After virus exposure, early bystander naïve CD8 T cell activation relies on NAD+ salvage metabolism

CD8 T cells play a central role in antiviral immunity. Type I interferons are among the earliest responders after virus exposure and can cause extensive reprogramming and antigen-independent bystander activation of CD8 T cells. Although bystander activation of pre-existing memory CD8 T cells is known to play an important role in host defense and immunopathology, its impact on naïve CD8 T cells remains underappreciated. Here we report that exposure to reovirus, both in vitro or in vivo, promotes bystander activation of naïve CD8 T cells within 24 hours and that this distinct subtype of CD8 T cell displays an innate, antiviral, type I interferon sensitized signature. The induction of bystander naïve CD8 T cells is STAT1 dependent and regulated through nicotinamide phosphoribosyl transferase (NAMPT)-mediated enzymatic actions within NAD+ salvage metabolic biosynthesis. These findings identify a novel aspect of CD8 T cell activation following virus infection with implications for human health and physiology.

NAD+ depletion enhances reovirus-induced oncolysis in multiple myeloma

Cancer cell energy metabolism plays an important role in dictating the efficacy of oncolysis by oncolytic viruses. To understand the role of multiple myeloma metabolism in reovirus oncolysis, we performed semi-targeted mass spectrometry-based metabolomics on 12 multiple myeloma cell lines and revealed a negative correlation between NAD+ levels and susceptibility to oncolysis. Likewise, a negative correlation was observed between the activity of the rate-limiting NAD+ synthesis enzyme NAMPT and oncolysis. Indeed, depletion of NAD+ levels by pharmacological inhibition of NAMPT using FK866 sensitized several myeloma cell lines to reovirus-induced killing. The myelomas that were most sensitive to this combination therapy expressed a functional p53 and had a metabolic and transcriptomic profile favoring mitochondrial metabolism over glycolysis, with the highest synergistic effect in KMS12 cells. Mechanistically, U-¹³C-labeled glucose flux, extracellular flux analysis, multiplex proteomics, and cell death assays revealed that the reovirus + FK866 combination caused mitochondrial dysfunction and energy depletion, leading to enhanced autophagic cell death in KMS12 cells. Finally, the combination of reovirus and NAD+ depletion achieved greater antitumor effects in KMS12 tumors in vivo and patient-derived CD138+ multiple myeloma cells. These findings identify NAD+ depletion as a potential combinatorial strategy to enhance the efficacy of oncolytic virus-based therapies in multiple myeloma.

RTN4 Knockdown Dysregulates the AKT Pathway, Destabilizes the Cytoskeleton, and Enhances Paclitaxel-Induced Cytotoxicity in Cancers

Reticulon-4 (RTN4), commonly known as a neurite outgrowth inhibitor (Nogo), is emerging as an important player in human cancers. Clinically, we found lower RTN4 expression in patient-derived tumors was associated with significantly better survival in lung, breast, cervical, and renal cancer patients. To identify the role of RTN4 in cancer biology, we performed mass spectrometry-based quantitative proteomic analysis on cancer cells following RTN4 knockdown and found its link with pro-survival as well as cytoskeleton-related processes. Subsequent mechanistic investigations revealed that RTN4 regulates lipid homeostasis, AKT signaling, and cytoskeleton modulation. In particular, downregulation of RTN4 reduced sphingomyelin synthesis and impaired plasma membrane localization of AKT, wherein AKT phosphorylation, involved in many cancers, was significantly reduced without any comparable effect on AKT-related upstream kinases, in a sphingolipid-dependent manner. Furthermore, knockdown of RTN4 retarded proliferation of cancer cells in vitro as well as tumor xenografts in mice. Finally, RTN4 knockdown affected tubulin stability and promoted higher cytotoxic effects with chemotherapeutic paclitaxel in cancer cells both in vitro and in vivo. In summary, RTN4 is involved in carcinogenesis and represents a molecular candidate that may be targeted to achieve desired antitumor effects in clinics.

Dying to Be Noticed: Epigenetic Regulation of Immunogenic Cell Death for Cancer Immunotherapy

Immunogenic cell death (ICD) activates both innate and adaptive arms of the immune system during apoptotic cancer cell death. With respect to cancer immunotherapy, the process of ICD elicits enhanced adjuvanticity and antigenicity from dying cancer cells and consequently, promotes the development of clinically desired antitumor immunity. Cancer ICD requires the presentation of various "hallmarks" of immunomodulation, which include the cell-surface translocation of calreticulin, production of type I interferons, and release of high-mobility group box-1 and ATP, which through their compatible actions induce an immune response against cancer cells. Interestingly, recent reports investigating the use of epigenetic modifying drugs as anticancer therapeutics have identified several connections to ICD hallmarks. Epigenetic modifiers have a direct effect on cell viability and appear to fundamentally change the immunogenic properties of cancer cells, by actively subverting tumor microenvironment-associated immunoevasion and aiding in the development of an antitumor immune response. In this review, we critically discuss the current evidence that identifies direct links between epigenetic modifications and ICD hallmarks, and put forward an otherwise poorly understood role for epigenetic drugs as ICD inducers. We further discuss potential therapeutic innovations that aim to induce ICD during epigenetic drug therapy, generating highly efficacious cancer immunotherapies.

Abstract 2506: Citral reduces breast tumor growth by inhibiting cancer stem cell marker ALDH1A3

Breast cancer stem cells (CSCs) can be identified by increased Aldefluor activity which is primarily due to aldehyde dehydrogenase 1A3 (ALDH1A3) expression. In addition to being a CSC marker, ALDH1A3 regulates genes expression via inducing retinoic acid (RA) signaling and plays an important role in mediating progression of cancers, including breast, melanoma, lung and glioblastoma. Therefore, ALDH1A3 represents a novel druggable anti-cancer target of interest. There are no currently characterized inhibitors of the ALDH1A3 isoform, so twelve general ALDH inhibitors were tested for their effectiveness in targeting ALDH1A3 activity. Ability to directly inhibit ALDH activity was quantified with the Aldefluor assay on a patient tumor xenograft and on breast cancer cell lines with known ALDH isoform activity. Inhibition of RA signaling was quantified by measuring expression of the RA-inducible genes RARRES1 and RARβ. To investigate the anti-cancer properties of these compounds, apoptosis was quantified with the annexin V assay. Citral significantly reduced ALDH1A3- and ALDH2-associated Aldefluor activity in breast cancer cell lines and also reduced Aldefluor activity of a patient-derived xenograft. Citral reduced expression of RA-inducible genes through reducing ALDH1A3 activity. Citral induced apoptosis in vitro in an ALDH-independent manner in breast cancer cell lines and reduced proliferation in the MDA-MB-231 breast cancer cell line. Nanoparticle (NP)-encapsulated citral was generated for in vivo use and administered intravenously to female NOD/SCID mice harbouring MDA-MB-231 ALDH1A3-overexpression tumors. 10mg/kg NP-citral significantly decreased the growth of ALDH1A3-driven MDA-MB-231 tumors. Nanoparticle-encapsulated citral shows promise as an adjuvant therapy for patients with tumors that have a large population of high-ALDH1A3 CSCs.

Citation Format: Margaret L. Thomas, Roberto De Antueno, Krysta Coyle, Brianne Cruickshank, Michael Giacomantonio, Roy Duncan, Carman Giacomantonio, Paola Marcato. Citral reduces breast tumor growth by inhibiting cancer stem cell marker ALDH1A3. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 2506.

Abstract B23: Citral reduces ALDH1A3 activity in breast cancer: Potential applications in targeting breast cancer stem cells

Breast tumors contain a subpopulation of cells known as cancer stem cells (CSCs) which are highly tumorigenic, resistant to typical chemo- and radiotherapy, and express high levels of aldehyde dehydrogenase (ALDH) isoforms ALDH1A3 and ALDH1A1. These enzymes initiate retinoic acid (RA) signaling and potentially contribute to detoxification of chemotherapy. A compound that inhibits these enzymes could be used as an adjuvant therapy to target breast CSCs and/or re-sensitize this population to chemotherapy. In particular, there are no currently characterized inhibitors of the ALDH1A3 isoform, so twelve general ALDH inhibitors were tested for their effectiveness in targeting ALDH1A3 activity. Ability to directly inhibit ALDH activity was quantified with the Aldefluor assay on a patient tumor xenograft and on breast cancer cell lines MDA-MB-231, MDA-MB-468, and SKBR3. Inhibition of RA signaling was quantified by measuring RA-inducible gene expression after 24 hours treatment with ALDH inhibitor. To investigate the anti-cancer properties of these compounds, apoptosis was quantified with the annexin V assay after 24 hours treatment. To determine if increased ALDH1A3 expression is involved in chemoresistance, MDA-MB-231 cells overexpressing ALDH1A3 and MDA-MB-468 cells with ALDH1A3 shRNA knockdown were treated for 72 hours with doxorubicin, 4-hydroperoxycyclophosphamide, or paclitaxel. Increased ALDH1A3 expression did not affect the amount of chemotherapy-induced apoptosis or cell proliferation rates. Citral significantly reduced ALDH1A3-mediated expression of RA-inducible genes and significantly reduced the ALDH activity of the patient-derived xenograft as well as ALDH1A3-overexpression MDA-MB-231 cells. Citral induced apoptosis in an ALDH1A3-dependant manner in breast cancer cell lines, and its ability to reduce MDA-MB-231 in vivo growth was investigated by implanting MDA-MB-231 cells in female NOD/SCID mice and injecting with 0.1mg/kg citral. Tumor size was not affected by citral injections, however recent data suggests that micelle-encapsulated citral has the potential to reduce tumor bulk. Should citral prove to be an effective breast cancer and ALDH1A3 inhibitor in future tumor xenograft experiments, this compound could potentially be used as adjuvant therapy for breast cancer patients.

Citation Format: Margaret L. Thomas, Krysta M. Coyle, Brianne Cruickshank, Michael Giacomantonio, Melissa Wallace, Carman Giacomantonio, Paola Marcato. Citral reduces ALDH1A3 activity in breast cancer: Potential applications in targeting breast cancer stem cells. [abstract]. In: Proceedings of the AACR Special Conference on Advances in Breast Cancer Research; Oct 17-20, 2015; Bellevue, WA. Philadelphia (PA): AACR; Mol Cancer Res 2016;14(2_Suppl):Abstract nr B23.

Core needle biopsy of breast cancer tumors increases distant metastases in a mouse model

INTRODUCTION: Incisional biopsies, including the diagnostic core needle biopsy (CNB), routinely performed before surgical excision of breast cancer tumors are hypothesized to increase the risk of metastatic disease. In this study, we experimentally determined whether CNB of breast cancer tumors results in increased distant metastases and examine important resultant changes in the primary tumor and tumor microenvironment associated with this outcome. METHOD: To evaluate the effect of CNB on metastasis development, we implanted murine mammary 4T1 tumor cells in BALB/c mice and performed CNB on palpable tumors in half the mice. Subsequently, emulating the human scenario, all mice underwent complete tumor excision and were allowed to recover, with attendant metastasis development. Tumor growth, lung metastasis, circulating tumor cell (CTC) levels, variation in gene expression, composition of the tumor microenvironment, and changes in immunologic markers were compared in biopsied and non-biopsied mice. RESULTS: Mice with biopsied tumors developed significantly more lung metastases compared to non-biopsied mice. Tumors from biopsied mice contained a higher frequency of myeloid-derived suppressor cells (MDSCs) accompanied by reduced CD4 + T cells, CD8 + T cells, and macrophages, suggesting biopsy-mediated development of an increasingly immunosuppressive tumor microenvironment. We also observed a CNB-dependent up-regulation in the expression of SOX4, Ezh2, and other key epithelial-mesenchymal transition (EMT) genes, as well as increased CTC levels among the biopsy group. CONCLUSION: CNB creates an immunosuppressive tumor microenvironment, increases EMT, and facilitates release of CTCs, all of which likely contribute to the observed increase in development of distant metastases.

Coexistence of meconium ileus with duodenal atresia and trisomy 21 in a newborn: a case report

The coexistence of duodenal atresia (DA) may mask the antenatal ultrasound findings of meconium ileus (MI) and delay its postnatal diagnosis. We report a rare case of MI in a newborn infant diagnosed antenatally to have trisomy 21 and DA. The diagnosis of MI was only established intraoperatively after the patient showed persistent signs of intestinal obstruction following the surgical repair of the DA.

Research publication in pediatric surgery: a cross-sectional study of papers presented at the Canadian Association of Pediatric Surgeons and the American Pediatric Surgery Association

INTRODUCTION

Several studies have examined predictors of publication of research presented in scientific meetings in different disciplines. A tendency toward publishing studies with positive results has been described as "publication bias." Our objective was to determine the proportion of the studies that were published, time to publication, and factors that could predict publication in pediatric surgery.

METHODS

The abstract books of the Canadian Association of Pediatric Surgeons and the American Pediatric Surgery Association meetings for 2001 to 2002 were reviewed. Data were gathered regarding the methodology and characteristics of each study. Case reports and editorials were excluded. A Medline search was then conducted to determine the publication status. Analysis using univariate and multivariate techniques was undertaken, comparing the difference between published and unpublished studies.

RESULTS

Two hundred seven abstracts were reviewed. Of the 183 abstracts included, 118 (64.5%) were published. Most studies were published 1 year after presentation (93.2%). Presentation in the American Pediatric Surgery Association meeting and research originating from North America and reporting statistically significant results were significantly associated with subsequent publication on univariate analysis. The presence of statistically significant results was the only factor associated with successful publication on multivariate analysis (odds ratio, 3.3; confidence interval, 1.5-7.7).

CONCLUSION

The strong association between successful publication and the presence of statistically significant results point to the strong possibility of publication bias affecting decisions made about publishing research in the pediatric surgery.

Rectal prolapse in autistic children

Rectal prolapse in children is not uncommon, but surgery is rarely indicated. In mentally challenged adults and children, rectal prolapse occurs more frequently than in the general population and often requires surgical intervention in the second to third decade of life. The authors describe 3 children with autism and mental retardation who presented with rectal prolapse at an earlier age than would be anticipated with mental retardation alone. All 3 children required surgical intervention.

Undifferentiated mesenchymal neoplasm of the esophagus in a child: case report and comparison with gastrointestinal stromal tumor

Mesenchymal neoplasms of the esophagus are relatively uncommon in adults and exceedingly rare in children. Childhood tumors consist almost exclusively of smooth muscle tumors (leiomyomas). We report a case of an undifferentiated mesenchymal neoplasm occurring in the distal esophagus of a 15-year-old boy which is not a gastrointestinal stromal tumor. To our knowledge, this is the first reported case of such a neoplasm occurring in the esophagus of either an adult or child.

A complication associated with central line removal in the pediatric population: retained fixed catheter fragments

BACKGROUND

There are many reports on the complications that occur at the time of insertion and during the life of central venous indwelling catheters. However, there is no literature that describes the complications that occur at the time of removal of these lines.

METHODS

A retrospective review of 136 central line (Broviacs [B], Port-A- Caths [PC] and Hickmans [HC]) removals during the last 5 years was undertaken.

RESULTS

A total of 97% were removed after completion of chemotherapy, and 3% because of sepsis or malfunction. Three PC lines broke at the time of removal resulting in a length of line remaining in the central venous system (the superior vena cava, innominate vein, and bracheo-cephalic subclavian junction). Two lines were inserted by a cut-down technique into the external jugular and one line by the percutaneous technique into the subclavian vein. At follow-up, none of the residual lines were associated with thrombus formation, and none showed any evidence of migration.

CONCLUSIONS

This review identifies a specific problem that can occur with central line removal. Both the long-term affects of residual catheter within the central venous system and the need to remove the foreign body have yet to be addressed.

Mediastinal polyembryoma associated with Klinefelter syndrome

A 4.5-year-old boy presented with isosexual precocious puberty and an anterior mediastinal mass. Surgical resection demonstrated a teratoma with foci of malignant mixed germ cell tumor elements of polyembryoma. On further investigation he was found to have Klinefelter syndrome. Most mediastinal germ cell tumors are treated with adjuvant therapy. He was managed with surgical excision alone and is well at 2 years follow-up. The rationale for this approach is discussed.

Splenic injuries in children: correlation between imaging and clinical management

For non-operative management of splenic injuries in children, questions remain as regards imaging, length of hospital stay, and follow-up. We reviewed our experience concerning these issues over the past 15 years. The charts of all children with splenic injuries from January 1983 to December 1998 were reviewed. All computed tomography (CT) scans were reviewed and classified according to degree of splenic injury. Fisher's exact test and a linear regression model were used to analyze data. Sixty-nine males and 23 females under 16 years of age were identified; 57 (62%) had CT scans; 8 underwent a laparotomy; and 6 (6.5%) died. Age, on hemoglobin admission, and duration of intensive-care-unit stay were significantly related to hospital stay (median 8 days). Motor vehicle-pedestrian-related injuries correlated significantly with mortality. CT class did not correlate with mortality (P = 0.68) or hospital stay (P = 0.2). Follow-up data were available for 66 patients, 36 of them with imaging. Follow-up imaging did not impact on clinical decisions and no late sequelae were identified.

Congenital cervical teratoma in neonates. Case report and review

Cervical teratomas are uncommon neoplasms. Although these lesions are histologically benign they are usually large and may cause airway obstruction. Cervical teratomas are usually diagnosed at birth. In-utero diagnosis is possible by prenatal ultrasound which assists in planning early airway management and surgical intervention. Mortality is significant but prognosis is good with airway control and complete surgical excision. However, pressure injury of contiguous structures can limit resectability and adversely affect outcome. Malignant cervical teratoma with metastasis has been reported mostly arising in adults with poor outcome. We present nine cases of neonatal cervical teratoma identified at two institutions between 1984 and 1996. One patient died before surgical intervention. All others underwent resection. There was one intraoperative death and one postoperative death. The remaining six patients did well postoperatively with no significant sequelae with 3 to 14 years follow-up.

Femoral hernia in children

BACKGROUND/PURPOSE

Femoral herniae are uncommon in children and easily misdiagnosed. To evaluate performance with femoral hernia in children, the authors reviewed their experience for the past two decades.

METHODS

All patients under 15 years of age with femoral hernia (January 1977 to January 1998) were reviewed. Age, gender, presentation, surgical findings and procedure, and previous repair were recorded.

RESULTS

There were nine girls (53%) and eight boys (47%). Age range was 2 to 15 years. Thirteen were right side (77%), three were left side (18%), and one was bilateral (6%). All presented with a recurrent lump in the groin, one with incarceration. Duration of symptoms ranged from 1 day to 3 years (median, 3 months). Six cases were diagnosed correctly preoperatively (35%); the others were thought to be either an inguinal hernia or recurrent inguinal hernia.

CONCLUSIONS

Femoral hernia in childhood is a challenging clinical problem because of its rarity and similar clinical presentation as indirect inguinal hernia. The frequency with which an incidental indirect inguinal hernia sac or patent processus vaginalis can be found at surgery can perpetuate a misdiagnosis. The absence of an expected indirect inguinal hernia sac or an apparent recurrence of an indirect inguinal hernia should lead to consideration of a possible femoral hernia.

Management of impalpable testes: indications for abdominal exploration

Various approaches to the management of the impalpable testis in cases of cryptorchidism have been advocated. The authors' experience over the past 13 years was reviewed to try to determine an optimal approach. Of 1,305 patients with undescended testicles seen between February 1982 and December 1995, 157 boys (12.03%) had impalpable testes with 17 having bilateral impalpable testes for a total of 174 impalpable testes. A hernia sac was present in 155 impalpable testes with a testicle present in all cases. No hernia sac was found in 19 impalpable testes, five of which had no testicle present. This was confirmed by either open exploration or laparoscopy. One hundred forty-eight boys underwent groin exploration as initial treatment, 13 of these had bilateral impalpable testes. In addition to the five absent testicles with no hernia sac, one patient with a hernia sac and no testicle evident benefited from subsequent laparoscopy to identify an intraabdominal testicle. All other patients underwent routine orchidopexy or orchidectomy (one case with grossly malformed testicle). Nine boys underwent laparoscopy as initial treatment, four of these had bilateral impalpable testes. Two abnormal testicles were found and removed. Groin exploration and subsequent orchidopexy was definitive treatment in all other cases. The association of a hernia sac with an impalpable undescended testicle is very significant (P < .00001 Fisher's Exact test). The absence of a sac therefore may reflect an alternate diagnosis. When no sac is found with a testicle in the groin, this may represent an ectopic testicle. When no sac is found with no testicle, this may represent a vanishing testicle. From this experience the authors conclude that groin exploration should be the initial approach to impalpable testes. The presence of a hernia sac with an absent testicle demands further exploration; the absence of a hernia sac with an absent testicle suggests a vanishing testicle and may need no further exploration.

Disorders in foregut diverticulization: congenital hepaticoesophageal fistula in a baby with laryngotracheoesophageal cleft

Congenital fistulae between the biliary tract and the proximal foregut are rare. Nineteen cases have been reported involving a fistula tract between the left hepatic duct and the distal trachea or proximal bronchus. Herein the authors describe a fistula between the hepatic duct and the esophagus. A baby girl had a type III laryngotracheoesophageal cleft repaired in the neonatal period. In the course of investigating her bilious vomiting a DISIDA scan showed radionuclide excretion into the distal esophagus. A percutaneous cholangiogram through the gallbladder showed no drainage from the common bile duct into the duodenum, while the proximal left hepatic duct drained into the distal esophagus. The fistula was divided adjacent to the esophagus and the biliary system was drained through a Roux-en-Y cholecystojejunostomy. Fourteen months later she is doing well with no evidence of hepatic compromise.

Perianal ependymoma presenting in the neonatal period

Extraspinal ependymomas are a rare type of glioma that may arise in the sacrococcygeal region, presenting as a pelvic mass in an infant or child. Ependymoma presenting in the newborn period has not been described previously. Herein we describe a case of a newborn boy who presented with a perianal ependymoma, which was subsequently found to have presacral extension. The major diagnostic challenge this case presented was to rule out the alternative diagnosis of sacrococcygeal teratoma or a developmental malformation/heterotopia.

Routine neonatal circumcision?

Routine neonatal circumcision is still a controversial procedure. This article attempts to clarify some of the advantages and disadvantages of neonatal circumcision. The increased rate of penile cancer among uncircumcised men appears to justify the procedure, but that alone is not sufficient justification. The final decision on neonatal circumcision should be made by parents with balanced counsel from attending physicians.

Impact of diagnostic laparoscopy in the management of the unilateral impalpable testis

OBJECTIVE

To evaluate the impact of laparoscopy on the management of children with a unilateral impalpable testis.

PATIENTS AND METHODS

The study population consisted of 27 children who underwent a primary inguinal exploration for a unilateral impalpable testis.

RESULTS

Twelve of 27 (44%) children had inguinal or 'peeping' testes and 10 of 27 (37%) had blind-ending vasa and vessels in the inguinal canal; four of these 10 had atrophic tubular tissue in the excised remant. Four of 27 (15%) had blind-ending vasa and vessels proximal to the internal ring. Only one child had a testis proximal to the internal ring. Only the four children (15%) with blind-ending vasa and vessels proximal to the internal ring would have benefited from a laparoscopy by avoiding an inguinal exploration.

CONCLUSIONS

Because of the time, expense and limited usefulness of laparoscopy in altering the management of children with a unilateral unpalpable testis, we reserve laparoscopy for cases where inguinal exploration has failed.

Survival in neonatal congenital hernia without extracorporeal membrane oxygenation support

The experience with high-risk congenital diaphragmatic hernia (CDH) at an institution that does not offer extracorporeal membrane oxygenation (ECMO) was reviewed. Between January 1, 1983 and December 31, 1993, 38 children presented with Bochdalek-type CDH. Excluded were two infants with lethal cardiac anomalies and four presenting after 4 hours of age. Thus, the authors identified 32 high-risk patients. All had early respiratory distress and were intubated within 5 hours of birth. Sixteen were inborn; 16 were referred to the Izaak Walton Killam Children's Hospital (IWK) within 24 hours of birth. There were 19 males and 13 females. Three died before surgery could be attempted. Twenty-two survived, giving an overall survival rate of 69% (22 of 32). For 28 of the 32, the best preoperative postductal Pao2 (BPDPao2) was recorded. Fifteen of the 28 children had a BPDPao2 of greater than 100 mm Hg. Survival in this group was 14 of 15 (93%). Thirteen of the 28 patients had a BPDPao2 of less than 100 mm Hg. Survival in this group was 5 of 13 (38%). These survival rates are comparable to those of centers offering ECMO. BPDPao2 appears to be a useful discriminating variable.

Omental-mesenteric inflammatory pseudotumor. Cytogenetic demonstration of genetic changes and monoclonality in one tumor

BACKGROUND

Extrapulmonary inflammatory pseudotumor (plasma cell granuloma) is an uncommon lesion in adults and children, and little is known either of its etiology or clinical characteristics. However, it remains a significant source of morbidity to patients and confusion to clinicians.

METHODS

Case reports are presented of three patients with intraabdominal inflammatory pseudotumor who recently underwent surgery. A review of the recent world literature is also presented. Clinical and laboratory characteristics of omental-mesenteric inflammatory pseudotumor are reviewed along with a discussion of its etiology.

RESULTS

Cytogenetic data from cells of one patient show a derivative chromosome evolved from a translocation between the long arm of chromosome 2 and the short arm of chromosome 9 [(2;9)(q1,3;p2,2)].

CONCLUSIONS

The lesion is monoclonal, and genetic changes may play a crucial role in the development of this neoplasm. Omental-mesenteric inflammatory pseudotumor appears to represent a distinct clinicopathologic entity as a benign neoplasm in children.

Routine inguinal hernia repair in the pediatric population: is office follow-up necessary?

Routine inguinal hernia repair in the pediatric population has a low complication rate. Very few complications are identified at follow-up, which brings into question the necessity of the traditional postoperative visit. A retrospective review of patients who had undergone a routine inguinal hernia repair in 1991 at our institution was done in order to determine our current follow-up practices and complication rate. To determine the perceived necessity for the follow-up visit, parents were given a short telephone questionnaire. Of 175 eligible patients, questionnaires were completed on 145. Of these 145 patients, 77 were seen in follow-up by the pediatric surgeon only, 43 by the family doctor only, 12 were seen by both, and 13 patients had no physician follow-up. The sole complication was a stitch abscess (complication rate 0.7%). Results of the questionnaire showed that 90% of parents felt the follow-up visit was "helpful," 80% felt it was "necessary," and 35% would have been satisfied with telephone follow-up. The main purpose of the postoperative visit appears to be parental reassurance. Careful preoperative and postoperative instruction and reassurance may be sufficient in a significant number of cases.

Nipple discharge and breast lump related to Montgomery's tubercles in adolescent females

Four adolescent girls, aged 12 to 14 years, were seen for evaluation of spontaneous nipple discharge, two of whom had associated breast lumps in the ipsilateral breast. Clinical examination showed the discharge to be arising from one or several of Montgomery's areolar tubercles, with the breast lumps localized to the subareolar region immediately beneath the discharging tubercle. The secretions were episodic, thin, varied in color from clear to brown, but were not milky. All discharges resolved within 3 to 5 weeks, and the associated breast lumps resolved within 4 months without treatment. There were no associated clinical complaints or physical findings and detailed endocrinologic assessments including serum prolactin, luteinizing hormone (LH), follicle-stimulating hormone (FSH), thyroid function tests, and 17 beta estradiol; they were all normal. None of these patients was pregnant, and follow-up from 4 to 18 months did not reveal evidence of recurrence or other pathology. Experience gained from these four cases suggests that cysts and spontaneous, non-milky discharge related to Montgomery's tubercles in otherwise healthy, nonpregnant adolescent females, represents a benign, self-limiting problem. Unless other indications are present, endocrinologic investigation is unnecessary and spontaneous resolution can be expected.

Neurenteric cysts--a spectrum

This review encompasses seven patients with clinically important cystic lesions of the gastrointestinal (GI) tract, exhibiting a wide range of vertebral anomalies and connections to the neural canal. Three patients had mediastinal masses connected to lower cervical and upper thoracic anomalous vertebrae with intraspinal extensions. In addition, one of these patients had a separate, juxtapancreatic intestinal duplication cyst. One infant with colonic duplication had a lumbar vertebral anomaly and an epithelial-lined tract between the two. Another patient had a presacral cystic mass which was the site of recurrent infections and meningitis until a connection with the rectum was divided. A newborn baby had a completely split notochord syndrome with a large dorsal enteric fistula. Finally, one patient had a dorsal enteric cyst with a direct intraspinal connection. Four of the seven patients had associated significant congenital anomalies, two of whom died early in the neonatal period. The rest of the patients did well. This broad range of enteric lesions with associated vertebral and intraspinal abnormalities suggests that the clinical spectrum of neurenteric cystic lesions is much wider than is generally appreciated.

Paraesophageal hernia after Nissen fundoplication: a real complication in pediatric patients

Eighty-nine pediatric patients aged 6 weeks to 20 years (mean, 3.8 years) who underwent Nissen fundoplication were reviewed. Follow-up, including upper gastrointestinal (GI) series, was obtained in 55 patients (61.8%). Fifteen patients developed paraesophageal hernia (PEH) (16.8%). PEH was diagnosed between 4 and 36 months following fundoplication (mean, 17 months). Patients were divided into three groups: A, those with significant mental dysfunction (45); B, those with previous tracheoesophageal fistula (12); and C, others (32). Incidence of PEH is 20% for group A, 16.8% group B, and 12.5% group C. Combining groups B and C, 5 of 25 patients (20%) who underwent fundoplication at less than 1 year of age developed PEH, whereas one of 19 older patients (5.3%) developed PEH. One of 25 patients (4%) who had crural repair at fundoplication developed PEH, whereas 14 of 64 patients without crural repair (21.9%) developed PEH. At surgery, PEH occurred at the left posterolateral aspect of esophagus. We conclude that (1) follow-up after fundoplication should continue for 36 months and include upper GI series; (2) patients under one year of age undergoing fundoplication may be at a higher risk for PEH; and (3) technical refinement including crural repair may be required to prevent PEH.

Neonatal ovarian torsion: report of three cases and review of the literature

Ovarian cysts are common incidental findings in term infants and, if unusually large, may result in dystocia, torsion, or rupture. Torsion and infarction of a normal ovary tend to occur in older childhood. During a 4-month period, 3 cases of neonatal ovarian torsion were observed after antenatal ultrasonography had detected fetal pelvico-abdominal cystic lesions. The three infants were explored between 4 and 16 days of age. Ovarian torsion was right-sided in all 3, and 1 ovary had been autoamputated. The resected specimens were nontense, thin-walled cysts, filled with hemorrhagic fluid, that measured between 4.5 and 8 cm in diameter. Microscopically, focal calcification and widespread necrosis precluded recognition of underlying histologic landmarks. Neonatal ovarian cysts or cystic ovaries greater than 4 cm in diameter should be excised, even if asymptomatic, because they are prone to, or have undergone, torsion.

Fine needle aspiration cytology of metastatic malignant rhabdoid tumor

The diagnosis and management of pediatric neoplasms using fine needle aspiration (FNA) has been neglected as compared to neoplasms occurring in adults. A case of metastatic malignant rhabdoid tumor diagnosed by FNA cytology is presented, and the cytologic morphology, which to our knowledge has not previously been reported, is described. The ultrastructural findings in the histologic specimen are also depicted. This case demonstrates the feasibility and need for further exploration of the use of FNA in pediatric oncology.

Antenatal sonographic diagnosis of adrenal neuroblastoma

We report an infant with adrenal neuroblastoma diagnosed prenatally by ultrasonography. Early diagnosis is essential since survival is inversely related to the increasing age of the patient.

Thirty years of experience with pediatric primary malignant liver tumors

Since 1950, 48 infants and children from 10 weeks to 16 years of age presented with primary hepatic malignancy. Signs and symptoms ranged from asymptomatic to those of malignant disease. All patients had a palpable abdominal mass. Jaundice was seen in five patients, four of whom had preexisting cirrhosis. Three male children had evidence of precocious puberty. Whereas liver function tests were usually normal, alpha-fetoprotein levels, when elevated, proved useful diagnostically and as a tumor marker in follow-up. Hepatic angiography and computed tomography (CT) scans have provided the most valuable preoperative assessment of hepatic architecture. Sixteen infants and children underwent resection for cure. Eleven of these patients are alive and disease free 6 months to 23 years later. Six additional patients had incomplete resection with subsequent radiotherapy and/or chemotherapy; only one such patient is disease-free past 3 years. Twenty-six tumors could only be biopsied; most of these patients died within 12 months regardless of what treatment they received. The histology was hepatoblastoma in 39 patients, hepatocellular carcinoma in 4, fibrolamellar carcinoma in 4, and malignant mesenchymal tumor (mesenchymoma) in 1. The patients with hepatocellular carcinoma and mesenchymoma all died. Three of four patients with fibrolamellar carcinoma are alive and disease-free following resection up to 3 years; this histology seems favorable. The other survivors had hepatoblastoma. The role of adjunctive chemotherapy and/or radiotherapy has not yet been determined.

Blunt hepatic trauma in children: experience with operative and nonoperative management

Between 1974 and 1982, 32 children were treated for blunt hepatic trauma. Twenty-three injuries were secondary to motor vehicle accidents. Twenty-three patients had associated injuries. The hepatic injury was treated surgically in 18 patients. Urgent surgery for massive bleeding was required in 7 patients; 8 underwent laparotomy for continued bleeding after initial stabilization; 2 underwent laparotomy for marked abdominal tenderness, and 1 for an expanding hepatic hematoma. Various excisional, debridement, suture, and drainage procedures were employed. Seven patients died, 5 from uncontrollable bleeding and 2 from associated severe head injury. The eleven survivors did well. The only postoperative complications were two wound infections. Fourteen patients were managed nonoperatively. Liver scan provided the diagnosis in all. Five of these patients required blood transfusion, and the mean volume of transfusion was 33cc/kg. The hospital courses in all cases were uneventful, and there were no late complications. A follow-up liver scan was obtained in 11 patients, showing resolution of the injury in all. We conclude that laparotomy is necessary for hepatic injury when it is associated with continuous massive bleeding. Hemodynamically stable patients can be managed nonoperatively, even when the blood-transfusion requirements are significant.

Should prophylactic antibiotics be given perioperatively in acute appendicitis without perforation?

The authors question the need to give prophylactic antibiotics perioperatively in all cases of acute appendicitis without perforation to reduce the rate of wound infection. A retrospective study of 82 patients showed a wound infection rate of 4.8%; 3 of 53 patients who did not receive antibiotics had a wound infection compared with 1 of 29 patients who received antibiotics. A prospective double-blind clinical trial was performed comparing the results of perioperative administration of cefamandole and placebo. One of 21 patients who received the placebo had a wound infection; none of the 21 patients given cefamandole had infection. Thus, the authors conclude that, although reports in the literature suggest that antibiotics given perioperatively decrease the rate of wound infection in acute appendicitis without perforation, the incidence of such infection is too low to warrant routine administration. They suggest that such antibiotic use be reserved for those suspected of having more serious disease.

Torsion of the testicle in the newborn

Torsion of the testicle in the neonate is uncommon. Only nine cases were seen in a 10-year period at the Izaak Walton Killam Hospital for Sick Children in Halifax, Nova Scotia. The authors describe briefly five of their cases to exemplify the features of and problems associated with this condition. They emphasize that (a) a reddish blue, nontender, scrotal or hemiscrotal swelling in the neonate should be considered as torsion of the testicle until proven otherwise and (b) torsion of the testicle in the neonate is a surgical emergency. If testicular tissue is to be saved urgent scrotal exploration is mandatory. The torsion may occur in utero (as is the usual case), at time of birth or post partum, but the time of occurrence cannot be judged. Finally, the authors discuss some of the controversies in the surgical management of this entity, including the surgical approach and management of the contralateral hemiscrotum.