Treatment of stage IV-S neuroblastoma: a study of 34 cases treated between 1982 and 1987

Between January 1982 and December 1987, of 283 children with neuroblastoma treated in the Pediatric Department of Institut Gustave Roussy, 34 were stage IV-S. Two groups were distinguished according to the initial clinical presentation: 16/34 patients had life-threatening symptoms and needed immediate treatment, and 18/34 had no life-threatening symptoms. Hepatic irradiation was used in 12/16 patients of the first group with respiratory distress. Chemotherapy was used in three patients. Of these 16 patients, three patients died of progressive disease (one patient died of a reason not related to the tumor). Twelve are alive in first complete remission and one in second complete remission. Of the 18 patients of the second group, eight had spontaneous complete remission, and one of them relapsed thereafter and died despite treatment. Ten patients needed treatment, radiotherapy, and/or chemotherapy depending on the site of disease progression. Two of them died of the disease. The overall disease-free survival for these 34 patients is 75% at 90 months postdiagnosis. Using this therapeutic strategy, it was possible to avoid any treatment of metastases in 25% of the patients.

Dose-dependent neurotoxicity of high-dose busulfan in children: a clinical and pharmacological study

Busulfan is known to be neurotoxic in animals and humans, but its acute neurotoxicity remains poorly characterized in children. We report here a retrospective study of 123 children (median age, 6.5 years) receiving high-dose busulfan in combined chemotherapy before bone marrow transplantation for malignant solid tumors, brain tumors excluded. Busulfan was given p.o., every 6 hours for 16 doses over 4 days. Two total doses were consecutively used: 16 mg/kg, then 600 mg/m2. The dose calculation on the basis of body surface area results in higher doses in young children than in older patients (16 to 28 mg/kg). Ninety-six patients were not given anticonvulsive prophylaxis; 7 (7.5%) developed seizures during the 4 days of the busulfan course or within 24 h after the last dosing. When the total busulfan dose was taken into account, there was a significant difference in terms of neurotoxicity incidence among patients under 16 mg/kg (1 of 57, 1.7%) and patients under 600 mg/m2 (6 of 39, 15.4%) (P less than 0.02). Twenty-seven patients were given a 600-mg/m2 busulfan total dose with continuous i.v. infusion of clonazepam; none had any neurological symptoms. Busulfan levels were measured by a gas chromatographic-mass spectrometry assay in the plasma and cerebrospinal fluid of 9 children without central nervous system disease under 600 mg/m2 busulfan with clonazepam:busulfan cerebrospinal fluid:plasma ratio was 1.39. This was significantly different (P less than 0.02) from the cerebrospinal fluid:plasma ratio previously defined in children receiving a 16-mg/kg total dose of busulfan. This study shows that busulfan neurotoxicity is dose-dependent in children and efficiently prevented by clonazepam. A busulfan dose calculated on the basis of body surface area, resulting in higher doses in young children, was followed by increased neurotoxicity, close to neurotoxicity incidence observed in adults. Since plasma pharmacokinetic studies showed a faster busulfan clearance in children than in adults, this new dose may approximate more closely the adult systemic exposure obtained after the usual 16-mg/kg total dose, with potential inferences in terms of anticancer or myeloablative effects. The busulfan dose in children and infants undergoing bone marrow transplantation should be reconsidered on the basis of pharmacokinetic studies.

Brain tumours under the age of three. The price of survival. A retrospective study of 20 long-term survivors

Between 1975 and 1989, 98 children with brain tumours under the age of three at time of diagnosis were entered into a retrospective study. Twenty of them are alive and free of tumour more than five years after treatment and were evaluated in this study. Thirteen tumour localizations were infratentorial and 7 were supratentorial. A histological examination was performed in 15 patients: 5 ependymomas, 6 medulloblastomas and 4 astrocytomas were identified. Fifteen patients underwent surgical removal of tumour, all but one received radiotherapy and 8 were given chemotherapy. Only two children have not late effects. Analysis of long-term sequelae in survivors showed central endocrinopathies in 14 (70%), a neurological handicap in 13 (65%) and impaired cognitive functions in 17 (85%). Irradiation was clearly responsible for mental sequelae in 7 patients and endocrinopathies in 6 patients. The other possible causes are tumour injury, hydrocephalus or surgery. The risks incurred with radiotherapy and advances in infant brain tumour therapy are discussed.

Cerebrospinal fluid and plasma methotrexate levels following high-dose regimen given as a 3-hour intravenous infusion in children with nonHodgkin's lymphoma

In the French nonHodgkin's lymphoma protocols, central nervous system prophylaxis is provided by high-dose methotrexate (HD-MTX), given as a 3-hour IV infusion of 3 g/m2 MTX along with intrathecal MTX injection. The incidence of CNS relapse is less than 3%. We designed a study to evaluate the MTX transfer across the blood brain barrier in terms of cytotoxic concentrations, during these short-term infusions. Cerebrospinal fluid and plasma MTX levels were measured during 61 courses in 29 children with nonHodgkin's lymphoma; none of them had central nervous system disease. Samples were obtained either 4, 12, 18, or 24 hours after the start of HD-MTX IV infusion. A potentially cytotoxic MTX level (10(-6)M) was reached in all courses at 4 hours (median: 2.3 X 10(-6)M) and remained available in 8/16 courses at 12 hours (median: 1.0 X 10(-6)M) and in only 2/17 courses at 18 hours (median: 0.29 X 10(-6)M). Twenty-four hours after the start of HD-MTX IV infusion, CSF MTX level was always less than 10(-6)M. The plasma MTX levels were 260, 1.3, 1.0, and 1.7 X 10(-6)M at 4, 12, 18, and 24 hours, respectively. There was no correlation between plasma and CSF MTX levels. These data show that potentially cytotoxic MTX concentrations can be reached in CSF after a 3-hour IV infusion of 3 g/m2 in every patient and remain available for at least 8 hours in half of them.

Enhanced cutaneous radiation effects following high-dose busulfan therapy

Fifteen patients received irradiation after combined chemotherapy with high-dose busulfan followed by autologous or allogeneic bone marrow transplantation. Of nine patients irradiated between day 30 and day 70 after their engraftment, seven developed an increased radiation response in the skin: four showed enhanced reactions during irradiation, and three had a total or severe definitive alopecia more than 16 months after CNS irradiation. Six patients were irradiated after day 70; they had either normal reactions or none at all within the cutaneous radiation portals. The possibility that busulfan might be a radiosensitizer is raised.

Pharmacokinetics of high-dose busulfan in children

The pharmacokinetics of high-dose busulfan given orally at 1 mg/kg every 6 h over 4 days (total dose, 16 mg/kg) in combined chemotherapy followed by autologous bone marrow transplantation was studied in 12 children with a mean age of 7 years (range, 4-14 years). Busulfan levels in biological fluids were measured by a gas chromatographic assay with mass fragmentographic detection, using a deuterated analogue as the internal standard. In a high-dose regimen, busulfan followed one-compartment model kinetics with zero-order absorption. A mean maximal concentration of 803 +/- 228 ng/ml was achieved at 92-255 min after dosing. The mean elimination half-life was 2.33 h, and the mean total clearance was 119 +/- 54 ml/min per m2, with an apparent distribution volume of 27.10 +/- 11.50 l/m2. A mean trough level of 370 ng/ml was found throughout the 4 days of the chemotherapy course. There were no significant variations in pharmacokinetic parameters measured after the first and last doses. Busulfan was monitored in the CSF of nine children at 3.25-7 h after the last dose and was detected in all patients, with a mean CSF-to-plasma concentration ratio of 0.95 (range, 0.5-1.4).

[Prophylaxis of Gram-positive infections after bone marrow graft. Controlled study of the 6-day administration of vancomycin. Intermediate analysis of 60 patients]

We prospectively evaluated after randomization in 60 consecutive recipients of bone marrow transplantation the efficiency of a short administration of vancomycin (10 mg/kg I.V. q 6 H, day -5 to +1). Thirty-three patients were randomized as controls and 27 were designed to receive vancomycin. Both groups were similar in terms of age, diagnosis, status, allogeneic or autologous graft, in vitro marrow treatment or not. Eighteen patients (30%) experienced bacteremias: 15/18 bacteremias were due to Gram positive organisms, including 11 streptococci. These infections occurred with a similar frequency in both groups, the relatively low incidence of bacteremias in this study needs further evaluation in new patients to insure the prophylactic effects of a course of vancomycin in bone marrow transplant recipients.

Juvenile granulosa cell tumor of the ovary in children: a clinical study of 15 cases

Juvenile granulosa cell tumor (JGCT) in children accounted for 12% of all ovarian tumors treated in the Institut Gustave-Roussy (IGR) Pediatric Department from 1967 to 1985. The median age of the 15 girls was 8 years 7 months (range, 22 months to 15 years 7 months). Precocious pseudopuberty was present in six of the seven girls under 8 years. Of the other seven girls, one developed virilization symptoms. Surgery was the first treatment in each case. According to the Wollner classification, there were six stage I, one stage II, six stage III (including four ruptured tumors), and one stage IV JGCT cases. One patient was not available for staging. An adjuvant treatment (five chemotherapy and one radiotherapy combined with chemotherapy) was administered to six patients. Eleven girls are alive and free of disease, with a median follow-up of 6 years (range, 2 to 18 years). Four girls relapsed 6 to 17 months after surgery and died. Two of these relapses occurred in bone. The prognosis for JGCT in children is favorable for the lower stages when treated with surgery, but the best treatment for extensive and recurrent disease has yet to be determined.

Differentiated thyroid carcinoma in childhood: long term follow-up of 72 patients

Seventy-two children with differentiated thyroid cancer who were 16 years old or younger at the time of initial treatment were followed for a median time of 13 yr. Initially, 18% had lung metastases, and 74% had palpable lymph nodes. Capsular invasion was found in 67%, and histological lymph node involvement in 90%. The recurrent laryngeal nerve chain and the jugulo-carotid chain were involved with the same frequency (greater than 80%). The anterior superior mediastinum was involved only in patients with involvement of the recurrent laryngeal nerve chain. Forty-three patients had a complete remission after initial treatment. In patients without distant metastases for whom surgery was macroscopically incomplete, relapses occurred 5 times more frequently than in patients whose surgery was complete. Six patients died from thyroid carcinoma at ages ranging from 19-44 yr, 12-33 yr after initial treatment, and 1 died from intercurrent disease. Despite favorable long term survival (90.3% at 20 yr), the standardized mortality ratio was equal to 8.1. This study underlines the need for complete surgical treatment and compulsive follow-up, which should be continued throughout the patient's life, in order to detect and effectively treat relapses of thyroid cancer.

Hyponatremia and renal sodium wasting in patients receiving cisplatinum

Three children with malignant solid tumors developed hyponatremia with renal sodium wasting associated with other signs of tubular dysfunction, such as hypokalemia or hypomagnesemia, a few days after cis-diammine dichloroplatinum (CDDP) administration. The normalization of serum electrolyte disturbances was obtained with increased parenteral intakes in fluids and electrolytes, and renal sodium wasting stopped by itself a few days later.