Ethical and medicolegal issues in pediatric oncology

All the concerns of medical ethics in the care of cancer in adults pertain to the management of cancer in children. The differences in the ethical dilemmas stem from the status of the child in society, and the consequent view we have on the degree of meaningful participation that can be given children in their care. Much of that view of the rights of the child has little to do with the fact that the child has cancer. However, the presence of a life-threatening illness makes us more extreme in our ideas and less willing to compromise our view of what is proper for a child. The very elaborate, self-sustaining structure within which children with cancer are treated makes it very difficult to examine the questions as individuals. Nevertheless, we must do so continually to remain ethically sound and morally justified.

Phase I trial of procarbazine as a 5-day continuous infusion in children with central nervous system tumors

Seven children with previously treated brain tumors were enrolled in a phase I trial of 5-day continuous-infusion procarbazine at 360, 480, and 638 mg/m2/day. Vitamin B6 levels were monitored. Myelosuppression was moderate though occasionally delayed, and nausea and vomiting were mild. At the highest dose level, a patient experienced severe psychosis that persisted for several weeks. From that dose-limiting toxicity and the degree of myelosuppression, the recommended dose for phase II trials in children is the same as for adults, 450 mg/m2/day.

Survival and neurologic outcome of infants with medulloblastoma treated with surgery and MOPP chemotherapy. A preliminary report

The results of treatment of infants with medulloblastoma using surgery and chemotherapy, without the use of radiation therapy, are reported. Both survival and outcome, in terms of growth, neurologic deficit, and intelligence are compared with the same parameters in children treated conventionally. Although preliminary, our results suggest that chemotherapy combined with surgery is a valid option for the treatment of infants with this type of neoplasm.

Effect of trimethoprim/sulfamethoxazole prophylaxis on outcome of childhood lymphocytic leukemia. A Pediatric Oncology Group Study

The Pediatric Oncology Group (POG) undertook a prospective randomized trial using a single chemotherapy regimen with or without trimethoprim/sulfamethoxazole (TS). In a previous acute lymphocytic leukemia (ALL) study of initial therapy, investigators were free to use TS prophylaxis or not. Analysis of those data seemed to favor TS for duration of continuous complete remission. In the study reported here, of 126 randomized patients with ALL, 63 received TS. There was no effect of TS on disease-free survival after 3 years follow-up. Overall severe toxicity did not differ. However, granulocytopenia was somewhat more severe in the TS group. Hepatic toxicity, measured by enzyme elevation approached significance in the TS group versus controls. Some institutions declined randomization and treated with or without TS as a routine. Outcome and toxicities did not differ from randomized patients. There was no statistically significant effect on severe, life-threatening or fatal infection between the randomized TS versus control groups. Children not receiving TS developed varicella more often, a disease for which one would not expect TS to show a preventative effect. Pneumocystis pneumonias were not reported. The authors conclude that TS prophylaxis did not increase the continuous complete remission rate in children with ALL or decrease the incidence of infection. Toxicity is somewhat higher on TS.

Living beyond cure. Transcending survival

The care and cure of cancer in children is decades ahead of the care and cure of cancer in adults. Cure is the norm. However, the cure of a disease and the consequence of that disease are complex concepts. Cure has at least three components: a biological cure, a psychological cure, and a social cure. Pediatric oncology has begun to address all three forms of cure, and both the biological and psychosocial cures are realistic goals. The challenge still before us is the acceptance of cancer as another normal childhood illness. Cancer patients need to transcend survival. Cancer must become just another event among other common events in a person's life. The future will come because we think it is already here and act accordingly, rather than because it is a concretely definable reality.

Evaluation of polyamine levels in cerebrospinal fluid of children with brain tumors

Cerebrospinal fluid (CSF) polyamine levels were analyzed retrospectively in 21 pediatric patients with different types of intracranial malignant tumors to determine the benefit of following these markers during the clinical management of brain tumors. The tumors included 16 medulloblastomas and 1 each of germinoma, ependymoma, primitive neuroectodermal tumor, astrocytoma, and malignant teratoma. The clinical course of each patient was followed by neurologic examination, cranial computed tomography, CSF cell count, and cytology after cytocentrifugation. The correlation of CSF putrescine and spermidine levels with the clinical course of the brain tumors was analyzed. The following results were obtained: (1) A significant increase in CSF putrescine levels was observed in children with medulloblastoma when there was recurrent or metastatic disease in the sites close to the CSF pathway compared with the children whose disease status was stable after successful treatment (P less than 0.005). (2) The increase of CSF putrescine levels was the earliest predictor of recurrence or metastasis near the CSF pathway. (3) In tumors other than medulloblastoma, the levels of polyamines were not predictive of disease activity with the possible exception of germinoma. (4) Spermidine levels in the CSF were of limited clinical importance for patients with brain tumors. CSF putrescine levels may be the earliest and most sensitive quantitative marker of the progression of medulloblastoma, and their evaluation should be included in the diagnostic work-up and follow-up examination of children with medulloblastoma.

The pathophysiology of undernutrition in the child with cancer

The physiologic consequences of malnutrition in children with cancer are reviewed. It is stressed that the child with cancer has a nutritional state that is no different from the average population from which the child comes. What little malnutrition is seen is calorie malnutrition. The physiologic consequences are those seen in any malnourished patient. Once the patient is being treated for cancer and the cancer course has progressed, the complications of chemotherapy and radiotherapy add to the difficulty in interpretation. However, the problem of decreased resistance to infection is one of the major problems that result from this malnutrition. The one nutrient found deficient in children with cancer is iron. Because transferrin is sensitive to prolonged protein malnutrition and because of the high level of ferritin in children with certain cancers, interpretation of laboratory values defining iron deficiency is difficult and iron homeostasis may well be very deranged.

Spontaneous cure of end-stage acute nonlymphocytic leukemia complicated with chloroma (granulocytic sarcoma)

Spontaneous regression of end-stage acute nonlymphocytic leukemia (ANLL) complicated with chloroma (granulocytic sarcoma) was observed in a child after the patient had been sent home for terminal care. The patient was initially found to have the 8;21 translocation and has survived without any evidence of disease 101 months after the initial diagnosis and 80 months after the discontinuation of all therapy. Spontaneous regression of a wide variety of tumors has been reported, but this observed case has no features in common with those cases. Special implications of this case are discussed.

Medical decisions in the selection of therapy for the child with cancer

This paper discusses the treatment development that has taken place for children with cancer. It is argued that the physician is a coequal partner with other members of the total care team of the child. The factors that demand individualization of therapy will be discussed, and the stages in medical decision making will be reviewed. The physician is not a member of the team as a researcher, but as a medical care giver. The physician also has special knowledge. The expertise that is brought to the team by a physician must ultimately be an understanding of the pathophysiology of the disease. Once therapy is designed on pathophysiological understanding, cancer can become just another disease among the possible diseases of childhood, and medical decision making can be done rationally and eventually, to a large degree, in the hometown community.

The French-American-British (FAB) classification of leukemia. The Pediatric Oncology Group experience with lymphocytic leukemia

The Pediatric Oncology Group institutions initiated extensive subclassification of cases of acute lymphocytic leukemia (ALL) at diagnosis into laboratory-designated categories. Included was a French-American-British (FAB) classification of all new patients, which was reviewed by a central six-member committee. In addition, on the basis of immunologic criteria, patients were defined as having T-, B-, pre-B-, or "null" cell leukemia. Slides from 617 patients were reviewed. Five hundred forty-six (88.5%) were classified as L1, 51 (8.3%) were classified as L2, 9 (1.5%) were classified as L3, and the remainder could not be assigned. Concordance within the committee was good: in 71% of the cases the committee was unanimous, and in an additional 17% only one member disagreed. In only 11 cases (1.8%) was diagreement such that a majority classification could not be assigned. Institutions assigned L2 more frequently. There was a strong correlation with L3 for B-cell disease only. However, four patients had unequivocal B-cell disease and unmistakable L1 morphologic type, whereas one and had L3 morphologic features and had non-B-cell disease. There was no correlation between the other immunologic markers or periodic acid-Schiff stain and FAB classification, nor between L1 or L2 and risk factors. However, for the 248 null cell and pre-B-cell patients, L2 was more frequent among patients in the poor-risk group (P = 0.008). The time to first failure was significantly shorter for patients with L3 morphologic type. The induction failure rate of L2 patients was significantly greater than that of L1 patients (P = 0.016). With analysis of the duration of remission and adjustment for risk factors, the impact of L2 morphologic characteristics on outcome was not significant (P = 0.18) in null cell patients. Even unadjusted for risk factors, there was no impact of L2 morphologic type on outcome in the pre-B-cell phenotype. It can be concluded that other risk factors overshadow the impact of L1 and L2 morphologic features in predicting duration of remission.

Caring toward cure

Care determines cure and, therefore, the mode of care dictates the outcome. The medical needs do not determine care, but rather define the reality within which the child has to live. Where that care is given to the child should be a haven, just as home ought to be a secure place to be oneself. The child participates in the therapeutic community as much as the child participates in the family. Therefore, the treatment environment of the child should be designed to foster caring toward cure. The care that is given will determine the truly cured child. The children must be allowed to be themselves so that they can be cared for and thereby their cure assured. To accomplish that, medical care must be incorporated into a normalizing, structured, therapeutic community wherein the child can exercise autonomy and the care givers, compassion.

Second malignant neoplasm in treated Hodgkin's disease. Report of a patient and scope of the problem

The condition of a 6-year-old boy was diagnosed as mixed-cellularity Hodgkin's disease that involved the right side of the neck. Five years after the completion of radiation therapy for the involved area, followed by six courses of chemotherapy with mechlorethamine hydrochloride (nitrogen mustard), vincristine sulfate, procarbazine hydrochloride, and prednisone, he developed cerebral gliosarcoma. Numerous second malignant neoplasms have been reported in adults following treatment for Hodgkin's disease; however, the sequence of events in our patient is a new finding that has not, to our knowledge, been reported previously. While the second malignant tumor may have been induced by prior treatment, direct evidence is lacking.

Clinical and biologic features predict a poor prognosis in acute lymphoid leukemias in infants: a Pediatric Oncology Group Study

Analysis of remission induction rates for 1,117 children 18 months to 10 years of age (group 1) and 90 infants less than 18 months of age (group 2) with acute lymphoid leukemia (ALL) and of duration of continuous complete remission (CCR) for 454 in group 1 and 33 in group 2 revealed that infants fared significantly worse in both measures of outcome (P = .03 and P less than .0001). To examine potential reasons for the poor prognosis of affected infants, clinical and biologic features of their ALL were compared. Infants had higher WBC counts (P less than .001), a higher incidence of massive splenomegaly (P less than .001), massive hepatomegaly (P less than .001), more central nervous system (CNS) disease at diagnosis (P less than .01), and lower platelet counts (P less than .001). Also, their blasts were less often PAS+ (P = .02). The incidence of non(T, B, pre-B), T and pre-B immunophenotypes of ALL did not differ significantly between the two groups. However, in patients with non(T, B, pre-B) ALL, the majority (51%) of infants had common ALL antigen (CALLA)-negative blasts, as compared with only 7% in group 1 (P less than .001). Furthermore, infants with non(T, B, pre-B) cell ALL who were less than 12 months of age were almost always CALLA- (18 of 21). The blasts of children from both groups usually expressed Ia-like antigens. These data illustrate that infants with ALL have extensive and bulky disease more often than do older children and are more often affected with a prognostically unfavorable phenotype of acute leukemia (AL) which expresses Ia-like antigens but is more often PAS- and CALLA-. We believe that these clinical and biological differences predict and explain in part the observed poor response to treatment of infants with ALL.

Cisplatin in recurrent pediatric brain tumors. A POG Phase II study. A Pediatric Oncology Group Study

Forty-six evaluable pediatric patients with primary recurrent brain tumors resistant to standard therapy were treated with cisplatin, 60 mg/m2/day, X2 days every 3 to 4 weeks, to study the efficacy and toxicity of this drug. Complete and partial responses, documented by computed tomography (CT) scan, were demonstrated in 4 of 10 patients with medulloblastoma and 3 of 15 patients with ependymoma. No activity was documented in astrocytic tumors. Dose limiting major toxicities were renal and auditory. It is recommended that the new analogues of cisplatin with less toxicity be studied in these tumors.

MOPP regimen as primary chemotherapy for brain tumors in infants

Seventeen infants with central nervous system malignancies, all with tissue diagnosis, were treated with the combination chemotherapy nitrogen mustard, vincristine, procarbazine and a steroid (MOPP) as primary therapy following surgery. Diagnoses include: 7 astrocytomas (grade: 3-I, 3-II, 1-III), 6 medulloblastomas, 2 ependymoma/astrocytoma mixed, 1 ependymoma and 1 primitive neuroectodermal tumor. Fourteen were under 2 years of age, 2 between 2 and 3 years of age, and 1 between 3 and 4 years of age. Fifteen responded and 2 failed. Of the responders, 6 are in continuous complete remission (median duration 28.9+ months) and 9 are in relapse (median duration of remission 10.3 months). Of the 2 patients who failed and 9 who relapsed, 4 expired and 6 are living in partial or complete remission. We conclude that MOPP therapy is well tolerated, has effectiveness, and allows postponement of potentially debilitating radiotherapy in infants with brain tumors.

Nutrition and cancer: physiological interrelationships

There are many tumors that have paraneoplastic syndromes. Furthermore, location of certain tumors can result in very specific effects on the host, especially tumors in the hypothalamus, the intestinal tract, or the liver. Finally, tumors of the immune system can have significant distant consequences. However, from direct experimental evidence, from model systems, and from the utilization of nutritional manipulation in the treatment of cancer, the data suggest very strongly that there is no unique cancer malnutrition. Early diagnosed cancer does not show malnutrition as a presenting symptom. Furthermore, all metabolic disturbances can be explained on the basis of the metabolic differences of tumor cells and normal cells and are very frequently proportional to the bulk of the tumor. The cachexia that is associated with malignancies is more likely cachexia in cancer patients than it is a specific cancer cachexia, unless the tumor burden is very large. This point was clearly made in a short review of the causes of cachexia in nearly 1500 cancer patients in Russia (145). Brennan also feels that most cases of malnutrition are uncomplicated starvation, and cancer cachexia has many features seen in major injury or sepsis (16). This distinction has great implications in the management of cancer patients.

Immunologic evaluation in the nutritional assessment of children with cancer

Eighty-one newly diagnosed untreated pediatric cancer patients (48 hematopoeitic malignancies, 17 solid tumors, 16 benign diseases) were evaluated with immunologic and nutritional parameters. The mean absolute lymphocyte count was adequate in the three groups. Reduced T-lymphocytes were seen in the solid tumors. Mitogenic response of hematopoietic and solid tumor patients' lymphocytes was low. Correlation of immunologic, dietary, and nutritional factors showed that for patients with solid tumors there was a positive significant correlation between weight/height percent and lymphocyte reactivity to phytohemagglutinin, concanavalin A, and pokeweed mitogen (p less than .05). Iron intake showed a significant positive correlation with in vitro mitogen reactivity for the solid tumor group (p less than .05) and benign diseases (p less than 0.01). Immune derangements found among patients with hematopoietic malignancies can be due to replacement of normal bone marrow with malignant cells. In solid tumor patients mitogen reactivity appears to be a reflection of nutritional state, and dietary iron is a possible factor.

Improving the therapeutic ratio of craniospinal irradiation in medulloblastoma

Radiation therapy delivered to the entire cerebrospinal axis is indicated for a number of pediatric brain tumors, especially medulloblastoma. Improved radiotherapy techniques have changed the near fatal prognosis for children with medulloblastoma to a 50%, 5-year survival. Nevertheless, the treatment results in substantial acute toxicity, and many survivors have serious sequelae. Further improvement in survival with optimal surgery and radiotherapy is not expected unless chemotherapy is added. Refinements in radiotherapy technique, however, can improve the therapeutic ratio of the treatment by lowering its side effects. In the last year children who required craniospinal irradiation at M. D. Anderson Hospital were treated with 6 MV photons to the brain and primary tumor and with 15-17 MeV electrons to the spinal canal. The elective dose to the whole brain was 30 Gy in 17 fractions and 30 Gy in 20 fractions to the spine. The primary tumor received an additional 20-25 Gy. An electron-beam dose distribution was drawn on a computerized tomography (CT) reconstructed sagittal plane. The electron energy was selected so that the 90% isodose line was at least 3 mm anterior to the cord after correction for bone heterogeneity. The treatment was well tolerated in the first five patients. It is projected that the current technique will cause fewer late effects and improve the tolerance to chemotherapy.

Medulloblastoma in infants and children: computed tomographic follow-up after treatment

Thirty-six proven cases of medulloblastoma were reviewed by serial CT follow-up examinations from 4 months to 10 years, 2 months after the initial diagnosis, with a mean follow-up time of 3 years, 9 months. The children ranged in age from 10 months to 16 years, 7 months at the time of follow-up. The tumor recurred at the primary site in 20 cases (56%). Leptomeningeal metastasis was demonstrated on CT in 14 cases (39%); seven of these patients also presented with solid subarachnoid metastases. Thirteen patients (36%) showed evidence of severe brain atrophy, which was confined to the posterior fossa in seven of the 13. Calcification resulting from mineralizing microangiopathy developed in five cases (14%), including three patients who had extensive dystrophic calcification in the corticomedullary junction and the deep-seated nuclei of the cerebrum and cerebellum. Only one case of leukoencephalopathy was observed. The patterns of tumor recurrence in the posterior fossa that is severely deformed by surgery and other treatment modalities and leptomeningeal spread of tumor are discussed.