Second cutaneous neoplasms after acute lymphoblastic leukemia in childhood

Two cases of second cutaneous neoplasms, one with adenoid cystic carcinoma of the skin and the other with basal cell carcinoma, both occurring 7 years after treatment for childhood acute lymphoblastic leukemia (ALL) are reported. Although such cutaneous neoplasms are generally reported in patients over 40 years of age, our cases, which were diagnosed at the ages of 9 and 14, are the first report of the occurrence of such cutaneous neoplasms following ALL. The neoplasms arose from the scalp of two patients who had received cranial irradiation for central nervous system prophylaxis. The possible link between leukemia therapy incorporating irradiation and the pathogenesis of second cutaneous neoplasms in the scalp is discussed.

Hepatic resection for cystic lesions of the liver

OBJECTIVE

The purpose of this study was to report the authors' experience with hepatic resection for cystic lesions of the liver.

SUMMARY BACKGROUND DATA

Past experience with aspiration, sclerosing therapy, internal drainage, fenestration, and marsupialization are of limited value. Hepatic resection has evolved into a safe operation over the last two decades.

METHODS

A retrospective study of 44 patients with various cystic lesions of the liver (polycystic disease, 2; solitary or multiple congenital cysts, 19; biliary cystadenoma, 6; cystadenocarcinoma, 3; squamous cell carcinoma, 3; Caroli's disease, 5; and hydatid cyst, 6) was performed.

RESULTS

After 7 trisegmentectomies, 24 lobectomies, 6 left lateral segmentectomies, and 7 nonanatomical hepatic resections, only 1 operative death occurred in a Jehovah's Witness. Symptomatic relief was complete and permanent in all of the patients with benign congenital or parasitic hepatic cysts, except for the two patients with polycystic disease of the liver. One of the 3 patients with adenocarcinoma and 3 patients with squamous cell carcinoma of the cyst wall died of tumor recurrence between 3 and 14 months after hepatic resection.

CONCLUSIONS

Hepatic resection is safe and effective for cystic lesions of the liver. Symptomatic relief is complete and permanent after hepatic resection, except in cases of diffuse polycystic disease of the liver. Liver transplantation should be considered for diffuse polycystic disease of the liver when the symptoms are extremely severe.

Small bowel and liver/small bowel transplantation in children

A clinical trial of intestinal transplantation was initiated at the University of Pittsburgh in May 1990. Eleven children received either a combined liver/small bowel graft (n = 8) or an isolated small bowel graft (n = 3). Induction as well as maintenance immunosuppression was with FK-506 and steroids. Four patients were male, and seven were female; the age range was 6 months to 10.2 years. There were 3 deaths (all in recipients of the combined liver/small bowel graft), which were attributed to graft-versus-host disease (n = 1), posttransplant lymphoproliferative disease (n = 1), and biliary leak (n = 1). Transplantation of the intestine has evolved into a feasible operation, with an overall patient and graft survival rate of 73%. These survivors are free of total parenteral nutrition, and the majority are home. These encouraging results justify further clinical trials.

Contrast examination of the small bowel in patients with small-bowel transplants: findings in 16 patients

OBJECTIVE

The purpose of this study was to describe the findings on contrast examinations of the gastrointestinal tract in patients with small-intestinal transplants.

SUBJECTS AND METHODS

Sixteen consecutive adult transplant recipients received a total of 17 allografts: eight isolated small-bowel, six small-bowel and liver, and three multivisceral (stomach, duodenum, pancreas, small-bowel, liver). Grafts included the entire mesenteric small bowel. Gastrointestinal contrast studies were done in asymptomatic patients according to protocol and in patients having clinical indications for examination. Median time from transplantation to examination was 78 days (range, 5-768 days). Seventy-five gastrointestinal contrast examinations were performed: 53 upper gastrointestinal and small-intestinal series, 12 upper gastrointestinal series, eight enteroclyses, and two water-soluble contrast enemas. Radiographs were analyzed for postsurgical anatomy, integrity of anastomoses, allograft radiologic appearance, small-bowel transit time, and rate of gastric emptying.

RESULTS

Usual postsurgical anatomy included native-to-donor duodenojejunal, jejunojejunal, and gastrogastric anastomoses and donor-to-native ileocolonic and ileoileal anastomoses. No anastomotic complications were found. Leaks at native duodenal and colonic stumps resulted in a duodenocutaneous fistula and an abscess, respectively. Moderate to marked thickening of mucosal folds consistent with edema was present in nine allografts (53%) and 11 (17%) of 66 upper gastrointestinal and small-intestinal examinations, primarily in the early postoperative period. Chronic loss of allograft mucosal folds developed in four grafts in three patients; pathologic diagnoses included acute and chronic rejection and enteric infection; a jejunocutaneous fistula developed in one such patient. Transit times of barium through the small intestine ranged from 0.2 to 17.8 hr (median, 2 hr). Self-limited delayed gastric emptying was present in 14 patients (88%) and 32 (60%) of 54 upper gastrointestinal and small-intestinal examinations.

CONCLUSION

Gastrointestinal contrast examinations in recipients of small-bowel transplants are useful for assessing graft anatomy, enteric anastomoses, and gastrointestinal motor function. Most intestinal grafts showed normal caliber and mucosal pattern and exhibited active peristalsis. Abnormal findings included self-limited postoperative edema of graft mucosal folds, chronic loss of the mucosal folds due to rejection and/or enteric infection, delayed gastric emptying that improved with time, leaks from native duodenal and colon stumps, and a jejunocutaneous fistula in a failing graft. Small-intestinal transit times were similar to those observed in patients not receiving transplants, although there was wide variation.

Rat liver lipids during ex vivo warm and cold ischemia and reperfusion

Rat livers were flushed and stored ex vivo in Krebs-Henseleit buffer at 37 degrees C for 3 hr or in University of Wisconsin solution at 2 degrees C for 48 hr. After this they were perfused with recirculated Krebs-Henseleit solution at 37 degrees C for 1 hr. Levels of phospholipids (PL), free fatty acids (FFA), and conjugated dienes were determined at various times during ischemia and after 1 hr of reperfusion. After 3 hr warm ischemia, total PL content decreased by about 30% primarily because of decreases in phosphatidylcholine and phosphatidylethanolamine. One hour of reperfusion normalized PL levels. Total PL content was unchanged up to 48 hr of cold ischemia because of offsetting alterations in levels of PL classes. FFA accumulation during warm ischemia was about half that during cold ischemia. Conjugated diene concentration increased fivefold during warm ischemia but was unchanged during cold ischemia. Low PL levels and FFA accumulation along with production of conjugated dienes suggest that lipid oxidation is a major mechanism of PL degradation during warm, but not cold, ischemia of the liver.

Technical aspects of intestinal transplantation

Since the advent of the potent immunosuppressive agent FK 506, intestinal transplantation has become a feasible therapeutic option for patients with irreversible intestinal failure. In this chapter, we present our clinical experience with intestinal transplantation, focusing on the technical aspects of both the donor and recipient operations. The logistics of the operative procedure have been described previously.

Liver xenotransplantation

During the past 30 years orthotopic liver transplantation has become a highly successful form of surgical treatments. The significant advances achieved in this field have led to an increased demand for organs and created a wide gap between organ availability and organ supply. A wider availability of organs for transplantation would allow an expansions rather than a contraction of the indications for transplantation, and, at the same time a relaxation of the patient selection criteria. All these facts clearly justify the renewed interest observed in the last decade in xenotransplantation. The original concept of xenografting, meaning the transplantation of cells, tissues, or organs between different species, is so ancient that it is easily recognizable in Greek and Roman mythology. The centaur Chiron, the teacher of Esculapius, and the Chimera are legendary examples of discordant xenogeneic creatures. However, it is only during this century that scientists have been able to bring this idea into the clinical arena. The early efforts were prompted by the shortage of humans organs at a time when there were few alternatives for treating end-stage organ failure.

Intestinal transplantation in children under FK 506 immunosuppression

Intestinal transplantation, solitary (n = 3) or in combination with the liver (n = 7), was performed in 10 pediatric patients with intestinal failure. The liver was only replaced if there was liver failure and portal hypertension. Immunosuppression was based on FK 506. Two patients died, one of graft-versus-host disease and one of lymphoproliferative disease. One patient as still in the intensive care unit 1 month posttransplantation due to perioperative complications. The function of the intestinal grafts in the remaining patients is normal. All nutrition and medications including immunosuppression are being administered enterally. This series indicates that small bowel transplantation, alone or in combination with the liver, is feasible in pediatric patients.

Pediatric liver transplantation. History, recent innovations, and outlook for the future

Pediatric liver transplantation has advanced remarkably over the past three decades. One-year survival has progressively increased to nearly 90% in patients transplanted for most forms of liver disease. Parallel advances in organ procurement, operative technique, immunosuppression, and infection control are responsible for improved patient survival. Among the most important advances are use of the University of Wisconsin (UW) organ preservation solution, the employment of venovenous bypass and/or "piggyback" operative technique, the development of cyclosporine A (CyA) and FK506, and the emergence of acyclovir, ganciclovir, foscarnet, and alpha interferon to combat life-threatening viral infections. The current organ shortage is being addressed by "cutdown" liver transplantation, "split liver" transplantation, and living-related donations. The next decade is likely to see advances in multi-visceral transplantation, induction of chimerism by simultaneous bone marrow-solid organ transplantation, and performance of cross-species xenografting.

Pharmacokinetics of FK506 in liver transplant recipients after continuous intravenous infusion

The first-dose pharmacokinetics of FK506 was studied in nine orthotopic liver transplant patients receiving continuous intravenous infusion of 0.15 mg/kg/day. Multiple blood samples were obtained during the infusion and plasma FK506 concentrations were measured by enzyme-linked immunosorbent assay. The plasma clearance ranged from 0.47 to 5.8 L/minute, and the half-life ranged from 4.5 hours to 33.1 hours. These results indicate the pharmacokinetics of FK506 to be highly variable between patients. FK506 is extensively distributed outside the plasma compartment. FK506 is extensively metabolized in the body, with less than 1% of the administered dose being excreted in the urine as unchanged FK506. The large variability in FK506 kinetics during the immediate post-operative period is attributed to the variability in the functional status of the liver in the transplant patients. Because of the long half-life of FK506, it takes more than 45 hours to reach steady-state concentrations after continuous infusion. Based on the estimated kinetic parameters, it appears that a combination of a bolus or a rapid infusion of .02 mg/kg with a continuous infusion of 0.05 mg/kg/day will provide and maintain a concentration of more than 2 ng/mL from the beginning of the drug treatment.

[Intensive chemotherapy for alveolar soft part sarcoma with lung metastasis in a child]

Alveolar soft part sarcoma (ASPS) is one of the soft tissue sarcomas characterized by metastasis early in the course of the disease, regardless of slow tumor growth. The ultimate clinical outcome is, therefore, very poor. To date, the efficacy of combination chemotherapy for this tumor has not been confirmed. We present a case of ASPS in an 8-year-old boy with bilateral pulmonary metastasis who received systemic combination chemotherapy (CPM/IFO/ACD/ADR/CD DP/VP-16 as induction, and VCR/ACD as maintenance therapy) for eleven months. The result showed that despite the prevention of tumor progression, such intensive chemotherapy could not cure the disease. Besides refinement of chemotherapy regimens, immunotherapy might be considered for ASPS.

Cell migration and chimerism after whole-organ transplantation: the basis of graft acceptance

Improvements in the prevention or control of rejection of the kidney and liver have been largely interchangeable (1 , 2 ) and then applicable, with very little modification, to thoracic and other organs. However, the mechanism by which anti rejection treatment permits any of these grafts to be “accepted” has been an immunological enigma (3 , 4 ). We have proposed recently that the exchange of migratory leukocytes between the transplant and the recipient with consequent long-term cellular chimerism in both is the basis for acceptance of all whole-organ allografts and xenografts (5 ). Although such chimerism was demonstrated only a few months ago, the observations have increased our insight into transplantation immunology and have encouraged the development of alternative therapeutic strategies (6 ).

Cell migration and chimerism after whole-organ transplantation: the basis of graft acceptance

Improvements in the prevention or control of rejection of the kidney and liver have been largely interchangeable (1, 2) and then applicable, with very little modification, to thoracic and other organs. However, the mechanism by which anti rejection treatment permits any of these grafts to be “accepted” has been an immunological enigma (3, 4). We have proposed recently that the exchange of migratory leukocytes between the transplant and the recipient with consequent long-term cellular chimerism in both is the basis for acceptance of all whole-organ allografts and xenografts (5). Although such chimerism was demonstrated only a few months ago, the observations have increased our insight into transplantation immunology and have encouraged the development of alternative therapeutic strategies (6).

Liver allograft rejection in sensitized recipients. Observations in a clinically relevant small animal model

A sequential analysis of liver allograft rejection in sensitized rats using immunopathological and ultrastructural microscopy is described. Lewis rats were primed with four ACI skin grafts and challenged with an arterialized ACI orthotopic liver allograft 14 to 17 weeks later. The sensitization resulted in a mix of IgG and IgM lymphocytotoxic antibodies at a titer of 1:512 at the time of transplantation. Specificity analysis of pretransplant immune sera revealed a predominance of IgG anti-class I major histocompatibility complex (RT1) antibodies with a minor IgG fraction showing apparent endothelial cell specificity (non-RT1). This level of sensitization was associated with accelerated graft failure in 3 to 5 days from mixed humoral and cellular rejection. Sequential analysis of serial posttransplant graft biopsies revealed diffuse vascular IgG deposition and platelet thrombi in portal veins and periportal sinusoids within 3 minutes after reperfusion. This was followed by endothelial cell hypertrophy and vacuolization, periportal hepatocyte necrosis, arterial spasm, focal large bile duct necrosis, and hilar mast cell infiltration and degranulation. However, the liver allografts did not fail precipitously and hyperacute rejection was not seen. Kupffer cell phagocytosis of the sinusoidal platelets began as early as 30 minutes posttransplant and by 24 hours, the platelet thrombi had decreased. Cholangioles appeared focally at the edge of the limiting plates by 2 to 3 days, apparently in response to earlier periportal hepatocyte damage. A mononuclear portal and perivenular infiltrate became evident at 3 days, and graft failure was attributed to both antibody and cell-mediated rejection (Furuya et al: Preformed lymphocytotoxic antibodies: Hepatology 1992, 16: 1415-1422). The model described resembles observations in crossmatch positive human liver allograft recipients. The mechanisms of hepatic graft resistance to antibody mediated rejection and the possible long term consequences of early damage to the biliary tree are discussed.

The transplantation of gastrointestinal organs

Over a period of 33 years, it has become possible to successfully transplant individual intra-abdominal viscera or combinations of these organs. The consequences have been, first, new information about the metabolic interrelations that the visceral organs have in disease or health; second, the addition of several procedures to the treatment armamentarium of gastrointestinal diseases; and third, a more profound understanding of the means by which all whole organ grafts are accepted.