Increased incidence of cancer in infants in the U.S.: 1980-1990

Cancer incidence and survival trends among infants in the United States from 1975 to 2014

BACKGROUND

Cancer among infants (<1 year old) has unique epidemiologic, clinical, and genetic characteristics compared with cancer in older children. Nonetheless, data on secular trends in infant cancer incidence and survival in the United States is sparse.

METHODS

Population-based data from nine areas of the Surveillance Epidemiology and End Results (SEER) were used to estimate the incidence, average annual percentage change (APC) for trends, and survival of malignant neoplasm among infants from 1975 to 2014. Data were stratified by gender, race, registry, and cancer type.

RESULTS

There were 3437 new infant cancer cases with an overall incidence of 23.6/100 000. Neuroblastoma was the most common infant malignancy (6.5/100 000), followed by leukemia (3.8/100 000), and brain and central nervous system tumors (3.3/100 000). The incidence rate increased significantly from 1975 to 2014 (APC 0.68; 95% CI 0.30-1.06; P < .05). Variations in overall incidence rates were uneven across SEER registry geographic areas, with the lowest rates among both males and females in New Mexico. Relative to other racial distribution, infant cancer rates were highest among Whites. The relative survival rates improved over time for all tumors except for renal, sarcomas, and germ cells and were not significantly different by gender or race.

CONCLUSIONS

Cancer incidence among infants increased over time largely driven by leukemia, germ cell, and sarcoma mainly among male infants. The overall survival for infant cancer has improved over the past 40 years, especially since 1990 for hepatic tumors, lymphoma, and leukemia. Further research is needed to explore the potential impacts of genetic, environmental, and perinatal factors for possible explanations for these increased cancer incidence trends.

Trends in International Incidence of Pediatric Cancers in Children Under 5 Years of Age: 1988-2012

BACKGROUND

Pediatric cancer incidence has been steadily increasing over the last several decades with the largest increases reported in infants. Few evaluations have looked at international pediatric cancer incidence trends in the youngest children. The aim of this analysis was to evaluate trends in cancer incidence in children under 5 years of age, overall and by type, using data from Cancer Incidence in 5 Continents (CI5) from 1988 to 2012 (CI5 volumes VII-XI).

METHODS

Rates of cancers in children ages 0-4 years were extracted from registries available in CI5 from 1988 to 2012. To overcome small numbers in individual registries, numerators and denominators were aggregated within regions corresponding to the United Nations' geoscheme. Average annual percent change (AAPC) was estimated using Poisson regression.  Robust standard errors were used in all models to correct for overdispersion in some regions, and 95% Wald confidence intervals and P values were reported. The top five cancers by increasing AAPC were ranked within each region.

RESULTS

Overall, in children under 5 years, increasing incidence was seen in multiple regions for acute lymphoblastic leukemia, acute myeloid leukemia, ependymal tumors, neuroblastoma, and hepatoblastoma. Hepatoblastoma had the largest AAPC in 11 out of 15 regions and showed an increase in all regions except southern Asia. Astrocytic tumors were the only cancer that decreased over the time period.

CONCLUSIONS

We evaluated 25 years of cancer incidence in children ages 0-4 years and observed increases in incidence for hepatoblastoma, leukemia, neuroblastoma, and ependymal tumors. Further etiologic evaluation will be required to explain these increases in incidence.

Incidence and Survival Cancer Trends in Children and Adolescents in the Provinces of Florence and Prato (Central Italy), 1985–1997

Aims and background

The incidence of childhood and adolescent cancers has been increasing during the last decades in most Western countries. Improvements in cancer survival rates have also been observed according to the availability of more efficient therapies.

Methods and study design

A total of 518 cancer cases (age, 0–19 years) incident in the period 1985–1997 in the Tuscany Cancer Registry area, corresponding to the Provinces of Florence and Prato (Central Italy), were analyzed. Incidence rates and estimated annual percentage change were computed according to sex, 5-year age groups and diagnostic groups of the International Classification for Childhood Cancer. All patients were actively followed at 31.12.1998, and 5-year survival rates were computed for cases diagnosed in 1985–1990 and 1991–1997.

Results

Overall age-standardized incidence rates were 186.7/106 for males and 175.4 for females. In 1991–1997, standardized incident rates were 50.8 for leukemias, 44.6 for lymphomas, and 34.3 for CNS tumors. There was a marked increasing trend for lymphomas that grew at a yearly rate of +12.1% and less evident increasing tendency for leukemias, CNS tumors and carcinomas. The overall survival rate was 88% at one year, 78% at 3 years, and 74% at 5 years. A slight improving tendency in survival was evident over time.

Conclusions

The study pointed out that in the examined area, during 1985–1997, there was a significant increasing incidence trend for lymphomas. Survival rates were as high as in other Western countries – evidence of the high level of diagnostic and treatment services in the area.

Neonatal adrenal findings: significance and diagnostic approach. Description of two cases

Abnormal adrenal findings such as hemorrhage or calcifications in the neonate can stem from a variety of etiologies. Clinical presentation can vary significantly based on the degree of hemorrhage or the associated condition. Thorough work‐up is important to rule out critical underlying conditions as well as adrenal insufficiency.

A single center experience in 266 patients of infantile malignancies

INTRODUCTION

The diagnosis and management of cancer in infantile age group is a significant challenge to pediatric oncologists. Malignancies occurring in infants often have different clinical and biological behavior in comparison to older children. This study was performed with an aim to find out the profile of infantile cancers at a tertiary care cancer center in South India.

METHODS

The present study was a retrospective analysis of infants presenting with malignancy between 2003 and 2012 to our center in South India.

RESULT

A total of 4588 pediatric patients were registered in the Department of Pediatric Oncology at our institute between 2003 and 2012. Among those, 266 (5.79%) of the patients were infants (0-1 years). There were 65.75% males and 34.25% females. Solid tumors were the most common malignancy in this age group (72.56%). Leukemias were observed in 67 (25.19%) infants. ALL was the most common hematological malignancy (17.29%) followed by AML (5.64%). Common solid tumors in descending orders were neuroblastoma, soft tissue sarcoma, renal tumors, germ cell tumors, retinoblastoma and hepatoblastoma. Thirteen (4.89%) neonates were seen in our study. The most common malignancy in neonates was neuroblastoma.

CONCLUSION

The distribution of malignancy in infants is quite different from that which is found in older children. Although neuroblastoma is the most common infantile tumor in western countries, in our study leukemia is the most common infantile malignancy. Embryonal tumors such as neuroblastoma, Wilms tumor, retinoblastoma, and hepatoblastoma were more prevalent in infants. Solid tumors were the most common malignancy in infants which is followed by leukemia.

Treatment of a rare ganglioneuroma with resection and reconstruction of the mandible: a case report and literature review

Ganglioneuromas are rare neuroblastic tumors that develop from the neural crests of the sympathetic nervous system. Because ganglioneuromas of the mandible have been infrequent, they do not have a standardized management protocol. As of 2000, only 5 cases had been reported. Ganglioneuromas are unique tumors that can undergo histologic maturation from a malignancy to a benign variant. We present the case of a 15-year-old boy with a ganglioneuroma of the mandible and the results of surgical management, including immediate reconstruction with a free fibula microvascular flap.

Cancer incidence and survival among infants in Israel, 1998-2007

Cancer during the first year of life is relatively rare and often has clinical and biological properties different from those of the same histologic type of cancer occurring in older children. The aim of this study was to find differences in epidemiology and survival between infants and older children and to compare the percentage of distribution of infant cancer types in Israel with that reported in the United States. We collected infant <1 year of age cases diagnosed between 1998 and 2007 as having cancer from the database of the Israel National Cancer Registry, a total of 309 cases with an incidence rate of 228.5 cases per million. The largest group was diagnosed with neuroblastoma (35%) with an incident rate of 80 per million, followed by leukemia (15.9%), with acute lymphoid leukemia and acute myeloid leukemia accounting for most of this group and central nervous system malignancies comprised 10.7% of infant cancer. One hundred and fifty four new cases of infant girls was diagnosed compared to 155 infant boys with an incidence rates of 234 cases per million for girls and 224.7 for boys, not statistically significant (F:M rate ratio of 1.04). The 5-year survival rates seen in the different groups were leukemia: 55.3%, lymphoma: 71%, CNS tumors: 53.3%, neuroblastoma: 93.4%, retinoblastoma: 94.7% renal tumors: 90.9%, hepatic tumors: 63.3%, soft tissue sarcoma: 76.2%, germ cell neoplasms: 83.3%, and other epithelial neoplasms: 100%. Our study did not find survival differences with statistical significance upon comparing survival rates between different genders and ethnic groups.

Current concepts in pediatric liver tumors

Liver tumors in children can be classified into benign or malignant; some of the benign lesions can have the potential of malignant transformation, and therefore the therapeutic approach may change. These neoplasms account for nearly 1-2% of all pediatric tumors and they have gained significant attention in the last decades due to data suggesting that the incidence may be increasing 5% annually. We know that with new and improved imaging modalities some of these lesions may be detected more often than before. Recent studies showed that liver cancer represented 2% of malignancies in infants by 1980s and this was doubled in incidence to 4% in the following 10 yr. In this review our aim is to discuss all primary liver tumors in children with attention to their clinicopathological and immunohistochemical features followed by the current standard of care.

Long-term follow-up of infantile Wilms tumor treated according to International Society of Pediatric Oncology protocol: seven years' follow-up

OBJECTIVES

To report the long-term follow-up of patients with infantile Wilms tumor treated according to the International Society of Pediatric Oncology study 9 protocol.

METHODS

We retrospectively reviewed our medical reports for diagnosed WT in patients aged 6-12 months from January 2001 to January 2009. The clinical presentation, stage, operative details, pathologic findings, and outcomes for these infants were analyzed. We reviewed the charts of these patients throughout the whole disease course through long-term follow-up, paying particular attention to the details of the clinical presentation, stage at presentation versus postoperative stage, intraoperative findings, pathologic findings, and outcomes.

RESULTS

The records revealed 16 patients with a median age of 7.5 months. All patients had presented with an abdominal mass, and 25% had presented with abdominal pain and hematuria. Associated congenital anomalies were observed in 16.7% of the patients. A favorable histologic type was found in 91.7% of the patients and 8.3% had an unfavorable histologic type. The median follow-up period was 57 months. Postoperative complete remission was achieved in all patients who underwent surgery. Relapse developed in 1 patient. The 7-year disease-free survival rate was 93.8%, and the 7-year overall survival rate was 75%.

CONCLUSIONS

The long-term follow-up data using the International Society of Pediatric Oncology study 9 protocol revealed good outcomes. The protocol was a safe and an effective line of therapy, associated with decreased morbidity and improved survival. Also, the reduction in tumor volume resulted in easier surgical procedures, with no intraoperative complications.

Familial retinoblastoma in developing countries

BACKGROUND

Although screening for familial retinoblastoma has been shown to be beneficial we suspected that such screening programs may be less than optimal in developing countries (DC).

METHODS

Retrospective cohort study comparing patients with familial retinoblastoma from five centers in DC (Argentina, Brazil, Turkey, Jordan, and Venezuela) versus a reference center in the USA.

RESULTS

Ninety-two (32 from the USA and 60 from DC) patients were included. Forty-one (44.6%) patients avoided enucleation, 42 (45.7%) had 1 eye removed, and 9 (9.8%) underwent bilateral enucleation. Eleven (11.9%) had major pathology risk factors at enucleation. There were no cases of metastatic disease at diagnosis. Detection via screening was significantly less common in DC than in the USA (23.3% vs. 71.8%, P < 0.0001). Patients in DC were diagnosed at a significantly later age and with more advanced intraocular disease that led to increased risk of bilateral enucleation. Patients detected by screening in DC were significantly younger at diagnosis, had less advanced intraocular disease, better ocular preservation rates and survival results than those whose retinoblastoma was not detected via early screening. Five-year pEFS was 0.92 for the patients treated in the USA and 0.81 for the patients in DC (P = 0.42). Seven events occurred (extraocular relapse four in patients from DC and second malignancies in three).

CONCLUSIONS

Patients with familial retinoblastoma are less likely to be diagnosed by screening in DC and had higher morbidity and mortality caused by recurrent extraocular retinoblastoma.

Liver tumors in children

Malignant liver tumors account for slightly >1% of all pediatric malignancies, with roughly 150 new cases of liver tumors diagnosed in the U.S. annually. The embryonal tumor, hepatoblastoma, accounts for two thirds of malignant liver tumors in children. Other liver malignancies in children include hepatocellular carcinoma, sarcomas, germ cell tumors, and rhabdoid tumors. Benign tumors of the liver in children include vascular tumors, hamartomas, and adenomas. There is an apparent increase in the incidence of hepatoblastoma with perinatal exposures and decreased premature infant mortality as postulated causes for this increased risk. The known causes and associations of liver tumors in children as well as the approaches to diagnosis and treatment of children are discussed in this review article.

Cytopathologic findings in an immature cystic teratoma: Report of an unusual case

Teratomas are uncommon, usually benign tumors often found in young women. We describe the cytopathology of an unusual case of a large congenital teratoma in a 6-day-old girl. The patient initially showed signs of abdominal distention and a follow-up ultrasound and computerized-tomography (CT) revealed a cystic mass in the pelvis. An ultrasound-guided fine-needle aspiration (FNA) showed small round blue cells suspicious for a primitive neuronal tumor. Resection of the mass displayed a cystic teratoma with distinct nests of small round blue cells representing immature neuroepithelial and glial tissue. Also noted were admixed mature elements of a cystic teratoma. Cytologic finding of a small round blue cell tumor, therefore, was the immature component of the teratoma. This case illustrates the difficulties in diagnosing teratomas due to their extraordinary diversity.

A report of nine newborns with congenital brain tumours

BACKGROUND

Although rare, brain tumours represent one of the relatively larger groups of congenital neoplasias. Most studies on congenital neoplastic disease deal with several types of neoplasms and are dominated by leukaemias, retinoblastomas and systemic solid tumours. Few studies are dedicated to congenital brain tumours. We present nine newborns (four boys and five girls) who were diagnosed with congenital brain tumours during the 8-year period 1 January 1992-31 December 1999 at our institution, which covers all paediatric neuro-oncology cases for Eastern Denmark.

EPIDEMIOLOGY

Two of the cases were referred from Western Denmark for surgery, and were therefore excluded from the calculation of incidence. During the same period, a total of 172 children below the age of 15 years were diagnosed as having primary central nervous system tumours. The seven remaining congenital cases thus represent 4% of all paediatric brain tumour cases in the area (95% confidence interval 1.7-8.3%). The population of the referral area is 2.383x10(6), and based on the total number of living births, the incidence of congenital brain tumour was calculated to be 2.9 per 100,000 live births. The ages of the mothers were 28-33 years, corresponding to the present mean age of 31 years for Danish primipara. The gestational age varied between 35 and 42 weeks, and the birth weights were 3,044-4,790 g.

RISK FACTORS

Two patients with p53-related glioblastoma multiforme (GBM) had relatives with p53-related neoplasms. In one case, the mother was treated for cancer of the ovary with surgery and chemotherapy 2 months before conception.

CLINICAL FEATURES

In five of the cases, brain abnormality was suspected antenatally. The clinical features of the newborns were limited to enlarged head circumferences, associated hydrocephalus, and asymmetric skull growth.

DIAGNOSIS AND TREATMENT

Three babies were treated with complete tumour resection. In the remaining six cases, a guided or open biopsy to obtain histology was made after CT/MRI imaging. The histological diagnoses were teratoma in four cases, GBM in two cases, anaplastic astrocytoma in two cases and, finally, haemangioma capillare in one case.

OUTCOME

Four of the patients (44%) are still alive, including two patients with totally resected combined orbital/intracranial teratomas, one patient with a totally resected haemangioma and one patient with anaplastic astrocytoma who did not receive any treatment apart from supportive care. The survival lengths of the five neonates who died varied between 1 day and 51 days.

Cancer incidence in the age range 0–34 years: Historical and actual status in Denmark

On the basis of 55 years of continuous cancer registration in Denmark, we present cancer incidence rates, time trends and birth cohort analyses for persons aged 0-34 years. The group of 40,750 cancer patients showed a substantial over-representation of males aged 1-24 years. The cancer pattern among young (15-34 years) men was dominated by testicular cancer (35%), lymphomas (14%) and tumors of the brain (13%), while the pattern among young women was governed by invasive cervical cancer (19%), malignant melanoma (15%) and cancer of the breast (12%). In this age range, a positive time trend was seen after 1970, equivalent to average annual percentage increases of 1.9% for men and 1.8% for women, due mainly to markedly increasing trends for testicular cancer, malignant melanoma, brain tumors, thyroid cancer, skin carcinomas and skin sarcoma among men, and for brain tumors, non-Hodgkin lymphoma, malignant melanoma, skin carcinomas and thyroid cancer among women. We saw no clear time trend for breast cancer among women. The cancer pattern among children (0-14 years) was similar to that reported for other white populations.

4-Aminobiphenyl induces liver DNA adducts in both neonatal and adult mice but induces liver mutations only in neonatal mice

The mechanisms underlying the susceptibility of neonatal mice to genotoxic carcinogens were investigated by analyzing the DNA adducts and mutations induced in the livers of neonatal and adult Big Blue transgenic mice by 4-aminobiphenyl (4-ABP), a potent human and rodent carcinogen. Neonatal and adult mice were treated with a regimen of 4-ABP known to induce tumors in neonatal mice. Animals were sacrificed 1 day after the last treatment for DNA adduct analysis and 8 weeks after the last treatment for analysis of lacI and cII mutant frequency (MF). N-(Deoxyguanosin-8-yl)-4-ABP was the major DNA adduct identified in the livers of the 4-ABP-treated mice and levels of this adduct were significantly higher in treated animals than in the controls for both the neonates and adults. Adduct levels for adult females (44.0 +/- 4.8 adducts/10(6) nucleotides) were higher than in neonatal females (25.9 +/- 2.2 adducts/10(6) nucleotides), while adduct levels in adult males (13.5 +/- 2.0 adducts/10(6) nucleotides) were lower than in neonatal males (33.8 +/- 4.1 adducts/10(6) nucleotides). 4-ABP treatment significantly increased the liver cII MFs in both sexes of neonatal mice but not in adult mice. Sequence analysis of cII mutant DNA revealed that 4-ABP induced a unique spectrum of mutations in neonatal mice, characterized by a high frequency of G:C-->T:A transversion, while the mutation spectrum in 4-ABP-treated adults was similar to that of control mice. Our results indicate that DNA adduct formation by 4-ABP depends as much on sex as it does on age, whereas the conversion of DNA adducts into mutations differed with animal age. These observations suggest that neonates are more sensitive than adults to genotoxic carcinogens because the relatively high levels of cell division in the developing animal facilitate the conversion of DNA damage into mutation. Supplementary material for this article can be found on the International Journal of Cancer website at http://www.interscience.wiley.com/jpages/0020-7136/suppmat/index.html

Cancer in infants: a review of 82 cases

Cancer occurring in infants often has clinical and biological properties that are different from those of the same histologic type of cancer occurring in older children. The histologic distribution of cancers in infants and that in older children are also different. The aim of this study was to find these differences between infants and older children, and to compare the percent distribution of infant cancer subtypes with that reported by other countries. The authors collected infant cases diagnosed as having cancer from the database of the Cancer Registry in our Medical Center between 1995 and 2001. Subjects were selected subjects from inpatient logs, and their medical records were reviewed. Eighty-two infants (40 males and 42 females), including 12 neonates, were diagnosed with cancer over this 7-year period. Acute leukemia was diagnosed in 21 infants (25.6%; acute myeloid leukemia in 12, and acute lymphoblastic leukemia in 9), retinoblastoma in 14 (17.1%), neuroblastoma in 12 (14.6%), brain tumor in 9 (11.0%), germ cell tumor in 8 (9.8%), renal cancer in 8 (Wilms tumor 3, mesoblastic nephroma 1, renal sarcoma 1, rhabdoid tumor 3), hepatoblastoma in 5 (6.1%), and soft tissue sarcoma in 5 (rhabdomyosarcoma 1, fibrosarcoma 3, other sarcoma 1). The overall disease-free survival rate was 61.0% (50/82) with a median follow-up duration of 6.8 years for the survivors. The 4 most common types of cancer occurring in infants are the same in the present series and in most larger childhood cancer series reported by other countries; but rank differently. In this study there were more infants with acute leukemia and retinoblastoma, and less with neuroblastoma. The prognosis is poor for infant leukemia and rhabdoid tumor, while it is good for embryonal tumors and germ cell tumors occurring in infancy.

Epidemiology of cancer in children under one year of age in Mexico City

In this work, the epidemiology of cancer in children under one year of age in Mexico City is described. A survey (observational, descriptive and prolective study) from 1 January 1996 to 31 December 1999 was conducted at two paediatric hospitals of the Instituto Mexicano de Seguro Social in Mexico City (IMSS-MC). To calculate both the general and the by sex incidence (rates are given per 10) all new cases recorded for children under one year of age (numerator) and Mexico City population served by the IMSS (denominator) were used. When the total of 34 cases that fulfilled the requirements was analysed, an incidence of 194.5 was obtained. Leukaemia occupied first place with a rate of 68.6 and hepatic and germinal cells tumours occupied second place with an incidence of 28.6, whereas peripheral nervous system tumours (neuroblastoma) showed a very low rate (11.4). Overall, the male/female ratio for tumours was 1.4:1, with the ratio varying with different types of tumours. Cancer incidence in this population was shown to be close to that in developed countries, but differed in the distribution of the type of tumour: leukaemia had a very high incidence and that for neuroblastoma was very low.

Age-dependent sensitivity of Big Blue transgenic mice to the mutagenicity of N-ethyl-N-nitrosourea (ENU) in liver

The incidence of childhood cancer is increasing and recent evidence suggests an association between childhood cancer and environmental exposure to genotoxins. In the present study, the Big Blue transgenic mouse model was used to determine whether specific periods in early life represent windows of vulnerability to mutation induction by genotoxins in mouse liver. Groups of mice were treated with single doses of 120 mg N-ethyl-N-nitrosourea (ENU)/kg body weight or the vehicle either transplacentally to the 18-day-old fetus or at postnatal days (PNDs) 1, 8, 15, 42 or 126; the animals were sacrificed 6 weeks after their treatment. The cII mutation assay was performed to determine the mutant frequencies (MFs) in the livers of the mice. Liver cII MFs for both sexes were dependent on the age at which the animals were treated. Perinatal treatment with ENU (either transplacental treatment to the 18-day-old fetus or i.p. injection at PND 1) induced relatively high MFs. However, ENU treatment at PNDs 8 and 15 resulted in the highest mutation induction. The lowest mutation induction occurred in those animals treated as adults (PND 126). For instance, the cII MF for the PND 8 female group was 646 x 10(-6) while the MF for female adults was only 145 x 10(-6), a more than 4-fold difference. Molecular analysis of the mutants found that A:T-->T:A transversions and A:T-->G:C transitions characterized the pattern of mutations induced by ENU in both the neonate and adult mice, while the predominate type of mutation in the controls was G:C-->A:T. The results indicate that mouse liver is most sensitive to ENU-induced mutation during infancy. This period correlates well with the age-dependent sensitivity to carcinogenicity in mouse liver, suggesting that mutation is an important rate-limiting factor for age-related carcinogenesis.

Increasing incidence rates of childhood malignant diseases in Sweden during the period 1960–1998

We analysed the trends in incidence rates of childhood cancer in Sweden. All cases of malignant diseases and benign brain tumours in children, 0-14 years old, reported to the Swedish Cancer Registry 1960 to 1998 were included, n=9298. Cases were classified according to the International Classification of Childhood Cancer. Average annual change in incidence rate was calculated to +1.01%, (95% confidence interval CI=0.80, 1.22). An increase in incidence rate per year was found for leukaemia, +0.85% (95% CI=0.42, 1.28), lymphomas +1.87% (95% CI=1.17, 2.58), CNS (central nervous system) tumours +1.45% (95% CI=1.02, 1.88), sympathetic nervous system tumours +1.61% (95% CI=0.79, 2.44), hepatic tumours +2.62% (95% CI=2.02, 3.21), and germ cell and gonadal tumours +1.21% (95% CI=0.23, 2.19). Of the CNS tumours, significant changes were seen for low-grade glioma/astrocytoma +2.10% (95% CI=1.41, 2.80), benign brain tumours +3.77% (95% CI=2.47, 5.10), and PNET/medulloblastoma +1.96% (95% CI=0.48, 3.46). Changes in diagnostic criteria and better diagnostic tools may have contributed to these results.

Early recognition of infant malignancy: the five most common infant cancers

The incidence of cancer in children is rising in the U.S. Although cancer in the first year of life is relatively rare, understanding the early signs and symptoms of and the historical factors associated with most common infant cancers is essential for providing optimal care to these infants and their families. Neonatal nurses and nurse practitioners play a pivotal role in early recognition and detection of infant malignancy. This article reviews the incidence of and historical factors associated with infant cancers and discusses clinical presentations and available diagnostic images as well as screening tools for the five most common types of infant malignancy.

Effects on brain development leading to cognitive impairment: a worldwide epidemic

This article reviews causes of cognitive impairment in children with a focus on those in developing countries. The number of children with cognitive limitations is increasing, and for the majority there is little access to professional expertise. Causes include malnutrition, genetic diseases, infectious diseases such as meningitis, parasites, and cerebral malaria, in utero drug and alcohol exposure, newborn asphyxia, low birth weight, head injuries, and endocrine disorders. Many of these are preventable; however, resources for prevention are limited in most developing areas of the world. The challenge for this century is to encourage community leaders and government officials to take on the prevention of cognitive impairment as the highest priority for society. This article proposes that specialists in child behavior and development work with United Nations agencies to develop a "world cognitive impairment watch" to assess and assist each country annually in terms of risk factors, prevention programs, and early intervention programs.

Clinical and social factors that affect the time to diagnosis of Mexican children with cancer

BACKGROUND

There are few studies on the factors that influence the time to diagnosis (TD) in childhood cancer. The object of the present study was to determine the influence of some clinical and social factors associated to TD in children with cancer seen at Mexico City (MC) hospitals.

PROCEDURE

A retrospective study was performed. A total of 4,940 clinical records of children with cancer were reviewed. Cases of cancer were grouped, according to the International Classification of Childhood Cancer. The median (med) TD was calculated for each group (type) of cancer. The association between delayed TD (longer than 1 month) and type, age at diagnosis, parental educational level, medical institution, and place of residence was analyzed, for which the odds ratio (OR) and 95% confidence intervals (CI) were obtained.

RESULTS

Leukemias had the shortest TD (med = 1 month), while Hodgkin disease (HD) and retinoblastoma had the longest TD (med = 5 months). The highest risk for delayed TD was in children with HD (OR = 7.0; 95% CI 5.3-9.3), in the 10-14 age group (OR = 1.8; 95% CI 1.4-2.3), with low maternal educational level (OR = 1.5; 95% CI 1.2-2.1), in the population with no access to social security (OR = 1.3; 95% CI 1.1-1.4), and whose place of residence is far from MC (OR = 1.5; 95% CI 1.2-2.1).

CONCLUSIONS

In Mexican children with cancer, age at diagnosis, and societal characteristics are important factors affecting timely diagnosis.

The clinical presentation of environmental health problems and the role of the pediatric provider. What do I do when I see children who might have an environmentally related illness?

The practice of environmental health is concerned with the protection of the community. There are a number of tools used for assessment of environmental hazards, but environmental health is most reliant on the use of risk assessment. Risk assessment is a set of tools used to assess hazards on a community level, based on human studies, ecological studies, or toxicity testing of animals.

Risk-based management of solid tumors in children

BACKGROUND

During the past 25 years significant improvements in survival (56% to 75%) have been observed for children with malignant solid tumors. Multidisciplinary cooperative studies using combined therapy (surgery, chemotherapy, and irradiation) have played a major role. This report describes how recognition of biologic and genetic factors has permitted risk categorization and resulted in new treatment protocols that individualize care.

METHODS

Genetic alterations and biologic factors concerning the multiple endocrine neoplasia syndromes, Wilms' tumor, and neuroblastoma are described.

RESULTS

Using the these data new treatment protocols are designed according to whether a patient is categorized as having a low-, intermediate-, or high-risk tumor, which determines the intensity and type of treatment required.

CONCLUSIONS

Identification of biologic markers and specific gene alterations may be critical in establishing the behavior of tumors (low versus high-risk). Risk-based management permits individualized care for each patient, maximizes survival, minimizes morbidity, and improves the quality of life.

Adrenal masses in the newborn

The incidence of neonatal adrenal tumors is increasing due to the expanded use and accuracy of prenatal ultrasonography in routine obstetric care. Although adrenal and juxtarenal masses may represent benign lesions (adrenal hemorrhage, subdiapragmatic extralobar pulmonary sequestration), the majority of masses either are premalignant or malignant. Previous algorithms for the diagnosis and management of these lesions have been guided primarily by the high incidence of neuroblastomas within this group. Improved insight into the relatively benign behavior of many neonatal neuroblastomas has stimulated debate regarding the appropriate management schema for neonatal adrenal masses. Moreover, the increasing recognition of benign juxtarenal lesions further challenges the conventional dogma. This review discusses the major categories of adrenal masses to help generate a rational algorithm for diagnosis and therapy.

Incidence and survival for cancer in children and young adults in the North of England, 1968-1995: a report from the Northern Region Young Persons' Malignant Disease Registry

The Northern Region Young Persons' Malignant Disease Registry records information on young people under 25 years old diagnosed with cancer in the Northern Region of England. Incidence and survival rates were calculated for children and young adults diagnosed with cancer between 1968 and 1995. There were 2099 (M:F 1.28:1) children (age 0-14 years) and 2217 (M:F 1.23:1) young adults (15-24 years) diagnosed with a first cancer between 1968 and 1995. The age-standardized rate (ASR) for childhood cancer was 121 per million 0 to 14 year-olds per year. For young adults the ASR was 175 per million 15 to 24 year-olds, per year. Incidence of childhood cancer increased over time at a rate of 12 extra cases per million children, per decade (P < 0.001). In young adults incidence rates increased by 16 extra cases per million 15 to 24 year-olds, per decade (P < 0.001). For childhood cancer 5-year survival was 42% for those diagnosed 1968-1977, 57% for 1978-1987 and 71% (95% CI 67-75) for 1988-1995. Survival for young adults over the three periods was 45%, 62% and 73% (95% CI 70-78) respectively. The cumulative risk of developing cancer before the age of 25 is 1 in 285. Over the 28-year period there were significant improvements in survival and modest increases in incidence in both children and young adults.

Metastatic neuroblastoma with ganglioneuromatous differentiation and mandibular involvement

Neuroblastic tumors comprise neuroblastoma (NB), ganglioneuroblastoma, and ganglioneuroma (GN). NBs have shown remarkable differentiation capabilities, which include spontaneous regression. In the last 3 decades, the prognosis for metastatic NB has improved significantly. The ability to distinguish prognostic subtypes based on clinical and biologic features allows for understanding of this disease process and development of management procedures. NBs are often asymptomatic and remain undetected until a large abdominal mass or metastasis is found. GN, the most differentiated variant, is a benign neoplasm with significant growth potential and ability to cause clinical complications. GN of the mandible has seldom been reported in the literature in English. We present a case of NB metastatic to the mandible exhibiting ganglioneuromatous differentiation. We discuss the current understanding of the biology, grading, classification, and prognostic implications of NB.

Risk-based management: current concepts of treating malignant solid tumors of childhood

BACKGROUND

Improved survival with pediatric malignancies has been positively influenced by multidisciplinary cooperative studies using surgery, chemotherapy, and radiation therapy, but one-third of all children with cancer succumb to their condition. The identification of biologic and genetic characteristics as risk factors for the various tumors has led to changes in treatment using risk-based management as the template for care.

STUDY DESIGN

The purpose of this report is fourfold: (1) to review survival data concerning three solid malignant tumors of childhood (Wilms' tumor, rhabdomyosarcoma, and neuroblastoma), (2) to describe important prognostic genetic and biologic risk factors for each tumor, (3) to update changes in staging criteria, and (4) to familiarize the reader with the concept of risk-based management, which individualizes treatment in an attempt to maximize survival and minimize longterm morbidity.

RESULTS

The overall survival rates for Wilms' tumor, rhabdomyosarcoma, and neuroblastoma are currently 90%, 70%, and 40%, respectively. Most patients with Wilms' tumor have favorable histology and survive after nephrectomy and chemotherapy, but 10% have poor prognostic variables, including unfavorable (anaplastic) histology, chromosomal loss on 1p and 16q, and diploidy. Instances of lung or liver metastases, major tumor spillage during resection, remote lymph node involvement, and bilateral tumors have worse outcomes. Rhabdomyosarcoma is associated with chromosomal translocation of t(2:13) in alveolar types, the p53 tumor suppressor gene, and 11p15. Survival is dependent on the tumor site and pretreatment clinical group. Orbit, paratesticular, vulvar, and vaginal tumors have a good prognosis, but other genitourinary tumors, extremity and trunk lesions, and parameningeal head and neck tumors have a worse prognosis. Survival rates by clinical group are stage I, 93%; II, 81%; III, 73%; and IV, 30%. Resectability, lymph node involvement, DNA ploidy, and pretreatment TNM staging affect outcomes. Neuroblastoma is an embryonal tumor with bizarre behavior and can regress, mature, or rapidly progress. Most patients have advanced disease at diagnosis. Neuroblastoma is associated with loss of heterozygosity on chromosome 1p36 and occasionally deletions on 14q and 17q. Survival is affected by age and stage (at less than 1 year, stages I [95% to 100%], II [85% to 90%], and IV-S [more than 80%] do better) and other risk factors. Patients with advanced disease (older than 1 year, stage III [70%], and stage IV [12%]) often have amplification of the N-myc oncogene, diploid tumors, 1p36 deletion, and unfavorable histology and fare worse.

CONCLUSIONS

On the basis of these data, children with solid tumors are currently categorized into low-, intermediate-, and high-risk groups. Newer protocols individualize treatment using risk factors as predictors of outcomes. Risk-based management allows the clinician to weigh the risks and benefits of treatment for each patient to maximize survival, minimize longterm morbidity, and improve the quality of life.

Neonatal brain tumors: a review

This article presents two cases of infants with brain tumors and reviews the literature pertinent to congenital and neonatal brain tumors. Information regarding epidemiology, presentation, prognosis, and clinical management are also addressed with specific regard to differences between neonatal and childhood brain tumors. An appeal is made to consider (1) coordination of the care of these children through pediatric multidisciplinary neuro-oncology programs; (2) enrollment, whenever possible, in clinical trials; and (3) submission of available tumor tissue to pediatric tumor banks to assure its availability to interested researchers.

Congenital leukemia: successful treatment of a newborn with t(5;11)(q31;q23)

A male neonate presented with a high white cell count, an 11q23 translocation, and M5b leukemia. He was treated at 3 days of age with intensive combination chemotherapy after progressing despite exchange transfusions. The patient achieved complete remission at 28 days of age. Therapy was completed at the age of 6 months. At the time of this report, the patient is 17 months old and remains in remission. Twenty-nine patients with congenital acute myeloid leukemia were also reviewed. Twenty of these patients received varying therapies. Ten of the treated patients achieved complete remission; two died of toxicity; and eight died of progressive disease. Two patients had a translocation affecting 11q23. Congenital leukemia is a rare and usually fatal condition in patients without Down syndrome. The patient reported here shows that survival may be achieved with very intensive chemotherapy plus supportive care, despite extremely high white blood cell counts and unfavorable translocation.