Therapeutic strategy of papillary cystic and solid neoplasm (PCSN): a rare non-endocrine tumor of the pancreas in children

Papillary-cystic and solid neoplasm (PCSN) are rare tumors. Two personal observations and a review of the literature are presented with a total of 44 pediatric patients in addition to a total of 67 published cases in the review of Cohen (Pediatr. Surg. Int. 6 (1991) 128) and Snadjauf (Eur. J. Pediatr. Surg. 9 (1999) 416). Overall, PCSN shows a clear predominance in females and only occasionally occurs in males. Typically they grow to a large tumor mass with minimal symptoms. Their histologic and immunocytologic characteristics cause diagnostic difficulties, especially on frozen sections of small biopsies. The tumors are assumed to origin from pluripotent stem cells and present as tumors of low malignancy with a favorable prognosis. Nevertheless 10 children have been reported to develop metastases, 5 have demonstrated an invasive growth pattern and 4 local recurrence. But only two of the 111 pediatric cases have died from their tumor burden. Treatment of choice is a complete surgical resection, which is true for the primary tumor and for metastases as well as local recurrences. In our 2 patients one had spleen-conserving left pancreatic resection and one mesopancreatectomy with roux-en-y-reconstruction leading to long-term cure. Adjuvant therapy in curative resected patients is unnecessary and does not appear to improve prognosis.

Neurogenic appendicopathy in children

BACKGROUND

In a prospective multicenter study, we could show that neurogenic appendicopathy is a histological entity. This study compares the general and the pediatric population with respect to clinical presentation and incidence of neurogenic appendicopathy (NA).

METHODS

Included were patients that underwent appendectomy for suspected appendicitis, excluded were patients younger than 6 years and patients with missing data. Neurogenic appendicopathy was diagnosed by S-100 immunochemistry and/or haematoxylineosin (H.E.) staining. Two age groups (< or = 14 y and > 14 y) were compared with respect to the frequency of NA.

RESULTS

In only four cases out of 84 children (4.8%) did we find neurogenic appendicopathy compared to 48 patients (24.2 %) out of 198 adolescents and adults. In the subgroup with negative appendectomy, the frequency of NA was 16.7% (< or = 14 years) and 56.6% (> 14 years). A clinical differentiation between neurogenic appendicopathy and acute appendicitis was not possible because of the small sample size.

CONCLUSION

Neurogenic appendicopathy is a very rare histopathological entity in children. History and clinical examination do not make it possible for us to differentiate preoperatively between acute appendicitis and neurogenic appendicopathy.

Fibrosarcoma in infants and children: a retrospective analysis - overdiagnosis in earlier years

During a 30-year period, 22 patients considered to have a fibrosarcoma (FS) were treated. In a retrospective study the clinicopathologic findings were summarized. With histologic and immunohistochemical re-evaluation, the diagnosis was confirmed in 8 cases. For 6 further patients FS was very probable but specimens were not available. In 8 cases the diagnosis was revised and benign lesions were found in 7. Two patients with irresectable tumors died (infantile FS, FS of mesentery and retroperitoneum). After repeated local recurrences and spread on the affected extremity, an amputation was life-saving in 1 boy. In earlier years many tumors were classified as FSs. Today, immunohistochemistry and molecular-biological methods are valuable tools to clearly identify these tumors. Wide local excision or en-bloc resection without sacrificing any significant function of the part should be the primary form of treatment in infants. Primary re-excision after incomplete excision should have priority over any adjuvant treatment. Preoperative chemotherapy may avoid incomplete resection or mutilation in cases with extended congenital FS.

[Implantable catheter systems]

Central venous access devices represent a definitive improvement in childhood cancer therapy. The silicone elastomer catheters offer a both save and easy access, low related morbidity and acceptance by patient. Tunnelled right atrial catheter (Broviac, Hickman-Crawford or Quinton) for long-term use are firstline choice for venous access. Although ports reduce the number of complications and manipulations associated with percutaneous catheters, they are not devoid of problems. Related complications are catheter infection and occlusion or damage. The different techniques of venous vascular access and management of complications are reported.

Therapeutic management of rare malignant pancreatic tumors in children

Malignant pancreatic tumors in children are rare. The major problem for the clinician is a lack of experience and of accepted therapeutic strategies. Malignant pancreatic tumors in children show a pattern different from that in adults. In infants, especially pancreatoblastomas, solid cystic tumors of females, and endocrine carcinomas of the pancreas must be expected. We report our experience in three patients with malignant pancreatic tumors (one pancreatoblastoma and two malignant endocrine pancreatic carcinomas) and review the present literature with a focus on the typical clinical and biologic features and the presently recommended therapeutic strategies. Pancreatoblastomas and solid cystic tumors are mainly found in the head of the pancreas. Fibrotic capsules with rare, late metastases are characteristics of these tumors, indicating total resection to be an important therapeutic procedure. Pancreatoblastomas should additionally be treated with chemotherapy (ADM, IFO, cis-PL, VP16). Endocrine carcinomas of the pancreas (malignant gastrinomas and malignant insulinomas) should also primarily be treated with radical surgery, including extensive lymph node dissection. In case of distant metastases, local resection (liver) or somatostatin in combination with chemotherapy (streptozocin in the case of malignant insulinomas) may be used.

Treatment of children with relapsed soft tissue sarcoma: report of the German CESS/CWS REZ 91 trial

BACKGROUND

The present study was performed to evaluate the possibilities of relapse treatment in patients heavily pretreated for a soft tissue sarcoma.

PATIENTS AND METHODS

Prospective, multicenter study in 44 soft tissue sarcoma (STS) patients with first relapse. Primary diagnosis was embryonal rhabdomyosarcoma (RME) in 17 patients, alveolar rhabdomyosarcoma (RMA) in 13, primitive neuroectodermal tumor (PNET) in 6, and miscellaneous soft tissue sarcomas in 8 patients. Initial chemotherapy consisted of carboplatin/etoposide combination (150 mg/m2 each, days 1 to 4) followed by local therapy including surgical treatment and, whenever possible, radiotherapy.

RESULTS

In 11/17 patients without primary tumor resection, CR or PR was achieved following the initial two cycles of chemotherapy (61%). The probability of event-free survival (pEFS) for RME patients was 0.41 +/- 0.12 at 5 years, and 0.25 +/- 0.12 for RMA patients. But, in contrast no PNET patient or patient with another soft-tissue sarcoma achieved long-term remission. Additional local radiotherapy significantly (P = 0.002) improved pEFS (3-year estimates of 0.23 +/- 0.2 vs. 0.1 +/- 0.1 in patients without radiotherapy).

CONCLUSIONS

In patients with RME, relapse treatment employing a carboplatin/etoposide combination may induce a second remission in approximately 40% of patients. Surgical excision and additional local radiotherapy seem to be essential to maintain a stable remission. In patients with RMA or PNET, however, this treatment strategy is of no long-term benefit.

Extracranial non-testicular teratoma in childhood and adolescence: introduction of a risk score for stratification of therapy

PATIENTS AND METHODS

According to previous literature incomplete tumor resection, coccygeal or ovarian primary site and immaturity are known risk factors for relapse in teratoma. To establish a risk score points are allocated for resection, primary site and histology in the following manner and added: incomplete resection 4 points, primary site coccyx 3 points, ovary 2 points, other site 1 point, histological grading 0-3 points. This score system is evaluated on 270 extracranial non-testicular teratoma cases collected between 1982 and 1995 in the MAKEI cooperative treatment protocols of the German Society of Pediatric Oncology and Hematology. Treatment was resection alone (230 patients) or resection followed by postoperative adjuvant chemotherapy (40 patients).

RESULTS

Patients treated with surgery alone: 28/230 (12%) patients relapsed, 14/230 (6%) patients showed highly malignant histology (mostly yolk sac tumor) in relapse. Mortality in case of relapse was 6/28 (21%). Patients scoring > or = 6 points (n = 45) had a relapse rate of 21/45 (47%) resulting in a 23%-mortality (5/21). Patients scoring < 6 points (n = 185) had a 4%-relapse risk (8/185) resulting in 13%-mortality (1/8) (p < 0.01). Patients treated with surgery and adjuvant chemotherapy: 7/40 patients (18%) suffered a relapse, none of them showing malignant histology. Mortality rate in case of relapse was 3/7 (43%). Patients scoring > or = 6 points initially treated with adjuvant chemotherapy (n = 18) had a relapse rate of 7/18 (39%), compared to patients scoring < 6 points (n = 22), in whom no relapses occurred (p < 0.01). There were no highly malignant relapses in the group treated with adjuvant chemotherapy. Regardless of the scored points the difference in highly malignant relapse histology comparing the group treated with surgery and adjuvant chemotherapy to the group treated with surgery was statistically significant (p = 0.02).

CONCLUSION

The risk score system marks a high risk group including 63/270 (23%) of all evaluated extracranial non-testicular teratoma cases (scoring > or = 6 points). In this group 28/35 (80%) of relapses and 8/9 (89%) of tumor deaths occurred. For this high risk group a randomized trial will be suggested to evaluate the effect of adjuvant chemotherapy on the rate of malignant relapses. It should also be investigated, if adjuvant chemotherapy will influence relapse rate and mortality.

Pancreatoblastoma in children. Case report and review of the literature

Pancreatolblastomas are rare embryonal malignancies in childhood. We report a 3-year-old girl with a tumor of the head of pancreas. Staging by bone scintigraphy and CT scans of abdomen and chest did not show evidence of metastatic disease. Tumor markers showed elevated levels of alpha-1 fetoprotein (64 ng/ml; normal 0-10 ng/ml) and lactate dehydrogenase (423 U/l; normal range below 300 U/l). The tumor was macroscopically completely removed by local resection. Postoperative tumor grading was pT1, NO, MO. The child recovered very soon after surgery without severe complications. Tumor markers dropped to normal values, indicating complete remission (follow-up time 12 months). According to the biological growth characteristics of pancreatoblastomas and to the literature, localized and non-metastatic tumors should be completely resected without radical pancreatoduodenectomy and without adjuvant chemotherapy. This is the most conservative therapy with a good prognosis. However, metastatic disease, primarily inoperable conditions or local relapses are indications for chemotherapy combined with radiotherapy and followed by resection of the tumor. At present, the prognosis of such cases is rather poor.

Effect of hyperthermia 42.5 degrees C/120 min on 3H-thymidine incorporation in different tissue components of Wilms' tumors: an in vitro study

BACKGROUND

Survival rates of Wilms' tumors are correlated to tumor histology. Clinical studies and histological investigations have shown that different histological tumor components of Wilms' tumors also reveal different sensitivities to cytostatic agents and ionizing radiation. The aim of this study is to examine the effect of hyperthermia to Wilms' tumors, generally, and to the different tumor tissues composing nephroblastomas.

MATERIAL AND METHOD

The 3H-thymidine labelling indices (LI) of 23 Wilms' tumors and one renal rhabdomyosarcoma were studied by an autoradiographic in vitro method at temperatures of 37.5 degrees C/120 min and 42.5 degrees C/120 min. The LI of each tumor was measured and likewise the LI of all histological tumor components defining standard risk and high risk. The effect of hyperthermia was calculated as the percentage of inhibition of 3H-thymidine incorporation.

RESULTS

Labelling indices between 22.4% and 46.3% (mean 33.2%) characterized Wilms' tumors as highly malignant and fast growing tumors. The LI of Wilms' tumors of standard risk and high risk did not differ significantly (33.8% vs. 30.4%). Also, epithelium and blastema of the same groups showed comparable high LI of 31.4% and 34.4%, respectively, and of 32.1% and 26.8%, respectively. The LI of stroma was significantly lower (11.9% and 10.9%). The mean LI of fetal-like rhabdomyoblastic cell elements of ten tumors was 24.5%. These tumor cells revealed a significantly higher LI than rhabdomyosarcomatous cells in one Wilms' tumor and one renal rhabdomyosarcoma (10.2% and 9.0%, respectively). The LI of anaplastic structures of one tumor was more than twice as high as the LI of surrounding tumor tissue. In vitro hyperthermia significantly inhibited 3H-thymidine incorporation into all nephroblastomas. Inhibition ranged between 13.7% and 84.6%, at an average of 47.3%. Four high risk tumors, as well as the single anaplastic and rhabdomyosarcomatous cells responded significantly stronger to heat than standard risk tumors (mean inhibition of 62.6% vs. 42.1%). Hyperthermia was more effective for blastema compared to epithelium and stroma. There was no correlation between the effect of hyperthermia and the amount of the 3H-thymidine LI at normothermia.

CONCLUSION

The tremendous inhibition of DNA synthesis by hyperthermia particularly in high risk tumors and highly malignant tumor components is of clinical interest for children with Wilms' tumors resistant to conventional therapy.

[In vitro studies of DNA synthesis inhibition by hyperthermia (42.5 degrees C, 120 min) and cytostatic drugs in embryonal tumors and sarcomas in childhood]

The effect of hyperthermia (HT), (42.5 degrees C, 120 min), cytostatic agents and the simultaneous application of HT and cytostatics on embryonal tumors and sarcomas in children was studied using an autoradiographic in vitro method. The 3H-thymidine and 3H-uridine incorporation inhibition was measured. HT inhibits DNA and RNA synthesis in a range of 42.0%-51.0% and 45.6%-58.3%. HT enhances the effect of the cytostatic agents ADM, CPM, cis-PL, BLM and BCNU highly significantly. In each case and without exception the simultaneous application of HT and cytostatics overcomes primary resistance to HT or the cytostatic concerned.

Pre-emptive analgesia: comparison of preoperative with postoperative caudal block on postoperative pain in children

We have compared in 25 children the effect of preoperative with postoperative caudal block on pain after circumcision in a double-blind, randomized study. After induction of anaesthesia, patients were allocated randomly to receive a caudal block either before (n = 14) or immediately after (n = 11) surgery. Postoperative pain was rated on a paediatric pain scale. If pain occurred, children received paracetamol in a dose related to body weight. Using the Mann-Whitney U test (significance < or = 0.05) there was no significant difference in cumulative postoperative analgesic requirements within the first 48 h and in times to first analgesic administration between the groups. Cumulative pain score, assessed every 30 min for the first 8 h after operation, was significantly lower for those patients who received caudal anaesthesia after operation. Thus we could not demonstrate any advantage in performing caudal block before compared with after surgery.

Total body hyperthermia in combination with etoposide and melphalan in a child with acute myelomonocytic leukemia

In vitro and clinical studies have shown antineoplastic effects of hyperthermia alone and in combination with other treatment modalities. Synergistic cytotoxic effects of chemotherapy and hyperthermia have been demonstrated on leukemic cell clones in vitro. It seems that hyperthermia is effective in overcoming chemotherapy resistance. Several groups treated solid tumors by using total body hyperthermia (TBHT). However, only a few studies have been reported investigating the clinical effects of TBHT in myeloproliferative disorders. We report the case of a 7-year-old boy with myelomonocytic leukemia treated with TBHT (2 hours, 42 degrees C) combined with etoposide (600 mg/m2), melphalan (30 mg/m2) and hyperglycemia (200-300 mg/dl). Within 24 hours after TBHT, the leukemic cells decreased after TBHT from 53,000/microliters to zero. Skin leukemic infiltrates, resistant to conventional treatment, also responded well. Although our patient relapsed 34 days after TBHT, these results indicate that TBHT in combination with cytotoxic treatment may be a useful treatment modality in refractory leukemia.

[Treatment of otherwise incurable tumor diseases in childhood using whole-body hyperthermia and chemotherapy]

Conventional methods of treatment having failed in 17 children (aged 9/12 to 16 5/12 years) with incurable solid malignant tumours underwent whole-body hyperthermia (41.8-42.0 degrees C, for 2-3 h), hyperglycaemia (20-25 mmol/l) and polychemotherapy. Five children had neuroblastoma (stage 4), three Wilm's tumour (stage 4 or 5, unfavourable histology), five skeletal sarcoma with metastases, three inoperable malignant liver tumour, and one brainstem tumour of unknown histology. Whole-body hyperthermia was induced by extracorporeal blood warming in an haemodialysis apparatus under neuroleptic analgesia, thermistors measuring the temperature in the oesophagus, rectum, trachea and skin. There were on average four treatment sessions (between one and ten, total 58), a week apart. The result could be assessed in 12 children: one persisting complete remission (19 months-metastasising renal rhabdoid tumour), eight partial or incomplete remissions, and three nonresponders (osteogenic sarcoma; Ewing sarcoma; brainstem tumour). If the risk can be satisfactorily judged the method is useful and of bearable toxicity. The results point to a high antitumour effectiveness of combined hyperthermia and chemotherapy.

[Simultaneous occurrence of Wilm's tumor and multiple lung hamartomas in a 15-year-old girl]

The observation of multiple adenofibroleiomyomatous hamartomas of the lung in a 15-year-old girl 7 years after treatment of a Wilms' tumour caused diagnostic difficulties that are discussed. The diagnosis was finally established by thoracotomy and tumour resection. The simultaneous occurrence of Wilms' tumours and benign or malignant tumours points to genetic factors in the development of both tumours.

[Malignant fibrous histiocytoma of the mandible in a 1 6/12-year-old boy]

A report on malignant fibrous histiocytoma of the mandible in a 1 6/12-year-old boy, a condition rarely seen in children. Because of inoperability radiotherapy was used resulting in complete tumour remission. The clinical course was complicated by a tracheo-oesophageal fistula and aspiration pneumonia. The spontaneous closure of the fistula occurred 5 months after tracheostomy and catheter jejunostomy. After 2 10/12 years there is no evidence of tumour disease. Possibilities and problems of therapy are discussed.

[Therapy of testicular tumors in childhood]

Between 1954 and 1984 41 primary testicular tumours were treated in 40 children at the age of 0 to 9 years as well as 9 secondary testicular tumours in malignant systemic diseases or metastases. The histological reclassification of the number of cases revealed 15 yolk-sac-tumours, 10 differentiated teratomas of immature subtype, 1 intermediary malignant teratoma, 3 undifferentiated malignant teratomas, 2 Sertoli-cell-tumours (1 double-sided) and 5 rhabdomyosarcomas. 2 children each with undifferentiated malignant teratomas and rhabdomyosarcomas died, all before 1970. 5 children with yolk-sac-tumours and 2 with rhabdomyosarcomas who since 1974 have been treated with Ablatio testis and combination chemotherapy live without tumour. Histological classification and division into stages are proved and form the basis of a therapy conception which in all testicular tumours apart from the Ablatio testis contains the chemotherapy of different intensity (HTK-84), taking into consideration form of tumour, stage and age of the children. The retroperitoneal lymphadenectomy is recommended only in the proof of metastases.

[Mesoblastic nephroma--a malignant tumor with low grade of malignancy]

The mesodermally differentiated and only in newborns and young infants occurring mesoblastic nephroma is regarded as benign. Recidivations with malignant course, inclination to infiltration and richness in mitosis make arise doubts about the benignity despite good prognosis. The results of a proliferation-kinetic examination received by an autoradiographic in vitro method of a mesoblastic nephroma which was observed in a 20-day-old infant are characteristic for a malignant tumour of low degree of malignity: 3H-thymidine marking index 5.8%, DNA synthesis time 18.2 hours, mean generation time 141.1 hours (= 5.9 days). Growth fraction 0.28 and potential doubling time of the tumour 16.4 days. These data decisively deviate from those of the Wilms-tumours, which are cell-kinetically characterized as extraordinarily quickly growing, highly malignant tumours. The position of the mesoblastic nephroma in the system of the dysontogenetic renal tumours is briefly discussed. The ureteronephrectomy performed in time is the only necessary therapeutic measure, since also the mesoblastic nephroma follows the general rule of dysontogenetic tumours that the prognosis is the better the younger the infant is.

[Causes of proximal atresia of the ureter in congenital hydronephrosis]

The proximal ureter atresia as a cause of a congenital hydronephrosis with functioning normal kidney is to a certain extent unknown. The histological elaboration of an uretero-pelvic resection preparation of a 7-year-old boy after Anderson-Hynes-plasty showed the transition of a stenosis of the ureter passage into a ureter atresia. Cause of the development of a proximal ureter atresia are secondary changes of the structure in the ureteropelvic segment due to the disturbed urodynamics in stenosis of the ureter passage. The possibilities of the genesis of atresia are discussed and it is referred to the clinical picture of the disease.

[The role of cell proliferation kinetics and cytostatica - test for sensitivity of neuroblastomas, recurrent tumours and tumour metastases (author's transl)]

Using auto-radiographic techniques in vitro studies performed to analyse the growth rate in 13 cases of neuroblastoma, 6 recurrent tumours (assorted) and 7 metastatic tumours. The cell kinetic parameters using 3H thymidine markers, DNS synthesis, mitotic rate and mean cycle rate were investigated. The growth rate can only be calculated approximately. The results show that neuroblastomas grow incredibly fast. The cell-cycle period varies between 13.1 and 266.3 hours and averages 71 hours. Recurrent tumours have a tendency to have the same growth rate as the primary tumour. Primary metastases of Wilm's tumours and osteogenic sarcomas proliferate rapidly with a cell-cycle of 13.0- 87.0 hours (average 37.7 hours). All tumours have a distinctly individual proliferation pattern. Cell division and growth rate of malignant tumours are important in relation to radiotherapy and the use of cytotoxic drugs. These factors are expressed as a "cell-kinetic therapeutic index", which helps to predict the effectiveness of cytotoxic drugs and radiotherapy. Two cases of neuroblastoma were classified as resistant. Most tumours excluding the fibrosarcomas react well against two cytotoxic reagents. The cell-kinetic pattern and the sensitivity results are used in determining the treatment of recurrences and metastases. The relationship of these investigations in clinical practice is discussed.

[Metastasising squamous-cell carcinoma of the skin in a ten-year-old girl]

Because of recurrent paronychia of the right thumb "granulation" tissue was removed from the nail-bed of a ten-year-old girl. Histological examination revealed a cornified squamous-cell carcinoma. About five months later a lymph-node metastasis was found in the right axilla. After radical dissection of the axillary region further lymph-node metastases were found, as well as a lymphangitic carcinosis with tumour infiltration in the veins. Despite telecobalt radiation there were recurrent retastases which could no longer be removed by operation. Two years after the diagnosis the girl died. Necrospy revealed diffuse tumour infiltration of the soft tissue of the axilla, upper arm, shoulder, neck and thoracic wall on the right, including the breast tissue, with thoracic para-aortic-abdominal and left-sided axillary lymph-node metastases, and lung and pleural metastases bilaterally.

[Proximal ureteral atresia in childhood]

A rare cause of the congenital hydronephrosis is the proximal atresia of the ureter. With the help of 6 own cases morphology, clinic and therapy of this clinical picture are discussed. The differentiation from Wilms's tumour renders differential-diagnostic difficulties. It seems that a clinical description of this picture of a disease is hitherto not yet existing.