C-type natriuretic peptide plasma levels are reduced in obese adolescents

The high prevalence of obesity in children may increase the magnitude of lifetime risk of cardiovascular disease (CD). At present, explicit data for recommending biomarkers as routine pre-clinical markers of CD in children are lacking. C-type natriuretic peptide (CNP) is assuming increasing importance in CD; in adults with heart failure, its plasma levels are related to clinical and functional disease severity. We have previously reported five different reference intervals for blood CNP as a function of age in healthy children; however, data on plasma CNP levels in obese children are still lacking. Aim of this study was to assess CNP levels in obese adolescents and verify whether they differ from healthy subjects. Plasma CNP was measured in 29 obese adolescents (age: 11.8 ± 0.4 years; BMI: 29.8 ± 0.82) by radioimmunoassay and compared with the reference values of healthy subjects. BNP was also measured. Both plasma CNP and BNP levels were significantly lower in the obese adolescents compared to the appropriate reference values (CNP: 3.4 ± 0.2 vs 13.6 ± 2.3 pg/ml, p<0.0001; BNP: 18.8 ± 2.6 vs 36.9 ± 5.5 pg/ml, p=0.003). There was no significant difference between CNP values in males and females. As reported in adults, we observed lower plasma CNP and BNP levels in obese children, suggesting a defective natriuretic peptide system in these patients. An altered regulation of production, clearance and function of natriuretic peptides, already operating in obese adolescents, may possibly contribute to the future development of CD. Thus, the availability of drugs promoting the action of natriuretic peptides may represent an attractive therapeutic option to prevent CD.

Plasma C-type natriuretic peptide levels in healthy children

C-type natriuretic peptide (CNP) is assuming increasing importance in cardiovascular disease, and in adults its plasma levels are related to clinical and functional disease severity. Data are scarce regarding the reference values for CNP in infancy. Aim of this study was to assess the reference intervals for CNP in human healthy newborns and infants. Plasma CNP was measured in 121 healthy children divided into: 41 newborns (age 0-3 days), 24 newborns (4-30 days), 22 infants (1-12 months) and 32 children (1-12 years). A group of 32 healthy adult subjects (age 64 ± 1 years) was also studied. CNP was measured by a specific radioimmunoassay. Between- and within-assay variability resulted ≤ 30 and 20%, respectively and analytical sensitivity 0.77 ± 0.05 pg/tube. Plasma CNP resulted significantly higher in children than in adult subjects (13.6 ± 1.2 pg/ml vs. 7.4 ± 1.0 pg/ml, p=0.030). When the results were analyzed as a function of the age the reference intervals for plasma CNP resulted: 11.6 ± 2.1 pg/ml for newborns (0-3 days), 16.4 ± 3.7 pg/ml for newborns (4-30 days), 15.4 ± 2.7 pg/ml for infants (1-12 months), 13.6 ± 2.3 pg/ml for children (1-12 years) [p=0.01 newborns (4-30 days) vs. adults; p=0.03 infants (1-12 months) vs. adults]. CNP showed the highest concentrations after 12h of life with a peak between 4 and 5 days of life and with a progressive decline afterwards. According to these data at least five different reference intervals for CNP determinations should be used. These observations may be helpful for future clinical application of CNP in human children.

Marriage and parenthood among childhood cancer survivors: a report from the Italian AIEOP Off-Therapy Registry

BACKGROUND

The aim of this study was to describe the patterns of marriage and parenthood in a cohort of childhood cancer survivors included in the Off-Therapy Registry maintained by the Italian Association of Pediatric Hematology and Oncology.

DESIGN AND METHODS

We analyzed a cohort of 6,044 patients diagnosed with cancer between 1960 and 1998, while aged 0 to 14 years and who were 18 years old or older by December 2003. They were followed up through the regional vital statistics registers until death or the end of follow up (October 30, 2006), whichever occurred first, and their marital status and date of birth of their children were recorded. The cumulative probabilities of being married and having a first child were computed by gender and compared by tumor type within the cohort. Marriage and fertility rates (the latter defined as the number of live births per woman-year) were compared with those of the Italian population of the same age, gender, area of residence and calendar period by means of the observed to expected (O/E) ratios.

RESULTS

During the follow-up period, 4,633 (77%) subjects had not married. The marriage O/E ratios were 0.56 (95% CI: 0.51-0.61) and 0.70 (95% CI: 0.65-0.76) among men and women, respectively. Overall, 263 men had 367 liveborn children, and 473 women had 697 liveborn children. The female fertility O/E ratio was 0.57 (95% CI: 0.53-0.62) overall, and 1.08 (95% CI: 0.99-1.17) when analyses were restricted to married/cohabiting women

CONCLUSIONS

Childhood cancer survivors are less likely to marry and to have children than the general population, confirming the life-long impact of their previous disease on their social behavior and choices. The inclusion of counseling in the strategies of management and long-term surveillance of childhood cancer patients could be beneficial to survivors as they approach adulthood.

Foscarnet therapy for congenital cytomegalovirus liver fibrosis following prenatal ascites

We report on an infant with multi-system disease including liver fibrosis, right microphthalmia with cataract, interstitial pneumonitis, and hyperechoic lesions in the basal ganglia and in the periventricular and thalamic regions. Prenatal ascites with hepatomegaly concomitantly with detection of cytomegalovirus (CMV) DNA in the amniotic fluid, following recurrent maternal CMV infection, had been shown. Although CMV culture and DNA detection were negative in the urine, the infant was given foscarnet because CMV infection was demonstrated in the liver by DNA detection and immunohistochemical staining. Favorable clinical outcome and absence of CMV in the liver were subsequently shown. Our case suggests that congenital CMV disease following maternal recurrence may not be associated with disseminated infection but only with intracellular infection. The diagnosis should therefore be based on CMV detection in the involved organs. Moreover, this is the first report on the possible efficacy and safety of foscarnet for therapy of immunocompetent infants with congenital CMV disease.

Neuroblastoma in the newborn. A study of the Italian Neuroblastoma Registry

AIM

Presenting features, treatment and outcome of 134 newborns with neuroblastoma diagnosed over a 27-year period are described.

METHODS

Analyses were performed on the entire cohort and on patients distributed over three periods of diagnosis.

RESULTS

Twenty-seven tumours (20.1%) were detected prenatally. Localised disease prevailed (65.7%) with an increase of stage 1 patients over time from 18.8% to 46.5%. Disseminated disease accounted for 34.3% of tumours with only one stage 4 and 45 stage 4S. Five-year overall survival (OS) of the entire cohort was 88.3%. Five/88 patients with localised disease died, including three who died of complications (OS, 95.3%). The only stage 4 patient survived. Eleven/45 stage 4S patients died, including 7/18 symptomatic and 4/27 asymptomatic (OS, 74.1%).

CONCLUSION

The outcome of neuroblastoma in newborns is excellent. In localised tumours, surgery-related deaths outnumbered deaths due to disease. Symptomatic stage 4S patients were at greater risk of dying.

Effects on platelet function of combination etoposide and carboplatin chemotherapy in pediatric oncology patients

The effects of a therapeutic course of the combination of carboplatin and etoposide on platelet function have been evaluated in 10 pediatric patients with brain tumors. Platelet count, in vitro aggregation tests, P-selectin expression and agonist-induced ATP release were evaluated before, and 7 and 15 days after one cycle of chemotherapy. The analysis of the results demonstrated the presence of an in vitro platelet aggregation defect in response to collagen and arachidonic acid in all patients 7 days after therapy. A concomitant decrease of collagen- and arachidonic acid-induced ATP release was also observed. Both platelet aggregation and ATP release returned to baseline values 15 days after chemotherapy administration. Conversely, in vitro platelet aggregation and secretion induced by ADP and epinephrine were unaltered by carboplatin and etoposide administration. Furthermore, P-selectin expression was negative at baseline and did not change after chemotherapy. These results support the hypothesis that combination etoposide and carboplatin chemotherapy in pediatric patients is responsible for possible disturbances in biochemical pathways required for platelet secretion and aggregation.

[Transdermal fentanyl: a new tool for pain therapy in pediatric oncology]

OBJECTIVES

Transdermal fentanyl delivery system (TFDS) offers advantages if oral administration of opioids is difficult because of progressive disease or poor compliance, in cancer patients (pts). The current study was conducted to assess the efficacy and safety of TFDS in a pediatric cancer population.

PATIENTS AND METHODS

Twenty-one pts were enrolled between June 2004 and December 2005. TFDS was applied if pts had pain under non opioids treatment, according to our step-by-step "pain protocol". Starting dose of TFDS was decided considering the dose of the last non opioids drug used. All pts didn't receive other opioids therapy before TFDS. Degree of pain was assessed using visual and numeric scales.

RESULTS

Sixteen males and 5 females were studied, median age was 8 years (range 3-14 years). They were affected by moderate to severe pain, because of progressive and/or metastatic disease. Median starting dose was 50 microg/h (range 25-100 microg/h). Highest reached dose was 200 microg/h. In 75% of pts, starting dose was adequate. In other pts, optimal dosage was found within 36 hours. Thus, pain total control was obtained in 100% of pts, with a median delay, from starting TFDS, of 24 hours (range 12-48 hours). No toxicity was observed but a moderate lethargy, within the first 12 hours, in 30% of pts.

CONCLUSIONS

TFD was found to be an effective and safe system to treat pain in pediatric cancer pts. All pts and their families showed high compliance with TFDS. It could be also taken in account for outpatient therapy.

Phase II trial of temozolomide in children with recurrent high-grade glioma

PURPOSE

The objective of the study was to evaluate the efficacy and toxicity of Temozolomide (TMZ) administered for 5 consecutive days in three daily dosing in children with recurrent or refractory high-grade glioma.

PATIENTS AND METHODS

Twenty-four patients with a median age of 10.5 years were enrolled onto this open-label, multicenter, phase II study. The patients were previously treated with surgical resection (17 of 24), radiotherapy (19 of 24) and chemotherapy (18 of 24). Therapy was administered orally three times a day for 5 consecutive days at the dose of 200 mg/m(2)/dx5 for chemotherapy naive patients. In patients heavily pretreated with chemotherapy the starting dose was of 150 mg/m(2)/dx5.

RESULTS

A total of 95 cycles were administered. The median progression free-survival (PFS) was 3 months for the entire group while disease stabilization was obtained in 7 patients (29.1%), all with supratentorial tumors. No CR or PR was observed. TMZ treatment showed a limited toxicity. Thrombocytopenia was the most common hematological adverse effect. Our data suggest a marginal activity of TMZ in children with recurrent high-grade glioma.

[The cardiac natriuretic peptides]

Cardiac natriuretic peptides (including ANP, BNP, CNP and urodilatin) constitute a family of peptide hormones and neurotransmitters, sharing similar chemical structure (characterized by a cysteine bridge) and biological function. ANP and BNP are cardiac hormones because they are principally produced and secreted by cardiomyocytes. CNP is principally produced and secreted by endothelial cells, while urodilatin only by renal tubular cells. Natriuretic peptides share a direct diuretic, natriuretic and vasodilator effect and an inhibitory action on ventricular myocyte contraction as well as on remodeling, restenosis and other inflammatory processes of myocardium and smooth muscle cells. Cardiac natriuretic peptides share their biological action by means of specific receptors (NPR), which are present into the cell membranes of target tissues. Three different subtypes of NPRs have been so far identified in mammalian tissues. NPR-A and NPR-B are generally considered to mediate all known biological actions throughout the guanylate cyclase (GC) intracellular domain, while the third member of the natriuretic peptide receptor family, the NPR-C receptor, has not a GC domain. It is generally thought that the NPR-C is not linked to GC and so serves as a clearance receptor. Natriuretic peptides constitute a family sharing both endocrine. paracrine and autocrine actions and neurotransmitter and immuno-modulator functions. Therefore, it can be hypothesized that the cardiac natriuretic peptide system is closely related with other regulatory systems in a biological hierarchical networks.

Evaluation of carboplatin pharmacokinetics in pediatric oncology by means of inductively coupled plasma mass spectrometry

Carboplatin is widely used in pediatric oncology to treat different tumors. Aim of the present study was to assess the potential of sector field inductively coupled plasma mass spectrometry (SF-ICPMS) in evaluating the area under the plasma platinum concentration vs time curve in pediatric patients presenting solid tumors and treated with carboplatin 349-1000 mg m-2. Seventeen patients were enrolled and 23 courses of chemotherapy were evaluated. Plasma was ultrafiltered and free carboplatin was measured in ultrafiltrates as platinum by SF-ICP-MS. Comparison was made between different equations to obtain a target AUC. Limits of detection and of quantification, intra- and inter-day repeatability of the measurements, recovery of the 'free-carboplatin' confirmed SF-ICP-MS as a reliable technique in the quantification of serum platinum in anticancer carboplatin-based therapies.

Detection and clinical significance of disseminated tumour cells at diagnosis in bone marrow of children with localised rhabdomyosarcoma

Identification of patients with a poor prognosis for non-metastatic rhabdomyosarcoma (RMS) remains a clinical challenge. Prospective analysis for the presence of disseminated RMS cells in bone marrow at diagnosis, using immunocytochemistry, with MyoD1 and myogenin as markers, was carried out. Thirty-seven patients treated on RMS88 and RMS96 Italian protocols underwent staging investigations, and in addition marrow examination for occult tumour cells. All patients had negative marrow involvement using cytomorphology, but 10/37 were positive with immunostaining. With a median follow-up of 46 months (range, 12-115), 7 patients had died and 30 were disease-free. Overall survival probability was 92% in patients with no occult marrow infiltration, 47% with occult marrow infiltration (P=0.001); event-free survival probability was 89% in the former and 50% in the latter (P=0.01). Disseminated tumour cells are indicative of disease spread and are significantly linked to recurrence at distant sites and poorer outcome. Marrow examination at diagnosis using immunocytochemistry may be an additional tool to modulate treatment.

Tropisetron: optimal dosage for children in prevention of chemotherapy-induced vomiting

The antiemetic efficacy and tolerability of Tropisetron (Navoban, Novartis Pharma Switzerland AG, Bern), a selective 5-hydroxytriptamine receptor antagonist, has been assessed in the prevention of acute vomiting in children receiving chemotherapy for solid tumors. Tropisetron iv was given 30 min before administration of chemotherapy at a dose of 5 mg in children <20 kg body weight and at a dose of 10 mg in those >20 kg. A total of 50 children were studied in 189 courses of chemotherapy. Control of emesis was defined as total in absence of acute vomiting, as major if 1 or 2 events of acute vomiting occurred, and as not controlled if >2 events of acute vomiting occurred. Response was studied, taking into account Tropisetron dosage, degree of emetogenicity of the chemotherapeutic agents in pretreated and non-pretreated patients, and according to age groups. Tropisetron, administered in a single daily dose of 8-12 mg/m(2), was found to be very effective in completely controlling acute emesis in 92% of the courses of moderately and highly emetogenic chemotherapy administered to pediatric patients with solid tumors. Moreover, Tropisetron, at this dosage, did not lead to any adverse effects.

Clinical and molecular evidence for c-kit receptor as a therapeutic target in neuroblastic tumors

PURPOSE

Clinicobiological characteristics of neuroblastic tumor (NT) expressing c-kit tyrosine kinase receptor and/or its ligand, stem cell factor (SCF), are debated. This study aimed at investigating the clinicobiological features of primary NTs expressing c-kit and/or SCF in order to define the clinical relevance of selective therapeutic targeting.

EXPERIMENTAL DESIGN

c-Kit and SCF expression was studied in 168 NTs using immunohistochemistry and in 106 of 168 using Northern blot. Quantitative determination of c-kit expression in 54 additional NTs was also done using real-time reverse transcription-PCR. Correlations between c-kit and SCF expression and clinicobiological features were analyzed using chi2 test, univariate, and multivariate regression analyses.

RESULTS

c-Kit protein was detected in 21 of 168 NTs (13%) and its mRNA in 23 of 106 NTs (22%). SCF protein was shown in 30 of 106 NTs (28%) and its mRNA in 33 of 106 NTs (31%). No mutations in exon 11 of c-kit gene were identified. By univariate analysis, c-kit and SCF expression correlated with advanced stage, MYCN amplification, and 1p36 allelic loss. Cox simple regression analysis showed that overall survival probability was 17% in the c-kit-positive subset versus 68% in the negative (P < 0.001), 43% in the SCF-positive subset versus 78% in the negative (P < 0.001). When using real-time reverse transcription-PCR, significant levels of c-kit mRNA were found in 35 of 54 NTs (65%), but the correlations with clinicobiological features were no longer documented.

CONCLUSIONS

c-Kit expression can be detected in the majority of primary NTs. High levels of expression are preferentially found in tumors with unfavorable clinicobiological variables. c-Kit may represent a useful therapeutic target in a subset of otherwise untreatable NTs.

Conservative therapy in intraocular retinoblastoma: response/recurrence rate

PURPOSE

To evaluate the response/recurrence rate and the outcome in intraocular retinoblastoma treated with chemoreduction and focal therapy, the authors performed a retrospective review of their patients.

METHODS

The series included 46 newly diagnosed patients with unilateral or bilateral intraocular retinoblastoma (58 eyes) receiving carboplatin/etoposide chemotherapy associated with focal therapy (laser or cryotherapy). The mean follow-up was 53 months (range 11-125).

RESULTS

Fifty-one eyes (88%) presented with complete response after four to eight courses of chemotherapy combined with focal treatment. The response rate was 100% in group 1, 94% in group 2, 100% in group 3, 83% in group 4, and 70% in group 5 (5 vs. 1-4, P < 0.03; 5-4 vs. 1-3, P < 0.025). Twenty-nine eyes (57%) relapsed after a mean of 7 months (range 2-36). The relapse rate was 30% in group 1, 27.% in group 2, 67% in group 3, 80% in group 4, and 100% in group 5 (5 vs. 1-4, P < 0.001; 4-5 vs. 1-3, P < 0.001). Seven of 18 cases achieved a second complete response with further conservative treatment (total courses 8-14). Twenty-nine eyes (50%) were treated without external-beam radiotherapy or enucleation: 90% in group 1, 69% in group 2, 67% in group 3, 33% in group 4, and 6% in group 5 (5 vs. 1-4, P < 0.01; 5-4 vs. 1-3, P < 0.001). Ten eyes (17%) required external-beam radiotherapy and 21 eyes (36%) enucleation. The ocular salvage rate was 67%.

CONCLUSIONS

Although all groups of patients with intraocular retinoblastoma responded to carboplatin/etoposide chemotherapy associated with focal therapy, all the cases in group 5 relapsed. This approach is questionable in group 5, in which could be justified to delay aggressive treatment in a very young child.

Nutritional status in childhood malignancies

In children affected by tumor, nutritional status is important to sustain aggressive chemotherapy and to support normal growth during and after therapy. The aim of this study was to investigate the prevalence of nutritional status disorders in a sample of pediatric oncology day-hospital patients. We measured weight and height in patients affected by solid tumors on or off therapy at short-term follow-up (1-24 mo). The study was performed at a pediatric oncology day-hospital over a period of 20 consecutive days. A suitable computer package was used to estimate relative body weight (%RBW) and body mass index (BMI) for each patient. Thereafter, the same sample was divided into four weight classes (underweight, normal weight, overweight, and obese) according to %RBW and BMI. Moreover, patients were divided into two groups: on and off therapy. In the off-therapy group, no patient was underweight; in the on-therapy group, 26.3% and 15.8% of patients were underweight (not significant) according to %RBW and BMI, respectively. The prevalence of overweight (overweight ++obese) according to %RBW was 36.9% in the on-therapy group and 52.9% in the off-therapy group (P < 0.05); whereas the prevalence of overweight according to BMI was 21% in the on-therapy group and 35.3% in the off-therapy group (P = 0.05). These preliminary data suggest that, in pediatric oncology, nutritional assessment is required to provide nutritional strategies in on-therapy patients whose underweight status prevalence is impressive or in off-therapy children in whom the causes of overweight should be explored.

Medulloblastoma as a secondary malignancy after radiotherapy-free treatment for acute lymphoblastic leukemia

Malignant brain tumors have been reported to occur in survivors of childhood acute lymphoblastic leukemia (ALL) more frequently than in the noncancer control population. The strongest risk factor seems to be cranial radiotherapy, used as central nervous system (CNS) prophylaxis. We report the case of a 9-year-old girl affected with metastatic medulloblastoma that developed 6 years after a diagnosis of acute lymphoblastic leukemia. CNS prophylaxis for ALL consisted of intrathecal methotrexate plus cytarabine (20 administrations) and 4 courses of high-dose methotrexate (5g/m2). No prophylactic cranial radiotherapy was administered. The child, in first complete remission, was well until the occurrence of a second tumor. She was treated for medulloblastoma with craniospinal radiotherapy and chemotherapy. At present, she is alive but with disease. As the unusual association of these 2 malignancies in this patient, the p53 status was investigated using FISH analysis by specific DNA probe; no p53 mutation was detected.

Recombinant interferon alfa 2a in hepatic hemangiomatosis with congestive heart failure: a case report

A 45-day-old patient was admitted with dyspnea, hepatomegaly, tachycardia, holosystolic murmur in the precordial region, and continuous murmur at the right hypochondrium. Four cutaneous angiomas were noted. Instrumental examinations revealed congestive heart failure and multiple focal lesions in the liver with typical features of hemangiomas. The therapy with subcutaneous interferon-alfa-2a (IFN-alpha) was administered for 12 months with progressive regression of cutaneous hemangiomas, liver lesions, and cardiological alterations. IFN-alpha therapy was effective without any significant adverse effects.