Treatment of overt isolated testicular relapse in children on therapy for acute lymphoblastic leukemia. A report from the Childrens Cancer Group

BACKGROUND

Fifty-seven children with acute lymphoblastic leukemia (ALL) receiving therapy who experienced overt isolated testicular relapse while in bone marrow remission were entered into a study that featured an intensive retreatment regimen.

METHODS

The objective was to determine whether a change in chemotherapy and local irradiation would prevent subsequent marrow relapse and increase the survival rate. The regimens used (modified Berlin-Frankfurt-Munster or modified New York) delivered acceptable therapy based on analyses of toxicity data.

RESULTS

Overall survival at 5 years from the time of testicular relapse was 47%, with an event-free survival of 43%. Events have been documented in 28 of 55 evaluable children. Analysis of these patients revealed that 23 children had bone marrow relapse, 4 children had central nervous system relapse, and 1 child had testicular relapse. In addition, two patients were removed from the study for toxicity, one child for infection (mucormycosis), and five children had a bone marrow transplantation while in remission and became ineligible to continue in the study. Two children were removed at the request of their parents, and nine children were lost to follow-up.

CONCLUSION

Because of their high risk of developing systemic relapse, boys with ALL who experience isolated overt testicular relapse during active therapy should be retreated with intensive treatment.

Beckwith-Wiedemann syndrome: development of nephroblastoma during the surveillance period

Two children, with Beckwith-Wiedemann syndrome and hemihypertrophy who were followed by ultrasonography, developed a large nephroblastoma in the interval between two abdominal ultrasound examinations. The customarily suggested bi-annual examinations are not frequent enough and may give physicians and parents a false sense of security.

Jejunal atresia with 'apple peel' deformity. A report of eight survivors

Jejunal atresia with an "apple peel" deformity is one of the most severe forms of intestinal atresia. Until quite recently, neonatal mortality rates as a result of this anomaly were high. Early diagnosis, appropriate surgery, and prolonged parenteral nutrition have led to a spectacular improvement of the survival rates. We are reporting eight cases of apple peel atresia--all eight patients survived. The pathophysiology, diagnostic aspects, surgical approaches, and postoperative management are discussed.

Radiographic-endoscopic correlations in the examination of airway disease in children

The results of radiographic examinations and flexible fiberoptic endoscopy (FFE) of the airways were correlated in 100 pediatric patients. For the diagnosis of laryngomalacia, tracheal stenosis and tracheal granulomas. FFE proved to be more accurate than radiography. In epiglottitis and croup, the two methods were comparable. In bronchial and resulting parenchymal disease, the chest films served as the endoscopist's guide because the consequences of bronchial obstruction manifested rapidly on chest roentgenograms. FFE was particularly useful when the chest films did not reveal or lateralize a clinically suspected foreign body. FFE was not error-free; in a small number of cases, radiologic methods provided critical diagnoses, which were not arrived at by endoscopy.

"Apple peel" atresia of the small bowel: prenatal diagnosis of the obstruction by ultrasound

35-year-old woman developed polyhydramnios during her first pregnancy. Ultrasound confirmed this and showed high bowel obstruction. Delivery was uneventful, the infant was asymtomatic. Abdominal films, however, demonstrated a high jejunal obstruction. At surgery "apple peel" atresia of the small bowel was found. Good outcome.

Wilms tumor, misdiagnosed preoperatively: a review of 19 National Wilms Tumor Study I cases

This study establishes the difficulty in making specific diagnoses in children with retroperitoneal tumors when only excretory urograms are used in diagnosis. Complementary use of excretory urography and ultrasonography should make the number of preoperative errors less by separating cases of Wilms tumor from those with cystic disease. This investigation underscores the hazards inherent in the use of preoperative irradiation and chemotherapy, since some children with benign disease are likely to receive inappropriate therapy.

"Contrast buttle": a sign indicating perforation of the digestive tract

Bubble formation outside the digestive tract that correlated with small perforations was observed in two infants during water-soluble contrast material studies using a 50% solution of Gastrografin in water. The causes of extraluminal bubbles are discussed; in vitro experiments demonstrated the mechanism of formation and the radiographic characteristics of the various types of bubbles. Extraluminal bubbles appearing during a water-soluble contrast material examination actually represent contrast bubbles. The radiographic density of the bubble walls varies. When the bubbles are small and diluted contrast material is used, it is not possible to detect the presence of contrast material radiographically. Contrast material bubbles are likely to be observed only if a low surface tension contrast agent is used, such as Gastrografin full- or half-strength in water). Extraluminal contrast material bubble formation may identify and localize a small perforation of the gut when other findings are inconclusive.

Radiographic manifestations of bone marrow transplantation in children

Radiographically detectable complications in 35 children after bone marrow transplant are reviewed. These complications are most frequently due to infection, chemoradiotherapeutic toxicity, and graft versus host disease (a transplant rejection phenomenon peculiar to bone marrow transplant patients). The pulmonary complications within the first 2 months are secondary to a form of interstitial lung disease. Interstitial lung disease has a strong correlation with graft versus host disease. Extrapulmonary visceral complications include hepatosplenomegaly, nephromegaly, and hemorrhagic cystitis. These are due to graft versus host disease, radiation, and chemotherapeutic toxicities, respectively. Sinusitis, cerebral atrophy, and intracerebral hematomas are less frequent complications. Osteoporosis due to steroids is the single most important osseous complication.

Renovascular hypertension in children and adolescents

Renovascular disease often leads to hypertension in children. The most frequent cause is fibromuscular dysplasia of focal type affecting main and peripheral arteries. Diastolic readings in excess of 110 mm Hg with normal serum creatinine and urinalysis are suggestive of renovascular disease. Excretory urography was positive in 65% of patients with unilateral disease. Radionuclide scans complement a positive excretory urogram but may be positive when the urogram is negative. Plasma renin activity was raised in the majority of patients; if the patient does not have peripheral branch stenosis, the renal vein renin ratio will lateralize in unilateral renal disease. The overall results of surgery are encouraging: 86% of surgical procedures alleviated hypertension in unilateral disease.

Complete obstruction of the gastric antrum in children following acid ingestion

We report on two children who experienced delayed complete obstruction of the gastric antrum following concentrated acid ingestion. Both patients required initial tube gastrostomy and subsequent antrectomy with intestinal reconstruction. Unlike the more common alkaline corrosives, ingested acids tend to spare the esophagus and gastric fundus. While gastric perforation and vascular collapse may occur immediately following overwhelming acid ingestion, the more common course is chronic gastric antral inflammation with subsequent fibrosis and, in some cases, complete stricture. Delayed surgical reconstruction is recommended to permit the acute inflammation and edema to subside.

Gray-scale ultrasonography of the normal female pelvis

The pelvis was evaluated with gray-scale ultrasound in 45 normal females, important aspects of instrumentation, changes in scanning techniques, and pitfalls in the identification of various normal anatomical structures are described, and normal ranges of uterine size and ovarian volume are reported.

Obstruction of the airways by the heart and pulmonary vessels in infants

It is well known that certain cardiovascular abnormalities, frequently compress the airways in infants [1]. Two additional cardiac mechanisms of airway obstruction are described in this paper: progressive compression of the bronchial tree by left sided cardiac enlargement and infantile cardiac asthma due to compression of the small airways by pulmonary venous congestion. Functional and reversible collapse of the trachea is a frequent finding in cardiac asthma. Infants with these entities often appear to have primary pulmonary disease when in fact the underlying cause of their distress is cardiac in origin.

Ileo-ileal intussusception in the newborn. Report of a radiologically diagnosed case

Ileo-Ileal intussusception was demonstrated preoperatively in a newborn infant by gastrografin enema with deliberate reflux of the contrast material into the small bowel. An intraluminal filling defect and stretching of the mucosal folds were demonstrated. The indications and proper use of contrast enemas are discussed.

Pre and postoperative ventricular function in infants and children with right ventricular volume overload

Hemodynamic and ventricular volume parameters were evaluated in 21 patients (24 studies) with total anomalous pulmonary venous return (TAPVR), 11 patients with secundum atrial septal defect (ASD), and eight patients who had complete correction of TAPVR or ASD. Right and left ventricular (RV and LV) volume parameters were calculated according to Simpson's rule and the area length methods, respectively. In infants with TAPVR, RV end-diastolic volume was larger than normal, but RV ejection fraction was significantly less than normal. LV end-diastolic volume and LV ejection fraction were all less than normal in infants with or without pulmonary hypertension, and the values did not correlate with the cardiorespiratory symptoms. In children with TAPVR or ASD, RV end-diastolic volume and output were higher than normal preoperatively and decreased to normal or near normal values postoperatively. The data suggest that pulmonary venous obstruction and/or RV failure are responsible for cardiorespiratory symptoms in infants with TAPVR and early surgical intervention is recommended in these patients.

Fiberoptic endoscopy and upper gastrointestinal series: comparative analysis in infants and children

Fiberoptic endoscopy is a new and highly efficient diagnostic tool which is being increasingly used in the pediatric age group. Its use in children requires general anesthesia, special facilities, and technical expertise. We have compared the results of upper gastrointestinal barium studies and fiberoptic endoscopy in 75 cases. Results agreed in approximately two-thirds of the cases; in one-third there was disagreement. Superficial lesions in the esophagus, stomach, and duodenum were most often missed by conventional barium studies. False positive radiologic reports were primarily related to the region of the duodenum.

Assessment of velar and lateral wall movement by oral telescope and radiographic examination in patients with velopharyngeal inadequacy and in normal subjects

Thirty-one patients referred to the Craniofacial Anomalies Clinic for speech evaluation were evaluated by endoscopy and cineradiographic examination (lateral and submentovertical projection). Movement of the velar and lateral walls was examined by both procedures in order to determine the accuracy of the endoscopy in assessing velopharyngeal movement. Cineradiography confirmed endoscopic observation in a large percentage of patients. In a second study, lateral wall motion was assessed in 20 cleft palate patients with repaired hard and soft palate but with velopharyngeal inadequacy. Four categories of closure defined in a previous study on normal subjects were used to classify lateral wall movement in the cleft palate patients. Mesial lateral motion past the sides of the velum during phonation occurred less frequently in patients with velopharyngeal inadequacy than in persons with normal strucutres. The absence of lateral wall motion was observed more often in the cleft palate patients, although in over half of these patients the lateral walls moved mesially and filled Rosenmuller's fossa (lateral recesses). Degree of lateral wall movement, which varies among cleft palate patients, should be estimated before construction of a prosthesis or pharyngeal flap in order to determine whether occlusion of the lateral gutters will occur during phonation.

Recurrent renovascular hypertension. Report of an unusual case

A 7-year-old girl with histologically proved fibromuscular dysplasia underwent renal autotransplantation with prompt return of the blood pressure to normal. Two months later, immediately after tonsillectomy, severe hypertension recurred with marked narrowing of the previously patent anastomosis. After 4 weeks on antihypertensive therapy, the patient became normotensive again and remained so for 18 months, with marked widening of the anastomosis. It is possible that this complication might be explained on an immunologic basis.

The submentovertical projection in the radiographic analysis of velopharyngeal dynamics

In assessing lateral pharyngeal wall movement during routine cinefluorographic examination for velopharyngeal adequacy, the inclusion of submentovertical projection is important to the lateral projection of the velum. The main structures of the nasopharynx and surrounding areas are defined, and a method to obtain visualization of this area in normal subjects is described. The degree of lateral pharyngeal wall movement varies among normal individuals and may affect the success of pharyngeal flap operations in patients with velopharyngeal inadequacy.