Bilateral anorchia in infancy: occurence of micropenis and the effect of testosterone treatment

OBJECTIVE

To analyze the clinical and histological findings in boys with bilateral anorchia and the response to testosterone treatment on penis length.

STUDY DESIGN

Patients were divided into two groups according to the absence (group A, n = 29) or the presence (group B, n = 26) of palpable intrascrotal or inguinal mass at first clinical examination.

RESULTS

A micropenis was found in 46% of patients (n = 24) with a similar proportion in both groups. Testosterone treatment induced a mean penis length gain of 1.9 +/- 1.3 SDS (standard deviation score). However, micropenis persisted in six patients. Histological examination (n = 18) confirmed the absence of any testicular structure with deferent ducts being present unilaterally or bilaterally in all but three patients. In these three patients, a hemorrhagic testis, probably as a result of a mechanical torsion, was found.

CONCLUSIONS

The presence of isolated micropenis in almost half of patients with bilateral anorchia strongly suggests that the testicular damage frequently occurs during the second half of gestation after male sexual differentiation. In most cases, testosterone treatment stimulates the penile growth. Although the pathogenesis of bilateral anorchia may be heterogeneous, our study suggests that gonads may have been functionally abnormal before they disappeared, and suggests that some patients have an intrinsic endocrine disorder.

Recommandations pour la pratique clinique : Standards, Options et Recommandations pour la prise en charge par radiothérapie des patients atteints d'ostéosarcome

CONTEXT

The "Standards, Options and Recommendations" (SOR) project, started in 1993, is a collaboration between the Federation of French Cancer Centres (FNCLCC), the 20 French regional cancer centres, and specialists from French public universities, general hospitals and private clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and the outcome of cancer patients. The methodology is based on a literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery.

OBJECTIVE

To update the SOR recommendations for the use of radiation therapy in the management of patients with osteosarcoma. This work was performed in collaboration with the French society against cancers in children and adolescent (SFCE).

METHODS

Data have been identified by literature search using Medline (from January 1992 to October 2003). In addition several Internet sites were searched in October 2003.

RESULTS

The 3 mains standards are: 1) local and exclusive curative irradiation is not indicated as primary treatment for osteosarcoma or for local and operable recurrence, except for lesion in inaccessible sites or if the patient refuses surgery; 2) local and prophylactic adjuvant irradiation is not indicated for the treatment of osteosarcoma after chemotherapy (neoadjuvant and/or adjuvant) and complete macro or microscopic surgery, except for non-operable R1 or R2 surgical resection; 3) whole-lung prophylactic irradiation is not indicated in non-metastatic osteosarcoma. Systemic metabolic radiotherapy for pain treatment, using samarium-153 ethylenediaminetetramethylene phosphonic acid (Sm-153-EDTMP) can be offered to patients with painful metastatic osteosarcoma or in case of recurrent bone sites inaccessible to local therapies (surgery, external irradiation).

[Rectal localization of Burkitt's lymphoma]

BACKGROUND

Rectal tumors are rare in childhood and among them malignant tumors are even less common. Only eight cases of primary rectal lymphomas were reported in children, with various presenting signs and histology. Burkitt's lymphomas are among these cases.

CASE REPORT

A five-year-old child presented with hematochezia and unusual constipation. The rectal examination showed a voluminous intra rectal mass. Radiographic and pathologic examinations led to the diagnostic of Burkitt's lymphoma with medullary involvement. Complete remission was obtained after initial chemotherapy but a local relapse occurred and the child died eight months later.

CONCLUSION

Hematochezia associated with unusual constipation impose a rectal examination. Early diagnosis of a rectal tumor may allow patients survival.

Does nephroblastomatosis influence the natural history and relapse rate in Wilms' tumour? A single centre experience over 11 years

The presence of multifocal or diffuse nephrogenic rests (NRs) in one or both kidneys is termed nephroblastomatosis (Nbm). Nbm may be a predisposing factor for Wilms' tumour (WT). The aim of this retrospective study was to evaluate the impact of Nbm on the outcome of WT in children. We assessed the outcome of 81 children with Wilms tumours and practical implications of Nbm in the treatment and follow-up. All the pathology slides have been reviewed in 1997. 63 had WT without Nbm (group A) and 18 had WT associated with Nbm (group B). There was no statistical difference between the two groups according to the age at diagnosis and histology. Clinical abnormalities were more frequent in group B (33 versus 8%). There was no statistical difference between the percentage of stage IV in both groups, but bilaterality (stage V) was present only in the group B. Relapse was observed in 20/81 patients (25%): 11 (17%) in group A and 9 (50%) in group B. Mean delay of relapse was longer (25 months) in group B than in group A (10 months). For the whole population, with a median follow-up of 9 years, the event-free survival (EFS) and the overall survival (OS) probabilities were respectively 74%+/-10 and 83%+/-9 at 120 months. The difference in EFS between groups A (82+/-9%) and B (38%+/-29) was significant (P=0.004). The discovery of Nbm in the non-tumoral part of the kidney with WT can be an adverse factor and in particular favours the subsequent development of a new Wilms tumour. It justifies separate follow-up guidelines.

Epstein-Barr virus-related lymphoproliferative disease complicating childhood acute lymphoblastic leukemia: no recurrence after unrelated donor bone marrow transplantation

A 16-year-old boy in complete remission of ALL, undergoing oral maintenance therapy, developed intestinal perforation related to EBV-associated lymphoproliferative disease (LPD). He was successfully managed with surgical resection, acyclovir, immunoglobulins and discontinuation of maintenance therapy. Leukemic marrow relapse occurred 3 months later, treated by polychemotherapy followed by unmanipulated BMT from a matched unrelated EBV seropositive donor. Donor lymphocytes were infused twice after transplant because of delayed immunologic recovery and severe CMV colitis. This was followed by acute GVHD requiring prolonged immunosuppressive treatment. Despite intensive and prolonged immunosuppression, recurrence of LPD was not observed. Following EBV-related LPD, allogeneic BMT can be performed if indicated. Selection of an EBV seropositive donor is of major importance for the prevention of LPD recurrence as the recipient may be protected by passive transfer of EBV-specific cytotoxic T cells.

Leukaemic presentation of small cell variant anaplastic large cell lymphoma: report of four cases

We report four cases of a rare subtype of CD30-positive anaplastic large cell lymphoma (ALCL) with a predominant small cell component (small cell variant of ALCL) presenting with a leukaemic feature. Lymph node biopsy showed malignant cells of varying size with a predominant population of small to medium-sized malignant cells associated with large anaplastic cells strongly positive for CD30 and epithelial membrane antigen (EMA). Both large and small cells were reactive with antibody ALK1, which recognizes the chimaeric NPM-ALK protein associated with the t(2;5)(p23;q35). All patients presented with hyperleucocytosis with atypical small lymphocytes. Bone marrow involvement was detected on both aspirate and bone marrow trephine where scattered malignant cells were only demonstrated by immunostaining for CD30 and ALK protein. Atypical cells in peripheral blood, lymph node and skin biopsies showed a T or null cell phenotype. Cytogenetic analysis of blood, bone marrow and/or lymph node revealed the t(2:5)(p23;q35) characteristic of ALCL. The patients responded to chemotherapy but showed early relapse without abnormal cells in peripheral blood. This report shows that the small cell variant of ALCL may have a leukaemic presentation with peripheral blood involvement by atypical lymphocytes and provides evidence that, in the small cell variant of ALCL, the small cell component is a part of the malignant clone.

Autoradiographic distribution of brainstem substance P binding sites in humans: ontogenic study and relation to sudden infant death syndrome (SIDS)

The precise distribution of substance P (SP) binding sites in the human brainstem was investigated in normal cases (3 fetuses and 24 new-borns) and in 9 cases of Sudden Infant Death Syndrome (SIDS) by in vitro quantitative autoradiography. We discussed the widely but uneven distribution of SP binding sites as regards to the role of SP in brainstem cardio-respiratory ontogenic control and its possible involvement in SIDS.

Juvenile granulosa cell tumor of the ovary in infants: a clinicopathologic study of three cases and review of the literature

The clinical and pathological features of three cases of juvenile granulosa cell tumors occurring in infants were studied. Precocious pseudopuberty developed in two patients and acute abdominal symptoms related to the rupture of the tumor developed in one. Surgery was the only treatment in each case and no adjuvant therapy was delivered. No patient experienced relapse. Histological examination showed a predominantly diffuse pattern with prominent luteinization. Call-Exner bodies were absent. Two tumors had multilocular thin walled cysts containing large amounts of estradiol, the third one contained rudimentary microfollicles. The prognosis of juvenile granulosa cell tumors in infancy appears more favorable than those occurring in older patients. No case of tumor recurrence has been reported in infancy so far. Surgery appears to be the state-of-the-art treatment of these tumors and additional therapy (chemotherapy or radiotherapy) must be discussed with caution, even in advanced stages.

Correlation of granuloma structure with clinical outcome defines two types of idiopathic disseminated BCG infection

Bacillus Calmette Guérin (BCG) is an attenuated strain of Mycobacterium bovis that is currently used as a live vaccine for human tuberculosis. Disseminated BCG infection may rarely occur following vaccination of children. In half of the cases, regarded as idiopathic, no well-defined immunodeficiency condition can account for the infection. However, the high rates of parental consanguinity and familial forms and the associated opportunistic infections with Salmonella suggest that these idiopathic BCG infections result from one or several new type(s) of inherited immune disorder(s). As an approach to the description and understanding of this newly described condition, the associated lesions were examined. Samples from 14 patients collected from a French national retrospective study were analysed. Pathological data from 22 cases reported in the world literature were also reviewed. Two types of granuloma were found. The first type (type I, tuberculoid) consisted of well-circumscribed and well-differentiated granulomas, with epithelioid and multinucleated giant cells containing very few acid-fast rods, surrounded by lymphocytes and fibrosis and occasionally with central caseous necrosis. The second type (type II, lepromatous-like) consisted of ill-defined and poorly differentiated granulomas, with few if any giant cells and lymphocytes but widespread macrophages loaded with acid-fast bacilli. Most children displayed a single type of granuloma. One half displayed type 1 lesions and the other half displayed type II lesions. There was a strong correlation between the type of granuloma and the clinical outcome. Tuberculoid lesions were associated with survival, whilst lepromatous-like lesions correlated with death. Correlation of granuloma structure with clinical outcome defines two types of idiopathic disseminated BCG infection. The phenotypic heterogeneity of the course of BCG infection reflects distinct pathogenic mechanisms and probably results from a genotypic heterogeneity of the underlying inherited immune disorder.

[Renal biopsy in the elderly]

Fifty years after the first percutaneous needle biopsies of the kidney, enough results have been obtained to evaluate indications in elderly patients, a population group we define as over 75 years of age. In approximately 50% of the patients in this group, the indication for renal biposy is a nephrotic syndrome. The lesions usually observed involve extramembranous glomerulonephritis or minimal change glomerulopathy. The biopsy may also reveal amylosis. Chronic renal failure is the predominant reason for nephrology consultation in the elderly. Although all of these patients do not undergo biopsy, in our experience, results show chronic glomerulopathies, mainly IgA, in about half of the case as well as chronic interstitial nephritis and nephroangiosclerosis. The aging process also leads to acute renal failure in many patients. Biopsy would not be indicated in case of shock, drug toxicity or obstruction but in approximately 10% of the cases histology can reveal a specific parenchymal lesion. The technique for renal biopsy is the same in elderly patients as in younger adults. Renal biopsy can be considered as a safe diagnostic tool of considerable importance when ordered by a nephrologist, performed by an experienced operator and read by a well-trained pathologist. In many cases it is essential to in order to provide patients over 75 with the same quality care as younger adults.

Sclerosing hemangioma of the lung: radiological findings and pathological diagnosis

We present a case of sclerosing hemangioma of the lung, revealed as a solitary round mass on routine chest radiography in a 14-year-old patient. CT and MRI findings were consistent with a solid neoplasm but no specific characteristics were identified. Analysis of the surgical biopsy material led to a cytological diagnosis of adenocarcinoma. Definitive diagnosis of sclerosing hemangioma of the lung was established on pathological examination of the whole surgical specimen.

Nephrogenic rest associated with a mesoblastic nephroma--what does it tell us?

A 3-year-old girl presented with a tumor in the right kidney that was found to be a mesoblastic nephroma on histological examination. In addition, between the tumor and renal parenchyma there was a large perilobar sclerosing nephrogenic rest--a finding that has rarely been reported previously in non-Wilms renal tumors of childhood. We believe this supports the theory that both mesoblastic nephroma and Wilms tumor arise from the developing kidney but the key difference is the time point at which induction of neoplasm occurs.

Crescentic glomerulonephritis and crystals within glomerular capillaries in an AIDS patient treated with foscarnet

We report on a 28-year-old AIDS patient who developed a rapidly progressive glomerulonephritis while being treated with foscarnet for cytomegalovirus retinitis. Renal biopsy showed crescentic proliferation related to crystals within the glomerular capillaries. The role of foscarnet in this unusual renal syndrome is discussed.

[Detection of human papillomavirus DNA by in situ hybridization and gene amplification]

In situ hybridization with non radioactive probes is attractive for human papillomaviruses (HPV) detection. Its sensitivity has been greatly improved by using different hybridization conditions, techniques for revealing the DNA-DNA hybrids and method of observation and various cell lines derived from human uterine carcinomas (CaSki, SiHa and HeLa cells) which contain 500-600 copies of HPV DNA, 1-2 copies of HPV 16 and 20-50 copies of HPV DNA 18, respectively. In situ gene amplification increased the detection of HPV DNA since hybridization spots were visible in SiHa cells on slides; a specific signal was observed in HeLa cells in suspensions examined by flow cytometry. Confocal microscopy is an alternative method to in situ gene amplification since viral DNA is detectable in SiHa cells with or without gene amplification. Thus, the techniques used in this study are potentially useful for research of single cellular genes.

Fetal Niemann-Pick disease type C: ultrastructural and lipid findings in liver and spleen

We present the first ultrastructural study of liver and spleen from a 20-week fetus with Niemann-Pick disease type C in correlation with lipid studies of these tissues. The lipid storage pattern was characteristic of the disease and although the distribution of the lipid storage was similar to that of affected children, ultrastructural studies emphasized that many inclusions were qualitatively different. These are discussed. Concomitant with this complex lipid storage, ultrastructural evidence of cholestasis was observed and the early hyperplasia of pericanalicular microfilaments leads us to question the presence of a toxic metabolite which might induce cholestasis by acting upon microfilaments.