospital and University of Virginia, Charlottesville, VA; Stephen P. Dunn, duPont Hospital for Children and Thomas Jefferson University, Philadelphia; Sarangarajan Ranganathan, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; and Milton J. Finegold, Baylor College of Medicine, Houston, TX
| | - Marcio Malogolowkin
- Allison F. O'Neill and Christopher B. Weldon, Dana-Farber Cancer Institute, Boston Children's Hospital, and Harvard Medical School, Boston, MA; Alexander J. Towbin and Greg M. Tiao, Cincinnati Children's Hospital, Cincinnati, OH; Mark D. Krailo, University of Southern California Keck School of Medicine, Los Angeles; Caihong Xia and Yun Gao, Children's Oncology Group, Monrovia; Marcio Malogolowkin, University of California Davis Comprehensive Cancer Center, Sacramento, CA; M. Beth McCarville, Wayne L. Furman, and Carlos Rodriguez-Galindo, St Jude Children's Research Hospital; Max R. Langham Jr, Le Bonheur Children's Hospital and University of Tennessee, Memphis; Howard M. Katzenstein, Vanderbilt University School of Medicine, Monroe Carell Jr Children's Hospital, Nashville, TN; Rebecka L. Meyers, Primary Children's Hospital and University of Utah, Salt Lake City, UT; Eugene D. McGahren, University of Virginia Children's Hospital and University of Virginia, Charlottesville, VA; Stephen P. Dunn, duPont Hospital for Children and Thomas Jefferson University, Philadelphia; Sarangarajan Ranganathan, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; and Milton J. Finegold, Baylor College of Medicine, Houston, TX
| | - Carlos Rodriguez-Galindo
- Allison F. O'Neill and Christopher B. Weldon, Dana-Farber Cancer Institute, Boston Children's Hospital, and Harvard Medical School, Boston, MA; Alexander J. Towbin and Greg M. Tiao, Cincinnati Children's Hospital, Cincinnati, OH; Mark D. Krailo, University of Southern California Keck School of Medicine, Los Angeles; Caihong Xia and Yun Gao, Children's Oncology Group, Monrovia; Marcio Malogolowkin, University of California Davis Comprehensive Cancer Center, Sacramento, CA; M. Beth McCarville, Wayne L. Furman, and Carlos Rodriguez-Galindo, St Jude Children's Research Hospital; Max R. Langham Jr, Le Bonheur Children's Hospital and University of Tennessee, Memphis; Howard M. Katzenstein, Vanderbilt University School of Medicine, Monroe Carell Jr Children's Hospital, Nashville, TN; Rebecka L. Meyers, Primary Children's Hospital and University of Utah, Salt Lake City, UT; Eugene D. McGahren, University of Virginia Children's Hospital and University of Virginia, Charlottesville, VA; Stephen P. Dunn, duPont Hospital for Children and Thomas Jefferson University, Philadelphia; Sarangarajan Ranganathan, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; and Milton J. Finegold, Baylor College of Medicine, Houston, TX
| | - Howard M Katzenstein
- Allison F. O'Neill and Christopher B. Weldon, Dana-Farber Cancer Institute, Boston Children's Hospital, and Harvard Medical School, Boston, MA; Alexander J. Towbin and Greg M. Tiao, Cincinnati Children's Hospital, Cincinnati, OH; Mark D. Krailo, University of Southern California Keck School of Medicine, Los Angeles; Caihong Xia and Yun Gao, Children's Oncology Group, Monrovia; Marcio Malogolowkin, University of California Davis Comprehensive Cancer Center, Sacramento, CA; M. Beth McCarville, Wayne L. Furman, and Carlos Rodriguez-Galindo, St Jude Children's Research Hospital; Max R. Langham Jr, Le Bonheur Children's Hospital and University of Tennessee, Memphis; Howard M. Katzenstein, Vanderbilt University School of Medicine, Monroe Carell Jr Children's Hospital, Nashville, TN; Rebecka L. Meyers, Primary Children's Hospital and University of Utah, Salt Lake City, UT; Eugene D. McGahren, University of Virginia Children's Hospital and University of Virginia, Charlottesville, VA; Stephen P. Dunn, duPont Hospital for Children and Thomas Jefferson University, Philadelphia; Sarangarajan Ranganathan, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; and Milton J. Finegold, Baylor College of Medicine, Houston, TX
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Katzenstein HM, Furman WL, Malogolowkin MH, Krailo MD, McCarville MB, Towbin AJ, Tiao GM, Finegold MJ, Ranganathan S, Dunn SP, Langham MR, McGahren ED, Rodriguez-Galindo C, Meyers RL. Upfront window vincristine/irinotecan treatment of high-risk hepatoblastoma: A report from the Children's Oncology Group AHEP0731 study committee. Cancer 2017; 123:2360-2367. [PMID: 28211941 DOI: 10.1002/cncr.30591] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 12/15/2016] [Accepted: 01/03/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND The identification of new therapies for high-risk (HR) hepatoblastoma is challenging. Children's Oncology Group study AHEP0731 included a HR stratum to explore the efficacy of novel agents. Herein, the authors report the response rate to the combination of vincristine (V) and irinotecan (I) and the outcome of patients with high-risk hepatoblastoma. METHODS Patients with newly diagnosed metastatic hepatoblastoma or those with a serum α-fetoprotein (AFP) level <100 ng/mL were eligible. Patients received 2 cycles of V at a dose of 1.5 mg/m2 /day intravenously on days 1 and 8 and I at a dose of 50 mg/m2 /day intravenously on days 1 to 5. Patients were defined as responders if they had either a 30% decrease in tumor burden according to Response Evaluation Criteria In Solid Tumors (RECIST) or a 90% (>1 log10 ) decline in their AFP level. Responders were to receive 2 additional cycles of VI intermixed with 6 cycles of the combination of cisplatin, doxorubicin, 5-fluorouracil, and vincristine (C5VD). Nonresponders were to receive 6 cycles of C5VD alone. RESULTS A total of 32 patients with a median age at diagnosis of 26 months (range, 11-159 months) were enrolled between September 2009 and February 2012. Fourteen of 30 evaluable patients were responders (RECIST and AFP in 6 patients, RECIST only in 3 patients, and AFP only in 5 patients). The median AFP decline after 2 cycles of VI for the entire group was 345,565 ng/mL (85% of the initial AFP). The 3-year event-free and overall survival rates were 49% (95% confidence interval, 30%-65%) and 62% (95% confidence interval, 42%-77%), respectively. CONCLUSIONS The VI combination appears to have substantial activity against HR hepatoblastoma. The ultimate impact of this regimen in improving the outcomes of children with HR hepatoblastoma remains to be determined. Cancer 2017;123:2360-2367. © 2017 American Cancer Society.
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Affiliation(s)
- Howard M Katzenstein
- Division of Pediatric Hematology/Oncology, Monroe Carell Jr. Children's Hospital at Vanderbilt University, Nashville, Tennessee
| | - Wayne L Furman
- Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Marcio H Malogolowkin
- Division of Pediatric Hematology/Oncology, University of California at Davis Comprehensive Cancer Center, Sacramento, California
| | - Mark D Krailo
- Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles, California
| | - M Beth McCarville
- Department of Diagnostic Imaging, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Alexander J Towbin
- Department of Radiology and Medical Imaging, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Greg M Tiao
- Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Sarangarajan Ranganathan
- Department of Pathology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Stephen P Dunn
- Department of Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Max R Langham
- Division of Pediatric Surgery, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Eugene D McGahren
- Division of Pediatric Surgery, University of Virginia Children's Hospital, Charlottesville, Virginia
| | - Carlos Rodriguez-Galindo
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Rebecka L Meyers
- Department of Pediatric Surgery, Primary Children's Medical Center, Salt Lake City, Utah
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Savoie KB, Thomas F, Nouer SS, Langham MR, Huang EY. Age at presentation and management of pediatric intussusception: A Pediatric Health Information System database study. Surgery 2016; 161:995-1003. [PMID: 27842915 DOI: 10.1016/j.surg.2016.09.030] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 08/23/2016] [Accepted: 09/16/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Intussusception is uncommon in children older than 3 years, and use of enema reduction in older children is controversial. We sought to determine whether older children are at greater risk of requiring operative intervention and/or having pathology causing lead points, such that enema reduction should not be attempted. METHODS The Pediatric Health Information System database was reviewed from January 1, 2009-June 30, 2014. Patients were followed for 6 months from initial presentation or until bowel resection occurred. Successful enema reduction was defined as having radiologic reduction without additional procedures. RESULTS A total of 7,412 patients were identified: 6,681 were <3 years old, 731 patients were >3 years old. In those >3 years old, 450 (62%) were treated successfully with enema reduction; the rate of patients with a tumor diagnosis was similar in patients <3 years old and patients >3 years old (5% vs 6%, P = .07). The rate of a Meckel's diagnosis was greater in patients >3 years old (2% vs 14%, P < .0001). In patients >3 years old, duration of stay between patients who underwent primary operative therapy versus those who underwent operative therapy after enema reduction was similar (4 days vs 4 days, P = .06). Older age was not associated with increased risk of recurrent admission for intussusception (P = .45). CONCLUSION Pediatric Health Information System data suggest that enema reduction may be safe and effective for a majority of children even if older than 3 years.
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Affiliation(s)
- Kate B Savoie
- Department of General Surgery, University of Tennessee Health Science Center, Memphis, TN; College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, TN
| | - Fridtjof Thomas
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Simonne S Nouer
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Max R Langham
- Department of General Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Eunice Y Huang
- Department of General Surgery, University of Tennessee Health Science Center, Memphis, TN.
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Langham MR, Walter A, Boswell TC, Beck R, Jones TL. Identifying children at risk of death within 30 days of surgery at an NSQIP pediatric hospital. Surgery 2015; 158:1481-91. [DOI: 10.1016/j.surg.2015.04.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 04/11/2015] [Accepted: 04/22/2015] [Indexed: 10/23/2022]
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Loh A, Bishop M, Krasin M, Davidoff AM, Langham MR. Long-term physiologic and oncologic outcomes of inferior vena cava thrombosis in pediatric malignant abdominal tumors. J Pediatr Surg 2015; 50:550-5. [PMID: 25840061 DOI: 10.1016/j.jpedsurg.2014.11.044] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 11/24/2014] [Accepted: 11/24/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND The long-term physiologic and oncologic outcomes of treatment for inferior vena cava (IVC) thrombosis in children with malignant abdominal tumors are unclear. METHODS We conducted a retrospective review of children with malignant IVC tumor thrombosis treated at our institution between January 1996 and December 2011. Extent of tumor thrombus was classified using the Hinman system. Disease stage, management, and oncologic and physiologic outcomes and complications were evaluated. RESULTS We identified 15 patients (median age, 4.7 years): 12 with Wilms tumor, 2 with hepatoblastoma, and 1 with adrenocortical carcinoma. Neoadjuvant chemotherapy changed Hinman levels in 2 (13%) patients. IVC thrombus resection was complete in 6 (40%) patients, partial in 7 (47%) patients, and not performed in 1 (6.7%) patient. On follow-up imaging, 8 (53%) patients' IVCs were patent, 6 (40%) had residual thrombus, and 1 (6.7%) was surgically interrupted. Three (20%) patients had perioperative complications, and 2 (13%) experienced transient effects related to IVC occlusion. CONCLUSIONS Surgical management of tumor thrombus in the vena cava of children with solid abdominal tumors is challenging. Evidence on which to base strong treatment recommendations is lacking. Few long-term physiologic complications were observed.
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Affiliation(s)
- Amos Loh
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN 38105, United States; Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore
| | - Michael Bishop
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN 38105, United States
| | - Matthew Krasin
- Department of Radiological Sciences, St. Jude Children's Research Hospital, Memphis, TN 38105, United States
| | - Andrew M Davidoff
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN 38105, United States; Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN 38103, United States
| | - Max R Langham
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN 38105, United States; Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN 38103, United States; Division of Pediatric Surgery, Le Bonheur Children's Hospital, Memphis, TN 38103, United States.
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Abstract
This review is focused on the special issues and challenges confronting physicians and surgeons caring for an unborn child, or a newborn with a liver tumor. Liver tumors at this age are very rare and they make it difficult for pediatric surgeons to gain experience necessary to obtain good results. On the other hand, adult hepatobiliary surgeons faced with a fetus or infant with a liver mass are ill equipped to care for the patient even if they have done a high volume of adult liver surgery and are expert in the field. Often a team approach is the best solution.
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Affiliation(s)
- Max R Langham
- University of Tennessee Health Science Center, Division of Pediatric Surgery, University of Tennessee Health Science Center, 51 N Dunlap Suite 230, Memphis, TN 38105, USA.
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Pershad J, Waters TM, Langham MR, Li T, Huang EY. Cost-effectiveness of diagnostic approaches to suspected appendicitis in children. J Am Coll Surg 2014; 220:738-46. [PMID: 25667142 DOI: 10.1016/j.jamcollsurg.2014.12.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 12/15/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Our group recently published a clinical pathway (Le Bonheur Clinical Pathway [LeB-P]) that used the Samuel Pediatric Appendicitis Score with selective use of ultrasonography (USG) for diagnosis of children at risk for appendicitis. The objective of this study was to model the cost-effectiveness of implementing the LeB-P compared with usual care. STUDY DESIGN We constructed a decision analytic model comparing hospital costs for the following diagnostic strategies for suspected appendicitis: emergency department clinician judgment alone, USG on all patients, CT on all patients, overnight observation with surgical evaluation without studies, and the LeB-P. Prevalence of disease, outcomes probabilities, and hospital and professional costs for each option were derived from published literature, national cost data, and our previous study results. Cost-effectiveness was calculated using these 3 sets of parameters. RESULTS In the base case model, USG was the preferred strategy over LeB-P and overnight observation with surgical evaluation without studies. Emergency department clinician judgment alone and CT were dominated by the other pathways, based on either lower diagnostic accuracy or increased costs. Compared with LeB-P, USG costs $337 less per patient evaluated, but increased the diagnostic error rate by 2%. Using LeB-P rather than USG would cost an institution an additional $17,206 to eliminate one misdiagnosis, which is known as the incremental cost-effectiveness ratio. CONCLUSIONS Although performing USG on all children with suspected appendicitis was determined to be the most cost-effective strategy, using the Pediatric Appendicitis Score with selective use of USG (LeB-P) improved diagnostic accuracy at a moderate increase in cost and decreased CT use.
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Affiliation(s)
- Jay Pershad
- Department of Emergency Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Teresa M Waters
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Max R Langham
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Tao Li
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Eunice Y Huang
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN.
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Williams RF, Interiano RB, Paton E, Eubanks JW, Huang EY, Langham MR, Blakely ML. Impact of a randomized clinical trial on children with perforated appendicitis. Surgery 2014; 156:462-6. [PMID: 24878457 DOI: 10.1016/j.surg.2014.03.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 03/20/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND We previously conducted a randomized, clinical trial comparing early appendectomy with interval appendectomy for perforated appendicitis. The purpose of the present study was to evaluate the effect this clinical trial had on subsequent practice patterns and outcomes for patients with perforated appendicitis at the free-standing children's hospital conducting the trial. METHODS A retrospective study was conducted comparing children with perforated appendicitis treated before the trial (2005-2006) and after the trial (2009-2011). Early appendectomy was performed within 24 hours of diagnosis; interval appendectomy occurred 4-6 weeks after initial treatment with antibiotics. Patient characteristics, treatment variables, and outcomes were collected and compared. RESULTS The pretrial group consisted of 92 patients-62 (67%) underwent early appendectomy, and 30 (33%) patients had interval appendectomy. The posttrial group was composed of 103 patients, with 87 (84%) undergoing early appendectomy and 16 (16%) interval appendectomy (P = .005). The groups were similar in patient and admission characteristics, although the posttrial group had a lower percentage of self-pay patients and fewer computed tomography scans; health care use was similar between groups. Overall, the posttrial group had fewer adverse events (18% vs 34%, P = .02), specifically fewer wound infections (2% vs 14%, P = .001) and fewer unplanned readmissions (7% vs 16%, P = .04) than the pretrial group. In the posttrial group, those patients selected for interval appendectomy were more likely to complete the planned course of therapy than in the pretrial group. CONCLUSION A clinical trial conducted at our institution to evaluate currently available treatment options for perforated appendicitis did change practice patterns at our hospital. After the trial, there was an increase in the use of early appendectomy, a decrease in the number of computed tomography scans performed per patient, and a reduction in the overall adverse event rate.
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Affiliation(s)
- Regan F Williams
- LeBonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN.
| | - Rodrigo B Interiano
- LeBonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN
| | - Elizabeth Paton
- LeBonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN
| | - James W Eubanks
- LeBonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN
| | - Eunice Y Huang
- LeBonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN
| | - Max R Langham
- LeBonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN
| | - Martin L Blakely
- Surgery Department, Vanderbilt University Medical Center, Nashville, TN
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Lally KP, Lasky RE, Lally PA, Bagolan P, Davis CF, Frenckner BP, Hirschl RM, Langham MR, Buchmiller TL, Usui N, Tibboel D, Wilson JM. Standardized reporting for congenital diaphragmatic hernia--an international consensus. J Pediatr Surg 2013; 48:2408-15. [PMID: 24314179 DOI: 10.1016/j.jpedsurg.2013.08.014] [Citation(s) in RCA: 183] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 08/26/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND/PURPOSE Congenital diaphragmatic hernia (CDH) remains a significant cause of neonatal death. A wide spectrum of disease severity and treatment strategies makes comparisons challenging. The objective of this study was to create a standardized reporting system for CDH. METHODS Data were prospectively collected on all live born infants with CDH from 51 centers in 9 countries. Patients who underwent surgical correction had the diaphragmatic defect size graded (A-D) using a standardized system. Other data known to affect outcome were combined to create a usable staging system. The primary outcome was death or hospital discharge. RESULTS A total of 1,975 infants were evaluated. A total of 326 infants were not repaired, and all died. Of the remaining 1,649, the defect was scored in 1,638 patients. A small defect (A) had a high survival, while a large defect was much worse. Cardiac defects significantly worsened outcome. We grouped patients into 6 categories based on defect size with an isolated A defect as stage I. A major cardiac anomaly (+) placed the patient in the next higher stage. Applying this, patient survival is 99% for stage I, 96% stage II, 78% stage III, 58% stage IV, 39% stage V, and 0% for non-repair. CONCLUSIONS The size of the diaphragmatic defect and a severe cardiac anomaly are strongly associated with outcome. Standardizing reporting is imperative in determining optimal outcomes and effective therapies for CDH and could serve as a benchmark for prospective trials.
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Affiliation(s)
- Kevin P Lally
- UT Health Medical School and Children's Memorial Hermann Hospital, Houston, TX, USA.
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Meyers RL, Tiao GM, Dunn SP, McGahren ED, Langham MR. Surgical management of children with locally advanced hepatoblastoma. Cancer 2012; 118:4090-1; author reply 4094-5. [DOI: 10.1002/cncr.26715] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Meyers RL, Tiao GM, Dunn SP, Langham MR. Liver transplantation in the management of unresectable hepatoblastoma in children. Front Biosci (Elite Ed) 2012; 4:1293-302. [PMID: 22201955 DOI: 10.2741/e460] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Complete surgical resection is essential to long-term survival in children with hepatoblastoma. We present the guidelines from the Children's Oncology Group (COG), liver tumor study group of the Societe Internationale Oncologie Pediatrique (SIOPEL), and German Pediatric Oncology Group (GPOH) for early referral of children with potentially unresectable hepatoblastoma to a specialty center with expertise in extreme resection and liver transplantation. Patients who will become candidates for liver transplantation should receive chemotherapy following the same protocols as for children undergoing a partial hepatectomy. The Pediatric Liver Unresectable Tumor Observatory (PLUTO) is an international prospective database established to collect data and make future recommendations on controversial issues regarding the use of transplant in hepatoblastoma including: 1) What is the optimal treatment of multifocal tumors. 2) What is the role of extreme resection vs. liver transplant in patients with major venous involvement. 3) What is the role of transplant in patients who present with lung metastasis. 3) Should patients with tumor relapse be offered a rescue transplant. 4) What is the role of pre- and post- transplant chemotherapy.
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Affiliation(s)
- Rebecka L Meyers
- University of Utah, Primary Children's Medical Center, Salt Lake City, UT 84113, USA.
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Meyers RL, Tiao GM, Dunn SP, Langham MR. Liver transplantation in the management of unresectable hepatoblastoma in children. Front Biosci (Elite Ed) 2012. [PMID: 22201955 DOI: 10.2741/460] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Complete surgical resection is essential to long-term survival in children with hepatoblastoma. We present the guidelines from the Children's Oncology Group (COG), liver tumor study group of the Societe Internationale Oncologie Pediatrique (SIOPEL), and German Pediatric Oncology Group (GPOH) for early referral of children with potentially unresectable hepatoblastoma to a specialty center with expertise in extreme resection and liver transplantation. Patients who will become candidates for liver transplantation should receive chemotherapy following the same protocols as for children undergoing a partial hepatectomy. The Pediatric Liver Unresectable Tumor Observatory (PLUTO) is an international prospective database established to collect data and make future recommendations on controversial issues regarding the use of transplant in hepatoblastoma including: 1) What is the optimal treatment of multifocal tumors. 2) What is the role of extreme resection vs. liver transplant in patients with major venous involvement. 3) What is the role of transplant in patients who present with lung metastasis. 3) Should patients with tumor relapse be offered a rescue transplant. 4) What is the role of pre- and post- transplant chemotherapy.
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Affiliation(s)
- Rebecka L Meyers
- University of Utah, Primary Children's Medical Center, Salt Lake City, UT 84113, USA.
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Blakely ML, Williams R, Dassinger MS, Eubanks JW, Fischer P, Huang EY, Paton E, Culbreath B, Hester A, Streck C, Hixson SD, Langham MR. Early vs interval appendectomy for children with perforated appendicitis. ACTA ACUST UNITED AC 2011; 146:660-5. [PMID: 21339413 DOI: 10.1001/archsurg.2011.6] [Citation(s) in RCA: 121] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To compare the effectiveness and adverse event rates of early vs interval appendectomy in children with perforated appendicitis. DESIGN Nonblinded randomized trial. SETTING A tertiary-referral urban children's hospital. PATIENTS A total of 131 patients younger than 18 years with a preoperative diagnosis of perforated appendicitis. INTERVENTIONS Early appendectomy (within 24 hours of admission) vs interval appendectomy (6-8 weeks after diagnosis). MAIN OUTCOME MEASURES Time away from normal activities (days). Secondary outcomes included the overall adverse event rates and the rate of predefined specific adverse events (eg, intra-abdominal abscess, surgical site infection, unplanned readmission). RESULTS Early appendectomy, compared with interval appendectomy, significantly reduced the time away from normal activities (mean, 13.8 vs 19.4 days; P < .001). The overall adverse event rate was 30% for early appendectomy vs 55% for interval appendectomy (relative risk with interval appendectomy, 1.86; 95% confidence interval, 1.21-2.87; P = .003). Of the patients randomized to interval appendectomy, 23 (34%) had an appendectomy earlier than planned owing to failure to improve (n = 17), recurrent appendicitis (n = 5), or other reasons (n = 1). CONCLUSIONS Early appendectomy significantly reduced the time away from normal activities. The overall adverse event rate after early appendectomy was significantly lower compared with interval appendectomy. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00435032.
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Affiliation(s)
- Martin L Blakely
- Division of Pediatric Surgery, University of Tennessee Health Science Center, Memphis, TN 38111, USA.
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Williams RF, Blakely ML, Fischer PE, Streck CJ, Dassinger MS, Gupta H, Renaud EJ, Eubanks JW, Huang EY, Hixson SD, Langham MR. Diagnosing Ruptured Appendicitis Preoperatively in Pediatric Patients. J Am Coll Surg 2009; 208:819-25; discussion 826-8. [DOI: 10.1016/j.jamcollsurg.2009.01.029] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2008] [Accepted: 01/14/2009] [Indexed: 10/21/2022]
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Dassinger MS, Eubanks JW, Langham MR. Full Work Analysis of Resident Work Hours. J Surg Res 2008; 147:178-81. [DOI: 10.1016/j.jss.2008.03.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2008] [Revised: 03/07/2008] [Accepted: 03/10/2008] [Indexed: 11/28/2022]
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Winfield RD, Ang DN, Chen MK, Kays DW, Langham MR, Beierle EA. The use of Seprafilm in pediatric surgical patients. Am Surg 2007; 73:792-5. [PMID: 17879686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
Hyaluronate carboxymethylcellulose (Seprafilm; Genzyme Corp., Cambridge, MA) has been demonstrated to be safe and efficacious for the prevention of abdominal and pelvic adhesions; however, information is scarce regarding its use in children and adolescents. We wanted to characterize our experience with Seprafilm in a pediatric surgical population. After Institutional Review Board approval, we searched our hospital and pediatric surgery database for cases in which Seprafilm was used and retrospectively reviewed medical records for demographic and clinical information. Between July 2000 and October 2005, 18 patients had Seprafilm placed. Patients ranged in age from 0.25 to 18 years. Seven patients had not undergone any previous operations. Of patients having undergone prior surgery, the most common preceding intervention was a Ladd's procedure. Seprafilm was applied in a variety of scenarios, the most frequently being adhesiolysis for bowel obstruction. No patient required reoperation for obstruction. Two patients underwent subsequent operations for unrelated reasons; one was noted to have no significant adhesions, but the other had extensive adhesions. No patient demonstrated signs or symptoms of small bowel obstruction, intraperitoneal abscess, or localized inflammatory reaction to Seprafilm. Seprafilm was successfully used in our pediatric surgical population without complications.
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Affiliation(s)
- Robert D Winfield
- University of Florida College of Medicine, Department of Surgery, Division of Pediatric Surgery, Gainesville, Florida, USA
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Abstract
Hyaluronate carboxymethylcellulose (Seprafilm®; Genzyme Corp., Cambridge, MA) has been demonstrated to be safe and efficacious for the prevention of abdominal and pelvic adhesions; however, information is scarce regarding its use in children and adolescents. We wanted to characterize our experience with Seprafilm® in a pediatric surgical population. After Institutional Review Board approval, we searched our hospital and pediatric surgery database for cases in which Seprafilm® was used and retrospectively reviewed medical records for demographic and clinical information. Between July 2000 and October 2005, 18 patients had Seprafilm® placed. Patients ranged in age from 0.25 to 18 years. Seven patients had not undergone any previous operations. Of patients having undergone prior surgery, the most common preceding intervention was a Ladd's procedure. Seprafilm was applied in a variety of scenarios, the most frequently being adhesiolysis for bowel obstruction. No patient required reoperation for obstruction. Two patients underwent subsequent operations for unrelated reasons; one was noted to have no significant adhesions, but the other had extensive adhesions. No patient demonstrated signs or symptoms of small bowel obstruction, intraperitoneal abscess, or localized inflammatory reaction to Seprafilm®. Seprafilm® was successfully used in our pediatric surgical population without complications.
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Affiliation(s)
- Robert D. Winfield
- The University of Florida College of Medicine, Department of Surgery, Division of Pediatric Surgery, Gainesville, Florida
| | - Darwin N. Ang
- The University of Washington College of Medicine, Department of Surgery, Division of Trauma and Critical Care, Seattle, Washington; and
| | - Mike K. Chen
- The University of Florida College of Medicine, Department of Surgery, Division of Pediatric Surgery, Gainesville, Florida
| | - David W. Kays
- The University of Florida College of Medicine, Department of Surgery, Division of Pediatric Surgery, Gainesville, Florida
| | - Max R. Langham
- The University of Tennessee Health Science Center, Department of Surgery, Division of Pediatric Surgery, Memphis, Tennessee
| | - Elizabeth A. Beierle
- The University of Florida College of Medicine, Department of Surgery, Division of Pediatric Surgery, Gainesville, Florida
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Abstract
Severe liver disease is an unusual but potentially fatal complication of sickle-cell disease (SCD). Liver transplantation has been complicated by ongoing SCD and thrombosis. We reviewed 214 pediatric transplants done at our institution from 1990 to 2005. Three patients were transplanted for complications of SCD, including intrahepatic cholestasis and viral hepatitis. Overall patient and graft survival was 66%. One patient died after 6 years from a subdural hematoma. There were not any incidences of graft loss, primary nonfunction, or thrombosis. All 3 patients required between 1 and 4 postoperative transfusions to keep hemoglobin (Hgb) >9 g/dL with an S fraction of less than 25%. One patient required a preoperative transfusion for a hemoglobin S (HbS) fraction of 30%. Mean follow-up has been 4.2 years (range, 2.6-5.4 years). All 3 children continued to suffer sequelae from their SCD. One child suffered from recurrent sickle-cell hepatopathy and chronic graft failure. In conclusion, children with SCD can in rare instances develop acute and chronic liver failure. These children can be successfully transplanted with good outcomes. Careful attention must be paid to HbS fraction and hemoglobin level to prevent sickling and vascular thrombosis. Unfortunately, liver transplant cannot alter the natural course of the disease.
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Affiliation(s)
- Kristin L Mekeel
- Division of Transplantation, Department of Surgery, University of Florida, Gainesville, FL 32610, USA
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Abstract
Cystic fibrosis (CF) is an inherited genetic defect in epithelial chloride transport that results a multisystem disease affecting the sweat glands and the pulmonary and digestive systems. Although pulmonary disease remains the primary cause of morbidity and mortality in these patients, up to 8% may develop focal biliary cirrhosis and portal hypertension. Liver transplantation is an accepted therapy for these patients. About 85% of CF patients develop pancreatic exocrine insufficiency and up to 34% will develop diabetes requiring insulin. We describe a series of 9 patients who underwent liver transplantation (6 transplantation of liver only [LO], and 3 combined en bloc liver-pancreas [LP] transplantation) for CF-related liver disease at our institution,. All 9 patients had pretransplant pancreatic exocrine insufficiency requiring enzyme supplementation. Of the 9, 5 patients (55%) had preoperative insulin dependent diabetes, including all 3 patients who underwent liver pancreas transplantation. Liver-pancreas transplants were performed en bloc. One-year patient survival for both LO and LP patients was 100%. Five-year patient survival was 83% for the LO patients and 100% for the LP patients. All LP patients are off insulin and do not require pancreatic enzyme supplementation. All patients receiving LO continue to need exogenous pancreatic enzyme supplementation. In the 6 patients who received LO, 2 were insulin dependent prior to surgery, and they remain insulin dependent after transplant. Of the 4 patients who received LO who were not insulin dependent pretransplant, 3 have now developed insulin-dependent diabetes. Patients receiving LO were more likely to be diabetic and require exogenous pancreatic enzymes after transplant than those receiving LP (83% vs. 0%, P = 0.04, and 100% vs. 0%, P = 0.01, respectively). In conclusion, patients with CF and end-stage liver disease requiring liver transplantation may benefit from combined liver-pancreas transplantation.
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Affiliation(s)
- Kristin L Mekeel
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA
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Abstract
BACKGROUND This study examines the results of liver transplantation (LT) in children 5 kg or less. Reports suggest an increased morbidity and mortality in children weighing 5 kg or less as compared to larger children. However, over half of all children needing LT are <1 year old. Improving outcomes in very small children is a major goal of liver transplantation. METHODS All children under 21 years of age transplanted from January 1990 to June 2005 were included in this study. One hundred sixty-eight primary liver transplants were done: 61 in children less than one year of age and 20 in infants weighing 5 kg or less at LT (2 to 5 kg). These 20 infants underwent 23 transplants. Whole organs were used in 39% of transplants, and reduced or split grafts were used in 61%. Arterial reconstruction using aortic conduits was done in 22%. Analysis included Fischer's exact or Chi square test for non-parametric analysis while patient survival was calculated using the Kaplan-Meier method test with differences in survival assessed using the log rank test. RESULTS Five-year survival for infants 5 kg or less was 74%, and graft survival was 60%, which was not different from patients transplanted that were >5 kg. There were three perioperative deaths, one from primary graft non-function, and two from portal vein thrombosis. There were no bile leaks or hepatic artery thromboses. Bacterial, fungal, and viral infections made up the vast majority of the postoperative complications (65%), with viral infections resulting in two graft losses requiring re-transplantation. Rejection occurred in 25% of patients, of which one required OKT3. Five of the 23 liver transplants in infants less than 5 kg were done prior to 1996, with a five-year graft survival of only 20%. Improvements in technique and postoperative care after 1996 led to improved graft and patient survival of 77% and 86% respectively. CONCLUSIONS Liver transplantation for infants weighing less than 5 kilograms can be technically challenging but can have equivalent graft and patient survival when compared to larger children requiring liver transplantation. Infants should not be denied liver transplantation based on weight alone.
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Affiliation(s)
- Kristin L Mekeel
- Division of Transplantation and Hepatobiliary Surgery, University of Florida, Gainesville, FL 32410, USA
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Affiliation(s)
- Max R Langham
- Division of Pediatric Surgery, University of Tennessee Health Science Center, 777 Washington Avenue, Suite P220, Memphis, TN 38105, USA.
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Fujita S, Fujikawa T, Mekeel K, Gonzalez R, Langham MR, Foley DP, Hemming AW, Howard RJ, Reed AI. Localized intraocular posttransplant lymphoproliferative disorder after pediatric liver transplantation. Transplantation 2006; 81:493-5. [PMID: 16477246 DOI: 10.1097/01.tp.0000188694.19925.d4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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