Serum vanillylmandelic acid/homovanillic acid contributes to prognosis estimation in patients with localised but not with metastatic neuroblastoma

In 211 patients with neuroblastoma, serum vanillylmandelic acid (VMA) and homovanillic acid (HVA) levels were determined and correlated to stage, histological differentiation, ferritin, neuron-specific enolase, lactate dehydrogenase (LDH) and outcome. Elevated serum VMA and/or HVA levels were found 16% less frequently than elevated urine levels. The incidence of the elevated serum levels increased with stage (stages I-III 58%, IV 78%, IVS 100%). Increased VMA/HVA ratios were not associated with a higher grade of tumour differentiation. Serum ferritin and neuron-specific enolase showed no correlation, and LDH a borderline non-random correlation with the serum catecholamine metabolites. Using age-related reference values a quotient of serum VMA/HVA (P = 0.061) < 0.7 indicated a poorer event-free survival (48 +/- 10%) than ratios > or = 0.7 (event-free survival 81 +/- 6%) for children with localised neuroblastoma (P = 0.0004). No correlation with prognosis was detected for patients with stage IV and stage IVS disease. We conclude that serum VMA and HVA determinations may be useful as tumour markers for 71% of neuroblastoma patients, and aid in estimating the prognosis in children with localised disease.

Malignant rhabdoid tumor: primary intracranial manifestation in an adult

Clinical, histopathological, and ultrastructural features of an extended intracranial malignant neoplasm are presented. Following incomplete extirpation of a large epidural tumor at the temporal base of the skull, the 21-year-old male patient suffered from several local recurrences and died at the age of 27. The neoplasm was defined by its histopathological and ultrastructural characteristics and by the pattern of its antigenicity as a malignant rhabdoid tumor (MRT). Considering previous publications on MRT, this case may be the first of primary intracranial MRT appearing in an adult.

Malignant peripheral neuroectodermal tumor and its necessary distinction from Ewing's sarcoma. A report from the Kiel Pediatric Tumor Registry

A new classification scheme is proposed for the differential diagnosis of Ewing's sarcoma and malignant peripheral neuroectodermal tumor (MPNT) based on conventional light microscopic and immunohistochemical findings. The presence of Homer-Wright rosettes and/or the expression of at least two neural markers is diagnostic of MPNT Ewing's sarcoma. Ewing's sarcoma was diagnosed in cases lacking Homer-Wright rosettes and expressing no neural marker or only one in immunohistochemistry. Using this "new" approach considerable differences were found between both tumor types. Although most MPNT were located in the thoracopulmonary region, Ewing's sarcoma was located predominantly in the pelvis and extremities. The mean age of MPNT patients was greater than that of Ewing's sarcoma patients. Most importantly, however, was a statistically significant difference in prognosis: disease-free survival in Ewing's sarcoma patients at 7.5 years follow-up was 60% compared with 45% MPNT patients (P = 0.026). The detection of HNK-1 in MPNT indicated a more aggressive biologic behavior, and the expression of protein S-100 appeared to be correlated with a more favorable clinical course.

Malignant peripheral neuroectodermal tumor and its necessary distinction from Ewing's sarcoma. A report from the Kiel Pediatric Tumor Registry

A new classification scheme is proposed for the differential diagnosis of Ewing's sarcoma and malignant peripheral neuroectodermal tumor (MPNT) based on conventional light microscopic and immunohistochemical findings. The presence of Homer-Wright rosettes and/or the expression of at least two neural markers is diagnostic of MPNT Ewing's sarcoma. Ewing's sarcoma was diagnosed in cases lacking Homer-Wright rosettes and expressing no neural marker or only one in immunohistochemistry. Using this "new" approach considerable differences were found between both tumor types. Although most MPNT were located in the thoracopulmonary region, Ewing's sarcoma was located predominantly in the pelvis and extremities. The mean age of MPNT patients was greater than that of Ewing's sarcoma patients. Most importantly, however, was a statistically significant difference in prognosis: disease-free survival in Ewing's sarcoma patients at 7.5 years follow-up was 60% compared with 45% MPNT patients (P = 0.026). The detection of HNK-1 in MPNT indicated a more aggressive biologic behavior, and the expression of protein S-100 appeared to be correlated with a more favorable clinical course.

[Cystic space occupying lesion of the upper pole of the kidney in a newborn infant. Case report and differential diagnosis]

In a newborn female infant a cystic lesion in the upper pole of the right kidney was detected by sonography 4 weeks before an uneventful delivery. In the postnatal period the sonographic examination, IVP, CT, and the biochemical data as well were not able to classify definitely this lesion as a benign cyst, adrenal hemorrhage or cystic malignoma. Therefore a laparatomy was performed, which revealed a cystic neuroblastoma.

Infantile desmoid-type fibromatosis. Morphological features correlate with biological behaviour

It is generally agreed that the biological behaviour of infantile desmoid-type fibromatosis is unpredictable in terms of the likelihood of local recurrence. We evaluated the prognostic importance of the number of slit-like blood vessels with a mean diameter of less than 20 microns and of the quantity of undifferentiated mesenchymal cells. In addition, we studied the immunophenotypic characteristics of the proliferating cells and their nucleolar organizer region (AgNOR) numbers and distribution. Statistical analysis showed that the tendency to recur locally was correlated with larger numbers of slit-like blood vessels and undifferentiated mesenchymal cells. The proliferating cells were identified by immunohistochemistry as myofibroblasts. No correlation was found between AgNOR numbers and clinical course of the disease. We conclude that histological features easily evaluated by conventional light microscopy provide useful information on the possible course of infantile desmoid-type fibromatosis.

Facial palsy with elevated protein in otherwise normal CSF in a child with Lyme disease

This is a report on an eight-year-old girl who presented with facial palsy, headache, fatigue, arthralgias and myalgias six weeks after two tick bites. Physical examination was unremarkable with the exception of a left-sided facial palsy. Laboratory investigation revealed normal complete blood count, ESR and CRP. The spinal tap showed a protein of 63 mg/dl, glucose 45 mg/dl and no cells. IFT titres to Borrelia burgdorferi in serum and CSF were significantly elevated. The diagnosis was supported by Western blot analysis. Treatment was started with ceftriaxone i.v. for a total of 14 days. Under this therapeutic regimen the patient improved substantially within five days. Investigation of CSF in patients with facial palsy may help to establish the diagnosis of Lyme disease by simultaneously measuring IFT to B. burgdorferi in serum and spinal fluid, even in cases where CSF shows little or no signs of inflammation.

[Impulse cytophotometry determination of the DNA content of paraffin-fixed neuroblastoma]

The aim of the study was to develop a method to obtain a single cell suspension from paraffin fixated neuroblastoma tissue for measuring the DNA content by flow cytometry, and to detect possible correlation between the histological grading and the DNA stemline, and to relate these findings to the patients' prognosis. 51 samples of the fixated neuroblastoma tissue were measured. It was possible to determine the DNA content in 38 probes of the material. 79% of the evaluated samples showed aneuploid DNA stemlines, 21% showed euploid stemlines. Despite the small number of probes it was found, that in relation to the histological grading of neuroblastoma a lower grade of malignancy correlated with an euploid DNA content and a higher grade of malignancy correlated with an aneuploid DNA content. A correlation between DNA stemlines and the patients' prognosis was not found.

Synovial sarcoma in children and adolescents. A report from the Kiel Pediatric Tumor Registry

Of 49 cases of synovial sarcoma, which represent 5.8% of all soft tissue sarcomas with confirmed diagnosis in the files of the Kiel Pediatric Tumor Registry (Kiel, Germany), 35 occurred in patients up to the age of 18 years. The lower extremities were the most common. The 35 cases included 21 biphasic and 14 monophasic fibrous synovial sarcomas. The different cell types constituting synovial sarcoma could be demonstrated by conventional light microscopic study, but more readily so by immunohistochemical study, particularly when antibodies against cytoskeletal components were applied. Aberrant antigen expression was noticed for the neural markers, protein S-100, and neuron-specific enolase. Moreover, four tumors were positive for Ki M7. Collagen type IV was found in all tumors tested. For the 20 patients enrolled in the Cooperative Soft Tissue Sarcoma Study of the German Society of Pediatric Oncology (GPO) the survival rate at 7 years is 63%. When five patients with initial recurrence are excluded, the survival rate is 72%. It is concluded that immunohistochemical study is useful in the diagnosis and differential diagnosis of synovial sarcomas despite certain limitations. Multimodality treatment approach has improved the overall prognosis. There is no relationship between histologic subtype and prognosis according to the classification scheme employed in this study.

Determination of the anatomical size of ventricular septal defects on the basis of hemodynamic data and noninvasive assessment of pulmonary to systemic vascular resistance ratio Rp/Rs by Doppler-echocardiography

The pulmonary and systemic flow (Qp/Qs) and resistance ratios (RP/Rs) were determined in children with isolated ventricular septal defects (VSD) to derive an "effective defect resistance" (Rd/Rs) representing the ratios of the resistance of the defect to the systemic vascular resistance. The defect size (expressed as the ratio of the area of the defect to the cross-sectional area of the ascending aorta) was related to the calculated "effective defect resistance," where a significant (non-linear) correlation was found. The effective resistance of the defect is a useful aid for estimation of the anatomical size of a ventricular septal defect. The close correlation between anatomical size and the hemodynamic parameter Rd/Rs allows one to calculate the ratio Rp/Rs with this concept using noninvasive Doppler-ultrasound and echocardiography. This was performed in 21 children with VSD who underwent cardiac catheterisation. The noninvasive calculated flow ratio Qp/Qs and the resistance ratio Rp/Rs showed a close correlation to the values measured at cardiac catheterisation.

[Frequency of odontogenic tumors in the growth period]

424 odontogenic tumors were diagnosed at the Department of Oral Pathology in Hamburg Eppendorf and the Department of Maxillofacial Surgery in Kiel between 1965 and 1989. 106 of these odontogenic tumors were found in patients of 16 years and under. More often than not the odontogenic tumors of this age group were complex and compound odontomas, totalling 67%. When comparing these with other odontogenic tumors it must be taken into consideration that--although included in the WHO classification--odontomas are often referred to as hamartomas and not real tumors, because they lack the typical features of tumors. Compared with the adult age group, the relative frequency of ameloblastic fibromas, ameloblastic fibro-odontomas and odontogenic myxomas was remarkable. Nevertheless, because of the great differences between the two age groups, direct comparisons of these findings with each other should be made with reservation.

Renal cell carcinoma in children: histology, immunohistochemistry, and follow-up of 10 cases

Ten renal cell carcinomas in children under 15 years were investigated. The average age was 122.5 months and the girls predominated in our cases (7 girls, 3 boys). By using the classification of Thoenes et al., Pathol Res Pract 181: 125-143, 1986 a predominance of clear cell-eosinophilic tumor cell type and of the tubulopapillary growth pattern was found. Immunohistochemistry revealed a heterogeneity of cytokeratin expression. By using the monoclonal antibodies Cam 5.2 and KL 1, cytokeratins were found in 7 cases each. The other 4 cytokeratin antibodies used were less sensitive. The expression of cytokeratin 13 in 3 cases suggested a more complex histogenesis than assumed. Vimentin was found in 3 tumors, but an association to a higher grade (G) of malignancy was not found in these cases. One tumor expressed the Tamm-Horsfall-protein, which is predominantly found in the distal tubule of the normal kidney. In summary the results of immunohistochemistry characterized the great heterogeneity of these tumors. Follow-up information was available in 9 cases. All patients with G I- and G II-tumors were free of disease after an average time of 39.6 months (mean 27 months). Two of the 3 cases with G III-tumors died after 9 and 15 months, despite additional chemo- or radiotherapy. Therefore tumors of grade I and II of the Thoenes classification seem to have a good prognosis.

Neuroendocrine differentiation in hepatoblastoma. An immunohistochemical investigation

Hepatoblastoma exhibits a wide range of epithelial and mesenchymal lines of differentiation. Neuroendocrine differentiation in this tumor has not previously been reported. We investigated seven hepatoblastomas of different subtypes (five pure epithelial hepatoblastomas, including one small-cell hepatoblastoma, and two mixed hepatoblastomas) using a broad panel of antibodies against epithelial, mesenchymal, neural, and neuroendocrine markers, alpha-1-antitrypsin (alpha 1-AT), alpha-1-antichymotrypsin (alpha 1-ACT), alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA), serotonin, and 14 regulatory peptides. Chromogranin A-immunoreactive neuroendocrine tumor cells, some of which also exhibited immunoreactivity for serotonin and somatostatin, were found in the fetal and embryonal parts of the mixed hepatoblastomas. The osteoid-like material in the mixed hepatoblastomas contained cells with immunoreactivity for chromogranin A, neuron-specific enolase, keratin, and alpha 1-AT, alpha 1-ACT, AFP, and CEA, in addition to S-100 protein and vimentin. Parallels to the neuroendocrine differentiation in hepatoblastomas are found in tumors of the gastrointestinal tract and bronchopulmonary tree. These tumors may also exhibit a neuroendocrine component; that is, multidirectional differentiation may occur, as in hepatoblastoma. The immunoreactivity of some of the cells of the osteoid-like material for keratin, alpha 1-AT, alpha 1-ACT, AFP, CEA, and chromogranin A suggests that these cells--and probably the surrounding material--are of epithelial origin.

Cytokeratin expression in malignant Triton tumor

A malignant Triton tumor in a 9-year-old boy is described. The first biopsy which was taken from the thenar prominence was diagnosed as a monophasic fibrous synovial sarcoma based on the finding of a spindle cell neoplasm with plump nuclei and cytokeratin expression. The true nature of the tumor became apparent when a second biopsy was investigated. In this specimen a rhabdomyosarcomatous component was found in association with a spindle cell sarcoma fulfilling the criteria of a malignant schwannoma. Immunohistochemical staining using antibodies against vimentin, desmin, muscle-specific actin, cytokeratin, glial fibrillary acidic protein, protein S-100, Leu 7 and myoglobin served to distinguish the two tumor components and documented the possible reactivity of malignant Triton tumor for cytokeratins.

Simultaneous palsy of facial and vestibular nerve in a child with Lyme borreliosis

We describe a boy with borreliosis characterized by lymphocytic meningitis and simultaneous palsy of facial and vestibular nerves on the left side. A mild sensoneural affection was also confirmed by brainstem evoked response audiometry. While symptoms of vestibular dysfunction quickly decreased during antibiotic treatment, facial palsy improved only slowly.

The applicability of immunohistochemistry in the diagnosis and differential diagnosis of malignant soft tissue tumors. A reevaluation based on the material of the Kiel Pediatric Tumor Registry

The diagnosis and differential diagnosis of malignant soft tissue tumors not infrequently poses great difficulties, especially in those cases which lack any feature of differentiation by conventional light microscopy. These difficulties have been partially resolved through the application of ultrastructural investigations. Recently considerable progress has been achieved using immunohistochemistry. At the Kiel Pediatric Tumor Registry we were able to reduce the percentage of unclassified soft tissue sarcomas from 17.6% in 1982 to 4.5% in 1989. Particularly useful were antibodies against the different types of intermediate filaments, muscle-specific actin, myoglobin, and the neural markers neuron-specific enolase and protein S-100. In contrast to the expected immunophenotype rhabdomyosarcomas, malignant peripheral neuroectodermal tumors and malignant schwannomas showed expression of cytokeratins. Moreover, in many cases rhabdomyosarcomas and synovial sarcomas expressed neural markers. Ewing's sarcoma and malignant peripheral neuroectodermal tumor are histogenetically related, but differ in grade of neural differentiation. In all soft tissue sarcomas immunohistochemistry is very useful to obtain information on the cellular heterogeneity. Despite the great achievements not every soft tissue sarcoma can be diagnosed with certainty. There will always be a baseline of unclassified cases due to problems which are not caused by the tumor itself but rather by diagnostic circumstances.

[Plasma separation in acute, intravenous phenytoin poisoning]

A two year old boy suffered an acute phenytoin intoxication following intravenous treatment of seizures. After two days in coma detoxification with plasma separation was started. The course of clinical symptoms and phenytoin elimination is described and the efficacy of the method in treating phenytoin intoxication is discussed.

Undifferentiated sarcoma of the liver in childhood: morphology, flow cytometry, and literature review

Nine cases of undifferentiated sarcoma of the liver in childhood were investigated by conventional light microscopy, immunohistochemistry, and DNA flow cytometry. Different histologic patterns were discernible. In some cases, areas resembling poorly differentiated rhabdomyosarcoma were present. This histologic diversity was supported by the immunohistologic detection of desmin and cytokeratins in five cases. When evaluated by flow cytometry, four of five cases investigated were diploid; only one was aneuploid, and this patient had the most aggressive course. Follow-up investigations of our patients and those described in the literature revealed that the prognosis of this type of tumor is not as bad as is generally assumed. Of the patients reported in the literature with detailed follow-up information, 37.5% survived without evidence of disease for an average of 37.5 months, death occurred in 47.5% after an average of 11.9 months, and 15.0% were alive with disease.

[Dysgerminomas. Clinical aspects, therapy and prognosis with reference to the cooperative therapy study MAIKEI 83/86 for non-testicular germ cell tumors of the Society of Pediatric Oncology]

In comparison to other malignant germ cell tumors, dysgerminomas of the ovary show a high sensitivity to radiotherapy. According to histology and biological behaviour, dysgerminomas of the ovary are similar to testicular seminomas, which seem to be very sensitive to chemotherapy. Therefore, in the protocol for non-testicular germ cell tumors of the German Society of Pediatric Oncology (GPO) a treatment for dysgerminomas is established, in which the indication for primary tumor resection and a supplementary radiotherapy, or, in selected cases, primary chemotherapy and delayed tumor resection after the spreading, has been graded. After a median follow-up of 26 months, 17 of 18 patients were alive and disease-free, from which 3 patients with tumor progression after initial ovariectomy are in the second remission phase following relapse therapy. One patient died of tumor progression despite combined chemotherapy and irradiation. With a stratified therapy regime, fertility could be preserved with high probability in 13 of 17 patients.

Abdominal, retroperitoneal and sacrococcygeal tumours of the newborn and the very young infant. Report from the Kiel Paediatric Tumour Registry

We examined 226 abdominal, retroperitoneal and sacrococcygeal tumours in newborns and infants aged 6 months or less. Most frequent were neuroblastomas (n = 83) followed by germ cell tumours (n = 76), 37 of which were immature and 32 were mature teratomas. Fully malignant germ cell tumours and malignant germ cell tumour components were much rarer in this age group (9.2%) than in older children (58.1%). The majority of germ cell tumours were localized in the sacrococcygeal region (72.4%). Next in frequency were tumours of the kidney (n = 54), including 28 congenital mesoblastic nephromas. In contrast to children over 6 months of age, kidney tumours were frequently low grade malignant with a favourable prognosis. Among liver tumours there were 19 infantile haemangioendotheliomas and 9 hepatoblastomas. By contrast, at ages 7-24 months hepatoblastomas (n = 28) were much more frequent than haemangioendotheliomas (n = 2). Tumours in the newborn and very young infant differ from those in older children in many respects: (1) the relative frequency; (2) localization; (3) distribution of histological types; (4) degree of differentiation, often associated with a tendency toward maturation but occasionally also with increasing malignancy; and (5) prognosis, which is comparatively favourable.

Combination chemotherapy in malignant non-seminomatous germ-cell tumors: results of a cooperative study of the German Society of Pediatric Oncology (MAKEI 83)

In January 1983, the German Society of Pediatric Oncology started a cooperative trial (MAKEI 83) for non-testicular germ-cell tumors. The pilot phase closed in December 1985. The treatment regimen was stratified according to histology, tumor site and tumor stage. In malignant non-seminomatous germ-cell tumors (mNSGCTs), chemotherapy consisted of four courses of 3 mg/m2 vinblastine, on days 1 and 2 and 15 mg/m2 bleomycin on days 1-3, given by continuous infusion, and 20 mg/m2 cisplatin on days 4-8 with mannitol diuresis. Courses were repeated every 3 weeks. In mNSGCT patients with ovarian FIGO stages III-IV or extragonadal primaries, second-look surgery was carried out, followed by four additional courses of chemotherapy with 100 mg/m2 VP-16 on days 1-3, 1.5 g/m2 ifosfamide on days 1-5 with mesna uroprotection and 20 mg/m2 cisplatin on days 1-5 with mannitol diuresis. In patients with sacrococcygeal germ-cell tumors, en bloc resection of the tumor, including the coccygeal bone, was mandatory. During the registration period, 57 patients with mNSGCTs were entered: 37 protocol patients and 20 follow-up patients. The event-free survival for protocol patients at 57 months was 78% +/- 6% and that for follow-up patients was 40% +/- 10% (Kaplan-Meier): the crude survival for both groups was 83% +/- 6% and 54% +/- 12%, respectively. After a review by a panel of pathologists, the histological diagnoses in 7% of all registered cases of germ-cell tumors were changed. The results of the present studies show that the histological subclassification of mNSGCTs, tumor site and tumor stage no longer had prognostic value.

[Malignant testicular tumors in children. Concept of the cooperative therapy study MAHO 88 based on MAHO 82]

The German society of Pediatric Oncology (GPO) designed in 1982 a cooperative study to improve the outlook of patients with malignant testicular germ cell tumors (MAHO 82). So far the combined modality therapy was effective to increase the relapse free survival (Haas et al. 1988). From the data the MAHO 88 protocoll was outlined as follows: Yolk sac tumor: Unilateral orchiectomy; Stage I A - wait and see. Stage I B/C-IV 4 courses standard chemotherapy. If alpha-feto-protein after 2 courses is still positive explorative laparatomy has to be performed. Malignant teratoma (MTI, MTU, MTT), seminoma: Unilateral orchiectomy. Stage I: 4 courses standard chemotherapy. Stage II-IV: 2 courses standard chemotherapy, explorative laparatomy. During explorative laparatomy 3 different approaches are recommended: Modified lymphadenectomy, radical lymphadenectomy or removal of "bulky disease". In case of presence of vital tumor cells patients with teratoma receive "salvage therapy", patients with seminoma receive instead x-irradiation. If only differentiated teratoma cells are found in addition 2 courses of standard chemotherapy are administered. Standard chemotherapy consists of Vinblastine, Bleomycine and Cis-platinum, salvage therapy of VP 16, Ifosfamide and Cis-platinum.

[Sonographic diagnosis of alobar holoprosencephaly]

The alobar form of holoprosencephaly is characterised by a huge spherical ventricle localized in the midline. The monoventricle communicates with a large occipital cyst, the "dorsal sac". Both thalami and plexus chorioidei are fused in the midline. The interhemisperic fissure and the falx cerebri are absent as well as the corpus callosum and the septum pellucidum.