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.

Successful twin pregnancy in panhypopituitarism caused by suprasellar germinoma

BACKGROUND

Pregnancy in a woman with hypopituitarism from a suprasellar germinoma is rare.

CASE

A 27-year-old woman presented with panhypopituitarism from a suprasellar germinoma. She had diabetes insipidus, hypothyroidism, adrenal cortex dysfunction, and hypogonadotropic ovarian failure. When treated with thyroxin, cortisol, antidiuretic hormone, human menopausal gonadotropin, and human chorionic gonadotropin, she conceived and gave birth to healthy twins.

CONCLUSION

Hormonal replacement therapy and ovulation induction resulted in a successful pregnancy in a woman with panhypopituitarism.

Pineal germinoma with intratumoral hemorrhage after neuroendoscopic tumor biopsy

CASE REPORT

We report an intratumoral hemorrhage immediately after a ventricular endoscopic procedure in an 18-year-old man who had a pineal germinoma with symptomatic hydrocephalus. The patient was successfully treated using long tract external ventricular drainage and urgent radiation therapy.

DISCUSSION

The contributing factors for the acute reduction of intracranial pressure to zero during the endoscopic procedure are discussed.

High uptake on 11C-methionine positron emission tomographic scan of basal ganglia germinoma with cerebral hemiatrophy

We herein describe a 12-year-old male patient with a germinoma of the basal ganglia who presented with progressive hemiparesis. MR imaging showed ipsilateral cerebral hemiatrophy predominantly in the left basal ganglia, whereas no mass or enhancement was depicted. Single photon emission CT revealed no significant uptake of thallium, whereas (11)C-methionine positron emission tomography showed clearly discernible uptake in the left putamen. Stereotactic biopsy, referencing the results of (11)C-methionine positron emission tomography, was performed, allowing histologic verification of germinoma to be established. (11)C-methionine positron emission tomography was the only technique that indicated the precise localization of the tumor in our patient and enabled biopsy-based final diagnosis of the basal ganglia germinoma without any overt mass formation.

A case of germinoma in the septum pellucidum manifesting as amnesia and hemiparesis

BACKGROUND

We report a rare case of germinoma mainly located in the septum pellucidum.

CASE DESCRIPTION

A 19-year-old man presented with germinoma located in the septum pellucidum manifesting as amnesia and right hemiparesis. Magnetic resonance imaging demonstrated a heterogeneously enhanced mass in the septum pellucidum and abnormal T2-weighted signals in the left basal ganglia. An anterior transcallosal approach was performed to remove the mass in the septum pellucidum. The histological diagnosis was germinoma. Radiotherapy and chemotherapy were given. He was discharged with slight amnesia and right hemipareis.

INTERPRETATION

Intracranial germinoma can arise from the septum pellucidum.

[Testicular microlithiasis: report of 14 cases]

Testicular microlithiasis (TM) is a comparatively rare condition in which calcified congelations fill the lumina of the seminiferous tubules. Using high-frequency linear transducers (10 MHz), TM is easily demonstrated as tiny punctate echogenic foci, which typically do not give an acoustic shadow, and is classified into classic type (CTM) and limited type (LTM) on the basis of the presence of five or more microliths at least on one image of the testes. Fourteen patients were found to have TM, 6 of which were LTM and 8 were CTM. In one patient with CTM, coexisting mixed germ cell tumor (seminoma, embryonal cell carcinoma) was demonstrated. Until further data are available, it seems reasonable to consider patients with TM as having an increased risk of developing a primary testicular tumor.

Increased Risk of Carcinoma In Situ In Patients With Testicular Germ Cell Cancer With Ultrasonic Microlithiasis In the Contralateral Testicle

PURPOSE

We compared clinical and histological data regarding the contralateral testicle in a population of men diagnosed with testicular germ cell cancer to find features associated with an increased risk of bilateral neoplasia.

MATERIALS AND METHODS

Clinical data obtained from the records of 79 men seen during the period 1998 to 2001 included history, physical and ultrasound examination, and the results of semen and hormonal analysis. Contralateral testicular biopsies were obtained from all men and analyzed for carcinoma in situ (CIS), microcalcifications (microliths) and other signs of testicular dysgenesis.

RESULTS

Ultrasound examination of the contralateral testicle was performed in 64 of the cases. The echo pattern was judged normal in 30 cases, slightly irregular in 22, irregular in 3 and showed microlithiasis in 9. The frequency of microlithiasis seen on ultrasound was significantly higher among patients with CIS (p <0.001) compared to those with a normal echo pattern (Fisher's exact test). The overall frequency of reported cryptorchidism was 18.7% with no difference in seminoma and nonseminoma distribution between patients with or without a history of cryptorchidism. The median age of patients with cryptorchidism, 25.8 years (range 15.8 to 31.7), was significantly younger (the Mann-Whitney test p <0.05) than the age of those with normal testicular descent, 31.4 years (range 17.8 to 52.9).

CONCLUSIONS

The finding of contralateral testicular microlithiasis on ultrasound in a patient with testicular germ cell cancer increases the risk of harboring carcinoma in situ in that testicle (odds ratio 28.6; CI: 4.8-170.4). Conversely, a normal ultrasound pattern does not exclude the risk of CIS. Whether sonographic microlithiasis found in other subgroups of patients or in men from the general population also implies an increased risk of testicular CIS remains to be clarified.

Testicular carcinoma in situ in patients with extragonadal germ-cell tumours: the clinical role of pretreatment biopsy

BACKGROUND

The aim of this study was to determine the prevalence of testicular carcinoma in situ (CIS) in patients with a malignant extragonadal germ-cell tumour (EGGCT) and the incidence of metachronous invasive testicular cancer (TC) in relation to the pretreatment demonstration of CIS.

PATIENTS AND METHODS

Sixty-eight patients with EGGCT (53 retroperitoneal, 15 mediastinal) had pre-chemotherapy histological assessment of one (13) or both (55) testicle(s). A total of 123 testicles were examined for the presence of CIS.

RESULTS

Testicular CIS was found in 21 patients (31%) (18 retroperitoneal EGGCT, three mediastinal EGGCT). Two patients had bilateral CIS. Five patients, four of them with proven pretreatment CIS, developed a metachronous TC. The 10-year invasive-free TC survival rate for all 68 patients was 88%, but only 65% for those with proven pretreatment CIS. The overall 10-year survival rate for all patients was 82%. CIS was demonstrated in seven of 48 trans-scrotal core biopsies, in 10 of 56 trans-scrotal surgical biopsies and in five of 11 orchiectomy specimens.

CONCLUSIONS

Approximately one-third of patients with EGGCT present with testicular CIS, predominantly those with a retroperitoneal tumour. These patients have a considerable risk of metachronous TC development in spite of chemotherapy. The pretreatment demonstration of testicular CIS in patients with EGGCT gives the possibility of individualised counselling and safe follow-up, and is therefore highly recommended. The data are in agreement with a multi-site development of malignant germ-cell tumours, but do not exclude the possibility that the retroperitoneal EGGCTs in particular represent metastases from a burned-out TC.

Reversible hearing loss associated with a malignant pineal germ cell tumor. Case report

In patients with pineal tumors, clinical symptoms are due to direct compression of adjacent structures. The most common signs include increased intracranial pressure (80%) caused by obstruction of the sylvian aqueduct, and Parinaud syndrome (50%) caused by direct compression of the superior colliculi. Hearing loss is rare in patients with tumors in this location. The authors report on the case of a 12-year-old boy in whom a malignant pineal germ cell tumor was found together with the unusual occurrence of severe hearing loss due to direct bilateral compression of the inferior colliculi. This condition resolved completely after tumor regression.

Ovarian germ cell malignancy and human immunodeficiency virus (HIV) infection: a case report

The occurrence of germ cell tumors in patients with human immunodeficiency virus (HIV) infection has not been previously reported. However, with the HIV pandemic in certain parts of the world, this association has become a reality. The approach to management as well as the role of adjuvant radiotherapy and chemotherapy is problematic as many of these therapies are toxic. The appropriate management of such tumors will remain elusive for sometime. The presentation, management, and outcome of ovarian endodermal sinus tumor in a HIV-infected patient is reported.

Aggressive hepatectomy for complete remission of metastatic germ cell tumor following chemotherapy: report of a case

A 12-year-old girl presented with hemoperitoneum caused by disseminated liver tumors accompanying a retroperitoneal germ cell tumor and was rescued by transcatheter hepatic arterial embolization. Following systemic chemotherapy, the liver tumors decreased in size and number, although the retroperitoneal tumor was resistant to therapy. We simultaneously resected the retroperitoneal tumor, and the liver lesions by extended left lobectomy combined with resection of the three major (right, middle, and left) hepatic veins, while preserving the inferior right hepatic vein. The postoperative course was uneventful, and liver regeneration evaluated by serial computed tomography was almost completed by three months following surgery. Pathological examination of the resected tumors revealed benign (mature) teratomas. Since complete removal of tumors critically influences the outcome in patients with mature teratoma, aggressive surgery is advocated for extensive tumors. The present case clearly demonstrated that extended hepatectomy with resection of three major hepatic veins is feasible and provides an opportunity for achieving complete remission in patients with metastatic germ cell tumor of the liver.

Adjuvant ketamine analgesia for the management of cancer pain

OBJECTIVE

To review the clinical literature evaluating the utilization of intravenous ketamine for the management of cancer-related pain, to summarize the data that suggest ketamine is an appropriate adjuvant method of providing analgesia and to report a case of successful pain management using ketamine in a patient with recurrent testicular cancer at our institution.

DATA SOURCES

Primary literature was identified through a MEDLINE search (1966-March 2002), and additional information was obtained through secondary and tertiary sources.

DATA SYNTHESIS

The available data suggest that supplementation of morphine with ketamine improves analgesia in patients with cancer, and also provides insight to the controversy regarding the efficacy and adverse effects of various ketamine doses. At subanesthetic doses, ketamine may be beneficial at reducing opioid requirements and related adverse effects.

CASE SUMMARY

A 34-year-old white man with recurrent testicular cancer was admitted with radiating neuropathic pain of the legs and lower back. The patient was suspected to also be experiencing opioid adverse effects; therefore, alternative analgesic options were warranted. Ketamine was successful in reducing patient-reported pain and was also well tolerated.

CONCLUSIONS

Ketamine is an adjuvant analgesic for the treatment of cancer-related pain when other agents either fail or are intolerable. Accordingly, there are several factors that may prevent adequate pain control with opioid use; therefore, alternative analgesic options should be considered. Promise exists for ketamine as a contemporary analgesic in the appropriate patient.

[CVS-cardiac thrombosis related in a child with an intracranial germinoma]

We report a case of a CVC infection with a grave cardiac thrombosis in a child afflicted with intracranial functioning germinoma. During the second chemotherapeutic cycle we found a positive blood culture and a partial CVC occlusion; echocardiography showed a 2 cm diameter interatrial thrombus. After removal of the CVC a voluminous thrombus in the right atrium persisted. The profibrinolytic factor's concentration was normal, and so we preferred to use aspirin, the most common antiplatelet agent, combined with antibiotic and antimycotis therapy. This treatment allowed us to observe the disappearance of the thrombus by 25 days.

Mixed germ cell tumour of the spinal cord in a young dog

A spinal cord mixed germ cell tumour was identified in a two-year-old, female Airedale terrier with a history of progressive paraplegia. At necropsy, a discrete pale pink spinal cord mass was identified at the L5 vertebra, which extensively invaded the associated spinal cord segments L6 and L7. Histologically, the tumour was located within the subarachnoid space and invaded the spinal cord. It was composed of three different types of cells: small round cells, forming clusters or islands, similar to germ cells identified in testicular germinomas; large cells with eosinophilic or amphophilic cytoplasm, forming trabeculae; and a third, rarer type of well differentiated epithelial cells, forming acinar or tubular structures. Immunohistochemical examination revealed reactivity to antibodies against alpha-fetoprotein and broad spectrum cytokeratins. The composition, cytological features and immunohistochemical staining of this neoplasm are similar to germ cell tumours previously reported in the suprasellar region and in the eye of dogs.

Does retroperitoneal lymphadenectomy for testicular germ cell tumor require a different approach in the presence of horseshoe kidney?

PURPOSE

We report our management of stage II testicular nonseminomatous germ cell tumor in 2 patients with horseshoe kidney and discuss the technical challenges posed by this renal fusion anomaly. The embryology and clinical anatomy of horseshoe kidney are discussed with particular reference to the anomalous vascular pattern and routes of testicular lymphatic drainage in this setting. Modifications and innovations of the standard technique of retroperitoneal lymphadenectomy in the presence of horseshoe kidney are discussed in light of our experience with these patients at 2 major tertiary care cancer centers. The significance of contemporary advanced noninvasive radiological techniques, such as helical computerized tomographic angiography with digital 3-dimensional reconstruction and magnetic resonance angiography, in the surgical planning and safe performance of surgery is emphasized.

MATERIALS AND METHODS

Two young male patients treated at 2 major American teaching hospitals who had coexistent stage II testicular nonseminomatous germ cell tumor and horseshoe kidney underwent salvage retroperitoneal lymph node dissection.

RESULTS

There was no evidence of recurrence in these 2 patients 12 and 15 months after surgery, respectively.

CONCLUSIONS

Horseshoe kidney poses special technical problems during retroperitoneal lymphadenectomy for testicular tumors due to anomalous renal and intra-abdominal vascular patterns. Helical computerized tomography angiography is useful for meticulous surgical planning and the safe performance of surgery in this setting.

Huge retroperitoneal germinoma presenting with pathological fracture of the spine

Primary retroperitoneal germ cell tumors are extremely rare neoplasms. The most common presenting features are abdominal pain and palpable abdominal masses. Pathological fractures of the spine presenting as bilateral lower leg weakness are exceptionally rare. We describe a 16-year-old girl who developed progressive paraplegia after a minor falling injury. Radiological study demonstrated a huge retroperitoneal tumor with invasion of the T12 vertebral body and spinal canal. A posterior surgical approach was used to perform laminectomy (T12, L1), removal of the intraspinal tumor and internal fixation with transpedical screws (T10, T11 to L2,3), and posterolateral fusion. Postoperative combination chemotherapy for six cycles with cisplatin (100 mg/m2 per day for 1 day every 3 weeks), bleomycin (15 units intravenously weekly for 18 weeks) and etoposide (100 mg/m2 per day for 3 days every 3 weeks) were given and the tumor responded dramatically. The patient had fully recovered without evidence of sequelae or recurrence at 2 years after operation. To the authors' knowledge, this is the first case in which a huge retroperitoneal germinoma presented as pathological fracture of the spine and spinal cord compression. The effectiveness of the postoperative cisplatin-based chemotherapy against this tumor made major retroperitoneal surgery to remove the main tumor mass unnecessary is also demonstrated.

Pineal region tumor manifesting initially as hearing impairment

An 18-year-old male presented with a pineal region germinoma with hearing impairment as the chief complaint. Magnetic resonance image demonstrated a well-enhanced multi-cystic tumor extending into the upper fourth ventricle and wall of the bilateral lateral ventricles. Audiometry revealed bilateral mild hearing impairment in the low frequencies. Auditory brainstem response recording showed low amplitudes in all waves (IV-V/I ratio < 1) with prolong latencies (I-V and III-V) on the right but no discernable wave at 60 dB clicks on left. Hearing impairment and audiometric findings were improved after ventriculoperitoneal shunt operation. The hearing impairment appeared to be a mixed (conductive and sensorineural) type. The tumor was responsible for the sensorineural deafness because of invasion and compression of the central auditory structures. The inferior brachium was maximally compressed anterolaterally by the dilated bilateral lateral ventricles and posteromedially by the tumor. Hydrocephalus caused conductive deafness by halting or arresting the footplate of stapes movement, as a consequence of high-pressure transmission through the cochlear aqueduct.

Temporary ventricular drainage and emergency radiotherapy in the management of hydrocephalus associated with germinoma

OBJECT

The authors used an alternative strategy to avoid shunt placement for hydrocephalus associated with germinoma, and the ensuing complications.

METHODS

Between 1998 and 2000, five patients presenting with germinomas of the pineal area and symptomatic obstructive hydrocephalus were treated with a novel strategy. On arrival, they underwent ventriculostomy placement and one of several surgical procedures to obtain tissue for diagnosis. Within several days of the initial diagnosis, stereotactically guided fractionated radiotherapy was started. All patients experienced rapid tumor shrinkage and resolution of hydrocephalus, allowing discontinuation of external ventricular drainage without the need for permanent shunting of cerebrospinal fluid. To date, follow up reveals 100% radiographically and clinically confirmed tumor control.

CONCLUSIONS

Prompt resolution of hydrocephalus and absence of complications make this a potentially valuable therapy for control of germinomas and their symptoms.

Dendritic cell infiltration in a patient with seminomatous germ cell tumor of the testis: is there a relationship with infertility and tumor stage?

PURPOSE

Inflammatory cells, such as dendritic cells, are considered to trigger the antitumoral immune response against tumors, such as testicular cancer. Male infertility associated with cancer may be due to endocrine or immunological factors. We investigated possible associations of antigen expression with dendritic cells, histiocytic cells and seminoma stage as well as with impaired spermatogenesis.

MATERIALS AND METHODS

From 1992 to 1999, 30 patients with seminoma underwent orchiectomy at our center, including 14 who underwent spermiography before orchiectomy. Streptavidin-biotin immunostaining was performed on paraffin -embedded tumor specimens using antibodies against protein S-100 for dendritic cells and CD68-KP1 antigen.

RESULTS

Light infiltration by less than 20 dendritic cells and less than 103 CD68+ cells was associated with tumor size greater than 1.5 cm. in 75% and 80% of patients, respectively. Strong infiltration by greater than 20 dendritic cells and greater than 103 CD68+ cells was associated with negative lymph nodes in 86% of patients. Slight infiltration by dendritic cells was observed in 71% of patients with a sperm count of greater than 8.6 million per ml. and in 100% with more than 45% motile sperm (p not significant and 0.02, respectively). Necrospermia increased with dendritic and CD68+ cell infiltration. No association was noted among preoperative serum tumor marker levels, the sperm count and immunostaining.

CONCLUSIONS

Sperm autoimmunity is a plausible mechanism of infertility in men with germ cell tumors. Dendritic cells may induce antitumor cell cytotoxic reactions, but may also be cytotoxic to sperm cells or lead to inhibited spermatogenesis. Further studies focusing on tumor rejection antigen and the cloning of specific cytotoxic T lymphocyte against gametes are required to confirm these finding.