High-dose melphalan, etoposide, total-body irradiation, and autologous stem-cell reconstitution as consolidation therapy for high-risk Ewing's sarcoma does not improve prognosis

PURPOSE

To determine whether consolidation therapy with high-dose melphalan, etoposide, and total-body irradiation (TBI) with autologous stem-cell support would improve the prognosis for patients with newly diagnosed metastatic Ewing's sarcoma (ES).

PATIENTS AND METHODS

Thirty-two eligible patients with newly diagnosed ES metastatic to bone and/or bone marrow were enrolled onto this study. Treatment was initially comprised of five cycles of induction chemotherapy (cyclophosphamide, doxorubicin, and vincristine alternating with ifosfamide and etoposide) and local control. Peripheral-blood stem-cell collection was performed after the second cycle of chemotherapy, with delay if the bone marrow was persistently involved. If patients had a good response to initial therapy, they proceeded to consolidation therapy with melphalan, etoposide, TBI, and stem-cell support.

RESULTS

Of the 32 eligible patients, 23 proceeded to high-dose therapy consolidation. Of the nine patients who did not proceed to consolidation, four were secondary to progressive disease and two were secondary to toxicity. Three patients died from toxicity during the high-dose phase of the therapy. The majority of the patients who underwent high-dose consolidation therapy experienced relapse and died with progressive disease. Two-year event-free survival (EFS) for all eligible patients is 20%. The 2-year post-stem-cell reconstitution EFS for the subset of 23 patients who received consolidation therapy is 24%. Analysis of peripheral-blood stem-cell collections by molecular techniques for minimal residual disease showed contamination of at least some samples by tumor cells in all three patients with available data.

CONCLUSION

Consolidation with high-dose melphalan, etoposide, TBI, and autologous stem-cell support failed to improve the probability of EFS in this cohort of patients with newly diagnosed metastatic ES.

The frozen section yesterday and today: pediatric solid tumors--crucial issues

This article is the offshoot of a Pediatric Oncology Group (POG) seminar presented at the Adams Mark Hotel, Denver, Colorado, Friday, May 21, 1999, titled "The Frozen Section in Pediatric Solid Tumors--Crucial Issues." There were eight presenters who spoke on a wide range of topics that included historical perspectives of the frozen section and discussion of the following systems: brain, renal, germ cell, bone, soft tissue, and lymph nodes. To complement these presentations, a pediatric surgeon explained his concern and philosophy regarding the use of frozen sections, and a lawyer tackled the issues and risks in rendering a frozen section diagnosis. We think that this review covers all the important aspects of the frozen section in our current practice of pediatric pathology.

Hepatic hemangioendothelioma: clinical experience and management strategy

PURPOSE

This study sought to define management strategies based on clinical experience in treating infantile hepatic hemangioendothelioma.

METHODS

A retrospective analysis of patients with hemangioendothelioma presenting to a tertiary liver transplantation center between 1989 and 1997 was performed.

RESULTS

Thirteen patients (median age, 14 days) with hemangioendothelioma were identified. Congestive heart failure (P<.03) and abdominal mass (P<.081) were predictive of 5-month mortality rates. Ultrasonography and computerized axial tomography were the diagnostic modalities most commonly used. Treatment strategies consisted of medical management (steroids and alpha-interferon) and interventional modalities (hepatic artery ligation or embolization, resectional surgery, or orthotopic liver transplantation). Patients who underwent resectional surgery, with or without orthotopic liver transplantation, had a lower 5-month mortality rate (P<.02) and a greater 2-year survival rate (P<.003) than did those who underwent hepatic artery ligation or embolization. Early morbidity and mortality tended to be a consequence of the primary lesion, whereas late morbidity and mortality were reflective of the treatment modality used.

CONCLUSIONS

In cases of failed medical management, resectional therapy should be used when possible. If partial hepatectomy is not technically achievable, hepatic artery embolization should be used either as definitive therapy or as a temporizing measure until orthotopic liver transplantation is possible.

Subglottic injury, gastric juice, corticosteroids, and peptide growth factors in a porcine model

OBJECTIVES

To study the effects of mucosal injury, gastric juice, and corticosteroids and to determine the presence of peptide growth factors in the subglottic mucosa in a porcine model.

STUDY DESIGN

Prospective cohort animal study.

METHODS

In this model of subglottic injury, five groups (n = 5 each) of piglets were used. Injury was induced by electrocautery (acute), electrocautery plus repeated saline application (chronic), electrocautery plus repeated gastric juice application (chronic plus gastric juice), or repeated gastric juice application (gastric). Control piglets had normal saline applied repeatedly.

RESULTS

Histopathologic findings for the gastric juice group included basal cell hyperplasia (80%), squamous metaplasia (80%), and mucosal ulceration (40%). Control piglets showed squamous metaplasia (80%) but no basilar hyperplasia or ulceration. Immunohistochemistry detected peptide growth factors and epidermal growth factor receptor (EGFR) in all groups. Decreased staining was most frequent in the acute injury group. Quantitative reverse transcriptase polymerase chain reaction (RT-PCR) documented lower expression of EGFR in the gastric juice group (P = .01).

CONCLUSIONS

These findings suggest that peptide growth factors and EGFR are part of normal subglottic mucosal turnover. Noxious stimuli decrease production of these factors. Gastric juice had adverse effects documented by histopathology and molecular techniques.

Latent Epstein-Barr virus infection demonstrated in low-grade leiomyosarcomas of adults with acquired immunodeficiency syndrome, but not in adjacent Kaposi's lesion or smooth muscle tumors in immunocompetent patients

BACKGROUND

Incidence of smooth muscle tumors is increased in patients with human immunodeficiency virus infection and organ transplant recipients. Smooth muscle tumors in immunocompromised patients often occur in unusual locations and exhibit evidence of latent infection by clonal, presumably tumorigenic, Epstein-Barr virus (EBV).

OBJECTIVE

To investigate the presence of EBV latent infection in smooth muscle tumors in patients with acquired immunodeficiency syndrome and in immunocompetent patients.

DESIGN

Twenty-two extrauterine, extraintestinal smooth muscle and myofibroblastic tumors were reviewed pathologically, and clinical charts were screened. Tumors were malignant (15 patients), benign (6 patients), and borderline (1 patient). Tissue specimens were investigated for latent EBV infection by latent membrane protein immunocytochemistry and EBV-encoded RNA in situ hybridization.

SETTING

University Hospital of the University of Nancy, France.

PATIENTS

Patients were 18 adults and four children. Two adults had acquired immunodeficiency syndrome. Both had low-grade leiomyosarcomas located in adrenal gland. Moreover, in patient 1, leiomyosarcoma was multifocal in pericardium and lymph node; in lymph node, muscle tumor was adjacent to nodal and skin Kaposi's lesions.

RESULTS

In both patients with acquired immunodeficiency syndrome and leiomyosarcoma, latent infection by EBV could be demonstrated in tumor cells, contrasting with absence of detectable EBV infection in adjacent non-neoplastic tissues and nearby Kaposi's lesions. Latent infection by EBV could not be demonstrated in smooth muscle and myofibroblastic tumors in immunocompetent patients.

CONCLUSIONS

Latent EBV infection is associated with smooth muscle cell tumors in immunocompromised patients, but not in immunocompetent patients.

Malignancy after retinoblastoma: secondary cancer or recurrence?

The risk of second malignancy after retinoblastoma is reported to be as high as 20% at 10 years after initial diagnosis. This incidence may be an overestimate because of difficulties in distinguishing a second malignancy from recurrent tumor. We encountered a patient with bilateral retinoblastoma who developed a temporal mass 3.5 years after initial treatment for what had first been diagnosed as rhabdomyosarcoma; further study suggested that it was recurrent retinoblastoma manifesting as primitive neuroectodermal tumor (PNET) with multilineage differentiation. Chromosome 13 abnormalities were compatible with either rhabdomyosarcoma or recurrent retinoblastoma. To determine how often second malignancies in retinoblastoma patients may be confused with recurrent primary tumor, we reviewed our experience at Children's Hospital of Pittsburgh. Of 43 retinoblastoma patients seen between 1951 and 1992, presumed second malignancies were documented in four, including the current case. Of the three other second tumors, one had both neural and skeletal muscle differentiation; another was diagnosed as rhabdomyosarcoma unclassifiable as embryonal or alveolar; the last was an osteosarcoma. Only the osteosarcoma was clearly a second neoplasm; two and perhaps three of the other cases may be recurrent retinoblastoma. The distinction between second malignancy and recurrent retinoblastoma may be difficult but is worth determining, because treatment may differ, depending on the correct designation.

Interferon-alpha affects the immune response in post-transplant lymphoproliferative disorder

Post-transplant lymphoproliferative disorder (PTLD) is associated with Epstein-Barr virus (EBV) and characterized by fever, lymphadenopathy, and graft dysfunction. We describe the clinical course of an EBV seronegative 11-yr-old boy who underwent double lung transplantation and subsequently developed PTLD in the graft. A reduction in immunosuppression and the addition of acyclovir did not result in improvement. Treatment with interferon-alpha (IFN-alpha), however, led to dramatic clinical, radiographic, and histologic improvement. Semiquantitative measurements of cytokine mRNA in his bronchoalveolar lavage cells prior to therapy with IFN-alpha revealed high levels of IL-4 and IL-10 mRNA, which decreased significantly with treatment. We speculate that the beneficial effect of IFN-alpha in the treatment of PTLD is directly related to the inhibition of type 2 helper (Th2-like) T-cells.

Recurrent Epstein-Barr virus-associated lesions in organ transplant recipients

Posttransplant lymphoproliferative disorders (PTLD) are related to Epstein-Barr virus (EBV) and range from lymphoid hyperplasias to lymphomas. The authors report 11 transplant recipients with recurrent EBV-associated lesions. Four patients presented with EBV-positive mononucleosis-like lymphadenitis. One had recurrence of a similar lesion and the other three developed polymorphic PTLDs. Matched clonal studies in one patient showed clonal lymphoid and EB viral populations in the recurrent lesion, but not in the initial lesion. Six patients presented with polymorphic PTLDs. Five later developed histologically dissimilar tumors that resembled non-Hodgkin's lymphoma (two B-cell and one T-cell origin), Hodgkin's disease (one patient), or smooth muscle tumor (one patient). Matched clonal studies were available from one patient and showed that the primary and recurrent lesions were clonally distinct. The sixth patient had recurrence of histologically and clonally identical polymorphic PTLD. One patient presented with monomorphic PTLD and developed recurrence of a clonally identical tumor after a 6-month remission. This study shows that a few patients with EBV-associated lesions have clinical recurrence, which may be either a relapse of the original process or a new EBV-associated lesion. In some patients, the new lesion appeared to represent a more fully developed malignancy that did the antecedent lesion.

Imaging of post-transplant spindle cell tumors

Spindle/smooth muscle cell proliferation is an additional neoplastic process related to immunosuppression and EBV infection. We describe four post transplant children with this diagnosis. Multiple organ systems may be involved, particularly the liver, gastrointestinal tract, and lungs. Lesions are radiographically, clinically, and endoscopically indistinguishable from those of post-transplant lymphoproliferative disease (PTLD).

Indolent course of advanced neuroblastoma in children older than 6 years at diagnosis

BACKGROUND

An early observation suggests that children older than 6 years of age at diagnosis of neuroblastoma constitute a favorable prognostic group.

METHODS

Kaplan-Meier plots of survival of all such patients diagnosed at the Children's Hospital of Pittsburgh 1975-1992 were compared with curves of concurrently treated patients with Stage IV disease who were 1-6 years of age at diagnosis ("younger patients"). Known prognostic features, including stage and primary site of disease, pattern of metastases, histopathology, MYCN gene amplification, and urinary catecholamine metabolite ratios, were reviewed.

RESULTS

Of 17 children diagnosed after the age of 6 years ("older patients"), 13 patients had Evans' Stage IV disease and 4 had Stage III disease. The median survival was 3.24 years (range, 0.63-15.04 years) for the entire cohort and 3.07 years for those children with Stage IV disease. This compared with a median survival of 1.05 years in 34 concurrent younger patients (P < 0.01). In most cases, disease in these older patients was characterized by a short-lived complete or partial remission followed by aggressive recurrent disease that was partially and only transiently chemo- or radiosensitive. Only 3 patients (2 with Stage IV disease) are in continuous complete remission at 3, 5 10/12, and 14 1/2 years from diagnosis. Although poor prognostic factors were common, including the presence of bony metastases (12/17), biopsy material from pretreatment tumor specimens demonstrated a single MYCN gene copy number in all patients and favorable histology in 15 of 16 samples.

CONCLUSION

Older children with neuroblastoma have a more indolent course than do younger patients, a finding that appears to be related to favorable histology and the absence of MYCN amplification. Examination of larger numbers of such patients from cooperative groups should lead to a better understanding of what appears to be a subset of pediatric patients with neuroblastoma who may benefit from specifically tailored treatment protocols.

Fluorescence in situ hybridization (FISH) detection of MYCN oncogene amplification in neuroblastoma using paraffin-embedded tissues

The expression and degree of amplification of the MYCN oncogene in neuroblastoma provide an important indicator of disease prognosis. Detection of MYCN amplification has been described using Southern blotting or polymerase chain reaction (PCR) on DNA from fresh or frozen tissue samples, and using in situ hybridization mainly on metaphase spreads or smears of cultured neuroblastoma cells. In this article, we describe fluorescence in situ hybridization (FISH) results on detection of MYCN amplification in formalin-fixed, paraffin-embedded samples of 25 neuroblastoma and 20 nonneuroblastoma pediatric tumors. MYCN amplification was readily detectable by FISH in eight of the neuroblastomas; correlation with results obtained by Southern analysis was perfect. Of the nonneuroblastoma tumors, only one of three retinoblastoma cases showed MYCN amplification. In contrast to the Southern blot technique, FISH demonstrated the state of amplification heterogeneity of the tumor cells as well as the nature of the amplification units: double-minute chromosomes (DMs) or homogeneously staining regions (HSRs). The results indicate that FISH is a rapid and reliable method for detection of MYCN oncogene amplification in routinely processed samples and may be used to supplant the Southern blot technique.

The Third Intergroup Rhabdomyosarcoma Study

PURPOSE

The ultimate goal of the Third Intergroup Rhabdomyosarcoma Study (IRS-III, 1984 to 1991) was to improve treatment outcome in children with rhabdomyosarcoma through clinical trials comparing risk-based protocols of surgery and multiagent chemotherapy, with or without irradiation.

PATIENTS AND METHODS

One thousand sixty-two previously untreated, eligible patients who were entered onto the study after surgery were randomized or assigned to treatment by clinical group (I through IV), histology (unfavorable or favorable), and site of the primary tumor. Initial responses, progression-free survival (PFS), and survival (S) were the end points used in comparisons between randomized groups and between patients treated in IRS-III and IRS-II (1978 to 1984).

RESULTS

The overall outcome of therapy in IRS-III was significantly better than in IRS-II (5-year PFS, 65% +/- 2% v 55% +/- 2%; P < .001 by stratified testing). Patients with group I favorable-histology tumors fared as well on a 1-year regimen of vincristine and dactinomycin (VA), as did a comparable group treated with VA plus cyclophosphamide (C) (5-year PFS, 83% +/- 3% v 76% +/- 4%; P = .18). Results for patients with group II favorable-histology tumors, excluding orbit, head, and paratesticular sites, were inconclusive regarding the benefit from addition of doxorubicin (ADR) to VA. Patients with group III tumors, excluding those in special pelvic, orbit, and other selected nonparameningeal head sites, fared much better on the more intensive regimens of IRS-III than on pulsed VAC or VAC-VADRC in IRS-II (5-year PFS estimates, 62% +/- 3% v 52% +/- 3%; P < .01); however, there were no significant differences in outcome among the groups treated in IRS-III. Patients with metastatic disease at diagnosis (clinical group IV) did not benefit significantly from the more complex therapies evaluated in IRS-III.

CONCLUSION

Intensification of therapy for most patients in IRS-III, using a risk-based study design, significantly improved treatment outcome overall. The largest gain from this strategy was realized in patients with gross residual tumor after biopsy (clinical group III). It was also possible to decrease therapy for selected patient subsets without compromising survival.

The association of Epstein-Barr virus with smooth-muscle tumors occurring after organ transplantation

BACKGROUND

Epstein-Barr virus (EBV) has been associated with nasopharyngeal carcinoma, some lymphomas, and lymphoproliferative disease after organ transplantation. Many lymphoproliferative tumors that occur after transplantation are clonal, a property that classifies them as neoplastic. Clonality can be determined by analysis of the extrachromosomal circular DNA episomes produced by EBV infection.

METHODS

We describe three young children in whom smooth-muscle tumors developed 18 months to 5 1/2 years after liver transplantation with immunosuppression. We examined the tumors by microscopy and with immunohistochemical studies and molecular genetic analyses of the EBV DNA:

RESULTS

The tumors were composed of spindle cells with smooth-muscle features and resembled those described in patients with the acquired immunodeficiency syndrome. Immunohistochemical analysis was negative for EBV latent membrane protein and EBV receptor (CD21), but positive for EBV nuclear antigen 2. In situ hybridization revealed nuclear EBV sequences, and molecular genetic analysis showed the EBV genome to be clonal in all three patients.

CONCLUSIONS

Smooth-muscle tumors that developed after organ transplantation contained clonal EBV, suggesting that the virus has a role in the development of these neoplastic lesions.

Fetal parvovirus B19 infection and liver disease of antenatal onset in an infant with Ebstein's anomaly

Fetal parvovirus B19 infection has been reported in association with hydrops and fetal demise, myocarditis, and congenital anomalies, as well as with normal outcome of pregnancy. One infant with liver disease of fetal onset associated with parvovirus B19 infection has been described. We have seen another such infant, in whom marked siderosis of the liver suggested accelerated destruction of erythrocytes and portal tract fibrosis with proliferation of bile ducts suggested intrauterine infection. Viral cytopathic effects were not seen. Maternal serum obtained postpartum contained IgM class antibodies against parvovirus B19, and parvovirus B19 nucleic acid sequences were identified in the infant's liver by polymerase chain reaction studies. We propose that recognition of this combination of siderosis with fibrosis and bile duct proliferation will permit identification of cases of fetal parvovirus B19 infection.

MIC2 analysis in pediatric lymphomas and leukemias

Monoclonal antibodies to the glycoprotein product of the MIC2 gene strongly and reliably stain primitive neuroectodermal tumors and Ewing's sarcomas, and are negative in neuroblastomas and most rhabdomyosarcomas. Therefore, these antibodies are helpful in the diagnosis of small round cell tumors of childhood (SRCT). Lymphomas also are in the differential diagnosis of SRCT, but few have been studied with respect to MIC2 protein expression. In the present study we used the 12E7 antibody to assess MIC2 expression in 82 pediatric non-Hodgkin's lymphomas. Forty lymphoblastic, 22 small noncleaved, and 20 large cell lymphomas were studied. Strong immunoreactivity was found in 37 of the 40 (93%) lymphoblastic lymphomas, whereas only one of the 22 (5%) small noncleaved lymphomas was 12E7 positive. Four of the 20 (20%) large cell lymphomas also were immunoreactive. Three 12E7+ lymphoblastic lymphomas were primary in bone and were of B-progenitor lineage; Ewing's sarcoma was included in the initial differential diagnosis of these cases. Evaluation of 125 pediatric acute lymphocytic leukemia (ALL) cases for MIC2 expression showed similar results, with all 36 T-cell ALLs showing strong expression, one of eight B-cell (Burkitt-like) ALLs showing 12E7 expression, and 62 of 81 B-progenitor ALLs showing 12E7 positivity. We conclude that among the SRCTs, MIC2 expression is not limited to Ewing's sarcoma and primitive neuroectodermal tumors, but also shows strong and reliable expression in lymphoblastic lymphomas and related leukemias. MIC2 analysis continues to be helpful in the diagnosis of SRCT, provided that a panel of antibodies is used. In addition, the possibility that MIC2 analysis may aid in the distinction of lymphoblastic lymphomas from small noncleaved lymphomas needs to be further addressed.

Ewing's sarcoma--routine diagnostic utilization of MIC2 analysis: a Pediatric Oncology Group/Children's Cancer Group Intergroup Study

Ewing's sarcoma and peripheral neuroectodermal tumor (PNET) are small blue cell tumors with no reliable positive diagnostic markers. However, Ewing's sarcoma and PNET recently have been shown to strongly express an antigen determined by the MIC2 gene, whereas other blue cell tumors of childhood for the most part do not. MIC2 analysis therefore offers a distinctive addition to the panel of immunohistochemical stains used to differentiate among small blue cell tumors of childhood, since it represents the first positive marker for Ewing's sarcoma and PNET. This study addresses the reliability of MIC2 analysis using the monoclonal antibody 12E7 on tumors registered in the current Intergroup Ewing's Sarcoma protocol. Of 244 tumors, 221 (91%) showed a diffuse strong membranous pattern. The antibody appears to withstand all the fixation variables inherent in a multi-institutional study. We conclude that MIC2 expression is highly reliable as a positive marker for the Ewing's sarcoma/PNET family of tumors when the results are interpreted in the total context with clinical and pathologic parameters.

Extracellular matrix of small round cell tumors of childhood: an immunohistochemical study of 67 cases

Sixty-seven childhood tumors were studied immunohistochemically for the extracellular matrix element type IV collagen, laminin, and fibronectin. Tumors included Ewing's sarcoma, primitive neuroectodermal tumor, small cell osteosarcoma, neuroblastoma or ganglioneuroblastoma, rhabdomyosarcoma, and lymphoma. It was found that small cell osteosarcoma was often positive for fibronectin but not type IV collagen or laminin, a new observation. In the lymphomas, matrix proteins were rarely found. Ewing's sarcoma was variably positive for type IV collagen and laminin, but fibronectin was absent. Extracellular laminin and fibronectin were found in one of two cases of primitive neuroectodermal tumor. In neuroblastoma and ganglioneuroblastoma, the matrix components were rarely found. These results, discrepant with findings in cultured cells, may reflect the altered capacity of tumors to produce these proteins in vitro, which suggests that caution should be exercised in drawing conclusions regarding the nature or histogenesis of tumors from data obtained with cultured tumor cells. Embryonal rhabdomyosarcoma frequently contained all matrix elements in the extracellular space and in a dotlike pattern in the cytoplasm; alveolar rhabdomyosarcoma rarely contained these proteins and never exhibited the dotlike pattern. The frequent finding of matrix proteins in embryonal rhabdomyosarcoma but only rarely in alveolar rhabdomyosarcoma and the unique immunostaining pattern in embryonal rhabdomyosarcoma may prove to be a useful adjunct in the diagnosis of childhood tumors.

Rhabdomyosarcomas do not contain mutations in the DNA binding domains of myogenic transcription factors

Skeletal myogenesis is regulated by a group of transcription factors (MyoD, myogenin, myf5, and myf6) that are "basic helix-loop-helix" proteins that bind to the promoters of muscle-specific genes and promote their expression. We have previously shown that after a mutation of Leu122 to Arg the DNA binding basic domain of MyoD confers c-myc-like functional characteristics to the protein. In this study we used single-strand conformation polymorphism analysis to determine whether such mutations occur naturally in rhabdomyosarcomas. We have found that the basic domains of all the myogenic factors remain unaltered in rhabdomyosarcomas. Selection against such mutations may be the result of functional redundancy of these myogenic transcription factors.

Proteus syndrome: emphasis on the pulmonary manifestations

Published articles on the radiologic aspects of Proteus syndrome are sparse. This report highlights the features of this disease with specific attention to the serious pulmonary manifestations that may occur at an early age. Two cases of Proteus syndrome and severe lung disease are presented, with complete autopsy in one case and correlative surgical pathologic data in the other. Multiple superficial and visceral vascular abnormalities were present in both cases. Both patients developed rapidly progressive diffuse cystic emphysematous pulmonary disease leading to the death of one patient at age 18 years and a heart-lung transplant in the other at age 8 1/2 years. Extensive gross pulmonary cysts were evident pathologically with diffuse panlobar emphysema microscopically. Studies of collagen and cultured fibroblasts in one patient revealed no abnormality. The early presentation, rapid progression and potentially lethal nature of lung involvement has not previously been emphasized.

The Intergroup Rhabdomyosarcoma Study-II

BACKGROUND

Intergroup Rhabdomyosarcoma Study (IRS)-II, (1978-1984) had the general goals of improving the survival and treatment of children with rhabdomyosarcoma (RMS).

METHODS

Nine hundred ninety-nine previously untreated eligible patients entered the study after surgery and were randomized or assigned to therapy by IRS Clinical Group (I-IV), tumor site, and histologic type. Outcomes were compared between treatments and with results of IRS-I (1972-1978).

RESULTS

Patients in Group I, excluding extremity alveolar (EA) RMS, were randomized to standard vincristine (V), dactinomycin (A), and cyclophosphamide (C) or standard VA. At 5 years, disease-free survival (DFS) and survival (S) rates were similar between VAC and VA (DFS: 80%, 70%, P = 0.47; S: 85%, 84%, P = 0.73). Patients in Group II, excluding EA RMS, received radiation and were randomized to intensive VA or repetitive-pulse VAC. Outcomes were similar for rates of DFS (69%, 74%, P = 0.83) and S (88%, 79%, P = 0.17). Patients in Group III, excluding certain pelvic tumors, received radiation and were randomized to repetitive-pulse VAC or repetitive-pulse VAdrC-VAC (Adr, Adriamycin [doxorubicin]). Complete remission (CR) rates were close at 74%, 78%, respectively (P = 0.32), as were percentages in CR (73%) and S (66%) rates; the latter outcomes were significantly better than IRS-I (CR: 56%, P < 0.001; S: 50%, P < 0.001). Central nervous system prophylaxis for Group III patients with cranial parameningeal sarcoma increased S rate to 67% from 45% in IRS-I (P < 0.001). Patients in Group IV received the same regimens as Group III; the CR rate was 53%, 38% remained in CR and S rate was 27% with and 26% without Adr (P = 0.90). At 5 years, S rate for IRS-II, including EA and all pelvic tumors, was 63%: an 8% increase over IRS-I (P < 0.001). Outcomes by primary site were as good as, or better than, the IRS-I experience.

CONCLUSIONS

Combining all Groups and treatments in IRS-II, the major improvement in S rate at 5 years between studies was in nonmetastatic patients (71% for IRS-II versus 63% for IRS-I, P = 0.01).

The Intergroup Rhabdomyosarcoma Study-II

BACKGROUND

Intergroup Rhabdomyosarcoma Study (IRS)-II, (1978-1984) had the general goals of improving the survival and treatment of children with rhabdomyosarcoma (RMS).

METHODS

Nine hundred ninety-nine previously untreated eligible patients entered the study after surgery and were randomized or assigned to therapy by IRS Clinical Group (I-IV), tumor site, and histologic type. Outcomes were compared between treatments and with results of IRS-I (1972-1978).

RESULTS

Patients in Group I, excluding extremity alveolar (EA) RMS, were randomized to standard vincristine (V), dactinomycin (A), and cyclophosphamide (C) or standard VA. At 5 years, disease-free survival (DFS) and survival (S) rates were similar between VAC and VA (DFS: 80%, 70%, P = 0.47; S: 85%, 84%, P = 0.73). Patients in Group II, excluding EA RMS, received radiation and were randomized to intensive VA or repetitive-pulse VAC. Outcomes were similar for rates of DFS (69%, 74%, P = 0.83) and S (88%, 79%, P = 0.17). Patients in Group III, excluding certain pelvic tumors, received radiation and were randomized to repetitive-pulse VAC or repetitive-pulse VAdrC-VAC (Adr, Adriamycin [doxorubicin]). Complete remission (CR) rates were close at 74%, 78%, respectively (P = 0.32), as were percentages in CR (73%) and S (66%) rates; the latter outcomes were significantly better than IRS-I (CR: 56%, P < 0.001; S: 50%, P < 0.001). Central nervous system prophylaxis for Group III patients with cranial parameningeal sarcoma increased S rate to 67% from 45% in IRS-I (P < 0.001). Patients in Group IV received the same regimens as Group III; the CR rate was 53%, 38% remained in CR and S rate was 27% with and 26% without Adr (P = 0.90). At 5 years, S rate for IRS-II, including EA and all pelvic tumors, was 63%: an 8% increase over IRS-I (P < 0.001). Outcomes by primary site were as good as, or better than, the IRS-I experience.

CONCLUSIONS

Combining all Groups and treatments in IRS-II, the major improvement in S rate at 5 years between studies was in nonmetastatic patients (71% for IRS-II versus 63% for IRS-I, P = 0.01).

Consistent numerical chromosome aberrations in congenital fibrosarcoma

Cytogenetic analysis of a congenital fibrosarcoma of the volar forearm from a 2.5-month-old boy revealed a mosaic karyotype 46,XY/49,XY,+11,+17,+20. This pattern of specific trisomies provides additional support to the cytogenetic findings in five cases of congenital fibrosarcoma reported previously. Trisomy 11 appears to be characteristic of congenital fibrosarcoma with additional trisomies 8, 17, and 20 as common findings.

Second malignancies in very-long-term survivors of childhood cancer

PURPOSE

Although most second malignancies are treatment related, their occurrence also may be due to an underlying systemic disease or chromosomal abnormalities shared by multiple organs in which they are tumorigenic. We attempted to identify unusual tumor pairs that might provide a clue to shared genetic etiologies.

PATIENTS AND METHODS

Medical records and tumor registry correspondence of 1,743 patients (0 to 18 years at diagnosis) were reviewed. For those said to have a second malignancy, biopsy and autopsy records and slides were reviewed to confirm initial and secondary diagnoses.

RESULTS

Two hundred fifty-eight patients had follow-up of at least 10 years and 157 of at least 20 years. Second malignancies were identified in 14 patients. The estimated cumulative incidence of a second cancer was approximately 1% within 10 years. At 20 years after diagnosis, the actuarial estimate was 3%. Although most second cancers were likely treatment related, several tumor pairs could not clearly be explained on that basis, including thyroid carcinoma followed by an ovarian sarcoma, and acute lymphoblastic leukemia associated with renal leiomyosarcoma. Based on one case in this series and a review of the literature, associations between Wilms' tumor, abdominal radiation, and adenocarcinoma of the colon and hepatocellular carcinoma are suggested.

CONCLUSIONS

We conclude that continued surveillance of very-long-term survivors of childhood cancer, which is usually accomplished by internists, family practitioners, and adult oncologists, may be one approach to defining the life-time incidence of second malignancies. In addition, although the yield is likely to be small, descriptions of unexpected tumor pairs may target families for studies of pleiotropic genetic abnormalities.

MR and CT imaging of ethanol-treated liver tumors in an animal model

To characterize the radiographic appearance of liver lesions over time following ethanol injection, seven New Zealand white rabbits underwent surgical implantation of small fragments of VX-2 carcinoma within the liver. Upon reaching 1 cm in diameter, a tumor nodule was directly injected with absolute ethanol. Another nodule in the same animal was injected with saline as a control. Imaging was performed 6-24 days after the injections by high resolution CT and MRI, and correlation obtained with the pathologic specimens. Long TR spin-echo MR sequences were found to characterize the ethanol-treated regions of liver most accurately. Liver tissue infarcted by alcohol could be differentiated from tumor and necrosis by virtue of its short T2 relaxation value. There were no distinguishing features by other imaging techniques between the ethanol-treated and control tumor nodules. Peripheral contrast enhancement was demonstrated in both, corresponding to fibrous tissue around the ethanol-injected regions, and to viable tumor in the case of controls.

Prognostic implications of bronchoalveolar lavage neutrophilia in patients with Pneumocystis carinii pneumonia and AIDS

The clinical records and bronchoalveolar lavage (BAL) cell differential counts were analyzed in 96 patients at risk for Pneumocystis carinii pneumonia (PCP) from human immunodeficiency virus (HIV) infection to determine if this information may be prognostically useful and to identify possible mechanisms of BAL neutrophilia. In 60 patients with PCP, 15 fatalities or episodes of respiratory failure occurred, and 14 of these patients had greater than 5% BAL neutrophils. Only one of 33 patients with PCP and less than 5% BAL neutrophils died. In contrast, there was no correlation between survival and BAL neutrophil percentages in 33 patients who did not have PCP. Three patients with HIV infection without lung disease had normal BAL cell differentials. Intra-alveolar and interstitial leukocytes found in 17 transbronchial lung biopsies in patients with PCP indicate that the alveolar and interstitial compartments of the lung may be the source of BAL neutrophils. Pathologic evidence of increased severity of diffuse alveolar damage to explain BAL neutrophilia was not found. As BAL neutrophil percentages in PCP had both positive and negative predictive value, this information may be useful to stratify therapeutic trials or to identify the patient with PCP who is at high risk of a complicated or fatal outcome.

Pleuropulmonary actinomycosis associated with a systemic-to-pulmonary artery fistula and contralateral metastatic back mass

We report a case of systemic-to-pulmonary artery fistula associated with thoracic actinomycosis and with metastatic hematogenous dissemination to the soft tissues of the back. The difficulty in diagnosing thoracic actinomycosis may predispose to the increased incidence of hematogenous spread of this disease. Although resection of pulmonary tissue including the infectious mass was required in previous cases, resection of the pleural mass alone was curative in this patient when combined with penicillin therapy.

Arteriotracheal fistula in patients treated for lymphoma

Exsanguinating hemorrhage is an unusual cause of death in patients who are being treated for neoplasms. We report two cases of adolescents with mediastinal non-Hodgkin's lymphoma who each developed a fistula between the right brachiocephalic trunk and the trachea following mediastinal irradiation and systemic chemotherapy. During the hospital course, the patients had each suffered a respiratory arrest and undergone difficult endotracheal intubation. The tracheal ulcerations at the fistula sites were unsuspected prior to autopsy.

Bridging bronchus and posterior left pulmonary artery: a unique association

A 6-month-old female with a lifelong history of respiratory distress became increasingly difficult to manage and required right upper and middle pulmonary lobectomies for worsening emphysema and mediastinal shift. The postoperative course was stormy and confusing and the patient died despite emergency tracheostomy. The autopsy disclosed an anomalous bronchus to the right lower lobe, originating from the left mainstem bronchus. In addition, the left main pulmonary artery was positioned posterior to the left mainstem bronchus. Two other cases of bridging bronchus have been reported, but the association with posterior left pulmonary artery has not been described.

Gonadoblastoma: unusual presentation in a patient lacking persistent müllerian ducts

We report a patient with a disorder of sexual differentiation who presented with a 46,XY karyotype, absent internal Müllerian ducts, a vaginal pouch, hypospadias, and bilateral cryptorchidism with a gonadoblastoma in one testis. A human chorionic gonadotropin stimulation test and tissue 5-alpha-reductase and androgen receptor assays were normal. Except for the absence of internal Müllerian ducts, this patient most closely resembles the disorder of dysgenetic male pseudohermaphroditism (DMP). On this basis, we hypothesize that the internal Müllerian ducts in DMP may manifest anywhere along a spectrum that extends from normal to complete absence of structures depending on the degree of gonadal dysgenesis. This case also illustrates the importance of testicular biopsy in patients with dysgenetic testes because of the high likelihood of germ cell neoplasms in these gonads.

Extraosseous Ewing's sarcoma versus primitive rhabdomyosarcoma: diagnostic criteria and clinical correlation

A light and electron microscopic study of 51 cases of Ewing's sarcoma of bone (ESB) and 33 soft tissue sarcomas (carrying a variety of light microscopic diagnoses, including primitive rhabdomyosarcoma) in children and young adults was performed to clarify the similarities and differences among these tumors. Ultrastructural criteria were developed to evaluate the neoplasms. Remarkable ultrastructural uniformity was found in the cases of ESB. In contrast, the soft tissue sarcomas could be divided into two distinct groups on the basis of the ultrastructural criteria: those closely resembling primitive areas of otherwise differentiated rhabdomyosarcomas, and those indistinguishable from ESB. It is proposed that the diagnosis of soft tissue Ewing's sarcoma be reserved for lesions identical to ESB by both light and electron microscopy. The first group of sarcomas may be histogenetically related to rhabdomyosarcoma and should be distinguished from extraosseous Ewing's sarcoma, as their clinical behavior appears to be quite different.

A sibship with hypokalemic alkalosis and renal proximal tubulopathy

A new syndrome, characterized by hypokalemic alkalosis, hyperreninemia, aldosterone, high urinary prostaglandin E2 excretion, normal BP, and resistance of BP to angiotensin II is described in three of four siblings. Histologic examination of tissue obtained by biopsy from the kidneys showed an intense staining of the proximal tubular cells, as well as an extreme hypertrophy of the proximal tubular basement membranes, features that previously have not been observed. On electron microscopic examination, the characteristic changes of the tubular cells consisted of very dense cytoplasm, compact mitochondria, and pyknotic nuclei. In contrast to Bartter's syndrome, the juxtaglomerular apparatus were of normal appearance. Glomerular filtration rate and renal plasma flow were within normal limits. Fractional distal delivery of proximal tubular solute and fractional chloride reabsorption in the thick ascending limb of the loop of Henle were normal. The findings of a genetic linkage between the syndrome and the major histocompatibility system suggests that this familial tubulopathy is an inherited disorder.

Extraskeletal Ewing's sarcoma: results of combined modality treatment

Eleven patients with extraskeletal Ewing's sarcoma (EES) were treated with combined modality therapy at the National Cancer Institute. The diagnosis of EES was reserved for lesions that were identical to Ewing's sarcoma of bone by light and electron microscopy. Diagnostic work-up to rule out a skeletal primary included bone scan, localized views of adjacent bone, and bone tomography. Seven patients presented with an extremity primary and four patients had a truncal primary. No patients had evidence of metastases at presentation. Patients were treated with combined modality therapy consisting of high-dose local irradiation and vincristine, actinomycin D, and cyclophosphamide chemotherapy following a biopsy or local excision. No attempt was made to excise widely the primary tumor mass. Gross tumors generally responded rapidly to the combined modality treatment. Of 11 patients, seven (64%) remain disease free, with a follow-up of three to seven years from completion of therapy. Long-term local control was established in nine of 11 patients (82%). Autopsy findings on two patients with local failure showed no tumor involvement of adjacent bone. Attempts at gross resections by radical surgical procedures do not routinely appear to be necessary in light of the high local control rates with high-dose irradiation.

Ewing's sarcoma. Characterization in established cultures and evidence of its histogenesis

We have studied the ultrastructure and collagen biosynthetic profiles of three cultured lines of Ewing's sarcoma (ES) to better understand the histogenesis of this tumor. The histology and ultrastructure of the original tumors were characteristic of ES. Light and electron microscopic appearance of the cell lines and of tumors formed in nude mice from injection of these lines were similar to the native tumors. Isozyme studies of the ES cell lines demonstrated that they were not HeLa and were different from other known cell lines. Collagen profiles performed by immunofluorescence, polyacrylamide gel electrophoresis, and immunoprecipitation showed conclusively that ES in tissue culture produces collagen types I, III, and IV. This collagen profile coupled with the morphologic and ultrastructure features of the ES cell lines leads us to conclude that Ewing's sarcoma is derived from a multipotential primitive mesenchymal cell, uncommitted to osteoblastic, fibroblastic, or endothelial origin.

Pulmonary histopathologic changes associated with melphalan therapy

A case of fatal pulmonary fibrosis and atypical epithelial proliferation (AEP) in a patient with multiple myeloma treated with melphalan is presented. Review of 10 other autopsied patients with myeloma treated with melphalan but no thoracic radiation, other cytotoxic agents, or highdose oxygen therapy revealed one other patient who died with extensive pulmonary fibrosis and AEP. Four other patients with AEP not associated with pneumonitis or fibrosis were also found, while no such changes were found in 11 autopsy controls or 11 patients with myeloma who did not receive cytotoxic agents. Melphalan should be added to the growing list of agents capable of causing severe fibrotic pulmonary reactions.

Long bone ossifying fibromas

Ossifying fibromas involving the tibia were seen in two patients. In both patients, the radiographic appearance of the lesions suggested fibrous dysplasia, but histopathologic evaluation demonstrated findings similar to ossifying fibroma of the mandible and facial bones. Radiologic and pathologic recognition of this entity is necessary for proper treatment.

Vasoactive intestinal polypeptide and gastrin-producing islet cell carcinoma

A 61-year-old woman had watery diarrhea, hypochlorhydria, hypokalemia, and elevated serum gastrin levels. She had islet cell carcinoma of the body of the pancreas with multiple metastases to the liver. Radioimmunoassay and immunofluorescence demonstrated both vasoactive intestinal polypeptide (VIP) and gastrin in the surgically removed carcinoma and in a metastatic focus. Electron microscopical findings confirmed the presence of two cell types whose secretory granules had characteristics ascribed to these two hormones. Plasma prostaglandin E levels were also elevated above normal. Serum VIP levels became elevated to the Verner-Morrison range prior to her death of a bleeding duodenal ulcer two years after initial symptoms.

Nonfunctioning argyrophilic tumor (APUDoma) of the hepatic duct: simplified methods of detecting biogenic amines in tissue

This report documents a foregut endocrine neoplasm in an unusual location, the main hepatic bile duct, and describes simplified methods of detecting similar endocrine tumors. Formaldehyde fume-induced fluorescence (FIF) is a quick, specific method to demonstrate biogenic amines. FIF combined with histochemical procedures showing abundant alpha-glycerol phosphate dehydrogenase and esterases indicates the neural crest origin of these and related neoplasms. Amine precursor uptake and decarboxylation (APUD) is a significant marker of these cells and gives them their name.